Dissolution of phenytoin precipitate with sodium bicarbonate in an occluded central venous access device.

OBJECTIVE: To report a case of restored patency of a central venous access device occluded by precipitate of phenytoin sodium injection. CASE SUMMARY: A patient experienced total occlusion of an implanted subcutaneous port caused by precipitation of phenytoin. Phenytoin sodium injection was mixed inadvertently with dextrose 5% in NaCl 0.45% injection during intravenous administration. Dextrose 5% in NaCl 0.45% injection, which is acidic (pH 4.0), caused the phenytoin sodium injection, a basic solution (pH 12.0), to precipitate. Local instillation of sodium bicarbonate 8.4% injection to decrease the pH of the medium restored patency of the occluded port. DISCUSSION: There are reports of local instillation of solvent restoring central ports occluded by lipid-containing parenteral nutrient admixture, calcium phosphate salt precipitate, and coagulated blood. No report of local instillation into an occluded port to dissolve precipitate of phenytoin could be found. Several factors are involved in the precipitation and dissolution of phenytoin. The key factor in this case was the hydrogen ion concentration (pH) of the solution. Decreased pH caused the precipitation, but increased pH caused the dissolution of the precipitate of phenytoin. CONCLUSIONS: Sodium bicarbonate injection was a suitable agent for clearing precipitate of phenytoin in this case of an occluded implanted central venous access device.

Impact of social work on recidivism and non-medical complaints in the emergency department.

Recidivism among patients treated in the hospital Emergency Department (ED) is a significant factor in resource depletion. This study substantiates the efficacy of social work intervention in the ED using recidivism as an outcome measure. Data was collected on all patients seen by social work during the first 12 months of social work services to the ED between the hours of 3:00 p.m. and 11:30 p.m. The greatest decline in recidivism occurred where social work used a proactive intervention strategy as opposed to a more support oriented intervention.

A worldwide perspective on the epidemiology and primary prevention of liver cancer.

Liver cancer is one of the ten most common cancers in the world with a pronounced geographic variation. The incidence of hepatocellular cancer is low in the Western countries compared to the high prevalence in South Africa, Asia, and the Pacific Islands. Risk factors, early signs and symptoms, and the strategies for early detection are discussed. Primary prevention involves conducting mass immunization for hepatitis B virus in endemic countries along with education programs to improve food hygiene, decreasing alcohol intake, using sterile implements for immunizations and injections, smoking cessation, avoiding unnecessary blood transfusions and screening of blood for transfusions.