Risk Factors for Intravenous Propacetamol-Induced Blood Pressure Drop in the Neurointensive Care Unit: A Retrospective Observational Study.

BACKGROUND: Intravenous propacetamol is commonly used to control fever and pain in neurocritically ill patients in whom oral administration is often difficult. However, several studies reported that intravenous propacetamol may cause blood pressure drop. Thus, we aimed to investigate the occurrence and risk factors for intravenous propacetamol-induced blood pressure drop in neurocritically ill patients. METHODS: This retrospective study included consecutive patients who were administered intravenous propacetamol in a neurointensive care unit at a single tertiary academic hospital between April 2013 and June 2020. The exact timing of intravenous propacetamol administration was collected from a database of the electronic barcode medication administration system. Blood pressure drop was defined as a systolic blood pressure below 90 mm Hg or a decrease by 30 mm Hg or more. Blood pressure, pulse rate, and body temperature were collected at baseline and within 2 h after intravenous propacetamol administration. The incidence of blood pressure drop was evaluated, and multivariable logistic regression analysis was performed to identify risk factors for blood pressure drop events. RESULTS: A total of 16,586 instances of intravenous propacetamol administration in 4916 patients were eligible for this study. Intravenous propacetamol resulted in a significant decrease in systolic blood pressure (baseline 131.1 ± 17.8 mm Hg; within 1 h 124.6 ± 17.3 mm Hg; between 1 and 2 h 123.4 ± 17.4 mm Hg; P < 0.01). The incidence of blood pressure drop events was 13.5% within 2 h after intravenous propacetamol. Older age, lower or higher baseline systolic blood pressure, fever, higher Acute Physiology and Chronic Health Evaluation II score, and concomitant administration of vasopressors/inotropes or analgesics/sedatives were significant factors associated with the occurrence of blood pressure drop events after intravenous propacetamol administration. CONCLUSIONS: Intravenous propacetamol can induce hemodynamic changes and blood pressure drop events in neurocritically ill patients. This study identified the risk factors for blood pressure drop events. On the basis of our results, judicious use of intravenous propacetamol is warranted for neurocritically ill patients with risk factors that make them more susceptible to hemodynamic changes.

Intravenous Fluid Selection for Unruptured Intracranial Aneurysm Clipping : Balanced Crystalloid versus Normal Saline.

OBJECTIVE: While balanced crystalloid (BC) could be a relevant fluid regimen with buffer system compared with normal saline (NS), there have been no studies on the optimal fluid for surgery of an unruptured intracranial aneurysm (UIA). This study aimed to compare the effects of fluid regimens between NS and BC on the metabolic and clinical outcomes of patients who underwent surgery for UIA. METHODS: This study was designed as a propensity score matched retrospective comparative study and included adult patients who underwent UIA clipping. Patient groups were categorized as NS and BC groups based on the types of pre-operative fluid and the amount of fluid administered during surgery. The primary outcomes were defined as electrolyte imbalance and acidosis immediately after surgery. The secondary outcomes were the length of stay in the intensive care unit (ICU) and duration from the end of the operation to extubation. RESULTS: A total of 586 patients were enrolled in this study, with each of 293 patients assigned to the NS and BC groups, respectively. Immediately after surgery, serum chloride levels were significantly higher in the NS group. Compared to the NS group, the BC group had lower incidence rates of acidemia (6.5% vs. 11.6%, p=0.043) and metabolic acidosis (0.7% vs. 4.4%, p=0.007). As compared to NS group, BC group had significantly shorter duration from the end of the operation to extubation (250±824 vs. 122±372 minutes, p=0.016) and length of stay in ICU (1.37±1.11 vs. 1.12±0.61 days, p=0.001). Throughout multivariable analysis, use of BC was found to be significant factor for favorable post-operative results. CONCLUSION: This study showed that the patients who received BC during UIA clipping had lower incidence of metabolic acidosis, earlier extubation and shorter ICU stay compared to those who received NS. Therefore, using BC as a peri-operative fluid can be recommended for patients who undergo surgery for UIA.

Redundant combinations of antianaerobic antimicrobials: impact of pharmacist-based prospective audit and feedback and prescription characteristics.

This study aimed to evaluate the impact of the intervention targeting the redundant combination of antianaerobic antimicrobials on its incidence and associated antimicrobial consumption. To reveal the characteristics of the combination and the change in the related workload over time was an additional aim of the study. The combinations of metronidazole or clindamycin with antianaerobic antimicrobials were classified into redundant or acceptable, according to the target indications. A pharmacist-based prospective audit and feedback targeting the redundant antianaerobic combination was conducted. Segmented regression analysis was performed to evaluate the impact of the intervention. As a quantitative index of the interventional activity, the change in the number of signed consultation notes was evaluated. After the initiation of the intervention, the median monthly cumulative incidence of the redundant combination decreased from 5.29 (Interquartile range [IQR] 4.94-5.70) to 3.33 (IQR 2.87-3.71) (p < 0.001) per 1000 admissions per month. The consumption of concurrently administered metronidazole and clindamycin decreased from 3.34 (IQR 2.97-4.10) to 1.74 (IQR 1.19-1.93) (p < 0.001) per 1000 patient-days per month. Segmented regression analysis revealed that the monthly cumulative incidence decreased by 28.5% after the initiation of the intervention (change in level - 1.640, p = 0.019) and the monthly consumption decreased by 33.9% (change in level - 1.409, p = 0.009). The number of consultation notes per 1000 admissions per month decreased over time (regression coefficient - 0.004, p < 0.001). The pharmacist-based intervention significantly reduced the incidence and associated antimicrobial consumption of the redundant antianaerobic combination. The overall related workload reduced steadily over time.

Impact of an Antimicrobial Stewardship Program on Unnecessary Double Anaerobic Coverage Prescription.

BACKGROUND: Co-administration of two or more antimicrobials with anti-anaerobic activity is not recommended except in certain circumstances. We therefore conducted an intervention to reduce unnecessary double anaerobic coverage (DAC) prescription. MATERIALS AND METHODS: The intervention consisted of education using an institutional intranet and prospective audits and feedback provided through collaboration between a pharmacist and an infectious diseases physician in Seoul National University Bundang Hospital, a tertiary hospital in Seongnam, Republic of Korea, in 2013. The study period was 1 year which contained 6 months of pre-intervention period and 6 months of intervention period. To estimate the overall effect of the intervention, we compared the monthly number of patients receiving unnecessary DAC for more than 3 days and the proportion of patients receiving unnecessary DAC for more than 3 days among all patients receiving DAC. RESULTS: The average monthly number of patients receiving unnecessary DAC for more than 3 days after screening decreased by 73.9% in the intervention period from 26.8 to 7.0. Wilcoxon rank sum test revealed there was a significant statistical difference in the monthly number of patients receiving unnecessary DAC for more than 3 days (P = 0.005). The proportion of patients receiving unnecessary DAC for more than 3 days after screening among all patients identified as receiving necessary or unnecessary DAC also decreased by 67.8% in the intervention period from 42.3% to 13.6% (P < 0.001). CONCLUSION: The multidisciplinary antimicrobial stewardship program with combined methods reduced unnecessary DAC prescription successfully.

Terminal and internal olefin epoxidation with cobalt(II) as the catalyst: evidence for an active oxidant Co(II)-acylperoxo species.

A simple catalytic system that uses commercially available cobalt(II) perchlorate as the catalyst and 3-chloroperoxybenzoic acid as the oxidant was found to be very effective in the epoxidation of a variety of olefins with high product selectivity under mild experimental conditions. More challenging targets such as terminal aliphatic olefins were also efficiently and selectively oxidized to the corresponding epoxides. This catalytic system features a nearly nonradical-type and highly stereospecific epoxidation of aliphatic olefin, fast conversion, and high yields. Olefin epoxidation by this catalytic system is proposed to involve a new reactive Co(II)-OOC(O)R species, based on evidence from H(2)(18)O-exchange experiments, the use of peroxyphenylacetic acid as a mechanistic probe, reactivity and Hammett studies, EPR, and ESI-mass spectrometric investigation. However, the O-O bond of a Co(II)-acylperoxo intermediate (Co(II)-OOC(O)R) was found to be cleaved both heterolytically and homolytically if there is no substrate.

Amide-based nonheme cobalt(III) olefin epoxidation catalyst: partition of multiple active oxidants Co(V)=O, Co(IV)=O, and Co(III)-OO(O)CR.

A mononuclear nonheme cobalt(III) complex of a tetradentate ligand containing two deprotonated amide moieties, [Co(bpc)Cl(2)][Et(4)N] (1; H(2)bpc = 4,5-dichloro-1,2-bis(2-pyridine-2-carboxamido)benzene), was prepared and then characterized by elemental analysis, IR, UV/Vis, and EPR spectroscopy, and X-ray crystallography. This nonheme Co(III) complex catalyzes olefin epoxidation upon treatment with meta-chloroperbenzoic acid. It is proposed that complex 1 shows partitioning between the heterolytic and homolytic cleavage of an O-O bond to afford Co(V)=O (3) and Co(IV)=O (4) intermediates, proposed to be responsible for the stereospecific olefin epoxidation and radical-type oxidations, respectively. Moreover, under extreme conditions, in which the concentration of an active substrate is very high, the Co-OOC(O)R (2) species is a possible reactive species for epoxidation. Furthermore, partitioning between heterolysis and homolysis of the O-O bond of the intermediate 2 might be very sensitive to the nature of the solvent, and the O-O bond of the Co-OOC(O)R species might proceed predominantly by heterolytic cleavage, even in the presence of small amounts of protic solvent, to produce a discrete Co(V) O intermediate as the dominant reactive species. Evidence for these multiple active oxidants was derived from product analysis, the use of peroxyphenylacetic acid as the peracid, and EPR measurements. The results suggest that a less accessible Co(V)=O moiety can form in a system in which the supporting chelate ligand comprises a mixture of neutral and anionic nitrogen donors.

Robust and efficient amide-based nonheme manganese(III) hydrocarbon oxidation catalysts: substrate and solvent effects on involvement and partition of multiple active oxidants.

Two new mononuclear nonheme manganese(III) complexes of tetradentate ligands containing two deprotonated amide moieties, [Mn(bpc)Cl(H(2)O)] (1) and [Mn(Me(2)bpb)Cl(H(2)O)]⋅CH(3)OH (2), were prepared and characterized. Complex 2 has also been characterized by X-ray crystallography. Magnetic measurements revealed that the complexes are high spin (S = 5/2) Mn(III) species with typical magnetic moments of 4.76 and 4.95 µ(B), respectively. These nonheme Mn(III) complexes efficiently catalyzed olefin epoxidation and alcohol oxidation upon treatment with MCPBA under mild experimental conditions. Olefin epoxidation by these catalysts is proposed to involve the multiple active oxidants Mn(V)=O, Mn(IV)=O, and Mn(III)-OO(O)CR. Evidence for this approach was derived from reactivity and Hammett studies, KIE (k(H)/k(D)) values, H(2)(18)O-exchange experiments, and the use of peroxyphenylacetic acid as a mechanistic probe. In addition, it has been proposed that the participation of Mn(V)=O, Mn(IV)=O, and Mn(III)-OOR could be controlled by changing the substrate concentration, and that partitioning between heterolysis and homolysis of the O-O bond of a Mn-acylperoxo intermediate (Mn-OOC(O)R) might be significantly affected by the nature of solvent, and that the O-O bond of the Mn-OOC(O)R might proceed predominantly by heterolytic cleavage in protic solvent. Therefore, a discrete Mn(V)=O intermediate appeared to be the dominant reactive species in protic solvents. Furthermore, we have observed close similarities between these nonheme Mn(III) complex systems and Mn(saloph) catalysts previously reported, suggesting that this simultaneous operation of the three active oxidants might prevail in all the manganese-catalyzed olefin epoxidations, including Mn(salen), Mn(nonheme), and even Mn(porphyrin) complexes. This mechanism provides the greatest congruity with related oxidation reactions by using certain Mn complexes as catalysts.

Monomeric, trimeric, and tetrameric transition metal complexes (Mn, Fe, Co) containing N,N-bis(2-pyridylmethyl)-2-aminoethanol/-ate: preparation, crystal structure, molecular magnetism and oxidation catalysis.

The reaction of N,N-bis(2-pyridylmethyl)-2-aminoethanol (bpaeOH), NaSCN/NaN(3), and metal (M) ions [M = Mn(II), Fe(II/III), Co(II)] in MeOH, leads to the isolation of a series of monomeric, trimeric, and tetrameric metal complexes, namely [Mn(bpaeOH)(NCS)(2)] (1), [Mn(bpaeO)(N(3))(2)] (2), [Fe(bpaeOH)(NCS)(2)] (3), [Fe(4)(bpaeO)(2)(CH(3)O)(2)(N(3))(8)] (4), [Co(bpaeOH)(NCS)(2)] (5), and [Co(3)(bpaeO)(2)(NO(3))(N(3))(4)](NO(3)) (6). These compounds have been investigated by single crystal X-ray diffractometry and magnetochemistry. In complex 1 the Mn(II) is bonded to one bpaeOH and two thiocyanate ions, while in complex 2 it is coordinated to a deprotonated bpaeO(-) and two azide ions. The oxidation states of manganese ions are 2+ for 1 and 3+ for 2, respectively, indicating that the different oxidation states depend on the type of binding anions. The structures of monomeric iron(II) and cobalt(II) complexes 3 and 5 with two thiocyanate ions are isomorphous to that of 1. Compounds 1, 2, 3, and 5 exhibit high-spin states in the temperature range 5 to 300 K. 4 contains two different iron(III) ions in an asymmetric unit, one is coordinated to a deprotonated bpaeO(-), an azide ion, and a methoxy group, and the other is bonded to three azide ions and two oxygens from bpaeO(-) and a methoxy group. Two independent iron(III) ions in 4 form a tetranuclear complex by symmetry. 4 displays both ferromagnetic and antiferromagnetic couplings (J = 9.8 and -14.3 cm(-1)) between the iron(III) ions. 6 is a mixed-valence trinuclear cobalt complex, which is formulated as Co(III)(S = 0)-Co(II)(S = 3/2)-Co(III)(S = 0). The effective magnetic moment at room temperature corresponds to the high-spin cobalt(II) ion (∼4.27 µ(B)). Interestingly, 6 showed efficient catalytic activities toward various olefins and alcohols with modest to excellent yields, and it has been proposed that a high-valent Co(V)-oxo species might be responsible for oxygen atom transfer in the olefin epoxidation and alcohol oxidation reactions.

Tetra-µ-benzoato-bis-{[trans-1-(2-pyrid-yl)-2-(4-pyrid-yl)ethyl-ene]zinc(II)}.

The paddle-wheel-type centrosymmetric dinuclear title complex, [Zn(2)(C(7)H(5)O(2))(4)(C(12)H(10)N(2))(2)], contains four bridging benzoate groups and two terminal trans-1-(2-pyrid-yl)-2-(4-pyrid-yl)ethyl-ene (L) ligands. The inversion center is located between the two Zn(II) atoms. The octa-hedral coordination around the Zn(II) atom, with four O atoms in the equatorial plane, is completed by an N atom of the L mol-ecule [Zn-N = 2.0198 (15) Å] and by the second Zn(II) atom [Zn⋯Zn = 2.971 (8) Å]. The Zn(II) atom is 0.372 Šout of the plane of the four coordinating O atoms.

Bis(di-2-pyridylmethane-diol-κN,O,N')nickel(II) dinitrate.

The title compound, [Ni(C(11)H(10)N(2)O(2))(2)](NO(3))(2), consists of an Ni(II) atom coordinated by two tridentate chelating di-2-pyridylmethane-diol [(2-py)(2)C(OH)(2)] ligands. The Ni(II) atom is located on an inversion center. The geometry around the Ni(II) atom is distorted octa-hedral. The gem-diol (2-py)(2)C(OH)(2) ligand adopts the coordination mode η(1):η(1):η(1). The Ni-N and Ni-O bond lengths are typical for high-spin Ni(II) in an octa-hedral environment [Ni-N = 2.094 (2) and 2.124 (3) Å, and Ni-O = 2.108 (3) Å]. One of the hydr-oxy H atoms is split over two positions which both inter-act with the nitrate anion. The occurence of different O-H⋯O hydrogen bonds leads to the formation of a layer parallel to the (101) plane.