Clozapine-Induced Severe Toxicity: Exploring the Pharmacokinetic Profile of Clozapine and Its Significance in Hemodynamic Instability - A Case Report.

Hemodynamic instability in patients with clozapine intoxication can indirectly reflect the serum concentration of clozapine.We have described a case of a 32-year-old pregnant woman who developed life-threatening clozapine toxicity at 28 weeks of gestation. The levels of clozapine and norclozapine in the serum were high. We initiated hemoperfusion(HP) and other detoxification therapies to remove the drug. The patient had severely dilated peripheral blood vessels, which led to cardiac symptoms such as fatal hypotension and uncontrollable tachycardia, resulting in very high cardiac output and elevated Central venous oxygen saturation (ScvO2). Pharmacological intervention significantly improved the hemodynamics.In light of our observations in the ongoing case, we posit that evaluating hemodynamic parameters before and after blood detoxification could serve as a valuable means to gauge effectiveness and provide guidance for treatment.

[The effect of blood glucose fluctuations on prognosis of critically ill patients in intensive care unit].

OBJECTIVE: To determine the association between glucose fluctuations and hospital mortality in intensive care unit (ICU) patients. METHODS: A retrospective study involving 90 critically ill patients in ICU according to the patients' outcome were divided into survivors (49 cases) and nonsurvivors (41 cases), in whom the blood glucose level was monitored in the first 72 hours, and the initial blood glucose (GluAdm), the average blood glucose (GluAve), glucose standard deviation (GluSD), coefficient of variation glucose (GluCV) were determined, then GluAdm, GluAve, GluSD, and GluCV were compared between survivors and nonsurvivors, and the receiver operating characteristic curve (ROC curve) was applied to evaluate the association between blood glucose fluctuation and prognosis. According to the values of GluSD, GluCV, the critically patients were divided into four subgroups, and mortality in ICU and hospital was compared. RESULTS: The levels of GluAdm, GluAve, GluSD, GluCV of nonsurvivors were higher than those of survivors [GluAdm: (11.47+/-3.91) mmol/L vs. (9.23+/-2.96) mmol/L, GluAve: (9.22+/-1.31) mmol/L vs. (8.28+/-1.15) mmol/L, GluSD: (2.62+/-0.97) mmol/L vs. (1.66+/-0.64) mmol/L, GluCV: 0.28+/-0.10 vs. 0.20+/-0.07, all P<0.05]. When ROC was applied, the area under the curve (AUC) of GluSD, GluCV were 0.782+/-0.049 and 0.757+/-0.053, they were higher than that of the GluAdm and GluAve (0.669+/-0.058 and 0.690+/-0.056, both P<0.05). When GluSD was 4.35-5.66 mmol/L, the ICU mortality was 95.7%, hospital mortality was 98.6%; when GluCV was 0.378-0.500, the ICU mortality was 83.3%, hospital mortality was 100.0%. CONCLUSION: The increase in GluSD and GluCV in critically ill patients is significantly correlated with ICU mortality and hospital mortality, and they are more valuable in predicting ICU mortality than GluAdm, GluAve. Diminution in fluctuation of blood glucose might be an important aspect of glucose management.

Association between HLA-DR Expression and Multidrug-resistant Infection in Patients with Severe Acute Pancreatitis.

Multidrug-resistant (MDR) bacterial infection is a common complication of severe acute pancreatitis (SAP). This study aimed to explore the association between human leukocyte antigen-antigen D-related (HLA-DR) expression and multidrug-resistant infection in patients with SAP. A total of 24 SAP patients who were admitted to Nanjing Drum Tower Hospital between May 2015 and December 2016 were enrolled in the study. The percentages of CD4+, CD8+, natural killer (NK), and HLA-DR (CD14+) cells and the CD4+/CD8+ cell ratio on days 1,7,14, and 28 after admission were determined by flow cytometry. Eighteen patients presented with the symptoms of infection. Among them, 55.6% patients (10/18) developed MDR infection. The most common causative MDR organisms were Enterobacter cloacae and Acinetobacter baumannii. The CD4+/CD8+ cell ratio and the percentage of NK cells were similar between patients with non-MDR and patients with MDR infections. In patients without infection, the HLA-DR percentage was maintained at a high level throughout the 28 days. Compared to the patients without any infection, the HLA-DR percentage in patients with non-MDR infection was reduced on day 1 but increased and reached similar levels on day 28. In patients with MDR infection, the HLA-DR percentage remained below normal levels at all-time points. It was concluded that persistent down-regulation of HLA-DR expression is associated with MDR bacterial infection in patients with SAP.