Intravenous gammaglobulin was compared with the standard British intramuscular preparation in patients with hypogammaglobulinaemia and chronic bronchitis. Five patients were given six months' treatment with the weekly intramuscular preparation and six months' treatment with intravenous gammaglobulin given once every 18 days. During the trial they recorded symptoms of infection, absence from work, and sputum volume; lung function tests were performed during the intravenous treatment. The half life of the intravenous IgG and changes in serum IgG and C1q concentrations were also measured in seven other patients who received intravenous gammaglobulin every two weeks for 12 weeks. IgG concentrations, sputum volume, and infection scores were significantly better during intravenous treatment and there were no adverse effects from the intravenous gammaglobulin. These five patients were significantly more healthy when they received an intravenous gammaglobulin preparation, probably because the intravenous preparation increased serum IgG concentrations. Although longer studies are needed, intravenous gammaglobulin should be considered for patients with severe chest disease and those who cannot tolerate intramuscular injections.
Intravenous medication administrations have a high incidence of error but there is limited evidence of associated factors or error severity.
To measure the frequency, type and severity of intravenous administration errors in hospitals and the associations between errors, procedural failures and nurse experience.
Prospective observational study of 107 nurses preparing and administering 568 intravenous medications on six wards across two teaching hospitals. Procedural failures (eg, checking patient identification) and clinical intravenous errors (eg, wrong intravenous administration rate) were identified and categorised by severity.
Of 568 intravenous administrations, 69.7% (n=396; 95% CI 65.9 to 73.5) had at least one clinical error and 25.5% (95% CI 21.2 to 29.8) of these were serious. Four error types (wrong intravenous rate, mixture, volume, and drug incompatibility) accounted for 91.7% of errors. Wrong rate was the most frequent and accounted for 95 of 101 serious errors. Error rates and severity decreased with clinical experience. Each year of experience, up to 6 years, reduced the risk of error by 10.9% and serious error by 18.5%. Administration by bolus was associated with a 312% increased risk of error. Patient identification was only checked in 47.9% of administrations but was associated with a 56% reduction in intravenous error risk.
Intravenous administrations have a higher risk and severity of error than other medication administrations. A significant proportion of errors suggest skill and knowledge deficiencies, with errors and severity reducing as clinical experience increases. A proportion of errors are also associated with routine violations which are likely to be learnt workplace behaviours. Both areas suggest specific targets for intervention.
Medication errors; intravenous medications; nurses; patient safety; information technology; quality of care; healthcare quality; health services research; medication safety
Status epilepticus (SE) is a serious neurological condition and requires prompt treatment. Sodium valproate has been used to treat SE successfully but its role as the first-line antiepileptic drug (AED) is still controversial. This study evaluated the efficacy of intravenous sodium valproate to determine if it is non-inferior to intravenous phenytoin in SE treatment.
Patients diagnosed as SE during 2003–2010 who were of an age of more than 15 years and received either intravenous sodium valproate or intravenous phenytoin as the first-line treatment were enrolled. Clinical characteristics and outcomes of SE were recorded and analyzed. The differences of outcomes between sodium valproate and phenytoin group were determined by descriptive statistics.
During the study period, there were 37 and 17 SE patients who received intravenous phenytoin and intravenous sodium valproate as the first-line treatment, respectively. All patients received diazepam 10 mg intravenously as a rescue medication before starting the antiepileptic agents if uncontrolled except one patient in the sodium valproate group. There were no significant differences between the phenytoin and sodium valproate groups in all outcome variables including numbers of patients with clinically-controlled seizures, non-dependent patients, time to seizure control, and duration of hospitalization, and death. No serious cardiovasculars event such as hypotension occurred in either group.
Intravenous sodium valproate is non-inferior to intravenous phenytoin as the first-line treatment in SE with no significant cardiovascular compromises.
Phenytoin; Sodium valproate; Efficacy; Status epilepticus; Comparison
The pharmacokinetics of once-daily oral levofloxacin (study A) or intravenous levofloxacin (study B) in 40 healthy male volunteers were investigated in two separate randomized, double-blind, parallel-design, placebo-controlled studies. Levofloxacin at 500 mg or placebo was administered orally or intravenously as a single dose on day 1; daily oral or intravenous dosing resumed on days 4 to 10. In a third study (study C), the comparability of the bioavailabilities of two oral and one intravenous levofloxacin formulations were investigated with 24 healthy male subjects in an open-label, randomized, three-way crossover study. Levofloxacin at 500 mg as a single tablet or an intravenous infusion was administered on day 1; following a 1-week washout period, subjects received the second regimen (i.e., the other oral formulation or the intravenous infusion); the third and final regimen was administered following a 1-week washout period. The concentrations of drug in plasma and urine were measured by validated high-pressure liquid chromatography methods. Pharmacokinetic parameters were estimated by noncompartmental methods. In both study A (oral levofloxacin) and study B (intravenous levofloxacin), steady state was attained within 48 h after the start of the multiple dosing on day 4. Levofloxacin pharmacokinetics were linear and predictable for the single and multiple 500-mg, once-daily oral and intravenous dosing regimens, and the values of the pharmacokinetic parameters for the oral and intravenous administrations were similar. Study C indicated that levofloxacin was rapidly and completely absorbed from the oral tablets, with mean times to the maximum concentration of drug in serum of approximately 1.5 h and mean absolute bioavailability of > or =99%. These results support the interchangeability of the oral and intravenous routes of levofloxacin administration.
Audits of medication and intravenous fluid orders and of return to the pharmacy of unused intravenous solutions were conducted in 1980 at a university teaching hospital in response to a prevailing impression among pharmacists that physicians' orders were often written in an incomplete, nonstandardized fashion and that intravenous fluid wastage was common. A disturbing number of order were incomplete and judged to be ambiguous. Less than 25% of orders for intravenously given solutions contained adequate instructions for subsequent administration of fluids. Intravenous fluid return amounted to an estimated loss of $137,695 per year in wasted material and labor.
The results of the audits were disseminated among the staff. In addition, the pharmacy changed its operations to detect more quickly and correct the problems caused by ambiguous orders. Later studies showed a reduction in the return of unused intravenous fluids and some improvement in order writing. Inadequate and ambiguous orders were still judged to be a problem, however, especially intravenous fluid orders that omitted instructions for subsequent fluid requirements and “open-ended” intravenous fluid orders. Such orders were eight times more likely to be associated with return of unused intravenous fluids than orders with adequate instructions for giving fluids subsequently.
Serum human growth hormone (HGH), serum immunoreactive insulin (IRI), plasma free fatty acids, and blood glucose were measured during intravenous glucose and intravenous tolbutamide tolerance tests in 13 normal and 13 prediabetic (offspring of two diabetic parents) males, closely matched for weight and age. Only prediabetics with normal glucose tolerance during oral, intravenous, and cortisone-primed glucose tolerance tests were evaluated.
Mean serum HGH levels were significantly higher in prediabetics in response to intravenous tolbutamide and at the end of the 3-hr intravenous glucose tolerance tests (IVGTT). This is interpreted as a hyperresponsiveness of the growth hormone-releasing mechanisms in prediabetic subjects.
The insulin response during the first 10 min of an IVGTT was significantly reduced in prediabetic males as compared to normal controls, whereas the insulin response to intravenous tolbutamide was not significantly different at the same time intervals in the same subjects.
It appears, therefore, that measuring IRI during an IVGTT can be valuable in detecting the earliest signs of diabetes even before any disturbance of blood glucose homeostasis is seen.
The possibility that growth hormone hypersecretion in prediabetics might play a role in the pathogenesis of human diabetes mellitus is discussed.
The authors examined charts for evidence of the use of intravenous fluids in all patients who died from malignant disease occurring in a tertiary care teaching hospital during a one-year period. Of 106 patients who were identified, 86 received intravenous fluids within their last 30 days of life, and 73 died with an intravenous line running.
Intravenous fluid use appeared to be independent of age, sex, language, presence of family members, primary tumour site, presence of metastases, duration of illness, and presence of a “no cardiopulmonary resuscitation” order. Total lengths of stay and survival time after obtaining “do not resuscitate” orders were longer in those who died without intravenous fluids. More than two-thirds of patients with cancer who died in hospital did so with an intravenous line.
“do not resuscitate” orders; family medicine; intravenous fluid administration; oncology; palliative care
Acute ischemic stroke is a major cause of morbidity and mortality in Europe, North America, and Asia. Its treatment has completely changed over the past decade with different interventional approaches, such as intravenous trials, intra-arterial trials, combined intravenous/intra-arterial trials, and newer devices to mechanically remove the clot from intracranial arteries. Intravenous thrombolysis with tissue plaminogen activator (tPA) within 4.5 hours of symptoms onset significantly improved clinical outcomes in patients with acute ischemic stroke. Pharmacological intra-arterial thrombolysis has been shown effective until 6 hours after middle cerebral artery occlusion and offers a higher rate of recanalization compared with intravenous thrombolysis, whereas combined intravenous/ intra-arterial thrombolysis seems to be as safe as isolated intravenous thrombolysis. The more recent advances in reperfusion therapies have been done in mechanical embolus disruption or removal. Merci Retriever and Penumbra System have been approved for clot removal in brain arteries, but not as a therapeutic modality for acute ischemic stroke since it is no clear whether mechanical thrombectomy improves clinical outcome in acute stroke. However, mechanical devices are being used in clinical practice for patients who are ineligible for tPA or who have failed to respond to intravenous tPA. We summarize the results of the major thrombolytic trials and the latest neurointerventional approaches to ischemic stroke.
Thrombolysis; intra-arterial thrombolysis; mechanical thrombectomy; cardioembolic stroke; stroke subtype.
Pediatric peripheral venipuncture and intravenous cannulation are difficult. However, successful venipuncture and intravenous cannulation are absolutely required for pediatric clinical risk management. This study assessed the success rate of venipuncture and intravenous cannulation when transmitted light was applied to the pediatric dorsum manus. The subjects included 100 young children who were scheduled for dental treatment or oral surgery under general anesthesia. Anesthesia was induced, and insertion of an intravenous catheter into the dorsum manus was attempted with or without using transmitted light. The patients were evaluated to determine whether the venipuncture was successful, and whether the intravenous cannulation of the external catheter was successful. The success rate of venipuncture was 100% when transmitted light was used, and 83% when the transmitted light was not used (P = 0.000016). In addition, the success rate of intravenous cannulation was 88% when transmitted light was used, and 55% when the transmitted light was not used (P = 0.0000002). The shape of the vein in the dorsum manus can be clearly recognized when transmitted light is used. The use of light significantly increased the success rate of intravenous cannulation, because it allowed direct confirmation of the direction to push the intravenous catheter forward. The use of transmitted light allows for more successful venipuncture and intravenous cannulation in young children.
transmitted light; pediatric peripheral venipuncture; pediatric peripheral intravenous cannulation
Dental fear may be the most common reason for referral for intravenous sedation. Intravenous sedation offers many patients an opportunity to obtain needed dental care. However, intravenous sedation also has costs and may not help patients overcome their fear. Given a sample of 518 dentally-fearful patients in the USA presenting for dental care, this study examined the variables which predicted receiving intravenous sedation or not. About one-fifth of the patients received intravenous sedation, while the others received only cognitive behavioural therapy. Having more carious teeth, higher dental fear, more negative beliefs about dentists, lifetime diagnoses of panic disorder and/or generalized anxiety disorder, fewer existing coping skills, and a lower desire to cope with the dental situation were each predictive of having intravenous sedation. When the variables were considered simultaneously, only lower desire to cope contributed uniquely to the prediction. In a setting where psychological treatment for dental fear is available, patients’ desire to cope with their fear was the most important factor in determining whether they received intravenous sedation or not.
Our group is attempting to construct an artificial pancreas based on intravenous glucose monitoring and intravenous insulin delivery. To do so, the pharmacology of intravenous insulin administration must be studied. We used a pig model to determine the inherent lag time in the insulin/blood glucose system. The goal was to suggest a method that reduces the blood glucose level in a rapid and yet predictable manner.
Six pigs received continuous intravenous insulin infusions at 0.04, 0.08, or 0.4 IU/kg/h for 60 min. Two pigs received short-term intravenous infusions at 0.4 IU/kg/h for 2 min, repeated five times at 60-min intervals. Four animals received five intravenous insulin bolus injections at 60-min intervals, two at 0.01 IU/kg and two 0.02 IU/kg, with a final dose of 0.04 IU/kg. The blood glucose level was measured every 1–5 min.
A high rate of intravenous insulin infusion led to rapid declines in blood glucose levels. The same rapid decline was achieved when the infusion was halted after 2 min. Using the latter method and with intravenous insulin boluses, blood glucose levels started to rise again after approximately 15–20 min. Insulin boluses led to a first detectable decrease in blood glucose level after 2–6 min and to a maximum rate of decrease shortly thereafter.
We found that intravenous bolus injections of insulin lowered blood glucose levels rapidly and predictably. Repetitive small intravenous insulin boluses together with an accurate and fast-responding intravascular continuous glucose monitor should be studied as a method of closed-loop glycemic control.
Preliminary data are given on the LD50 of PdCl2 following different routes of exposure and on the LD50 of PtCl4 following intravenous exposure. The retention, tissue distribution, and excretion of 103Pd and 191Pt in rats was determined following oral, intravenous, intratracheal, and inhalation exposure. The highest retention for both 103Pd and 191Pt was obtained following intravenous dosing, and the lowest retention occurred after oral dosing. Following a single oral dose, almost all of the 103Pd and 191Pt was excreted in the feces due to nonabsorption, whereas after intravenous dosing, similar quantities were excreted in both the urine and feces. Tissues containing the highest concentrations of these metals were the kidney, spleen and liver. Following intravenous dosing of pregnant rats, a small amount of 103Pd and 191Pt was found in the fetuses.
To compare the efficacy of intravenous methylprednisolone and intravenous dexamethasone on visual recovery and evaluate their side-effects for the treatment of optic neuritis.
Materials and Methods:
Prospective, randomized case-controlled study including 21 patients of acute optic neuritis presenting within eight days of onset and with visual acuity less then 20/60 in the affected eye who were randomly divided into two groups. Group I received intravenous dexamethasone 200 mg once daily for three days and Group II received intravenous methylprednisolone 250 mg/six-hourly for three days followed by oral prednisolone for 11 days. Parameters tested were pupillary reactions, visual acuity, fundus findings, color vision, contrast sensitivity, Goldmann visual fields and biochemical investigations for all patients at presentation and follow-up.
Both groups were age and sex-matched. LOGMAR visual acuity at presentation was 1.10 ± 0.52 in Group I and 1.52 ± 0.43 in Group II. On day 90 of steroid therapy, visual acuity improved to 0.28 ± 0.33 in Group I and 0.36 ± 0.41 in Group II ( P =0.59). At three months there was no statistically significant difference in the color vision, contrast sensitivity, stereoacuity, Goldman fields and the amplitude and latency of visually evoked response between the two groups. The concentration of vitamin C, glucose, sodium, potassium, urea and creatinine were within the reported normal limits.
Intravenous dexamethasone is an effective treatment for optic neuritis. However, larger studies are required to establish it as a safe, inexpensive and effective modality for the treatment of optic neuritis.
Dexamethasone; methylprednisolone; optic neuritis.
Intravenous cannulation is a very common procedure. Venous aneurysm secondary to peripheral intravenous cannulation is extremely rare. Moreover, venous aneurysm can mimic other conditions and may confuse the issue.
We describe a case of a 45-year-old woman who was referred with the diagnosis of varicose vein of right arm. A history of intravenous cannulation at the same site was noted that raised suspicion. The swelling was compressible and turned out to be a venous aneurysm. The lesion was completely excised. Postoperative recovery was uneventful. Histology findings were in conformity with the preoperative diagnosis.
Caution should be exercised in diagnosing varicose vein at a site that bears a history of intravenous cannulation. The case also raises an important issue regarding consent. Should patients undergoing peripheral intravenous cannulation be warned of this rare complication?
The efficacy of intravenous itraconazole solubilized in hydroxypropyl-beta-cyclodextrin was assessed in a rat model of Aspergillus fumigatus pneumonia. Immunosuppressed rats were infected by intratracheal inoculation of A. fumigatus conidia. Intravenous administration of various doses of itraconazole was started immediately after infection and continued once a day for 7 days. A 10-mg dose of intravenous itraconazole per kg was as effective on survival as 1 mg of amphotericin B per kg daily (a survival rate of 100% in 28 days), while treatment with 1 mg/kg did not increase the survival rate. The 50% lethal dose of intravenous itraconazole given to immunosuppressed and uninfected rats for 7 days was 24.5 mg/kg/day. A microbiological assay to estimate accumulation in tissue after five daily intravenous administrations of itraconazole at 10 mg/kg showed that itraconazole and its active metabolites were present in the lungs for at least 6 h, reaching the MIC as previously described (B. Dupont and E. Drouchet, Rev. Infect. Dis. 9(Suppl. 1):71-76, 1987; A. Espinel-Ingroff, S. Shadomy, and R. J. Gebhart, Antimicrob. Agents Chemother. 26:5-9, 1984). Intravenous itraconazole was considered to be worth evaluating in clinical trials of aspergillosis.
There have been no studies on the susceptibility and host immune responses to an intranasal infection with Listeria monocytogenes. In this study, we compared the susceptibilities and cytokine responses between intranasal and intravenous infections with L. monocytogenes in mice. Moreover, we compared efficiency of acquisition of host resistance to L. monocytogenes infection between intranasally and intravenously immunized mice because an intranasal immunization of vaccines is reportedly available for induction of adaptive immunity against various infectious pathogens. The susceptibility to an intranasal infection with L. monocytogenes was markedly lower than that to the intravenous infection. The bacterial growth in the lungs, spleens, and livers was substantially similar between intranasally and intravenously infected mice. Titers of endogenous gamma interferon (IFN-γ) and tumor necrosis factor-α (TNF-α) in the spleens, livers, and lungs were parallel to bacterial numbers in each organ of mice during intranasal infection and intravenous infection. IFN-γ-deficient mice and TNF-α-deficient mice were highly susceptible to intranasal infection as well as intravenous infection. Susceptibilities to intranasal and intravenous L. monocytogenes infection were the same in these cytokine-deficient mice. These results suggest that both IFN-γ and TNF-α play critical roles in host resistance to intranasal L. monocytogenes infection as well as the intravenous infection. Acquisition of host resistance to intravenous and intranasal L. monocytogenes infection was induced in intranasally immunized mice as well as intravenously immunized mice, suggesting that intranasal immunization is effective for prevention of a systemic infection with L. monocytogenes.
The sodium salt of 7-cyanacetamidocephalosporanic acid (CAA) had a relatively short serum half-life in rabbits (21 min by intravenous and 30 min by intramuscular administration) and in humans (33 min by intravenous injection). The drug was not extensively bound (about 35%) to serum in either species. Even after large doses (500 mg/kg), CAA was not well absorbed from the gastrointestinal tract of rabbits. Urinary excretion of antibacterial activity was rapid after intravenous and intramuscular administration in rabbits and after intravenous administration in men. Expressed as unchanged CAA, antibacterial activity appeared in the urine to the extent of 84% for humans, 35% for rabbits and 32% for rats. Excretion proceeded partly by active renal tubular secretion in rabbits. In this latter species, low concentrations of the active drug were detected in cerebrospinal fluid and bile after an intravenous dose of 25 mg/kg. CAA was well tolerated after intravenous administration of a single dose in both rabbits and humans.
Labetalol 1-5 mg/kg administered intravenously to normal subjects in the supine position produced an immediate mean fall in systolic (16%) and diastolic (25%) blood pressure with a concomitant increase in heart rate (12%). After graded exercise, intravenous labetalol inhibited increases in heart rate and blood pressure. Isoprenaline log dose response curves of increase in heart rate and reduction in diastolic pressure after intravenous labetalol shifted to the right in a parallel manner compared with pre-labetalol response curves suggestive of competitive antagonism at beta-adrenoceptor sites. Similarly, phenylephrine dose response curves of increase in systolic pressure before and after intravenous labetalol were suggestive of competitive antagonism at alpha-adrenoceptor sites. The ratio of relative potency alpha: beta adrenoceptor antagonism after intravenous labetalol was approximately 1:7, whereas in the same subjects after oral labetalol the ratio was approximately 1:3 as previously reported. Using the inhibition of isoprenaline tachycardia to estimate the potency of the beta-adrenoceptor antagonism of labetalol relative to that of propranolol the potency ratio was 1:6. However, using inhibition of Valsalva tachycardia as the index, the estimated ratio was approximately 1:3. Estimates of relative potency using inhibition of tilt tachycardia were complicated by the additional effects upon blood pressure after labetalol not seen after propranolol. Labetalol produced adrenoceptor blockade at both alpha and beta sites in man sufficient to explain its therapeutic antihypertensive effect.
The efficacy of sotalol in treating acute atrial fibrillation and flutter after open heart surgery was compared with that of a digoxin/disopyramide combination. Forty adult patients with postoperative atrial arrhythmias were randomised into either group 1 (sotalol 1 mg/kg bolus intravenously plus 0.2 mg/kg intravenously over 12 hours) or group 2 (digoxin 0.75 mg intravenously, then two hours later disopyramide 2 mg/kg intravenous bolus and 0.4 mg/kg/h intravenously for 10 hours). In each group, 17 out of 20 patients reverted to sinus or junctional rhythm within 12 hours. The time to reversion in group 1 was significantly shorter than in group 2. Systolic blood pressure fell by greater than or equal to 20 mm Hg or to less than or equal to 90 mm Hg during drug administration in 17 out of 20 patients in group 1 (sotalol withdrawn in two) and in none out of 20 in group 2. Two patients in group 1 developed transient bradycardia (sotalol withdrawn in one). None of 17 patients in group 1 and two of 17 in group 2 relapsed temporarily into atrial fibrillation during the 12 hours of intravenous treatment. On continued oral treatment, one late relapse occurred in group 1 and five in group 2, and five patients in group 2 had disopyramide withdrawn because of anticholinergic side effects (acute urinary retention in four). Sotalol was as effective as the digoxin/disopyramide combination and acted significantly faster. Sensitivity to beta blockade in these patients may be related to high plasma catecholamine concentrations known to occur after cardiopulmonary bypass.
A postal questionnaire inquiring about routine sedation and premedication practice for upper gastrointestinal endoscopy was sent to 1048 doctors. Of 665 appropriate returns, 81% were from consultant physicians and surgeons. Most endoscopists (90%) reported using an intravenous benzodiazepine for at least three quarters of endoscopies and 54% of physicians and 69% of surgeons always did so. Midazolam was the intravenous sedative used by a third of all respondents and 13% also used an additional intravenous agent, usually pethidine. Over the previous two years a total of 119 respiratory arrests, 37 cardiac arrests, and 52 deaths were identified. Adverse outcomes were reported more frequently by consultant physicians, by those who 'titrated' the intravenous sedative, and by those who used an additional intravenous agent, but were reported equally frequently by endoscopists using midazolam and endoscopists using diazepam. There is an urgent need for a prospective study to identify the circumstances and risk factors associated with adverse outcomes related to endoscopy.
OBJECTIVE--to assess whether male prostitution is an independent risk factor for HIV infection among male (intravenous and nonintravenous) drug users. DESIGN--a cross-sectional study. SETTING--various low-threshold methadone clinics and the sexually transmitted diseases clinic of the Municipal Health Service in Amsterdam and a drug-treatment centre in The Hague. PARTICIPANTS--343 male intravenous drug users and 106 male non-intravenous drug users. MAIN OUTCOME MEASURES--characteristics concerning drug use behaviour, sexual behaviour, and sociodemography, related to prostitution and HIV-antibodies. RESULTS--of the 449 study participants, 88 (20%) reported a history of prostitution; no differences were found between intravenous and non-intravenous drug users. Younger age, West German nationality, and having had private homosexual sex contacts, were independent predictors of a history of prostitution. Independent predictors of HIV infection were (1) longer residency in Amsterdam; (2) having had predominantly homosexual private sex contacts; (3) longer duration of intravenous drug use; and (4) frequent needle sharing. CONCLUSION--no evidence was found to suggest that male prostitution in itself contributed to the risk of HIV infection.
The NHS Executive is keen to promote "hospital at home" services in Britain, as part of its philosophy of keeping more care in the community and also to relieve the increasing demand for hospital beds. One such service is the provision of intravenous antimicrobial therapy in the community. Yet, compared with the United States, where home or outpatient intravenous antimicrobial therapy programmes are well developed, experience in Britain and Europe is limited, reflecting a difference in cultural attitudes and healthcare structures between the two continents. Only a few units in Britain currently run home intravenous antimicrobial therapy programmes, and several issues need to be addressed if more treatment is to be provided outside hospital. These include an assessment of the need for community intravenous antibiotic treatment and which patient groups many benefit. The main motive for community intravenous treatment should be better patient care and not simply a reduction in healthcare costs. At present the pace of change is being set by a few clinical enthusiasts and by commercial organisations, whereas the NHS deserves a more organised strategy for purchasing treatment with intravenous antibiotics in the community.
The efficacy and toxicity of ganciclovir given by intravenous or intravenous plus intravitreal injection were studied in nine patients with cytomegalovirus (CMV) retinitis; seven with AIDS and two with drug induced immunodeficiency. Five patients had retinitis with macular involvement in six sighted eyes; six patients had only peripheral retinitis in seven eyes. In two patients (two eyes) with macular involvement intravenous plus intravitreal injection of ganciclovir preserved sight; intravenous infusion alone did not in four eyes of three other patients. In seven eyes (six patients) with peripheral retinitis vision was retained regardless of the route of ganciclovir treatment. Following intravenous ganciclovir drug levels in the vitreous fluid were 1.4-2.2 mmol/l, that is, 44 and 65% of the concomitant serum concentration. Clinically and at necropsy three eyes showed no evidence of toxicity from intravitreal injection of ganciclovir. All of five patients with AIDS who received intravenous ganciclovir for more than one week developed leucopenia. CMV retinitis of the macula may be benefited with minimal drug toxicity by intravitreal injection of ganciclovir. Treatment of peripheral CMV retinitis in patients with AIDS may be optional.
This article details a double-blind, randomized, placebo-controlled pilot study evaluating the analgesic efficacy and clinical acceptability of intravenous tramadol in patients undergoing surgical removal of an impacted third molar tooth under local anesthesia and intravenous sedation with propofol. Forty-five ASA status 1 dental outpatients were randomly allocated to 2 groups of 22 (group A) and 23 (group B) patients each (n = 45). Group A (T/P) received intravenous tramadol 1.5 mg/kg injected over 2 minutes, followed by a bolus dose of intravenous propofol 0.4 mg/ kg. Maintenance consisted of a continuous infusion of propofol 3 mg/kg/h, with an additional bolus dose of 0.4 mg/kg intravenously 2-3 minutes prior to the infiltration of the local anesthetic solution. Group B (P/P) patients received no tramadol but instead a saline placebo solution and an identical amount of propofol. Overall, in this study, postoperative pain was much better controlled in the group receiving tramadol 1.5 mg/kg intravenously despite there being no significant difference in the dose of propofol administered in both groups. Intravenous tramadol, when given with propofol, did not affect the cardiovascular, respiratory, and sedative effects of propofol. Following tramadol, despite being an opioid, no nausea and vomiting were reported in the early postoperative period, indicating the value of using tramadol with propofol. Thus, this pilot study demonstrated the potential use of intravenous tramadol with propofol in day-case dento-alveolar surgery.