Public health, Poison center, Environmental. Lynn Gardner 1 , Robert J. Geller 1 , Anil T. The use of other less inv asive. Children due to have. Blood was obtained by. Data analysis used Pearson correlations, scatter plots. The mean absolute difference between the. Internal controls suggested no variations,. The convenience of lead screening by measurement of.
The vasoactive properties of the novel. T akahiro Yamamoto 1 , David M. Wood 1 , Paul I. Methoxetamine is an arylcyclohexylamine deriv ative. The aim of this study was to inv estigate the vasoactive. Two pulmonary arteries of male W istar rats were pre-. Krebs buffer solution at pH 7. Following washout, a prostaglandin. PGH2 analogue U or norepinephrine were added to induce. Contractions of the two arteries were achieved with 10 nanoM.
Methoxetamine at concentrations of 0. This study suggests that methoxetamine possesses. Further experiments using this and other. Bath salt, Substance abuse, Drug of abuse. Leucovorin pharmacokinetics in patients. Glucarpidase is a recombinant form of carboxy-. It is administered with IV. Open-label, multicenter PK study in pts treated with. Arm A or without glucarpidase Arm B.
Plasma samples for LV. The median pre-glucarpidase methotrexate MTX plasma con-. Similarly, median L V doses were Glucarpidase does not reduce exposure to 6S-LV. Renal toxicity , Antineoplastic, Antidote. There is currently no standardized method for ascer-. The objecti ve of this study is. Patients were recruited from an urgent care clinic at a. Patients were asked to verbally.
Among patients with non-reported drugs, 11 V ariable V alue. Gender Female 17 Age years Mean SD Ethnicity Hispanic 12 There was no dif fer-. Even when utilizing a comprehensiv e systematic. As the medication history. Reasons for failure to. While concealment is expected for. This may have sig-. Urine drug screen, Medication history, Emergency. External validation of the prognostic utility of. Manini 1 , Robert S. Hoffman 3 , David Vlahov 2.
US is currently experiencing its worst drug overdose epidemic. While diverse metabolic mechanisms may lead to. W e previously demonstrated an association. In this study we externally validate the prognostic. This was an observational, prospecti ve, cohort study. The study outcome was inpatient fatality.
The ROC area under the curve c statistic for pre-. In this large external v alidation study, the initial. Clinicians should consider using. Ammonia concentrations peak later than valproic. Rushton , Priyanka V akkalanka , Lewis S. V alproic acid VPA has been widely reported to. The objective of this study is to determine the time course in. A single poison center database serving approximately. Cases were restricted to toxicological consults requested from a.
All cases that had at least. Forty-one cases met the search criteria and six cases met. All six cases demonstrated delayed maximum. NH3 levels following peak VP A levels. The included cases were. On average the NH3 level peak ed 8. VP A level could not predict the maximum ammonia level; there. Our results demonstrate that peak NH3 levels lag. It is the metabo-. Carnitine depletion prevents oxidation of fatty acids into acetyl-co-. Consequently , in overdose, as VP A transitions.
In a small retrospective descriptive study , NH3. In patients with per-. Anticonvulsant, Neurotoxicity , Ingestion. Evaluation of Log P value as a predictor of seizures. Rumiko Kondo 2 , Kazui Soma 3. Center , Kitasato University, Kanagawa J apan;. Medicine, Kitasato University, Kana gawa Japan. The logarithm of the 1-octanol-water partition. Structure-Activity Relationship models for predicting the phar-.
Because most drugs cross the. The objective of this. We conducted a revie w of the causes of seizures. The Log P values for drugs highly. In this survey , we collected the Log P values of Seventy of these 88 causes. The leading causes of seizures such as. W e also calculated the BBB permeability rates that. It was shown that the shift. When Log P of the causative agent of the poisoning.
T oxicokinetics and toxicodynamics of massive. Hofer 1 , Hugo Kupferschmidt 1 , Alessandro Ceschi 1 ,. Rivaroxaban RXA is a novel oral selective. There is little information on patterns. At admission he was fully conscious, temperature Without further treatment, v alues 23 h post. This massive RXA overdose led to very high. RXA plasma concentrations, which have never been reported. Inhibition of FX activity showed the. Although there seems to be.
Rivaroxaban, Factor Xa inhibitor , Prothrombin. Analysis of the response to treatment with. The cyclic antidepressants are a group of drugs widely distributed. Nowadays the sodium bicarbonate SB rep-. QRS and the heart rate HR on a model of rat with amitriptyline. In this work a total of 42 wistar rats were included to integrate. Control group; Group 2: Amitriptyline poisoning treated with. SB and Group 4: Amitriptyline poisoning treated with HBO.
With respect to QRS at minutes we observed a mean of Finally, at minutes we get a mean QRS on Based on the previous we conclude that amitriptyline poison-. Present study suggests that the HBO therapy can be used safely. Hyperbaric oxygen therapy, Amitriptyline poisoning,. Antidepressant, Cardiac toxicity, Electrocardiogram.
The magic absorbing bead risk of. Darracq 1 , Landen Rentmeester 1 , Jennifer Cullen 1 ,. W e sought to determine. PEG and Electrolytes ,. Diameter prior to addition to media and. Growth in each of the media was observed. Clumping of the three beads. While clumping was not observed. Markedly prolonged elevation of serum. Christian 1 , Patrick M. Nitromethane with or without methanol is found. This elevation is due to the interference of nitromethane with. Jaffe colorimetric method used to determine the serum CR con-.
The duration of this effect is poorly described. W e report a. The patient presented to a local emergency department about one. At the time of presentation, the patient was. His vital signs and physical examination were. Initial laboratory results revealed. Results for abstract number Hours post-ingestion 3 4 10 20 36 LFTs, and UA were within normal range. Center was consulted and recommended observation only. Nitromethane is contained in many fuels used.
Exposure to nitromethane is. While this interaction is well known, the duration of. A prolonged elevation in serum. We report a rare case of factitious ele vation of creati-. In this case we document. The kinetics of elimination and interference with the. Jaffe colorimetric method require further study. Renal toxicity, Nitromethane, Laboratory. Should we GoLytely in recommending whole. Christian 1 , Sean M. Bryant 2 , Steven E. According to a published position statement, whole.
Utilizing Crystal Reports V ersion Analysis included patient demographics, substance, PEG. Descriptive statistics were used to report the data. During the study period, WBI was performed in The mean age was 29 years range: Substances and frequencies were: XL 2 , batteries 2 , opioid patch 2 , and methamphetamine plus. Procedural administration of PEG and end-.
Although these data are limited by the retrospective. WBI irrigation is rarely. A similar , previous study performed by. More recently, our data reveal. Further research is needed to determine. Decontamination, Poison center, Ingestion. Strategies for managing antidote shortages. Kimberly Barker 1 , Justin Loden 2. Drug shortages in the U. Reduced availability of drugs were reported from January This number increased to in alone. T oxicologists and poison control centers PCC have.
Neither of these approaches focuses on alternatives in the manage-. To identify current antidote shortages and assess alter -. We conducted a search of the American Society of Health-. Studies investigating inadequate antidote stocking. As the medical community has not adequately. Hospital pharmacists across the U. T oxicologists and PCC should be. Antidote, FDA, Poison center.
Clinical Experience with uridine triacetate for. Bamat 1 , Robert Tremmel 1 , Thomas King 2 ,. Joan Helton 1 , Reid von Borstel 1. It is typically administered by IV infusion, at or near its. The use of infusion. Partial or total dihydropyrimidine dehy-. Uridine triacetate is an orally bioavailable direct biochemical. Approximately patients at excess risk of 5-FU toxicity due. More than 80 of these cases have occurred since Uridine triacetate was provided under emergency IND.
Patients received uridine triacetate 10g q6h. Clinical outcomes, including safety. To date 98 patients ov erexposed to 5-FU have been treated. Reductions in or absence of GI, hematologic, and other toxicities. Mild or no adverse. Uridine triacetate appears to be a safe. Antidote, Medical toxicology , Overdose. Descriptive analysis of patients receiving.
Digoxin DIG is the most commonly prescribed. The administration of DIG. Ho wever, there ha ve been few studies describing. As a result, an 8-year retrospec-. Utilizing Crystal Reports version Data collected included reported amount and time of DIG. Of the cases, 79 No one presented in cardiac arrest. The mean initial DIG C. There were 7 6. Review of RPC recommendations found that in 24 In the 38 cases encouraged to obtain post-DIF C.
A total of 8 patients had both pre-. The majority of cases in which DIF was admin-. K did not correlate with the degree of presenting DIG C. Cardiac glycoside, Antidote, Overdose. Surfactant administration as treatment for. Abby Willaert 1 , Benjamin S. Orozco 2 , Kenneth Maslonka 3 ,. John McNamara 3 , Jon B.
Cole 2 , Samuel J. Hydrocarbon aspiration HA is well described as a. W e present a case of HA-. A previously healthy month-old boy presented to the. Emergency Department via priv ate car after witnessed aspiration. Initial vital signs included respira-. Physical exam showed a Glasgow Coma Scale score of 9,. The patient was intubated and venous blood gas. Chest x-ray showed bilateral. V enovenous ECMO was initiated due to.
After 24 hours, ECMO support needs decreased marginally and. He was extubated on day 14 and had a complete recovery. Hydrocarbons are organic compounds ubiqui-. Proposed mechanisms of lung injury include disruption of the. ES administration may be a useful adjuvant in cases of. Haloperidol successfully treats cannabinoid. Witsil 1 , Jami L. Hickey 1 , Mark B. Cannabinoid hyperemesis syndrome CHS is.
ED with vomiting for 4 days. He has been admitted to our hospital. Only hot showers and abstinence help his symp-. He was gi ven haloperidol 5mg IV , within 1. Within 1 hour he improved, had no more v omit-. He was then given haloperidol 5 mg IV , within. He was then given haloperidol 5 mg IV , within 2 hours his. All 4 patients arrived convinced hospital admission. All had no psychiatric problems.
Haloperidol has antiemetic ef fects via D2 agonism in the. Other than hot showers, CHS often resists conven-. Cannabinoid hyperemesis syndrome, Antidote,. Forgoing the Folate Fair or F olly? Lim 1 , Sean M. A recent outbreak of methanol poisoning in Libya high-. HD and alcohol dehydrogenase ADH inhibition are the cornerstone. Patients with reported methanol ingestions were included. One hundred and two methanol ingestions met inclusion.
F A was recommended. Of those who received ADH inhibition or. Comparatively, F A was only recom-. One-third of all methanol exposures meeting inclusion. Additionally , a greater number of FA rec-. A sharp decline in FA recommendation occurred. However , in light of its safety margin and lack of. Methanol, Antidote, Folic Acid. Sodium acetate substitution for sodium. Osterhoudt , Jeanette Trella , Fred Henretig. Sodium bicarbonate is used to treat poisoning from. W e describe the.
A sodium acetate infusion given to a month-. Additionally , a year-old girl with tachycardia,. All 4 patients fully. No adverse ev ents were attributed to sodium acetate in. Sodium acetate may be metabolized to sodium. All four children treated with. It is not kno wn. Drug shortages can force clinicians to consider use. These four cases provide information that. This series may also be useful in. Sodium Acetate, Antidote, Cardiac toxicity.
Whale blubber is a thick layer of vascularized adipose. It contains a rich network of collagen. Whale blubber, referred by the Inuit as. Muktuk, is an important staple of their diet due to its high-caloric. A set of 2 year old female twins with no medical. Given concerns for a. Upon arriv al to the closest emergency department. Flat plates were performed. During their entire emergency department visit, both children. Six hours after their ingestion,.
There is no published data on blubber being. This case describes how Muktuk enhanced. The mechanism behind its cathartic. It can be theorized that with its high lipid con-. Multiple dose activated charcoal fails to reduce. Phenobarbital is a sedative hypnotic known to have. Treatment modalities to enhance. A 47 year-old woman with bipolar disorder. There were no other reported ingestions. Home medications also included carbamazepine, alprazolam,.
Upon arrival to the ED, she was unresponsi ve and. A total of eight doses of charcoal were. She did not undergo UA or. Serial phenobarbital levels demonstrated a slow decline. On Day 5, patient began to regain consciousness as her. Extubation was attempted on Day 6,. Due to vocal cord and esophageal swelling visualized dur-.
Studies have demonstrated that this can be. HD has also been. This case report highlights the need to consider alter-. Potential risks of each modality , individual patient. Enhanced elimination, Acti vated charcoal,. Grandparent involvement in exploratory. Kevin Osterhoudt 2 , Fred Henretig 2. Exploratory pediatric poisonings EPPs in young.
Grandparents GPs also provide child care, and prior studies. Thus, the aims of this. In this retrospective cohort study, electronic medi-. Patients were included if. Patients were excluded if they had food or medication. Patients were characterized with. Predictor variables included GP in volve-. GP involvement w as. GPs home in 5. GP home cases were more often symptomatic There was no association between GP caregiving or medications.
EPPs resulting in hospital care, and GP homes were a particular risk. Limits of this study in estimating risk of GP. Pediatric, Epidemiology , Grandparents. A novel agent for agitated delirium: Kopec 2 , Jane Lavelle 1 , Kevin C. Ketamine is used in procedural sedation and general. Ketamine is a noncompetitive N-methyl-D-aspartic. W e present a novel case series describing the use of. After 20 minutes he was gi ven 2 mg lora-.
An 18yo female with schizophrenia exhibited paranoid and. She w as physically abusive toward staf f and. In the ED 3 separate doses of 1 mg. Over 8 hours a total. Adequate sedation was achieved within 10 minutes. A 16yo male presented with erratic behavior. IV but continued his violent behavior. He then received 2. In 45 minutes, he awoke and was giv en 2. A urine sample con-.
Agitated delirium is a serious condition that places. Patients can develop rhabdomyolysis,. Chemical sedation should be. There is limited data on the. However , in this novel case series describing successful sedation of. Ketamine may be an alternative agent to manage. Protracted seizures after vilazodone pediatric. Salzman 3 , Fred Henretig 2. Selective serotonin reuptake inhibitor SSRI ov er-. Vilazodone hydrochloride is a ne w dual action antidepressant.
A 3-year-old, 18 kg, male presented to the emergency depart-. En route he received 3 mg lorazepam intramuscu-. ED requiring 2 mg lorazepam intravenously IV. HR bpm, RR 30, temp Electrocardiogram showed sinus rhythm. Laboratory values were pertinent for: In the PICU, 8 hours post ingestion, he continued to. A vilazodone lev el was. He had no further seizure. On hospital day 3 he.
Vilazodone is a ne w dual action antidepressant. Seizures were not reported as an adverse event in any clinical trials,. However , a week canine study demonstrated seizures and sei-. One pre vious case. Further research is needed to characterize. Pediatric overdose of vilazodone HCl may lead to. Cardiopulmonary arrest and death in a patient. Jonathan Gaudet 2 , V. Amantadine is an anti viral and anti-Parkinson agent.
T oxicity consists of antimuscarinic, sympathomimetic and car-. The clinical effects after repeated supratherapeutic exposures. W e report a case of. A 55 year old male with a history of frontal lobe. Medications on admission included aman-. The patient noted and ques-. The amantadine dosing error was recognized and. T welve hours later the patient devel-. On transfer to ICU his neuropsychiatric.
Amantadine concentrations 2 and 5 hours. On day 2 following ICU admission he developed rhabdomyolysis. Due to the possibility of neuroleptic malignant. The patient never regained. This case illustrates the full scope of amanta-. Unique to this case are the clinical deterioration stemming from a. W e present a case of amantadine toxicity from an. Amantadine, Chronic overdose, Neuroleptic malignant. T rending levels and.
Donepezil DPZ is a reversible, central anticho-. Case reports of overdose describe symptomatic brady-. W e report an unintentional DPZ overdose with serum levels in a. A year-old otherwise healthy man with a history. The patient reported ingesting the pills when he mis-. He presented to the Emer-. He was confused, somnolent and diaphoretic with a.
An ECG demonstrated sinus bra-. The patient was given 1 mg intra venous atropine with. He was admitted to the medical intensive care. Serum lev els of DPZ. He was dischar ged on the third hospital day, asymptomatic. Donepezil is a likely medication for overdose. Since most patients with memory loss are. W e present a case of symptomatic DPZ overdose. This patient had marked. This case highlights the. Severe hyper calcemia secondary to chronic. Susan Kim-Katz , Warittha Srisansanee.
The American Academy of Pediatrics recommends. W e report a case of inadver-. A full term, exclusively breastfed infant w as rec-. Child was given 1ml 20 drops of. The baby , now 41 days. In the ED, patient was sleepy but arouseable. HR , RR 24, T Ionized Ca drawn the next day. Ultrasound of kidneys showed echogenic. No J waves were seen. The availability of various concentrations of liquid vit. D preparations can lead to confusion about proper dosing.
Vitamin D, Hypercalcemia, Chronic overdose. Prolonged Hypertension from a 1, fold. Smith 1 , Robert S. Hoffman 1 , Lewis S. Clonidine is a central alpha2 adrenergic agonist. Although clonidine ov erdose usually causes hypoten-. A 7 year-old boy with a past medical history of. ADHD and pervasive de velopmental disorder was brought to the. The patient w as administered his morning dose of. He was intubated using etomidate and succinylcholine and. The patient remained hypertensi ve.
The pharmacist was contacted on suspicion of a compounding. Clonidine is a centrally acting alpha2-adrenergic. This is typically fol-. In this massive o verdose, it is likely that. As many patients are unable to sw allow pills, pharma-. In this case, a compounding error, where 4. A systems approach to checking compounded. Serotonin syndrome occurs very infrequently in.
T win A admit-. T win B was initially noted to be acting more active than usual;. T win A v omited twice at home, however,. Approximately two hours after arri val, T win B achieved. Diaphoresis, 7 mm reac-. He required further boluses of intrav enous. The patient remained awak e and agitated through-. A serum sertraline concen-.
This supports the hypothesis that children. Furthermore, the serum sertraline concentration is. Selective serotonin reuptak e inhibitors, Serotonin. Retrospective re view of loperamide ingestion. Spiller 1 , Devin A. Wiles 2 , Marcel J. Loperamide is an OTC phenyl-piperidine deriva-. The drug is a meperidine analog which. Loperamide maintains the anti-diarrheal effects of its. In an effort to.
There was a prominent age. Serious outcomes were infrequent in adults and rare in children. Case reports suggest a risk of opiate-like effects, espe-. W e found 3 children 14d, 4y, 7y with. Pediatric ingestions of phenazopyridine. Bryson 1 , Carol DesLauriers 2. Center , Chicago IL. Little data exists for unintentional pediatric. Adult ov erdoses manifest as methemoglobinemia. The purpose was to determine an amount at which. The RPC found cases in children aged 6 months .
Overall, cyanosis was reported in 3 cases, 1 of which had a. Cyanosis was reported in Actual metHgb levels were not av ailable for this data subset. There did not seem to be a correlation between the. One limitation is ingestion quantities are often. Major effect 25 0. The quantity ingested is often unreliable. CNS depression is the main sx. Admission is rarely needed. Further evaluation is needed to determine an accurate. Description of pediatric medication errors.
Medication errors have the potential to occur in all. Children are passively at risk as caregi vers are most. This information can subsequently be used to develop. To describe the most common types of pediatric. A retrospecti ve analysis was conducted utilizing call. Cases coded as a pediatric. Overall results were analyzed, and a subanalysis was conducted.
A total of medication error cases were reported in. This trend continued for the 7 8 year age. As was the case for the. Identifying medications and contributing factors. Pediatric, Poison center, Medication Error. A coronary angiogram demonstrated a normal coronary circulation, with severe biventricular dysfunction on echocardiogram. Her admission was further complicated by cardiac failure with severe dyspnea at rest and a pulmonary embolus 10 days later for which she was commenced on warfarin.
After discussing the potential risks difficult refills and repeat of the misplaced injection; injection site bleeding risk from warfarin during refills and a recommendation to trial transdermal fentanyl analgesia with explantation of the IDDD, the patient requested her IT therapy be recommenced. The IDDD was re-filled under fluoroscopic guidance with the same solution of clonidine 18, mcg and morphine 90 mg in 18 mL of 0.
It was increased to the original rate of 0. The patient was discharged from hospital 3 weeks after presentation. Subsequently, IDDD refills were performed in a tertiary-level pain management center and at times required fluoroscopic guidance, because of difficulties in accessing the refill port due to overlying tissue changes. Subsequent refills were reportedly much easier.
We considered other explanations for the patient's presentation. First, the patient had a history of epilepsy, but there was no reported seizure activity that might explain the patient's obtunded conscious state and hemodynamic instability. Third, the operator may have inadvertently injected the IT solution into the side catheter access port; the use of correct IDDD refill equipment makes this unlikely.
Finally, a drug preparation error may have occurred; however, the IT analgesic solution was pre-prepared in a tertiary hospital pharmacy and verified as correct. The root cause analysis of this event determined that there was an inadvertent and unrecognized injection of an IT solution specifically clonidine into the soft tissues surrounding the IDDD. Literature review yielded two cases similar to ours, the first being a clonidine overdose following inadvertent subcutaneous injection while filling an IDDD for epidural infusion in a patient with cancer pain.
However, there is confusion in the case description with the patient reportedly receiving analgesia via an intrathecal catheter. In that case, the subcutaneous injection of 12, mcg of clonidine and hydromorphone The second case report was of a hydromorphone overdose mg when the IT injection was erroneously delivered subcutaneously rather than into the IDDD's injection port . If this occurs, the medications could be delivered subcutaneously or via the side port of the implanted IDDD.
This could potentially deliver several months worth of medications directly in to the CSF or in to the subcutaneous tissues. Accidental injection into the catheter access side port of some implantable IDDDs is a well-recognized complication during refills, resulting in IT overdoses [5,6]. Difficulties in obtaining injection port access during refills may be due to IDDD misplacement deep tissue , migration or inversion, anatomical distortion e.
In our case, there were documented difficulties accessing the port before and after the incident, most likely due to scar tissue formation over the port site, as seen on subsequent ultrasound examination. This case may have been complicated by the patient undergoing refills in a remote local hospital and highlights potential safety issues using IT analgesia in centers that do not have timely access to tertiary-level medical care in case of complications. The patient relocated to a metropolitan area following the incident, with refills subsequently performed at a tertiary-level pain management center.
There are systems and procedural techniques that may reduce the risk of ISTI and its related complications. Furthermore, it recommended that staff and patients be informed of the problem of ISTIs with IT drug over- or-underdoses, and that such events be reported to the national health care regulatory authority . In part based on suggestions in the case report by Coyne et al.
If port access remains difficult, the IDDD needs to be relocated. There is also a higher all-cause mortality rate 3. When considering effectiveness , a systematic review concluded that there was limited evidence level II-3 or level III, on US preventive services task force criteria for positive long-term outcomes with IT analgesia for the treatment of CNCP  , and there was a paucity of quality data, particularly from randomized controlled trials RCTs.
Although epidural clonidine reduced pain in patients with CRPS who failed to respond to sympathectomy  , a systematic review reported a scarcity of evidence for the treatment of CRPS with neuraxial clonidine, with further trials needed . When assessing the risks and benefits of IT analgesia, the effects of drugs inadvertently deposited into tissues during IDDD refills need serious consideration, as our case report highlights. Clonidine, bupivacaine, and opioids are arguably the most hazardous drugs in this context.
These are listed in Table 2. Doses of intrathecal analgesic agents delivered during inadvertent soft-tissue injection at maximum concentrations during IDDD refills. In the dose range of significant cardiovascular and sedative side effects in rats receiving an intravenous bolus dose . A smaller reservoir may provide a degree of safety by limiting the potential drug volume and dose that can be misinjected.
However, smaller reservoirs also require more frequent refills, thereby increasing the risk of inadvertent soft-tissue or IDDD side-port injections. Most published case reports of clonidine toxicity have been oral overdoses in the pediatric population, with the high incidence thought to be due to the greater availability and prescribing of the drug for psycho-behavioral conditions . The initial manifestation of an oral clonidine overdose is sedation, usually within an hour of ingestion.
This may be followed by the development of hypothermia, apnea, coma, miosis or mydriasis, bradycardia, and fluctuations in blood pressure . In cases of massive clonidine overdose, both hypertension and hypotension have been reported, with a biphasic blood pressure response being observed . Most of these responses were observed in our patient after subcutaneous deposition of 18, mcg of clonidine. Naloxone has been suggested as an antidote for bradycardia, hypotension, and coma following oral clonidine overdose in a number of case studies and case series [29,30].
This is based on the observation that some patients with hyperadrenergic tone have higher concentrations of endogenous opioids and may respond to naloxone following clonidine overdose. However, the evidence for its use is inconsistent and no large trials have addressed this question . Given that the elimination half-life of systemic clonidine is approximately 1216 hours and up to hours in renal failure, it may take several days for clonidine to be eliminated .
It took 3 days for our patient to achieve hemodynamic stability after the overdose. In our case, the ISTI of 90 mg of morphine, although potentially hazardous, was relatively easy to manage with naloxone and supportive respiratory care. In one case report, hydromorphone was inadvertently injected subcutaneously instead of intrathecally. This was successfully managed with a titrated naloxone infusion .
However, with current IDDDs and drug formulations, there is the potential to misinject up to mg of morphine, mg of hydromorphone, and 36,, mcg of fentanyl see Table 2. There is the potential to inject 2, mg of bupivacaine into the soft tissues or intravenously, which is toxic and potentially fatal see Table 2 , considering the maximum recommended daily dose is mg . If a large dose of bupivacaine were inadvertently injected subcutaneously, toxic effects would presumably occur.
The initial symptoms of bupivacaine toxicity include dizziness, tinnitus, circumoral tingling, tremors, and confusion. This means that clearance from the plasma would not be complete until after 7. Ziconotide is a conotoxin derivative, N-type calcium channel blocker with a narrow therapeutic range. There are no case reports or data in the literature of inadvertent intravenous or tissue injections of ziconotide .
There are also no clearly available data on the bioavailability of subcutaneous ziconotide, although limited intravenous animal studies have been performed. Penetration of the bloodbrain barrier by ziconotide is poor and the drug is susceptible to hydrolysis by various serum peptidases with a serum half-life of 1. Despite the paucity of information in the literature, subcutaneous absorption may be clinically relevant given that this is the mode of delivery of conotoxins in nature and similar peptides e.
Researchers are also exploring intravenous or subcutaneous routes of delivery of newer conotoxins . Mammalian animal studies suggest that intravenous bolus doses of 0. The side effect profile of ziconotide includes altered consciousness, psycho-cognitive disturbances, seizures, hemodynamic instability hypotension , and raised creatine kinase levels.
On a theoretic basis at least, there is potential for adverse effects with inadvertent tissue injection of ziconotide. Therefore, the maximal bolus dose delivered during inadvertent tissue injection is in the range of 36 mg see Table 2. There are no case reports or data for overdose of baclofen by ISTI. Oral baclofen overdoses in the range of 802, mg mean mg mainly caused adverse neurological effects such as sedation, muscle weakness, and seizures; however, rhabdomyolysis, hypertension, cardiac dysrhythmias, and respiratory failure, requiring supportive therapy including ventilation, have been reported.
Symptoms include fever, pruritus, altered conscious state, lethargy, labile hemodynamics, and severe muscle rigidity. The clinical presentation may be mistaken for neurolept malignant syndrome. If severe and untreated, rhabdomyolysis, disseminated intravascular coagulation, and multiorgan failure can develop. Treatment includes supportive care and resuscitation, restoration of baclofen therapy if possible, high-dose benzodiazepines or dantrolene .
While cases of oral clonidine overdose have been reported in the medical literature for some time, this is the first reported case of a clonidine overdose following an IDDD refill for treatment of CNCP, with only one similar case being reported . The incidence of this potentially lethal complication is unknown and there is scant mention of this problem in the literature.
It is sobering to consider the high doses of potentially lethal drugs that can be misinjected, as listed in Table 2. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account.