Ismet Parlak

Rate of metoclopramide infusion affects the severity and incidence of akathisia

Objective: To investigate the effect of the rate of metoclopramide infusion on akathisia incidence, severity, onset of symptoms, and duration in patients with headache, and/or nausea/vomiting in the emergency department (ED) setting. Methods: Prospective, double blind, randomised clinical study comparing two rates of intravenous infusion of metoclopramide over a period of six months at a tertiary university hospital ED. Results: A total of 300 patients presented to the ED met the inclusion criteria: 151 (50.3%) with nausea/vomiting, 108 (36%) with headache, and 41 (13.7%) with headache and nausea/vomiting. Of these, 154 patients (51.3%) were given 10 mg metoclopramide as a slow intravenous infusion over 15 minutes plus placebo (SIG group) and 146 patients were given 10 mg metoclopramide intravenous bolus infusion over two minutes plus placebo (BIG group). Nine of the 154 patients in the SIG group (5.8%) had akathisia compared with 36/146 patients (24.7%) in the BIG group (p<0.001, OR 5.273, 95% CI 2.43 to 11.403). Severe akathisia were observed in 13/45 (28.8%). The incidence of severe akathisia was significantly higher in the BIG group (30.5%; 11/36) than in the SIG group (22.2%; 2/9), p = 0.009. Metoclopramide successfully relieved the presenting symptom(s) of 137/146 (90.8%) and 139/154 (90.2%) patients in the BIG and SIG groups, respectively. Conclusions: This study suggests that slowing the rate of infusion of metoclopramide is an effective strategy for reducing the incidence of akathisia in patients with headache, and/or nausea/vomiting in ED.

Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes

Study objective: To compare analgesic effects of metoclopramide (MTP), pethidine (PET), and combination of metoclopramide-pethidine (M-PET) in the treatment of adult patients with acute primary vascular and tension type headache admitted in the emergency department (ED). Methods: All consecutive adult patients admitted into a university hospital ED in six months with acute vascular and tension type headache were recruited. The patients whose complaints had lasted no longer than seven days were randomised to four groups and thereby received 10 mg MTP intravenously plus placebo intramuscularly (MTP), 10 mg MTP intravenously plus 50 mg PET intramuscularly (M-PET), 50 mg PET intramuscularly plus placebo intravenously (PET); and intramuscular and intravenous placebo (PLC) in a blinded fashion. The patients were asked to report the degree of pain at 0, 15, 30, and 45 minutes on visual analogue scale (VAS) and demographic data and any side effects encountered were recorded. Rescue medication was used if required by the patient because of poor pain relief. Results: Data regarding 336 patients meeting inclusion criteria were analysed. Mean VAS values recorded at 45 minutes were significantly higher in PLC group than in others (p = 0.000). When the PLC group was excluded, VAS scores in MTP and M-PET groups were significantly lower than in PET group (p = 0.038). Though unimportant, the incidence of side effects recorded in PET group was found to be significantly higher than in the other groups (p = 0.003). Conclusion: These data suggest that MTP produces more effective analgesia than PET in both vascular and tension type headache in patients with acute primary headache episodes.

A study of depression and anxiety among doctors working in emergency units in Denizli, Turkey

Background: Major work has been carried out on the psychological well-being of emergency room doctors in the US, Canada and in other developed countries, but little has been published regarding the same in the countries in economic transition. Objective: To determine the level of, and the factors related to, depression and anxiety among doctors working in emergency units in Denizli, Turkey. Methods: This cross-sectional study was conducted in May 2004, using a sample of 192 doctors employed in emergency units in Pamukkale University Hospital, the City Hospital, the Social Security Hospital, private hospitals, citywide primary healthcare centres and 112 emergency services in Denizli, Turkey. Data were obtained using a self-administered questionnaire, including questions on sociodemographic characteristics and two instruments determining the level of depressive symptoms and anxiety. Logistic regression was the method chosen for multivariate statistical analysis. Results: The mean (standard deviation (SD)) depression score was 10.6 (6.5) and the frequency (%) of depression was 29 (15.1). Not having any hobby and having high anxiety scores were salient factors among doctors experiencing depressive symptomatology in bivariate comparisons. Logistic regression analysis showed that not having any hobby (p = 0.07) and having increased anxiety scores (p<0.001) were positive contributors to depression scores. The mean (SD) anxiety score was 8.7 (8.2) and the frequency (%) of anxiety was 28 (14.6). Being a woman, having a low monthly income and having high depression scores contributed considerably to the anxiety of doctors in bivariate comparisons. Low monthly income (<1000 v 1000–2000 YTL) (p = 0.03), the number of years spent in emergency units (p = 0.03) and having high depression scores (p<0.001) were the factors that contributed significantly to the anxiety of doctors in the multivariate regression analysis. Conclusion: The considerable amount of depression and anxiety found among doctors in this study should trigger further work. Studies using more powerful designs would help to illuminate the factors leading to depression and anxiety, which result in attrition among doctors from emergency units.

Can Spirometry, Pulse Oximetry and Dyspnea Scoring Reflect Respiratory Failure in Patients with Chronic Obstructive Pulmonary Disease Exacerbation?

Objective: To evaluate the extent to which oximetry, spirometry and dyspnea scoring can reflect hypoxemia and hypercapnia among patients admitted to the emergency department (ED) with acute exacerbations of chronic obstructive pulmonary disease. Subjects and Methods: Spirometry, oxygen saturation by pulse oximetry (SpO2), arterial blood gas analysis and dyspnea scoring assessments were made in the ED. Correlations of these parameters were evaluated by means of Pearson’s test. Pulse oximetry cutoff values to express hypoxemia were demonstrated by receiver operating characteristic (ROC) curves. Results: 76 patients with a mean age of 68.0 years were included in the study. Mean spirometric values, expressed as percentages of predicted values, were forced expiratory volume in 1 s (FEV1) = 23.1 ± 9%; forced vital capacity (FVC) = 32.8 ± 11%, and mean FEV1/FVC = 72.4 ± 21.6%. While there was a positive correlation between the SpO2,SaO2 and PaO2 values (r = 0.91 and 0.80, respectively), a negative correlation (r = –0.74) was observed between PaCO2 and SpO2. In determining hypoxemia, both SpO2 and FEV1 were sensitive (83.9 and 90.3%, respectively) while dyspnea scoring was the most sensitive (93.5%). In the evaluation by means of an ROC curve, a saturation of 88.5% for the pulse oximeter was the best cutoff value to reflect hypoxemia (sensitivity 95.6%, specificity 80.6%). Conclusion: SpO2 alone appears to be as highly specific as a combination of other tests in the evaluation of hypoxemia. A cutoff value for SpO2 of ≤88.5% is proposed as a criterion in screening for hypoxemia.

Intravenous administration of metoclopramide by 2 min bolus vs 15 min infusion: does it affect the improvement of headache while reducing the side effects?

Objective: To determine the therapeutic effect (alleviation of vascular type headache) and side effects of a slow intravenous metoclopramide infusion over 15 min compared with those effects of a bolus intravenous metoclopramide infusion over 2 min in the treatment of patients with recent onset vascular type headache. Material and methods: All adults treated with metoclopramide for vascular type headache were eligible for entry into this clinical randomised double blinded trial. This study compared the effects of two different rates of intravenous infusion of metoclopramide over a period of 13 months at a university hospital emergency department. During the trial, side effects and headache scores were recorded at baseline (0 min), and then at 5, 15, 30 and 60 min. Repeated measures analysis of variance was used to compare the medication’s efficacy and side effects. Results: A total of 120 patients presenting to the emergency department met the inclusion criteria. Of these, 62 patients (51.7%) were given 10 mg metoclopramide as a slow intravenous infusion over 15 min (SIG group) and 58 patients (48.3%) were given 10 mg metoclopramide intravenous bolus infusion over 2 min (BIG group). 17 of the 58 patients in the BIG group (29.3%) and 4 of the 62 patients (6.5%) in the SIG group had akathisia (p = 0.001). There were no significant differences between the BIG and SIG groups in terms of mean headache scores (p = 0.34) and no adverse reactions in the study period. Metoclopramide successfully relieved the headache symptom(s) of patients in both the BIG and SIG groups. Conclusion: Slowing the infusion rate of metoclopramide is an effective strategy for the improvement of headache and reducing the incidence of akathisia in patients with vascular type headache.

Slow infusion metoclopramide does not affect the improvement rate of nausea while reducing akathisia and sedation incidence

Objective To compare the effects of metoclopramide infusion in emergency department (ED) patients complaining of nausea to determine the changes in its therapeutic effect and prevention of side effects such as akathisia and sedation. Methods A prospective, randomised, double blind trial, from 1 March 2007 to 1 May 2008 in the ED of Pamukkale University Faculty of Medicine. Patients with moderate to severe nausea were randomised and divided into two groups: group 1 received 10 mg metoclopramide as a slow intravenous infusion over 15 min plus placebo (SIG); group 2 received 10 mg metoclopramide as an intravenous bolus infusion over 2 min plus placebo (BIG). The whole procedure was observed, and nausea scores, akathisia and vital changes were recorded. Results 140 patients suffering from moderate to severe nausea in the ED were included in the study. There was no significant difference between the groups in terms of mean nausea scores during follow-up (p=0.97). A significant difference in akathisia incidence was observed between the groups (18 (26.1%) in the BIG and 5 (7%) in the SIG) (p=0.002). There was also a significant difference in sedation incidence between the groups (19 (27.5%) in the BIG and 10 (14.5%) in the SIG) (p=0.05). Conclusion Even though slowing the rate of infusion of metoclopramide does not affect the rate of improvement in nausea, it may be an effective strategy for reducing the incidence of akathisia and sedation in patients with nausea.

The role of inferior vena cava diameter in volume status monitoring; the best sonographic measurement method? ☆

OBJECTIVES This study aims to determine the site of and the best sonographic method for measurement of inferior vena cava (IVC) diameter in volume status monitoring. METHODS This observational before-and-after study was performed at the intensive care unit of the emergency department. It included hypotensive adult patients with suspected sepsis who were recommended to receive at least 20 mg/kg fluid replacement by the emergency physician. The patients were fluid replaced at a rate of 1000 mL/h, and maximum and minimum IVC diameters were measured and the Caval index calculated sonographically via both B-mode and M-mode. Hence, IVCs volume response was assessed by a total of 6 parameters, 3 each in M-mode and B-mode. Freidman test was used to assess the change in IVC diameter with fluid replacement. Wilcoxon test with Bonferroni correction was used to determine which measurement method more sensitively measured IVC diameter change. RESULTS Twenty-eight patients with a mean age of 71.3 were included in the final analysis.The IVC diameter change was significant with all 6 methods (P < .001). The IVC minimum diameter change measured on M-mode during inspiration (M-mode i) was the only measurement method that significantly showed diameter change with each 500-mL fluid replacements. The initial and the subsequent M-mode i values after each 500 mL of fluid were 5.65 ± 3.34; 8.05 ± 3.66; 10.16 ± 3.61, and 11.21 ± 2.94, respectively (P < .001, P < .002, and P < .003, respectively). CONCLUSION Inferior vena cava diameter was changed by fluid administration. The M-mode i method that most sensitively measures that change may be the most successful method in volume status monitoring.

A comparison of the prophylactic uses of topical mupirocin and nitrofurazone in murine crush contaminated wounds.

OBJECTIVES This work was conducted to study the prophylactic efficacy of 2 topical antibiotic ointments (mupirocin and nitrofurazone) against wound infection in experimental contaminated crush wounds. METHODS Male Wistar rats underwent two 2-cm incisions at the back side and randomized into 3 groups--placebo (n = 14), mupirocin (n = 14), and nitrofurazone (n = 14)--and infected with either Staphylococcus aureus or S. pyogenes. All wound edges were crushed for 5 seconds with hemostats to simulate crush injury before inoculation of the microorganisms. Half of the wounds were sutured and the other half left open. These wounds were treated 3 times daily for 6 days with topical mupirocin, nitrofurazone, or petrolatum (as placebo). At the end of 6 days, excisional biopsies were taken from wound edges and histopathologic assessments were made based on neutrophilic infiltration, edema formation, myofibroblastic proliferation, and granulation tissue formation. For the microbiologic assessments, quantitative tissue cultures were made. RESULTS In S. aureus-inoculated wounds, mupirocin showed higher antibacterial activity against bacterial colonization and reduced infection rates compared to placebo groups. The same effect was observed for the infection rates in S. pyogenes-inoculated wounds. In S. pyogenes-inoculated open wounds, nitrofurazone showed higher antibacterial activity against infection, but this effect was not observed in closed wounds. In S. pyogenes- and S. aureus-infected wounds, mupirocin treatment significantly lowered infection rates compared to nitrofurazone treatment. Histopathologic examination showed higher myofibroblastic proliferation and higher volume of granulation tissue in the nitrofurazone groups compared to the mupirocin groups. CONCLUSION Topical mupirocin application was effective against crush wound infections inoculated with S. pyogenes and S. aureus. Nitrofurazone provides better granulation tissue formation, but did not effectively prevent bacterial colonization and infection in crush contaminated wounds.

Evaluation of the outcome of out-of-hospital cardiac arrest resuscitation efforts in Denizli, Turkey.

The objective of this study was to evaluate the outcomes and associated factors for short-term success and long-term survival rates of resuscitated non-traumatic out-of-hospital cardiac arrest (OHCAs) in Denizli, Turkey. All non-traumatic OHCA patients from the Emergency Departments of the Pamukkale University and City Hospitals between the dates of January 1, 2004 and March 1, 2005 were included in this study. A successful outcome was defined as the return of spontaneous circulation or breathing, or evidence of a palpable pulse or a measurable blood pressure. Information on post-resuscitation long-term survival up to 9 months also was obtained by telephone. A total of 222 adults experiencing OHCAs were resuscitated. The number of successful outcomes was 85 (38.3%); 25 (11.2%) were discharged alive; and 21 (9.4%) were alive at the 9-month follow-up. The predicted mean arrest time was 11.7 min (95% confidence interval 10.27-13.2). Type of transportation to the Emergency Department (ambulance, 32.1% vs. private vehicle, 44.5%; p = 0.057), place of arrest (home, 32.6% vs. other, 44.0%; p = 0.08), first rhythm at the scene (asystole, 22.9% vs. ventricular fibrillation-pulseless ventricular tachycardia, 48.0%, vs. pulseless electrical activity, 12.5%; p = 0.056), and advanced cardiac life support starting time (the first 8 min, 46.8% vs. later than 8 min, 32.0%; p = 0.025) had an effect on outcome. Intensive public education for diagnosis and appropriate reporting of OHCA, the importance of bystander cardiopulmonary resuscitation, and the use of automated external defibrillators have an impact on the potential to increase the number of survivors.

The role of inferior vena cava diameter in the differential diagnosis of dyspneic patients; best sonographic measurement method?

STUDY OBJECTIVE We aimed to determine the role of inferior vena cava (IVC) diameter in making a differentiation between dyspnea of cardiac (acute heart failure [AHF]) and pulmonary origin. We also attempted to determine the best sonographic method for the measurement of IVC diameter. METHODS This prospective observational study was conducted at the intensive care unit of the emergency department of a training and research hospital. This study enrolled patients with the main symptom of dyspnea who were categorized into 2 groups, cardiac dyspnea and pulmonary dyspnea groups, based on the final diagnosis. All patients underwent sonographic measurement of minimum and maximum diameters of IVC, and the caval index (CI) was calculated in both M-mode and B-mode. The sensitivity, specificity, and likelihood ratios (LR) of the IVC values for the differentiation of the 2 groups were calculated. RESULTS This study included a total of 74 patients with a mean age of 72.8 years. Thirty-two patients had dyspnea of cardiac origin, and 42 patients had dyspnea of pulmonary origin. The IVC diameter measured with B-mode during inspiration (B-mode i) was the most successful method for differentiation of the 2 groups. B-mode i values greater than 9 mm predicted dyspnea of cardiac origin with a sensitivity of 84.4% and a specificity of 92.9% (+LR: 11.8, LR: 0.16). CONCLUSION Sonographic assessment of the IVC diameter may be used as a rapid, readily, nonexpensive, complication-free, and reproducible technique for the differentiation of cardiac and pulmonary causes of dyspnea. B-mode i measurement may be more successful in the differentiation of dyspnea compared with other IVC diameters and calculations.