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Mutsago T, Kazzazi D, Ibrahim Y, Kazzazi F, Patel H, Pafitanis G. Phenytoin Induced Purple Glove Syndrome: An Effective Management Technique. Hosp Pharm 2024; 59:276-281. [PMID: 38764997 PMCID: PMC11097927 DOI: 10.1177/00185787231224064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
Background: Purple glove syndrome (PGS) is a rare condition characterized by limb edema, discoloration, and pain associated with intravenous and oral phenytoin administration. The pathophysiology is poorly understood, and there is no established treatment. Simple cases have previously been managed with hyaluronidase subcutaneous injections, with more severe cases resulting in compartment syndrome, debridement, or even amputation. Methods/Results: In this case report, a 2-year-old boy with status epilepticus developed PGS after receiving intravenous phenytoin via a cannula on the dorsum of the right hand. The patient was successfully managed by locally infiltrating subcutaneous hyaluronidase diffusely to the affected area, titrating its dose to effect, rather than aiming to adhere to any specific dosing limitation. The child was reviewed daily by the Plastic Surgery team until being discharged, and focal lesions began to demarcate after 48 hours, with epidermal loss but no deeper trauma. The epidermis peeled within one month, with healthy underlying skin found underlying when followed up in clinic. Conclusions: This case illustrates that subcutaneous administration of hyaluronidase and titrating to effect provides an effective and safe treatment for treating distal cases of early PGS in children.
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Göbel M, Pfützner W, Mügge F. [Purple discoloration on the arm after phenytoin extravasation-purple glove syndrome?]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:428-430. [PMID: 38289365 DOI: 10.1007/s00105-024-05295-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Manuel Göbel
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland.
| | - Wolfgang Pfützner
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland
| | - Felicitas Mügge
- Klinik für Neurologie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Baldingerstr. 1, 35043, Marburg, Deutschland
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Parepalli A, Acharya S, Kumar S, Andhale A, Saboo K. Phenytoin-Induced Exanthematous Drug Eruption: A Rare Complication to Watch Out for! Cureus 2024; 16:e58665. [PMID: 38774164 PMCID: PMC11106509 DOI: 10.7759/cureus.58665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/19/2024] [Indexed: 05/24/2024] Open
Abstract
Phenytoin is a first-generation anticonvulsant medicine that efficiently cures a wide range of seizures, including status epilepticus, complex partial seizures, and generalized tonic-clonic seizures (GCTS). The major advantage of phenytoin is that its neurological functions are preserved. Phenytoin works by inhibiting voltage-dependent membrane Na channels, which are essential to generate action potential. This function inhibits the positive feedback, leading to high-frequency repeated firing, reducing seizure spread in the focal region. A purple color rash on the chest, abdomen, and trunk developed in a 21-year-old female patient after being treated with phenytoin is being reported. The presentation, pathophysiology, and management are also reviewed.
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Affiliation(s)
- Avinash Parepalli
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sourya Acharya
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sunil Kumar
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Amol Andhale
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Keyur Saboo
- Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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4
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Rublee C, Hynes EC, Paavola N, Tremolet de Villers K, McLaughlin J. An Emergency Department Quality Improvement Project for Intravenous Levetiracetam Administration. J Pharm Pract 2024; 37:265-270. [PMID: 36189751 DOI: 10.1177/08971900221131920] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Levetiracetam is a readily available, safe anticonvulsive medication. It is frequently administered as IV piggyback with a pump, carrier fluid, and tubing. The Established Status Epilepticus Treatment Trial demonstrated levetiracetam being similarly effective to previously used treatments in doses up to 4500 mg administered over 10 minutes. Objective: We sought to compare usage, cost, and waste of IV piggyback with IV push administration of levetiractam following implementation of an IV push protocol in an academic emergency department. Methods: A three-month review of levetiracetam administration was done following protocol implementation using IV push for initial treatment of benzodiazepine-refractory status epilepticus. The review quantified the number of IV push vs IV piggyback doses for all indications and evaluated cost of supplies necessary for administration. Results: During the study period, 137 patients received 142 doses of IV levetiracetam. Fifty-one doses (36%) were given as IV push rather than IV piggyback. The majority of doses 116 (82%) were 1000-2000 mg and 11 doses (8%) 3500-4500 mg. Estimated three-month savings with complete transition of IV piggyback to IV push would exceed $6000 just in our ED. The amount of sterile solution carrier fluid was also reduced and IV pump time freed. Conclusion: Implementation of an emergency department IV push levetiracetam protocol resulted in cost savings. Opportunities remain to improve clinical implementation practices. Medication administration represents one crucial target area where healthcare systems can implement policies to reduce waste and commit to climate-smart health care.
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Affiliation(s)
- Caitlin Rublee
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Emilie Calvello Hynes
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Paavola
- University of Colorado Health, University of Colorado Hospital, Aurora, CO, USA
| | | | - Julie McLaughlin
- University of Colorado Health, University of Colorado Hospital, Aurora, CO, USA
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Modi D, Jonnalagadda S, Campbell GA, Dalwadi G. Enhancing Oil Solubility of BCS Class II Drug Phenytoin Through Hydrophobic Ion Pairing to Enable High Drug Load in Injectable Nanoemulsion to Prevent Precipitation at Physiological pH With a Potential to Prevent Phlebitis. J Pharm Sci 2023; 112:2427-2443. [PMID: 36958691 DOI: 10.1016/j.xphs.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/16/2023] [Accepted: 03/16/2023] [Indexed: 03/25/2023]
Abstract
This work investigates the micellar titration of phenytoin (a weakly acidic drug) with cetyltrimethylammonium hydroxide (CTAH) to form a hydrophobic ion-pair to enhance oil solubility of phenytoin, followed by an effort to formulate nanoemulsion that could potentially prevent precipitation of phenytoin at physiological pH. The ion-pair formulated in nanoemulsion was evaluated for in vitro precipitation during serial dilution at physiological pH. The formation of ion-pair during titration was explained in context of pH-solubility data. The mathematical model successfully integrated ionization and micellization equilibria to reflect on dominant mechanisms for solubilization. The micellar phenomenon during titration was confirmed using Dynamic Light Scattering (DLS). The phase changes of the excess undissolved solids during titration were evident from X-Ray Powder Diffraction (XRPD) and Fourier Transform Infrared Spectroscopy (FTIR). This analysis confirmed the conversion of phenytoin into ionized state and its subsequent ionic interaction with CTAH forming hydrophobic ion-pair complex (HIP). The complete ion pair formation was evident at pHmax (8.8 to 9.2), and its 1:1 stoichiometry was confirmed using HPLC (Phenytoin and CTAH) and H1 NMR, hence could also be called as a lipophilic salt. The ion-pair (salt) was insoluble in water and showed remarkably high partition coefficient (log P) in octanol/water. As characterized by Hot Stage Microscopy (HSM), the melting point of the ion-pair complex was lowered to 150.8⁰C compared to the free acid (> 300οC), this was even further lowered to 81.1 °C when evaluated in castor oil. This led to approximately eight-fold higher solubility of hydrophobic ion pair (HIP) in castor oil compared to the free acid form. The high miscibility in castor oil was suitable to formulate a high drug load injectable dispersed system. This was successfully achieved with lecithin and polysorbate as emulsifiers without leaching drug into continuous phase at pH 7.4. This nanoemulsion (<300 nm, and > +30 mV zeta potential) remain stable when evaluated over a period of one month. A serial dilution study of the nanoemulsion was performed in PBS buffer, microscopic observations suggested no birefringence despite incubation at 25°C for several hours. This result indicated that Phenytoin remained strongly partitioned within dispersed oily phase with a higher drug loading when ion-paired phenytoin was used. The higher drug load could enable a small volume slow bolus injection to meet 50 mg/min or lower delivery rate criteria for Phenytoin in the clinical set up. This provided a pathway to further explore potential injectable nano-emulsion formulations that could alleviate typical phlebitis issue associated with the injectable phenytoin solution administration at physiological pH.
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Affiliation(s)
- Dimple Modi
- GlaxoSmithKline, Pharmaceutical Research and Development, Medicinal Science & Technology, 1250 S. Collegeville Road, Collegeville, PA 19426, United States; Saint Joseph's University, Philadelphia, PA 19104, United States
| | | | - Gossett A Campbell
- GlaxoSmithKline, Pharmaceutical Research and Development, Medicinal Science & Technology, 1250 S. Collegeville Road, Collegeville, PA 19426, United States
| | - Gautam Dalwadi
- GlaxoSmithKline, Pharmaceutical Research and Development, Medicinal Science & Technology, 1250 S. Collegeville Road, Collegeville, PA 19426, United States.
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6
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Morgan LA, Hrachovec JB, Goodkin HP. Pediatric Status Epilepticus: Treat Early and Avoid Delays. Paediatr Drugs 2023:10.1007/s40272-023-00570-1. [PMID: 37178271 DOI: 10.1007/s40272-023-00570-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
Abstract
Pediatric convulsive status epilepticus (cSE) is a neurologic emergency with potential for morbidity and mortality. Rapid treatment and escalation of therapies to achieve early seizure control is paramount in preventing complications and providing the best patient outcomes. Although guidelines recommend early treatment, cessation of out-of-hospital SE is undermined by treatment delay and inadequate dosing. Logistical challenges include prompt seizure recognition, first-line benzodiazepine (BZD) availability, comfort and expertise in administration of BZD, and timely arrival of emergency personnel. In-hospital, SE onset is additionally impacted by delays to first- and second-line treatment and availability of resources. This review presents an evidence-based, clinically oriented review of pediatric cSE, including its definitions and treatments. It provides evidence and rationale for timely treatment of first-line BZD treatment followed by prompt escalation to second-line antiseizure medication therapies for established SE. Treatment delays and barriers to care are discussed, with practical considerations for opportunities for areas of improvement in the initial treatment of cSE.
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Affiliation(s)
- Lindsey A Morgan
- Division of Pediatric Neurology, Department of Neurology, University of Washington, 4800 Sand Point Way NE, Neurology, MB.7.420, Seattle, WA, 98105, USA.
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Jennifer B Hrachovec
- Quality and Clinical Effectiveness, Center for Quality and Patient Safety, Seattle Children's Hospital, Seattle, WA, USA
| | - Howard P Goodkin
- Departments of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, VA, USA
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Perez Del Nogal G, Rodaniche A, Saragadam SD. Purple Glove Syndrome: Recognizing a Rare Complication of Intravenous Phenytoin. Cureus 2022; 14:e23958. [PMID: 35547441 PMCID: PMC9085657 DOI: 10.7759/cureus.23958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 11/05/2022] Open
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8
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Clay JL, Fountain NB. A critical review of fosphenytoin sodium injection for the treatment of status epilepticus in adults and children. Expert Rev Neurother 2021; 22:1-13. [PMID: 34726961 DOI: 10.1080/14737175.2021.2001328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency that can occur in patients with or without epilepsy. Rapid treatment is paramount to mitigate risks of neuronal injury, morbidity/mortality, and healthcare-cost burdens associated with SE. Fosphenytoin is the prodrug of phenytoin designed to enable faster administration and improved tolerability as compared to intravenous (IV) phenytoin in the treatment of SE. AREAS COVERED This review evaluates the chemistry, pharmacokinetics, pharmacodynamics, safety, and tolerability of fosphenytoin. Efficacy data for fosphenytoin in the treatment of SE in adults and children are analyzed from initial phase I trials in 1988 through current phase III trials, including the Established Status Epilepticus Treatment Trial (ESETT). EXPERT OPINION IV phenytoin is an established treatment of SE, but its alkaline aqueous vehicle is associated with dermatologic irritation and systemic complications when rapidly infused. The water-soluble nature of its prodrug, fosphenytoin, allows for rapid infusion, and it is rapidly converted to phenytoin when administered intravenously or intramuscularly. In the ESETT, IV fosphenytoin demonstrated similar efficacy in treatment of established SE when compared to IV levetiracetam and IV valproate in adults and children, making it a reasonable choice in the treatment of SE that is unresponsive to benzodiazepines.
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Affiliation(s)
- Jordan L Clay
- University of Kentucky Comprehensive Epilepsy Program, Department of Neurology, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Nathan B Fountain
- F.E. Dreifuss Comprehensive Epilepsy Program, Department of Neurology, University of Virginia Health Systems, Charlottesville, VA, USA
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9
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A case of "purple glove syndrome". Neurol Sci 2021; 42:4329-4331. [PMID: 34184167 DOI: 10.1007/s10072-021-05417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
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10
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Meziane-Tani A, Foreman B, Mizrahi MA. Status Epilepticus: Work-Up and Management in Adults. Semin Neurol 2020; 40:652-660. [PMID: 33176372 DOI: 10.1055/s-0040-1719112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Status epilepticus is one of the most common neurological emergencies and is likely to have increasing prevalence in coming years given an aging "baby boomer" population in the United States. Because status epilepticus is associated with significant morbidity and mortality, identification and treatment are paramount. Care should be taken to exclude nonorganic mimics and infectious and metabolic causes. Status epilepticus can be classified into stages with associated recommendations for escalation in therapy, increasing from push-dose benzodiazepines to continuous anesthetic infusions and other nontraditional therapies. Concurrent electroencephalogram monitoring helps to identify, localize, and assess resolution of ictal patterns alongside antiseizure drug administration. A protocol is proposed for the management of status epilepticus in a step-wise fashion.
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Affiliation(s)
- Assia Meziane-Tani
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Moshe A Mizrahi
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
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11
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Patocka J, Wu Q, Nepovimova E, Kuca K. Phenytoin - An anti-seizure drug: Overview of its chemistry, pharmacology and toxicology. Food Chem Toxicol 2020; 142:111393. [PMID: 32376339 DOI: 10.1016/j.fct.2020.111393] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/16/2020] [Accepted: 04/24/2020] [Indexed: 12/22/2022]
Abstract
Phenytoin is a long-standing, anti-seizure drug widely used in clinical practice. It has also been evaluated in the context of many other illnesses in addition to its original epilepsy indication. The narrow therapeutic index of phenytoin and its ubiquitous daily use pose a high risk of poisoning. This review article focuses on the chemistry, pharmacokinetics, and toxicology of phenytoin, with a special focus on its mutagenicity, carcinogenicity, and teratogenicity. The side effects on human health associated with phenytoin use are thoroughly described. In particular, DRESS syndrome and cerebellar atrophy are addressed. This review will help in further understanding the benefits phenytoin use in the treatment of epilepsy.
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Affiliation(s)
- Jiri Patocka
- Faculty of Health and Social Studies, Department of Radiology and Toxicology, University of South Bohemia Ceske Budejovice, Ceske Budejovice, Czech Republic; Biomedical Research Centre, University Hospital, Hradec Kralove, Czech Republic
| | - Qinghua Wu
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove, Czech Republic; College of Life Science, Yangtze University, Jingzhou, 434025, China
| | - Eugenie Nepovimova
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Kamil Kuca
- Biomedical Research Centre, University Hospital, Hradec Kralove, Czech Republic; Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove, Czech Republic.
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12
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Zaccara G, Giorgi FS, Amantini A, Giannasi G, Campostrini R, Giovannelli F, Paganini M, Nazerian P. Why we prefer levetiracetam over phenytoin for treatment of status epilepticus. Acta Neurol Scand 2018; 137:618-622. [PMID: 29624640 DOI: 10.1111/ane.12928] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 11/30/2022]
Abstract
Over last fifty years, intravenous (iv) phenytoin (PHT) loading dose has been the treatment of choice for patients with benzodiazepine-resistant convulsive status epilepticus and several guidelines recommended this treatment regimen with simultaneous iv diazepam. Clinical studies have never shown a better efficacy of PHT over other antiepileptic drugs. In addition, iv PHT loading dose is a complex and time-consuming procedure which may expose patients to several risks, such as local cutaneous reactions (purple glove syndrome), severe hypotension and cardiac arrhythmias up to ventricular fibrillation and death, and increased risk of severe allergic reactions. A further disadvantage of PHT is that it is a strong enzymatic inducer and it may make ineffective several drugs that need to be used simultaneously with antiepileptic treatment. In patients with a benzodiazepine-resistant status epilepticus, we suggest iv administration of levetiracetam as soon as possible. If levetiracetam would be ineffective, a further antiepileptic drug among those currently available for iv use (valproate, lacosamide, or phenytoin) can be added before starting third line treatment.
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Affiliation(s)
- G. Zaccara
- Unit of Neurology; Department of Medicine; Usl centro Toscana Health Authority; Firenze Italy
| | - F. S. Giorgi
- Neurology Unit; Azienda Ospedialiero Universitaria Pisana; Pisa Italy
| | - A. Amantini
- SOD Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - G. Giannasi
- Emergency Department; Usl centro Toscana Health Authority; Firenze Italy
| | - R. Campostrini
- Unit of Neurology; Department of Medicine; Usl centro Toscana Health Authority; Firenze Italy
| | - F. Giovannelli
- Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA); University of Florence; Firenze Italy
| | - M. Paganini
- Neurology Unit; Careggi University Hospital; Florence Italy
| | - P. Nazerian
- Emergency Department; Careggi University Hospital; Firenze Italy
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13
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Lawson T, Yeager S. Status Epilepticus in Adults: A Review of Diagnosis and Treatment. Crit Care Nurse 2018; 36:62-73. [PMID: 27037340 DOI: 10.4037/ccn2016892] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Status epilepticus is a medical emergency that requires rapid diagnosis and treatment. Nonconvulsive status epilepticus is frequently underdiagnosed and therefore undertreated, which can lead to permanent neuronal damage resulting in disability or death. Despite the frequent occurrence and morbidity associated with status epilepticus, this topic has received little attention within the literature. A systematic approach to treatment should start with management of airway, breathing, and circulation, followed by administration of benzodiazepines and intravenous antiepileptic drugs, and rapid escalation of therapy to prevent morbidity and mortality. Armed with the information in this article, nurses will have a higher-level understanding of what to do when encountering a patient in status epilepticus.
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Affiliation(s)
- Thomas Lawson
- Thomas Lawson is an acute care nurse practitioner in the neuroscience critical care unit at Ohio State University Wexner Medical Center, Columbus, Ohio.Susan Yeager is the lead acute care nurse practitioner in the neuroscience critical care unit at Ohio State University Wexner Medical Center and a clinical instructor at The Ohio State University College of Nursing Columbus, Ohio.
| | - Susan Yeager
- Thomas Lawson is an acute care nurse practitioner in the neuroscience critical care unit at Ohio State University Wexner Medical Center, Columbus, Ohio.Susan Yeager is the lead acute care nurse practitioner in the neuroscience critical care unit at Ohio State University Wexner Medical Center and a clinical instructor at The Ohio State University College of Nursing Columbus, Ohio
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14
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Gil JA, Shah KN, Suarez L, Weiss APC. Upper-Extremity Extravasation: Evaluation, Management, and Prevention. JBJS Rev 2017; 5:e6. [PMID: 28796697 DOI: 10.2106/jbjs.rvw.16.00102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kalpit N Shah
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Luis Suarez
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Arnold-Peter C Weiss
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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15
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Abstract
BACKGROUND Purple glove syndrome (PGS) is a poorly understood severe adverse drug reaction that is typically associated with intravenous phenytoin administration. Although fosphenytoin is thought to circumvent this risk of PGS, we reveal a rare case of PGS in a patient treated with fosphenytoin therapy. CASE SUMMARY A 71-year-old male with history of epilepsy was admitted for seizures and traumatic brain injury and intravenous fosphenytoin and levetiracetam were initiated. The patient continued to have seizure activity on continuous electroencephalography for which fosphenytoin dosing was increased with subsequent seizure control. Serum phenytoin levels became elevated with a total level reaching as high as 25.8ug/mL. Three days into fosphenytoin therapy he developed PGS in both hands. Causation was assessed with the Naranjo adverse drug reaction algorithm that suggested fosphenytoin was probably the cause of PGS. Ten days after discontinuing the fosphenytoin and administering a 7-day course of methylprednisolone, the purple glove syndrome completely resolved. CONCLUSION Early recognition and emergent management of PGS are key for optimal recovery. Although fosphenytoin has a significantly reduced risk of associated PGS compared to phenyotin, increased awareness for fosphenytoin-induce PGS can accelerate intervention and minimize morbidity of this rare yet detrimental adverse reaction.
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16
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Clark SL, Leloux MR, Dierkhising RA, Cascino GD, Hocker SE. IV fosphenytoin in obese patients: Dosing strategies, safety, and efficacy. Neurol Clin Pract 2016; 7:45-52. [PMID: 29849211 DOI: 10.1212/cpj.0000000000000322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Previous studies evaluated the disposition of IV phenytoin loading doses and found that obese patients had increased drug distribution into excess body weight, larger volumes of distribution, and longer half-lives when compared to their nonobese counterparts. We assess the safety and efficacy of fosphenytoin loading doses in patients with different body mass indices (BMIs). Methods A retrospective chart review was conducted in 410 patients who received fosphenytoin. Patients were divided into 2 groups: BMI <30 (nonobese) and BMI ≥30 (obese). Patient demographics, fosphenytoin dose administered in mg/kg body weight, renal and liver function tests, fosphenytoin drug levels, and pre- and post-fosphenytoin administration vital signs were collected to assess for adverse events. Necessity of additional antiepileptic loading doses was used as a surrogate for clinical efficacy. Results The median dose of fosphenytoin administered was 19 mg/kg (interquartile range 15-20). The most frequently encountered adverse event was hypotension, which occurred in 39% of the cohort. Using a Bonferroni adjustment for multiple comparisons, there were no differences in adverse events between the 2 groups. The need for additional antiepileptic loading doses was not different between the 2 groups (p = 0.07). Conclusions The incidence of adverse events and the need for repeat loading antiepileptic medications was similar between the 2 groups. From our findings, the patients in our study did not receive empiric loading dose adjustments and the current method of loading fosphenytoin achieves similar outcomes, regardless of the patient's BMI.
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17
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Caccavale S, Ruocco E. Acral manifestations of systemic diseases: Drug-induced and infectious diseases. Clin Dermatol 2016; 35:55-63. [PMID: 27938813 DOI: 10.1016/j.clindermatol.2016.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Drug reactions and systemic diseases often involve the skin. In particular, most drug-induced reactions and many infectious diseases present with dermatologic manifestations localized acrally, that is on distal portions of limbs (hand, foot) and head (ears, nose). A detailed review of all acral dermatologic signs of drug reactions and systemic diseases is beyond the scope of this paper, although some of these disorders will be discussed specifically here.
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Affiliation(s)
- Stefano Caccavale
- Department of Dermatology, Second University of Naples, Naples, Italy.
| | - Eleonora Ruocco
- Department of Dermatology, Second University of Naples, Naples, Italy
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