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Biomedical subjects

Robert A Balk

Publications and source records attributed to Robert A Balk.

12 recordsLinked to original sources
PubMed2005

Acute lung injury induced by arsenic trioxide in a patient with refractory myelodysplastic syndrome.

Arsenic trioxide has been used successfully for the treatment of refractory acute promyelocytic leukemia and has shown promise in the treatment of myelodysplastic syndrome (MDS), although it is not a labeled indication. Retinoic acid syndrome is manifested by fever, dyspnea, peripheral edema, pulmonary infiltrates, and pleural and/or pericardial effusions and is typically seen in conjunction with all- trans retinoic acid therapy of acute promyelocytic leukemia. We report a case of acute lung injury and a retinoic acid syndrome-like illness in a patient who received arsenic for MDS. To our knowledge, this is the first such report, and clinicians should be aware of this potentially life-threatening complication of arsenic trioxide treatment in patients with MDS.

Aged↗
PubMed2005

Identification of endotracheal tube malpositions using computerized analysis of breath sounds via electronic stethoscopes.

Endotracheal tube (ETT) malpositioning into a mainstem bronchus or the esophagus may result in significant hypoxemia. Current methods to determine correct ETT position include auscultation, radiography, and bronchoscopy, although the current acceptable standard procedure for proper endotracheal (versus esophageal) intubation is detection of end-tidal carbon dioxide (ETco(2)) by capnography, capnometry, or colorimetric ETco(2) devices. Unfortunately, capnography may be unavailable or unreliable in nonhospital/emergency settings or in low cardiac output states, and it does not detect endobronchial intubation. The purpose of this study was to quantify and assess breath sound characteristics using electronic stethoscopes placed over each hemithorax and epigastrium to determine their ability to detect ETT malposition. We recorded breath sounds in 19 healthy, non-obese adults before general surgical procedures. After intubation of the trachea, the ETT was bronchoscopically positioned 3 cm above the carina, after which 3 breaths of 500 mL were given and breath sounds were recorded. A second ETT was placed in the esophagus and the same series of breaths and recordings were performed. Finally, the tracheal ETT was advanced into the right mainstem bronchus and breath sounds were recorded. Using computerized analysis, breath sounds were digitized and filtered to remove selected frequencies, and acoustic signals and energy ratios were obtained for all 3 positions. Total energy ratios using band-pass filtering of the acoustic signals accurately identified all esophageal and endobronchial intubation (P < 0.001). These preliminary results suggest that this technique, when incorporated into a 3-component, electronic stethoscope-type device, may be an accurate, portable mechanism to reliably detect ETT malposition in adults when ETco(2) may be unavailable or unreliable.

Blood Gas Analysis↗
PubMed2005

Methotrexate pulmonary toxicity.

Methotrexate is a commonly prescribed antineoplastic and immune modulating compound that has gained wide acceptance in the management of rheumatoid arthritis, psoriasis, sarcoidosis and a number of neoplastic disorders. Although generally considered safe and easy to use, methotrexate has been associated with a number of adverse reactions. Pulmonary toxicity has been well-described and may take a variety of forms. Pulmonary infiltrates are the most commonly encountered form of methotrexate pulmonary toxicity and these infiltrates resemble hypersensitivity lung disease. This discussion focuses primarily on low-dose methotrexate pulmonary toxicity and will discuss the diagnosis using clinical, pulmonary function, radiographical and pathological manifestations. Suggestions for clinical monitoring to detect adverse effects are given. In addition, management of pulmonary toxicity through discontinuation of the methotrexate, support and possibly the administration of corticosteroids is discussed.

Adrenal Cortex Hormones↗
PubMed2004

Optimum treatment of severe sepsis and septic shock: evidence in support of the recommendations.

Severe sepsis and septic shock are among the most common causes of death in noncoronary intensive care units. The incidence of sepsis has been increasing over the past two decades, and is predicted to continue to rise over the next 20 years. While our understanding of the complex pathophysiologic alterations that occur in severe sepsis and septic shock has increased greatly asa result of recent clinical and preclinical studies, mortality associated with the disorder remains unacceptably high. Despite these new insights, the cornerstone of therapy continues to be early recognition, prompt initiation of effective antibiotic therapy, and source control, and goal-directed hemodynamic, ventilatory,and metabolic support as necessary. To date, attempts to reduce mortality with innovative, predominantly anti-inflammatory therapeutic strategies have been extremely disappointing. Observations of improved outcomes with physiologic doses of corticosteroid replacement therapy and activated protein C (drotrecogin alfa[activated]) have provided new adjuvant therapies for severe sepsis and septic shock in selected patients. This article reviews the components of sepsis management and discusses the available evidence in support of these recommendations. In addition, there is a discussion of some promising new strategies.

Anti-Infective Agents↗
PubMed2003

New treatment strategies for severe sepsis and septic shock.

PURPOSE OF REVIEW: Severe sepsis and septic shock are common causes of morbidity and mortality in critically ill patients. The complexities of the septic cascade continue to emerge and may identify new targets for innovative patient management. This review will highlight some of the recent advances in our management of the patient with sepsis. RECENT FINDINGS: The early administration of adequate antibiotic therapy, effective source control, and goal-directed hemodynamic resuscitation are the cornerstone of successful management. Prevention of the complications of critical illness and maintenance of normal glucose levels are also important elements of effective management. In patients with vasopressor-dependent septic shock, evaluation for inadequate cortisol response and the provision of physiologic doses of replacement steroids for those found to be deficient may result in improved survival. Administration of drotrecogin alfa (activated), (activated protein C) has been shown to improve survival in patients with severe sepsis and septic shock who have a high risk of mortality. Because of its anticoagulant properties, caution must be exercised with the use of activated protein C in those patients who meet the contraindications for its use or who have risk factors for increased bleeding complications. SUMMARY: Significant advances have been made in our understanding of the septic cascade and our ability to manage patients with severe sepsis and septic shock. Despite these advances, significant morbidity and mortality continue. In addition, there is also considerable impact on the financial and overall function of the patient.

Acute Disease↗
PubMed2003

Steroids for septic shock: back from the dead? (Pro).

The use of corticosteroids as adjunctive therapy for severe sepsis and septic shock has been a source of controversy for the past 35 years. Despite a wealth of preclinical data supporting both survival and physiologic benefit for early steroid use, the data in human sepsis have been much less convincing. There have even been reports suggesting the potential for harm associated with the administration of early high-dose corticosteroids in patients with severe sepsis and septic shock. Recent trials have reported hemodynamic and survival benefits associated with the use of more physiologic steroid replacement therapy in patients with vasopressor-dependent septic shock. These results coupled with the observation of "relative adrenal insufficiency" in some patients with severe sepsis and septic shock may once again establish a defined role for corticosteroid therapy in the management of severe sepsis and septic shock.

Blood Pressure↗
PubMed2003

Torsade de pointes associated with the administration of intravenous haloperidol:a review of the literature and practical guidelines for use.

Haloperidol is the most commonly used medication for the treatment of delirium and psychosis in the critically ill patient. Whilst generally considered to be safe, haloperidol has been associated with a number of important cardiovascular side effects. The major toxicities include hypotension, cardiac arrhythmias and prolongation of the corrected QT (QTc) interval. In particular, torsade de pointes, a polymorphic ventricular tachyarrhythmia, has been associated with both intravenous and oral haloperidol administration. The management of torsade de pointes consists of discontinuation of the possible offending agent(s), correction of electrolyte abnormalities, administration of magnesium sulfate and, if necessary, overdrive pacing. Although clinicians should be aware of this potentially lethal complication of intravenous haloperidol therapy, it should not deter clinicians from using intravenous haloperidol to treat acute agitation in the critically ill patient with a normal QTc.

Antipsychotic Agents↗
PubMed2002

Adenosine deaminase inhibition attenuates microvascular dysfunction and improves survival in sepsis.

The ability of increased endogenous adenosine to mitigate microvascular derangements in sepsis was studied. Pentostatin (2'-deoxycoformycin), an inhibitor of adenosine deaminase, was administered to mice immediately after induction of sepsis by cecal ligation and puncture. Intravital video microscopy of cremasteric postcapillary venules was performed. Leukocyte rolling and adhesion were significantly increased in septic mice compared with control mice. Treatment of septic mice with pentostatin significantly decreased leukocyte rolling and adhesion (6.02 +/- 0.09 versus 1.72 +/- 0.12 rolling cells/min, 2.07 +/- 0.04 versus 0.62 +/- 0.05 adherent cells/100 microm per minute; p < 0.001). Albumin leakage (ratio) was significantly attenuated in septic animals treated with pentostatin (0.42 +/- 0.05 versus 0.21 +/- 0.04; p < 0.01). Circulating levels of interleukin-6, tumor necrosis factor-alpha, and soluble tumor necrosis factor type II receptor were decreased in septic mice treated with pentostatin. Survival was significantly improved at 48 hours in mice treated with pentostatin. These results suggest an important role for adenosine in modulating both leukocyte-dependent and -independent mechanisms of endothelial injury in sepsis. Exploiting the advantageous action of endogenous adenosine represents a potentially useful and novel therapeutic approach for the treatment of sepsis.

Adenosine Deaminase↗
PubMedDate not supplied

Torsade de pointes associated with the administration of intravenous haloperidol.

Torsade de pointes is a malignant dysrhythmia that has been reported in a variety of clinical settings and associated with several pharmacologic agents. Patients with a prolonged QTc for heart rate are at higher risk for the development of this arrhythmia. We review the literature supporting the relationship of haloperidol to the development of this malignant dysrhythmia. Clinicians in the critical care setting should be aware of potentially lethal drug-induced ventricular tachydysrhythmias such as torsade de pointes.

Administration, Oral↗