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[Effect of the therapy with vitamin K on coagulation factors in celiac disease in children].

The Authors carried out a study on 37 untreated coeliac children to investigate the behaviour of K-dependent factors after vitamin K administration. The children were randomized into two groups: 22 children receiving a single dose of 10 mg i.m. of Phytonadione (Konakion, Roche) on the initial day of GFD and 15 children who did not receive vitamin K administration. PT, PTT and clotting activity of Factors II, VII, IX, X were determined before the treatment and/or GFD, and after 24 hours, 7 and 15 days. The results demonstrated that vitamin K administration determined a rapid increase in clotting activity of all K-dependent factors after 24 hours. These values remained normal after 7 and 15 days, except for Factor II, which slightly decreased on the 7th day. On the contrary, the children not treated, had levels similar to those of acute stage. After 7 days these values showed a slight increase and reached normal limits on the 15th day. No significant changes were seen in either PT or PTT in the two groups. They were constantly prolonged, reaching normal limits on the 15th day. These results indicate that the vitamin K deficiency, not only seems constant in children with CD, but also seems responsible for the haemocoagulative deficit of the K-dependent factors. After GFD when intestinal absorption is regained, all parameters returned to normal. The Authors concluded that K-dependent factors can be used as short-term indexes of improved intestinal absorption and that the coeliac children with severely compromised nutritional status can be treated with vitamin K (10 mg bolus).

Blood Coagulation Factors↗

Hypoprothrombinemia associated with cefamandole use in a rural teaching hospital.

The incidence of hypoprothrombinemia (prothrombin time greater than or equal to 2 s above the highest control) associated with concurrent cefamandole nafate usage in our institution was determined. Of 77 patients receiving cefamandole for no less than 48 hours, serial prothrombin time was monitored in 31 (40.2%). Four (12.9%) of 31 in whom a baseline normal prothrombin time was obtained developed hypoprothrombinemia during cefamandole therapy. An additional three patients for whom baseline prothrombin time was not determined were noted to have hypoprothrombinemia during therapy with cefamandole. Two patients had clinically significant bleeding episodes. The prothrombin time normalized in six of seven patients following administration of fresh frozen plasma, phytonadione therapy, discontinuation of cefamandole, or a combination of the three. This study illustrated that the incidence of hypoprothrombinemia associated with concurrent cefamandole use is relatively high. Serial prothrombin time monitoring is indicated when patients receive cefamandole.

Adult↗

Twice-daily moxalactam versus gentamicin and clindamycin in patients with penetrating abdominal trauma.

The effectiveness and total costs of moxalactam administered every 12 hours versus a combination of gentamicin and clindamycin for prophylactic use in patients with penetrating abdominal trauma were compared. Fifty patients scheduled for laparotomy after penetrating abdominal wounds were randomly assigned to receive either clindamycin phosphate 600 mg every six hours with gentamicin (as the sulfate salt) 3-5 mg/kg/day in three divided doses or moxalactam disodium 2 g every 12 hours. Therapy was begun preoperatively and continued for a minimum of three days in patients without hollow-organ injury and five days in patients with hollow-organ injury; total duration of therapy could not exceed four weeks. Patients receiving moxalactam also received phytonadione 10 mg intramuscularly once a week. Although wound cultures from several patients were positive for Staphylococcus epidermidis, Pseudomonas aeruginosa, and enterococci, no symptomatic infections developed. No direct toxic effects of moxalactam or gentamicin-clindamycin were seen; transient abnormalities in blood-coagulation tests or serum creatinine concentration occurred in several patients. Although mean drug costs per patient for moxalactam and gentamicin-clindamycin were similar, the mean cost of therapy per patient was $125.23 higher for the combination regimen than for moxalactam when laboratory, personnel-time, and supply costs were added to drug costs. Moxalactam given every 12 hours was a safe and effective alternative to the combination of gentamicin and clindamycin for preventive use in the study patients with penetrating abdominal trauma.

Abdominal Injuries↗

Compatibility of common additives in protein hydrolysate/dextrose solutions.

The compatibility of common additives in protein hydrolysate/dextrose solutions was studied. The additives included electrolytes (calcium gluconate, potassium phosphate and magnesium sulfate), vitamins (M.V.I., Solu B Forte, phytonadione, cyanocobalamin and folic acid), insulin and heparin sodium. Various concentrations of the admixtures were observed at intervals throughout a 24-hour period. Combinations which displayed no physical change were subjected to spectrophotometric analysis. Thin-layer chromatography was used to examine those mixtures which displayed a spectral change. The principal incompatibility problems are related to concentrations of calcium gluconate and potassium phosphate. The order of mixing affected the concentration tolerances. The vitamins, insulin, heparin and magnesium, in usual therapeutic concentrations, appeared to be compatible in the protein hydrolysate/dextrose solution.

Drug Incompatibility↗

Don't use the wrong vitamin K.

The emergency use of vitamin K is essentially limited to the reversal of drug-induced hypoprothrombinemia. In patients with adequate liver function, phytonadione acts promptly and predictably in this capacity whereas the derivatives of menadione counteract coumarin drugs only slightly or not at all. It is dangerous to rely on menadione analogues, and these drugs should be removed from emergency room drug stores.

Dicumarol↗

Compatibility and stability of electrolytes, vitamins and antibiotics in combination with 8% amino acids solution.

The compatibility and stability of the following additives in an 8% amino acids and 50% dextrose solution intended for total parenteral nutrition were studied: potassium phosphate, calcium gluconate, magnesium sulfate, multiple vitamine mixtures, folic acid, cyanocobalamin, phytonadione, insulin, ampicillin, cephalothin, kanamycin and gentamicin. In addition to physical examination, techniques of ultraviolet spectroscopy, thin-layer chromatography and microbiologic assay were used to delineate compatibility characteristics. The principle compatibility problems are generated by elevated concentrations of calcium and phosphate. The efficacy of ampicillin, cephalothin and kanamycin in the amino acids/dextrose solution, with or without additives, did not appear to be significantly different from control samples prepared in sterile water. It appeared that gentamicin might be significantly more effective in the test solutions than in sterile water, but further investigation is needed to verify this. A comprehensive study of the stability of vitamins in parenteral nutrient solutions must be made before a final judgment can be made.

Amino Acids↗

Compatibility considerations in parenteral nutrient solutions.

Information on compatibility of nutrients and drugs with parenteral nutrient (PN) solutions is reviewed and evaluated. Precipitation of calcium phosphate when calcium and phosphate salts are added can be affected by pH, amino acid concentration, amino acid product, temperature, sequence of additives, specific salt used, and time since admixture; precipitate formation can occur gradually over 24 hours. Insulin is chemically stable in PN solutions, but adsorption to the infusion system can cause decreased availability. Poor delivery of vitamin A via PN solutions has been reported. The sodium bisulfite content of amino acid injections may cause degradation of thiamine, but studies simulating clinical use are needed. Folic acid stability in PN solutions has been demonstrated, and phytonadione appears to be stable. Drug administration via PN solutions may be advantageous when fluid intake is restricted or peripheral vein access is limited and in home PN therapy. Summarized are results of studies involving heparin, cimetidine hydrochloride, aminophylline, amphotericin B, iron dextran, hydrochloric acid, corticosteroids, narcotics, metoclopramide, digoxin, and fluorouracil. Many antibiotics are probably stable, especially when administered by co-infusion rather than by direct mixture in the PN solution container. When lipids are mixed in the same container with amino acid-dextrose solutions, compatibility and stability of electrolytes, vitamins, and trace elements must be reassessed. Practical research is needed, and availability of additives should be studied in specific patient populations and for specific PN formulations. Valid conclusions are dependent on careful study design.

Adrenal Cortex Hormones↗

Factor V deficiency and its reversal with gluten restriction. In a patient with celiac disease.

Hemorrhagic manifestations in patients with celiac disease are uncommon and, when present, are usually due to a deficiency of the vitamin K-dependent clotting factors. A patient with celiac disease was seen with a severe bleeding diathesis associated with deficiencies of factor V. The deficiencies of vitamin K-dependent clotting factors were rapidly reversed with parenteral administration of phytonadione. Factor V levels returned to normal levels only after gluten restriction.

Adult↗

Acetaminophen poisoning: a case report of the use of acetylcysteine.

Acetylcysteine treatment of acetaminophen overdose (24--30 g) in a 31-year-old female is reported. Acetylcysteine was used to prevent acetaminophen-induced hepatotoxicity. An oral loading dose of 7 g of acetylcysteine was followed with oral administraton of 3.6 g every four hours for 17 doses. Liver enzymes were elevated on the fourth day after overdose. Phytonadione was administered on days four through six for elevated prothrombin time ratios. Only mild elevations of liver enzymes still were present on day seven. Previous case reports and studies of acetaminophen-induced hepatotoxicity and acetylcysteine therapy are reviewed. The use of acetylcysteine in this case appeared to be beneficial.

Acetaminophen↗

Delayed elevation of international normalized ratio with concurrent clarithromycin and warfarin therapy.

Clarithromycin is rarely reported to cause disturbances in anticoagulation. Theoretically, clarithromycin administered concurrently with warfarin could result in enhanced anticoagulation, since many properties of clarithromycin are similar to those of erythromycin, which interacts with warfarin. A search of the National Library of Medicine produced no published reports of an interaction between the drugs. Erythromycin competitively inhibits hepatic metabolism of warfarin, specifically the R-warfarin enantiomer, by the cytochrome P450 3A3 and 3A4 pathways, resulting in increased prothrombin time and international normalized ratio (INR). Two men, age 61 and 70 years, who received stable warfarin regimens, experienced supratherapeutic elevations in prothrombin time (98.4 and 26.8 sec) and INR (90.3 and 5.6), respectively. While taking warfarin, both patients experienced dramatically increased anticoagulation effects 5 days after starting clarithromycin for atypical pneumonia. They were similarly managed for overanticoagulation by discontinuing clarithromycin, holding warfarin, and receiving intravenous phytonadione. Neither man suffered from medical complications related to anticoagulation. Until clear documentation of the exact mechanism and temporal relationship of this interaction is known, patients receiving warfarin who require the concurrent clarithromycin should have prothrombin time and INR closely monitored.

Aged↗