Antithrombotic and thrombolytic therapy in acute cardiac care.

This article explores the use of antithrombotic and thrombolytic therapy in acute cardiac care, and looks at traditional anticoagulant agents, newer antithrombin agents, thrombolytic agents, and others.     

The use of refocusing in acute psychiatric care

Acute psychiatric provision in the UK is not fit for purpose. Many acute wards are chaotic, untherapeutic and can be intimidating or even dangerous. In this article the authors present a model for organisational and personal change that has had a positive impact on patients and staff, and has done so at reduced financial cost and with reduced clinical risk.     

The use of erythropoiesis-stimulating agents in the intensive care unit

Anemia is common in critically ill patients, but treatment with red blood cell transfusions can have unwanted effects. Limiting the occurrence and severity of anemia by using erythropoietic agents (iron and/or recombinant erythropoietin), therefore, remains an attractive option during the intensive care unit stay but also after hospital discharge. Moreover, these agents may have additional beneficial properties. In this article the authors review the rationale for the administration of iron and/or erythropoietin in critically ill patients.     

Bleeding time and antiplatelet agents in normal volunteers.

Clinical trials have shown that antiplatelet agents are effective in the prevention of thrombosis in arterial diseases and increase bleeding time. To compare the effects of three such drugs [acetylsalicylic acid (ASA) at two dose levels, ticlopidine and indobufen] on bleeding time, we performed a randomized cross-over study on 12 normal subjects. All received the four treatments (ASA 300 mg daily and 500 mg twice daily, ticlopidine 250 mg twice daily and indobufen 200 mg twice daily, each for 6 days plus one dose on day 7) in a sequential manner with a washout period of 15 days between the treatments. Bleeding time was measured using a Surgicut device (Ortho, Milan, Italy) before treatment, 2 and 24 h after the first administration, and before and 2, 24, 48 and 72 h after the last administration. ASA (at both doses) and indobufen quickly induced a significant prolongation of bleeding time, but the effect of indobufen soon wore off after the treatment was stopped, unlike that of ASA. In contrast, ticlopidine treatment prolonged bleeding time only after the first 24 h, and after 7 days the mean value was significantly higher than with ASA (both doses) and indobufen. This significant difference in bleeding time between ticlopidine and the other drugs was still present 48 h after the end of treatment.     

Anticoagulants and antiplatelet agents in pregnancy

Anticoagulants and antiplatelet agents are currently used during pregnancy as treatment or prophylaxis for thromboembolic disease. Main adverse events of these agents are bleeding episodes, which put the pregnancy at risk. Unfractionated and low molecular weight heparins are first-line treatment or prophylaxis for thromboembolism. If an antiplatelet agent is needed, aspirin alone or in combination with heparins can be safely administered. Coumarine derivatives are still contraindicated during pregnancy because of teratogenicity and/or bleeding. No adequate data are yet available on the safety profile of the new antiplatelet agents or the direct thrombin inhibitors. Special considerations are discussed on the risks of regional anesthesia, as well as on nursing during anticoagulation.     

Update on restraint use in acute care settings.

This article will discuss alternatives to restraint use in the management of patients who have difficult behavior or an increased risk for injury in the acute care, surgical setting. A discussion of the efficacy and adverse effects of restraint use will be followed by review of new regulations established by HCFA and JCAHO and suggestions for care that minimizes restraint use.     

The use of blood transfusions and erythropoietin-stimulating agents in Swedish palliative care

Goals of work  To outline the use of blood transfusions and erythropoietin-stimulating agents (ESAs) in palliative care in Sweden and to get an idea of whether or not these usually very sick patients benefit from the treatment. Patients and methods  An internet-based questionnaire was sent out to 24 specialized palliative care units within the Swedish palliative research network. All data were registered by each member directly into a web-based survey generator from which the results were extracted and analyzed. Main results  Twenty-two units registered 1,046 patients (median age 68 years, 87% had a cancer diagnosis). Among these patients, 900 were enrolled in advanced home care and the others were treated in in-patient units. Erythrocyte transfusions were given to 174 patients (17%) during the month before registration with a mean amount of 2.9 units (range 1–18) given to each patient. Erythrocyte transfusions were given to 18% of the patients with a malignancy and to 11% of the patients with a non-malignant disease. Six patients also received thrombocyte transfusions. One hundred seventeen patients (68%) were judged to benefit from the erythrocyte transfusions. Eighty-two (58%) of the 141 transfused patients enrolled in advanced home care received their transfusions in their homes. ESAs was given to 127 patients (12%). Conclusions  Transfusions are not uncommon in Swedish palliative care. A majority seemed to benefit from the transfusions. Since they are expensive and time consuming, the effect should, however, be carefully evaluated in every individual in order to avoid ineffective treatment.     

The use of physical restraints in an acute care hospital

To fill the knownledge gap on the extension and quality of physical restraints in acute care hospitals a survey aiming at evaluating knowledge, opinions and behaviours of nurses in this area of care was performed. A questionnaire administered to the nurses of a large Italian hospital obtained a response rate of 66.2% (227 nurses) and the situation of 77 patients (15.8% of admitted patients) hospitalised and constrained in the target wards was reported. The physical restraints were widely used in intensive care and medical specialty wards (bed rails and limbs constraints). The main reasons for restraining the patients were: disorientation, agitation, aggressiveness, and balance disturbances. The application of constraints is an autonomous of the nurses decision in 60.8% of cases and the information is seldom reported in clinical or nursing records. Fifty-two per cent of nurses feel uneasy in constraining patients because of the relational implications with relatives. Lack of knowledge on ethical and legal implications and on the possible negative effects of constraining patients, on the different forms of constriction and on alternative strategies warrant an educational intervention to control and improve the implementation of physical measures of containment.     

The use of inotropic agents in acute and chronic congestive heart failure

This article reviews our current understanding of the physiology of myocardial contraction; recent research into its mechanical, macromolecular, and biochemical foundations; and its role in the clinical syndromes of congestive heart failure. This review serves as a background for discussing the mechanism of action and pharmacology of currently available and experimental inotropic agents. The clinical applications of these drugs are discussed and the successes and failures of the pharmacologic approach to patients with congestive heart failure analyzed.     

Delirium and use of sedation agents in intensive care

Aim: The aim of the review was to consider the relationship between delirium and aspects of sedative and analgesic drug use in mechanically ventilated intensive care patients. The basis for routine delirium screening and the implications for nurses are discussed along with a brief outline of the treatment of delirium. Background and context: Delirium is common in intensive care patients and like other markers of organ failure is associated with worse outcomes. The risk of developing delirium is dependent on the patients’ individual vulnerability and on the burden of precipitating factors they are exposed to. Detection of delirium in intensive care patients is often difficult and requires the regular use of a validated screening tool. Intensive care patients are exposed to multiple delirium risk factors, and sedative and analgesic agents present an important subgroup, which we can attempt to control. Sedative and analgesic drug choice, their mode of administration, monitoring and titration have consequences for delirium development. Method: Literature review. Conclusions: Sedative and analgesic drugs have an important role in the prevention and treatment of delirium in intensive care patients. Routine delirium screening should be included as part of sedation monitoring practice. When detected, treatment is focused on the prompt correction of precipitating factors, non‐pharmacological interventions and appropriate drug therapy for symptom control.     

Modern antiplatelet agents in coronary artery disease

Dual antiplatelet therapy is well recognized in the prevention of thrombotic complications of acute coronary syndrome and percutaneous coronary interventions. Despite clinical benefits of aspirin and clopidogrel therapy, a number of limitations curtail their efficacy: slow onset of action, variability in platelet inhibitory response and potential drug–drug interactions. Furthermore, the single platelet-activation pathway targeted by these agents allows continued platelet activation via other pathways, ensuring incomplete protection against ischemic events, thus, underscoring the need for alternate antiplatelet treatment strategies. A number of novel antiplatelet agents are currently in advance development and many have established superior effects on platelet inhibition, clinical outcomes and safety profile than clopidogrel in high-risk patients. The aim of this review is to provide an overview of the current status of P2Y12 receptor inhibition and PAR-1 antagonists in determining a future strategy for individualized antiplatelet therapy.     

The potential role of antiplatelet agents in modulating inflammatory markers in atherothrombosis

Atherothrombosis is the process that links atherosclerotic lesion development with unpredictable and life-threatening ischemic vascular events such as angina, myocardial infarction, transient ischemic attack, and stroke. Atherothrombosis is triggered when an unstable atherosclerotic lesion is ruptured, leading to platelet activation and thrombus formation. Inflammatory mediators are responsible for lesion instability leading to rupture, and in recent years atherothrombosis and its underlying condition of atherosclerosis have come to be recognized as manifestations of inflammatory disease. Inflammatory mediators may therefore serve as early markers of atherothrombosis. Measurement of early markers may be used to predict future ischemic events and improve risk stratification in patients following diagnosis of atherothrombotic disease. In addition, detection of such markers may help to optimize the use of current therapies to manage atherothrombosis. Molecules that may serve as early markers of atherothrombotic disease include C-reactive protein, CD40 ligand, myeloperoxidase, pregnancy-associated plasma protein and plasminogen activator inhibitor-1. Early indications are that levels of these markers are influenced by therapies currently in use in the treatment of atherothrombotic conditions, including antiplatelet agents. Ongoing studies will provide further insight into routine assessment of inflammatory markers as a guide to the management of patients with atherothrombosis.     

Advance directives use in acute care hospitals

It is a federal requirement for health care organizations to provide and obtain information from admitted patients about their rights to self-determination and executing an advance directive. But how compliant are acute care organizations with this law? This article explores the extent to which hospitalized patients in one Southeastern United States organization had advance directive documentation; its correlation with socioeconomic factors, and the success of educating patients and providing care that is consistent with patient's wishes.     

Treatment of intermittent claudication with antiplatelet agents

In a double-blind study, 296 patients with intermittent claudication (Fontaine stage II) were treated with 250 mg ticlopidine twice daily, 500 mg aspirin every third day plus 75 mg dipyridamole three times daily, or 300 mg xanthinol nicotinate three times daily for 6 months. Ticlopidine and aspirin/dipyridamole, but not xanthinol nicotinate, improved platelet aggregation, reduced beta-thromboglobulin, platelet factor IV and fibrinopeptide A concentrations, and increased antithrombin III concentrations and red blood cell filterability. No changes in lipid profiles, platelet count or fibrinogen were recorded following any treatment. The doppler systolic blood pressure ratio was improved in patients treated with ticlopidine or aspirin/dipyridamole, but not with xanthinol nicotinate. It is concluded that antiplatelet treatment is useful for the treatment of limb arteriopathy.     

Bleeding time and antiplatelet agents in normal volunteers

Summary Clinical trials have shown that antiplatelet agents are effective in the prevention of thrombosis in arterial diseases and increase bleeding time. To compare the effects of three such drugs [acetylsalicylic acid (ASA) at two dose levels, ticlopidine and indobufen] on bleeding time, we performed a randomized cross-over study on 12 normal subjects. All received the four treatments (ASA 300 mg daily and 500 mg twice daily, ticlopidine 250 mg twice daily and indobufen 200 mg twice daily, each for 6 days plus one dose on day 7) in a sequential manner with a washout period of 15 days between the treatments. Bleeding time was measured using a Surgicut device (Ortho, Milan, Italy) before treatment, 2 and 24 h after the first administration, and before and 2, 24, 48 and 72 h after the last administration. ASA (at both doses) and indobufen quickly induced a significant prolongation of bleeding time, but the effect of indobufen soon wore off after the treatment was stopped, unlike that of ASA. In contrast, ticlopidine treatment prolonged bleeding time only after the first 24 h, and after 7 days the mean value was significantly higher than with ASA (both doses) and indobufen. This significant difference in bleeding time between ticlopidine and the other drugs was still present 48 h after the end of treatment.     

The rational use of antimicrobial agents in simple wounds.

The wounds in most patients presenting to the Emergency Department will heal uneventfully and do not require the use of antimicrobial agents. Specific indications for antimicrobial use include simple wounds in patients with lymphedema, orthopedic prostheses, or in those patients prone to bacterial endocarditis. Relative indications include high-risk wounds in compromised hosts, wounds contaminated with feces, saliva, or vaginal secretions, or wounds clinically infected at the time of presentation. More important than antimicrobial administration is the commitment to aggressive, timely wound care. Pitfalls in therapy center around the injudicious use of antimicrobial agents. Such therapy does not give the physician permission to close wounds that should be left open or to give less than optimal wound care. Physicians should be keenly aware of the fact that antimicrobial use is not innocuous. The economic burden and potential for adverse side effects must be weighed against the fact that the wounds in 90% to 95% of patients presenting to the Emergency Department will heal without the use of antimicrobial agents.