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Clinical Toxicology (Philadelphia, Pa.) May 2024Pulmonary edema is a rare complication occurring after naloxone administration, but the causal relationship remains insufficiently investigated. We aimed to determine... (Review)
Review
INTRODUCTION
Pulmonary edema is a rare complication occurring after naloxone administration, but the causal relationship remains insufficiently investigated. We aimed to determine the likelihood of naloxone as the causative agent in published cases of pulmonary edema.
METHODS
A literature search was conducted across multiple databases, utilizing database-specific search terms such as "pulmonary edema/chemically induced" and "naloxone/adverse effects." Each case report was evaluated using the Naranjo scale, a standardized causality assessment algorithm.
RESULTS
We identified 49 published case reports of pulmonary edema following naloxone administration. The median total dose of naloxone was 0.2 mg for patients presenting following a surgical procedure and 4 mg for out-of-hospital opioid overdoses. Based on the Naranjo scale, the majority of cases were classified as "possible" ( = 38) or "probable" ( = 11) adverse reactions, while no "definite" cases of naloxone-induced pulmonary edema were identified. Many patients were classified as "possible" due to limited patient information or other potential risks, such as fluid administration or airway obstruction. Forty-six of 49 patients survived (94 percent).
DISCUSSION
Pulmonary edema may occur after both low and high doses of naloxone; however, low doses were primarily reported in the surgical population. Despite this complication, the majority of patients survived. Furthermore, no case report in our analysis was classified as a "definite" case of naloxone-induced pulmonary edema which limits the establishment of causality. Future studies should explore patient risk factors, including surgical versus outpatient setting and opioid-naïve versus opioid-tolerant for developing pulmonary edema and employ a causality assessment algorithm.
CONCLUSIONS
These case reports suggest pulmonary edema can occur following naloxone administration, irrespective of dose. According to the Naranjo scale, there were no definite cases of naloxone-induced pulmonary edema. Overall, we suggest the benefits of naloxone administration outweigh the risks. Naloxone should be administered to treat opioid overdoses while monitoring for the development of pulmonary edema.
Topics: Naloxone; Pulmonary Edema; Humans; Narcotic Antagonists; Analgesics, Opioid; Opiate Overdose; Drug Overdose
PubMed: 38865087
DOI: 10.1080/15563650.2024.2348108 -
Europace : European Pacing,... Jun 2024Patients with structural heart disease (SHD) undergoing catheter ablation (CA) for ventricular tachycardia (VT) are at considerable risk of periprocedural complications,...
AIMS
Patients with structural heart disease (SHD) undergoing catheter ablation (CA) for ventricular tachycardia (VT) are at considerable risk of periprocedural complications, including acute haemodynamic decompensation (AHD). The PAINESD score was proposed to predict the risk of AHD. The goal of this study was to validate the PAINESD score using the retrospective analysis of data from a large-volume heart centre.
METHODS AND RESULTS
Patients who had their first radiofrequency CA for SHD-related VT between August 2006 and December 2020 were included in the study. Procedures were mainly performed under conscious sedation. Substrate mapping/ablation was performed primarily during spontaneous rhythm or right ventricular pacing. A purposely established institutional registry for complications of invasive procedures was used to collect all periprocedural complications that were subsequently adjudicated using the source medical records. Acute haemodynamic decompensation triggered by CA procedure was defined as intraprocedural or early post-procedural (<12 h) development of acute pulmonary oedema or refractory hypotension requiring urgent intervention. The study cohort consisted of 1124 patients (age, 63 ± 13 years; males, 87%; ischaemic cardiomyopathy, 67%; electrical storm, 25%; New York Heart Association Class, 2.0 ± 1.0; left ventricular ejection fraction, 34 ± 12%; diabetes mellitus, 31%; chronic obstructive pulmonary disease, 12%). Their PAINESD score was 11.4 ± 6.6 (median, 12; interquartile range, 6-17). Acute haemodynamic decompensation complicated the CA procedure in 13/1124 = 1.2% patients and was not predicted by PAINESD score with AHD rates of 0.3, 1.8, and 1.1% in subgroups by previously published PAINESD terciles (<9, 9-14, and >14). However, the PAINESD score strongly predicted mortality during the follow-up.
CONCLUSION
Primarily substrate-based CA of SHD-related VT performed under conscious sedation is associated with a substantially lower rate of AHD than previously reported. The PAINESD score did not predict these events. The application of the PAINESD score to the selection of patients for pre-emptive mechanical circulatory support should be reconsidered.
Topics: Humans; Tachycardia, Ventricular; Male; Female; Middle Aged; Catheter Ablation; Retrospective Studies; Hemodynamics; Cicatrix; Aged; Hypotension; Pulmonary Edema; Postoperative Complications; Risk Factors
PubMed: 38864730
DOI: 10.1093/europace/euae145 -
Laboratory Animals Jun 2024Two healthy Landrace pigs anaesthetized with propofol suffered rapid onset of fatal sepsis. Clinical signs included severe arterial hypotension, loss of peripheral...
Two healthy Landrace pigs anaesthetized with propofol suffered rapid onset of fatal sepsis. Clinical signs included severe arterial hypotension, loss of peripheral oxygenation, low end-tidal CO, clinical onset of pulmonary oedema and cardiac dysfunction. Gross and histopathological examination revealed loss of vascular integrity with severe lung oedema and congestion, haemorrhages in several organs and fluid leakage into body cavities. Large numbers of Gram-negative bacteria, primarily sp., were present in the anaesthetic infusion containing propofol and were also cultured from internal organs of both pigs. The propofol was likely contaminated by bacteria after inappropriate handling and storage in the operating room. This report illustrates the potential for severe nosocomial infection when applying propofol in animals and humans and may serve as a reminder of the importance of strict aseptic practice in general, and specifically in the handling of this anaesthetic agent.
PubMed: 38863139
DOI: 10.1177/00236772231200524 -
Cardiovascular and Interventional... Jun 2024To determine the safety and efficacy associated with drainage volumes greater than 1,500 mL in a single, unilateral thoracentesis without pleural manometry measurements.
PURPOSE
To determine the safety and efficacy associated with drainage volumes greater than 1,500 mL in a single, unilateral thoracentesis without pleural manometry measurements.
MATERIALS AND METHODS
This retrospective, single-institution study included 872 patients (18 years and older) who underwent ultrasound-guided thoracentesis. Patient and procedures data were collected including demographics, number of and laterality of thoracenteses, volume and consistency of fluid removed, and whether clinical or radiologic evidence of re-expansion pulmonary edema (REPE) developed within 24 h of thoracentesis. Fisher's exact test was used to test the significance of the relationship between volume of fluid removed and evidence of REPE.
RESULTS
A total of 1376 thoracenteses were performed among the patients included in the study. The mean volume of fluid removed among all procedures was 901.1 mL (SD = 641.7 mL), with 194 (14.1%) procedures involving the removal of ≥ 1,500 mL of fluid. In total, six (0.7%) patients developed signs of REPE following thoracentesis, five of which were a first-time thoracentesis. No statistically significant difference in incidence of REPE was observed between those with ≥ 1,500 mL of fluid removed compared to those with < 1,500 mL of fluid removed (p-value = 0.599).
CONCLUSIONS
Large-volume thoracentesis may safely improve patients' symptoms while preventing the need for repeat procedures.
PubMed: 38858252
DOI: 10.1007/s00270-024-03773-2 -
Chest Jun 2024A 57-year-old man was admitted to our hospital via the ED presenting in reduced general condition because of an infection of unknown origin, generalized edema, and...
A 57-year-old man was admitted to our hospital via the ED presenting in reduced general condition because of an infection of unknown origin, generalized edema, and dyspnea at rest (peripheral capillary oxygen saturation, 89%) that required 2 L/min intranasal oxygen. Anamnesis was complicated by an infection-triggered delirium, but his wife reported an increasing physical decay that had led to bed confinement. The BP was reduced at 88/55 mm Hg with a normal heart rate of 86 beats/min. Lung auscultation showed mild bipulmonal rales. Previous comorbidities were a BMI of 42 kg/m, an insulin-dependent type 2 diabetes mellitus with a severe diabetes-related chronic kidney disease stage G4A3, and systemic arterial hypertension.
Topics: Humans; Male; Middle Aged; Pulmonary Artery; Vascular Calcification; Tomography, X-Ray Computed; Diagnosis, Differential
PubMed: 38852977
DOI: 10.1016/j.chest.2024.02.022 -
Phytomedicine : International Journal... Jul 2024Acute respiratory distress syndrome (ARDS) is an acute respiratory disease characterized by bilateral chest radiolucency and severe hypoxemia. Quzhou Fructus Aurantii...
BACKGROUND
Acute respiratory distress syndrome (ARDS) is an acute respiratory disease characterized by bilateral chest radiolucency and severe hypoxemia. Quzhou Fructus Aurantii ethyl acetate extract (QFAEE), which is prepared from the traditional Chinese respiratory anti-inflammatory natural herb Quzhou Fructus Arantii, has the potential to alleviate ARDS. In this work, we aimed to investigate the potential and mechanism underlying the action of QFAEE on ARDS and how QFAEE modulates the STING pathway to reduce type I interferon release to alleviate the inflammatory response.
METHODS
Lipopolysaccharide (LPS), a potential proinflammatory stimulant capable of causing pulmonary inflammation with edema after nasal drops, was employed to model ARDS in vitro and in vivo. Under QFAEE intervention, the mechanism of action of QFAEE to alleviate ARDS was explored in this study. TREX1 mice were sued as a research model for the activation of the congenital STING signaling pathway. The effect of QFAEE on TREX1 mice could explain the STING-targeted effect of QFAEE on alleviating the inflammatory response. Our explorations covered several techniques, Western blot, histological assays, immunofluorescence staining, transcriptomic assays and qRT-PCR to determine the potential mechanism of action of QFAEE in antagonizing the inflammatory response in the lungs, as well as the mechanism of action of QFAEE in targeting the STING signaling pathway to regulate the release of type I interferon.
RESULTS
QFAEE effectively alleviates ARDS symptoms in LPS-induced ARDS. We revealed that the mechanism underlying LPS-induced ARDS is the STING-TBK1 signaling pathway and further elucidated the molecular mechanism of QFAEE in the prevention and treatment of ARDS. QFAEE reduced the release of type I interferons by inhibiting the STING-TBK1-IRF3 axis, thus alleviating LPS-induced pneumonia and lung cell death in mice. Another key finding is that activation of the STING pathway by activators or targeted knockdown of the TREX1 gene can also induce ARDS. As expected, QFAEE was found to be an effective protective agent in alleviating ARDS and the antagonistic effect of QFAEE on ARDS was achieved by inhibiting the STING signaling pathway.
CONCLUSIONS
The main anti-inflammatory effect of QFAEE was achieved by inhibiting the STING signaling pathway and reducing the release of type I interferons. According to this mechanism of effect, QFAEE can effectively alleviate ARDS and can be considered a potential therapeutic agent. In addition, the STING pathway plays an essential role in the development and progression of ARDS, and it is a potential target for ARDS therapy.
Topics: Animals; Interferon Type I; Mice; Anti-Inflammatory Agents; Membrane Proteins; Lipopolysaccharides; Respiratory Distress Syndrome; Signal Transduction; Lung; Disease Models, Animal; Male; Humans; Mice, Inbred C57BL; Drugs, Chinese Herbal; Plant Extracts; Pneumonia
PubMed: 38850630
DOI: 10.1016/j.phymed.2024.155373 -
Military Medicine Jun 2024HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) Syndrome is a rare but serious complication of pregnancy that can lead to disseminated intravascular...
HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) Syndrome is a rare but serious complication of pregnancy that can lead to disseminated intravascular coagulation, pulmonary edema, respiratory failure, hepatic and renal injury, and death if not recognized and treated promptly. A 36-year-old nulligravid (G0) active duty Marine at 36 weeks and 1 day gestation with dichorionic diamniotic twins presented to triage for routine cervical examination found to have elevated blood pressures and symptomatic thrombocytopenia, with a suspected diagnosis of HELLP. A multidisciplinary decision was made by anesthesiology, obstetrics and gynecology, and pediatrics to deliver the twins to avoid any further complications. The twins were in cephalic presentation and the patient desired to attempt a vaginal delivery. Due to the patient's thrombocytopenia, neuraxial anesthesia (spinal and/or epidural) left the patient at a high risk of developing catastrophic complications such as an epidural hematoma, and the subsequent motor block/weakness would likely lessen the patient's ability to participate in active labor for a vaginal delivery. A Cesarean section under general anesthesia was also to be avoided as the patient's elevated risk of catastrophic hemorrhage would be worsened by volatile anesthetic agents which cause significant uterine vascular relaxation and reduced uterine muscular tone. Ultimately, the decision was made to provide analgesia through a remifentanil PCA (patient-controlled analgesia) for labor and a ketamine bolus for delivery. The mother delivered both twins vaginally in the operating room without perioperative complication. This case demonstrates the safety of alternate forms of anesthesia for delivery when neuraxial anesthesia is contraindicated.
PubMed: 38850222
DOI: 10.1093/milmed/usae296 -
Pulmonary Pharmacology & Therapeutics Jun 2024Interferon gene stimulator (Sting) is an indispensable adaptor protein that plays a crucial role in acute lung injury (ALI) induced by sepsis, and the PARP-1/NLRP3...
BACKGROUND
Interferon gene stimulator (Sting) is an indispensable adaptor protein that plays a crucial role in acute lung injury (ALI) induced by sepsis, and the PARP-1/NLRP3 signaling pathway may be an integral component of the inflammatory response mediated by Sting. However, the regulatory role of Sting in the PARP-1/NLRP3 pathway in ALI remains insufficiently elucidated.
METHODS
Using lipopolysaccharide (LPS) to induce ALI in C57BL/6 mice and HUVEC cells, an in vivo and in vitro model was established. In vivo, Sting agonists and inhibitors were administered, while in vitro, Sting was knocked down using siRNA. ELISA was employed to quantify the levels of IL-1β, IL-6, and TNF-α. TUNEL staining was conducted to assess cellular apoptosis, while co-immunoprecipitation was utilized to investigate the interaction between Sting and NLRP3. Expression levels of Sting, NLRP3, PARP-1, among others, were assessed via Western blotting and RT-qPCR. Lung HE staining and lung wet/dry ratio were evaluated in the in vivo mouse model. To validate the role of the PARP-1/NLRP3 signaling pathway, PARP-1 inhibitors were employed both in vivo and in vitro.
RESULTS
In vitro experiments revealed that the Sting agonist group exacerbated LPS-induced pulmonary pathological damage, pulmonary edema, inflammatory response (increased levels of IL-6, TNF-α, and IL-1β), and cellular injury, whereas the Sting inhibitor group significantly ameliorated the aforementioned injuries, with further improvement observed in the combination therapy of Sting inhibitor and PARP-1 inhibitor. Western blotting and RT-qPCR results demonstrated significant suppression of ICAM-1, VCAM-1, NLRP3, and PARP-1 expression in the Sting inhibitor group, with this reduction further enhanced in the Sting inhibitor + PARP-1 inhibitor treatment group, exhibiting opposite outcomes to the agonist. Furthermore, in vitro experiments using HUVEC cell lines validated these findings.
CONCLUSIONS
Our study provides new insights into the roles of Sting and the PARP-1/NLRP3 signaling pathway in inflammatory responses, offering novel targets for the development of therapeutic interventions against inflammatory reactions.
PubMed: 38848887
DOI: 10.1016/j.pupt.2024.102303 -
JBJS Case Connector Apr 2024A 37-year-old man American Society of Anesthesiologists grade 1 patient with lumbar canal stenosis at the L4-L5 level underwent endoscopic decompression. Toward the end...
CASE
A 37-year-old man American Society of Anesthesiologists grade 1 patient with lumbar canal stenosis at the L4-L5 level underwent endoscopic decompression. Toward the end of the procedure, the patient developed sudden-onset bradycardia, followed by ventricular arrhythmia and acute pulmonary edema. The patient was successfully managed with resuscitation and supportive management and recovered uneventfully thereafter. A diagnosis of perioperative stress cardiomyopathy was subsequently made after evaluation of the patient.
CONCLUSION
The possibility of takotsubo cardiomyopathy should be considered in cases of acute perioperative cardiac decompensation and pulmonary edema in patients undergoing spinal surgery.
Topics: Humans; Takotsubo Cardiomyopathy; Adult; Male; Spinal Stenosis; Endoscopy; Lumbar Vertebrae; Decompression, Surgical; Intraoperative Complications
PubMed: 38848407
DOI: 10.2106/JBJS.CC.24.00031 -
Journal of the American College of... Jun 2024This article provides a report of a case of organ dysfunction, myonecrosis, rhabdomyolysis, multifocal ischemic cerebral infarcts, and cerebral edema after a patient's...
This article provides a report of a case of organ dysfunction, myonecrosis, rhabdomyolysis, multifocal ischemic cerebral infarcts, and cerebral edema after a patient's use of xylazine and fentanyl. Within the US opioid epidemic, xylazine is emerging as a troubling national sub-story. The prevalence of xylazine within illicitly manufactured opioids and the proportion of opioid-involved overdose deaths with detected xylazine are rising dramatically, the latter increasing 276% between 2019 and 2022. A 27-year-old woman with opioid use disorder, active intravenous drug use, and prior bacteremia presented to our institution's emergency department (ED) with left lower extremity pain and associated weakness, new acute bilateral hearing loss, multiple electrolyte derangements, and cerebral infarcts followed by cerebral edema, leading to an emergent sub-occipital decompressive craniectomy and placement of an external ventricular drain. A definitive mechanism was not determined; however, we hypothesized that xylazine toxicity played a role in her clinical presentation, which could have future clinical implications, including the possibility to incorporate xylazine as part of toxicology screens.
PubMed: 38846102
DOI: 10.1002/emp2.13187