DOCSLIB.ORG

THINK of KETAMINE for HEADACHE Comparing 1–2 Doses of Intranasal Ketamine (0.75 Mg/Kg, with the Option for 0.25 Mg/Kg 30 Min Later) to I.V

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
THINK of KETAMINE for HEADACHE Comparing 1–2 Doses of Intranasal Ketamine (0.75 Mg/Kg, with the Option for 0.25 Mg/Kg 30 Min Later) to I.V The Journal of Emergency Medicine, Vol. 56, No. 4, pp. 455–456, 2019 Ó 2019 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter Editorial , THINK OF KETAMINE FOR HEADACHE comparing 1–2 doses of intranasal ketamine (0.75 mg/kg, with the option for 0.25 mg/kg 30 min later) to i.v. metoclo- Primary headache syndromes represent a significant pramide (10 mg) and diphenhydramine (25 mg) (9).Pro- burden of care in the emergency department (ED). Man- viders could opt to administer i.v. ketorolac (30 mg) or agement challenges include refractory, recurrent, or pro- dexamethasone (10 mg) in the control arm (9). Ketamine longed symptoms (1,2). Standard treatment varies, but displayed a clinically significant decrease in pain at often entails administration of parenteral dopamine 30 min (mean change in VAS 29.0 mm), though it was not antagonists, nonsteroidal anti-inflammatory drugs superior to the control arm (mean change in VAS (NSAIDs), fluids, corticosteroids, or diphenhydramine 22.2 mm) (9). A decrease in 13–18 mm has been described (1,2). Dopamine antagonists are an equivalent or as clinically significant (1,3). The intervention and control preferred treatment to NSAIDs, and some consider arm showed similar rates of adverse effects (65.4 and them first-line treatment; however, dopamine antagonists 66.7%, respectively); though there was a higher incidence can cause extrapyramidal effects, for example, restless- of mood changes and feelings of unreality in the ketamine ness or akathisia (5–46% of recipients) and diphenhydra- group, the study was not powered to detect these mine is often given to limit these effects (2,3). differences (9). The majority (80%) of the control arm addi- As an N-methyl-D-aspartate receptor antagonist, keta- tionally received i.v. ketorolac, which implies a similar mine is effective in acute pain management in the ED, effectiveness of intranasal ketamine to the combined admin- and both i.v. and intranasal ketamine have gained traction istration of i.v. diphenhydramine, metoclopramide, and in ED management of acute pain of various etiologies NSAID therapy at 30 min (9). The disparate outcomes (1,4). Evidence regarding ketamine in management of demonstrated by previously published literature on keta- primary headache syndromes has been conflicted (1,5–7). mine in management of primary headache compared to Afridi et al. demonstrated superiority of intranasal the THINK trial may be reflective of variations in ketamine ketamine over intranasal midazolam to decrease migraine dosing, routes, or rate of infusion, or by the selection of me- aura severity (6). In a randomized cross-over trial of 17 pa- toclopramide rather than other dopamine antagonists. tients, subcutaneous ketamine (0.08 mg/kg) displayed supe- Amidst the current opioid epidemic, comfort with rior migraine control compared with placebo (7).InanED- ketamine as a viable intervention for pain relief adds based, prospective placebo-controlled trial of 34 subjects, to the emergency medicine provider’s armamentarium i.v. bolus ketamine (0.2 mg/kg) showed no benefit in man- of nonopioid analgesics and, therefore, the investiga- agement of headache (5). tion of ketamine to manage pain from primary head- A prospective comparison of i.v. diphenhydramine ache is appealing. Further, the intranasal route of (25 mg) and prochlorperazine (10 mg) to i.v. ketamine administration may limit the need for placement of (0.3 mg/kg) and ondansetron in 54 patients was halted i.v. lines or administration of multiple parenteral med- early due to providers’ concern for ketamine-induced ications in this population. dysphoria (1). The prochlorperazine/diphenhydramine Given that the authors had prospectively registered the arm demonstrated superior improvement in patients’ vi- trial as a superiority trial, an admirable level of scientific sual analogue scales (VAS) pain scores at 45 and rigor dictated that Benish et al. did not claim noninferior- 60 min; there was not a significant difference in rates of ity of ketamine to a combined dopamine antagonist/ vomiting, restlessness, need for rescue medications, or diphenhydramine treatment strategy. An external valida- serious adverse events (1). Notably, the i.v. ketamine tion in a noninferiority trial would further strengthen the was administered as a 2-min “push” rather than infusion. case for intranasal ketamine as a first-line agent in the A 15-min infusion of ketamine decreases sedation or feel- management of primary headache. ings of unreality compared to push administration (8). The inclusion criteria for THINK generalize to ED pa- The THINK (Treatment of Headache with Intranasal Ke- tients with “benign” headache. The THINK trial supports tamine) trial is a timely addition to the literature (9).Benish ketamine as an alternative consideration for first-line or et al. report a well-designed, prospective, single-blind trial adjunctive therapy in management of primary headaches 455 456 Editorial in the ED, as well as in the setting of drug shortages or 2. Friedman BW, Esses D, Solorzano C, et al. A randomized controlled contraindications to dopamine antagonist or NSAID ther- trial of prochlorperazine versus metoclopramide for treatment of acute migraine. Ann Emerg Med 2008;52:399–406. apy (QTc prolongation or renal insufficiency). 3. Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K. A ran- domized controlled trial of intravenous haloperidol vs. intravenous metoclopramide for acute migraine therapy in the emergency depart- Robert Goodnough, MD ment. J Emerg Med 2015;49:326–34. Department of Emergency Medicine 4. Motov S, Drapkin J, Likourezos A, et al. Continuous intravenous University of California San Francisco sub-dissociative dose ketamine infusion for managing pain in the San Francisco, California emergency department. West J Emerg Med 2018;19:559–66. 5. Etchison A, Bos L, Ray M, et al. Low-dose ketamine does not California Poison Control System improve migraine in the emergency department: a randomized San Francisco Division placebo-controlled trial. West J Emerg Med 2018;19:952–60. San Francisco, California 6. Afridi SK, Giffin NJ, Kaube H, Goadsby PJ. A randomized controlled trial of intranasal ketamine in migraine with prolonged http://dx.doi.org/10.1016/j.jemermed.2019.01.008 aura. Neurology 2013;80:642–7. 7. Nicolodi M, Sicuteri F. Exploration of NMDA receptors in migraine: therapeutic and theoretic implications. Int J Clin Pharmacol Res 1995;15:181–9. REFERENCES 8. Motov S, Mai M, Pushkar I, et al. A prospective randomized, double- dummy trial comparing IV push low dose ketamine to short infusion of low dose ketamine for treatment of pain in the ED. Am J Emerg 1. Zitek T, Gates M, Pitotti C, et al. A comparison of headache treatment Med 2017;35:1095–100. in the emergency department: prochlorperazine versus ketamine. 9. Benish T, Villalobos D, Love S, et al. Treatment of headache with Ann Emerg Med 2018;71:369–77. intranasal ketamine. J Emerg Med 2019..
Load more

Recommended publications
  • For Personal Use Only
    SedatiWITH ANTIi ® Dowden Health Media CopyrightFor personal use only Initiate the antipsychotic at a reasonable, not overly high dose, then use a nonantipsychotic to help control insomnia, anxiety, and agitation For mass reproduction, content licensing and permissions contact Dowden Health Media. pSYCHIATRY i PSYCHOTICSon edation is a frequent side effect of antipsychot- ics, especially at relatively high doses. Antipsy- S chotics’ sedative effects can reduce agitation in acute psychosis and promote sleep in insomnia, but Manage, don’t long-term sedation may: • interfere with schizophrenia patients’ efforts to go accept adverse to work or school or engage in normal socialization • prevent improvement from psychosocial training, psychiatric rehabilitation, and other treatments. ‘calming’ eff ect This article discusses how to manage acute psycho- sis without oversedation and ways to address persistent sedation and chronic insomnia with less-sedating anti- Del D. Miller, PharmD, MD Professor of psychiatry psychotics or adjunctive medications. University of Iowa Carver College of Medicine Iowa City Neurobiology or psychopharmacology? Many patients experience only mild, transient som- nolence at the beginning of antipsychotic treatment, and most develop some tolerance to the sedating ef- fects with continued administration. Others may have persistent daytime sedation that interferes with nor- mal functioning. Sedation is especially common in elderly patients re- ceiving antipsychotics. Compared with younger patients, older patients receiving
    [Show full text]
  • The Case of Ketamine Allergy
    CASE REPORT The Case of Ketamine Allergy William Bylund, MD Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia Liam Delahanty, MD Maxwell Cooper, MD Section Editor: Rick A. McPheeters, DO Submission history: Submitted April 3, 2017; Revision received June 29, 2017; Accepted July 11, 2017 Electronically published October 3, 2017 Full text available through open access at http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.2017.7.34405 Ketamine is often used for pediatric procedural sedation due to low rates of complications, with allergic reactions being rare. Immediately following intramuscular (IM) ketamine administration, a three-year-old female rapidly developed facial edema and diffuse urticarial rash, with associated wheezing and oxygen desaturation. Symptoms resolved following treatment with epinephrine, dexamethasone and diphenhydramine. This case presents a clinical reaction to ketamine consistent with anaphylaxis due to histamine release, but it is uncertain whether this was immunoglobulin E mediated. This is the only case reported to date of allergic reaction to IM ketamine, without co- administration of other agents. [Clin Pract Cases Emerg Med.2017;1(4):323–325.] INTRODUCTION cardiac monitor, end tidal CO2 (ETCO2) and pulse oximetry Ketamine is a common medication, used in isolation as well (POx), in addition to being placed on two liters nasal cannula as with other agents, for pediatric sedation in the emergency (NC). No intravenous (IV) access was obtained prior to sedation. department (ED). It is often turned to because of its efficacy, ease Seventy milligrams (4.4mg/kg) of ketamine was administered IM of use, and favorable safety profile. Common side effects of into the right thigh.
    [Show full text]
  • Diphenhydramine Dosage Sheet Concord Pediatrics, P.A
    Diphenhydramine Dosage Sheet Concord Pediatrics, P.A. (603) 224-1929 BRAND NAMES: Benadryl INDICATIONS: Treatment of allergic reactions, nasal allergies, hives and itching. FREQUENCY: Repeat every 6 hours as needed. Don't give more than 4 times a day. DOSAGE: Determine by using the table below. Please speak with a medical provider before giving Diphenhydramine to a child under 1 year old. Child’s Dose in mg Children’s Liquid Chewable/Fastmelts Tabs/Caps/Gels Weight (lb) (12.5mg/ 5mL) 12.5mg tablets 25mg tablets *12-16 lbs 6.25 mg 2.5 mL *17-19 lbs 9.375 mg 3.75 mL *20-24 lbs 10 mg 4 mL 25-37 lbs 12.5 mg 5 mL 1 tab 38-49 lbs 18.75 mg 7.5 mL 1.5 tabs 50-69 lbs 25 mg 10 mL 2 tabs 1 tab 70-99 lbs 37.5 mg 15 mL 3 tabs 1.5 tabs >100 lbs 50 mg 20 mL 4 tabs 2 tabs Table Notes: *AGE LIMIT: For allergies, don't use under 1 year of age (Reason: it's a sedative). For colds, not recommended at any age (Reason: no proven benefits) and should be avoided if under 4 years old. Avoid multi-ingredient products in children under 6 years of age (Reason: FDA recommendations 10/2008). MEASURING the DOSAGE: Syringes and droppers are more accurate than teaspoons. If possible, use the syringe or dropper that comes with the medicine. If not, medicine syringes are available at pharmacies. Regular spoons are not reliable. ADULT DOSAGE: 50 mg Why use Diphenhydramine? Antihistamines can be used to treat your child’s runny nose, itchy eyes, and sneezing due to allergies.
    [Show full text]
  • Chronic Pain Management Toolkit
    Chronic Pain Management Urine Drug Testing Toolkit Screening (see chart on next page) Most guidelines recommend screening patients to determine risks of drug misuse and abuse and to mitigate those risks as much as possible. Unfortunately, there are no risk assessment tools that have been validated in multiple settings and populations. Screening is typically based on risk factors that can be identified through a thorough patient history, the use of prescription drug monitoring programs (PDMPs), the opioid risk tool (provided in this toolkit), and, on occasion, drug screening. However, it is important to standardize testing as cited risk factors (e.g. sociodemographic factors, psychological comorbidity, substance use disorders, etc.) might unfairly impact certain vulnerable populations. Involvement of the whole health care team and full disclosure and discussion of the screening protocol with patients is central to providing patient-centered and comprehensive pain management. Prior to drug testing, physicians should inform the patient of the reason(s) for testing, how often they will be tested, and what the results might mean. This gives patients an opportunity to disclose any additional drug or substance use which may help with identification of false positives and appropriate interpretation of test results. Physicians must understand the limitations of the urine and confirmatory tests available, including what substances are detected by a particular test, and the reasons for false-positive and false-negative tests. Changes in prescribing for a particular patient should not be based on the result of one abnormal screening test, but should only occur after looking at all available monitoring tools as well as repeating the drug screen with the most specific test available.
    [Show full text]
  • Children with Respiratory Disorders: Asthma and Allergies
    Oral Health Fact Sheet for Dental Professionals Children with Respiratory Disorders: Asthma and Allergies Asthma is a chronic respiratory disease associated with airway obstruction, with recurrent attacks of paroxysmal dyspnea, and wheezing due to spasmodic contraction of the bronchi. (ICD 9 code 493.2) Allergy is a hypersensitivity to an agent caused by an immunologic response to an initial exposure. (ICD 9 code 995.3) Prevalence • Asthma affects 9.3% of the population, higher in females and African-Americans Manifestations Clinical • Constriction of bronchi, coughing, wheezing, chest tightness, and shortness of breath Oral • Increased caries risk, enamel defects • Increased gingivitis and periodontal disease risk; and more calculus • Higher rates of malocclusion and increased: overjet, overbite, posterior crossbite; high palatal vault • Oral candidiasis, xerostomia, decreased salivary flow rate and salivary pH Other Potential Disorders/Concerns • none Management Medication SYMPTOM MEDICATION SIDE EFFECTS Breathing difficulties A. Bronchodilators (Β2-agonists) A. Oral candidiasis, xerostomia, decreased salivary flow rate B. Corticosteroids B. Oral candidiasis, dental caries C. Antihistamines C. Xerostomia D. Decongestants D. Xerostomia Sedation • Hydroxyzine and benzodiazepines recommended; avoid narcotics and barbiturates due to their histamine releasing properties → bronchospasm and potentiated allergic response. Intravenous sedation • Use extreme caution due to limited control of the airway. Avoid • Aspirin, other salicylates and NSAIDS (due to allergies) may provoke a severe exacerbation of bronchoconstriction; use acetaminophen. Behavioral Stress-management techniques; may use nitrous oxide in mild to moderate asthmatics after medical consultation. Anxiety can cause acute exacerbation. Children with Respiratory Disorders: Asthma and Allergies continued Dental Treatment and Prevention • Assess child’s risk of acute exacerbation/anaphylaxis during dental treatment prior to examination.
    [Show full text]
  • Ketamine and Serotonin Syndrome: a Case Report
    Residents’ Voices Ketamine and serotonin syndrome: A case report Clay Gueits, MD, and Martin Witkin, DO ong utilized as a rapid anesthetic, ket- with haloperidol (dose unknown) with amine has been increasingly used in reportedly good effect. On Day 7, she was Lsub-anesthetic doses for several psy- discharged home. chiatric indications, including depression, Upon returning home, she experienced suicidality, and chronic pain. Recently, persistent altered mental status. Her signifi- an intranasal form of esketamine—the cant other brought her to our hospital for fur- S-enantiomer of ketamine—was FDA- ther workup. Ms. O’s body temperature was Clay Gueits, MD approved for treatment-resistant depression. 37.6°C, and she was diaphoretic. Her blood Previously, researchers believed ketamine pressure was 154/100 mm Hg, and her heart mediated its analgesic and psychotropic rate was 125 bpm. On physical examination, effects solely via N-methyl-d-aspartate she had 4+ patellar and Achilles reflexes (NMDA) receptor antagonism, but emerg- with left ankle clonus and crossed adductors. ing research has described a seemingly more Her mental status exam showed increased complex receptor profile.1 One such ancillary latency of thought and speech, with bizarre pharmacologic mechanism is occupation of affect as evidenced by illogical mannerisms Martin Witkin, DO the serotonin receptor.1,2 However, there and appearance. She said she was “not feel- is sparse literature describing the possible ing myself” and would stare at walls for pro- Dr. Gueits is a PGY-2 Psychiatry extent of ketamine’s involvement in sero- longed periods of time, appearing internally Resident, Department of Psychiatry, tonin syndrome.3 Here, we describe a case preoccupied and confused.
    [Show full text]
  • Diphenhydramine (Systemic) Epinephrine (Systemic)
    DIPHENHYDRAMINE (SYSTEMIC) ^ Diphenhist [OTC] see DiphenhydrAMINE (Systemic) on page 34 Insomnia, occasional: Oral: Children 2 to 12 years, weighing 10 to 50 kg (off-label use): DiphenhydrAMINE (Systemic) Limited data available: 1 mg/kg administered 30 minutes before bedtime; maximum single dose: 50 mg (Russo, 1976) Brand Names: US Aler-Dryl [OTC]; Allergy Relief Childrens Children ≥12 years and Adolescents: Refer to adult dosing. [OTC]; Allergy Relief [OTC]; Altaryl [OTC]; Anti-Hist Allergy [OTC]; Motion sickness: Banophen [OTC]; Benadryl Allergy Childrens [OTC]; Benadryl Prophylaxis: Oral: Allergy [OTC]; Benadryl Dye-Free Allergy [OTC]; Benadryl [OTC]; Manufacturer's labeling: Infants, Children, and Adolescents: Complete Allergy Medication [OTC]; Complete Allergy Relief [OTC]; Note: Administer 30 minutes before motion Dicopanol FusePaq; Dicopanol RapidPaq; Diphen [OTC]; Diphenh- Weight-directed dosing: 5 mg/kg/day divided into 3 to 4 doses; ist [OTC]; Genahist [OTC]; Geri-Dryl [OTC]; GoodSense Allergy maximum: 300 mg daily Relief [OTC]; Naramin [OTC]; Nighttime Sleep Aid [OTC]; Nytol Fixed dosing: 12.5 to 25 mg 3 to 4 times daily Maximum Strength [OTC]; Nytol [OTC]; Ormir [OTC]; PediaCare Alternate dosing: Children 2 to 12 years: Limited data available: Childrens Allergy [OTC]; Pharbedryl; Pharbedryl [OTC]; Q-Dryl 0.5 to 1 mg/kg/dose every 6 hours; maximum single dose: [OTC]; QlearQuil Nighttime Allergy [OTC]; Quenalin [OTC] [DSC]; 25 mg. First dose should be administered 1 hour before travel Scot-Tussin Allergy Relief [OTC]; Siladryl
    [Show full text]
  • Reduced Levels of Serotonin 2A Receptors Underlie Resistance of Egr3-Deficient Mice to Locomotor Suppression by Clozapine
    Neuropsychopharmacology (2012) 37, 2285–2298 & 2012 American College of Neuropsychopharmacology. All rights reserved 0893-133X/12 www.neuropsychopharmacology.org Reduced Levels of Serotonin 2A Receptors Underlie Resistance of Egr3-Deficient Mice to Locomotor Suppression by Clozapine 1 2 3 4 4 4 Alison A Williams , Wendy M Ingram , Sarah Levine , Jack Resnik , Christy M Kamel , James R Lish , 4 3 4 5 5,6 Diana I Elizalde , Scott A Janowski , Joseph Shoker , Alexey Kozlenkov , Javier Gonza´lez-Maeso and ,4 Amelia L Gallitano* 1 2 School of Life Sciences, Arizona State University, Tempe, AZ, USA; Department of Molecular and Cell Biology, Life Sciences Addition, 3 4 University of California, Berkeley, CA, USA; University of Arizona College of MedicineFTucson, Tucson, AZ, USA; Department of Basic Medical 5 Sciences and Psychiatry, University of Arizona College of MedicineFPhoenix, Phoenix, AZ, USA; Department of Psychiatry, Mount Sinai 6 School of Medicine, New York, NY, USA; Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA The immediate-early gene early growth response 3 (Egr3) is associated with schizophrenia and expressed at reduced levels in postmortem patients’ brains. We have previously reported that Egr3-deficient (Egr3À/À) mice display reduced sensitivity to the sedating effects of clozapine compared with wild-type (WT) littermates, paralleling the heightened tolerance of schizophrenia patients to antipsychotic side effects. In this study, we have used a pharmacological dissection approach to identify a neurotransmitter receptor defect in Egr3À/À mice that may mediate their resistance to the locomotor suppressive effects of clozapine. We report that this response is specific to second- / generation antipsychotic agents (SGAs), as first-generation medications suppress the locomotor activity of Egr3À À and WT mice to a similar degree.
    [Show full text]
  • A Strategy to Decrease the Use of Risky Drugs in the Elderly
    REVIEW SUSAN M. FOSNIGHT, RPH, CGP, BCPS KYLE R. ALLEN, DO CME Clinical Staff Pharmacist, Department of Pharmacy, Summa Health Chief, Division of Geriatric Medicine, Medical Director, Post Acute CREDIT System, Akron, OH and Senior Services, Summa Health System; Associate Professor of Clinical Internal and Family Medicine, Northeastern Ohio Universities College of Medicine, Akron, OH CAROLYN M. HOLDER, MSN, RN, CNS SUSAN HAZELETT, MSN, RN Geriatrics Coordinator, Post Acute and Senior Services, Summa Research Associate, Summa Health System, Akron, OH Health System, Akron, OH A strategy to decrease the use of risky drugs in the elderly ■ ABSTRACT OME MEDICATIONS that are safe in most S patients are best avoided in elderly Many medications that are safe in most patients pose patients—and pharmacists can help physicians serious risks in older patients, including functional avoid them. decline, delirium, falls, and poorer outcomes. We describe In this paper we discuss three medications, our institution’s program of “academic detailing,” chosen on the basis of scientific evidence and designed to reduce the use of three high-risk drugs in our personal experience, that are associated elderly patients. with unacceptable risk in elderly patients and for which reasonable alternatives exist: ■ KEY POINTS meperidine, diphenhydramine, and amitripty- line. Meperidine, diphenhydramine, and amitriptyline all pose We also describe our institution’s program a high risk of adverse reactions in older adults. Safer of “academic detailing” to reduce their use. alternatives are available. Whenever a physician prescribes one of these high-risk drugs to an elderly patient at our In our program, the pharmacy computer system generates institution, a computer alerts the pharmacist, a daily report of elderly patients who are prescribed any who contacts the prescribing physician to explain the problems patients often have with of these three agents.
    [Show full text]
  • Nitrous Oxide: Pharmacology, Signs/Symptoms, Patient Selection
    Nitrous Oxide: Pharmacology, Signs/Symptoms, Patient Selection Characteristics of Oxygen Characteristics of Nitrous Oxide Clear Clear Colorless Colorless Tasteless Tasteless (to most) Odorless Odorless Produced by careful heating of ammonium Produced by fractional distillation of air nitrate, which decomposes into nitrous oxide and water vapor. An interesting Note: Another use for nitrous oxide has been as a boost for racecars. 2N2O → 2N2 + O2 As the reaction takes place in the combustion chamber of a car, 33% more gas is produced. This provides a boost to the piston and an increase in heat. Other effects: the oxygen given off accounts for more efficient combustion of fuel, the nitrogen buffers the increased cylinder pressure controlling combustion, and the latent heat of vaporization of the nitrous oxide reduces the intake pressure. The result is a dramatic increase in power and acceleration. Other Notes or Questions to Ask: http://bestdentalCE.com Sunday July 28, 2019 Page 1 of 46 Description of Nitrous Oxide Therapeutic Category - Sedative, Anxiolytic Uses - To induce sedation and analgesia in the anxious dental patient, a principal adjunct to inhalation and IV general anesthesia (GA) in medical patients Route of Administration – Inhalation Dosage - 20 - 70% administered via nasal hood Drug Uptake - N20 is rapidly absorbed via the lungs, onset 1-2 minutes Nitrous oxide is stable and inert at room temperature -- inherent Inherent Molecular Stability molecular stability Physical Constants of N2O • Density of Nitrous oxide = 1.997 g/L • Density of Air = 1.239 g/L Molecular Weight 44.013 Because nitrous oxide is more dense than Boiling Point @ 1 atm (°F) -129.1 air, the greatest concentration of unscavenged gas will be low and near the Freezing Point @ 1 atm (°F) -131.5 floor.
    [Show full text]
  • Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: an American Academy of Sleep Medicine Clinical Practice Guideline Michael J
    pii: jc-00382-16 http://dx.doi.org/10.5664/jcsm.6470 SPECIAL ARTICLES Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline Michael J. Sateia, MD1; Daniel J. Buysse, MD2; Andrew D. Krystal, MD, MS3; David N. Neubauer, MD4; Jonathan L. Heald, MA5 1Geisel School of Medicine at Dartmouth, Hanover, NH; 2University of Pittsburgh School of Medicine, Pittsburgh, PA; 3University of California, San Francisco, San Francisco, CA; 4Johns Hopkins University School of Medicine, Baltimore, MD; 5American Academy of Sleep Medicine, Darien, IL Introduction: The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults, when such treatment is clinically indicated. Unlike previous meta-analyses, which focused on broad classes of drugs, this guideline focuses on individual drugs commonly used to treat insomnia. It includes drugs that are FDA-approved for the treatment of insomnia, as well as several drugs commonly used to treat insomnia without an FDA indication for this condition. This guideline should be used in conjunction with other AASM guidelines on the evaluation and treatment of chronic insomnia in adults. Methods: The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine. A systematic review was conducted to identify randomized controlled trials, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, and patient values and preferences.
    [Show full text]
  • Typical and Atypical Antipsychotic Drugs Increase Extracellular Histamine Levels in the Rat Medial Prefrontal Cortex: Contribution of Histamine H1 Receptor Blockade
    ORIGINAL RESEARCH ARTICLE published: 17 May 2012 PSYCHIATRY doi: 10.3389/fpsyt.2012.00049 Typical and atypical antipsychotic drugs increase extracellular histamine levels in the rat medial prefrontal cortex: contribution of histamine H1 receptor blockade Matthew J. Fell 1†, Jason S. Katner 1, Kurt Rasmussen1, Alexander Nikolayev 2, Ming-Shang Kuo2, David L. G. Nelson1, Kenneth W. Perry 1 and Kjell A. Svensson1* 1 Psychiatric Disorders, Neuroscience Discovery Research, Eli Lilly and Company, Indianapolis, IN, USA 2 Translational Science, Eli Lilly and Company, Indianapolis, IN, USA Edited by: Atypical antipsychotics such as clozapine and olanzapine have been shown to enhance Bernat Kocsis, Harvard Medical histamine turnover and this effect has been hypothesized to contribute to their improved School, USA therapeutic profile compared to typical antipsychotics. In the present study, we examined Reviewed by: Francesc Artigas, Instituto de the effects of antipsychotic drugs on histamine (HA) efflux in the mPFC of the rat by means Investigaciones Biomédicas de of in vivo microdialysis and sought to differentiate the receptor mechanisms which under- Barcelona, Spain lie such effects. Olanzapine and clozapine increased mPFC HA efflux in a dose related Ritchie Brown, Harvard Medical manner. Increased HA efflux was also observed after quetiapine, chlorpromazine, and per- School, USA phenazine treatment. We found no effect of the selective 5-HT2A antagonist MDL100907, *Correspondence: Kjell A. Svensson, Neuroscience 5-HT2c antagonist SB242084, or the 5-HT6 antagonist Ro 04-6790 on mPFC HA efflux. Discovery Research, Lilly Research HA efflux was increased following treatment with selective H1 receptor antagonists pyril- Laboratories, Lilly Corporate Center, amine, diphenhydramine, and triprolidine, the H3 receptor antagonist ciproxifan and the Indianapolis, IN 46285, USA.
    [Show full text]