Nonconvulsive status epilepticus in two patients receiving tiagabine treatment

In the course of an open study on the add-on treatment of tiagabine (TGB) in patients with localization-related epilepsy syndromes, 2 of 9 patients developed nonconvulsive status epilepticus (NCSE) with electroclinical features consistent with those of atypical absence seizures. One patient had never had atypical absence seizures before. In both cases, immediate discontinuation of TGB was followed by complete and sustained electroclinical remission; we suggest a possible causative role of TGB. This observation may be consistent with a paradoxical effect of TGB in selected cases. Possible risk factors and a pathophysiological hypothesis are discussed.     

Hypoproteinemia, strong-ion difference, and acid-base status in critically ill patients

The present study was a prospective, nonrandomized, observational examination of the relationship among hypoproteinemia and electrolyte and acid-base status in a critical care population of patients. A total of 219 arterial blood samples reviewed from 91 patients was analyzed for arterial blood gas, electrolytes, lactate, and total protein. Plasma strong-ion difference ([SID]) was calculated from [Na+] + [K+] - [Cl-] - [La-]. Total protein concentration was used to derive the total concentration of weak acid ([A]tot). [A]tot encompassed a range of 18.7 to 9.0 meq/l, whereas [SID] varied from 48.1 to 26.6 meq/l and was directly correlated with [A]tot. The decline in [SID] was primarily attributable to an increase in [Cl-]. A direct correlation was also noted between PCO2 and [SID], but not between PCO2 and [A]tot. The decrease in [SID] and PCO2 was such that neither [H+] nor [HCO-3] changed significantly with [A]tot.     

Endocrine disorders in critically ill children

Endocrine disorders in critically ill infants and children can be the manifestation of an existing but previously unrecognized condition, or hormonal derangements precipitated by deleterious effects on endocrine function of a critical illness or its prescribed therapy. To achieve successful resolution of these crises, a general understanding of various endocrine dysfunctions, clinical symptomatology, diagnosis, and medical and nursing management is essential.     

Reversing oliguria in critically ill patients

Oliguria is a common occurrence in the ICU setting. In patients with preserved renal function, fluid challenges or low doses of diuretics are generally successful. In patients with oliguric renal failure, it is still essential to ensure adequate intravascular fluid volume, especially in critically ill patients. Loop diuretics remain the mainstay of treatment. When diuretic resistance is encountered, physicians should consider further optimization of hemodynamics, alternative loop diuretics, and combined drug therapy. In some cases, continuous renal replacement therapy can be very effective. Yet, while these interventions can help reduce the morbidity of severe volume overload, they have not been shown to improve mortality rates.     

Evaluation of pain in the critically ill patient

This article reviews the evaluation of pain in critically ill patients of all ages. Sources of pain and its physiologic significance are discussed. Factors influencing pain, perception, and behavior are also addressed to broaden health care professionals' vision of the difficulties associated with accurate pain assessment. The evaluation process, including a discussion of several tools ranging from visual analog scales to bispectral analysis, as well as goals of therapy are discussed. Finally, a practical approach to the assessment process, which supports the need for established, regularly used evaluation and treatment protocols, is proposed.     

Laparotomy for abdominal sepsis in the critically ill

A culture system designed to support the development of individual preantral mouse ovarian follicles has been employed to study follicle growth in the New World marsupial species Monodelphis domestica. Preantral follicles were isolated mechanically and cultured individually in microdrops under oil. Preliminary results indicate that follicle growth was positively correlated to the concentration of follicle-stimulating hormone (FSH) provided, with 1.0-1.5 IU FSH mL-1 producing the best results. Incubation at the body temperature of M. domestica (33 degrees C) was found to be preferable to that at 37 degrees C. The culture system was able to support follicle growth; however, despite follicles exceeding the size when antrum formation occurs in vivo, they remained preantral.     

Ifosfamide-induced nonconvulsive status epilepticus

OBJECTIVE: To describe a patient with ifosfamide-induced nonconvulsive status epilepticus. CASE SUMMARY: A 71-year-old woman with a history of malignant mixed mesodermal tumor involving the uterus, cervix, and vagina was admitted because of local recurrence. After receiving 3 doses of ifosfamide/mesna, she was found to be unresponsive. Physical examination and laboratory data revealed no significant changes. An electroencephalogram was consistent with the diagnosis of nonconvulsive status epilepticus. The patient's mental status returned to baseline after treatment with intravenous phenytoin and discontinuation of ifosfamide therapy. DISCUSSION: Central nervous system (CNS) toxicity has been described with ifosfamide, with most cases reported in the pediatric population. Among CNS toxicities, generalized tonic-clonic seizures have been reported in both children and adults. This represents the first report of nonconvulsive status epilepticus induced by ifosfamide. CONCLUSIONS: There was a temporal relationship between the onset of nonconvulsive status epilepticus and initiation of ifosfamide infusion. No other identifiable factor contributed to the unresponsiveness.     

Acquired carnitine abnormalities in critically ill children

In order to characterize the role of carnitine during metabolic stress, we prospectively determined carnitine profiles in plasma and urine on admission, days 2, 5, 10 and 15, among 28 critically ill children free of any known conditions associated with secondary carnitine deficiency. More than 25% of plasma and 50% of urinary carnitine measurements were abnormal; 96% (27/28) of patients displayed on at least one occasion an abnormal [< -2 SD or > +2 SD] carnitine value in plasma. Three children had extremely low [< 10 micromol/l] free carnitine (FC) levels in plasma. Plasma esterified and FC levels on admission were not related to the risk of mortality [PRISM score], to muscle lysis [CK values], and to the caloric intake. Levels of FC and esterified carnitine in plasma were unrelated to those measured in urine. Conclusion: Abnormal plasma and urine carnitine measurements are frequently found in critically ill children; the biological significance of these perturbations remains unclear. Caution must be exercised before concluding that an abnormal carnitine value is indicative of an underlying hereditary metabolic disorder in this population.     

Ionized magnesium concentrations in critically ill children

OBJECTIVE: To test the hypothesis that many critically ill children exhibit ionized hypomagnesemia despite having normal total magnesium (TMg) concentrations. DESIGN: A prospective, observational study with convenience sampling. SETTING: Pediatric and cardiovascular intensive care units of a large children's hospital. PATIENTS: Patients aged 1 day to 21 yrs admitted from January 1 to October 31, 1996. Patients with chronic renal failure or weight <3 kg were excluded. A group of healthy children involved in a school-based nutritional assessment study were also studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty-seven patients (5.4+/-5.7 [SD] yrs) and 24 healthy children (10.84+/-0.93 yrs, p< .001) were studied. Plasma was assayed for ionized magnesium (IMg) using a blood analyzer. Forty (59%)/67 critically ill subjects had IMg concentrations <0.40 mmol/L, the lowest published normal value and the lowest value observed in our group of healthy children. Of these, 24 (60%)/40 had normal TMg concentrations. IMg was significantly (p=.00) lower in critically ill subjects than in the group of healthy children (0.37+/-0.10 mmol/L vs. 0.46+/-0.03 mmol/L). IMg did not correlate strongly with ionized calcium (r2=0.49), albumin (r2=0.09), or pH (r2=0.18). CONCLUSION: Many critically ill children exhibit ionized hypomagnesemia with normal TMg concentrations. These children would not be recognized as magnesium-deficient based on routine TMg testing. Critically ill children exhibited significantly lower concentrations of IMg than a group of healthy children.