Delirium is highly prevalent among elderly post-operative patients with no pharmacological intervention approved by the Food and Drug Administration for prevention or treatment. We conducted a systematic evidence review to critically appraise literature related to the pharmacotherapy of post-operative delirium. Ten studies fulfilled our inclusion criteria with two interventions for delirium treatment and eight interventions for delirium prevention in post-operative patients. The quality of evidence of delirium treatment studies was poor, whereas the quality of evidence in delirium prevention studies ranges from moderate to high. Delirium treatment studies find similar delirium duration and length-of-stay outcomes between haloperidol and either morphine or ondansetron. Risperidone was found to reduce the conversion of sub-syndromal delirium to delirium in one study compared to placebo. Haloperidol, olanzapine, and ketamine were each found to reduce delirium incidence, whereas rivastigmine had no impact on delirium incidence or duration. Lighter anesthesia as monitored by bi-spectral index led to a decreased delirium incidence. Considering results from studies conducted prior to the dates of this review, the current evidence suggests that certain pharmacologic classes and lighter sedation using BIS monitoring may prevent post-operative delirium, although a conclusive recommendation for clinical practice must await further research.

Duty hour restrictions for residency training were implemented in the United States to improve residents’ educational experience and quality of life, as well as to improve patient care and safety; however, these restrictions are by no means problem-free. In this paper, we discuss the positive and negative aspects of duty hour restrictions, briefly highlighting research on the impact of reduced duty hours and the experiences of American residents. We also consider whether certain specialties (e.g., Emergency Medicine, Radiology) may be more amenable than others (e.g., Surgery) to duty hour restrictions. We conclude that feedback from residents is a crucial element that must be considered in any future attempts to strike a balance between reducing fatigue and enhancing education.

A 40-year-old man, who had regularly taken illicit amphetamine by intra-nasal inhalation for several years without ill effects, was admitted to hospital with signs of massive adrenergic overstimulation shortly after inhaling material which he had purchased in the belief that it was amphetamine. The administration of the beta-blocker practolol produced a paradoxical increase in blood pressure. After his discharge from hospital he suffered disabling feelings of anxiety for several weeks. Analysis of a sample of the material showed it to contain p-methyl amphetamine and N, p-dimethyl amphetamine.

No abstract

Introduction: Management of refractory shock in the setting of overdose can be challenging. We describe a case of vasodilatory and cardiogenic shock after bupropion and citalopram overdose. Vasopressors and conventional therapies failed to stabilize the patient resulting in placement of venoarterial extracorporeal membrane oxygenation (Va eCMo) for patient rescue and recovery. Case summary: a 23-year-old male presented after intentional bupropion and citalopram overdose. He developed seizures, acute respiratory failure, metabolic acidosis, severe refractory vasodilatory, and cardiogenic shock. the patient received mechanical ventilation, advanced Cardiac Life support (aCLs), Intralipid ® therapy, vasopressor support, and Va eCMo. total duration of eCMo was 72 h. serum laboratory studies drawn on the day of admission showed serum concentrations of citalopram (3400 ng/mL, reference range 9-200 ng/mL) and bupropion (597 ng/mL, reference range 50-100 ng/mL). the patient was extubated on hospital day 18 and discharged home with referral to outpatient psychiatry, 28 days after intentional overdose. Conclusions: this case illustrates successful recovery after hydroxocobalamin and Va eCMo in severe vasodilatory and cardiogenic shock following overdose of bupropion and citalopram.