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In addition order levitra soft 20mg with visa erectile dysfunction etiology, the provider can immediately detect whether undesirable tissue responses occur and modify treatment parameters accordingly to provide a safe order levitra soft 20mg otc best erectile dysfunction pills 2012, effective treatment order levitra soft 20 mg line erectile dysfunction quick remedy. Undesirable Clinical Endpoints Undesirable clinical endpoints are unintended tissue responses seen on the skin after pulsing the laser buy discount levitra soft 20mg line erectile dysfunction at age 26. They indicate potential thermal injury to the epidermis and are usually due to overly aggressive laser parameters for a given Fitzpatrick skin type. If any of these occur, it is advisable to discontinue treatment and cool the skin using wrapped ice packs for 15 minutes and compression for bleeding. Patients are monitored over the next few weeks for formation of enlarged blisters (bullae), intense erythema and induration (firmness), which may precede scarring. Performing Laser Treatments Guidelines for laser treatments using one device are provided in each chapter for the indication discussed. While the principles apply to most lasers used for that chapter’s indication, manufacturer recommendations for the specific device used at the time of treatment should be followed. If the patient is recently sun exposed or has tanned skin in the treatment area, it is advisable to wait 1 month before treating to reduce the risk of complications. In general, there should be subtle endpoints with initial treatments and pain should be less than or equal to 5 on a scale of 1–10. If no endpoints are observed, gradually increase the fluence in small increments as tolerated by the patient until desirable clinical endpoints are achieved. Postprocedure Skin Care for Laser Treatments Selection of postprocedure skin care products is determined by whether or not the skin is intact after treatment. The goal with all postprocedure products is to soothe, protect and hydrate the skin to promote healing and hasten resolution of erythema. Intact Skin Skin is intact after nonablative laser treatments for pigmented lesions, vascular lesions, hair removal, nonablative skin resurfacing, and for most tattoo removal treatments. However, if bleeding or blistering occurs with a laser treatment, such as tattoo removal, the skin is not intact and should be treated as such. Postprocedure erythema is managed with a topical corticosteroid cream applied twice daily, and the potency is based on the severity of erythema: low potency steroids (e. Nonocclusive moisturizers used postprocedure usually contain ingredients to soothe skin (such as borage and evening primrose seed oils) and promote healing (such as beta glucan and peptides). Nonintact Skin Laser treatments that create a wound, such as ablative skin resurfacing and some tattoo removal treatments, are managed differently from intact skin. These products are usually ointments and examples include Aquaphor® (Beiersdorf), Hydra Balm (SkinCeuticals), Protective Recovery Balm (biO2® ® Cosmeceuticals), and Puralube (Nycomed). Occlusive moisturizers are continued until re-epithelialization occurs, usually for 4–7 days after fractional ablative lasers, and up to 2 weeks or more after nonfractional ablative lasers. Cleansing nonintact skin after ablative laser treatment is discussed in the Aftercare section of Chapter 6. Therefore, sun protective measures such as hats and sun avoidance during this period of healing are very important to prevent pigmentary complications in the treatment area. Once the skin has fully re-epithelialized and is intact, a nonocclusive moisturizer is used and skin care is followed as outlined above. Treatment Intervals In general, nonablative laser procedures are performed as a series of treatments with consistent intervals between treatments for optimal results, while more aggressive procedures such as ablative laser treatments are performed less frequently, or singly. Nonablative laser treatments are usually performed every month or every 2 months, depending on the procedure and the treatment area. Ablative laser treatments for wrinkle reduction by comparison, are typically performed once every year or every few years. Subsequent Treatments Nonablative laser procedures are usually progressive, whereby treatment intensity is increased at each subsequent visit to enhance results. Fluence is usually increased and pulse width decreased to appropriately match the changing lesion characteristics. Typically, the fluence is initially increased for a few treatments and pulse width is decreased in later treatments. Ablative laser treatments are not progressive and, if a subsequent treatment is performed the following year, parameters may not change. Common Follow-Ups Patients may seek posttreatment follow-up for mild issues that are not necessarily complications and each chapter has a section on Common Follow-ups that discusses commonly encountered follow-up issues and provides recommendations for management. While nonablative laser treatments do not typically require scheduled follow-up visits, ablative laser treatments do require postprocedure visits to evaluate for wound healing, manage postprocedure skin care products, and assess for complications. Recommendations for ablative laser follow-up visits are provided in the Follow-up Visit section of Chapter 6. Results Photographs taken before and after laser procedures showing representative results are included in each chapter. Complications • Pain • Erythema • Edema • Hyperpigmentation • Hypopigmentation • Burn • Scar • Infection • Contact dermatitis • Milia • Failure to reduce or improve the intended lesion • Reduction of hair in or adjacent to the treatment area • Ocular injury • Urticaria • Petechiae and purpura This list is representative of some of the complications encountered with laser treatments. Complications specific to each procedure are reviewed in the respective chapters of this book along with strategies for management. Fortunately, most complications encountered are mild and spontaneously resolve without permanent sequelae. Mild complications from laser treatments include prolonged erythema and edema, acne eruptions, milia formation, and contact dermatitis. Severe complications include hypertrophic scarring, delayed onset hypopigmentation, ectropion, disseminated infection, and ocular injury. Nonablative lasers usually leave the skin intact and have milder complications compared to ablative lasers that create an open wound, which increases the frequency and severity of complications. Some of the most common and problematic adverse effects with lasers are associated with cutaneous thermal injury. Thermal injury can result in burns, scarring, and pigmentary changes (hyperpigmentation and hypopigmentation) and can occur with any laser. These patients have abundant epidermal melanin, which serves as a competing chromophore for lasers, increasing laser energy absorption and the risk of thermal injury. Use of aggressive laser parameters including short wavelengths, short pulse widths, small spot sizes, high fluences, and inadequate epidermal cooling are also associated with increased risk of thermal injury (Table 7). Use of checklists, such as the Preprocedure Checklists in each chapter of this book, is recommended to reduce the likelihood of laser complications from provider error. However, it should be noted that lasers are complex devices, laser–tissue interactions can vary with individual patients and even in the best of hands with the best technique, complications can occur. Hyperpigmentation, darkened skin coloration relative to surrounding skin, is a very common complication and has been reported with virtually every laser device. Hyperpigmentation usually resolves spontaneously over several months, although in rare instances it may be permanent. Hypopigmentation, lightened skin coloration relative to surrounding skin, is a less common but more significant complication than hyperpigmentation.
If the suture appears to be insecure purchase levitra soft 20mg with amex erectile dysfunction caused by lisinopril, it is either removed or converted to a figure-of-eight stitch purchase 20 mg levitra soft with mastercard impotence ultrasound. Pledgeted Sutures When the annulus is calcified or too friable to hold sutures securely cheap 20 mg levitra soft mastercard young living oils erectile dysfunction, pledgeted sutures (2-0 Ethibond or Ticron) are satisfactory alternatives levitra soft 20 mg with visa erectile dysfunction treatment hypnosis. It is technically easier to insert the sutures in an everted manner, with the pledgets lying above the annulus in the aorta. The alternative technique of placing sutures from below, which allows the pledgets to remain subannular, provides a secure and satisfactory buttressing effect. If utilized with a disc valve, the surgeon must ensure that no pledgets interfere with the normal movement of the disc. Whether the pledgeted sutures are placed from below or above the annulus, they are inserted into the sewing ring of the prothesis in a horizontal mattress fashion. Heart Block Deeply placed sutures near the noncoronary and right coronary annuli can injure the conduction tissues and give rise to various forms of heart block. When there is massive calcification extending onto the ventricular septum or when the tissues are friable because of endocarditis or abscess formation, this complication may be inevitable. Injury to the Left Coronary Artery the precise site of suture placement in the aortic annulus is often obscured by pathologic changes, calcifications, and deformities. Deep sutures placed near the left coronary annulus may puncture the left main coronary artery as it passes behind the aortic root. This is indeed a very grave error, and the surgeon must always be sensitive to this possibility and take every precaution to avoid its occurrence. If the structural or functional integrity of the left main coronary artery is in any way jeopardized, bypass grafting of all its major branches must be performed. Drying of the Tissue Prosthesis Tissue prostheses tend to lose moisture when in a dry field, a process accelerated by heat generated from the operating room overhead lights. As a precaution, the prosthesis must be kept moist by intermittently rinsing it with normal saline solution at room temperature. Suture Placement in Prosthetic Sewing Ring Suture needles are passed through the prosthetic sewing ring from below upward, with the needle exiting at the junction of the outside half with the inside half of the sewing ring. Sutures placed in such a manner in the sewing ring of a bioprosthesis are well away from the tissue-sewing ring interface and avoid traumatizing or perforating the tissue leaflets. Similarly, the suture knots will face away from the orifice of a mechanical valve, preventing contact with the disc or leaflets. Bioprosthetic Struts Position Before placing sutures in the prosthesis, every precaution should be taken to ensure that the tissue prosthesis is oriented so that the struts do not obstruct the coronary artery ostia. This strategy will likely ensure that the other two struts will not occlude the left or right coronary ostia. Seating the Prosthesis When all sutures have been accurately placed in the sewing ring, the prosthesis is gently lowered and fitted snugly in the annulus. Many surgeons rinse the sutures with saline solution for its lubricating effect, allowing the sutures to be pulled through the sewing ring more smoothly. Narrow Sinotubular Junction When the sinotubular junction of the ascending aorta is narrower than the aortic annulus, the appropriate size prosthesis will be too large to pass through it. In such situations, the holder is removed and the prosthetic low- profile valve is turned on end, then lowered and seated safely in the aortic annulus. Chemical or Thermal Injury to a Bioprosthesis Antibiotics or other chemical solutions may react with glutaraldehyde and produce irreversible damage to the tissue prosthesis. The surgeon should not attempt to manipulate and force a large prosthesis into a relatively small aortic annulus because this may distort the flexible ring and the valve leaflets, causing incompetence. Obstructive Elements No redundant tissue fragment, calcium, or subannular pledgets should protrude into the left ventricular outflow tract in such a way as to prevent satisfactory opening and closing of the valve. Normal valve function must be ensured and any obstructing element removed before final anchoring of the prosthesis. After the prosthesis has been satisfactorily seated, the sutures are tied down securely and cut short. Direction of Tying the direction of tying the sutures should always be parallel to the curve of the sewing ring. Long Suture Ends Sutures, when tied, must be cut short, and the direction of the knot must be leaning toward the periphery of the sewing ring of the prosthesis. A long suture end will scratch the leaflet tissue, resulting in chronic irritation, injury, and, finally, perforation of the tissue leaflets. A long suture end can also protrude into the prosthetic orifice and interfere with the normal closure of the occluding mechanism of a mechanical valve. Abnormal Location of the Coronary Artery Ostium Occasionally, the orifice of the left main coronary artery is located next to the commissure of the aortic annulus. Unobstructed Prosthesis Function Before closure of the aortotomy, it is imperative that normal, unobstructed opening and closing of a mechanical prosthesis be visually verified. Septal Hypertrophy Patients with long-standing aortic stenosis and/or hypertensive heart disease may have marked septal as well as concentric hypertrophy of the left ventricle. The surgeon must be cognizant of any discrepancy in size between the left ventricular outflow tract and the aortic annulus. The single-disc group of prostheses, exemplified by the Medtronic-Hall mechanical valve, can be rotated after implantation to ensure free movement of the disc. The smaller part of the disc that descends into the left ventricle must be positioned away from the septum. Most of the bileaflet prostheses can also be rotated and are subject to the same principle of free movement of the leaflets. When the left ventricular outflow is markedly limited by septal hypertrophy, some septal muscle mass can be excised. Aortotomy Closure the aortotomy closure is usually accomplished with continuous 4-0 Prolene or 5-0 Prolene sutures in a double- layer manner starting at each end of the incision. Bleeding from the Ends of Aortotomy Troublesome bleeding from the ends of the aortotomy can be prevented to some extent by suturing back and taking a bite of undivided aortic wall before continuing forward along the incision or using a pledget at each end. Coronary Air Embolism Air embolism to the coronary arteries, particularly the right coronary artery, probably does occur during the evacuation of air from the left ventricle. The pump flow is reduced, and the right coronary artery is temporarily occluded with digital pressure. The surgeon then partially unclamps the aorta and allows blood mixed with air trapped in the aortic root to flow freely from the vent opening on the aortotomy. High suction is applied to a slotted vent needle in the aortic root to continuously remove any air bubbles that may be ejected as the heart is filled and ventilation is begun (see Chapter 4). Friable Aortic Wall A friable aortic wall may necessitate the placement of additional reinforcing pledgeted sutures. Occasionally, when the aortic wall has been denuded of its adventitia or if the aorta is thin walled or friable, the aortotomy suture line can be reinforced with strips of autologous pericardium. Controlling Bleeding from the Aortotomy Ends To control bleeding from either end of the aortotomy, it is prudent to cross-clamp the aorta temporarily or to reduce the perfusion flow considerably; this will provide good exposure of the bleeding sites and facilitate satisfactory placement of pledgeted sutures to obtain absolute control of bleeding.
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Fibroblast-like and macrophage-like synovial cells perpetuate synovial inflammation through elaboration of cytokines that have paracrine and autocrine activities quality 20mg levitra soft erectile dysfunction free samples. In addition to cytokines purchase 20 mg levitra soft overnight delivery erectile dysfunction see a doctor, the products of several cell types also induce adhesion molecules and stimulate angiogenesis discount 20mg levitra soft mastercard disease that causes erectile dysfunction. Activated synovial cells also release metalloproteinases and other enzymes responsible for degradation of articular cartilage and erosion of bone levitra soft 20mg on-line impotence injections medications. Although joint sepsis after arthrocentesis or intra-articular steroid injection is a rare complication, infection has been reported in this context and may be more resistant to treatment. When a single or few joints are more inflamed more than others in a rheumatoid patient, joint sepsis should be excluded by arthrocentesis, Gram’s stain, and cultures of synovial fluid, blood, and other appropriate sites guided by the patient’s signs and symptoms. Inspection of the skin for a possible portal of bacterial entry and a thorough general examination are of utmost importance. Early surgical drainage with synovectomy may be the preferred treatment because there is more proliferative synovitis and an increased tendency for loculations to develop. Pulmonary infections are common, particularly among patients with poor mucociliary clearance, with ineffective cough, on immunosuppressive therapy, or with associated Sjögren syndrome. The differential diagnoses of the pleural effusions include malignancy, pulmonary infarction, viral or bacterial infection, tuberculosis, and empyema. Infectious empyema occurs with increased frequency in patients with preexisting rheumatoid pleural effusions and should be suspected in debilitated, anemic, or hypoproteinemic patients who have been treated with corticosteroids and have persistent fever and pleural effusions. In recurrent pleuritis or sterile empyema, intrapleural corticosteroids, systemic corticosteroids in moderate doses, and additional disease-modifying agents are recommended. High-dose corticosteroid therapy may not be effective and carries an increased risk of empyema formation. Physical and laboratory findings include dry crackles, diminished diffusion capacity, and restrictive physiology, as well as desaturation with exercise. Some patients may respond to corticosteroids alone, but the progressive nature of the disease may require treatment with cytotoxic agents, although it is unclear which immunosuppressants are most effective [12]. Obliterative alveolitis is often characterized by the abrupt onset of dyspnea and a dry cough with inspiratory crackles, sometimes with a mid-inspiratory squeak, a clear chest radiograph or finding of hyperinflation, irreversible airflow obstruction at low volumes on pulmonary function testing, mild-to-moderate arterial hypoxemia with a respiratory alkalosis, and progressive obliteration of small airways (1 to 6 mm in diameter) with constrictive bronchiolitis [13]. Despite the lack of adequate therapeutic trials, when patients present with rapidly progressive deterioration, recommendations based on expert opinion include bronchodilators, inhaled and oral corticosteroids (1 to 1. Rarely, chronic vasculitis may involve pulmonary as well as bronchial arterioles and result in pulmonary hypertension and cor pulmonale. Infectious pneumonia is particularly frequent and the major cause of mortality in rheumatoid patients. Pericarditis, myocarditis, endocarditis (valvulitis), coronary arteritis, aortitis, and cardiac conduction abnormalities have all been reported. The pericardial fluid has the same characteristics as pleural fluid (see the section “Pulmonary Involvement in Rheumatoid Arthritis”). Pericardiocentesis should be performed early when tamponade is suspected (see Chapter 17) or if there is a question of septic or suppurative pericarditis. Aspiration of pericardial fluid may temporarily improve cardiac function, but often the viscosity of the fluid, loculations, and thickness of the pericardium may necessitate pericardiectomy. The myocardium may be affected by granulomatous inflammation that results in heart failure or conduction system abnormalities. For patients with active systemic vasculitis, coronary arteritis may be the cause of myocardial infarctions. Involvement of the aorta, either by rheumatoid granulomas or inflammation of the aortic vasa vasorum, may result in dilatation of the aortic root and aortic valvular insufficiency. Arteritis of other major organs including the gastrointestinal tract, kidneys, heart, and lungs is clinically similar to polyarteritis nodosa. The brain and meninges, spinal cord, peripheral nerves, and muscles may be involved with granulomatous inflammation in the form of rheumatoid nodules or vasculitis; the spinal cord and cranial and peripheral nerves may also be compressed by skeletal and soft tissue structures, and the nervous system may be affected by hyperviscosity syndrome and medications. Manifestations that require immediate intervention include the sensation of anterior instability of the head during neck flexion, drop attacks, loss of urinary bladder and anal sphincter control, dysphagia, vertigo, hemiplegia, dysarthria, nystagmus, changes in level of consciousness, and peripheral paresthesias without evidence of a peripheral cause. For patients with manifestations of spinal cord and brain stem compression, surgical stabilization is indicated. For the nonsurgical candidate, a firm collar can be used in an effort to immobilize the neck and prevent further subluxation. Advances in diagnostic and therapeutic modalities have dramatically improved the survival of lupus patients with renal disease, but 10% to 20% of patients will develop end- stage renal disease. Weighted mean of number of renal transplants per study detailed patient survival at 1, 3, 5 years to be 93. Renal lesions are commonly pleomorphic, vary from one glomerulus to another, and temporally transition from one class to another over time. Semiquantitative scoring to define activity and chronicity may provide information on prognosis and guidelines for therapeutic options. In particular, the presence of proliferative lesions and chronic lesions is associated with greater mortality. In particular, hypovolemia, drug-induced interstitial nephritis or renal insufficiency, renal vein thrombosis, and contrast-induced acute tubular necrosis must be excluded. The long-term outcomes measured by death, end-stage renal disease, and doubling of serum creatinine were similar in both groups after 10 years [22]. Although renal survival rate is at 80% at 10 years, it is still associated with significant comorbidities of hyperlipidemia, and cardiovascular and thromboembolic diseases. Randomized trials have demonstrated decreased lupus activity when compared to placebo among patients receiving standard care. Often, it is difficult to separate active lupus psychosis from other causes such as functional disorders, uremia, illicit drug use, metabolic disturbances, medications, or infections. Peripheral nervous system syndromes include cranial neuropathies (4% to 49%) such as facial palsies and ocular muscle dysfunction. Pure sensory or motor abnormalities based on electromyography/nerve conduction studies occur in up to 47%, but plexopathy, Guillain–Barré syndrome, and autonomic neuropathy are rare. Electroencephalography generally reveals diffuse brain wave slowing, but focal activity suggests seizures. Changes in the gray matter that brighten on T2-weighted imaging suggest more acute events and may improve with therapy. Single-photon emission computerized tomography, which measures functional cerebral blood flow, has low specificity. Thoracentesis is indicated when the etiology of the fluid is uncertain or if respiratory compromise is present. Pleural fluid is characteristically exudative with high protein, pH is variable but can be low, and glucose slightly decreased in contrast to the uniformly low glucose and pH seen in rheumatoid pleural effusions. It cannot be differentiated from other forms of bronchopneumonia, and thus infectious etiologies should be excluded by appropriate studies. Patients characteristically present with acute dyspnea, tachycardia, severe hypoxemia, rales, sudden drop in hematocrit, and hemoptysis. Pathologic findings include intra-alveolar hemorrhage sometimes associated with interstitial pneumonitis or capillaritis, but pathology may only be bland hemorrhage. Immunopathologic studies may reveal granular deposition of IgG in alveolar septal walls and pulmonary vessels, thus suggesting a possible immune complex–mediated process.
Metoclopramide and ondansetron (or other serotonergic antiemetics) can also be given to control or prevent vomiting generic levitra soft 20mg otc erectile dysfunction specialist doctor. In addition order levitra soft 20mg free shipping discussing erectile dysfunction doctor, intestinal obstruction buy levitra soft 20mg without prescription impotence emotional causes, pseudo-obstruction discount levitra soft 20 mg on-line erectile dysfunction 60, and nonocclusive intestinal infarction have been reported in patients with decreased bowel motility treated with multiple doses of activated charcoal [82,83]. Extracorporeal Methods Peritoneal dialysis, hemodialysis, hemoperfusion, hemofiltration, plasmapheresis, and exchange transfusion are theoretically capable of removing any chemical from the blood [81]. Most toxins undergo significant tissue distribution, and few remain in the blood in amounts high enough to warrant extracorporeal removal. Hemodialysis is therefore most effective for toxins with volumes of distribution less than 1 L per kg. In addition, with dialysis techniques, only toxins that are small (molecular weight less than 500 to 1,500 Da), water soluble, and not highly bound to serum proteins (90% to 95% or less) readily diffuse across dialysis membranes. Low protein binding the clearance of a toxin by extracorporeal removal must be significantly greater than its intrinsic total body clearance (the sum of metabolic, renal, and other routes of clearance) to be considered effective from a pharmacokinetic perspective. As with other treatments, renal replacement therapy’s efficacy (ability to decrease morbidity and mortality) is based on observation, experience, and retrospective comparisons rather than on controlled prospective studies. Hemodialysis is considered effective for the treatment of barbiturate, bromide, chloral hydrate, ethanol, ethylene glycol, isopropyl alcohol, lithium, methanol, procainamide, acetaminophen, theophylline, and salicylate poisoning. Because hemodialysis can remove toxins from the blood faster than they can redistribute from tissue to blood, a rebound increase in blood concentration and clinical relapse may occur within 1 or 2 hours of treatment. Peritoneal dialysis may be useful when these methods are not available or technically difficult (in neonates) or when anticoagulation may be hazardous. Two blood-volume exchanges are usually performed using central or peripheral arteriovenous or venovenous access. Patients with extremes of temperature, severe agitation, or life-threatening metabolic abnormalities also benefit from intensive care. Some patients may require close observation and cardiac monitoring; but unless active interventions are likely to be necessary, admission to an intermediate care unit, telemetry unit, or emergency department observation unit is appropriate. Length of hospital stay for patients with self-poisoning can be reduced by use of a multidisciplinary team that involves a toxicologist and psychiatrist as well as medical personnel [84]. If they are given prescriptions, the amount of drug (1 to 2 week supply) and number of refills should be limited. Substance abusers should be counseled regarding attendant medical risks and given the opportunity for rehabilitation through referral for behavior modification, supervised withdrawal, and abstinence or maintenance therapy. Adults with accidental poisoning should be educated regarding the safe use of drugs and other chemicals. Assistance with the administration of medications may be required for visually impaired, elderly, developmentally delayed, or confused patients. Preventive education may be indicated for health care providers who have committed dosing errors or who are unaware of adverse drug interactions. When poisoning results from environmental or workplace exposure, the appropriate governmental agency (Environmental Protection Agency, Occupational Safety and Health Administration, National Institute of Occupational Safety and Health, or local state, or federal health departments) should be notified. Finally, physicians have a duty to warn the general public (via press releases) of acute environmental hazards. Kozer E, Vergee Z, Koren G: Misdiagnosis of a mexiletine overdose because of a nonspecific result of urinary toxicologic screening. Tomaszewski C, Runge J, Gibbs M, et al: Evaluation of a rapid bedside toxicology screen in patients suspected of drug toxicity. Bar-Oz B, Levichek Z, Koren G: Medications that can be fatal for a toddler with one tablet or teaspoonful: a 2004 update. Purkayastha S, Bhangoo P, Athanasiou T, et al: Treatment of poisoning induced cardiac impairment using cardiopulmonary bypass: a review. American Academy of Clinical Toxicology and European Association of Poisons Centre and Clinical Toxicologists: Position paper: ipecac syrup. American Academy of Clinical Toxicology and European Association of Poisons Centre and Clinical Toxicologists: Position paper: cathartics. American Academy of Clinical Toxicology and European Association of Poisons Centre and Clinical Toxicologists: Position paper: gastric lavage. American Academy of Clinical Toxicology and European Association of Poisons Centre and Clinical Toxicologists: Position paper: whole bowel irrigation. American Academy of Clinical Toxicology and European Association of Poisons Centre and Clinical Toxicologists: Position paper: single-dose activated charcoal. Eddleston M, Juszczak E, Buckley N, et al: Multiple-dose activated charcoal in acute self-poisoning: a randomized controlled trial. Mizutani T, Yamashita M, Okubo N, et al: Efficacy of whole bowel irrigation using solutions with or without adsorbent in the removal of paraquat in dogs. Arimori K, Furukawa E, Nakano M: Adsorption of imipramine onto activated charcoal and a cation exchange resin in macrogel-electrolyte solution. Arimori K, Deshimaru M, Furukawa E, et al: Adsorption of mexiletine onto activated charcoal in macrogel-electrolyte solution. Melandri R, Re G, Morigi A, et al: Whole bowel irrigation after delayed release fenfluramine overdose. American Academy of Clinical Toxicology and European Association of Poisons Centre and Clinical Toxicologists: Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. Longdon P, Henderson A: Intestinal pseudo-obstruction following the use of enteral charcoal and sorbitol and mechanical ventilation with papaveretum sedation for theophylline poisoning. It belongs to the same drug family as phenacetin and acetanilid, the coal tar or aminobenzene analgesics [1,2]. Therapeutic plasma concentrations range from 10 to 20 μg per L, and elimination after therapeutic dosing follows first-order kinetics, with an average half-life of 2 to 4 hours [1]. Elimination is slower in neonates and young infants [3], the elderly[2], and in patients with hepatic dysfunction [4]. The ingestion of very large doses and the concomitant ingestion of agents that delay gastric emptying (e. Hypersensitivity reactions, such as urticaria, fixed drug eruption, angioedema, laryngeal edema, and anaphylaxis, are extremely rare [6]. This was first recognized in Europe more than 50 years ago, and the first cases of hepatotoxicity in the United States were reported in 1975. In adults, glucuronidation is the predominant route; in infants and young children, sulfation is the major pathway. After overdose, the amount of drug metabolized by the P450 route increases, because of a greater total drug burden and saturation of alternative enzymatic pathways [11]. The degree of injury can range from asymptomatic elevations in aminotransferase levels to fulminant liver failure. Retrospective data suggest that significant toxicity is likely only after acute overdoses of greater than 250 mg per kg in adults [13], and prospective studies have suggested that toxicity is unlikely in unintentional pediatric ingestions of up to 200 mg per kg [17]. The possibility of toxicity at lower doses and skepticism regarding the accuracy of overdose histories have led to acceptance of a more conservative definition of risk, particularly in the United States. There is currently no valid estimation of the amount, frequency, or duration of the dosing that defines risk.
