Search PubMed⌕ Search

Biomedical subjects

R P Rapp

Publications and source records attributed to R P Rapp.

At least 73 records · Page 4Linked to original sources
PubMed1985

Hospital intravenous drug administration in the era of prospective payment.

Cost effectiveness in all aspects of hospital care is necessary for survival in the 1980s. Under the new prospective payment system, the emphasis will switch from selling at a profit to increasing profits by spending less. Pharmacists need to reexamine available alternatives and new horizons in each area of distributive services, especially in the way we dispense and administer intermittent intravenous drugs. Manufacturer's piggyback containers are readily available for about 60 percent of required doses, and significant cost savings could result in a relatively short period of time. Newer systems that use syringes should also be explored and an in-hospital evaluation program set up to decide which is the most cost-effective, acceptable system.

Drug Packaging↗
PubMed1985

Amino acid stability and microbial growth in total parenteral nutrient solutions.

The stability of amino acids in total parenteral nutrient (TPN) solutions stored for 30 days and the potential for stored TPN solutions to support growth of microbial contaminants were studied. Solutions of 3.5% crystalline amino acids and 25% dextrose with electrolytes were prepared either by using a commercially available amino acid solution with electrolytes or by adding electrolytes individually to a base TPN solution. Solutions were stored in polyvinyl chloride bags at refrigerated (4 degrees C) or room (25 degrees C) temperature for 30 days. Some bags were inoculated with Candida albicans or Pseudomonas maltophilia before storage to serve as positive controls for evaluation of microbial contamination. At appropriate intervals, bags of each type of solution under each storage condition were analyzed for amino acid content. Microbial growth was evaluated by filtering the contents of each bag and incubating the filter in brain-heart infusion broth. No microbial growth was detected in any of the study solutions, but all solutions inoculated with C. albicans and 2 of 16 solutions inoculated with Ps. maltophilia had evidence of growth. No significant decreases in the concentrations of any of the amino acids were noted for solutions stored at refrigerated temperature, but significant decreases in the concentrations of arginine and methionine were noted for solutions stored at room temperature. Total parenteral nutrient solutions can be stored for up to 30 days if they are kept at refrigerated temperatures and protected from light; however, quality assurance measures for these solutions should include end-product microbiologic testing.

Amino Acids↗
PubMed1985

Osmolality of small-volume intravenous admixtures.

Osmolalities of commonly administered small-volume i.v. admixtures were determined, and use of diluents with lower osmolality to achieve osmolality values less than 400 mOsm/kg was studied. The theoretical osmolality of 218 hypothetical admixtures of various concentrations of 34 injectable drugs in 50- or 100-mL quantities of 5% dextrose injection or 0.9% sodium chloride injection was calculated using sodium chloride equivalents. If the calculated osmolality value was greater than 400 mOsm/kg, an actual admixture was prepared and osmolality and density were measured. To determine how admixtures with osmolality values less than 400 mOsm/kg could be prepared, theoretical osmolality was calculated using 0.45% sodium chloride injection or sterile water for injection as the diluent. The calculated osmolality value was greater than 400 mOsm/kg for 52 (23.9%) of the 218 admixtures tested. Of the 52 measured osmolality values, 47 were within 15% of the calculated value. Calculated osmolality values for all admixtures were less than 400 mOsm/kg when 0.45% sodium chloride injection or sterile water for injection was used as the diluent. Admixture osmolality should be considered when preparing drugs for i.v. injection. For drugs with high osmolalities, 0.45% sodium chloride injection or sterile water for injection may be used as the diluent.

Anti-Bacterial Agents↗
PubMed1984

Nutritional assessment and therapy in advanced urothelial cancer.

Patients with advanced urothelial cancers often have cachexia and anorexia resulting in severe malnutrition and depressed immunologic function. Careful nutritional assessment early in their evaluation and early use of parenteral and enteral nutritional supplements play an important role in allowing these patients to withstand their therapies safely as well as in improving their prognosis.

Calorimetry↗
PubMed1984

Comparative accuracy of five intravenous-fluid controllers.

The accuracy of five gravity-feed infusion-control devices was compared using a gravimetric method. Two nonvolumetric drop-counting devices (IVAC 230 and, IMED 350) and three volumetric devices (Quest/Cutter Infusor, Anatros Rateminder, and IVAC 260) were compared at four different flow rates (10, 40, 125, 250 ml/hr) using four different solutions and two head heights (30 and 100 cm). The mean error rates for the IVAC 230 and the IVAC 260 devices were consistently high and negative (-6.32 and -12.60%, respectively). The mean error rates for the IMED, Anatros, and Quest/Cutter devices were 2.2, 1.8, and 0.7%, respectively. Conversion charts must be used to account for variation in drop size when different solutions and flow rates are used in the IVAC 230 and IMED 350 devices. At the low flow rates, the 60-drop/ml sets were more accurate than the 20-drop/ml sets. Of the volumetric devices, the Quest/Cutter Infusor and the Anatros Rateminder were more accurate than the IVAC 260. The Quest/Cutter Infusor was the most accurate of all controllers tested. For volumetric devices that use drop-counting technology, selecting an internal fluid code on the basis of solution ingredients is still necessary. For the new volumetric devices, conversion charts and fluid code selection are not necessary to achieve a high level of accuracy.

Evaluation Studies as Topic↗
PubMed1983

Failure of prophylactically administered phenytoin to prevent post-traumatic seizures in children.

We report the results of a randomized, double-blind, placebo-controlled study to determine whether phenytoin administered soon after a head injury lessens the incidence of late post-traumatic epilepsy in children. 41 patients were randomized into either a phenytoin or placebo group and followed for 18 months. The patients were administered phenytoin or placebo intravenously or intramuscularly within 24 h of hospital admission. The patients were parenterally administered phenytoin or placebo until oral doses could be tolerated. There was no significant difference in the percentage of children having seizures in the treated and placebo groups (p = 0.25).

Brain Injuries↗
PubMed1983

Parenteral nutrition in a patient with familial Type IV hypertriglyceridemia: a dilemma.

Patients with a Type IV familial hypertriglyceridemia should never receive intravenous fat emulsions. In addition, the amount of carbohydrate that can be given is limited. A 33-year-old white female, with Type IV hypertriglyceridemia, began receiving a parenteral nutrition regimen that included fat. A series of lipid studies was planned, coordinated with fat emulsion and glucose administration. The patient had persistently elevated basal triglyceride levels (greater than 250 mg/dL), which rose in response to both fat and carbohydrate administration. Serum cholesterol levels remained within the normal range. The disease was once known as "carbohydrate-induced lipemia" because of the dramatic rise in serum triglyceride following high carbohydrate diets. We suggest that serum triglyceride levels be monitored in all patients receiving parenteral nutrition; when such a patient is identified, fat emulsion should not be given and dextrose should be used in the smallest possible amounts to achieve a positive nitrogen balance.

Adult↗
PubMed1983

Cutaneous reactions in head-injured patients receiving phenytoin for seizure prophylaxis.

Two types of adverse effects are caused by phenytoin, reversible dose-dependent central nervous system effects and non-dose dependent hypersensitivity effects. The most common presenting symptom of the hypersensitivity reaction is the development of a morbilliform rash. During a 45-month period, 151 head-injured patients received phenytoin for seizure prophylaxis using an 11-mg/kg i.v. and a 13-mg/kg i.m. parenteral loading dose followed by an i.m. or p.o. maintenance dose for therapeutic blood concentrations (10 to 20 micrograms/ml). The patients were followed for 18 months. The incidence of skin reaction to phenytoin was 19.4%, or 24 of 124 patients. Cutaneous reactions occurred from Day 5 through Day 91 of phenytoin therapy. Two patients had more serious reactions after the cutaneous reaction. One patient developed exfoliative dermatitis, and 1 had a pseudolymphoma type syndrome. Both recovered. Patients with cutaneous reactions had higher absolute eosinophil counts (P = 0.01). Other laboratory parameters of the white blood count and the total lymphocyte counts did not differ significantly. Patients receiving dexamethasone had a higher incidence of rash, but this did not reach statistical significance. Because recent data have not documented a seizure-prophylactic effect of phenytoin, only a head-injured patient who has experienced a first posttraumatic seizure should receive the drug.

Adolescent↗
PubMed1983

Failure of prophylactically administered phenytoin to prevent early posttraumatic seizures.

A randomized double-blind placebo-controlled study was carried out to determine whether phenytoin administered soon after injury lessens the incidence of epilepsy in the 1st week after severe head trauma. In this study, 244 patients were randomized into either a phenytoin or placebo group. The patients in the phenytoin group were administered phenytoin intravenously or intramuscularly within 24 hours of hospital admission. Patients in the placebo group received intravenous or intramuscular diluent. The patients were switched from parenterally administered phenytoin or placebo as soon as oral doses could be tolerated. Over 78% of the phenytoin patients had plasma concentrations of at least 10 micrograms/ml at 1, 3, and 7 days after injury. There was no significant difference in the percentage of patients having early seizures in the treated and placebo groups (p = 0.99). There was no significant difference in the interval from injury to first seizure between the treated and placebo groups (p = 0.41). The early administration of phenytoin did not lessen the occurrence of seizures in the 1st week after head injury. Since the effectiveness of seizure prophylaxis has not been established, the authors suggest that anticonvulsant drugs be administered only after an early seizure has occurred.

Brain Injuries↗
PubMed1983

Failure of prophylactically administered phenytoin to prevent late posttraumatic seizures.

This randomized double-blind placebo-controlled study was undertaken in a series of 179 patients to determine whether phenytoin administered soon after head injury lessens the incidence of late posttraumatic epilepsy. When delayed hypersensitivity to phenytoin developed, the patient was switched to phenobarbital. The patients were followed for 18 months to detect the occurrence of seizures and to serially measure plasma phenytoin concentrations. There was no significant difference in the percentage of patients having late seizures in the treated and placebo groups (p = 0.75). The time between injury and seizures did not significantly differ between the two groups. The results provide no support for the continued use of phenytoin in the low therapeutic range for prophylaxis against late posttraumatic seizures. It cannot be concluded that higher phenytoin plasma concentrations and higher compliance rates than obtained in this study would not have significantly decreased the occurrence of late posttraumatic epilepsy. The finding that no patient with a phenytoin plasma concentration of 12 microgram/ml or higher had a seizure raises the question of whether phenytoin in blood concentrations in higher therapeutic ranges might lessen the occurrence of posttraumatic epilepsy, and should be studied further. Posttraumatic epilepsy is a major public health problem deserving a large cooperative trial to determine if phenytoin at higher blood levels than obtained in this study, or other currently available or newly developed drugs, can prevent the occurrence of posttraumatic epilepsy.

Adolescent↗
PubMed1983

The favorable effect of early parenteral feeding on survival in head-injured patients.

This prospective randomized controlled clinical trial compares the effects of early parenteral nutrition and traditional delayed enteral nutrition upon the outcome of head-injured patients. Thirty-eight head-injured patients were randomly assigned to receive total parenteral nutrition (TPN) or standard enteral nutrition (SEN). Clinical and nutritional data were collected on all patients until death or for 18 days of hospitalization. Survival and functional recovery were monitored in survivors for 1 year. Of the 38 patients, 18 were randomized to the SEN group and 20 to the TPN group. Demographically, the two groups of patients were similar on admission. There was no significant difference in the severity of head injury between the two groups as measured by the Glasgow Coma Scale (p = 0.52). The outcome for the two groups was quite different, with eight of the 18 SEN patients dying within 18 days of injury, whereas no patient in the TPN group died within this period (p less than 0.0001). The basis for the improved survival in the TPN patients appears to be improved nutrition. The TPN patients had a more positive nitrogen balance (p less than 0.06), and a higher serum albumin level and total lymphocyte count. More adequate nutritional status may have improved the patients' immunocompetence, resulting in decreased susceptibility to sepsis. The data from this study strongly support the favorable effect of early TPN on survival from head injury.

Adult↗
PubMed1983

Final in-line filtration: removal of contaminants from IV fluids and drugs.

The administration of intravenous fluids or drugs may allow particulate and microbiologic contamination to enter the bloodstream. Studies have implicated injected particles as a cause of postinfusion phlebitis. The process of manufacturing the infusion product will influence the type and quantify of injected particles. Particles greater than 8 microns are filtered by the lung, and depending on their reactivity, can cause pulmonary granulomas. Particles below 8 microns are initially filtered, cleared by phagocytosis, and ultimately migrate to the liver and spleen. Both nonvisible particles and microbial contaminants of fluids and drugs can be effectively removed by 0.45- or 0.22-micron in-line final filtration. When filters are employed, problems can occur, including air locking, clogging, and drug-binding. A knowledge of why and to what extent these problems can occur will allow in-line filters to be used effectively by health care practitioners.

Drug Contamination↗
PubMed1983

The effect of ten and twenty per cent safflower oil emulsion given as thirty to fifty per cent of total calories.

In a prospective study of seven patients undergoing operations, 10 and 20 per cent safflower oil emulsions were found to be safe and effective as a major component of adult parenteral nutrition. Specifically, clinically important adverse effects of the emulsions as monitored by clinical evaluation and screening hematologic and blood chemistry determinations were not identified. Further, an extensive coagulation profile in these patients has failed to identify procoagulant effects of parenteral safflower oil. The optimum dosage of fat for a balanced parenteral diet is not known. Linoleic acid administered as 4 per cent of total calories every other day will treat or prevent essential fatty acid deficiency, and this dosage may be considered a minimum requirement for parenteral fat. The data from this study demonstrate parenteral safflower oil administered as 30 to 50 per cent of total calories is effective in achieving nitrogen balance. The implication is that fat emulsions today allow the use of parenteral diets that match the normal diet consumed orally in terms of the balance of protein, carbohydrate and fat.

Adult↗
PubMed1982

The influence of dose frequency and agent toxicity on the cost of parenteral antibiotic therapy.

The influence of the number of daily doses on the overall cost of antibiotic therapy is examined in a general surgery patient population. Patients receiving a single first-generation cephalosporin are compared with patients receiving two or three antibiotics (including an aminoglycoside) in terms of (1) the cost of the drug and the supplies, (2) time required for nursing and pharmacy personnel to prepare and administer the doses, and (3) the influence of agent toxicity (renal function) on physician-ordered laboratory tests. On the whole, combination therapy including an aminoglycoside was four times as expensive as single-agent (first-generation cephalosporin) therapy. If future studies demonstrate that single-agent antibiotic therapy is as effective as traditional combination therapy for specific infectious diseases, the influence of the number of daily doses of drug and agent toxicity may support the cost-effective use of the newer agents.

Anti-Bacterial Agents↗
PubMed1981

Phenytoin-dexamethasone interaction: a previously unreported observation.

A possible drug interaction between phenytoin and dexamethasone was evaluated by comparing serum phenytoin concentrations in 23 patients receiving both drugs with those of a control group of 15 patients receiving phenytoin only. Serum phenytoin concentrations obtained 24 hours after a loading dose of 11 mg per kilogram body weight administered intravenously and 13 mg/kg given intramuscularly were examined. The total amounts of dexamethasone administered during the 24-hour period ranged from 16 to 150 mg. The average serum phenytoin concentration was 17.28 +/- 3.49 micrograms/ml in patients receiving both drugs, as compared to 12.48 +/- 3.52 micrograms/ml in patients receiving only phenytoin (p less than 0.001). Our results suggest that serum phenytoin concentrations should be monitored in patients receiving concurrent dexamethasone therapy.

Adult↗
PubMed1981

Theophylline toxicity after the use of aminophylline in the treatment of cerebral vasospasm.

We are reporting a case of theophylline toxicity after the initiation of i.v. aminophylline and isoproterenol in the treatment of cerebral vasospasm. The dose of aminophylline (125 mg/hour) previously recommended results in a toxic serum theophylline concentration in a majority of patients if the infusion is continued for more than 24 to 48 hours. The rapid achievement of an optimal serum level is obtained with a standard loading dose of 8.0 mg/kg. The initial infusion rate should be based on calculated pharmacokinetic data. Maintenance dosing adjustments are then based on serum determinations and the presence of toxic effects.

Aminophylline↗