Tramadol intoxication in infants: experience at a tertiary care hospital in Dhaka, Bangladesh

Background: Tramadol is a widely used opioid analgesic for different types of pain. Very few cases of acute tramadol intoxication in infants have been reported where respiratory and central nervous system depression are frequent. The aim of this study was to evaluate the clinical manifestation, treatment and outcome of tramadol intoxication in infants. Methods: This was a retrospective observational study of hospitalized infants in the Department of Neonatology and Paediatrics in BIRDEM General Hospital, Dhaka, Bangladesh from February 2014 to November 2019. Ten infants with history of administration of tramadol suppository were included in this study. Data regarding clinical features, cause of the “incident dose and route of administration” of tramadol, effects of naloxone and outcomes were recorded and analyzed. Results: Of 10 infants, 6 were male and 4 were female. The mean age was 5.1±3.0 months and the mean weight was 6.1±1.8 kg. The mean time of onset of symptoms after drug administration was 2.6±1.0 hours with a mean dose of 17.9±6.4 mg/kg body weight. The main clinical features were decreased level of consciousness (100%), seizure (80%), meiosis (80%) and apnoea (50%). In each 50% (5) of cases, tramadol was given erroneously instead of glycerine and paracetamol suppository. Among them 2 (20%) infants received tramadol suppository as an over-the-counter (OTC) drug. All infants were treated with naloxone without any side effect. In addition, three infants needed mechanical ventilation. The average duration of hospital stay was 89.3±47.4 hours. Nine infants were discharged and one (10%) died. Conclusions: Our study suggested that tramadol intoxication among infants is predominantly accidental. Early identification and prompt initiation of treatment are essential. The creation of public awareness about the safe storage of drugs at home and avoidance of OTC drugs can prevent tramadol intoxication in children. BIRDEM Med J 2021; 11(3): 197-201

Causes of Hypermagnesaemia: A Literature Review

Magnesium is one of the commonly overlooked electrolytes, yet it plays a vital role in many of the processes in the human body. The balance of magnesium can translate into subtle changes in a person’s daily life, causing fatigue and confusion, to extreme cases that can end up causing central nervous system depression, respiratory failure, or cardiac arrhythmias. It is vital to be familiar with the physiology of magnesium regulation and knowledgeable regarding the causes that can lead to its toxicity to ensure the prevention of the possibly fatal condition. Magnesium balance can be summarised as the difference between magnesium intake and its excretion. Any factor overwhelming either of the two factors can cause pathological levels of the electrolyte. In addition to learning preventive measures to help patients against effects of magnesium toxicity, it is also important that the medical community trains to be able to treat cases of hypermagnesaemia. This review assesses the latest advancements in knowledge of magnesium metabolism, examines the case reports of hypermagnesaemia in an attempt to list the causes of magnesium toxicity, and enumerates management advances for the condition.

Amitraz Poisoning: A Rare Case of an Unusual Pesticide Poisoning

Amitraz is a pesticide used in animals and agriculture. It consists of triazapentadiene which is a centrally acting alpha2 adrenergic agonist. Amitraz poisoning is uncommon in human beings. It occurs via the oral, dermal or inhalational route. The clinical manifestations are mainly central nervous system depression, respiratory depression and cardiovascular system depression. Very few reports of human intoxication have been documented so far. Keywords: Amitraz poisoning, pesticide poisoning, human intoxication.

Effects of isoflurane and sevoflurane alone and in combination with butorphanol or medetomidine on the bispectral index in chickens

Background The bispectral index (BIS) is an anaesthesia monitoring technique able to assess the level of central nervous system depression in humans and various animal species. In birds, it has been validated in chickens undergoing isoflurane anaesthesia. The aim of this study was to evaluate in an avian species the influence of isoflurane and sevoflurane on BIS, each at different minimum anaesthetic concentrations (MAC) multiples, alone or combined with butorphanol or medetomidine. Ten chickens (5 males and 5 females) underwent general anaesthesia with isoflurane or sevoflurane alone, and combined with either intramuscular administration of butorphanol (1 mg/kg) or medetomidine (0.1 mg/kg), in a prospective and cross-over study (i.e., 6 treatments per animal). BIS measurements were compared to heart rate (HR), non-invasive blood pressure (NIBP) and to a visual analogue scale (VAS) of anaesthesia depth. Results HR was significantly increased, and both NIBP and VAS were significantly reduced, with higher gas concentrations. NIBP (but not HR or VAS) was additionally affected by the type of gas, being lower at higher concentrations of sevoflurane. Butorphanol had no additional effect, but medetomidine led to differences in HR, NIBP, and in particular a reduction in VAS. With respect to deeper level of hypnosis at higher concentrations and the absence of difference between gases, BIS measurements correlated with all other measures (except with HR, where no significant relationship was found) The difference in BIS before (BISpre) and after stimulation (BISpost) did not remain constant, but increased with increasing MAC multiples, indicating that the BISpost is not suppressed proportionately to the suppression of the BISpre values due to gas concentration. Furthermore, neither butorphanol nor medetomidine affected the BIS. Conclusions The difference of degree of central nervous system depression monitored by BIS compared with neuromuscular reflexes monitored by VAS, indicate that BIS records a level of anaesthetic depth different from the one deducted from VAS monitoring alone. BIS provided complementary information such as that medetomidine suppressed spinal reflexes without deepening the hypnotic state. As a consequence, it is concluded that BIS improves the assessment of the level of hypnosis in chickens, improving anaesthesia monitoring and anaesthesia quality in this species.

The Association between the Number of Vacuum Pop-offs and Adverse Neonatal Outcomes

Objective Obstetrical vacuum manufacturers have long recommended a maximum of two to three pop-offs be allowed before abandoning the procedure. However, there is a paucity of evidence on the safety of vacuum-assisted vaginal delivery in relation to the number of pop-offs to support this recommendation. Our objective was to examine whether the number of pop-offs in a vacuum-assisted vaginal delivery was associated with adverse neonatal outcomes. Study Design This is a retrospective cohort study of women who underwent a trial of a vacuum-assisted vaginal delivery at a single tertiary care institution between October 2005 and June 2014. Maternal and fetal factors associated with the number of pop-offs were examined in bivariable analyses. Multivariable analyses were performed to determine the independent association of the number of pop-offs with adverse neonatal outcomes. Results Of the 1,730 women who met inclusion criteria, 1,293 (74.7%) had no pop-offs, 240 (13.9%) had one pop-off, 128 (7.4%) had two pop-offs, and 69 (4.0%) had three or more pop-offs. Neonatal scalp/facial lacerations, intracranial hemorrhage, seizures, central nervous system depression, and neonatal intensive care unit admission were all associated with the number of pop-offs in bivariable analyses. In multivariable analyses, compared to no pop-offs, having any vacuum pop-offs was associated with an increased odds of adverse neonatal outcomes. However, there was not a consistent dose–response relationship. Conclusion While having vacuum pop-offs in a vacuum-assisted vaginal delivery was associated with an increased risk of adverse neonatal outcomes, there did not appear to be a dose-dependent association with the number of pop-offs. Key Points

A Rare Case of Myocarditis Induced by Cannabis Use

Cannabis is one of the most commonly abused drugs in the world and there is a widespread misconception that cannabis is a safe drug without adverse effects. Tetrahydrocannabinol (THC) is one of the main chemicals of cannabis and considerable research suggests that cannabis and THC may have severe consequences on mental as well as physical health. However, the cardiovascular effects of cannabis are not well known. This article outlines the first reported case of pediatric death due to myocarditis induced by cannabis exposure. The subject is an 11-month-old male without any previous medical history that presented to the emergency department with central nervous system depression. The patient then went into cardiac arrest and died. Autopsy revealed myocarditis as the cause of death. Post-mortem blood analysis further revealed high concentrations of Δ-9-THC which is a metabolite of THC that can be detected for 24 hours after exposure. Considering that no other alternate causes of myocarditis have been confirmed, this raises cannabis exposure as the most likely cause. Although this is the first case of death from cannabis-induced myocarditis, there have been other cases wherein which cannabis exposure lead to myocarditis in young males. Altogether, these cases highlight the need for further investigation into the cardiovascular effects of cannabis and to consider cannabis in the diagnosis of myocarditis.

Intoxication by Harmel

Herbal medicine has taken a prominent place in the North African skincare system because of the increased installation of herbalists and healers, but unfortunately most of these do not have the required level to practice this medicine. The Harmel (Peganum harmala L.) belongs to the family Zygophyllaceae, which has 24 genera and 240 species. It is a herbaceous plant, perennial, glabrous, and bushy, from a height of 30–100 cm, with a thick rhizome, its strong, unpleasant odor reminiscent of that of the Rue (Ruta graveolens). The Harmel is a toxic plant widespread in North Africa which has an important place in traditional medicine in several indications. It is used as a sedative, antitussive, antipyretic, antirheumatic, and antihelminthic, and to treat some skin diseases. Harmel is ingested with a glass of water or mixed with honey or pounded with olive oil. The intoxications are mainly due to overdose; the absorption of a quantity of seed greater than a teaspoon causes hallucinations and vomiting. In France, Harmel as well as its compounds (Harmine, Harmaline, Harmol, and harmalol) have been classified among the astonishing substances. The clinical manifestations described in the literature include: digestive disorders, bradycardia; neurological disorders paralysis, central nervous system depression; renal disorders; and in severe cases, dyspnoea and hypothermia and hypotension.

The Effect of Relaxation Technique (Jacobsen and Benson) on Depression, Anxiety, and Stress in Patients with Multiple Sclerosis

Background: Multiple sclerosis (MS) is a chronic disease that affects the central nervous system. Depression, anxiety and stress are the most common psychiatric comorbidities in MS, which can have adverse consequences. The aim of this study was to determine the effect of relaxation (Jacobson and Benson) technique on depression, anxiety and stress in MS patients. Methods: This clinical trial was conducted since December 2016 to March 2017 in the Multiple Sclerosis Association and the Neurology Clinic of Farshchian Hospital (Sina) in Hamadan. Sixty patients with multiple sclerosis were randomly assigned to two experimental (n=30) and control (n=30) groups. The control group received routine care and experimental group received the relaxation technique (Jacobson and Benson) in 8 sessions of 60-minute twice a week for 4 weeks in addition to receiving routine care. The DASS-21 scale was completed by samples before and after the intervention. Results: Results of the study showed that in the intervention group, the scores of depression, anxiety and stress after using relaxation (Jacobson and Benson) was decreased significantly (P<0.05), while in the control group no significant decrease was observed (P<0.05). Conclusion: The results of this study showed that relaxation (Jacobson and Benson) is effective in reducing depression, anxiety and stress in patients with multiple sclerosis. Therefore, in addition to prescribing medication, it is suggested that complementary therapies be performed for these patients.

Features of electrophysiological activity in a neonate with severe post-hypoxic brain damage (post-hypoxic cerebral depression)

The article briefly presents the literature data and a description of the clinical dynamic observation of a patient with severe hypoxic brain damage (from the neonatal period to 4 months of life), in the conditions of the neonatal intensive care unit. The article describes the clinical picture, features of paroxysmal states and antiepileptic therapy, dynamics of neuroimaging data, electroencephalographic phenomena recorded in a patient with cerebral depression and structural cerebral injuries. The significance of electroencephalographic examination in the intensive care unit as an informative method for assessing cerebral activity in young children with central nervous system depression syndrome is shown. Disorganization of background activity, indicating structural cerebral damage, long-term persistence of slow-wave activity, detection of epileptic changes in the form of generalized flashes of pointed waves in the theta range, alpha-coma pattern, subsequently replaced by suppression of the background pattern in the patient, are typical electrophysiological disorders recorded in severe hypoxic encephalopathy. In conditions of limited opportunities for visual diagnosis of a patient with impaired consciousness, EEG remains the only method of obtaining information about the functional state of the brain, the data obtained during the study are an important prognostic criterion.

Respiratory Acidosis in the Intensive Care Unit

This chapter explains that the interpretation of acid–base abnormalities is an essential skill required when caring for critically ill patients. The differential causes of respiratory acidosis include central nervous system depression, upper and lower airway obstruction, and hypermetabolic states with increased production of CO2, such as malignant hyperthermia and thyroid storm. The treatment for hypoxic and hypercarbic respiratory failure involves reversing the offending agents if applicable, treatment of the underlying cause, and mechanical ventilation. The 2 commonly used strategies for mechanical ventilation are non-invasive ventilation with a mask and endotracheal intubation. The selection of ventilation strategy is dependent on numerous patient factors. Clinicians must set respiratory rate, tidal volume, positive end-expiratory pressure, inspiratory flow, fraction of inspired oxygen, mode (volume versus pressure control), and the amount of assistance per breath. All need to be tailored toward each patient’s specific goals. In patients with severe acidosis, there may be a temptation to hyperventilate in order to treat the hypercarbia and hypoxia as quickly as possible. This can be deleterious as high tidal volumes may lead to ventilator-induced lung injury due to volutrauma, cytotrauma, and barotrauma.