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Study Objective: To evaluate gastric alkalization and bacterial colonization in critically ill patients receiving stress ulcer prophylaxis with gastric tube feeds, sucralfate, intermittent intravenous cimetidine, or continuous intravenous cimetidine. DESIGN; Prospective, randomized, unblinded trial., Setting: Medical and surgical intensive care units of a large university-affiliated, tertiary care community hospital., Patients: Fifty-three evaluable critically ill patients with respiratory failure requiring mechanical ventilation., Interventions: Patients not receiving nasogastric tube feeds were randomized to sucralfate 1 g every 6 hours, cimetidine 300 mg by intravenous bolus every 8 hours, or cimetidine 900 mg by continuous intravenous infusion/24 hours. Gastric samples were obtained daily for pH and culture., Measurements and Main Results: Patients with respiratory failure and a high mortality rate had a mean gastric pH of 1.96 +/- 1.5 at study entry. There were no significant differences in gastric pH or gastric colonization among the three arms. Fourteen patients (26%) developed gastric colonization, which was statistically significant but poorly correlated with gastric alkalinity (r2=0.08, p<0.043)., Conclusion: Gastric luminal pH was unchanged regardless of which method was used for stress ulcer prophylaxis. Bacterial colonization was increasingly likely in patients with a persistent alkaline gastric environment.

Droperidol and haloperidol have demonstrated efficacy and safety in the treatment of acute delirium in critically ill patients. We conducted MEDLINE and manual searches of literature published from 1966-1996 to identify articles describing conduction disturbances associated with the drugs. The objectives were to describe the proposed mechanisms of acquired long QTc interval syndrome and torsades de pointes, and to recommend how critically ill patients receiving these agents should be monitored. We found 11 published reports of conduction disturbances associated with intravenous administration of droperidol or haloperidol. The majority of cases occurred in critically ill patients prescribed more than 50 mg/24 hours of either agent. Of the 18 patients described, 13 (72%) had a history of cardiovascular disease. Based on the small number of available case reports, it seems reasonable to suggest that the incidence of adverse cardiovascular effects due to droperidol and haloperidol is small. The mechanism of butyrophenone-induced QTc interval prolongation is not known, but is presumed to involve abnormal ventricular repolarization and the development of early after-depolarizations. Before initiating therapy with droperidol or haloperidol in critically ill patients, a baseline QTc interval and serum magnesium and potassium concentrations should be measured. If the baseline QTc interval is 440 msec or longer, and they are receiving other drugs that may prolong the QTc interval or they have electrolyte disturbances, a butyrophenone antipsychotic should be prescribed with caution. All critically ill patients receiving droperidol or haloperidol should undergo electrocardiogram monitoring and QTc interval measurement; special attention should be given to those receiving doses greater than 50 mg/24 hours, as these patients appear to be at greatest risk for development of conduction disturbances. Based on the currently available literature, in any critically ill patient receiving droperidol or haloperidol therapy whose QTc interval lengthens by 25% or more over baseline, therapy should be discontinued or the dosage reduced.

Life-threatening acute pulmonary embolism (PE) associated with circulatory shock requires effective therapy directed at removing the obstruction to flow in the pulmonary vasculature and improving hemodynamics. Options for treatment are pulmonary embolectomy and thrombolytic therapy. Although safe and effective, thrombolytic therapy is relatively contraindicated within 10 days of major surgery due to the risk of bleeding. Intravenous streptokinase was administered to a man on the third postoperative day for treatment of a massive PE associated with circulatory shock. Within 2 hours of initiating therapy, the patient experienced marked improvement in hemodynamics and tissue perfusion. No bleeding complications were noted. This case demonstrates that intravenous thrombolytics may be administered safely to patients who have recently undergone surgery. It also underscores that the decision to apply the therapy when relatively contraindicated must be made on an individual patient basis and thus ensure that potentially life-saving therapy is not withheld from those who require it most.