Acute exacerbations

Barbiturates reduce hepatic blood flow and glomerular filtration rate, but these drugs produce no adverse effects on hepatic or renal function. Barbiturates can exacerbate acute intermittent porphyria by inducing the production of hepatic ct -aminolevulinic acid (ALA) synthase (see Chapter 22). On rare occasions, thiopental has precipitated porphyric crisis when used as an induction agent in susceptible patients. 

Cryotherapy Cold/ice packs Ice massage Cold bath Vapocoolant sprays Decreased pain, edema, and inflammation Muscle relaxation and decreased spasticity Anti-inflammatory steroids (glucocorticoids) nonsteroidal anti-inflammatory analgesics (aspirin and similar NSAIDs) Skeletal muscle relaxants Peripheral vasodilators may exacerbate acute local edema Nonselective cholinergic agonists may stimulate the neuromuscular junction Some forms of cryotherapy may produce local vasoconstriction that temporarily impedes diffusion of drugs to the site of inflammation... 

Moursi M, Rising C L, Zelenock G B et al 1987 Dextrose administration exacerbates acute renal ischemic damage in anesthetized dogs. Archives of Surgery 122 ... 

Churg A, Muller NL, Silva Cl, et al. Acute exacerbation (acute lung injury of unknown cause) in UIP and other forms of fihrotic interstitial pneumonias. Am J Surg Pathol 2007 31 277-284. 

During COPD, the following symptoms occur, usually in the order mucus hypersecretion, ciliary dysfunction, airflow limitation, pulmonary hyperinflation, gas exchange abnormalities, pulmonary hypertension and cor pulmonale. Acute exacerbations appear to be mainly triggered by bacteria, viruses or environmental pollutants. They lead to a worsening of lung functions, wasting and increased mortality their psychosocial impacts include depression and anxiety that may be associated with the will to die. 

Picornavimses are small, nonenveloped RNA vimses. Members of this family include rhino- and enteroviruses, which are responsible for a variety of human diseases (viral respiratory infection, viral meningitis, myocarditis, pericarditis, encephalitis, chronic meningoencephalitis, herpangina, otitis media, neonatal enteroviral disease, and acute exacerbations of asthma). 

An acute and life-threatening exacerbation of asthma that does not respond to standard treatments of bronchodilators and corticosteroids. 

M ore than 200 viruses have been identified as capable of producing disease Acute viruses, such as the common cold, have a rapid onset and quick recovery. Chronic viral infections, such as acquired immunodeficiency syndrome (AIDS), have recurrent episodes of exacerbations (increases in severity of symptoms of the disease) and remissions (periods of partial or complete disappearance of the signs and symptoms). Display 14-1 describes the viruses discussed in this chapter. 

Iron salts occasionally cause gastrointestinal irritation, nausea, vomiting, constipation, diarrhea, headache, backache, and allergic reactions. The stools usually appear darker (black). Iron dextran is given by the parenteral route Hypersensitivity reactions, including fatal anaphylactic reactions, have been reported with the use of this form of iron. Additional adverse reactions include soreness, inflammation, and sterile abscesses at the intramuscular (IM) injection site Intravenous (IV) administration may result in phlebitis at the injection site When iron is administered via the IM route, a brownish discoloration of tlie skin may occur. Fhtients with rheumatoid arthritis may experience an acute exacerbation of joint pain, and swelling may occur when iron dextran is administered. 

Fhtients with rheumatoid arthritis may experience an acute exacerbation of joint pain, and swelling may occur with iron dextran therapy. 

Diagnostic testing of adrenocortical fundi on, nonsuppurative thyroiditis, hypercalcemia associated with cancer, acute exacerbations of multiple sderosis (MS)... 

Corticotropin is used for diagnostic testing of adrenocortical function. This drug may also be used for the management of acute exacerbations of multiple sclerosis, nonsuppurative thyroiditis, and hypercalcemia associated with cancer. It is also used as an anti-inflammatory and immunosuppressant drug when conventional glucocorticoid therapy lias not been effective (see Display 50-1). 

The first suggestion that abnormal noradrenergic transmission was linked with anxiety came from Redmond s laboratory in the 1970s when he drew attention to the similarities in the symptoms and signs of anxiety with those of the acute stress response (Redmond and Huang 1979). He went on to stimulate the locus coeruleus of (chair-restrained) monkeys and showed that this caused behavioural changes, some of which resembled a cluster of behaviours displayed by the animals when under threat. This work led to the proposal that anxiety was due to (or exacerbated by) excessive... 

Humans Hydrogen peroxide has been used as an enema or as a cleaning agent for endoscopes and may cause mucosal damage when applied to the surface of the gut wall. Hydrogen peroxide enteritis can mimic an acute ulcerative, ischaemic or pseudomembranous colitis, and ranges from a reversible, clinically inapparent process to an acute, toxic fulminant colitis associated with perforation and death (Bilotta and Waye, 1989). It is conceivable that anecdotal reports of exacerbation of IBD by iron supplementation (Kawai et al. 1992) are mediated by hydroxyl radical production by the Fenton reaction. 

Phencyclidine (PCP), a dissociative anesthetic agent, which is subject to abuse, produces behavioral effects in man that frequently resemble schizophrenia (Luisada 1978). Manifestations of persistent psychopathology frequently remain after the acute effects of PCP have diminished. With PCP, subjects may display autistic and delusional thinking typical of schizophrenics (Luby et al. 1959). A more striking link between schizophrenia and PCP comes from observations of cases in which PCP was given to hospitalized schizophrenics (Luisada 1978). After receiving PCP, these patients showed extreme exacerbation of their psychoses the reaction persisted for up to 6 weeks. By contrast, LSD produced no more severe effects in schizophrenics than in normal subjects. 

The dose-response curve for P2-adrenergic agonists is shifted to the right with increased levels of bronchoconstriction. This explains the need for higher and more frequent doses during an acute asthma exacerbation... 

Acute exacerbations usually result from an allergen or a viral infection... 

It is important for the clinician to identify the cause(s) of AHF in order to maximize treatment efficacy and reduce future disease exacerbations. Cardiovascular, metabolic, and lifestyle factors can all precipitate AHF. The most common precipitating factors for acute decompensation and how they contribute pathophysiologically are listed in Table 3-3. 

Moderate Major or minor surgery, age 40-60 years, and no clinical risk factors Major surgery, age less than 40 years, and no clinical risk factors Minor surgery, with clinical risk factor(s) Acutely ill (e.g., myocardial infarction, ischemic stroke, heart failure exacerbation), and no clinical risk factors 10-20 1-2 I o UFH 5000 units SC every 12 hours Dalteparin 2500 units SC every 24 hours Enoxaparin 40 mg SC every 24 hours Tinzaparin 3500 units SC every 24 hours IPC Graduated compression stockings... 

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