Diazepam has long been reported to be effective in the treatment of tetanus due to the combined anticonvulsant and muscle relaxation actions on tetanus muscle spasms and rigidity

Diazepam has long been reported to be effective in the treatment of tetanus due to the combined anticonvulsant and muscle relaxation actions on tetanus muscle spasms and rigidity. clonidine in a tetanus patient with acute renal failure and provides a novel way to successfully manage these patients. Case report An 18-year-old male patient weighing 58 kg was admitted to medicine ward with complaints of acute onset of muscular pain one day back with stiffness in body and fever (102F) for which he had taken some analgesics from a private practitioner. He NOX1 gave past history of superficial open wound on right elbow one month back which had healed. He had received Inj. Tetanus toxoid (TT) at that time. Tetanus was suspected along with a differential diagnosis of encephalitis and meningitis. He was admitted and given Inj. TT, antitetanus serum 1500 I.U., and metronidazlole. However patient had muscle spasms and complained of difficulty in breathing following which he was intubated and shifted to intensive care unit. Diazepam 10 mg.hour?1, rocuronium 30 mg.hour?1 by infusion and methocarbamol 100 mg TDS, chlorpromazine 50 mg BD were started. SIMV(Pressure control) with pressure support mode of ventilation with pressure control 20cmH2O, pressure support 20cmH2O upper pressure limit 40cmH2O, SIMV rate 12/minute, FiO2 0.4 with appropriate minute ventilation alarm limits on Siemens Servo ventilator 300 was used for ventilation. Apart from the routine investigations lumbar puncture for CSF examination, fundal examination and CT scan head were performed. CSF examination revealed increase in proteins. Patient required increasing doses of rocuronium for effective ventilation as was assessed from increase in inspiratory pressures and low minute ventilation alarms. On the second day, patient developed autonomic instability with wide fluctuations in heart rate and blood pressure (heart rate ranged from 40 to 130/minute, systolic blood pressure from 65 to 180mmHg and diastolic blood pressure from 40 to110 mmHg). These fluctuations were marked at the time of endotracheal suctioning and patient turning. Infusion of magnesium sulphate at 2 gm.hour?1 was added after a loading dose of 4 gm for adequate control of spasms and prevention of autonomic instability. Around the fourth day, patient developed fever (102F), decreased urine output (300 ml), elevated blood urea nitrogen PI-103 Hydrochloride (38mg/dl) and serum creatinine (2.4mg/dl) levels. PI-103 Hydrochloride The serum magnesium levels were 7.0 mEq/L. Meropenem 500 mg i.v. TDS was started after sending culture sensitivity reports based on suspicion of sepsis and culture sensitivity profile prevalent in our ICU. Cental venous pressure (using triple lumen CVP catheter 16G lumen size in right internal jugular vein) was within normal limits. Magnesium was stopped. Atracurium was used for paralysis, rocuronium was stopped. However patient had spasms and fluctuations in heart rate and blood pressure. Around the 5th day epidural catheter (Portex, 20G) was inserted in subarachnoid space using 18G Tuohy’s needle with patient in lateral decubitus position and threaded 3 cm cephalic. We administered clonidine 15 g intrathecally every 4 hourly through the catheter along with intravenous infusion of clonidine 50 g/hour. Clonidine which is usually available as 150 g/ml was diluted in normal saline to concentration of 15 g/ml and injected intrathecally after taking in consideration the lifeless space of the catheter (about 0.3ml). Intravenous fluids (Ringer’s lactate and dextrose 5% in normal saline) were administered to keep CVP in normal range. Strict intake and output charting was maintained. Patient was tracheostomised. Kidney function assessments and serum magnesium levels were done daily. Patient was hemodynamically stable (heart rate ranged from 76 to 110/minute, systolic blood pressure from 106 to 130 mmHg and diastolic blood pressure from 75 to 90 mmHg, after about 24 hours of starting clonidine. Kidney functions improved (blood urea nitrogen 22mg/dl on 7th day and 17mg/dl on 10th day and serum creatinine 1.8mg/dl on 7th day PI-103 Hydrochloride and 1.3mg/dl on 10th day) and magnesium levels decreased. Around the seventh day atracurium was stopped. Patient thereafter had no spasms. Intrathecal clonidine was reduced to 15 g every 8 hourly from 9th day. PI-103 Hydrochloride Diazepam and methocarbazole were stopped and intrathecal catheter removed around the 11th day. Patient was PI-103 Hydrochloride maintained on i.v. clonidine at 25 g/hour from 11th day which was stopped around the 13th day. Active physiotherapy was started and patient was weaned off the ventilator on 17th day. Tracheostomy was closed subsequently and patient discharged on 25th day. Discussion Tetanus is usually caused by the Gram-positive bacillus, Clostridium tetani. It is a spore forming obligate anaerobe normally found in ground. It is rarely cultured from wounds and the diagnosis is usually a clinical one. It produces two exotoxins, tetanospasmin and tetanolysin. Tetanolysin damages local tissue and provides optimal conditions for bacterial multiplication. It.