Raquel Gibly

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• Bey, T., Walter, F., Gibly, R., James, S., & Gharahbaghian, L. (2002). Survival after ethylene glycol poisoning in a patient with an arterial pH of 6.58. Veterinary and Human Toxicology, 44(3).
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  This ethylene glycol poisoning case had a blood pH of 6.58 and severe hypothermia (30.9 C). The patient received supportive care with dialysis and ethanol therapy. He survived in his premorbid state after 23 days in the hospital. A similar case survived ethylene glycol poisoning neurologically intact with an initial pH of 6.46. Although severe acidosis in the presence of serious illness is usually associated with a poor prognosis, our case emphasized the importance of aggressive supportive care and antidotal therapy for ethylene glycol poisoning even when there is a low pH.
• Gibly, R. L., Bey, T. A., Gharahbaghian, L., James, S. T., & Walter, F. G. (2002). Survival after ethylene glycol poisoning in a patient with an arterial pH of 6.58.. Veterinary and human toxicology, 44(3), 167-8.
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  This ethylene glycol poisoning case had a blood pH of 6.58 and severe hypothermia (30.9 C). The patient received supportive care with dialysis and ethanol therapy. He survived in his premorbid state after 23 days in the hospital. A similar case survived ethylene glycol poisoning neurologicaly intact with an initial pH of 6.46. Although severe acidosis in the presence of serious illness is usually associated with a poor prognosis, our case emphasized the importance of aggressive supportive care and antidotal therapy for ethylene glycol poisoning even when there is a low pH.
• Bey, T., Brammer, G., Gibly, R. L., Kohler, S., Torres, R., & Walter, F. G. (2000). Continuous intravenous flumazenil infusion for benzodiazepine poisoning.. Veterinary and human toxicology, 42(5), 280-1.
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  This is the first US report of continuous iv flumazenil infusion for benzodiazepine poisoning. A MEDLINE search from 1966 to 1999 revealed no similar reports in the US literature. A 24-y-o woman ingested 50, 2 mg (=100 mg) flunitrazepam tablets in a suicide attempt. She presented 30 min after ingestion with a temperature of 36.5 C, blood pressure of 90/36 mmHg, pulse of 84/min, and shallow respirations of 8/min. Her Glasgow coma scale (GCS) was 8. Her ECG showed sinus rhythm at 80/min, a QRS axis of 30 with no terminal 40 msec deviation, and a QRS interval of 84 msec. She received 0.2 mg flumazenil iv and her GCS improved to 15. She was orogastrically lavaged and given 50 g of activated charcoal. Resedation to a GCS of 8 recurred twice, requiring additional 0.3 mg and 0.5 mg boluses of flumazenil iv, totaling 1.0 mg over 1 h. Then, a continuous flumazenil infusion was started at 1.0 mg/h, maintaining her GCS at 15. Fourteen h later, the continuous flumazenil infusion was terminated, resulting in resedation and clinical hypoventilation. Flumazenil infusion was restarted at 1.0 mg/h with resolution of sedation and hypoventilation. Thirty h after overdose flumazenil infusion was terminated without resedation or hypoventilation. Continuous iv flumazenil infusion is not US Food and Drug Administration approved, and further study is necessary in carefully selected patients to determine its safety and efficacy.
• Brammer, G., Gibly, R., Walter, F., Bey, T., Torres, R., & Kohler, S. (2000). Continuous intravenous flumazenil infusion for benzodiazepine poisoning. Veterinary and Human Toxicology, 42(5).
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  This is the first US report of continuous iv flumazenil infusion for benzodiazepine poisoning. A MEDLINE search from 1966 to 1999 revealed no similar reports in the US literature. A 24-y-o woman ingested 50, 2 mg (=100 mg) flunitrazepam tablets in a suicide attempt. She presented 30 min after ingestion with a temperature of 36.5 C, blood pressure of 90/36 mmHg. pulse of 84/min, and shallow respirations of 8/min. Her Glasgow coma scale (GCS) was 8. Her ECG showed sinus rhythm at 80/min, a QRS axis of 30 with no terminal 40 msec deviation, and a QRS interval of 84 msec. She received 0.2 mg flumazenil iv and her GCS improved to 15. She was orogastrically lavaged and given 50 g of activated charcoal. Resedation to a GCS of 8 recurred twice, requiring additional 0.3 mg and 0.5 mg boluses of flumazenil iv, totaling 1.0 mg over 1 h. Then, a continuous flumazenil infusion was started at 1.0 mg/h. maintaining her GCS at 15. Fourteen h later, the continuous flumazenil infusion was terminated, resulting in resedation and clinical hypoventilation. Flumazenil infusion was restarted at 1.0 mg/h with resolution of sedation and hypoventilation. Thirty h after overdose flumazenil infusion was terminated without resedation or hypoventilation. Continuous iv flumazenil infusion is not US Food and Drug Administration approved, and further study is necessary in carefully selected patients to determine its safety and efficacy.
• Berg, R. A., Conroy, C., Gibly, R. L., Mcnally, J., Walter, F. G., & Williams, M. (1999). Continuous intravenous midazolam infusion for Centruroides exilicauda scorpion envenomation.. Annals of emergency medicine, 34(5), 620-5. doi:10.1016/s0196-0644(99)70164-2
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  We sought to describe the effects of continuous intravenous midazolam infusion as therapy for severe bark scorpion (Centruroides exilicauda) envenomation..A retrospective chart review from July 1, 1993, through January 1, 1998, identified all patients treated at a university hospital with International Classification of Diseases, Ninth Revision, codes 989.5 (toxic effect of venom) or E905.2 (scorpion sting causing poisoning). By using standardized collection forms, data were extracted from the medical record of every patient who had a grade III or IV envenomation and was treated with a continuous intravenous midazolam infusion..Our search identified 104 patients; 34 had grade III or IV envenomation. Of these, 33 were treated in the ICU with continuous intravenous midazolam infusion. Median patient age was 4 years (range, 1 to 68 years). Midazolam dosage was adjusted to induce a light sleep state to control agitation and involuntary motor activity. The median amount of midazolam resulting in the first recorded decrease in agitation and involuntary motor activity was 0.30 mg/kg (range, 0.03 to 1.76 mg/kg). This first evidence of clinical improvement was recorded as 1.00 hour (median), with a range of 0.00 to 3.75 hours. The initial midazolam infusion rate was 0.10 mg x kg(-1) x h(-1) (median), with a range of 0.01 to 0.31 mg x kg(-1) x h(-1). The maximal midazolam infusion rate was 0.30 mg x kg(-1) x h(-1) (median), with a range of 0.06 to 1.29 mg x kg(-1) x h(-1). The median time until the maximal midazolam infusion rate was 2.5 hours (range, 0.00 to 8.50 hours). The median duration of infusion was 9. 50 hours (range, 4.25 to 20.50 hours). The median length of stay in the ICU was 15.17 hours (range, 6.0 to 28.0 hours), and 85% of patients were discharged directly home. All patients had resolution of abnormal motor activity and agitation during their midazolam infusion. Transient hypoxemia without evidence of end-organ dysfunction was documented in 4 patients during midazolam therapy..A continuous intravenous midazolam infusion can be a safe, effective, and readily available treatment option for patients with grade III or IV C exilicauda envenomation.
• Walter, F. G., Bilden, E. F., & Gibly, R. L. (1999). Envenomations. Critical Care Clinics, 15(Issue 2). doi:10.1016/s0749-0704(05)70059-2
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  Envenomations are uncommon, challenging causes of critical care admissions. This article describes the diagnosis and treatment of envenomations that cause the most critical care admissions in the United States. Most are caused by the following animals: rattlesnakes, copperheads, cottonmouths, coral snakes, brown recluse spiders, and bark scorpions.
• Gibly, R. L., Berg, R. A., Nowlin, S. W., & Walter, F. G. (1998). Intravascular hemolysis associated with North American crotalid envenomation.. Journal of toxicology. Clinical toxicology, 36(4), 337-43. doi:10.3109/15563659809028030
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  This is a case of severe intravascular hemolysis, without significant coagulopathy, following envenomation by a North American crotalid. A MEDLINE search from 1966-1997, and a review of older literature, revealed no similar cases. A 4-year-old girl was envenomated in her right foot by a 2.5 foot-long rattlesnake whose description matched that of the Hopi rattlesnake (Crotalus viridis nuntius). The snake was not captured. Her initial hematocrit was 45%. In spite of treatment with antivenin and improvement in her lower extremity pain and swelling, her hematocrit decreased to 20.4%. Laboratory tests and clinical exam showed a Coombs positive hemolytic anemia without significant signs of coagulopathy.
• Gibly, R. L., Knopp, R. K., Roe, D. J., & Walter, F. G. (1998). Squamous cells as predictors of bacterial contamination in urine samples.. Annals of emergency medicine, 31(4), 455-8. doi:10.1016/s0196-0644(98)70253-7
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  To determine whether squamous cells in urine indicate bacterial contamination..We prospectively studied 105 consecutive women who presented to the emergency department with symptoms suggestive of a urinary tract infection. Two urine samples were collected from each woman, a midstream clean-catch (MSCC) sample and a catheterized (CATH) sample. Microscopic urinalyses to assess for squamous cells and urine cultures to assess for bacterial contamination were performed on all samples. Bacterial contamination was defined as growth of fewer than 10,000 colonies of a single species per milliliter or growth of three or more species of commensal bacteria (mixed flora) in a urine sample..Squamous cells were found in 99 of 105 CATH samples (94%); however, no CATH samples had bacterial contamination. Squamous cells were found in 101 of 105 MSCC samples (96%); however, only 22 MSCC samples (21%) had bacterial contamination..The presence of squamous cells in CATH urine samples obtained from women is not indicative of bacterial contamination. The presence of squamous cells in MSCC urine samples obtained from women also is not a good indicator, with an overall predictive value for bacterial contamination of 21%.
• Gibly, R. L., Walter, F. G., & Williams, M. (1998). Continuous intravenous midazolam infusions for Centruroides excilicauda envenomations. Clinical Toxicology, 36(5), 460-461.
• Walter, F., Gibly, R., Knopp, R., & Roe, D. (1998). Squamous cells as predictors of bacterial contamination in urine samples. Annals of Emergency Medicine, 31(4). doi:10.1016/S0196-0644(98)70253-7
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  Study objective: To determine whether squamous cells in urine indicate bacterial contamination. Methods: We prospectively studied 105 consecutive women who presented to the emergency department with symptoms suggestive of a urinary tract infection. Two urine samples were collected from each oman, a midstream clean-catch (MSCC) sample and a catheterized (CATH) sample. Microscopic urinalyses to assess for squamous cells nd urine cultures to assess for bacterial contamination were performed on all samples. Bacterial contamination was defined as growth of fewer than 10,000 colonies of a single species per milliliter or growth of three or more species of commensal bacteria (mixed flora) in a urine sample. Results: Squamous cells were found in 99 of 105 CATH samples (94%); however, no CATH samples had bacterial contamination. Squamous cells were found in 101 of 105 MSCC samples (96%); however, only 22 MSCC samples (21%) had bacterial contamination. Conclusion: The presence of squamous cells in CATH urine samples obtained from women is not indicative of bacterial contamination. The presence of squamous cells in MSCC urine samples obtained from women also is not a good indicator, with an overall predictive value for bacterial contamination of 21%.
• Gibly, R., Walter, F., James Kloster, R., Theodorou, A., & Osterloh, J. (1997). Cisapride poisoning. Veterinary and Human Toxicology, 39(4).
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  A MEDLINE search from 1966-1996 revealed no reports of cisapride poisoning. An 8-mo-old, 8.9 kg girl received 8 mL of cisapride (Propulsid Suspension, 1 mg/mL, Janssen Pharmaceutica, Titusville, NJ) rather than the usual dose of 0.8 mL, resulting in an inadvertent, 10-fold, iatrogenic, dosing error. She developed emesis, hyperactive bowel sounds, abnormal behavior, mild hyperthermia, tachycardia, hypertension, and thrombocytosis. This is the first published report of poisoning with cisapride.