This report illustrates potential concerns regarding the administration of Argatroban (AGN), a sm... more This report illustrates potential concerns regarding the administration of Argatroban (AGN), a small molecule, direct thrombin inhibitor, within the setting of multi-organ procurement (MOP). Herein, we outline the case of a large AGN bolus to the donor during MOP, and the passive transfer of a coagulopathy to the recipient of the transplanted liver. From this, we conclude that caution should be exercised when AGN is used in the setting of MOP.
Background: The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular as... more Background: The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD. Materials and methods: The surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither. Secondary outcomes included timing, etiology, and location of GIB. Multivariable logistic regression was used to compare treatment cohorts to GIB. Odds ratios, 95% confidence intervals, and P-values were reported from the model. Results: One hundred thirty-eight patients were included for final analysis, 19 of which had a GIB within 30 days of VAD implantation. Both H2RA and PPI use were associated with reduced GIB compared with the cohort with no acid suppressive therapy. In the multivariate analysis, the PPI cohort showed a statistically significant reduction in GIB (Odds ratio 0.18 [95% confidence interval 0.04-0.79] P ¼ 0.026). Conclusions: Using PPI postoperatively in patients with new VAD was associated with a reduced incidence of GIB. Given that GIB is a known complication after VAD placement, clinicians should consider the use of acid suppressive therapy for primary prevention.
Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe... more Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe enough to be sold as an over-the-counter medicine. Unlike other l-opioid receptor agonists, loperamide acts specifically in the myenteric plexus in the gastrointestinal tract, making the potential for abuse low and reports of toxicity extremely rare. We present a case of a patient previously in good health who developed episodes of cardiac pauses, nonsustained ventricular tachycardia, and eventually runs of sustained ventricular tachycardia with hemodynamic instability. She required cardiopulmonary resuscitation, multiple cardioversions, and placement of a pacemaker. Her medical history was remarkable only for type 2 diabetes and chronic postcholecystectomy diarrhea. Metformin was the only prescription medication she was taking at the time of presentation. However, she reported that she had been taking an entire bottle of Equate brand loperamide (144 mg) daily for~2 years. Loperamide overdoses associated with ventricular arrhythmias have been reported, but this is the first case to describe a serious ventricular arrhythmia associated with long-term use of a high dose of loperamide. Chronic overtreatment with loperamide may induce life-threatening arrhythmias.
Current Emergency and Hospital Medicine Reports, Jan 19, 2019
Purpose of Review We aimed to describe bleeding events associated with extracorporeal cardiopulmo... more Purpose of Review We aimed to describe bleeding events associated with extracorporeal cardiopulmonary resuscitation (eCPR) using two institutional heparin protocols. In addition, we discuss current barriers to optimal anticoagulation in this critical population. Recent Findings Patients initiated on venoarterial membrane oxygenation (VA-ECMO) are at risk of bleeding and thrombosis; both conditions can lead to severe morbidity or mortality. Intravenous heparin is the preferred form of anticoagulation for VA-ECMO. Prior studies have found elevated activated partial thromboplastin time (aPTT) may be an independent risk factor for bleeding; however, many studies lack standardization of bleeding scores and optimal anticoagulation targets. Summary All six patients initiated on VA-ECMO experienced at least one bleeding event. Of 71 aPTT levels collected, 44% were within therapeutic range, 18% were subtherapeutic, and 38% were supratherapeutic. There were no obvious correlation between aPTT levels and bleeding. Future studies are needed to evaluate anticoagulation strategies in this population.
Objective: Compare the duration of mechanical ventilation between patients receiving sedation wit... more Objective: Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Design: Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm. Setting: Level 1, university-based, 32-bed, adult, mixed trauma and surgical intensive care unit (SICU). Continuous sedation was delivered according to a protocol methodology with daily sedation vacation and spontaneous breathing trials. Choice of sedation agent was physician directed. Patients: Between 2010 and 2014, 149 SICU patients receiving mechanical ventilation for >24 h received dexmedetomidine with propofol. Propensity matching resulted in 143 pair cohorts. Interventions: Dexmedetomidine with propofol or propofol alone. Measurements and Main Results: There was no statistical difference in SICU length of stay (LOS), with a median absolute difference of 5.3 h for propofol alone group (p = 0.43). The SICU mortality was not statistically different (RR = 1.002, p = 0.88). Examining a 14-day period post-treatment with dexmedetomidine, on any given day (excluding days 1 and 14), dexmedetomidine with propofol-treated patients had a 0.5% to 22.5% greater likelihood of being delirious (CAM-ICU positive). In addition, dexmedetomidine with propofol-treated patients had a 4.5% to 18.8% higher likelihood of being above the target sedation score (more agitated) compared to propofol-alone patients. Conclusions: In this propensity matched cohort study, adjunct use of dexmedetomidine to propofol did not show a statistically significant reduction with respect to mechanical ventilation (MV) duration, SICU LOS, or SICU mortality, despite a trend toward receiving fewer hours of propofol. There was no evidence that dexmedetomidine with propofol improved sedation scores or reduced delirium.
Journal of Trauma-injury Infection and Critical Care, Oct 1, 2003
Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... Skip Navigation Links Home > October ...
This case report compared and contrasted calculations for dosing recombinant activated factor VII... more This case report compared and contrasted calculations for dosing recombinant activated factor VII (rFVIIa) in a morbidly obese patient using estimation of blood volume rather than actual weight or ideal body weight (IBW). A specific case report in a morbidly obese, critically ill patient with new diagnosis of acquired hemophilia A (AHA) was presented. A 64-year-old morbidly obese patient with AHA required emergent surgery for perforated diverticulitis and peritonitis. The patient required bypass treatment with rFVIIa and was initially dosed based on actual weight of 167 kg (body mass index 61). The patient had a history of deep vein thrombosis and new onset of atrial fibrillation. Based on numerous risk factors for both bleeding and the potential for thromboembolism, the rFVIIa dose was adjusted based on calculations using adjusted body weight and blood volume principles, which decreased dosage by 40%, from 15 to 9 mg. With no active bleeding, rFVIIa dosage was adjusted and rotating thromboelastography testing was added to coagulation parameter monitoring. With this change in dosage, hemostasis was maintained and 132 mg of rFVIIa was saved over an 8-day treatment period. There is very limited literature to direct clinicians on rFVIIa dosing in morbidly obese patients. Since obesity is prevalent in all patient populations, clinicians should consider an estimation of blood volume as a means to dose rFVIIa. Adjusting the dose of rFVIIa to account for changes in blood volume is a physiologic target that should help balance the risk of underdosing using IBW and the risk of overdosing using actual body weight.
Current Emergency and Hospital Medicine Reports, 2019
Purpose of Review We aimed to describe bleeding events associated with extracorporeal cardiopulmo... more Purpose of Review We aimed to describe bleeding events associated with extracorporeal cardiopulmonary resuscitation (eCPR) using two institutional heparin protocols. In addition, we discuss current barriers to optimal anticoagulation in this critical population. Recent Findings Patients initiated on venoarterial membrane oxygenation (VA-ECMO) are at risk of bleeding and thrombosis; both conditions can lead to severe morbidity or mortality. Intravenous heparin is the preferred form of anticoagulation for VA-ECMO. Prior studies have found elevated activated partial thromboplastin time (aPTT) may be an independent risk factor for bleeding; however, many studies lack standardization of bleeding scores and optimal anticoagulation targets. Summary All six patients initiated on VA-ECMO experienced at least one bleeding event. Of 71 aPTT levels collected, 44% were within therapeutic range, 18% were subtherapeutic, and 38% were supratherapeutic. There were no obvious correlation between aPTT levels and bleeding. Future studies are needed to evaluate anticoagulation strategies in this population.
The purpose of this study was to determine if fixed dose enoxaparin prophylaxis provided effectiv... more The purpose of this study was to determine if fixed dose enoxaparin prophylaxis provided effective anticoagulation for acute care surgery patients and to examine whether a real-time enoxaparin dose adjustment algorithm optimized anticoagulation. Acute care surgical patients placed on enoxaparin prophylaxis 30 mg twice daily were recruited prospectively. Peak steady state aFXa levels were drawn with a goal peak aFXa range of 0.2-0.4 IU/ml. A real time dose adjustment algorithm was implemented for patients with out-of-range levels. Fifty five patients were included. 56.4% of patients had low aFXa levels (<0.2 IU/mL). Real-time enoxaparin dose adjustment significantly increased the proportion of patients who achieved in-range peak aFXa levels, compared to standard dosing (74.5% vs 41.8%, p < 0.001). Patients with initial inadequate peak aFXa levels had a higher rate of 90-day post-operative VTE, although not statistically significant (16.1% vs. 8.3%, p = 0.50). The majority of ac...
Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe... more Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe enough to be sold as an over-the-counter medicine. Unlike other μ-opioid receptor agonists, loperamide acts specifically in the myenteric plexus in the gastrointestinal tract, making the potential for abuse low and reports of toxicity extremely rare. We present a case of a patient previously in good health who developed episodes of cardiac pauses, nonsustained ventricular tachycardia, and eventually runs of sustained ventricular tachycardia with hemodynamic instability. She required cardiopulmonary resuscitation, multiple cardioversions, and placement of a pacemaker. Her medical history was remarkable only for type 2 diabetes and chronic postcholecystectomy diarrhea. Metformin was the only prescription medication she was taking at the time of presentation. However, she reported that she had been taking an entire bottle of Equate brand loperamide (144 mg) daily for ~2 years. Loperamide o...
The Journal of Trauma: Injury, Infection, and Critical Care, 2003
Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... Skip Navigation Links Home > October ...
This report illustrates potential concerns regarding the administration of Argatroban (AGN), a sm... more This report illustrates potential concerns regarding the administration of Argatroban (AGN), a small molecule, direct thrombin inhibitor, within the setting of multi-organ procurement (MOP). Herein, we outline the case of a large AGN bolus to the donor during MOP, and the passive transfer of a coagulopathy to the recipient of the transplanted liver. From this, we conclude that caution should be exercised when AGN is used in the setting of MOP.
Background Critical care pharmacists are established and valuable members of the critical care te... more Background Critical care pharmacists are established and valuable members of the critical care team, however there is rarely written evidence of their daily involvement in the patient's electronic medical record (EMR). Documentation in the EMR has the advantage of ensuring a seamless pass-off and provides an opportunity to capture the pharmacist's cognitive and clinical impact in a way that traditional systems of tracking “interventions” fail to do. We investigated implementation of pharmacist progress notes in a surgical intensive care unit (ICU) and their utility in measuring pharmacist activity. Methods Daily pharmacist progress notes written in a surgical ICU over a period of 2 months were reviewed. Each pharmacist action identified through progress note review was quantified and scored by an independent reviewer using a newly developed scoring system, the clinical impact score (CIS). This was developed as a way to quantify pharmacist actions and to classify those action...
BACKGROUND The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular ass... more BACKGROUND The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD. MATERIALS AND METHODS The surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither. Secondary outcomes included timing, etiology, and location of GIB. Multivariable logistic regression was used to compare treatment cohorts to GIB. Odds ratios, 95% confidence intervals, and P-values were reported from the model. RESULTS One hundred thirty-eight patients were included for final analysis, 19 of which had a GIB within 30 days of VAD implantation. Both H2RA and PPI use were associated with reduced GIB compared with the cohort with no acid suppressive therapy. In the multivariate analysis, the PPI cohort showed a statistically significant reduction in GIB (Odds ratio 0.18 [95% confidence interval 0.04-0.79] P = 0.026). CONCLUSIONS Using PPI postoperatively in patients with new VAD was associated with a reduced incidence of GIB. Given that GIB is a known complication after VAD placement, clinicians should consider the use of acid suppressive therapy for primary prevention.
This case report compared and contrasted calculations for dosing recombinant activated factor VII... more This case report compared and contrasted calculations for dosing recombinant activated factor VII (rFVIIa) in a morbidly obese patient using estimation of blood volume rather than actual weight or ideal body weight (IBW). A specific case report in a morbidly obese, critically ill patient with new diagnosis of acquired hemophilia A (AHA) was presented. A 64-year-old morbidly obese patient with AHA required emergent surgery for perforated diverticulitis and peritonitis. The patient required bypass treatment with rFVIIa and was initially dosed based on actual weight of 167 kg (body mass index 61). The patient had a history of deep vein thrombosis and new onset of atrial fibrillation. Based on numerous risk factors for both bleeding and the potential for thromboembolism, the rFVIIa dose was adjusted based on calculations using adjusted body weight and blood volume principles, which decreased dosage by 40%, from 15 to 9 mg. With no active bleeding, rFVIIa dosage was adjusted and rotating thromboelastography testing was added to coagulation parameter monitoring. With this change in dosage, hemostasis was maintained and 132 mg of rFVIIa was saved over an 8-day treatment period. There is very limited literature to direct clinicians on rFVIIa dosing in morbidly obese patients. Since obesity is prevalent in all patient populations, clinicians should consider an estimation of blood volume as a means to dose rFVIIa. Adjusting the dose of rFVIIa to account for changes in blood volume is a physiologic target that should help balance the risk of underdosing using IBW and the risk of overdosing using actual body weight.
This report illustrates potential concerns regarding the administration of Argatroban (AGN), a sm... more This report illustrates potential concerns regarding the administration of Argatroban (AGN), a small molecule, direct thrombin inhibitor, within the setting of multi-organ procurement (MOP). Herein, we outline the case of a large AGN bolus to the donor during MOP, and the passive transfer of a coagulopathy to the recipient of the transplanted liver. From this, we conclude that caution should be exercised when AGN is used in the setting of MOP.
Background: The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular as... more Background: The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD. Materials and methods: The surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither. Secondary outcomes included timing, etiology, and location of GIB. Multivariable logistic regression was used to compare treatment cohorts to GIB. Odds ratios, 95% confidence intervals, and P-values were reported from the model. Results: One hundred thirty-eight patients were included for final analysis, 19 of which had a GIB within 30 days of VAD implantation. Both H2RA and PPI use were associated with reduced GIB compared with the cohort with no acid suppressive therapy. In the multivariate analysis, the PPI cohort showed a statistically significant reduction in GIB (Odds ratio 0.18 [95% confidence interval 0.04-0.79] P ¼ 0.026). Conclusions: Using PPI postoperatively in patients with new VAD was associated with a reduced incidence of GIB. Given that GIB is a known complication after VAD placement, clinicians should consider the use of acid suppressive therapy for primary prevention.
Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe... more Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe enough to be sold as an over-the-counter medicine. Unlike other l-opioid receptor agonists, loperamide acts specifically in the myenteric plexus in the gastrointestinal tract, making the potential for abuse low and reports of toxicity extremely rare. We present a case of a patient previously in good health who developed episodes of cardiac pauses, nonsustained ventricular tachycardia, and eventually runs of sustained ventricular tachycardia with hemodynamic instability. She required cardiopulmonary resuscitation, multiple cardioversions, and placement of a pacemaker. Her medical history was remarkable only for type 2 diabetes and chronic postcholecystectomy diarrhea. Metformin was the only prescription medication she was taking at the time of presentation. However, she reported that she had been taking an entire bottle of Equate brand loperamide (144 mg) daily for~2 years. Loperamide overdoses associated with ventricular arrhythmias have been reported, but this is the first case to describe a serious ventricular arrhythmia associated with long-term use of a high dose of loperamide. Chronic overtreatment with loperamide may induce life-threatening arrhythmias.
Current Emergency and Hospital Medicine Reports, Jan 19, 2019
Purpose of Review We aimed to describe bleeding events associated with extracorporeal cardiopulmo... more Purpose of Review We aimed to describe bleeding events associated with extracorporeal cardiopulmonary resuscitation (eCPR) using two institutional heparin protocols. In addition, we discuss current barriers to optimal anticoagulation in this critical population. Recent Findings Patients initiated on venoarterial membrane oxygenation (VA-ECMO) are at risk of bleeding and thrombosis; both conditions can lead to severe morbidity or mortality. Intravenous heparin is the preferred form of anticoagulation for VA-ECMO. Prior studies have found elevated activated partial thromboplastin time (aPTT) may be an independent risk factor for bleeding; however, many studies lack standardization of bleeding scores and optimal anticoagulation targets. Summary All six patients initiated on VA-ECMO experienced at least one bleeding event. Of 71 aPTT levels collected, 44% were within therapeutic range, 18% were subtherapeutic, and 38% were supratherapeutic. There were no obvious correlation between aPTT levels and bleeding. Future studies are needed to evaluate anticoagulation strategies in this population.
Objective: Compare the duration of mechanical ventilation between patients receiving sedation wit... more Objective: Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Design: Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm. Setting: Level 1, university-based, 32-bed, adult, mixed trauma and surgical intensive care unit (SICU). Continuous sedation was delivered according to a protocol methodology with daily sedation vacation and spontaneous breathing trials. Choice of sedation agent was physician directed. Patients: Between 2010 and 2014, 149 SICU patients receiving mechanical ventilation for >24 h received dexmedetomidine with propofol. Propensity matching resulted in 143 pair cohorts. Interventions: Dexmedetomidine with propofol or propofol alone. Measurements and Main Results: There was no statistical difference in SICU length of stay (LOS), with a median absolute difference of 5.3 h for propofol alone group (p = 0.43). The SICU mortality was not statistically different (RR = 1.002, p = 0.88). Examining a 14-day period post-treatment with dexmedetomidine, on any given day (excluding days 1 and 14), dexmedetomidine with propofol-treated patients had a 0.5% to 22.5% greater likelihood of being delirious (CAM-ICU positive). In addition, dexmedetomidine with propofol-treated patients had a 4.5% to 18.8% higher likelihood of being above the target sedation score (more agitated) compared to propofol-alone patients. Conclusions: In this propensity matched cohort study, adjunct use of dexmedetomidine to propofol did not show a statistically significant reduction with respect to mechanical ventilation (MV) duration, SICU LOS, or SICU mortality, despite a trend toward receiving fewer hours of propofol. There was no evidence that dexmedetomidine with propofol improved sedation scores or reduced delirium.
Journal of Trauma-injury Infection and Critical Care, Oct 1, 2003
Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... Skip Navigation Links Home > October ...
This case report compared and contrasted calculations for dosing recombinant activated factor VII... more This case report compared and contrasted calculations for dosing recombinant activated factor VII (rFVIIa) in a morbidly obese patient using estimation of blood volume rather than actual weight or ideal body weight (IBW). A specific case report in a morbidly obese, critically ill patient with new diagnosis of acquired hemophilia A (AHA) was presented. A 64-year-old morbidly obese patient with AHA required emergent surgery for perforated diverticulitis and peritonitis. The patient required bypass treatment with rFVIIa and was initially dosed based on actual weight of 167 kg (body mass index 61). The patient had a history of deep vein thrombosis and new onset of atrial fibrillation. Based on numerous risk factors for both bleeding and the potential for thromboembolism, the rFVIIa dose was adjusted based on calculations using adjusted body weight and blood volume principles, which decreased dosage by 40%, from 15 to 9 mg. With no active bleeding, rFVIIa dosage was adjusted and rotating thromboelastography testing was added to coagulation parameter monitoring. With this change in dosage, hemostasis was maintained and 132 mg of rFVIIa was saved over an 8-day treatment period. There is very limited literature to direct clinicians on rFVIIa dosing in morbidly obese patients. Since obesity is prevalent in all patient populations, clinicians should consider an estimation of blood volume as a means to dose rFVIIa. Adjusting the dose of rFVIIa to account for changes in blood volume is a physiologic target that should help balance the risk of underdosing using IBW and the risk of overdosing using actual body weight.
Current Emergency and Hospital Medicine Reports, 2019
Purpose of Review We aimed to describe bleeding events associated with extracorporeal cardiopulmo... more Purpose of Review We aimed to describe bleeding events associated with extracorporeal cardiopulmonary resuscitation (eCPR) using two institutional heparin protocols. In addition, we discuss current barriers to optimal anticoagulation in this critical population. Recent Findings Patients initiated on venoarterial membrane oxygenation (VA-ECMO) are at risk of bleeding and thrombosis; both conditions can lead to severe morbidity or mortality. Intravenous heparin is the preferred form of anticoagulation for VA-ECMO. Prior studies have found elevated activated partial thromboplastin time (aPTT) may be an independent risk factor for bleeding; however, many studies lack standardization of bleeding scores and optimal anticoagulation targets. Summary All six patients initiated on VA-ECMO experienced at least one bleeding event. Of 71 aPTT levels collected, 44% were within therapeutic range, 18% were subtherapeutic, and 38% were supratherapeutic. There were no obvious correlation between aPTT levels and bleeding. Future studies are needed to evaluate anticoagulation strategies in this population.
The purpose of this study was to determine if fixed dose enoxaparin prophylaxis provided effectiv... more The purpose of this study was to determine if fixed dose enoxaparin prophylaxis provided effective anticoagulation for acute care surgery patients and to examine whether a real-time enoxaparin dose adjustment algorithm optimized anticoagulation. Acute care surgical patients placed on enoxaparin prophylaxis 30 mg twice daily were recruited prospectively. Peak steady state aFXa levels were drawn with a goal peak aFXa range of 0.2-0.4 IU/ml. A real time dose adjustment algorithm was implemented for patients with out-of-range levels. Fifty five patients were included. 56.4% of patients had low aFXa levels (<0.2 IU/mL). Real-time enoxaparin dose adjustment significantly increased the proportion of patients who achieved in-range peak aFXa levels, compared to standard dosing (74.5% vs 41.8%, p < 0.001). Patients with initial inadequate peak aFXa levels had a higher rate of 90-day post-operative VTE, although not statistically significant (16.1% vs. 8.3%, p = 0.50). The majority of ac...
Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe... more Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe enough to be sold as an over-the-counter medicine. Unlike other μ-opioid receptor agonists, loperamide acts specifically in the myenteric plexus in the gastrointestinal tract, making the potential for abuse low and reports of toxicity extremely rare. We present a case of a patient previously in good health who developed episodes of cardiac pauses, nonsustained ventricular tachycardia, and eventually runs of sustained ventricular tachycardia with hemodynamic instability. She required cardiopulmonary resuscitation, multiple cardioversions, and placement of a pacemaker. Her medical history was remarkable only for type 2 diabetes and chronic postcholecystectomy diarrhea. Metformin was the only prescription medication she was taking at the time of presentation. However, she reported that she had been taking an entire bottle of Equate brand loperamide (144 mg) daily for ~2 years. Loperamide o...
The Journal of Trauma: Injury, Infection, and Critical Care, 2003
Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... Skip Navigation Links Home > October ...
This report illustrates potential concerns regarding the administration of Argatroban (AGN), a sm... more This report illustrates potential concerns regarding the administration of Argatroban (AGN), a small molecule, direct thrombin inhibitor, within the setting of multi-organ procurement (MOP). Herein, we outline the case of a large AGN bolus to the donor during MOP, and the passive transfer of a coagulopathy to the recipient of the transplanted liver. From this, we conclude that caution should be exercised when AGN is used in the setting of MOP.
Background Critical care pharmacists are established and valuable members of the critical care te... more Background Critical care pharmacists are established and valuable members of the critical care team, however there is rarely written evidence of their daily involvement in the patient's electronic medical record (EMR). Documentation in the EMR has the advantage of ensuring a seamless pass-off and provides an opportunity to capture the pharmacist's cognitive and clinical impact in a way that traditional systems of tracking “interventions” fail to do. We investigated implementation of pharmacist progress notes in a surgical intensive care unit (ICU) and their utility in measuring pharmacist activity. Methods Daily pharmacist progress notes written in a surgical ICU over a period of 2 months were reviewed. Each pharmacist action identified through progress note review was quantified and scored by an independent reviewer using a newly developed scoring system, the clinical impact score (CIS). This was developed as a way to quantify pharmacist actions and to classify those action...
BACKGROUND The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular ass... more BACKGROUND The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPIs) or histamine receptor antagonists (H2RA) for preventing GIB in patients with VAD. MATERIALS AND METHODS The surgical ICU and VAD databases within a large regional academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. An observational cohort study was conducted to identify which acid suppressing drug regimen was associated with the fewest number of GIB events within 30 d after VAD implantation: PPI, H2RA, or neither. Secondary outcomes included timing, etiology, and location of GIB. Multivariable logistic regression was used to compare treatment cohorts to GIB. Odds ratios, 95% confidence intervals, and P-values were reported from the model. RESULTS One hundred thirty-eight patients were included for final analysis, 19 of which had a GIB within 30 days of VAD implantation. Both H2RA and PPI use were associated with reduced GIB compared with the cohort with no acid suppressive therapy. In the multivariate analysis, the PPI cohort showed a statistically significant reduction in GIB (Odds ratio 0.18 [95% confidence interval 0.04-0.79] P = 0.026). CONCLUSIONS Using PPI postoperatively in patients with new VAD was associated with a reduced incidence of GIB. Given that GIB is a known complication after VAD placement, clinicians should consider the use of acid suppressive therapy for primary prevention.
This case report compared and contrasted calculations for dosing recombinant activated factor VII... more This case report compared and contrasted calculations for dosing recombinant activated factor VII (rFVIIa) in a morbidly obese patient using estimation of blood volume rather than actual weight or ideal body weight (IBW). A specific case report in a morbidly obese, critically ill patient with new diagnosis of acquired hemophilia A (AHA) was presented. A 64-year-old morbidly obese patient with AHA required emergent surgery for perforated diverticulitis and peritonitis. The patient required bypass treatment with rFVIIa and was initially dosed based on actual weight of 167 kg (body mass index 61). The patient had a history of deep vein thrombosis and new onset of atrial fibrillation. Based on numerous risk factors for both bleeding and the potential for thromboembolism, the rFVIIa dose was adjusted based on calculations using adjusted body weight and blood volume principles, which decreased dosage by 40%, from 15 to 9 mg. With no active bleeding, rFVIIa dosage was adjusted and rotating thromboelastography testing was added to coagulation parameter monitoring. With this change in dosage, hemostasis was maintained and 132 mg of rFVIIa was saved over an 8-day treatment period. There is very limited literature to direct clinicians on rFVIIa dosing in morbidly obese patients. Since obesity is prevalent in all patient populations, clinicians should consider an estimation of blood volume as a means to dose rFVIIa. Adjusting the dose of rFVIIa to account for changes in blood volume is a physiologic target that should help balance the risk of underdosing using IBW and the risk of overdosing using actual body weight.
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