Descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care: A multicenter evaluation across New Jersey.

PURPOSE: Nearly half of intensive care unit (ICU) patients will develop delirium. Antipsychotics are used routinely for the management of ICU delirium despite limited reliable data supporting this approach. The unwarranted continuation of antipsychotics initiated for ICU delirium is an emerging transitions of care concern, especially considering the adverse event profile of these agents. We sought to evaluate the magnitude of this issue across 6 centers in New Jersey and describe risk factors for continuation. METHODS: This multicenter, retrospective study examined adult ICU patients who developed ICU delirium from June 2016 to June 2018. Patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission. RESULTS: Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital. CONCLUSION: The continuation of antipsychotics for the management of delirium during transitions of care was a common practice across ICUs in New Jersey. Several risk factors for continuation of antipsychotics were identified. Efforts to reduce unnecessary continuation of antipsychotics at transitions of care are warranted.

Prolonged Anaphylaxis to Pfizer Coronavirus Disease 2019 Vaccine: A Case Report and Mechanism of Action.

BACKGROUND: In response to the devastating effects of the coronavirus disease 2019 pandemic, several vaccine prototypes have been developed, with the Pfizer/BioNTech (BNT162b2) platform being the first to receive emergency use authorization. Although taken to market on an unprecedented timeline, the safety profile of the drug during clinical trials was shown to be favorable. Shortly after release, reports from the Centers for Disease Control and Prevention demonstrated a higher-than-average rate of anaphylaxis to the vaccine that has been the cause for concern for safety officials and the general public alike. Here, we present a unique case of protracted anaphylaxis in a recipient of the BNT162b2. CASE SUMMARY: The patient is a 55-year-old female with a history of multiple allergic reactions who presented with respiratory distress and hives after receiving the first dose of the BNT162b2, despite premedication with IV steroids and diphenhydramine. The refractory nature of her reaction was demonstrated by edema of her tongue (visualized on nasolaryngoscopy), requiring an epinephrine infusion for nearly 3 days. She was discharged from the hospital with instructions not to receive the second dose of the vaccine. CONCLUSION: Although the exact etiology of anaphylaxis secondary to this messenger RNA-based vaccine is not completely clear, our literature search and review of the patient's course support either polyethylene glycol versus other excipient-related allergy as a possible cause. Based on the protracted nature to our patient's anaphylaxis, critical care management for patients with a true anaphylactic reaction to BNT162b2 may require monitoring for an extended period of time.