Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZDs) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative therapy for AWS. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim was to compare a BZD versus PHB protocol in the management of AWS in trauma patients. METHODS: We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low-dose oral PHB regimen. Patients were excluded if they were taking BZDs or barbiturates before admission, received propofol or dexmedetomidine before initiation of the study drug, presented with delirium tremens or seizures, or died or discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS; therapy escalation; oversedation; delirium-, intensive care unit-, and ventilator-free days; and length of stay. RESULTS: A total of 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy were not statistically significant (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.21-1.39); however, patients receiving PHB were less likely to develop uncomplicated AWS (OR, 0.08; 95% CI, 0.04-0.14) and less likely to require escalation of therapy (OR, 0.45; 95% CI, 0.24-0.84). The PHB group had a length of stay 3.1 days shorter than the BZD group ( p = 0.002). There was no difference in intensive care unit-, ventilator-, or delirium-free days. CONCLUSION: A PHB-based protocol for the management of AWS is a safe and effective alternative to BZD-based regimens in trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

The Effect of Propofol on Peri-Induction Hemodynamics and Resuscitation in Operative Penetrating Trauma.

BACKGROUND: Hemorrhaging trauma patients may be disproportionately affected by choice of induction agent during rapid sequence intubation (RSI). Etomidate, ketamine, and propofol are safe in the trauma population-at-large but have not been assessed in patients with ongoing hemorrhage. We hypothesize that in hemorrhaging patients with penetrating injury, propofol deleteriously affects peri-induction hypotension compared to etomidate and ketamine. METHODS: Retrospective cohort study. Primary outcome was the effect of induction agent on peri-induction systolic blood pressure. Secondary outcomes were the incidence of peri-induction vasopressor use and quantity of peri-induction blood transfusion requirements. Linear multivariate regression modeling assessed the effect of induction agent on the variables of interest. RESULTS: 169 patients were included, 146 received propofol and 23 received etomidate or ketamine. Univariate analysis revealed no difference in peri-induction systolic blood pressure (P = .53), peri-induction vasopressor administration (P = .62), or transfusion requirements within the first hour after induction (PRBC P = .24, FFP P = .19, PLT P = .29). Choice of RSI agent did not independently predict peri-induction systolic blood pressure or blood product administration. Rather, only presenting shock index independently predicted peri-induction hypotension. CONCLUSIONS: This is the first study to directly assess the peri-induction effects of anesthetic induction agent choice in penetrating trauma patients undergoing emergent hemorrhage control surgery. Propofol does not appear to worsen peri-induction hypotension regardless of dose. Patient physiology is most predictive of peri-induction hypotension.

Evaluation of inpatient medication guidance from an artificial intelligence chatbot.

PURPOSE: To analyze the clinical completeness, correctness, usefulness, and safety of chatbot and medication database responses to everyday inpatient medication-use questions. METHODS: We evaluated the responses from an artificial intelligence chatbot, a medication database, and clinical pharmacists to 200 real-world medication-use questions. Answer quality was rated by a blinded group of pharmacists, providers, and nurses. Chatbot and medication database responses were deemed "acceptable" if the mean reviewer rating was within 3 points of the mean rating for pharmacists' answers. We used descriptive statistics for reviewer ratings and Kendall's coefficient to evaluate interrater agreement. RESULTS: The medication database generated responses to 194 (97%) questions, with 88% considered acceptable for clinical correctness, 76% considered acceptable for completeness, 83% considered acceptable for safety, and 81% considered acceptable for usefulness compared to pharmacists' answers. The chatbot responded to only 160 (80%) questions, with 85% considered acceptable for clinical correctness, 65% considered acceptable for completeness, 71% considered acceptable for safety, and 68% considered acceptable for usefulness. CONCLUSION: Traditional search methods using a drug database provide more clinically correct, complete, safe, and useful answers than a chatbot. When the chatbot generated a response, the clinical correctness was similar to that of a drug database; however, it was not rated as favorably for clinical completeness, safety, or usefulness. Our results highlight the need for ongoing training and continued improvements to artificial intelligence chatbots for them to be incorporated reliably into the clinical workflow. With continued improvement in chatbot functionality, chatbots could be a useful pharmacist adjunct, providing healthcare providers with quick and reliable answers to medication-use questions.

Acquired Tracheomalacia Requiring Urgent Tracheostomy Exchange in Patients With COVID-19.

Tracheostomy for prolonged ventilation of patients with COVID-19 was often delayed due to high viral loads and persistent high ventilatory requirements. With prolonged intubation and significant dose corticosteroid use, patients with COVID-19 are at risk for tracheomalacia, and urgent tube exchange may be required to address persistent cuff leak and to maintain adequate mechanical ventilation. We sought to describe our single center experience with COVID-19 patients requiring tracheostomy and the tracheal complications that followed. We performed a review of patients with COVID-19 who underwent tracheostomy from June 2020 to October 2021. 45 patients were identified; 82.2% survived their index hospitalization. Tracheostomy was performed after 16.4 days of mechanical ventilation. 22.2% required urgent exchange to an extended length tracheostomy tube after 7.2 days from initial tracheostomy. Placement of an extended length tracheostomy tube can reduce cuff leak in ventilated COVID-19 patients and may be considered during initial tracheostomy placement.

The Efficacy and Safety of Methylnaltrexone for the Treatment of Postoperative Ileus.

BACKGROUND: Postoperative ileus (POI) is a surgical complication resulting in increased morbidity and length of stay (LOS). Usual care for POI includes bowel rest and gastric decompression. It has been questioned if methylnaltrexone (MNTX), a peripheral opioid antagonist, could be used as treatment for POI. The purpose of this study was to determine if MNTX is effective and safe for POI treatment. METHODS: This single-center, retrospective cohort study included patients ⩾ 18 years with a POI. Patients with acute colonic pseudo-obstruction, small bowel obstruction, and gastrointestinal malignancy were excluded. The intervention was MNTX administration. The primary outcome was time to ileus resolution. Secondary outcomes included LOS, duration of nasogastric tube, total parenteral nutrition requirement, and incidence of gastrointestinal perforations. RESULTS: 110 patients were included in the analysis; 28 received MNTX. Time to ileus resolution was 9.9 days for the MNTX group and 11.4 days for the control group (P = .38). Duration of gastric decompression was 4.6 days for the MNTX group and 4.2 days for the control group (P = .71). Length of stay was 19.9 days for the MNTX group and 19.7 days for the control group (P = .96). The percentage of TPN requirement was 17.9% in the MNTX group and 22.0% in the control group (P = .65). No gastrointestinal perforations were observed in either group. CONCLUSION: For the treatment of POI, MNTX did not significantly reduce time to resolution of ileus, LOS, duration of gastric decompression, or TPN requirements. However, no gastrointestinal perforations were seen, indicating that MNTX may be safely used in these patients.

Hyponatremia induced by hyperinsulinemia-euglycemia therapy.

PURPOSE: A case of symptomatic hyponatremia induced by hyperinsulinemia-euglycemia (HIE) therapy is reported. SUMMARY: A 59-year-old, 81.65-kg woman with hypertension, major depressive disorder, and anxiety arrived at a tertiary medical center 1.5 hours after an intentional overdose of oral amlodipine 200 mg, metoprolol tartrate 2,000 mg, and isosorbide mononitrate 1,200 mg. Upon arrival, her pulse was 63 beats/min and blood pressure was 106/56 mm Hg. The patient's blood pressure was refractory to fluids, calcium gluconate, and norepinephrine, resulting in initiation of HIE therapy. She had recurrent episodes of hypoglycemia, which required increases of the dextrose infusion and resulted in the patient receiving a total of 6.9 L of dextrose with free water. Seventeen hours into the hospitalization, the patient became obtunded due to hyponatremia (serum sodium concentration, 121 mmol/L). HIE therapy was discontinued, an infusion of 5% dextrose injection with sodium bicarbonate added was started, and a bolus of 3% sodium chloride was administered. Nine hours after the presentation of hyponatremia, the patient's serum sodium concentration normalized (137 mmol/L), and her symptoms resolved. The patient's blood pressure, pulse, and mental status continued to improve, and the patient was transferred out of the medical intensive care unit 41 hours after her arrival at the hospital. CONCLUSION: A woman who overdosed on amlodipine, metoprolol tartrate, and isosorbide mononitrate was treated with HIE therapy and developed symptomatic hyponatremia. Hyponatremia resolved after administration of dextrose with sodium bicarbonate infusion and 3% sodium chloride infusion and cessation of HIE therapy.

Prevalence and correlates of heavy smoking and nicotine dependence in adolescents with bipolar and cannabis use disorders.

The study examined the prevalence and correlates of heavy smoking and nicotine dependence in adolescents with bipolar and cannabis use disorders. Participants were 80 adolescents between 13 and 22 years of age with co-occurring bipolar I disorder and cannabis abuse or dependence who reported ever trying a cigarette. Diagnostic and symptom severity measures were completed as part of the baseline assessments for a clinical trial. Almost half (49%) of these participants who ever tried a cigarette were current heavy smokers (≥10 cigarettes/day), and 70% met DSM-IV-TR lifetime criteria for nicotine dependence. Heavy smoking was associated with older age, heavier marijuana use and greater compulsive craving, lifetime diagnoses of attention-deficit/hyperactivity disorder, conduct disorder, illicit drug use disorders, and poorer overall functioning. Nicotine dependence was related to White race, higher current mania severity, and poorer overall functioning. These findings suggest that heavy smoking and nicotine dependence were highly prevalent among these adolescents. Although both were associated with greater physical and psychosocial problems, only heavy smoking was linked to a clear pattern of more severe substance-related and psychiatric problems. Further research to elucidate mechanisms and develop interventions to address early, entrenched patterns of co-use of tobacco and marijuana is warranted.

Diagnosing Alcohol and Cannabis Use Disorders in Adolescents with Bipolar Disorder: A Preliminary Investigation.

OBJECTIVE: The aim of this report was to examine the accuracy of diagnosing substance use disorders in manic adolescents with bipolar disorder. METHODS: The substance use disorder modules of the KSADS-PL were administered to a sample of 80 manic adolescents (12-21 years old) with co-occurring bipolar and substance use disorders. Initial substance use disorder diagnoses obtained from the KSADS-PL were then compared to a best-estimate diagnosis derived from all available information, including a second diagnostic interview, the Child Semi-Structured Assessment for the Genetics of Alcoholism, Adolescent version (C-SSAGA-A). RESULTS: Relatively low diagnostic agreement was achieved across the initial and the best estimate diagnoses for both alcohol and cannabis use disorders. Age, race, and sex did not predict diagnostic agreement between the two evaluations. CONCLUSIONS: Results of this study call for more research on diagnosing substance use disorders and suggest that a single interview alone may not be accurate for diagnosing substance use disorders in manic adolescents with bipolar disorder.