Clinical decision support systems differ in their ability to identify clinically relevant drug interactions of immunosuppressants in kidney transplant patients.

WHAT IS KNOWN AND OBJECTIVE: In kidney transplant patients, clinically relevant drug-drug interactions (DDIs) with immunosuppressants potentially lead to serious adverse drug events (ADEs). The aim of this study was (i) to show that five clinical decision support systems (CDSSs) differ in their ability to identify clinically relevant potential DDIs (pDDIs) of immunosuppressants in kidney transplant patients and (ii) to compare CDSSs in terms of their ability to identify clinically relevant pDDIs in this context. METHODS: All pDDIs being possible between nine immunosuppressants and 234 comedication drugs were identified for 264 intensive care unit (ICU) kidney transplant patients from 1999 to 2010. For pDDI identification, five CDSSs were used: DRUG-REAX® , ID PHARMA CHECK® , Lexi-Interact, mediQ and Meona. PDDIs from high severity categories were defined as clinically relevant. Classification of pDDIs as clinically relevant/non-clinically relevant by a clinical pharmacist using Stockley's Drug Interactions was employed as benchmark. We analysed inter-rater agreement, sensitivity, specificity, positive predictive value and negative predictive value. RESULTS AND DISCUSSION: Clinical decision support systems generated a total of 759 pDDI alerts. A total of 240 pDDI alerts were in high severity categories. A total of 391 different pDDIs were identified. Only 5% (n = 35) of different pDDIs were identified by all CDSSs. A total of 49 pDDIs were classified as clinically relevant by clinical pharmacists' rating using Stockley's Drug Interactions. Meona (0·72) has the highest inter-rater agreement with the benchmark for clinically relevant pDDIs. ID PHARMA CHECK® and mediQ show highest sensitivities (0·74, respectively). Meona has the highest specificity (0·99) and positive predictive value (0·89). WHAT IS NEW AND CONCLUSION: Five CDSSs differ in their ability to identify clinically relevant pDDIs of immunosuppressants in kidney transplant patients. Data may assist in selecting CDSSs for kidney transplant patients in the ICU. Using CDSSs to identify clinically relevant pDDIs could prevent ADEs and contribute to the overall goal of avoiding patient harm and increasing patient safety.

[Bleeding origin, patient-related risk factors, and prognostic indicators in patients with acute gastrointestinal hemorrhages requiring intensive care treatment. A retrospective analysis from 1999 to 2010]. / Ursachen, patientenspezifische Risikofaktoren und prognostische Indikatoren bei akuter gastrointestinaler Blutung und intensivmedizinischer Therapieindikation. Eine retrospektive Untersuchung der Jahre 1999-2010.

BACKGROUND: Gastrointestinal bleeding (GIB) is a common problem in elderly patients involving severe comorbidities and concomitant antiplatelet or anticoagulatory therapy. The risk factors and prognostic indicators of patients with severe GIB requiring intensive care medical treatment have not been well evaluated. METHODS: A retrospective analysis of 7,376 patients from the medical intensive care unit (ICU) at the University Hospital Aachen was carried out between 1999 and 2010. RESULTS: Of 614 patients admitted to the ICU because of acute GIB, 463 (75%) presented with upper GIB (UGIB) and 151 (25%) with lower GIB (LGIB). Despite early endoscopic intervention and ICU treatment, UGIB had a mortality rate of 16%, whereas LGIB showed a significantly better prognosis (mortality <5%) in the ICU setting. Risk factors for OGIB-related mortality were hemodynamic instability, organ failure, comorbidities (especially liver cirrhosis), and rebleeding. In total, 218 patients (36%) were treated with antiplatelet or anticoagulatory drugs, which were associated with a favorable prognosis in the UGIB group. Elevated serum lactate levels upon admission were superior in predicting mortality than established indicators of prognosis such as the Rockall or the Glasgow-Blatchford score. CONCLUSIONS: Despite successful endoscopic intervention, severe acute UGIB is associated with a significant mortality rate of 16% in the ICU setting, determined by hemodynamic failure, organ dysfunction, and comorbidities. The serum lactate levels of patients with GIB on the day of admission to the ICU are prognostic.

[Gastrointestinal bleeding in liver cirrhosis at the ICU]. / Gastrointestinale Blutungen als Komplikation von Patienten mit Leberzirrhose auf der Intensivstation.

Due to portal hypertension and bleeding disorders, patients with liver cirrhosis are at increased risk for severe gastrointestinal bleedings (GIB), commonly requiring therapy at the intensive care unit (ICU). In order to identify epidemiological and prognostic factors for GIB in cirrhotic patients, we retrospectively analysed patients from our medical ICU from 1999 to 2010. Among 7376 critically ill patients, 650 (8.8 %) were diagnosed with liver cirrhosis. Hepatic cirrhosis was frequently found in ICU patients admitted due to severe GIB (23.2 % of 711 patients had cirrhosis). Moreover, patients with cirrhosis were at increased risk to develop severe GIB during intensive care treatment (40.9 % of 44 patients with GIB during ICU stay had cirrhosis). Besides the high rate of variceal bleedings (64.4 %) in cirrhotic patients, non-variceal haemorrhages were also common (28.5 %). We identified the MELD score and necessity of mechanical ventilation as independent risk factors for mortality in cirrhotic patients with severe GIB. Patients with liver cirrhosis and severe GIB had significantly impaired prognosis (case-related fatality rate of 26.1 % with cirrhosis vs. 6.8 % without cirrhosis), especially in cases of newly developed GIB during ICU therapy. Advanced therapeutic approaches and novel strategies are warranted to improve the critical prognosis of these high-risk patients.