Fever Associated With Dexmedetomidine in Adult Acute Care Patients: A Systematic Review of the Literature.

Dexmedetomidine-associated fever has been reported in the literature and can lead to lengthy workups and unnecessary antibiotic exposure. We conducted a systematic review to evaluate and describe the evidence of fever or hyperthermia caused by dexmedetomidine in adult patients. Data sources included PubMed/MEDLINE, EMBASE, CINAHL, and Web of Sciences. English-language studies of any design published from inception through April 2020 including conference abstracts were included. The target population was hospitalized adult patients. Quality of evidence was determined based on GRADE recommendations and risk of bias assessed using the Evidence Project Risk of Bias tool. Naranjo scores were assessed to determine the likeliness of adverse event being caused by dexmedetomidine. All data were extracted independently and with the guidance of a medical librarian. Four hundred and eighty-eight total citations were found on formal search, with 329 left after removal of duplicates. Independent record screening was performed, leaving 17 citations including 4 retrospective cohort studies, 1 case series, and 12 case reports. Quality of evidence ranged from very low to low for identified analyses. Evidence with patient-level data (case reports and series) were combined to establish a cohort for descriptive results. The median Naranjo score was 4 (range, 3 to 8), and dexmedetomidine doses ranged from 0.1 to 2 µg·h/kg. Obesity and cardiac surgery appear to be significant risk factors. Dexmedetomidine-associated fever appears uncommon, but the true incidence is unknown. Clinicians should keep dexmedetomidine-associated fever in their differential, and stewardship programs should consider assessing for this adverse effect in their patient monitoring.

Valproic Acid for the Management of Agitation and Delirium in the Intensive Care Setting: A Retrospective Analysis.

PURPOSE: Valproic acid has been proposed as an alternative agent for treatment of agitation and delirium in the intensive care unit (ICU). Clinical data to support the use of valproic acid for this indication are limited. The objective of this analysis was to assess the efficacy and safety associated with the use of valproic acid for the management of agitation and delirium in the ICU. METHODS: This retrospective descriptive analysis included patients who were prescribed valproic acid for a minimum of 3 days for the treatment of agitation and/or delirium in the cardiac, surgical, or medical ICU from May 31, 2015 to December 31, 2017. The prevalence of agitation and delirium was assessed during valproic acid therapy for up to 7 days. Additional data analyzed included opioid, sedative, and antipsychotic requirements and safety outcomes. FINDINGS: A total of 47 patients met the inclusion criteria. There was an observed downward trend in the prevalence of agitation (47.8% vs 16.7%) and delirium (84.8% vs. 63.3%) throughout valproic acid therapy. In addition, the proportion of patients who required dexmedetomidine, benzodiazepines, antipsychotics, and opioids decreased while patients were taking valproic acid. No adverse effects attributed to valproic acid occurred in this patient population. IMPLICATIONS: Valproic acid may be an alternative option to assist in the management of agitation and delirium in the ICU. Additional prospective data are needed to validate the use of this agent for the treatment of agitation and delirium in critically ill patients.

Evaluation of Inhaled Dornase Alfa Administration in Non-Cystic Fibrosis Patients at a Tertiary Academic Medical Center.

PURPOSE: The use of dornase alfa in a non-cystic fibrosis population has been proposed to help improve atelectasis and secretions. Data evaluating dornase alfa in a non-cystic fibrosis population are limited, and the prescribing practices at a tertiary academic medical center are unknown. METHODS: Adult patients ≥18 years of age were included if they received inhaled dornase alfa. Patients were excluded if they had cystic fibrosis. Data collected included demographic data, dornase alfa prescribing patterns, concomitant inhaled therapy, blood gas data, and documented efficacy and safety data. RESULTS: Seventy-six orders for dornase alfa therapy were included in the analysis. Of the patients, 18% had asthma and 19% had chronic obstructive pulmonary disease. Seventy-seven percent of the patients received concomitant inhaled therapy. Eighty-three percent of orders were for 2.5 mg of dornase alfa twice daily. The median (interquartile range [IQR]) number of doses received per patient was 6 (4-13) with a median (IQR) duration of 3 (2-7) days. After inhaled dornase alfa administration, 11% of patients were able to cough productively. No safety issues related to inhaled dornase alfa therapy were noted. CONCLUSIONS: Inhaled dornase alfa is commonly prescribed to improve atelectasis and secretions in a non-cystic fibrosis patient population at a tertiary academic medical center.

Intrapleural Antimicrobial Irrigation for Postpneumonectomy Empyema in Patients With Lung Cancer.

PURPOSE: Postpneumonectomy empyema (PPE) is a possible complication after a pneumonectomy in patients with lung cancer. The use of intrapleural (IP) antibiotic irrigation to treat infections in the pleural space may be indicated after systemic antimicrobial therapy, and drainage of the pleural space has been insufficient. METHODS: Adult patients ≥18 years old who received IP antibiotic irrigation between 2006 and 2011 were included. Demographic data, past medical history, surgical procedure, systemic antibiotics, and culture data were collected. Additionally, the IP antibiotic administered, the dose, and how it was prepared and administered were collected. RESULTS: A total of 18 patients were evaluated in this retrospective descriptive analysis. The majority of patients underwent an extrapleural pneumonectomy (EPP; 72%). Most patients received systemic antibiotics before IP antibiotic administration (95%). Vancomycin was the most common antibiotic used for both systemic therapy (100%) and IP irrigation (94%). The median number of IP antibiotic doses received per patient was 5.5 (interquartile range [IQR] 1-9). Recurrence of PPE within 6 months of initial PPE resolution occurred in 28% of patients. Intrapleural antibiotic irrigation was well tolerated in all patients. CONCLUSION: Vancomycin is most commonly used for IP antibiotic irrigation at our institution after patients have undergone a thoracic surgery, which was most commonly an EPP.