Rocuronium Dosing by Ideal vs Total Body Weight in Obesity: A Prospective, Observational Non-inferiority Study.

Background: Providing adequate paralysis and appropriate sedation is challenging in patients with obesity during rapid sequence intubation (RSI). Pharmacokinetic parameters play an important role in dosing of rocuronium due to low lipophilicity. Rocuronium may be dosed based on ideal body weight (IBW). Current guidelines do not offer recommendations for dosing in the setting of obesity. Dosing depends on clinician preference based on total body weight (TBW) or IBW. Objective: In this study we performed non-inferiority analysis to compare the intubation conditions, duration of paralysis, and incidence of new-onset tachycardia or hypertension after intubation in obese patients requiring RSI in the emergency department (ED). Methods: This was a single-center, prospective, observational study. Eligible for enrollment were adult patients with a TBW ≥30% IBW or body mass index ≥30 kilograms per meters squared who presented to the ED requiring RSI with the use of rocuronium. Rocuronium was dosed according to intubating physicians' preference. Physicians completed a survey assessing intubation conditions. Height and weight used for the calculation of the dose, the dose of rocuronium, time of administration, and time of muscle function recovery were recorded. Endpoints assessed included grading of view during laryngoscopy, first-past success, and duration of paralysis. Results: In total, 96 patients were included, 54 in TBW and 42 in IBW. The TBW cohort received a mean of 1 milligram per kilogram (mg/kg) compared to 0.71 mg/kg in the IBW group. Excellent intubation conditions were observed in 68.5% in the TBW group and 73.8% in the IBW group. The non-inferiority analysis for relative risk of excellent intubation was 1.12 (P = 0.12, [90% CI 0.80-1.50]). Conclusion: Non-inferiority analysis suggests that IBW dosing provides similar optimal intubation conditions when compared to TBW dosing, but the noninferiority comparison did not reach statistical significance. This study was unable to show statistical non-inferiority for IBW dosing.

Comparison of high- and low-dose 4-factor prothrombin complex concentrate for the emergent reversal of oral Factor Xa inhibitors.

Even though there are several reversal strategies available for oral Factor Xa inhibitor associated coagulopathies, 4-factor prothrombin complex concentrate (4F-PCC) is used commonly as the primary reversal agent at many institutions. A dose of 50 units/kg is recommended as safe and effective with growing data suggesting that a lower dosing strategy may be sufficient. This retrospective study included adult patients who received either high-dose (50 units/kg; maximum dose: 5000 units) or low-dose (25 units/kg; maximum dose: 2500 units) 4F-PCC for the emergent reversal of oral Factor Xa inhibitor-related life threatening bleeding. The primary outcome was the attainment of hemostatic effectiveness. Secondary outcomes were rates of thromboembolic events and inpatient mortality. 47 patients were included in the analysis of which 24 patients received high-dose and 23 patients received low-dose 4F-PCC. Overall hemostatic effectiveness was 87.5% in the high-dose group and 91.3% in the low-dose group. Thromboembolic event rate was 8.3% in the high-dose group compared to 4.4% within the low-dose group and inpatient mortality rate was 8.3% in the high-dose group and 4.4% in the low-dose group. Low-dose 4F-PCC (25 units/kg, maximum dose: 2500 units) for the reversal of oral Factor Xa inhibitors is a cost-effective alternative to high-dose 4F-PCC (50 units/kg; maximum dose: 5000 units) and provides effective hemostasis without increased rates of thromboembolic events or inpatient mortality.

Protocolized use of Factor Eight Inhibitor Bypassing Activity (FEIBA) for the reversal of warfarin induced coagulopathy.

INTRODUCTION: Coagulopathy due to warfarin in patients with major bleeding was traditionally reversed with fresh frozen plasma and intravenous (IV) vitamin K, but prothrombin complex concentrates (PCC) are increasingly used in the treatment of these patients. Factor Eight Inhibitor Bypassing Activity (FEIBA) is an activated four-factor PCC most commonly used in patients with hemophilia. We aimed to evaluate the efficacy and safety of FEIBA and IV vitamin K for the reversal of warfarin-associated coagulopathy in patients with major bleeding, by measuring the percentage of patients who achieved target INR ≤ 1.5 and the incidence of thrombotic adverse events (TAE). METHODS: In this prospective observational study, we enrolled patients presenting to the Emergency Department (ED) with warfarin associated coagulopathy (INR > 1.5) and major bleeding. Patients received FEIBA using an INR based dosing strategy and IV vitamin K. RESULTS: In 43 patients, median initial INR was 4.0 (2.7, 7.3 interquartile range (IQR)). Median time to result the second INR was 45 min (38, 55 IQR) and the median INR was 1.4 (1.3, 1.6 IQR). Out of the 43 patients, 93% achieved the target INR of ≤1.5. In-hospital mortality was 40% (17 patients). There were 11 TAEs in 6 patients (14%); 4 events in 2 patients (5%) were attributed to FEIBA. CONCLUSION: A protocolized use of FEIBA and IV vitamin K resulted in the efficacious reversal of warfarin-induced coagulopathy in patients with major bleeding. TAEs occurred in 14% of patients and were attributed to FEIBA in 5% of patients.

Vitreo-retinal hemorrhage after thrombolysis in a patient with acute ischemic stroke: a case report.

PURPOSE: Bleeding is the major side effect of thrombolysis with alteplase (tissue plasminogen activator, t-PA) used for the treatment of acute ischemic stroke. Life-threatening intracranial, retroperitoneal, gastrointestinal, respiratory, and genitourinary bleeding can occur with the use of t-PA. Vitreo-retinal bleeding in the context of acute ischemic stroke treatment has not been reported in the literature before and therefore is not posed as a potential risk during decision making. Here we describe the first reported case of vitreo-retinal hemorrhage due to alteplase administration in a patient with acute ischemic stroke. SUMMARY: An 84-year-old white male presented to the emergency room with complaints of right arm and leg weakness. The onset of symptoms was approximately 30 min prior to presentation to the emergency room. After ruling out contraindications including the presence of hemorrhage on head CT scan, patient was administered alteplase within 2 hours of symptom onset. Four hours after the administration of alteplase, the patient developed right-sided vision changes. A repeat CT scan demonstrated a newly developed right intraocular hemorrhage. Throughout the hospital course, patient's neurological status improved, but he continued to have right-sided visual loss. CONCLUSION: Clinicians should be aware of the potential for ocular hemorrhage especially in high-risk patients. The likelihood of a subsequent vision-loss needs to be therefore discussed with the patient and family in such situations.