Imipenem/cilastatin/relebactam pharmacokinetics in critically ill patients with augmented renal clearance.

BACKGROUND: Imipenem and relebactam are predominantly excreted via glomerular filtration. Augmented renal clearance (ARC) is a common syndrome in critically-ill patients with sepsis, and sub-therapeutic antibiotic concentrations are of concern. Herein, we describe the pharmacokinetics of imipenem/relebactam in critically-ill patients with ARC. METHODS: Infected patients in the ICU with ARC (CLCR ≥ 130 mL/min) received a single dose of imipenem/cilastatin/relebactam 1.25 g as a 30 min infusion. Blood samples were collected over 6 h for concentration determination. Protein binding was assessed by ultrafiltration. An 8 h urine creatinine collection confirmed ARC. Population pharmacokinetic models with and without covariates were fit using the non-parametric adaptive grid algorithm in Pmetrics. A 5000 patient Monte Carlo simulation assessed joint PTA using relebactam fAUC/MIC ≥8 and imipenem ≥40% fT>MIC. RESULTS: Eight patients with ARC completed the study. A base population pharmacokinetic model with two-compartments fitted the data best. The mean ±â€ŠSD parameters were: CL, 17.31 ±â€Š5.76 L/h; Vc, 16.15 ±â€Š7.75 L; k12, 1.62 ±â€Š0.99 h-1; and k21, 3.53 ±â€Š3.31 h-1 for imipenem, and 11.51 ±â€Š4.79 L/h, 16.54 ±â€Š7.43 L, 1.59 ±â€Š1.12 h-1, and 2.83 ±â€Š2.91 h-1 for relebactam. Imipenem/cilastatin/relebactam 1.25 g as a 30 min infusion every 6 h achieved 100% and 93% PTA at MICs of 1 and 2 mg/L, respectively. CONCLUSIONS: Despite enhanced clearance of both imipenem and relebactam, the currently approved dosing regimen for normal renal function was predicted to achieve optimal exposure in critically-ill patients with ARC sufficient to treat most susceptible pathogens.

Improving Decannulation and Swallowing Function: A Comprehensive, Multidisciplinary Approach to Post-Tracheostomy Care.

BACKGROUND: Multidisciplinary tracheostomy teams have been successful in improving operative outcomes; however, limited data exist on their effect on postoperative care. We aimed to determine the effectiveness of a multidisciplinary tracheostomy service alone and following implementation of a post-tracheostomy care bundle on rates of decannulation and tolerance of oral diet before discharge. METHODS: Prospective data on all subjects requiring tracheostomy by any trauma/critical care surgeon were collected from January 2011 to December 2013 following development of a tracheostomy service and continued following implementation of the post-tracheostomy care bundle. Rates of decannulation and tolerance of oral diet were compared between all groups: pre-tracheostomy service (baseline, historical control), tracheostomy service alone, and tracheostomy service with post-tracheostomy care bundle. RESULTS: Three hundred ninety-three subjects met the criteria for analysis with 61 in the baseline group, 124 following initiation of a tracheostomy service, and 208 after the addition of the post-tracheostomy care bundle. There were significant overall differences between all groups in the proportion of subjects decannulated, proportion of subjects tolerating oral diet, and number of subjects receiving speech evaluations. Pairwise comparisons showed no differences in decannulation or tolerance of oral diet following implementation of the tracheostomy service alone but significant improvement with the addition of the post-tracheostomy care bundle compared with baseline. (P = .002 and P = .005, respectively). Likewise, the number of speech language pathologist consults significantly increased compared with baseline only after the post-tracheostomy care bundle (P = .004). Time to speech evaluation significantly decreased with the post-tracheostomy care bundle compared with baseline and tracheostomy service (P < .013). CONCLUSIONS: The addition of a post-tracheostomy care bundle to a multidisciplinary tracheostomy service significantly improved rates of decannulation and tolerance of oral diet.

Resource-efficient mobilization programs in the intensive care unit: who stands to win?

BACKGROUND: Functional outcomes can improve with early intensive care unit (ICU) mobilization programs but require additional resources. Details regarding resource allotment and methods to deliver therapy are lacking. We describe an effective team-based, resource-efficient mobility program (REMP). METHODS: Consecutive admissions (November 2009 to March 2010) underwent an evaluation by a physical therapist and participation in the REMP. Sitting balance (SB), transfer from bed to chair, and ambulation were assessed on the initial evaluation and compared with ICU and hospital discharge using the Functional Independence Measure scale. RESULTS: Twenty-eight patients entered the REMP, and 31 patients served as controls. There were no differences in baseline characteristics or initial Functional Independence Measure scores for ambulation or SB. Bed-to-chair evaluation was higher in the controls (P < .024). Both groups improved across the 3 time periods on all measures; however, more REMP patients had a significantly improved SB at ICU and hospital discharge. CONCLUSIONS: A team-based, resource-efficient approach to early mobilization is feasible and effective in the ICU.

Web-based teaching module improves success rates of postpyloric positioning of nasoenteric feeding tubes.

BACKGROUND: Bedside protocols improve success rates of postpyloric nasoenteric tube (NET) placement by nutrition teams and experienced individuals. However, many hospitals require novice practitioners to perform these procedures and often choose fluoroscopy, endoscopy, or newer alternative devices to achieve success. Little is known about the ability to train inexperienced practitioners or the effectiveness of the methods used to implement these protocols. Web-based learning is a potential tool to improve knowledge and procedural skills. The authors created a self-directed Web-based teaching module (WBTM) to educate and standardize placement of postpyloric NETs. METHODS: Forty-three first-, second-, or third-year residents or medical or physician assistant students took pretests for knowledge and confidence surveys, viewed the WBTM, placed NET at the bedside, then took a posttest and confidence survey while awaiting confirmation of tube position by abdominal radiograph. Success was acknowledged if the tip of the NET was beyond the pylorus. A retrospective chart review was used to determine a historical success rate, which was used as a control. RESULTS: Knowledge and confidence significantly improved. Overall success rate of postpyloric NET placement for all participants on first attempt was 74.4% vs 46.7% in the control (P = .005). Improvement occurred in all subgroups, including those with no prior experience, who were successful 70.4% of the time (P = .009). CONCLUSIONS: This WBTM is simple to implement, inexpensive, and resource efficient. The improvement in postpyloric NET placement, especially among novice practitioners, demonstrates the benefit and applicability of this method of standardized education.

Mannequin simulation identifies common surgical intensive care unit teamwork errors long after introduction of sepsis guidelines.

INTRODUCTION: Groups of evidence-based guidelines were developed into a comprehensive treatment bundle as part of an international-based Surviving Sepsis Campaign to improve treatment of severe sepsis and septic shock. Conventional educational strategies of this sepsis treatment "bundle" may not ensure acceptable knowledge or completion of these specific tasks and may overlook other dynamic factors present during critical moments of a crisis. Simulation using multidisciplinary teams of clinicians through mannequin-based simulations (MDMS) may improve "bundle" compliance by identifying sepsis guideline errors, reinforcing knowledge, and exposing other potential causes of poor performance. METHODS: Seventy-four clinicians participated in the MDMS 14 months after hospital-wide introduction of the sepsis bundle. Additionally, each team was given a sepsis treatment-learning packet before the training session. Twelve teams underwent a MDMS of a patient in septic shock. Two evaluators recorded completed sepsis guideline tasks in real time. Sessions were videotaped and reviewed with the team in a postscenario debriefing session. Pre/posttests were also administered. RESULTS: Individual participants' pretest scores averaged 64.6% correct. Despite all but one team having at least one knowledgeable member with a pretest score of at least 80%, team task completion averaged only 60.4%. Team mean pretest scores and proportion of tasks completed were significantly correlated (P = 0.007), but correlations between specific tasks and related questions showed no relationship to knowledge. CONCLUSION: Inadequate completion of the sepsis guideline tasks during the MDMS could not be explained by inadequate pretest knowledge alone. MDMS may be a useful tool in identifying and exploring these unknown factors.