Avoiding Patient Harm With Parenteral Nutrition During Electrolyte Shortages.

Purpose: We report a case of a patient with gastrointestinal dysmotility and substantial drainage losses who required parenteral nutrition (PN) and developed a non-anion gap metabolic acidosis secondary to a shortage of concurrent potassium acetate and sodium acetate PN additives. We describe how severe PN-associated metabolic consequences were averted during this acetate shortage. Summary: The patient with inability to swallow and significant weight loss was admitted to the hospital and given PN after failure to tolerate either gastric or jejunal feeding due to dysmotility and severe abdominal distension and discomfort. PN was initiated and the nasogastric and jejunal tubes were left to low intermittent suction or gravity drainage (average losses of 800 mL and 1600 mL daily, respectively) to reduce abdominal distension. The patient had been stable on PN for approximately 2 months prior to when a shortage in potassium acetate and sodium acetate occurred. As a result, potassium and sodium requirements had to be met with chloride and phosphate salts. The patient developed a non-anion gap metabolic acidosis after 11 days of acetate-free PN. Progression to severe acidemia was avoided by administration of sodium bicarbonate daily for 3 days and replacement of 0.9% sodium chloride supplemental intravenous fluid with lactated ringers solution. Conclusion: This case report illustrates that PN component shortages require clinicians to closely monitor patients who require PN. In addition, clinicians may need to use creative therapeutic strategies to avoid potential serious patient harm during PN component shortages.

Adjunctive intraventricular antibiotic therapy for bacterial central nervous system infections in critically ill patients with traumatic brain injury.

BACKGROUND: Limited data exist on the role of adjunctive intraventricular (IVT) antibiotics for the treatment of central nervous system (CNS) infections in traumatic brain injury (TBI) patients. OBJECTIVE: To evaluate differences in CNS infection cure rates for TBI patients who received adjunctive IVT antibiotics compared with intravenous (IV) antibiotics alone. METHODS: We retrospectively identified patients with TBI and bacterial CNS infections admitted to the trauma intensive care unit (ICU) from 1997 to 2013. Study patients received IV and IVT antibiotics, and control patients received IV antibiotics alone. Clinical and microbiological cure rates were determined from patient records, in addition to ICU and hospital lengths of stay (LOSs), ventilator days, and hospital mortality. RESULTS: A total of 83 patients were enrolled (32 study and 51 control). The duration of IV antibiotics was similar in both groups (10 vs 12 days, P = 0.14), and the study group received IVT antibiotics for a median of 9 days. Microbiological cure rates were 84% and 82% in study and control groups, respectively (P = 0.95). Clinical cure rates were similar at all time points. No significant differences were seen in days of mechanical ventilation, ICU or hospital LOS, or hospital mortality. When only patients with external ventricular drains were compared, cure rates remained similar between groups. CONCLUSIONS: TBI patients with CNS infections had similar microbiological and clinical cure rates whether they were treated with adjunctive IVT antibiotics or IV antibiotics alone. Shorter than recommended durations of antibiotic therapy still resulted in acceptable cure rates and similar clinically relevant outcomes.

Capacity ratios to assess the solvency of a college's advanced pharmacy practice experience program.

OBJECTIVE: To use the capacity ratio to determine solvency in 10 advanced pharmacy practice experiences (APPEs) offered by a college of pharmacy. METHODS: Availability in each APPE was determined based on preceptor responses, and student need was tabulated from 3 preference forms. Capacity ratios were calculated by dividing preceptor availability by the sum of student requests plus 20% of student requests; ratios ≥ 1 indicated solvency. For the 3 required APPEs, minimum capacity ratios were calculated by dividing availability by the sum of student number plus 20% of the student number. When possible, the capacity ratio for the APPE was calculated by geographic zone. RESULTS: The 3 required APPEs had statewide minimum capacity ratios that were consistent with solvency: advanced community (2.8), advanced institutional (1.6), and ambulatory care (2.5). Only 3 of 7 elective APPEs demonstrated solvency. The elective APPEs for which requests exceeded availability were association management (0.8), emergency medicine (0.8), cardiology (0.6), and human immunodeficiency virus (HIV) ambulatory care clinic (0.4). Analysis by zone revealed additional insolvent practice experiences in some locations. CONCLUSIONS: The capacity ratio allowed for assessment of 10 APPEs and identification of practice experience areas that need expansion. While the capacity ratio is a proposed standardized assessment, it does have some limitations, such as an inability to account for practice experience quality, scheduling conflicts, and geographic zone issues.

Seizure activity during cetuximab infusion in a patient with metastatic colorectal cancer.

PURPOSE: The case of a patient with metastatic colorectal cancer who had a seizure during his intial cetuximab infusion is reported. SUMMARY: A 54-year-old Asian man received his first infusion of cetuximab after pretreatment with ondansetron, ranitidine, diphenhydramine, and dexamethasone. Approximately 15 minutes after initiation of the cetuximab infusion, the patient called for help. The nurse found the patient sitting up with a blank stare, and the patient began to have a generalized seizure. The emergency resuscitation team was called and administered lorazepam 2 mg i.v., at which time the seizure ceased. The patient required emergent intubation, but no cardiopulmonary resuscitation was necessary. After intubation, the patient was transferred to the intensive care unit. Computed tomography of the head found no evidence of lesions. The patient remained stable, was extubated, and was transferred out of the intensive care unit the next day. Fourteen days after the seizure, the patient returned for follow-up magnetic resonance imaging of the brain and head with gadolinium contrast. Per the radiologist's report, there were no enhancing lesions to suggest metastases, no abnormalities to suggest infarct or tumor, and no bone abnormalities, and the patient's brain volume was within normal limits for his age. Based on the Naranjo et al. probability scale score, the relationship between the patient's seizure and cetuximab infusion was probable. CONCLUSION: A 54-year-old Asian man developed seizure activity requiring emergent intubation during his initial cetuximab infusion for the treatment of metastatic colorectal cancer.

Lipid interactions of acylated tryptophan-methylated lactoferricin peptides by solid-state NMR.

Lactoferricin (LfB) is a 25-residue innate immunity peptide released by pepsin from the N-terminal region of bovine lactoferrin. A smaller amidated peptide, LfB6 (RRWQWR-NH2) retains antimicrobial activity and is thought to constitute the "antimicrobial active-site" (Tomita, Acta Paediatr Jpn. 1994; 36: 585-91). Here we report on N-acylation of 1-Me-Trp5-LfB6, Cn-RRWQ[1-Me-W]R-NH2, where Cn is an acyl chain having n = 0, 2, 4, 6 or 12 carbons. Tryptophan 5 (Trp5) was methylated to enhance membrane binding and to allow for selective deuteration at that position. Peptide/lipid interactions of Cn-RRWQ[1-Me-W]R-NH2 (deuterated 1-Me-Trp5 underlined), were monitored by solid state 31P NMR and 2H NMR. The samples consisted of macroscopically oriented bilayers of mixed neutral (dimyristoylphosphatidylcholine, DMPC) and anionic (dimyristoylphosphatidylglycerol, DMPG) lipids in a 3:1 ratio with Cn-RRWQ[&1-Me-W]R-NH2 peptides added at a 1:25 peptide to lipid ratio. 2H-NMR spectra reveal that the acylated peptides are well aligned in DMPC:DMPG bilayers. The 2H NMR quadrupolar splittings suggest that the 1-Me-Trp is located in a motionally restricted environment, indicating partial alignment at the membrane interface. 31P-NMR spectra reveal that the lipids are predominantly in a bilayer configuration, with little perturbation by the peptides. Methylation alone, in C0-RRWQ[1-Me-W]R-NH2, resulted in a 3-4 fold increase in antimicrobial activity against E. coli. N-acylation with a C12 fatty acid enhanced activity almost 90 fold.