An Unrecognized Problem in Optimizing Antimicrobial Therapy: Significant Residual Volume Remaining in Intravenous Tubing With Extended-Infusion Piperacillin-Tazobactam.

The fundamental process of medication therapy is that a medication is ordered, verified, and entirely administered to the patient. An unrecognized phenomenon across the antimicrobial landscape may be residual volume remaining within intravenous tubing, never getting to the patient. Evidence suggests that 40-60% of an antimicrobial may remain in the intravenous tubing. Across the globe, residual volume may be affecting thousands to millions of patients receiving antimicrobials each year. While residual volume may be profound for all antimicrobials, the challenges to remedy this problem are more imposing with extended-infusion administration techniques. The purpose of this article is to highlight residual volume as a potential problem in optimizing extended-infusion antimicrobial therapy with agents like piperacillin-tazobactam. Furthermore, to emphasize that recognizing this issue for antimicrobials and other medications is imperative for providers to assure every patient is receiving the medication ordered, in its entirety, to avert medication errors and optimize patient care.

A Case Report of a 74-Year-Old Immunocompromised Host Diagnosed with Pulmonary Blastomycosis and Pulmonary Hemorrhage.

BACKGROUND Blastomycosis is a rare opportunistic disease caused by inhalation of the fungus Blastomyces dermatitidis. Blastomycosis can occur in all individuals but is most commonly seen in immunocompromised hosts. If left untreated or not caught early enough, blastomycosis can progress to fulminant multilobar pneumonia, acute respiratory distress syndrome (ARDS), and even death. CASE REPORT A 74-year-old immunocompromised man in northeast Ohio presented to the Emergency Department with shortness of breath and hemoptysis. The patient had a negative evaluation for a gastrointestinal bleed and was found to have significant blood collection in the larynx and trachea. A bronchoscopy demonstrated right upper lobe hemorrhage and an infection with Blastomyces species. The patient was started on amphotericin B 5 mg/kg every 24 h for severe blastomycosis. The patient continued to have pulmonary hemorrhage and progressed to multilobar pneumonia and ARDS. Ultimately, the patient died due to respiratory distress after being hospitalized for 5 days. CONCLUSIONS Blastomycosis can present with multiple clinical manifestations, including pulmonary hemorrhage, in severe disease. Diagnostic delay of blastomycosis is common owing to a nonspecific patient presentation. Blastomycosis is an opportunistic infection; therefore, the fungus can be more commonly seen within immunocompromised hosts. The combination of diagnostic delay and immunocompromised hosts leads to an increased mortality rate from blastomycosis infections.

Use of Intravenous Hydroxocobalamin without Methylene Blue for Refractory Vasoplegic Syndrome After Cardiopulmonary Bypass.

BACKGROUND Cardiac vasoplegic syndrome is a form of vasodilatory shock characterized by profound vasodilation and low systemic vascular resistance, which results in significant hypotension despite high cardiac output and appropriate fluid resuscitation. In up to 45% of patients, cardiopulmonary bypass (CPB) can precipitate vasoplegic syndrome. Vasoplegic syndrome after CPB that is refractory to other vasopressors, such as catecholamine and vasopressin, has been successfully treated with inhibitors of the nitric oxide (NO) system, such as methylene blue and hydroxocobalamin. Methylene blue has been the treatment of choice because of its effectiveness for both prevention and rescue therapy. Hydroxocobalamin has demonstrated efficacy in combination with methylene blue, and also on its own when vasoplegic syndrome is refractory to methylene blue. CASE REPORT We present 2 cases that expand upon the existing evidence supporting the efficacy of hydroxocobalamin as a first-line option for inhibiting the NO system in vasoplegic syndrome that is refractory to other vasopressors. Specifically, we demonstrate the appropriate and successful use of hydroxocobalamin alone to treat refractory vasoplegic syndrome after CPB. CONCLUSIONS Refractory vasoplegic syndrome that occurs after CPB has been successfully treated with inhibitors of the NO system, such as methylene blue and hydroxocobalamin. The present cases expand upon the scant existing evidence of the efficacy of hydroxocobalamin as an appropriate option for refractory vasoplegic syndrome.

Epinephrine Auto-Injection After Allergic Reaction Leading to Gas Gangrene of the Leg.

BACKGROUND Clostridial myonecrosis, also known as gas gangrene, is a highly lethal necrotizing soft tissue infection. While commonly associated with trauma, clostridial myonecrosis may be the result of parenteral injection of medications. Epinephrine is the most commonly reported medication leading to gas gangrene. CASE REPORT A 60-year-old man presented to the Emergency Department (ED) with "the worst pain in his life" to the right thigh near the site at which he auto-injected epinephrine after multiple bee stings 10-11 h prior to arrival. Initial heart rate was 112 beats/min but all other vital signs were unremarkable at presentation. Due to extreme pain, a computed tomography (CT) scan was ordered, revealing prominent gas within the anterior compartment of the right thigh, mostly involving the vastus lateralis and rectus femoris, suggesting necrotizing fasciitis. Antimicrobials were initiated immediately and the patient was taken for surgical debridement within 70 min after obtaining the CT results. Clostridium perfringens was cultured from the patient's tissue. After several surgical debridement's, appropriate antimicrobial therapy, supportive care, and wound care, the patient's limb remained intact and he was discharged after 11 days. CONCLUSIONS With millions of epinephrine auto-injectors prescribed yearly in the United States, awareness of clostridial gas gangrene following epinephrine auto-injection for the provider may help guide decision-making in patients presenting with extreme pain, redness, or swelling near the injection site after epinephrine injection.

Pericardial effusion and cardiac tamponade requiring pericardial window in an otherwise healthy 30-year-old patient with COVID-19: a case report.

BACKGROUND: This case report demonstrates pericardial effusion, acute pericarditis, and cardiac tamponade in an otherwise healthy woman who had a positive test result for coronavirus disease 2019. Few case reports have been documented on patients with this presentation, and it is important to share novel presentations of the disease as they are discovered. CASE PRESENTATION: A Caucasian patient with coronavirus disease 2019 returned to the emergency department of our hospital 2 days after her initial visit with worsening chest pain and shortness of breath. Imaging revealed new pericardial effusion since the previous visit. The patient became hypotensive, was taken for pericardial window for cardiac tamponade with a drain placed, and was treated for acute pericarditis. CONCLUSION: Much is still unknown about the implications of coronavirus disease 2019. With the novel coronavirus disease 2019 pandemic, research is still in process, and we are slowly learning about new signs and symptoms of the disease. This case report documents a lesser-known presentation of a patient with coronavirus disease 2019 and will help to further understanding of a rare presentation.

The Safe Administration of Remdesivir in a Patient with Acute Kidney Injury Requiring Hemodialysis.

Remdesivir is a nucleoside analog prodrug with broad-spectrum antiviral activity, including against coronaviruses. This has prioritized the inclusion of remdesivir in coronavirus disease 2019 (COVID-19) clinical trials. The United States Food and Drug Administration has granted emergency use authorization for remdesivir. This emergency use authorization does not recommend the use of remdesivir in patients with estimated glomerular filtration rate (eGFR) less than 30 mL/min unless the benefits outweigh the risks. To date, there are no studies and scant information in the literature evaluating remdesivir utilization in patients with eGFR less than 30 mL/min or receiving hemodialysis. With little utilization data for patients with acute or chronic kidney injury, remdesivir may not be considered, leaving this patient population without the opportunity of a potentially beneficial treatment option. We present a case of one patient with eGFR less than 30 mL/min that required hemodialysis in which remdesivir was safely initiated, with therapy completed without any serious adverse events.

A Comparison of Adjusted Versus Unadjusted Doses of Polymyxin B Based on Renal Function and Incidence of Acute Kidney Injury.

PURPOSE: To determine whether or not polymyxin B needs dose adjustments based on renal function by comparing the incidence of acute kidney injury (AKI) in patients whose polymyxin B doses were adjusted versus not adjusted according to renal function. METHODS: This was a single-center, prospective study with a retrospective cohort taking place in an acute care community hospital. Forty-two patients treated with polymyxin B were evaluated between April 2012 and December 2015. The primary outcome was incidence of AKI at day 7 after initiation of polymyxin B therapy with secondary outcomes including microbiological cure, clinical cure, and 30-day mortality. RESULTS: There was no difference in the incidence of AKI at day 7 in patients with polymyxin B doses adjusted according to renal function versus patients without polymyxin B dose adjustment (20.0% vs 18.2%; P = .882). There were no differences between groups in occurrence of microbiological cure, clinical cure, or 30-day mortality (27.8% vs 57.1%; P = .065, 70.0% vs 72.7%; P = .845, 40.0% vs 31.8%; P = .581, respectively). CONCLUSION: The results from this study support the use of polymyxin B without any dose adjustment in the setting of renal impairment.

4-Factor Prothrombin Complex Concentrate Administration via Intraosseous Access for Urgent Reversal of Warfarin.

BACKGROUND: Vitamin K antagonist (VKA) reversal in patients with acute major bleeding and coagulopathy is an example of an urgent intervention in the emergency department. Intravenous (IV) prothrombin complex concentrate (PCC) may reverse VKA-induced coagulopathy in <30 min. In patients lacking IV access, effective PCC administration becomes problematic. No previous case reports have documented PCC infusion via intraosseous (IO) or alternative routes in this setting. CASE REPORT: A 74-year-old man presented to the emergency department (ED) after a head injury, with sudden onset of left-sided facial droop, weakness, hypertension, and dizziness. Initial vital signs include blood pressure of 221/102 mm Hg, a heart rate of 75 beats/min, and oxygen saturation of 96% on room air. Warfarin 3 mg once daily was among his medications. His international normalized ratio (INR) was 3.9 with a computed tomography scan showing intraparenchymal hemorrhage in the right temporal lobe. Multiple attempts for IV access at various sites were unsuccessful. Therefore, IO access was established. Because of his prolonged prothrombin time, elevated INR, and intraparenchymal hemorrhage, the decision was made to use 4-factor PCC to reverse the supratherapeutic INR. The INR normalized as an emergent right parietal hematoma evacuation was performed. After an inpatient course, the patient was eventually discharged. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VKAs, like warfarin, are commonly prescribed medications. When life-threatening hemorrhage is present, rapid reversal of a VKA-induced coagulopathy may be a life-saving therapy. In the event that IV access has not been established, we have demonstrated that IO access is a viable alternative route for PCC administration.

Novel approach to vancomycin level monitoring: Impact of a multidisciplinary monitoring system on timing of vancomycin levels.

PURPOSE: A novel approach to vancomycin level monitoring is described. METHODS: Vancomycin trough orders were added to the medication ordering system of a large teaching hospital and were generated when vancomycin was ordered. Pharmacists adjusted the order time so that the level was drawn appropriately. After pharmacist validation, the trough order appeared within the nursing medication list, and nurses were required to document when the level was drawn. Outcomes were evaluated before (retrospective group) and after (prospective group) implementation of this initiative. RESULTS: Among all patients for whom a vancomycin level was drawn, 24.0% of patients in the retrospective group had their first vancomycin level drawn within 2 hours of true trough, compared with 87.2% of patients in the prospective group (p < 0.0001). Among all patients receiving vancomycin, significantly more patients in the prospective group had a level drawn within 2 hours of the true trough compared with the retrospective group (71.9% versus 20.6%, p < 0.0001). Further, significantly more patients in the prospective group had a vancomycin level ordered compared with the retrospective group (100.0% versus 90.8%, p < 0.0001). The mean ± S.D. time from true trough that vancomycin levels were drawn was much longer in the retrospective group (184.9 ± 84.8 minutes versus 58.3 ± 60.7 minutes in the prospective group, p < 0.0001). CONCLUSION: A novel multidisciplinary approach to vancomycin trough monitoring involving automatic generation of trough orders, pharmacist validation of trough orders, and inclusion of trough orders in the nursing medication administration record was successful in significantly improving timing of vancomycin trough levels.

Prospective Comparison of Acute Kidney Injury During Treatment With the Combination of Piperacillin-Tazobactam and Vancomycin Versus the Combination of Cefepime or Meropenem and Vancomycin.

PURPOSE: To prospectively evaluate the observed incidence of acute kidney injury (AKI) in adult patients receiving the combination of piperacillin-tazobactam and vancomycin versus the combination of cefepime or meropenem and vancomycin for greater than 72 hours. METHODS: This was a prospective, open-label cohort study at a community academic medical center involving adult patients over a 3-month time period who received either the combination of piperacillin-tazobactam and vancomycin or the combination of cefepime or meropenem and vancomycin for greater than 72 hours. The patients were evaluated for AKI, defined using specific criteria introduced by Kidney Disease: Improving global outcomes (KDIGO) acute kidney injury work group in 2012. RESULTS: A total of 85 patients receiving either antimicrobial combination were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (37.3%) compared with the cefepime or meropenem and vancomycin group (7.7%; χ2 = 7.80, P = .005). CONCLUSION: The result of this study suggests that the risk of developing AKI is increased in patients receiving the combination of piperacillin-tazobactam and vancomycin versus those receiving the combination of cefepime or meropenem and vancomycin.

Evaluation and treatment of accidental autoinjection of epinephrine.

PURPOSE: A case of accidental autoinjection of epinephrine is described. SUMMARY: A 47-year-old man arrived at the emergency department after accidental injection of epinephrine with an autoinjector into his left thumb. His vital signs were stable at admission. The patient was allergic to nuts and thought he may have eaten something containing a pine nut. The patient reported feeling itching in his throat but had no shortness of breath or swollen tongue. He tried to self-administer an epinephrine injection, but it did not inject. While he was checking the device, it accidently injected into his left thumb pad. A review of systems revealed throat discomfort, a tingling sensation of the tongue, and a left-thumb puncture with pain. Physical examination of the left thumb pad revealed a pale, cool thumb with diminished capillary refill and punctuate black discoloration at the site of injection. Topical nitroglycerin paste was applied but had no effect, so terbutaline was ordered. The terbutaline injection was prepared as a 1:1 preparation of terbutaline sulfate 1 mg/mL and 0.9% sodium chloride injection. The immediate effects were the return of color from pale white to red and observable perfusion to the area within seconds. After 20 minutes, the red color remained, with observable perfusion and warmth, in addition to complete neurosensory function. Sixty minutes after terbutaline administration, the patient was discharged home. CONCLUSION: A 47-year-old man who accidentally injected himself in the thumb with an epinephrine autoinjector was successfully treated with subcutaneous terbutaline. The treatment had an immediate effect, including revascularization and resolution of pain.