Impact of Clinical, Unit-Specific Guidelines on Dornase Alfa Use in Critically Ill Pediatric Patients Without Cystic Fibrosis.

Purpose: The purpose of this study was to evaluate the impact of the implementation of pharmacist-guided, unit-specific dornase alfa utilization guidelines for patients without cystic fibrosis in an academic medical institution. The study reviewed the prescribing patterns in the institution's pediatric intensive care unit (PICU) and pediatric cardiac intensive care unit (PCICU) before and after the implementation of these guidelines. The primary objective of this study was to determine the effects of the guidelines on the number of dornase alfa doses prescribed in critically ill pediatric patients without cystic fibrosis. We also evaluated the pharmacoeconomic effect of the guidelines and the impact on clinical outcomes in these critically ill patients. Methods: This study was a single-center, retrospective evaluation of the implementation of pharmacist-guided, unit-specific dornase alfa guidelines. The guidelines were piloted on November 1, 2015. Pre-guideline implementation data were collected from February 1, 2015 to October 31, 2015. Post-guideline implementation data were collected from December 1, 2016 to August 31, 2016. We included patients admitted to the PICU and PCICU who had received at least 1 dose of dornase alfa and did not have a medical history or suspicion of cystic fibrosis. Results: During the pre-guideline data collection period, 1067 doses of dornase alfa were administered, and following guideline implementation, 239 doses were administered. The average total admission length of stay for patients admitted to the PICU or PCICU before guideline implementation and after implementation was 16.22 and 13.14 days, respectively (P = .042). Conclusions: The implementation of pharmacist-guided, unit-specific dornase alfa guidelines within the PICU and PCICU resulted in a 77.6% reduction in the use of dornase alfa among these units. The implementation of these guidelines led to a cost reduction of approximately US $87 707.76 over a 9-month period for the health system. During the study, the length of stay for patients admitted to the PICU and PCICU did not increase, indicating that the reduction in use of dornase alfa did not negatively affect the overall hospital length of stay for patients.

Treatment with Foscarnet after Allogeneic Hematopoietic Cell Transplant (Allo-HCT) Is Associated with Long-Term Loss of Renal Function.

Despite a well-established risk of chronic kidney disease (CKD) after allogeneic hematopoietic cell transplant (allo-HCT), the benefits of using nephrotoxic anti-infective agents to treat serious peritransplant infections often outweigh this risk. While there is no consensus on the optimal management of post-allo-HCT human herpes virus 6 (HHV6) reactivation, the nephrotoxic drug foscarnet is often used, although its long-term impact on renal function has not been established. We retrospectively reviewed 987 adult patients who underwent transplantation between 2002 and 2016, of whom 45.3% (n = 447) were exposed to foscarnet. The most frequent indications for foscarnet treatment were cytomegalovirus (n = 257, 57.5%) and HHV6 (n = 139, 31.1%). In the first 3 months post-transplant, patients exposed versus unexposed had similar rates of acute kidney injury and acute kidney failure (defined as 3 times baseline creatinine or <75% baseline estimated glomerular filtration rate [eGFR], 61.6% versus 58.7%, P = .42 and 28.1% versus 26.6%, P = .64, respectively). There was no difference in the eGFR at 3 months (P = .36), but patients treated with foscarnet had significantly lower median eGFRs (mL/min/1.73 m2) at 6 months (69.3, interquartile range [IQR] 51.4 to 92.8 versus 77.4, IQR 57.3 to 99.3; P = .009) and 12 months (67.8, IQR 52.7 to 85.0 versus 80.7, IQR 63.1 to 102.0; P < .001), respectively. There was also a significant difference in the decline in eGFR from baseline to 12 months (median 32.8, IQR 14.6 to 53.2 versus 21.9, IQR 6.4 to 37.4; P < .001), irrespective of the duration of foscarnet treatment. Multivariate analysis revealed that patients treated with foscarnet were more likely to experience a >30% decrease in eGFR from baseline to 12 months compared to those who were not (odds ratio, 2.30; 95% CI, 1.40 to 3.78; P = .001). We conclude that foscarnet use following allo-HCT had a profound impact on long-term renal function independent of other transplant-related factors.

Evaluation of Rescue Thrombolysis in Cardiac Arrest Secondary to Suspected or Confirmed Pulmonary Embolism.

BACKGROUND: Pulmonary embolism (PE) is the associated cause of unexplained cardiac arrest in 5% to 13% of patients. Although thrombolytic agents have been studied, patient outcomes during cardiac arrest are lacking. OBJECTIVE: The purpose of this study was to describe outcomes of patients who received thrombolytic therapy during cardiac arrest for suspected or confirmed PE. METHODS: This retrospective review included adults who received alteplase or tenecteplase during cardiac arrest for suspected or confirmed PE. The primary end point was incidence of survival to hospital discharge, whereas secondary end points included a description of dosing strategies of thrombolytic therapy, the incidence of return of spontaneous circulation (ROSC), the occurrence of minor or major bleeding, and intensive care unit and hospital lengths of stay. RESULTS: Of the 22 patients included in the study, 3 patients (13.6%) survived to hospital discharge, and ROSC was obtained in 11 patients (50%). Three patients had confirmed PE prior to cardiac arrest, with the remaining 19 patients having a documented suspicion for PE. The most frequent dosing strategy was alteplase 100 mg given via intravenous push (13 of 22 patients; 59%). One minor and no major bleeding events occurred. Conclusion and Relevance: Medical advances in PE management continue to evolve; yet the role of thrombolytic therapy in PE-related cardiac arrest remains unclear, with low overall rates of survival. These findings add to the relatively small body of evidence and highlight that optimal dosing remains unknown in this setting.

Management of Anticoagulant and Antiplatelet Medications in Adults Undergoing Percutaneous Interventions.

OBJECTIVE: Many radiologists are unfamiliar with the new antithrombogenic medications and how to modify patient management before nonvascular percutaneous procedures performed in a radiology department. In this article, we review the indications for use, mechanism of action, pharmacokinetics, dosing, and recommendations for periprocedural management of patients using these medications. CONCLUSION: To improve patient safety, radiologists involved in percutaneous procedures should have knowledge of the antithrombotics that will be encountered routinely in clinical practice.

Impact of liposomal bupivacaine administration on postoperative pain in patients undergoing total knee replacement.

STUDY OBJECTIVE: To determine whether liposomal bupivacaine, a long-acting anesthetic indicated for single-dose wound infiltration to produce postoperative analgesia, has an impact on postoperative pain in patients undergoing total knee arthroplasties (TKAs). DESIGN: Single-center retrospective cohort study. SETTING: Large tertiary and quaternary care hospital. PATIENTS: A total of 120 adults who underwent TKA between March 1, 2013, and October 31, 2013; of those patients, 55 patients received an intraoperative dose of liposomal bupivacaine 266 mg (active treatment group), and 65 did not receive the drug (control group). MEASUREMENTS AND MAIN RESULTS: The primary end point was the mean area under the curve (AUC) of numeric rating scale (NRS) pain scores from the end of surgery to 48 hours after surgery. Secondary end points included measures of postoperative pain up to 24 hours after surgery, opioid consumption within 48 hours after surgery, duration of hospitalization, and ambulation distance from the end of surgery to discharge. No significant differences were noted in the primary or secondary end points between patients who received or did not receive an intraoperative dose of liposomal bupivacaine. The mean ± SD AUC of NRS pain scores was 199.59 ± 67.11 and 192.94 ± 70.41 for the liposomal bupivacaine and control groups, respectively (p=0.658). Use of adjunctive analgesics was higher among patients in the control group, particularly for those receiving celecoxib, pregabalin, and continuous regional ropivacaine infusions, which may have minimized any differences in pain control between the treatment groups. CONCLUSION: Liposomal bupivacaine did not improve pain control in patients undergoing TKA when compared with historical management strategies; however, differences may have been obscured by increased utilization of adjunctive analgesics among patients in the control group.

Impact of intraoperative acetaminophen administration on postoperative opioid consumption in patients undergoing hip or knee replacement.

BACKGROUND: Opioid utilization for acute pain has been associated with numerous adverse events, potentially resulting in longer inpatient stays and increased costs. OBJECTIVE: To examine the effect of intravenous (IV) acetaminophen administered intraoperatively on postoperative opioid consumption in adult subjects who underwent hip or knee replacement. METHODS: This retrospective cohort study evaluated postoperative opioid consumption in 176 randomly selected adult subjects who underwent hip or knee replacement at Duke University Hospital (DUH). Eighty-eight subjects received a single, intraoperative, 1 g dose of IV acetaminophen. The other subjects did not receive any IV acetaminophen. This study evaluated mean opioid consumption (in oral morphine equivalents) during the 24-hour postoperative period in the 2 groups. Other endpoints included length of stay in the postanesthesia care unit (PACU), incidence of oversedation, need for acute opioid reversal, and adjunctive analgesic utilization. RESULTS: Subjects who were given a single dose of intraoperative acetaminophen received an average of 149.3 mg of oral morphine equivalents during the 24 hours following surgery compared to 147.2 mg in participants who were not exposed to IV acetaminophen (P = .904). The difference in average length of PACU stay between the IV acetaminophen group (163 minutes) and those subjects not exposed to IV acetaminophen (169 minutes) was not statistically significant (P = .588). No subjects in the study experienced oversedation or required acute opioid reversal. CONCLUSION: There was not a statistically significant difference in postoperative opioid consumption between patients receiving and not receiving IV acetaminophen intraoperatively.