Five-Year Outcomes After Implementing a Pain, Agitation, and Delirium Protocol in a Mixed Intensive Care Unit.

Objective: Assess for continued improvements in patient outcomes after updating our institutional sedation and analgesia protocol to include recommendations from the 2013 Society of Critical Care Medicine (SCCM) Pain, Agitation, and Delirium (PAD) guidelines. Methods: Retrospective before-and-after study in a mixed medical/surgical intensive care unit (ICU) at an academic medical center. Mechanically ventilated adults admitted from September 1, 2011 through August 31, 2012 (pre-implementation) and October 1, 2012 through September 30, 2017 (post-implementation) were included. Measurements included number of mechanically ventilated patients, APACHE IV scores, age, type of patient (medical or surgical), admission diagnosis, ICU length of stay (LOS), hospital LOS, ventilator days, number of self-extubations, ICU mortality, ICU standardized mortality ratio, hospital mortality, hospital standardized mortality ratio, medication data including as needed (PRN) analgesic and sedative use, and analgesic and sedative infusions, and institutional savings. Results: Ventilator days (Pre-PAD = 4.0 vs. Year 5 post = 3.2, P < .0001), ICU LOS (Pre-PAD = 4.8 days vs. Year 5 post = 4.1 days, P = .0004) and hospital LOS (Pre-PAD = 14 days vs. Year 5 post = 12 days, P < .0001) decreased after protocol implementation. Hospital standardized mortality ratio (Pre-PAD = 0.69 vs. Year 5 post = 0.66) remained constant; while, APACHE IV scores (Pre-PAD = 77 vs. Year 5 post = 89, P < .0001) and number of intubated patients (Pre-PAD = 1146 vs. Year 5 post = 1468) increased over the study period. Using the decreased ICU and hospital LOS estimates, it is projected the institution saved $4.3 million over the 5 years since implementation. Conclusions: Implementation of an updated PAD protocol in a mixed medical/surgical ICU was associated with a significant decrease in ventilator time, ICU LOS, and hospital LOS without a change in the standardized mortality ratio over a five-year period. These favorable outcomes are associated with a significant cost savings for the institution.

Daptomycin dosing based on ideal body weight versus actual body weight: comparison of clinical outcomes.

Daptomycin use at our institution changed to ideal body weight dosing based on a published analysis of pharmacokinetic-pharmacodynamic efficacy target attainment, bacterial ecology, and a desire to reduce drug toxicity. The current study compared outcomes between actual body weight and ideal body weight dosing of daptomycin before and after this intervention. In the evaluable group, 69 patients received doses based on actual body weight and 48 patients received doses based on ideal body weight. Patients were treated for documented Enterococcus species, Staphylococcus aureus, or coagulase-negative Staphylococcus infections, including bloodstream, intraabdominal, skin and soft tissue, urinary, and bone. There was no statistically significant difference in clinical success between the groups (88.9% for actual body weight compared to 89.1% for ideal body weight, P = 0.97). After we adjusted for gender, age, body mass index, concomitant 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, infection type, and organism type, clinical success rates remained similar between groups (adjusted odds ratio of 0.68 in favor of actual body weight, 95% confidence interval [CI] of 0.13 to 3.55). Microbiological outcomes, length of stay, mortality, and adverse effects were also similar between groups. Further studies are warranted to confirm that ideal body weight dosing provides similar outcomes to actual body weight dosing for all patients and types of infections and organisms.

Stress ulcer prophylaxis: reducing non-indicated prescribing after hospital discharge.

BACKGROUND: Gastric acid suppressant medications used as stress ulcer prophylaxis (SUP) in the intensive care unit (ICU) are often prescribed inappropriately after discharge. We present tools to reduce the use and cost of non-indicated SUP. OBJECTIVE: To reduce the non-indicated use of SUP after hospital discharge originally started in the ICU, using an education intervention and pharmacist-led medication reconciliation on patient care rounds and at hospital discharge. METHODS: In a retrospective medical record review using a historic control, 356 consecutively admitted patients to the medical/surgical ICU at the University of Wisconsin Hospital were assessed for the appropriate use of SUP at admission to the ICU, at transfer to a general care unit, and at hospital discharge. The education intervention involved teaching both the medical and pharmacist staff about indications for SUP using a memorandum and a pocket guide. Pharmacists also conducted medication reconciliation during daily patient care rounds and at discharge to justify medication use. The outcome of this study is the percentage of patients prescribed non-indicated gastric acid suppressants at hospital discharge. This outcome is compared to a previous study conducted at our hospital. RESULTS: Of 356 eligible patients, 308 (86.5%) received SUP while in the ICU. Thirty-nine (11%) were given continuing SUP after discharge from the hospital, of which 31 (8.7%) had no clear indication. This was a 64.3% reduction from the 24.4% found in the prior study (p < 0.0001). CONCLUSIONS: Educational materials that guide prescribing, pharmacist interaction on patient care rounds, and pharmacist-conducted medication reconciliation significantly reduced the prescribing of non-indicated gastric acid suppressant medications after hospital discharge.

Recommendations for the use of medications with continuous enteral nutrition.

PURPOSE: Recommendations for the use of medications with continuous enteral nutrition are provided. METHODS: A literature review was conducted to identify primary literature reporting medication interactions with continuous enteral nutrition. For medications without supporting literature, manufacturers were contacted for information. Package inserts for specific medications were also investigated for any information to help guide recommendations. If no specific recommendations were made by the pharmaceutical manufacturer or the package insert concerning administration of products with continuous enteral nutrition, a tertiary database was consulted. Recommendations were generated by a consensus of clinicians for those medications that lacked specific recommendations in the primary literature or from the pharmaceutical manufacturer. Documentation of medication interactions with continuous enteral nutrition and food was then collated along with specific recommendations on how to administer the medication with regard to continuous enteral nutrition. Recommendations were classified as strong (grade 1) or weak (grade 2). The quality of evidence was classified as high (grade A), moderate (grade B), or low (grade C). RESULTS: Forty-six medications commonly given to hospitalized patients were evaluated. Twenty-four medications had recommendations based on available data, and the remaining 22 medications had recommendations based on a consensus of clinicians. CONCLUSION: There was a lack of published data regarding drug-nutrient interactions for a majority of the drugs commonly administered to patients receiving continuous enteral nutrition. Clinicians should recognize potential drug-nutrient interactions and use available evidence to optimize patients' drug therapy.

Inappropriate continuation of stress ulcer prophylactic therapy after discharge.

BACKGROUND: Medications for stress ulcer prophylaxis are appropriately started in critically ill patients with risks for developing stress ulcers. It is unknown whether these drugs are discontinued once the risk factors are removed. OBJECTIVE: To assess the duration of stress ulcer prophylactic therapy in critically ill patients. METHODS: A retrospective chart review was conducted at a multidisciplinary, 24 bed medical/surgical intensive care unit (ICU) of a university-affiliated tertiary referral medical center. Three hundred ninety-four patients fulfilled eligibility criteria during the study period of July 1, 2005, through September 30, 2005. Patients were considered to be appropriately discharged from the hospital on gastric acid suppressants if they met any of the following criteria: continued mechanical ventilation, gastroesophageal reflux disease, peptic ulcer disease, history of gastrointestinal ulceration or bleeding within the past year, prescribed medications used for stress ulcer prophylaxis prior to admission, gastrointestinal bleed during hospitalization, or prescriber indication of reason to continue therapy. RESULTS: Three hundred fifty-seven patients received stress ulcer prophylaxis during their ICU stay. Of these, 80% continued on gastric acid suppressants on transfer from the ICU, with 60% of the therapy being inappropriate. The percentage of critically ill patients discharged from the hospital with inappropriate prescription of gastric acid suppressants was 24.4%. Based on the average wholesale cost, the total cost for unnecessary gastric acid suppressant therapy within the follow-up period was $13,973. CONCLUSIONS: Gastric acid suppressant medications initially prescribed for stress ulcer prophylaxis are frequently prescribed inappropriately on discharge for patients who were initially admitted to the medical/surgical ICU.

Propylene glycol-associated renal toxicity from lorazepam infusion.

OBJECTIVES: Using data from patients who developed elevations in serum creatinine concentrations while receiving continuous-infusion lorazepam, we sought to determine the correlations between the magnitude of serum creatinine concentration rise and each of the following variables: serum propylene glycol level, cumulative lorazepam dose, and duration of lorazepam administration. An additional objective was to identify clinical markers for propylene glycol toxicity. DESIGN: Retrospective chart review. SETTING: Medical-surgical intensive care unit and burn unit at a university hospital. PATIENTS: Eight patients who developed elevations in serum creatinine concentrations while receiving continuous-infusion lorazepam (range 2-28 mg/hr). MEASUREMENTS AND MAIN RESULTS: The mean cumulative dose of lorazepam was 4305 mg (range 1200-10,920 mg), and the mean propylene glycol level determined at the time of peak serum creatinine concentration was 1103 microg/ml (range 186-3450 microg/ml). Serum creatinine concentrations increased in all eight patients during lorazepam infusion and decreased in seven within 3 days after stopping infusion. A weak-to-moderate correlation existed between the magnitude of the rise in serum creatinine concentration and propylene glycol level (r=0.53). A weak-to-moderate correlation also was identified between cumulative lorazepam dose and magnitude of serum creatinine concentration rise (r=0.43), and a strong-to-moderate correlation was found between duration of lorazepam infusion and magnitude of serum creatinine concentration rise (r=0.60). Propylene glycol levels were strongly correlated with both serum osmolality and osmol gap. CONCLUSION: The patients' increased serum creatinine concentrations are likely to have resulted from exposure to propylene glycol as a result of lorazepam infusion. Serum osmolality and osmol gap may be useful markers for propylene glycol toxicity.

Pericardial infusion of tissue plasminogen activator in fibropurulent pericarditis.

A 61-year-old man developed a loculated fibropurulent pericarditis, a rare complication of bacteremia. This occurred as a complication of a Staphylococcal aureus bacteremia from a head and neck abscess following self-extraction of a tooth. Despite surgical intervention and placement of 2 pericardial drains, a refractory, inadequately drained infected pericardial effusion persisted. Although there is limited experience with thrombolytic therapy to dissolve a fibrin clot in the pericardium, break down loculated adhesions, and facilitate free drainage of infected material, lysis is well described in the management of exudative pleural effusions. After infusion of 30 mg of tissue plasminogen activator in 100 cc normal saline through the pericardial drain of the patient, a large amount of infected serosanginous material subsequently drained during the next 2 days. The patient became afebrile and culture negative, remained hemodynamically stable, and had resolution of his pericarditis and pericardial effusion on electrocardiogram and echocardiogram, respectively.