Impact of computerized dosing on eptifibatide-associated bleeding and mortality.

OBJECTIVE: The study aimed to determine the impact on eptifibatide-associated bleeding by implementing a computerized dosing algorithm in the cardiac catheterization suite. BACKGROUND: Excessive dosing of eptifibatide is associated with increased bleeding rates and hospital mortality. Although dosing adjustments based on renal function has been recommended, its implementation and clinical impact have not been assessed in daily practice. METHODS: A computerized algorithm was implemented in January 2006 to calculate appropriate eptifibatide infusion dose (1 microg kg(-1) min(-1) for creatinine clearance <50 mL/min or 2 microg kg(-1) min(-1) for creatinine clearance >or=50 mL/min) using the Cockroft-Gault formula. All patients had hemoglobin measured before and the day after the procedure. Bleeding within 24 hours and mortality during hospitalization were compared in consecutive patients before and after implementation of the algorithm. RESULTS: A total of 334 patients qualified for inclusion (pre-algorithm n = 91, post-algorithm n = 243). There was an increase in the proportion of patients receiving recommended doses of eptifibatide dosing (74.7% pre-algorithm vs 97.5% post-algorithm, P

Cardiac troponins in the intensive care unit: common causes of increased levels and interpretation.

BACKGROUND AND OBJECTIVES: Clinical chemistry is an important component of the diagnosis of many conditions, and advances in laboratory science have brought many new diagnostic tools to the intensive care unit clinician, including new biomarkers of cardiac injury like troponin T and I. Interpretation of these clinical laboratory results requires knowledge of the performance of these tests. SETTING AND PATIENTS: This article reviews the interpretation and performance of diagnostic markers of myocardial injury in patients with diverse clinical conditions of interest to critical care practitioners. CONCLUSIONS: Cardiac troponin I and T, regulatory components of the contractile apparatus, are sensitive indicators of myocardial injury and have become central to the diagnosis of myocardial infarction. The troponins are also released in a number of clinical situations in which thrombotic complications of coronary artery disease and resultant acute myocardial infarction have not occurred. These situations include conditions like pulmonary embolism, sepsis, myocarditis, and acute stroke. Elevated troponins in these conditions are thought to emanate from injured myocardial cells and, in most circumstances, have been associated with adverse outcomes. Practitioners should be mindful of the wide spectrum of diseases that may result in elevated troponin when interpreting these measurements.

To plug or not to plug?

Coronary artery disease remains a common problem in industrialized countries. Percutaneous coronary interventions are usually performed utilizing the femoral approach. Arterial puncture-closing devices have been developed in hope to avoid manual compression and shortening the period of rest. In a recent meta-analysis in the Journal of the American Medical Association these devices have shown only marginal benefits over manual compression. Further, well designed studies are necessary to document the comparative effects of these devices versus manual compression.

Guidelines for the inter- and intrahospital transport of critically ill patients.

OBJECTIVE: The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient. DATA SOURCE: Expert opinion and a search of Index Medicus from January 1986 through October 2001 provided the basis for these guidelines. A task force of experts in the field of patient transport provided personal experience and expert opinion. STUDY SELECTION AND DATA EXTRACTION: Several prospective and clinical outcome studies were found. However, much of the published data comes from retrospective reviews and anecdotal reports. Experience and consensus opinion form the basis of much of these guidelines. RESULTS OF DATA SYNTHESIS: Each hospital should have a formalized plan for intra- and interhospital transport that addresses a) pretransport coordination and communication; b) transport personnel; c) transport equipment; d) monitoring during transport; and e) documentation. The transport plan should be developed by a multidisciplinary team and should be evaluated and refined regularly using a standard quality improvement process. CONCLUSION: The transport of critically ill patients carries inherent risks. These guidelines promote measures to ensure safe patient transport. Although both intra- and interhospital transport must comply with regulations, we believe that patient safety is enhanced during transport by establishing an organized, efficient process supported by appropriate equipment and personnel.

Critical illness at mass gatherings is uncommon.

Gatherings of large numbers of people at concerts, sporting events, and other occasions lead to an assembled population with a potential for a wide variety of illnesses and injuries. The collection of large numbers of people in a single location has led some authors to recommend the placement of resuscitation equipment or other medical services in close proximity to these activities. These recommendations not withstanding, data on the frequency of critical illness at mass gatherings (a group exceeding 1000 persons) are difficult to ascertain. Therefore, it was the purpose of this study to describe the incidence of critical illnesses among assembled populations at mass gatherings. An observational prospective study was conducted involving patient encounters at a large, multipurpose, indoor mass-gathering complex in Houston, Texas occurring between September 1, 1996 and June 30, 1997. Demographic, treatment, disposition and diagnostic data were analyzed in a computerized database. Of the 3.3 million attendants to the 253 events analyzed during the 10-month study period, there were 2762 (0.08%) patient encounters. Fifty-two percent were women. Mean age was 32 +/- 15.6 years. Of these patients, 51.1% were patrons and the remaining patients were employees or contractors of the facility. A wide variety of illness was seen with trauma (39.5%), headache (31%), and other medical complaints (29.5%) being most frequent. Disposition of the patients included 95.3% being discharged to go back to the event and 2.2% being counseled to seek other medical attention. One hundred twenty-nine patients (4.7%) were referred to the Emergency Department (ED); of these, 70 were transferred for abrasions, lacerations, or skeletal injuries and 13 for chest pain. Of those referred to the ED, 50 (38.7%) patients were transported by ambulance and only 17.4% were admitted to telemetry, with none admitted to an ICU. It is concluded that critical illness at mass gatherings is infrequent, as seen in this study, with very few being admitted to telemetry and none to an ICU. Careful consideration of cost-benefit should occur when determining allocation of resources for these activities.

The effect of heliox-driven bronchodilator aerosol therapy on pulmonary function tests in patients with asthma.

To compare the effects of heliox-driven (He 80:O2 20) to air-driven (N 79:O2 21) beta2-agonist aerosol therapy on pulmonary function tests (PFTs) in patients with asthma, a prospective randomized crossover study was undertaken in the asthma clinic of the university-affiliated county hospital in Houston, TX. Thirty-one patients (22 female, age range 18-44) with clinically stable asthma consented. All patients were studied on two different days with both heliox and air as driving gas, therefore serving as their own controls. The PFTs including forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC), maximal mid-expiratory flow rate (FEF(25-75)), and maximal expiratory flow rate (FEFmax) were obtained while breathing ambient air at baseline and 30 min after the bronchodilator treatment. Albuterol sulfate 2.5 mg was nebulized with either heliox or compressed air at 8 L/min for 8 min. When heliox was used as driving agent, additional heliox was delivered via a closed system and no entrainment of external air was allowed. Primary outcome measure was absolute change in FEV1 (deltaFEV1). There were no statistically significant differences in baseline PFTs on the two days of the study. All patients had good bronchodilator response (> or = 12% improvement in FEV1) with either driving gas. The deltaFEV1 after heliox-driven bronchodilator (HDBD) and air-driven bronchodilator (ADBD) were 0.68+/-0.38 L/sec (CI: 0.54-0.82) vs. 0.51+/-0.26 L/sec (CI: 0.42-0.60), respectively (p=0.004). The deltaFEV1 with HDBD was 49+/-90% (range -36% to 433%) more than ADBD. A subgroup analysis showed this was largely due to better response rates in patients with moderate to severe obstruction. There was more improvement in both FVC and FEFmax with HDBD than ADBD (p<0.05). The changes in FEF(25-75) were similar. We conclude that HDBD therapy improves FEV1, FVC, and FEFmax significantly more than ADBD in patients with asthma. Further large randomized studies are needed to better characterize responders and the impact on clinical outcomes.

Acute exacerbations of obstructive lung disease.

Preview Because they are rapidly effective, inhaled beta2 agonists are the cornerstone of therapy in patients having an acute exacerbation of obstructive lung disease. In addition, inhaled anticholinergics, methylxanthines, systemic corticosteroids, and antibiotics are useful in appropriate situations. The authors describe assessment of these patients (who may be critically ill at presentation), provide recommendations for conventional therapy, and summarize alternative methods.