A Review of Push-Dose Vasopressors in the Peri-operative and Critical Care Setting.

During hospitalization, the risk of hypotension and associated sequelae remain important considerations for patient outcomes. The use of push-dose vasopressors (PDP) outside of the operating room has increased in recent years to combat the negative effects of hypotension. This narrative review evaluates the utility of PDP in its traditional perioperative setting as well as in areas of increasing use such as the emergency department and intensive care unit. Articles evaluating PDP highlight successful increases in blood pressure with all agents but differ in rates of adverse events and most lack direct comparison of PDP agents in regard to safety and efficacy. Agents utilized as PDP, including epinephrine, phenylephrine, norepinephrine, vasopressin, and ephedrine vary in mechanism of action, onset of action, and duration of action. These variations in pharmacology along with published literature may lead to differences in the preferred PDP for various clinical scenarios. Many adverse events associated with PDP have been due to dosing errors highlighting the importance of education surrounding the use of these agents. Additional research is necessary to further elucidate the risks and benefits of PDP in clinical practice, and to determine which PDP is truly preferred. Careful consideration should be given when determining the appropriateness of this administration method of vasopressors in various clinical scenarios.

Vancomycin-Associated Acute Kidney Injury in Critically Ill Adolescent and Young Adult Patients.

BACKGROUND: Risk factors for the development of vancomycin-associated acute kidney injury (AKI) have been evaluated in both pediatric and adult populations; however, no previous studies exist evaluating this in the critically ill adolescent and young adult patients. OBJECTIVE: Identify the incidence of AKI and examine risk factors for the development of AKI in critically ill adolescents and young adults on vancomycin. METHODS: This retrospective review evaluated the incidence of AKI in patients 15 to 25 years of age who received vancomycin, while admitted to an intensive care unit. Acute kidney injury in this population was defined as an increase in serum creatinine by 0.5 mg/dL or 50% from baseline. Patients who developed AKI were evaluated for specific risk factors compared to those who did not develop AKI. RESULTS: A total of 50 patients (20 developed AKI) were included in the study. There was no difference in vancomycin daily dose or duration of vancomycin therapy. Maximum vancomycin trough (31.15 mg/dL vs 12.5 mg/dL, P = .006), percentage of patients with concurrent nephrotoxic medication (95% vs 60%, P = .012) and concurrent vasopressor (55% vs 23%, P = .029) were higher in those who developed AKI. Percentage of patients who underwent a procedure while on vancomycin (35% vs 6.7%, P = .021) was also higher within the AKI group. CONCLUSIONS: Vancomycin-associated AKI occurred in 40% of critically ill adolescent and young adult patients. These patients may be more likely to develop vancomycin-associated AKI if they had undergone a procedure, as well as in the presence of high vancomycin trough levels, concurrent nephrotoxic agents, and concurrent vasopressor therapy.

Use of fomepizole, n-acetylcysteine, and hemodialysis for massive acetaminophen overdose.

Acetaminophen poisoning is the leading cause of liver transplantation within the United States, accounting for nearly 56,000 emergency department patient visits each year. Although n-acetylcysteine is commonly successful in preventing acetaminophen toxicity when given in a timely manner, reports do exist demonstrating n-acetylcysteine therapy failure, commonly in the setting of a massive ingestion. We present the use of a novel antidote cocktail of n-acetylcysteine, fomepizole, and hemodialysis to treat a massive acetaminophen ingestion. A 55-year old male with a past medical history significant for bipolar disorder and past suicidal ideation presented to the emergency department after being found unresponsive at home. Medical workup was significant for an estimated seven-hour acetaminophen level of 883 mcg/mL, with concomitant metabolic acidosis. The patient was diagnosed with severe acetaminophen poisoning and was promptly administered n-acetylcysteine. Due to the severity of the patient's ingestion and the concern for additional coingestants, the patient was also given fomepizole therapy and later underwent hemodialysis for more rapid toxin clearance. After a four-day stay in the hospital the patient was discharged to a mental-health facility with no signs of systemic injury.