Transportation of a commercial premixed intravenous insulin product through a pneumatic tube system.

PURPOSE: Delivery of insulin products via pneumatic tubes is often avoided in health systems, as agitation may cause insulin proteins to destabilize, resulting in loss of function through denaturation, aggregation, or other processes. The actual loss of potency due to delivery via pneumatic tubes has not been reported for new, ready-to-use insulin products. METHODS: Samples were drawn from 7 commercial intravenous (IV) bags containing a 100 units/100 mL premixed solution of regular insulin in sodium chloride injection (Myxredlin, Baxter). The bags were then exposed to 7 unique long-distance pneumatic tube routes. The posttransportation bags were visually inspected for evidence of foaming. Samples were drawn from the posttransportation bags and insulin concentrations were analyzed via an enzyme immunoassay and compared to pretransportation concentrations. RESULTS: All seven posttransportation insulin samples were within 10% of their respective pretransportation sample. No foaming was observed in any of the Myxredlin bags after transportation through the pneumatic tube system. CONCLUSION: Transporting 100 unit/100 mL Myxredlin i.v. bags through a pneumatic tube system does not result in a clinically significant loss of potency. Therefore, delivery of this drug product via a pneumatic tube system to patient care areas can be considered in daily practice.

Poractant Alfa Versus Beractant for Neonatal Respiratory Distress Syndrome: A Retrospective Cost Analysis.

OBJECTIVES: The objectives of this study were to determine the average medication cost per patient of poractant alfa and beractant, and to compare the outcomes of treatment with these agents. METHODS: We conducted a retrospective, observational, cohort study of patients who received surfactant, before and after an institutional formulary change from beractant to poractant alfa. The primary outcome was the average medication cost per case. Secondary measures were clinical outcomes, including duration of respiratory support, length of hospital stay, and the occurrence of complications. RESULTS: A total of 114 patients were enrolled; 38 were treated with poractant alfa and 76 patients were treated with beractant. Baseline characteristics were similar between groups. The average medication cost per patient was $1756.44 ± $1030.06 and $1329.78 ± $705.64 for poractant alfa and beractant, respectively (p = 0.011). Patients treated with poractant alfa had a shorter length of stay (45.0 ± 30.5 days) than patients treated with beractant (65.1 ± 37.1 days) (p = 0.010). Rates of pneumothoraces, pulmonary hemorrhage, necrotizing enterocolitis, intraventricular hemorrhage, and mortality did not differ significantly between groups. CONCLUSIONS: We found an unanticipated increase in drug cost with poractant alfa compared to beractant.

Regadenoson versus Dipyridamole: A Comparison of the Frequency of Adverse Events in Patients Undergoing Myocardial Perfusion Imaging.

STUDY OBJECTIVE: To compare the frequency of adverse events in patients undergoing myocardial perfusion imaging (MPI) with either regadenoson or dipyridamole. DESIGN: Single-center, retrospective cohort study. SETTING: Large community teaching hospital. PATIENTS: A total of 568 adults who underwent single-photon emission tomography MPI with either regadenoson (284 patients) or dipyridamole (284 patients) as a vasodilator agent, following an institution conversion from regadenoson to dipyridamole in the MPI protocol on July 15, 2013, for cost-saving purposes. MEASUREMENTS AND MAIN RESULTS: Data were collected from the patients' electronic medical records. The primary endpoint was the composite occurrence of any documented adverse event in each group. Secondary endpoints were individual components of the primary endpoint, reason for termination of the MPI examination (protocol completion or premature end due to an adverse event), use of an interventional agent to an treat adverse event, and cost-related outcomes. A higher proportion of patients in the regadenoson group experienced an adverse event than those who received dipyridamole (84.9% vs 56.7%, p<0.0001). None of the patients in either group required early MPI study termination due to an adverse event. No significant differences were noted between groups regarding use of aminophylline or other interventions to treat adverse events. The overall drug cost savings in the postconversion dipyridamole group was $51,526. CONCLUSION: Dipyridamole was associated with fewer adverse events than regadenoson in patients undergoing MPI. Dipyridamole offers a safe and cost-effective alternative to regadenoson for cardiac imaging studies.

Assessment of Postoperative Pain Control with an Elastomeric Pain Pump Following Cardiothoracic Surgery.

OBJECTIVE: To assess the effectiveness of local anesthesia, delivered via elastomeric pump to manage pain in patients undergoing cardiothoracic surgery. METHODS: A retrospective, comparative analysis evaluating adult cardiothoracic surgery patients (by median sternotomy) who received continuous infusion bupivacaine + traditional methods of pain control (N = 100) or traditional pain control alone (N = 100) from July 2011-October 2013. The primary efficacy end point was total postoperative opioid requirements for 96 hours following surgery. Secondary end points included postoperative pain scores, nonopioid analgesic requirements for 96 hours after surgery, and frequency of postoperative adverse events. RESULTS: Demographic characteristics were similar between both groups. No difference was noted in overall opioid utilization for the first 96 hours postoperatively between the two groups ( P = 0.36). Similar pain scores were reported by patients in both groups for 96 hours following surgery, with the highest pain scores reported during the first 24 hours following surgery ( P = 0.37). No difference between groups was noted in utilization of ketorolac or acetaminophen. Frequency of postoperative adverse events, including the use of antiemetic agents for nausea and vomiting, was similar in between both groups. CONCLUSION: The use of elastomeric pumps in patients undergoing cardiothoracic surgery for reducing postoperative opioid consumption and pain may not be as beneficial as previously reported.

Safety and Efficacy of a Pharmacist-Managed Patient-Controlled Analgesia Service in Postsurgical Patients.

PURPOSE: To compare the safety and efficacy of a pharmacist-managed patient-controlled analgesia (PCA) service with physician/midlevel provider-managed (standard) PCA services in postsurgical patients. METHODS: This was a multicenter, retrospective cohort study performed at 3 major hospitals in the Detroit, Michigan, metropolitan area. Postsurgical patients from October 2012 to December 2013 were included. The primary outcome compared the pain area under the curve adjusted for time on PCA (AUC/T) of patients receiving pharmacist-managed PCA services vs. standard care, up to 72 hours after initiation of PCA. Secondary outcomes included initial opioid selection, programmed PCA settings, duration of PCA use, frequency of adjunct analgesia utilization, and frequency of breakthrough analgesia utilization. Safety outcomes were assessed as a composite safety endpoint and individually. RESULTS: Total pain AUC/T scores did not differ between the pharmacist-managed and standard-managed groups (3.25 vs. 3.25, respectively; P = 0.98). Adjunct pain medications were given with similar frequency in the 2 groups; however, significantly fewer patients required breakthrough pain medication in the pharmacist-managed group (11% vs. 36%, respectively; P < 0.0001). A composite endpoint of any adverse event occurring was found to be greater in the pharmacist-managed group. This was driven by a higher proportion of patients requiring antiemetic use (46% vs. 32%; P = 0.04). CONCLUSION: A pharmacist-managed PCA service provided no difference in pain control compared to standard management. The requirement for breakthrough analgesia was decreased in the pharmacist group, while the need for antiemetic use was increased. Further research should be conducted to evaluate different PCA management strategies.

Continuation of Statin Therapy and Vasopressor Use in Septic Shock.

BACKGROUND: Studies have evaluated the use of statins in sepsis; however, no human studies have explored their effect on vasopressor requirements in septic shock. OBJECTIVE: The primary objective was to determine the effect of prehospital statin continuation on duration of vasopressor therapy in patients with septic shock. Secondary objectives included maximum and average vasopressor dose and in-hospital mortality. METHODS: This was a retrospective, institutional board-approved, observational cohort study in a community teaching hospital; 119 adult intensive care unit (ICU) patients with an ICD-9 code for septic shock and prehospital statin therapy were evaluated. Multivariate analyses were performed to address confounders. RESULTS: Of the 1229 patients screened, 119 (10%) met inclusion criteria; 73 patients (61%) had a statin continued within 24 hours of ICU admission. Crude analysis demonstrated no difference in vasopressor duration in the statin versus no statin group (3.3 vs 4.8 days; P = 0.21). There was no difference in either maximum (17.9 ± 16.1 vs 23.8 ± 21.7 µg/min norepinephrine equivalents [NEQs]; P = 0.1) or average vasopressor dose (9.5 ± 8.4 vs 12.1 ± 11.5 µg/min NEQ; P = 0.17). There was a decrease in mortality in the statin patients (43% vs 67 %; P = 0.05). On adjustment for potential confounders, there was no difference in any outcome, with a persistent trend toward lower mortality in the statin group. CONCLUSION: Continuation of prehospital statin therapy decreased neither duration nor dose of vasopressors in patients with septic shock but yielded a trend toward decreased mortality.

Evaluation of procedure-related bleeding risk in patients receiving bivalirudin during percutaneous coronary intervention.

BACKGROUND: Bivalirudin has historically been considered an attractive anticoagulant during percutaneous coronary intervention (PCI) because of reduced bleeding complications reported by early trials. Bivalirudin use during PCIs has been a subject of controversy because of conflicting data and recent findings. OBJECTIVE: To evaluate the clinical characteristics of patients receiving bivalirudin to determine if an opportunity to improve use exists based on risk of procedure-related bleeding. METHODS: This was a single-center, retrospective, observational study (n = 100) of all adult patients who received bivalirudin during cardiac catheterization at St John Hospital and Medical Center from June to August 2013. The risk of bleeding complications associated with PCI was estimated using a clinical risk algorithm developed from the National Cardiovascular Data Registry (NCDR). RESULTS: Treatment with bivalirudin was safe and effective. Of the 100 patients who received bivalirudin, only 34% were identified as having a high risk of procedure-related bleeding according to the NCDR clinical risk algorithm. There was no incidence of stent thrombosis noted and only 1 case of provisional glycoprotein IIb/IIIa inhibitor use. No episodes of Thrombolysis in Myocardial Infarction (TIMI) major bleeding were noted in the study population; however, 1 patient met TIMI minor bleeding criteria. Limitations of this study include small sample size and retrospective nature of the study. CONCLUSION: Opportunities to establish a more cost-effective use of bivalirudin may exist through implementation of protocols incorporating the NCDR risk assessment model.