Impact of an Antiretroviral Stewardship Team on the Care of Patients With Human Immunodeficiency Virus Infection Admitted to an Academic Medical Center.

BACKGROUND: Interdisciplinary antiretroviral stewardship teams, comprising a human immunodeficiency virus pharmacist specialist, an infectious diseases physician, and associated learners, have the ability to assist in identification and correction of inpatient antiretroviral-related errors. METHODS: Electronic medical records of patients with antiretroviral orders admitted to our hospital were evaluated for the number of interventions made by the stewardship team, number of admissions with errors identified, risk factors for occurrence of errors, and cost savings. Risk factors were analyzed by means of multivariable logistic regression. Cost savings were estimated by the documentation system Clinical Measures. RESULTS: A total of 567 admissions were included for analysis in a 1-year study period. Forty-three percent of admissions (245 of 567) had ≥1 intervention, with 336 interventions in total. The following were identified as risk factors for error: multitablet inpatient regimen (odds ratio, 1.834; 95% confidence interval, 1.160-2.899; P = .009), admission to the intensive care unit (2.803; 1.280-6.136; P = .01), care provided by a surgery service (1.762; 1.082-2.868; P = .02), increased number of days reviewed (1.061; 1.008-1.117; P = .02), and noninstitutional outpatient provider (1.375; .972-1.946; P = .07). The 1-year cost savings were estimated to be $263 428. CONCLUSIONS: Antiretroviral stewardship teams optimize patient care through identification and correction of antiretroviral-related errors. Errors may be more common in patients with multitablet inpatient regimens, admission to the intensive care unit, care provided by a surgery service, and increased number of hospital days reviewed. Once antiretroviral-related errors are identified, the ability to correct them provides cost savings.

3-Factor Versus 4-Factor Prothrombin Complex Concentrate for Warfarin Reversal in Severe Bleeding: A Multicenter, Retrospective, Propensity-Matched Pilot Study.

Current guidelines recommend 4-factor prothrombin complex concentrate (4PCC) for emergent reversal of bleeding secondary to warfarin. While current research has demonstrated superiority of 4PCC over plasma, direct comparisons with 3-factor PCC (3PCC) are lacking. The purpose of this study is to compare the efficacy and safety of 3PCC and 4PCC. We conducted a retrospective analysis of patients who received PCC at one of four medical centers. All patients in the 3PCC group were treated at one center that utilizes a fixed, weight-based dosing protocol. After evaluation of all patients meeting inclusion criteria, propensity-score matching was used to adjust for differences in treatment characteristics. There was no difference in the primary outcome of INR ≤ 1.4 between 3PCC and 4PCC in both the unmatched (85.7 vs. 90.6 %; p = 0.37) and matched (84.2 vs. 92.1 %; p = 0.48) analyses. There was a significant difference in goal INR achieved favoring 4PCC (56.3 vs 90.0 %; p < 0.02) when baseline INR > 4.0. A total of three thrombotic events were documented, all in the 4PCC group. We found no difference in the rate of INR reversal in those treated with 3PCC and 4PCC. However, those with a baseline INR > 4.0 may experience more successful INR reversal with 4PCC.

Continuous intravenous antiarrhythmic agents in the intensive care unit: strategies for safe and effective use of amiodarone, lidocaine, and procainamide.

The development of cardiac arrhythmias in the intensive care unit is common and associated with poor prognoses and outcomes. Because of the complexity of patients admitted to the intensive care unit, the management of arrhythmias is often difficult and may require multiple therapeutic interventions. In order for clinicians to appropriately manage arrhythmias, a thorough understanding of all available therapies, including intravenous antiarrhythmic agents, is essential. Suitable antiarrhythmic agents for use in the critical care setting include amiodarone, lidocaine, and procainamide. While these agents can be effective in managing cardiac arrhythmias, they also possess significant disadvantages and require additional monitoring during use. Therapy with these agents is often complicated because of the presence of significant associated adverse effects, clinician unfamiliarity, variable dosing strategies, and the potential for drug-drug interactions. The purpose of this review is to discuss indications and strategies for safe and effective use of amiodarone, lidocaine, and procainamide.

Intensive blood pressure control during the hyperacute phase of intracerebral hemorrhage in patients at risk for resistant hypertension: a retrospective cohort study.

INTRODUCTION: There are limited data evaluating intensive systolic blood pressure (SBP) control during the hyperacute phase of intracerebral hemorrhage (ICH) in patients with multiple risk factors for resistant hypertension. We evaluated the feasibility and safety of this intervention in a primary population that includes patients with multiple risk factors for resistant hypertension. MATERIALS AND METHODS: We conducted a retrospective analysis of ICH patients for which intensive SBP control (<140 mm Hg)- i.e. less than or equal to 140 was targeted. All patients possessed at least 2 risk factors that have been associated with resistant hypertension. Our primary objective was to determine the percentage of patients who achieved goal SBP within 1 hour of ICH diagnosis. Secondary objectives included identifying predictors of achieving goal SBP within 6 hours. RESULTS: Goal SBP within 1 hour was achieved in 8.1% of patients. The total number of risk factors a patient possessed was found to negatively predict ability to achieve goal SBP. For each risk factor possessed, the odds of achieving goal SBP within 6 hours are reduced by 31% (odds ratio, 0.69 [95% confidence interval, 0.54-0.89]). CONCLUSION: Intensive SBP control after ICH was difficult to achieve within 1 hour in those with risk factors for resistant hypertension. Patients' total risk factors were found to reduce the odds of achieving goal SBP within 6 hours.

Evaluation of a fixed, weight-based dose of 3-factor prothrombin complex concentrate without adjunctive plasma following warfarin-associated intracranial hemorrhage.

INTRODUCTION: Data regarding use of prothrombin complex concentrate (PCC) for international normalization ratio (INR) reversal in warfarin-associated intracranial hemorrhage (wICH) is variable with regards to dosages, adjunctive agents, and product choice. In 2012, we implemented a fixed, weight-based [30 IU/kg] dosing protocol of 3-factor PCC (3PCC) utilizing a rapid infusion rate and no requirement for fresh frozen plasma (FFP) following factor product administration. We aimed to evaluate the impact of this protocol on immediate and delayed INR reversal in patients admitted with wICH in the absence of FFP co-administration. METHODS: We conducted a retrospective review of patients receiving 3PCC following wICH between January 1, 2012 and December 10, 2013. The primary objective was to determine the percentage of patients achieving goal INR (≤1.4) following 3PCC administration. Patients were excluded if their bleed was not intracranial in origin, received a dose outside of the specified protocol, or were given FFP as an adjunctive agent. RESULTS: We included 35 patients with a mean presenting INR of 3.2 ± 1.3. Thirty patients (85.7%) achieved goal INR (≤1.4) following one dose of 3PCC. The mean INR after infusion of 3PCC was 1.3 ± 0.2. The median duration between 3PCC infusion and subsequent INR was 48.0 min (30-70.1 min). Vitamin K was utilized in 33 (94.3%) patients. No patient experienced a thromboembolic event within 7 days of 3PCC administration. CONCLUSIONS: Fixed, weight-based dosing of 3PCC without adjunctive FFP resulted in high rates of complete INR reversal without significant adverse events.

Remifentanil, ketamine, and fospropofol: a review of alterative continuous infusion agents for sedation in the critically ill.

Sedation and analgesia are integral aspects in the care of critically ill patients admitted to the intensive care unit. In recent years, many of the commonly used sedative agents in the United States have experienced manufacturing and sterility issues leading to decreased availability. In addition, current practice has shifted to providing lighter levels of sedation as clinicians have gained a better understanding of the consequences of prolonged deep sedation. Benzodiazepines have fallen out of favor due to findings including increased delirium and duration of mechanical ventilation. Alterations in end-organ function in critically ill patients may also lead to varied responses to commonly used sedatives. With numerous factors impacting choice of sedation in the intensive care unit, fospropofol, ketamine, and remifentanil have been considered potential alternatives to standard therapy. The purpose of this review was to discuss strategies for the safe and effective use of fospropofol, ketamine, and remifentanil for continuous intravenous sedation in critically ill patients.