Thromboelastography with platelet mapping: Limited predictive ability in detecting preinjury antiplatelet agent use.

BACKGROUND: Preinjury antiplatelet agent (APA) use in trauma patients can increase traumatic hemorrhage and worsen outcomes. Thromboelastography with platelet mapping (TEGPM) has characterized platelet function via arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition in nontrauma settings, but limited data exist in the acute trauma population. METHODS: A prospective observational study of adult trauma patients with suspected preinjury APA use who received TEGPM testing from 2017 to 2020 was performed. Patients on anticoagulants were excluded. Patients were grouped according to preinjury APA regimen: 81 mg or 325 mg of aspirin daily, 81 mg of aspirin and 75 mg of clopidrogrel daily, 75 mg of clopidrogrel daily, or no antiplatelet. Ability of TEGPM to detect APA use was assessed using predictive statistics and area under receiver operating characteristic curves (AUROCs). RESULTS: A total of 824 patients were included with most patients taking 81 mg of aspirin (n = 558). Patients on no antiplatelet were younger and had higher baseline platelet counts, while patients on 75 mg of clopidrogrel were more likely to be admitted after ground level fall. All other baseline characteristics were balanced. Admission TEG values were similar between groups. Median AA inhibition was higher in patients on aspirin containing regimens (p < 0.0001). Median ADP inhibition was higher in patients on clopidogrel containing regimens and those taking 325 mg of aspirin (p < 0.0001). Arachidonic acid inhibition accurately detected preinjury APA use and aspirin use (AUROC, 0.89 and 0.84, respectively); however, ADP inhibition performed poorly (AUROC, 0.58). Neither AA nor ADP inhibition was able to discern specific APA regimens or rule out APA use entirely. CONCLUSION: High AA inhibition accurately detects preinjury APA use in trauma patients. High ADP inhibition after trauma is common, limiting its utility to accurately identify preinjury APA use. Further study is needed to identify assays that can reliably detect and further characterize preinjury APA use in trauma populations. LEVEL OF EVIDENCE: Diagnostic test, level II.

Multicenter Prospective Evaluation of Parenteral Nutrition Preparation Time and Resource Utilization: 3-Chamber Bags Compared With Hospital Pharmacy-Compounded Bags.

BACKGROUND: Parenteral nutrition (PN) is a complex and costly therapy that places significant demands on healthcare resources. Commercially manufactured 3-chamber bags (3CBs) offer potential time and cost advantages compared with hospital pharmacy-compounded bags (HCBs); however, no data are yet available from studies comparing these delivery systems in US hospitals. The primary aim of this study was to evaluate the PN preparation time and resource utilization required for 3CBs compared with HCBs in US hospitals. METHODS: A prospective, multicenter, time and motion study was performed to evaluate the time from transcription to completion of PN preparation and costs for 3CBs compared with HCBs. The cost per bag included labor, PN products, medical consumables, and equipment. RESULTS: One hundred thirty-six PN prescriptions were prepared during the study (66 prescriptions for 3CBs and 70 prescriptions for HCBs). The mean ± standard deviation total time required for transcription, review, validation, and preparation of PN was 5.5 ± 1.3 minutes for 3CBs vs 14.3 ± 6.2 minutes for HCBs (P < .001). The mean total cost per PN bag was $81.60 for 3CBs and $131.17 for HCBs (mean difference, -$49.57). CONCLUSION: Commercial 3CBs reduced staff time by 62% and direct costs by 37% compared with HCBs. The results demonstrate that 3CBs offer potential cost-savings for hospitalized patients who require PN in US hospitals.

Composite Intravenous Fat Emulsion in a Postsurgical Critically Ill Patient: A Case Report.

Parenteral nutrition (PN), including lipids, in high-risk or poorly nourished critically ill patients is indicated when enteral nutrition is contraindicated; however, soybean oil-based PN can stimulate proinflammatory processes. Fish oil (FO) is generally less inflammatory and has recently been shown to be active in the resolution of inflammatory processes. In this study, we look at whether the use of a blended intravenous fat emulsion that includes soybean, medium-chain triglycerides, olive oil, and FO confers clinical benefits in critically ill patients.

Risk of thromboembolic events after protocolized warfarin reversal with 3-factor PCC and factor VIIa.

Bleeding events and life-threatening hemorrhage are the most feared complications of warfarin therapy. Prompt anticoagulant reversal aimed at replacement of vitamin K-dependent clotting factors is essential to promote hemostasis. A retrospective cohort study of warfarin-treated patients experiencing a life-threatening hemorrhage treated with an institution-specific warfarin reversal protocol (postimplementation group) and those who received the prior standard of care (preimplementation group) was performed. The reversal protocol included vitamin K, 3-factor prothrombin complex concentrate, and recombinant factor VIIa. Demographic and clinical information, anticoagulant reversal information, and all adverse events attributed to warfarin reversal were recorded. A total of 227 patients were included in final analysis, 109 in the preimplementation group and 118 in the postimplementation group. Baseline patient characteristics were similar in both groups, with the exception of higher average Sequential Organ Failure Assessment scores in the postimplementation group (P = .0005). The most common indication for anticoagulation reversal was intraparenchymal hemorrhage. Prereversal international normalized ratios (INRs) were similar in both groups. Attainment of INR normalization to less than 1.4 was higher, and rebound INR was lower in the postimplementation group (P < .0001; P = .0013). Thromboembolic complications were significantly higher in the postimplementation group (P = .003). Elevated baseline Sequential Organ Failure Assessment score and mechanical valve as an indication for anticoagulation were independently associated with thrombotic complications (P = .005). A warfarin reversal protocol consisting of 3-factor prothrombin complex concentrate, recombinant factor VIIa, and vitamin K more consistently normalized INR values to less than 1.4 as compared to the prior standard of care in a diverse patient population. This success came at the cost of a 2-fold increase in risk of thromboembolic complications.

Antimicrobial prophylaxis during Hirudo medicinalis therapy: a multicenter study.

BACKGROUND: Medicinal leeches (Hirudo medicinalis) are indicated for salvage of tissue flaps, grafts, or replants when venous congestion threatens tissue viability. The purpose of this study was to evaluate the efficacy of prophylactic antimicrobial agents in patients who received medicinal leech therapy. MATERIALS AND METHODS: A multicenter retrospective cohort study of all adult patients between January 1, 2010, and February 28, 2013, who received medicinal leech therapy was conducted. RESULTS: Antimicrobial prophylaxis was documented in 54 (91.5%) of the included patients, ciprofloxacin, trimethoprim-sulfamethoxazole, piperacillin-tazobactam, and ceftriaxone in 33 (61.1%), 18 (33.3%), 2 (3.7%), and 2 (3.7%) patients, respectively. Surgical site infection (SSI) was found in seven (11.9%) patients, all of whom received antimicrobial prophylaxis. Aeromonas spp. was isolated in four infections, and all isolates were resistant to the chosen prophylactic agent. The SSI incidence was similar between antimicrobial prophylaxis agents. CONCLUSION: Trimethoprim-sulfamethoxazole and ciprofloxacin appear equally effective at preventing leech-associated infections.