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Herein, we discuss a case of a 39-year-old male with hemophilia B, who developed end-stage liver disease secondary to nonalcoholic steatohepatitis, that underwent orthotopic liver transplantation (OLT) as a curative means for his liver disease and coagulation disorder. Existing case reports have demonstrated favorable outcomes in patients outside of the United States who received continuous infusions of recombinant factor IX replacement in the perioperative setting after liver transplant. Given limitations in the stability of the recombinant factor IX products in the United States, a dosing strategy was comprised of once daily bolus dosing to achieve satisfactory factor IX levels. Within 48 hours of initial surgery, the patient had sustained factor IX levels above 70% of normal and the patient required no further dosing of factor IX products to date. This strategy helped facilitate less frequent dosing as well as achieved targeted factor levels while synthetic function of the transplanted liver recovered.
RESUMO
PURPOSE: Neuromuscular blockade in the operating room necessitates the utilization of reversal agents to accelerate postoperative recovery and sustain operating room patient throughput. Cholinesterase inhibitors represent the historical standard of care for neuromuscular blockade reversal within anesthesia practice. Sugammadex, a synthetic gamma-cyclodextrin, was introduced to the market with evidence of more rapid and predictable reversal of neuromuscular blockade compared to alternative agents. Higher medication acquisition costs have limited more extensive use of sugammadex compared to that of neostigmine/glycopyrrolate. The purpose of this study was to examine the impact of sugammadex versus neostigmine/glycopyrrolate on perioperative efficiency to validate medication acquisition cost value. METHODS: A retrospective investigation was performed of patients with a surgical procedure at Houston Methodist Hospital from July 31, 2017 through August 1, 2018. The primary endpoint was time from reversal medication administration to operating room exit. Patient-specific doses were assessed to calculate average medication acquisition costs. The economic benefits of sugammadex were measured through review of average operating room and postanesthesia care unit costs per minute. RESULTS: There were a total of 640 surgical cases at Houston Methodist Hospital eligible for inclusion into the research study. The time from medication administration to operating room exit was significantly faster for sugammadex compared to neostigmine/glycopyrrolate (P<0.001) upon univariate analysis. However, when measured with linear regression, the difference in operating room exit time between sugammadex and neostigmine/glycopyrrolate was no longer statistically significant (P=0.122). Medication acquisition cost review highlighted a difference of $178.20, favoring use of neostigmine/glycopyrrolate. CONCLUSION: The utilization of sugammadex does not correlate to consequential time saved in the operating room or extrapolation to workflow capacity for increased surgical case volume. Consideration of the medication acquisition cost promotes more restrictive use of sugammadex to indications with clinical relevance.
RESUMO
Medication error is a preventable cause of morbidity and death in the inpatient population. We describe a patient with an antifungal overdose treated with therapeutic plasma exchange (TPE). The patient was diagnosed with cryptococcal meningitis and received an acute overdose of amphotericin B deoxycholate instead of the prescribed liposomal amphotericin B. Consequently, the patient developed clinical symptoms including tremors, hypertension, visual hallucinations, vertigo, fever, and acute renal failure. A series of four TPEs was emergently initiated, resulting in complete resolution of most symptoms.