Effect of Early Amiodarone Use on Warfarin Sensitivity, Blood Product Use, and Bleeding in Patients With a Left Ventricular Assist Device.

Data are scarce on the effect of amiodarone on warfarin sensitivity and related outcomes after placement of a left ventricular assist device (VAD). This retrospective study compared 30-day outcomes between patients on amiodarone vs no amiodarone after VAD implant. After exclusions, 220 patients received amiodarone and 136 patients did not. Compared to the no amiodarone group, the amiodarone group had a higher warfarin dosing index (0.53 [0.39, 0.79] vs 0.46 [0.34, 0.63]; P = 0.003), incidence of INR ≥ 4 (40.5 vs 23.5%; P = 0.001), incidence of bleeding (24.1 vs 14%; P = 0.021), and use of INR reversal agents (14.5 vs 2.9%, P ≤ 0.001). Amiodarone was associated with bleeding (OR, 1.95; 95% CI, 1.10-3.47; P = 0.022), but not after adjusting for age, estimated glomerular filtration rate, and platelet count (OR, 1.67; 95% CI, 0.92-3.03; P = 0.089). After VAD implant, amiodarone was associated with increased warfarin sensitivity and administration of INR reversal agents.

Incorporation of the Transverse Thoracic Plane Block Into a Multimodal Early Extubation Protocol for Cardiac Surgical Patients.

BACKGROUND: The aim for early extubation remains an important goal in cardiac surgical patients. Therefore, employment of a multimodal approach to pain management that includes a transverse thoracic plane block was retrospectively examined at a single-center tertiary care hospital on the effects of time to extubation, opioid consumption, and length of stay in patients undergoing cardiac surgery via median sternotomy. METHODS: Blocks were performed on all cardiac surgical patients except for those undergoing left ventricular assist device placement, thoracic transplant, emergent surgery, or redo sternotomy. Following additional exclusions for intra- and postoperative complications unrelated to anesthesia, final analysis was conducted on 75 patients per group. Multimodal pain management included intravenous analgesics and transverse thoracic plane block where patients received 15 mL 0.5% bupivacaine + epinephrine bilaterally under ultrasound guidance prior to incision. RESULTS: Following transverse thoracic plane block and multimodal analgesics, 50.6% of patients were extubated in the operation room versus 8.6% in the control group. Intraoperative opioids were decreased, and intensive care unit and total length of stay were reduced by 5 hours and 1 day, respectively, in block patients as compared with controls. Postoperative opioids were not significantly different. There were no reported complications directly attributed to the block. CONCLUSIONS: The transverse thoracic plane block and multimodal regimen for patients undergoing median sternotomy resulted in a significant number of patients extubated in the operation room without an increase in postoperative re-intubations. Moreover, the block appears to be a quick and safe procedure to utilize on cardiac surgery patients.

Ketamine Infusion Used to Successfully Control Refractory Status Epilepticus in a Pregnant Patient.

The management of SE during pregnancy is especially challenging to the treating physician. While antiepileptic medications might cause teratogenicity, SE can have significant morbidity and mortality on both the mother and the developing fetus. This case report demonstrated the successful use of ketamine infusion in the management of RSE in pregnancy without affecting the immediate outcome of pregnancy. The fetus survived this complicated ICU stay and outpatient follow-up was generally uncomplicated. The pregnancy was ended with a delivery of a normal female newborn.

Vancomycin continuous infusion versus intermittent infusion during continuous venovenous hemofiltration: slow and steady may win the race.

BACKGROUND: Vancomycin during continuous venovenous hemofiltration (CVVH) is either administered by intermittent infusion (II) or continuous infusion (CI). In this patient population, the best method to rapidly achieve target serum concentrations of 15 mcg/ml to 25 mcg/ml remains to be elucidated. We hypothesized that CI would achieve a target serum level of 15 mcg/ml to 25 mcg/ml within 24 h of the initiation of therapy more consistently than II. METHODS: A retrospective cohort study of adult patients admitted to the intensive care unit (ICU) between 2011 and 2014 receiving intravenous vancomycin with 24-hour serum level while on CVVH was included. Patients were excluded from this review if they had residual renal function during CVVH, were concomitantly on extracorporeal membrane oxygenation, or if the first dose of vancomycin was received six or more hours prior to the initiation of CVVH. The primary outcome was the achievement of a therapeutic level of 15mcg/ml to 25 mcg/ml by 24 hours. RESULTS: Fifty-nine patients met the inclusion criteria and 14 received CI and 45 in II. Therapeutic 24-hour levels were achieved in 14/14 versus 2/45 in CI and II, respectively (p < 0.001). Mean 24-hour vancomycin levels were 20.35 ± 2.78 mcg/ml for CI compared to 9.7 ± 3.52 mcg/ml for II (p < 0.001). Mean loading dose was 26.65 ± 3.06 mg/kg for CI compared to 17.58 ± 5.72 mg/kg for II (p < 0.001). Daily maintenance doses were 15.66 ± 6.26 mg/kg for CI compared to 17.28 ± 4.96 mg/kg for II (p = 0.339). In the subgroup of 27 patients who received vancomycin-loading dose >20 mg/kg, mean 24-hour levels were 20.35 ± 2.78 mcg/ml for CI versus 11.8 ± 2.7 mcg/ml for II (p < 0.001). No significant differences were found between patients in the two groups with respect to CVVH rate and length of CVVH prior to vancomycin administration. CONCLUSIONS: The results of our study suggest that critically ill patients on CVVH treated with CI achieved the target level faster than II and consistently keep the vancomycin level within target range.

Diffuse Alveolar Hemorrhage due to Acute Mitral Valve Regurgitation.

Diffuse alveolar hemorrhage (DAH) can be caused by several etiologies including vasculitis, drug exposure, anticoagulants, infections, mitral valve stenosis, and regurgitation. Chronic mitral valve regurgitation (MR) has been well documented as an etiological factor for DAH, but there have been only a few cases which have reported acute mitral valve regurgitation as an etiology of DAH. Acute mitral valve regurgitation can be a life-threatening condition and often requires urgent intervention. In rare cases, acute mitral regurgitation may result in a regurgitant jet which is directed towards the right upper pulmonary vein and may specifically cause right-sided pulmonary edema and right-sided DAH. Surgical repair of the mitral valve results in rapid resolution of DAH. Acute MR should be considered as a possible etiology in patients presenting with unilateral pulmonary edema, hemoptysis, and DAH.