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BACKGROUND: BRASH syndrome, or Bradycardia, Renal Failure, AV blockade, Shock, and Hyperkalemia, has recently become recognized as a collection of objective findings in a specific clinical context pertaining to emergency medicine and critical care. However, there is little emergency medicine and critical care literature specifically evaluating this condition. OBJECTIVE: We sought to define and review BRASH syndrome and identify specific management techniques that differ from the syndromes as they present individually. DISCUSSION: BRASH syndrome is initiated by synergistic bradycardia due to the combination of hyperkalemia and medications that block the atrioventricular (AV) node. The most common precipitant is hypovolemia or medications promoting hyperkalemia or renal injury. Left untreated, this may result in deteriorating renal function, worsening hyperkalemia, and hemodynamic instability. Patients can present with a variety of symptoms ranging from asymptomatic bradycardia to multiorgan failure. BRASH syndrome should be differentiated from isolated hyperkalemia and overdose of AV-nodal blocking medications. Treatment includes fluid resuscitation, hyperkalemia therapies (intravenous calcium, insulin/glucose, beta agonists, diuresis), management of bradycardia (which may necessitate epinephrine infusion), and more advanced therapies if needed (lipid emulsion, glucagon, or high-dose insulin infusion). Understanding and recognizing the pathophysiology of BRASH syndrome as a distinct entity may improve patient outcomes. CONCLUSIONS: BRASH syndrome can be a difficult diagnosis and is due to a combination of hyperkalemia and medications that block the AV node. Knowledge of this condition may assist emergency and critical care providers.
Asunto(s)
Bloqueo Atrioventricular , Hiperpotasemia , Insuficiencia Renal , Bradicardia/inducido químicamente , Electrocardiografía , Humanos , Hiperpotasemia/tratamiento farmacológico , SíndromeRESUMEN
OBJECTIVES: Given the high frequency of acute pulmonary exacerbations due to Pseudomonas aeruginosa in patients with cystic fibrosis (CF), piperacillin/tazobactam is commonly used in empirical regimens. While extended-infusion piperacillin/tazobactam has been employed as one strategy to optimize this agent's pharmacodynamics, this approach has not been well characterized in patients with CF. The objectives of this study were to characterize the pharmacokinetics and pharmacodynamics of extended-infusion piperacillin/tazobactam in adult patients with CF and derive optimized piperacillin/tazobactam dosing recommendations. METHODS: Six serum samples were collected from nine adult patients with CF hospitalized for acute pulmonary exacerbations who received 3/0.375 g of piperacillin/tazobactam intravenously for 4 h every 8 h. Population pharmacokinetic models were fitted to the data utilizing first-order, Michaelis-Menten (MM) and parallel first-order/MM clearance. Monte Carlo simulations were performed to determine the probability of target attainment (PTA) for regimens where free piperacillin concentrations were above the MIC for at least 50% of the dosing interval. RESULTS: The model incorporating MM clearance best described the data. Results of our simulation revealed that piperacillin/tazobactam dosed at 3-4 g for 30 min every 6-8 h led to <90% PTA against MIC values >4 mg/L. More intensive prolonged infusion regimens than are commonly used in practice, such as continuous infusions or 3 h infusions every 6 h, were needed to maximize the PTA for MICs ≥ 8 mg/L. CONCLUSIONS: Intensive prolonged infusion regimens are the best option to ensure optimal exposures against most susceptible isolates in adult patients with CF.
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Antibacterianos/farmacología , Antibacterianos/farmacocinética , Fibrosis Quística/complicaciones , Ácido Penicilánico/análogos & derivados , Neumonía Bacteriana/tratamiento farmacológico , Infecciones por Pseudomonas/tratamiento farmacológico , Adulto , Antibacterianos/administración & dosificación , Femenino , Humanos , Infusiones Intravenosas/métodos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Ácido Penicilánico/administración & dosificación , Ácido Penicilánico/farmacocinética , Ácido Penicilánico/farmacología , Piperacilina/administración & dosificación , Piperacilina/farmacocinética , Piperacilina/farmacología , Combinación Piperacilina y Tazobactam , Pseudomonas aeruginosa/efectos de los fármacos , Suero/química , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
The serum pharmacokinetic profile of intravenous (i.v.) tobramycin administration was characterized for a sample of nine adult patients with cystic fibrosis (CF) who were hospitalized for an acute pulmonary exacerbation. Current recommended i.v. tobramycin dosing protocols are predicted through modeling and simulation to be suboptimal. Empirical tobramycin regimens of ≥15 mg/kg of body weight administered i.v. once daily should be evaluated for adult patients with CF to optimize outcomes.
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Fibrosis Quística/tratamiento farmacológico , Infecciones por Pseudomonas/tratamiento farmacológico , Tobramicina/administración & dosificación , Tobramicina/farmacocinética , Administración Intravenosa , Adulto , Fibrosis Quística/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infecciones por Pseudomonas/sangre , Tobramicina/uso terapéutico , Adulto JovenAsunto(s)
Sepsis , Choque Séptico , Antibacterianos , Diagnóstico Precoz , Humanos , VasoconstrictoresRESUMEN
Limited information is available about current practice patterns involving the use of antibiotics in the inpatient management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). We sought to characterize current patterns of antibiotic use and to compare them to evidence-based guidelines. This study is a retrospective case series of patients at a regional tertiary care medical center. Charts were reviewed to identify patients admitted between January 2006 and 2008 with an initial diagnosis of AECOPD who had no evidence of another infectious process and who were not immunocompromised. Relevant data extracted from charts included initial clinical presentation, antibiotic administration, microbiological studies, and hospital course. One hundred sixteen admissions meeting inclusion criteria were identified. There was no statistically significant relationship between the presence of an established indication for antibiotic administration and the use of antibiotics, with roughly 75% of patients in all groups receiving therapy. A significant fraction of patients received combination therapy that was more appropriate for the management of pneumonia than for AECOPD. There were significant deviations between practice patterns and guidelines regarding the use and selection of antibiotics. Some of these may reflect areas of uncertainty in the primary literature and varying sets of guidelines.
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Antiinfecciosos/uso terapéutico , Pautas de la Práctica en Medicina , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Antiinfecciosos/economía , Ahorro de Costo , Análisis Costo-Beneficio , Costos de los Medicamentos , Quimioterapia Combinada , Utilización de Medicamentos , Medicina Basada en la Evidencia , Femenino , Adhesión a Directriz , Humanos , Pacientes Internos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/economía , Enfermedad Pulmonar Obstructiva Crónica/microbiología , Estudios Retrospectivos , Esputo/microbiología , Resultado del TratamientoRESUMEN
The complete blood count has a longstanding role in the diagnosis of septic shock. Despite its limitations, this is a pragmatic tool because patients will generally have a blood count measured upon presentation to the hospital. Therefore, it is sensible to extract as much information from these values as possible. Although the white blood cell count continues to attract the most attention, it is the least useful. Emerging evidence suggests that emphasis should be shifted to the neutrophil to lymphocyte ratio (NLR) and perhaps the fraction of immune granulocytes.
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Evidence-based medicine asks us to integrate the best available evidence with clinical experience and patient values. In the modern intensive care unit, the primary focus is on complex technology and electronic health records, often away from the bedside. Excess interventionism is the norm. The term "intensivist" itself implies an intensive management strategy, which can lead us away from a patient-centered practice and toward iatrogenic harm. Under the hashtag #zentensivist, an international, multiprofessional group of clinicians has begun to discuss via Twitter how to apply key principles of history taking, physical examination, physiology, pharmacology, and clinical research in a competent, compassionate, and minimalist fashion. The term "zentensivist" intentionally combines concepts seemingly at odds-Zen philosophy and intensive care-to describe a holistic approach to the art of caring for the critically ill. We describe the key tenets of zentensivist practice and how we may inspire these actions in those we lead and educate.
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BACKGROUND: Insulin via continuous intravenous infusion (ICII) is a standard of care for treating patients with diabetic ketoacidosis (DKA). Once DKA is resolved, ICII is transitioned to subcutaneous therapy. However, recent guidelines recommend continuation of home dose subcutaneous basal insulin (HDBI) in patients with DKA. The objective of this study was to evaluate outcomes in patients who received early vs delayed HDBI. METHODS: This is a retrospective cohort study of patients ≥16 years old admitted to the medical intensive care unit between 1 July 2012 and 30 June 2015 with a primary diagnosis of DKA who received ICII and HDBI. Patients were stratified into early or delayed groups if they received HDBI before or after resolution of DKA, respectively. The primary outcome was incidence of transitional failure, defined as resumption of ICII or recurrence of DKA after initial ICII discontinuation. RESULTS: A total of 106 admissions were included for analysis; 33 (31.1%) received early HDBI. The incidence of transitional failure was similar between the early and delayed groups (OR, 0.60; 95% CI, 0.26 to 1.44; P = 0.72). In the early group, ICII duration was shorter at 13.8 hours [interquartile range (IQR), 10.1 to 16.5] vs 17.1 hours (IQR, 12.6 to 21.1; P = 0.04), with a trend toward lower rates of hypoglycemia (OR, 0.41; 95% CI, 0.16 to 1.05; P = 0.058). CONCLUSION: There was no significant difference in incidence of transitional failure between early and delayed HDBI. Early HDBI was associated with a shorter duration of ICII and a trend toward less hypoglycemia. A prospective analysis is needed to confirm these findings.