Fibrinolytic and Anticoagulation Therapy in Patients Undergoing Ultrasound-Assisted Catheter-Directed Thrombolysis for Pulmonary Embolism.

BACKGROUND: Ultrasound-assisted, catheter-directed thrombolysis (UA-CDT) relieves right ventricular stress without a significant increase in the risk of bleeding compared to systemic thrombolysis. Although concomitant anticoagulation is provided to prevent thrombus expansion, the optimal anticoagulation regimen in patients receiving UA-CDT remains unknown. OBJECTIVE: We sought to describe anticoagulation practices for patients receiving UA-CDT. METHODS: Patients receiving UA-CDT for acute pulmonary embolism (PE) between Jan 1, 2013 to Sept 30, 2014 at a single center were analyzed. We collected patient characteristics, fibrinolytic and anticoagulant usage as well as clinical outcomes. RESULTS: Fourteen patients were included in the final analysis. The mean alteplase dose was 16.8 ± 5.6 mg and 24.3 ± 3.4 mg in unilateral and bilateral PE, respectively. Mean unfractionated heparin (UFH) rates were 7.4 (±2.17) IU/kg/hr and 12.4 (±3.1) IU/kg/hr during and after fibrinolytic therapy, respectively. The median aPTT was 42.4 sec [IQR 34.5-51.8] and 77.9 sec [IQR 66.5-96.8] during and after fibrinolytic therapy, respectively. There were no recurrent VTE within 30 days of hospital discharge. One patient had a major bleeding event (intracranial hemorrhage). CONCLUSION: In patients with acute PE, our institution utilized low levels of anticoagulation during fibrinolytic administration and therapeutic doses after completion of fibrinolytic infusion. Standardized protocols for anticoagulation during UA-CDT are warranted.

Prospective evaluation of inappropriate unable-to-assess CAM-ICU documentations of critically ill adult patients.

BACKGROUND: Delirium occurs in the intensive care unit and identification is often performed using a validated assessment tool such as the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) patients. The CAM-ICU has three ratings: positive, negative, and unable to assess (UTA). Patients may often be assigned UTA when it is inappropriate given the level of sedation or medical condition. The purpose of this study is to evaluate the rate of inappropriate UTA CAM-ICU documentations. METHODS: A single-center prospective observational analysis was performed evaluating CAM-ICU documentations from October 27, 2014, to December 26, 2014. Patients admitted to the medical and surgical ICU were included and excluded if admitted to the ICU for less than 24 h. CAM-ICU assessments were performed per institutional guidelines using CAM-ICU scoring as validated in literature. CAM-ICU patient documentations were recorded as positive, negative, UTA, or not assessed. Patients with an appropriate UTA documentation were deeply sedated, non-English speaking, or not medically able to participate in the assessment. The major endpoint assessed rates of inappropriate UTA CAM-ICU documentations. Minor endpoints evaluated adherence to CAM-ICU documentations and use of pharmacologic agents for symptoms of delirium. RESULTS: Sixty-one patients were identified with 45 (74 %) medical, 16 (26 %) surgical, of which 27 (44.3 %) were mechanically ventilated. There were 116 UTA documentations with 35 (30.2 %) identified as inappropriate. Of the 906 identified CAM-ICU documentation opportunities, adherence was 439 (48.5 %). Overall, 18 (29.5 %) of the 61 patients were administered pharmacologic agents for delirium management and 5 (27.7 %) had a positive CAM-ICU documented within 24 h. CONCLUSIONS: Rates of inappropriate UTA CAM-ICU documentations may be significantly higher than reported in literature. Additional research is needed to identify an acceptable rate of inappropriate UTA CAM-ICU assessments and its clinical impact on delirium management.

Regulatory, legislative, and policy updates with anticoagulant use.

Thromboembolism afflicts millions of patients annually in the United States and is associated with a significant cost burden. Recent advances in oral anticoagulation have provided clinicians with more options for management of these diseases. Accordingly, regulatory, legislative, and policy-making organizations have intervened with the aim of improving patient outcomes, ensuring patient safety, and reducing costs. There have been a number of recent developments in surveillance, litigation, and regulatory oversight that clinicians should recognize. In this review article we summarize key updates related to the management of anticoagulant therapy as it relates to thrombosis prevention and treatment.