Impact of initial fluid resuscitation volume on clinical outcomes in patients with heart failure and septic shock.

Background: Fluid resuscitation is a key treatment for sepsis, but limited data exists in patients with existing heart failure (HF) and septic shock. The objective of this study was to determine the impact of initial fluid resuscitation volume on outcomes in HF patients with reduced or mildly reduced left ventricular ejection fraction (LVEF) with septic shock. Methods: This multicenter, retrospective, cohort study included patients with known HF (LVEF ≤50%) presenting with septic shock. Patients were divided into two groups based on the volume of fluid resuscitation in the first 6 h; <30 mL/kg or ≥30 mL/kg. The primary outcome was a composite of in-hospital mortality or renal replacement therapy (RRT) within 7 days. Secondary outcomes included acute kidney injury (AKI), initiation of mechanical ventilation, and length of stay (LOS). All related data were collected and compared between the two groups. A generalized logistic mixed model was used to assess the association between fluid groups and the primary outcome while adjusting for baseline LVEF, Acute Physiology and Chronic Health Evaluation (APACHE) II score, inappropriate empiric antibiotics, and receipt of corticosteroids. Results: One hundred and fifty-four patients were included (93 patients in <30 mL/kg group and 61 patients in ≥30 mL/kg group). The median weight-based volume in the first 6 h was 17.7 (12.2-23.0) mL/kg in the <30 mL/kg group vs. 40.5 (34.2-53.1) mL/kg in the ≥30 mL/kg group (P <0.01). No statistical difference was detected in the composite of in-hospital mortality or RRT between the <30 mL/kg group compared to the ≥30 mL/kg group (55.9% vs. 45.9%, P=0.25), respectively. The <30 mL/kg group had a higher incidence of AKI, mechanical ventilation, and longer hospital LOS. Conclusions: In patients with known reduced or mildly reduced LVEF presenting with septic shock, no difference was detected for in-hospital mortality or RRT in patients who received ≥30 mL/kg of resuscitation fluid compared to less fluid, although this study was underpowered to detect a difference. Importantly, ≥30 mL/kg fluid did not result in a higher need for mechanical ventilation.

Review of Anticoagulation in Continuous Renal Replacement Therapy.

Continuous renal replacement therapy is an important, yet challenging, treatment of critically ill patients with kidney dysfunction. Clotting within the dialysis filter or circuit leads to time off therapy and impaired delivery of prescribed treatment. Anticoagulation can be used to prevent this complication; however, doing so introduces risk for unintended complications such as bleeding or metabolic derangements in patients who are already critically ill. A thorough understanding of indications, therapeutic options, and monitoring principles is necessary for safe and effective use of this strategy. This review provides clinicians important information regarding when to anticoagulate, differences in pharmacologic agents, recommended doses, routes of drug delivery, and appropriate laboratory monitoring for patients receiving anticoagulation to support continuous renal replacement therapy.

Acute Management of Hypertension Following Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH) is responsible for approximately 15% of strokes annually in the United States, with nearly 1 in 3 of these patients dying without ever leaving the hospital. Because this disproportionate mortality risk has been stagnant for nearly 3 decades, a main area of research has been focused on the optimal strategies to reduce mortality and improve functional outcomes. The acute hypertensive response following ICH has been shown to facilitate ICH expansion and is a strong predictor of mortality. Rapidly reducing blood pressure was once thought to induce cerebral ischemia, though has been found to be safe in certain patient populations. Clinicians must work quickly to determine whether specific patient populations may benefit from acute lowering of systolic blood pressure (SBP) following ICH. This review provides nurses with a summary of the available literature on blood pressure control following ICH. It focuses on intravenous and oral antihypertensive medications available in the United States that may be utilized to acutely lower SBP, as well as medications outside of the antihypertensive class used during the acute setting that may reduce SBP.

Successful Use of Ketamine for Central Neurogenic Hyperventilation: A Case Report.

This report describes the use of ketamine in a patient with central neurogenic hyperventilation following intracerebral hemorrhage. A 41-year-old man was admitted with right thalamic intracerebral hemorrhage with intraventricular extension requiring emergent external ventricular drain placement. After aggressive management of his neurologic status and other associated complications, the patient subacutely developed an altered respiratory pattern characterized by shallow, rapid breaths. After the use of multiple sedative agents to control respiratory drive had failed, a single 2 mg/kg bolus dose of intravenous ketamine was administered. In the 6 hours prior to ketamine dosing, respiratory rate ranged from 24 to 40 breaths per minute. Within minutes of ketamine administration, respiratory patterns improved and primarily ranged from 16 to 20. Twenty-four hours after ketamine administration, the patient was successfully extubated following 12 days of mechanical ventilation. Further research is needed to determine the widespread applicability of this strategy.

Evaluation of racial and socioeconomic disparities in medication pricing and pharmacy access and services.

PURPOSE: Results of a study to determine if disparities in drug pricing, pharmacy services, and community pharmacy access exist in a Tennessee county with a predominantly minority population are reported. METHODS: A cross-sectional survey of community pharmacies in Shelby County, a jurisdiction with a total population more than 60% composed of racial and ethnic minority groups, was conducted. Data collection included "out-of-pocket" (i.e., cash purchase) prices for generic levothyroxine, methylphenidate, and hydrocodone-acetaminophen; pharmacy hours of operation; availability of selected pharmacy services; and ZIP code-level data on demographics and crime risk. Analysis of variance, chi-square testing, correlational analysis, and data mapping were performed. RESULTS: Survey data were obtained from 90 pharmacies in 25 of the county's 33 residential ZIP code areas. Areas with fewer pharmacies per 10,000 residents tended to have a higher percentage of minority residents (p = 0.031). Methylphenidate pricing was typically lower in areas with lower employment rates (p = 0.027). Availability of home medication delivery service correlated with income level (p = 0.015), employment rate (p = 0.022), and crime risk (p = 0.014). CONCLUSION: A survey of community pharmacies in Shelby County, Tennessee, found that areas with a high percentage of minority residents had lower pharmacy density than areas with a high percentage of white residents. Pharmacies located in communities with low average income levels, low employment rates, and high scores for personal crime risk were less likely to offer home medication delivery services.

Continuous Infusion Antiepileptic Medications for Refractory Status Epilepticus: A Review for Nurses.

Status epilepticus requires treatment with emergent initial therapy with a benzodiazepine and urgent control therapy with an additional antiepileptic drug (AED) to terminate clinical and/or electrographic seizure activity. However, nearly one-third of patients will prove refractory to the aforementioned therapies and are prone to a higher degree of neuronal injury, resistance to pharmacotherapy, and death. Current guidelines for refractory status epilepticus (RSE) recommend initiating a continuous intravenous (CIV) anesthetic over bolus dosing with a different AED. Continuous intravenous agents most commonly used for this indication include midazolam, propofol, and pentobarbital, but ketamine is an alternative option. Comparative studies illustrating the optimal agent are lacking, and selection is often based on adverse effect profiles and patient-specific factors. In addition, dosing and titration are largely based on small studies and expert opinion with continuous electroencephalogram monitoring used to guide intensity and duration of treatment. Nonetheless, the doses required to halt seizure activity are likely to produce profound adverse effects that clinicians should anticipate and combat. The purpose of this review was to summarize the available RSE literature focusing on CIV midazolam, pentobarbital, propofol, and ketamine, and to serve as a primer for nurses providing care to these patients.