Cryoprecipitate for Alteplase-Related Hemorrhagic Conversion of Acute Ischemic Stroke.

Background: Evidence to support cryoprecipitate for reversal of alteplase-related hemorrhagic conversion of acute ischemic stroke is limited. Guidelines recommend cryoprecipitate as first line treatment, followed by aminocaproic acid as a conditional recommendation with very low-quality evidence. The purpose of this case series was to describe the use of cryoprecipitate for alteplase-related hemorrhagic conversion of acute ischemic stroke. Methods: This was an IRB-approved retrospective case series of adults who received cryoprecipitate for an alteplase-related hemorrhagic conversion of acute ischemic stroke at two comprehensive stroke centers within a large academic medical center. Thromboembolism at 14 days and hemostasis within 24 hours were collected. The outcomes of cryoprecipitate alone vs cryoprecipitate with aminocaproic acid (C + A) were also described. Results: A total of 19 patients were included. Thrombosis occurred in 1/19 (5%) and hemostasis occurred in 4/14 (29%) of evaluable patients. In-hospital mortality was seen in 9/19 (47%) patients. Seventy four percent (14/19) of patients received concomitant blood products other than cryoprecipitate and 63% received a concomitant reversal agent. Thirteen patients received cryoprecipitate alone and six received C + A. Thrombosis was seen in 1/13 (8%) vs 0/6 (0%) and hemostasis occurred in 2/11 (18%) and 2/3 (67%) evaluable cryoprecipitate vs C + A patients respectively. Conclusion: Cryoprecipitate was associated with a low rate of thrombosis and hemostasis for alteplase-associated hemorrhagic conversion of acute ischemic stroke. There was significant heterogeneity in treatment regimens, including the use of and dosing of adjunctive aminocaproic acid and monitoring of fibrinogen levels.

Rethinking the Drug Distribution and Medication Management Model: How a New York City Hospital Pharmacy Department Responded to COVID-19.

Beginning in March 2020, New York City began the fight against coronavirus disease 2019. Health care workers were faced with a disease that led to significant morbidity and mortality with no proven therapies. As hospitals became inundated with patients and underwent rapid expansion of capacity, resources such as drugs, protective and medical equipment, and hospital staff became limited. Pharmacists played a critical role in the management of clinical care and drug delivery during the pandemic. As members of the department of pharmacy within NewYork-Presbyterian Hospital, we describe our experiences and processes to overcome challenges faced during the pandemic. Strict inventory management through the use of daily usage reports, frequent communication, and minimization of waste was critical for the management of drug shortages. The creation of guidelines, protocols, and restrictions were not only used to mitigate drug shortages, but also helped educate health care providers and guided medication use. Managing technology through setting up new automatic dispensing cabinets to address hospital expansions and modifying the electronic order entry system to include new protocols and drug shortage information were also vital. Additional key pharmacist functions included provision of investigational drug service support and training of pharmacists, prescribers, nurses, and respiratory therapists to educate and standardize medication use. Through implementation of operational and clinical processes, pharmacists managed critical drug inventory and guided patient treatment. As the pandemic continues, pharmacists will remain vital members of the multidisciplinary team dedicated to the fight against the virus.

Aminocaproic Acid for the Reversal of Alteplase: A Case Series.

INTRODUCTION: The evidence to support the use of aminocaproic acid for reversal of alteplase is limited to case reports. Current guidelines recommend cryoprecipitate as first-line treatment, or an antifibrinolytic if cryoprecipitate is unavailable or cannot be used. This case series describes the use of aminocaproic acid for alteplase-related hemorrhage. MATERIALS AND METHODS: Patients who received aminocaproic acid within 48 hours of alteplase from January 1, 2014, to June 30, 2017 were included. Patients were excluded if aminocaproic acid was not administered for an alteplase-related hemorrhage. Thromboembolic complications at 14 days and hemostasis within 24 hours were documented. RESULTS: Sixteen patients received aminocaproic acid for an alteplase-related hemorrhage. Aminocaproic acid was given for hemorrhagic conversion of acute ischemic stroke in 7 of 16 patients and other types of hemorrhages in the remaining patients. Hemostasis occurred in 3 of 10 evaluable patients. Overall mortality was 63% (10/16). Administration of aminocaproic acid varied significantly (50% bolus, 12.5% infusion, 37.5% bolus plus infusion). One of 6 evaluable patients had a thromboembolic event. All patients received concomitant blood products. Cryoprecipitate was administered in 69% (11/16) of patients. CONCLUSIONS: There was no clear relationship between the timing or dose of aminocaproic acid and hemostasis, and it is unclear if administration of aminocaproic acid contributes to hemostasis.

Opioid and Benzodiazepine Requirements in Obese Adult Patients Receiving Extracorporeal Membrane Oxygenation.

Background: The use of extracorporeal membrane oxygenation (ECMO) sometimes requires deep levels of sedation (Richmond Agitation Sedation Scale [RASS] -5) in patients with acute respiratory distress syndrome (ARDS). The role of obesity in opioid and sedative requirements remains unclear in patients receiving ECMO. Objective: This study sought to determine whether obesity increases midazolam and opioid requirements in patients receiving venovenous (vv)-ECMO up to the first 7 days after initiation. Methods: This was a retrospective cohort study of adult patients with ARDS managed with vv-ECMO. Results: The obese (n = 38) and nonobese (n = 43) groups had similar baseline characteristics. Fentanyl equivalents were significantly higher on day 3 in the obese group (P = 0.02) despite similar RASS scores with no differences in midazolam requirements. There were no differences in duration of ECMO, length of stay, or mortality. Conclusion and Relevance: Daily midazolam requirements were not significantly different, and opioid requirements were only significantly higher in the obese group on day 3 despite similar levels of sedation. The impact of obesity with the addition of ECMO and how to adapt doses of medications remains elusive.