Activated Clotting Times Demonstrate Weak Correlation With Heparin Dosing in Adult Extracorporeal Membrane Oxygenation.

BACKGROUND: The optimal monitoring strategy for anticoagulation management in extracorporeal membrane oxygenation (ECMO) remains a clinical controversy. The Extracorporeal Life Support Organization Anticoagulation Guidelines suggest that multiple anticoagulation assays may be needed but do not specify a preferred management strategy. STUDY QUESTION: In adult ECMO patients, which anticoagulation assays demonstrate the highest correlation with unfractionated heparin (UFH) dose requirements? STUDY DESIGN: We performed a retrospective chart review of adult patients cannulated to ECMO between February 2013 and July 2015. MEASURES AND OUTCOMES: The primary outcome was the correlation between activated clotting time (ACT), activated partial thromboplastin time (aPTT), and anti-Xa and UFH dose. Secondary outcomes included correlations between anticoagulation assays. Correlations were calculated for the entire cohort, with subgroup analysis of venoarterial and venovenous ECMO patients. RESULTS: Forty-eight patients were included in the analysis, 26 initially cannulated to venoarterial ECMO and 22 to veno-venous ECMO. The median duration of ECMO therapy was 7 days. Mean UFH requirements were 1149 units/h or 15.3 units/kg/h. Total UFH dose was most correlated with anti-Xa levels (r = 0.467), whereas weight-based heparin dose was most correlated with aPTT (0.405). For correlations between anticoagulation assays, anti-Xa and aPTT were more highly correlated with each other (r = 0.633) compared with ACT. CONCLUSIONS: In adult patients requiring ECMO, anti-Xa and aPTT monitoring were correlated more closely with UFH dosing than ACT.

Safety of Intravenous Push Lacosamide Compared With Intravenous Piggyback at a Tertiary Academic Medical Center.

BACKGROUND: There are limited data regarding the incidence of adverse events associated with administering lacosamide by intravenous push (IVP) compared with IV piggyback (IVPB). OBJECTIVE: The objective of this analysis was to compare the safety profile, including cardiovascular effects, sedative effects, and IV site reactions of IVP and IVPB lacosamide administration. METHODS: A retrospective pre/post cohort analysis comparing patients who received lacosamide via IVP and IVPB was conducted. Safety end points included hypotension, bradycardia, medication-related sedation, and IV site reactions. The relationship between patient characteristics and the incidence of safety end points was analyzed using the Student t-test and χ2 test as appropriate. RESULTS: Bradycardia occurred after 0.19% of IVP administrations and 1.09% of IVPB administrations assessed (P = 0.07). Hypotension was observed in 3.16% of IVP administrations compared to 1.59% in the IVPB cohort (P = 0.12). Post lacosamide-related sedation was noted in 11.32% and 11.68% of the IVP and IVPB cohorts, respectively (P = 0.87). Infusion site reaction rates of 1.80% and 0.84% were documented in the IVP and IVPB cohorts, respectively (P = 0.33). Of note, only 1 adverse event required clinical intervention. One 200-mg dose in the IVP cohort required a fluid bolus postadministration. CONCLUSION AND RELEVANCE: IVP lacosamide was associated with a similar incidence of cardiovascular, neurological, and infusion site-related adverse events compared with IVPB, in which nearly every adverse event was deemed clinically insignificant. Lacosamide administered via IVP may be considered a safe alternative method of administration in the acute care setting.

The Effect of Concomitant Sirolimus and Propofol Therapy on Triglyceride Concentrations in Critically Ill Patients.

BACKGROUND: Sirolimus and propofol are both independently associated with the development of hypertriglyceridemia (HTG) during therapy. To date, there are no published reports describing synergistic or additive drug interaction resulting in HTG with concomitant use of these medications. STUDY QUESTION: To identify the occurrence of HTG in patients receiving concomitant sirolimus and propofol infusion therapy. METHODS: Adult patients receiving sirolimus and a continuous propofol infusion for at least 12 hours from January 2005 to August 2009 were retrospectively evaluated. Data included Acute Physiology and Chronic Health Evaluation II score, weight, length of propofol therapy, and baseline triglyceride (TG) concentrations. The major outcome was incidence of HTG (TGs ≥500 mg/dL). Minor outcomes included the change in TG concentration from therapy initiation and manifestations of propofol-related infusion syndrome (PRIS). RESULTS: Sixteen patients were included in the analysis, with 8 (50%) of the patients developing HTG. The patients in this case series had the following mean values: Acute Physiology and Chronic Health Evaluation II score of 20.2 ± 5.3, weight of 76.3 ± 21.2 kg, and baseline TG concentrations of 181.3 ± 89.7 mg/dL. Indications for sirolimus therapy included hematopoietic stem-cell transplantation (n = 15) and heart transplantation (n = 1). Mean length of propofol infusion was 99.8 ± 88.5 hours. The mean TG concentration during infusion was 515.6 ± 468.1 mg/dL. Fourteen (87.5%) patients had an increase of ≥100 mg/dL, 12 (75%) patients had an increase of ≥200 mg/dL, and 6 (37.5%) patients had an increase of ≥300 mg/dL in TG concentrations during therapy. Eleven patients developed one manifestation of PRIS, excluding HTG, and one patient had more than 2 new onset PRIS manifestations during propofol therapy. CONCLUSIONS: Coadministration of propofol and sirolimus can potentially result in HTG, which may warrant more frequent monitoring. Further analysis is needed to examine the mechanism and clinical impact of this interaction.

Etanercept for the Treatment of Transplantation-Related Lung Injury After Hematopoietic Stem Cell Transplantation.

Although some data suggest favorable outcomes with use of etanercept for treatment of transplantation-related lung injury, concerns, such as development of new infections, still exist. The objective of this study was to describe the usage of etanercept at our institution and to evaluate the efficacy and safety of etanercept for this indication. Adult patients receiving at least one dose of etanercept for the treatment of pulmonary complications in patients after hematopoietic stem cell transplant from January 2005 to December 2010 were retrospectively evaluated. Outcomes included hospital mortality, incidence of new infection after etanercept administration, and time from administration of first dose of etanercept to infection. Seventeen patients who received etanercept at our institution from January 2005 to December 2010 were included. Four patients (24%) survived their hospital stay, and 3 patients (18%) were alive at both 100 days and 1 year from the initiation of etanercept therapy. Four patients (24%) developed at least one confirmed new infection after the initiation of etanercept therapy. Both moderate and long-term survival in our cohort was low. Caution and careful assessment of the risks and benefits of therapy should be taken before initiation of etanercept for transplantation-related lung injury.

Clinical and Economic Impact of Formulary Conversion From Inhaled Flolan to Inhaled Veletri for Refractory Hypoxemia in Critically Ill Patients.

BACKGROUND: Flolan (iFLO) and Veletri (iVEL) are 2 inhaled epoprostenol formulations. There is no published literature comparing these formulations in critically ill patients with refractory hypoxemia. OBJECTIVE: To compare efficacy, safety, and cost outcomes in patients who received either iFLO or iVEL for hypoxic respiratory failure. METHODS: This was a retrospective, single-center analysis of adult, mechanically ventilated patients receiving iFLO or iVEL for improvement in oxygenation. The primary end point was the change in the PaO2/FiO2 ratio after 1 hour of pulmonary vasodilator therapy. Secondary end points assessed were intensive care unit (ICU) length of stay (LOS), hospital LOS, duration of study therapy, duration of mechanical ventilation, mortality, incidence of adverse events, and cost. RESULTS: A total of 104 patients were included (iFLO = 52; iVEL = 52). More iFLO patients had acute respiratory distress syndrome compared with the iVEL group (61.5 vs 34.6%; P = 0.01). There was no difference in the change in the PaO2/FiO2 ratio after 1 hour of therapy (33.04 ± 36.9 vs 31.47 ± 19.92; P = 0.54) in the iFLO and iVEL groups, respectively. Patients who received iVEL had a shorter duration of mechanical ventilation (P < 0.001) and ICU LOS (P < 0.001) but not hospital LOS (P = 0.86) and duration of therapy (P = 0.36). No adverse events were attributed to pulmonary vasodilator therapy, and there was no difference in cost. CONCLUSIONS: We found no difference between iFLO and iVEL when comparing the change in the PaO2/FiO2 ratio, safety, and cost in hypoxic, critically ill patients. There were differences in secondary outcomes, likely a result of differences in underlying indication for inhaled epoprostenol.

Utilization of a Pharmacy Clinical Surveillance System for Pharmacist Alerting and Communication at a Tertiary Academic Medical Center.

The objective of this analysis is to describe the utilization metrics of a pharmacy clinical surveillance system (PCSS) at a tertiary, academic medical center.We performed a retrospective database analysis assessing rule-based alerts (RBA), interventions and pharmacist communication notes documented in the PCSS from January 1, 2014 to December 31, 2014. Reports were generated on 92 unique RBAs sent to clinicians for evaluation. Metrics assessed included the number of RBAs that were triggered, clinically evaluated, intervened on by pharmacists, and therapeutic category of interventions. Pharmacy communication notes were also evaluated.A total of 399,979 RBAs were triggered through the PCSS. During that time, pharmacists documented a total of 17,733 interventions. The most common RBAs were related to lab abnormalities (132,487; 33 %) and anticoagulation/antiplatelet therapy (126,425; 32.1 %). Interventions were most frequently related to RBAs regarding anticoagulation/antiplatelet therapy (6412; 36 %) and antimicrobial therapy (3320; 19 %). Pharmacist communication was most commonly related to clarification of medication and lab orders, and therapeutic drug monitoring.Based on utilization metrics presented, the implementation of a PCSS has successfully generated RBAs to aid pharmacists in clinical practice and improved departmental documentation and communication. Further analysis is warranted to assess the impact of the RBAs, interventions, and communication notes on outcomes such as hospital cost and adverse drug events.

Enhanced responsibilities for pharmacy interns at a teaching hospital.

OBJECTIVE: To describe the implementation of a pharmacy intern distribution coordinator position and its impact on the intern's professional development. SETTING: Tertiary academic medical center. PRACTICE DESCRIPTION: In 2009, our institution implemented a pharmacy intern distribution coordinator position, which was previously staffed by a pharmacist. Interns, who are in their first through fourth professional year, take the lead in the medication distribution process while under the direct supervision of a pharmacist. The intern adjudicates the medication distribution process by ensuring proper processing, filling and timely delivery of the medications, as well as triaging inventory issues and maintaining open communication with the pharmacists about any medication issues. Additionally, the intern can make clinical interventions during the various checkpoints in the final verification process and answer drug information questions for fellow medical professionals. PRACTICE INNOVATION: Pharmacy intern resources and development are maximized via staffing in a medication distribution coordinator position previously staffed by a pharmacist. By adapting to the role of pharmacist early on in one's career, pharmacy interns are provided with a valuable opportunity to grow professionally. The position can foster the development of pharmacotherapy knowledge, communication skills, leadership experience, time management, and critical thinking by allowing pharmacy interns to practice at the top of their licensure. CONCLUSION: Our pharmacy intern distribution coordinator position provides interns with a professional development opportunity by assuming enhanced roles and responsibilities in a hospital pharmacy department. The expansion of the pharmacy intern's role can increase pharmacy department resources and provide a valuable platform for their development. Institutions should seek to maximize the opportunities for pharmacy interns to work at the peak of their licensure.

Evaluation of an institution-wide guideline for hyperglycemic emergencies at a tertiary academic medical center.

BACKGROUND: No previous studies exist examining implementation of an institution-wide guideline and order set for hyperglycemic emergencies (diabetic ketoacidosis [DKA] and hyperosmolar hyperglycemic state [HHS]). OBJECTIVE: Evaluate the impact of an institutional guideline and order set for hyperglycemic emergencies. METHODS: This retrospective descriptive study evaluated patients with a diagnosis of DKA or HHS. Two time periods were evaluated: phase 1 (PRE) assessed practice preguideline implementation, and phase 2 (POST) assessed practice postguideline and order set introduction. RESULTS: A total of 172 patients (91 PRE and 81 POST) were included in the analysis. There was no difference in the mean hospital length of stay (LOS) in the PRE versus POST groups (5.2 ± 4 vs 5.9 ± 8.6 days, P = .49). The mean intensive care unit (ICU) LOS was shorter in the POST group (64.8 ± 19 vs 37.1 ± 74.8 hours, P < .01). The POST group had an increase in frequency of assessments for clearance of urinary ketones (18 vs 33.3%, P = .03) and ß-hydroxybutyrate (16 vs 37%, P < .01). Frequency of point-of-care glucose testing (12.5 ± 4.6 vs 15.1 ± 4.7, P < .01) and time to anion gap closure (13 ± 9 vs 9.3 ± 7.4 hours, P < .01) improved in the POST group. There was no difference in the number of patients experiencing hypoglycemia or hypokalemia between both groups. CONCLUSIONS: Implementation of an institutional guideline and order set for hyperglycemic emergencies decreased ICU LOS and time to anion gap closure, with no difference in rates of hypoglycemia.

Safety of Intravenous Push Ertapenem Compared to Intravenous Piggyback at a Tertiary Academic Medical Center.

Background: Recent shortages of intravenous (IV) fluids have resulted in healthcare systems converting administration of many medications from IV piggyback (IVPB) to IV push (IVP). Administering medications via IVP presents numerous advantages; however, IV site reactions such as phlebitis and infiltration may occur. Objective: The objective of this analysis is to evaluate the infusion site safety of ertapenem given as peripheral IVP compared to IVPB in adult patients. Methods: This was an institutional review board-approved, single-center, retrospective study. Patients, ages 18 or older, receiving IV ertapenem were identified. The major endpoints analyzed were IV site reactions including phlebitis and infiltration. The Naranjo Nomogram was utilized to assess the causality of the reactions to determine the likelihood of whether the event was caused by the medication itself or other factors. Results: To date, 283 administrations (92 patients) in the IVP group and 319 administrations (82 patients) in the IVPB group were analyzed. There were 13 IV site reactions compared to 8 in the IVP vs IVPB group, respectively (P-value = 0.16). Ten of the events in the IVP group were deemed "possible" and 2 deemed "doubtful," while the remaining event was considered "probable" per the Naranjo Nomogram. Of the events in the IVPB group, all 8 were found to be "possible." Conclusion: The administration of IVP ertapenem showed comparable rates of infusion site reactions compared to IVPB. Implementation of IVP ertapenem appears to be associated with infusion site safety similar to IVPB and should be considered safe to administer.

Safety of Intravenous Push Levetiracetam Compared to Intravenous Piggyback at a Tertiary Academic Medical Center: A Retrospective Analysis.

INTRODUCTION: Medication administration via intravenous push presents multiple potential advantages; however, there may be an increased risk of adverse drug reactions. In 2020, Brigham and Women's Hospital changed levetiracetam intravenous administration to intravenous push (IVP). OBJECTIVE: The purpose of this analysis was to compare the safety profile of IVP to intravenous piggyback (IVPB) levetiracetam administration. METHODS: This institutional review board-approved, single-center, pre-post analysis was performed between 1 November, 2019 and 30 May, 2020. The electronic health record was used to identify all administrations of intravenous levetiracetam greater than 1000 mg in patients ≥ 18 years old. The major safety outcomes included hypotension, bradycardia, drug-induced sedation, and intravenous site reactions such as phlebitis and infiltration. The major efficiency outcome was the time from pharmacy order verification to first-dose administration. RESULTS: A total of 498 administrations in 162 patients were included in the analysis: 252 administrations in 84 patients in the IVP group and 246 administrations in 78 patients in the IVPB group. The incidence of bradycardia was 7 vs 3 (3.2% vs 1.5%, p = 0.34); hypotension 10 vs 6 (5.2% vs 3.5%, p = 0.44); sedation 21 vs 36 (19.3% vs 27.9%, p = 0.12); and peripheral IV site reactions 0 vs 1 (0% vs 0.6%, p = 0.39) in the IVP vs IVPB groups, respectively. The median time between order verification and first-dose administration was significantly reduced in the IVP vs IVPB group (23.5 vs 55 min, p < 0.001). CONCLUSIONS: Intravenous push levetiracetam administration of doses up to 4000 mg was associated with a similar incidence of cardiovascular, sedation, and infusion site-related adverse events compared to IVPB and resulted in a significant reduction in time to first-dose administration. Intravenous push levetiracetam in doses as high as 4000 mg may be considered safe with appropriate monitoring.

Evaluation of Cost, Workflow, and Safety of Implementing a Vial Transfer Device for Ready-to-Mix Drugs at an Academic Medical Center.

OBJECTIVE: To evaluate the cost, workflow, and safety of implementing a vial transfer device system. METHODS: In this retrospective analysis, pharmacy systems and electronic health record reports identified high-volume and high-cost medications prepared by a Vial2Bag® (V2B) system from July 2017 to June 2018. The major outcome was the extrapolated yearly cost avoidance (EYCA) from utilization of a V2B system, calculated by subtracting total costs of the V2B system from total cost of ready-to-use products and locally compounded sterile products. Secondary outcomes included a workflow and safety analysis. RESULTS: Implementing a V2B system led to a total EYCA of $2 295 261. A total of 283 209 potential V2B units were available for dispensing from automated dispensing systems and 41 082 yearly sterile product room units were avoided. A 0.02% safety report incidence per V2B administration was calculated at our institution. CONCLUSION: Use of a V2B system resulted in a substantial cost avoidance compared to purchasing commercial products and preparing locally compounded sterile products. The V2B system appears to be a safe addition to further optimize workflow but may require further investigation in prospective analyses.

Vasoactive Agents for Adult Septic Shock: An Update and Review.

PURPOSE: The objective of this article is to discuss the pharmacology, side effects, and clinical application of vasoactive therapy in the management of adult septic shock. SUMMARY: Sepsis is one of the most common reasons for admission to an intensive care unit with the incidence estimated to be greater than 750 000 cases per year in the United States. Clinicians should understand the basic pharmacology of available vasoactive agents to allow for routine and complex management of septic shock. CONCLUSION: While advances in research, identification, and early implementation of best practices for the treatment of sepsis has reduced mortality, rates remain high. Vasopressors and inotropes remain part of the core therapeutic modalities of sepsis management. Norepinephrine is the first-line vasopressor of choice for septic shock, though secondary vasopressors can be used depending on the patient's circumstances.

Incidence of propofol-related infusion syndrome in critically ill adults: a prospective, multicenter study.

INTRODUCTION: While propofol is associated with an infusion syndrome (PRIS) that may cause death, the incidence of PRIS is unknown. Determining the incidence of PRIS and the frequency of PRIS-related clinical manifestations are key steps prior to the completion of any controlled studies investigating PRIS. This prospective, multicenter study sought to determine the incidence of PRIS and PRIS-related clinical manifestations in a large cohort of critically ill adults prescribed propofol. METHODS: Critically ill adults from 11 academic medical centers administered an infusion of propofol for [>or=] 24 hours were monitored at baseline and then on a daily basis until propofol was discontinued for the presence of 11 different PRIS-associated clinical manifestations and risk factors derived from 83 published case reports of PRIS. RESULTS: Among 1017 patients [medical (35%), neurosurgical (25%)], PRIS (defined as metabolic acidosis plus cardiac dysfunction and [>or=] 1 of: rhabdomyolysis, hypertriglyceridemia or renal failure occurring after the start of propofol therapy) developed in 11 (1.1%) patients an average of 3 (1-6) [median (range)] days after the start of propofol. While most (91%) of the patients who developed PRIS were receiving a vasopressor (80% initiated after the start of propofol therapy), few received a propofol dose >83 mcg/kg/min (18%) or died (18%). Compared to the 1006 patients who did not develop PRIS, the APACHE II score (25 +/- 6 vs 20 +/- 7, P = 0.01) was greater in patients with PRIS but both the duration of propofol use (P = 0.43) and ICU length of stay (P = 0.82) were similar. CONCLUSIONS: Despite using a conservative definition for PRIS, and only considering new-onset PRIS clinical manifestations, the incidence of PRIS slightly exceeds 1%. Future controlled studies focusing on evaluating whether propofol manifests the derangements of critical illness more frequently than other sedatives will need to be large. These studies should also investigate the mechanism(s) and risk factors for PRIS.

"Inactive" ingredients in oral medications.

Oral forms of medications contain "inactive" ingredients to enhance their physical properties. Using data analytics, we characterized the abundance and complexity of inactive ingredients in approved medications. A majority of medications contain ingredients that could cause adverse reactions, underscoring the need to maximize the tolerability and safety of medications and their inactive ingredients.

Sedation and analgesia in the intensive care unit: evaluating the role of dexmedetomidine.

PURPOSE: A review highlighting the application of sedatives and analgesics in the intensive care unit (ICU) setting, with a focus on the use of dexmedetomidine, is presented. SUMMARY: Relevant and applicable clinical trials that resulted from a search of the literature from 1966 to July 2006 using key search terms such as dexmedetomidine, intensive care unit, sedation, delirium, and analgesia were evaluated. Many agents have been evaluated in the search of the optimal regimen for sedation and analgesia in the ICU, including opioids, benzodiazepines, propofol, and antipsychotic agents. Dexmedetomidine has demonstrated efficacy as a sedative analgesic on the basis of its ability to lower opioid, benzodiazepine, and propofol requirements in clinical trials. The role of dexmedetomidine in ICU clinical practice is limited because of a lack of mortality and other morbidity endpoints, such as ICU length of stay, hospital length of stay, time to extubation, long-term complications after discharge from the ICU, and delirium. The most commonly reported adverse effects of dexmedetomidine are secondary to its effects as an alpha(2)-receptor agonist and are cardiac in nature. A detailed cost analysis may be warranted to justify the relatively high acquisition cost of dexmedetomidine. CONCLUSION: Dexmedetomidine may be an effective agent for ICU sedation and analgesia. However, the lack of clinically relevant endpoints in trials, the concern about adverse cardiovascular effects, and the relatively high acquisition cost of this drug limit its use to a select number of patients who may benefit from its distinguished mechanism of action.

Evaluation of sedatives, analgesics, and neuromuscular blocking agents in adults receiving extracorporeal membrane oxygenation.

PURPOSE: The objective of this study was to evaluate the use of sedative, analgesic, and neuromuscular blocking agents (NMBAs) in patients undergoing extracorporeal membrane oxygenation (ECMO) support. MATERIALS AND METHODS: This was a 2-year, prospective, observational study of adult intensive care unit patients on ECMO support for more than 48hours. RESULTS: We analyzed 32 patients, including 15 receiving VA (venoarterial) ECMO and 17 VV (venovenous) ECMO. The median daily dose of benzodiazepines (midazolam equivalents) was 24mg, and the median daily dose of opioids (fentanyl equivalents) was 3875 µg. There was a moderate negative correlation between the day of ECMO and the median daily benzodiazepine dose (r=-0.5515) and a very weak negative correlation for the median daily opioid dose (r=-0.0053). On average, patients were sedated to Richmond Agitation Sedation Scale scores between 0 and -1. Continuous infusions of opioids, benzodiazepines, propofol, dexmedetomidine, and NMBAs were administered on 404 (85.1%), 199 (41.9%), 95 (20%), 32 (6.7%), and 60 (12.6%) ECMO days, respectively. Patients in the VA arm received a continuous infusion opioid (96.4% vs 81.6% days; P<.001) and benzodiazepine (58.2% vs 37.0% days; P<.001) more frequently. CONCLUSIONS: Patients received relatively low doses of sedatives and analgesics while at a light level of sedation on average. Patients rarely required neuromuscular blockade.

Barriers to glucose control in the intensive care unit.

Despite published evidence supporting glycemic control in critically ill patients, achieving euglycemia remains a problem in the intensive care units (ICUs) of many institutions. Clinicians seeking to implement the findings of published evidence in their practice face many potential barriers that make euglycemia difficult to achieve in patients in the ICU. Developing a comprehensive understanding of the many barriers to ICU glucose control can aide clinicians in attempting to change practice and improve patient outcomes. Barriers to ICU glucose control include the role of different health professionals in glucose management, communication among health care professionals, guidelines, protocols, ICU culture, fear of hypoglycemia, glucose monitoring, education, systems analysis, health care resources, nutritional needs, and drug utilization. By ensuring compliance, changing ICU culture, developing guidelines and protocols, and incorporating a multidisciplinary approach, clinicians can achieve glycemic control in the critically ill population and improve patient outcomes.

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.

Pathophysiology, assessment, and management of pain in critically ill adults.

PURPOSE: The pathophysiology of pain in critically ill patients, the role of pain assessment in optimal pain management, and pharmacologic and nonpharmacologic strategies for pain prevention and treatment are reviewed. SUMMARY: There are many short- and long-term consequences of inadequately treated pain, including hyperglycemia, insulin resistance, an increased risk of infection, decreased patient comfort and satisfaction, and the development of chronic pain. Clinicians should have an understanding of the basic physiology of pain and the patient populations that are affected. Pain should be assessed using validated pain scales that are appropriate for the patient's communication status. Opioids are the cornerstone of pain treatment. The use of opioids, administered via bolus dosing or continuous infusion, should be guided by patient-specific goals of care in order to avoid adverse events. A multimodal approach to pain management, including the use of regional analgesia, may improve patient outcomes and decrease opioid-related adverse events, though there are limited relevant data in adult critically ill patient populations. Nonpharmacologic strategies have been shown to be effective adjuncts to pharmacologic regimens that can improve patient-reported pain intensity and reduce analgesic requirements. Analgesic regimens need to take into account patient-specific factors and be closely monitored for safety and efficacy. CONCLUSION: Acute pain management in the critically ill is a largely underassessed and undertreated area of critical care. Opioids are the cornerstone of treatment, though a multimodal approach may improve patient outcomes and decrease opioid-related adverse events.

Evaluation of glucose management during therapeutic hypothermia at a Tertiary Academic Medical Center.

STUDY AIM: Alterations in metabolic function during therapeutic hypothermia (TH) decrease responsiveness to insulin and increase the risk of hyperglycemia. Glycemic control is associated with improved outcomes in selected patients; however, glycemic management strategies during TH are not defined. The objective of this analysis was to evaluate the glycemic metrics and IV insulin administration in critically ill patients during the cooling and rewarming phases of TH. METHODS: Data from 37 patients who received at least 6h of therapeutic hypothermia for cardiac arrest between January 2007 and January 2010 were retrospectively evaluated, 14 (37.8%) of whom had diabetes. RESULTS: The mean blood glucose was 9.16±3.22mmol/L and 6.54±2.45mmol/L; p<0.01 during cooling and rewarming, respectively. Twelve (32.4%) patients experienced at least one hypoglycemic event, defined as a blood glucose <4mmol/L. Nineteen (51.4%) patients experienced at least one hyperglycemic event, defined as a blood glucose >11.11mmol/L and 15 (40.5%) patients received IV insulin therapy. Patients on IV insulin had a higher incidence of diabetes (9 vs. 5; p<0.05), higher admission blood glucose (13.89±6.13 vs. 11.03±4.65mmol/L; p=0.11), and a higher incidence of hyperglycemia (14 vs. 2; p<0.01) and hypoglycemia (8 vs. 4; p<0.05). Of the patients on IV insulin, mean insulin requirements during cooling and rewarming were 15.2±16.1 and 7±12.5units/h, respectively. CONCLUSION: TH is commonly associated with hyperglycemia, hypoglycemia, and the use of IV insulin therapy. Further research is needed to determine optimal glycemic management strategies to prevent hyper- and hypoglycemia in patients during the different phases of TH.