Rapid administration of undiluted loading doses of levetiracetam.

OBJECTIVE: Rapid administration of antiseizure medications is a critical concept in the treatment of status epilepticus. Although undiluted levetiracetam (LEV) doses of up to 2500 mg have been evaluated, minimal data exist to support the safety of loading doses up to 4500 mg. This study will evaluate intravenous (IV) push administration of undiluted LEV from 2500 to 4500 mg for safety outcomes as well as tolerability. METHODS: This is a retrospective, observational, cohort analysis of adult patients who received at least one loading dose of undiluted IV push LEV from October 15, 2019, to April 30, 2022, at a large academic medical center in Phoenix, Arizona. Relevant outcomes include the safety and tolerability of rapid administration of undiluted LEV at higher loading doses. RESULTS: We evaluated 518 loading doses in 518 unique patients included during the study period. LEV was a new medication for witnessed or suspected seizures in 80.3% of patients, with 31.2% having a documented history of epilepsy or seizure disorder. At the time of LEV administration, 52.9% of patients were on a general medicine floor, 34.3% were in the intensive care unit, and 12.7% were in the emergency department. The median loading dose of LEV was 3600 mg (3000-4000 mg), with 4000 mg being the most common loading dose given. Peripheral IV lines were documented as the only available line in 78.6% of patients for loading dose administration. No adverse events associated with LEV administration were documented. SIGNIFICANCE: Rapid IV administration of undiluted doses of LEV is both safe and tolerable in loading doses of 2500-4500 mg, allowing for rapid drug administration in the setting of status epilepticus.

Rapid administration of undiluted intravenous levetiracetam.

OBJECTIVE: Operational delays have the potential to lead to suboptimal time to seizure control during status epilepticus. Levetiracetam (LEV) is an urgent control antiepileptic medication that offers relative lack of adverse effects and ease of monitoring. There are limited data published demonstrating safety and tolerability of undiluted rapid intravenous (IV) push of LEV in doses of 1000 mg or less. The purpose of this study was to evaluate the safety of IV push administration of LEV doses up to 4500 mg. METHODS: This is a retrospective, observational, cohort analysis of adult patients who received at least one dose of undiluted IV push LEV from October 15, 2019 to August 31, 2020 at a large academic medical center in Phoenix, Arizona. Outcomes of interest include safety and tolerability of rapid administration of undiluted LEV. RESULTS: There were 953 unique patients included during the study period. LEV was a new medication for witnessed or suspected seizure in 51.9% of patients, and 40.7% of patients had a documented history of epilepsy or seizure disorder. There were 8561 undiluted IV push LEV doses administered, 3674 (42.9%) of which were greater than 1000 mg. LEV was administered most often through a peripheral IV (79.1%). There were 12 patients with documented adverse drug events during the study period, with four potentially directly related to IV push LEV administration. These events were limited to local injection site reactions and included redness, burning, and loss of a peripheral IV line. SIGNIFICANCE: Rapid IV administration of undiluted LEV is both safe and tolerable in doses of up to 4500 mg, allowing for rapid drug administration, which is paramount during neurologic emergencies.

Pentobarbital coma for management of intracranial hypertension following traumatic brain injury: Lack of early response to treatment portends poor outcomes.

INTRODUCTION: Traumatic brain injury (TBI) results in the death of over 50,000 and the permanent disability of 80,000 individuals annually in the United States. Much of the permanent disability is the result of secondary brain injury from intracranial hypertension (ICH). Pentobarbital coma is often instituted following the failure of osmotic interventions and sedation to control intracranial pressure (ICP). The goal of this study was to evaluate the efficacy of pentobarbital coma with respect to ICP management and long-term functional outcome. METHODS: Traumatic brain injury patients who underwent pentobarbital coma at a level 1 trauma center between 2014 and 2021 were identified. Patient demographics, injury characteristics, Glasgow Coma Scale (GCS) scores, intracranial pressures (ICPs), and outcomes were obtained from the trauma registry as well as inpatient and outpatient medical records. The proportion of ICPs below 20 for each hospitalized patient-day was calculated. The primary outcome measured was GCS score at the last follow-up visit. RESULTS: 25 patients were identified, and the majority were male (n â€‹= â€‹23, 92%) with an average age of 30.0 years â€‹± â€‹12.9 and median injury severity score of 30 (21.5-33.5). ICPs were monitored for all patients with a median of 464 (326-1034) measurements. The average hospital stay was 16.9 days â€‹± â€‹11.5 and intensive care stay was 16.9 â€‹± â€‹10.8 days. 9 (36.0%) patients survived to hospital discharge. Mean follow-up time in months was 36.9 â€‹± â€‹28.0 (min-max 3-80). 7 of the 9 surviving patients presented as GCS 15 on follow-up and the remaining were both GCS 9. Patients presenting at last follow-up with GCS 15 had a significantly higher proportion of controlled ICPs throughout their hospitalization compared to patients who expired or with follow-up GCS <15 (GCS 15: 88% â€‹± â€‹10% vs. GCS <15 or dead: 68% â€‹± â€‹22%, P â€‹= â€‹0.006). A comparison of the daily proportion of controlled ICPs by group revealed negligible differences prior to pentobarbital initiation. Groups diverged nearly immediately upon pentobarbital coma initiation with a higher proportion of controlled ICPs for patients with follow-up GCS of 15. CONCLUSION: Patients that do not have an immediate response to pentobarbital coma therapy for ICH universally had poor outcomes. Alternative therapy or earlier palliation should be considered for such patients. In contrast, patients whose ICPs responded quickly to pentobarbital had excellent long-term outcomes.

The Declining Use of Opioids at a Level 1 Trauma Center.

BACKGROUND: The epidemic of opioid-related overdose in the United States prompted a public health response that included implementation of opioid prescribing guidelines and restrictions. Such directives, however, were not applicable to hospitalized trauma patients. We hypothesized that although prescribing mandates did not apply to hospitalized trauma patients, inpatient opioid administration had nonetheless decreased over time. METHODS: Opioid administrations for each patient admitted to a level I trauma center between January 1, 2016 and July 31, 2020 were converted into oral morphine milligram equivalents (MMEs) and summed at the patient level to obtain a total amount of MME administered for each hospitalization. MME was natural log transformed to achieve a normal distribution. General linear models were then used to determine the average patient MME administered by year. Patients who were pregnant or mechanically ventilated during their hospitalization were excluded. RESULTS: Six thousand five hundred ninety-four patients were included in our analysis, of which 5037 (76.4%) were treated with opioids during their hospitalization (morphine 72.7%, oxycodone 9.6%, tramadol 10.2%, fentanyl 5.5%, and hydromorphone 2.1%). The percentage of patients administered an opioid decreased stepwise from 79.3% in 2016 to 71.4% in 2020 (P < .001). For patients administered opioids, a 28% decrease in average total MME from 2016 to 2020 (P < .001) was observed. When stratified by ISS (<9, 9-15, 16+), average total MME consistently trended downward over time. CONCLUSION: Our trauma center realized a stepwise reduction in opioid administration in the absence of rules or restrictions surrounding in-hospital opioid prescribing.

Can we really make catheter-associated urinary tract infections a never event? A level 1 trauma center's experience with prophylactic antibiotic bladder irrigation.

BACKGROUND: Hospital-acquired catheter-associated urinary tract infections (CAUTIs) are considered "never events" and are reportable to Centers for Medicare and Medicaid Services as a quality indicator. Despite protocols to determine appropriate removal of urinary catheters as soon as possible, severely injured trauma patients often require prolonged catheterization during ongoing resuscitation or develop retention requiring catheter replacement, exposing them to risk for CAUTI. We evaluated whether prophylactic antibiotic bladder irrigation reduces the incidence of CAUTI in critically ill trauma patients. METHODS: As a quality initiative, gentamicin bladder catheter irrigation (GBCI) was performed on a level 1 trauma center's patients at risk for CAUTI in 2021, defined by indwelling Foley catheterization for a minimum of 3 days. We then conducted a retrospective study using a comparison cohort of 2020 admissions as the control group. Catheter-associated urinary tract infection rates per 1,000 catheterized days were compared between these two groups. Patients with traumatic bladder injuries were excluded. RESULTS: Our cohort included 342 patients with a median hospitalization of 11 (7-17) days, Injury Severity Score of 17 (10-26), and 6 (4-11) days of catheterization. Eighty-six patients, catheterized for 939 at-risk days, received twice-daily GBCI compared with 256, catheterized for 2,114 at-risk days, who did not. Zero patients in the GBCI group versus nine patients in the control group developed CAUTI. The incidence of CAUTI in the GBCI group was significantly less than in the control group (0/1,000 vs. 4.3/1,000 catheterized days, p = 0.018). CONCLUSION: Prophylactic antibiotic bladder irrigation was associated with a zero incidence of CAUTI among trauma patients at risk for CAUTI. This practice holds promise as effective infection prophylaxis for such patients. The optimal duration and frequency of irrigation remain to be determined. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Comparison of shock reversal with high or low dose hydrocortisone in intensive care unit patients with septic shock: A retrospective cohort study.

PURPOSE: This study aims to describe differences in shock reversal between hydrocortisone 200 mg and 300 mg per day dosing regimens in patients with septic shock. METHODS: This is a multi-center retrospective study including patients admitted to intensive care units with septic shock receiving vasopressors and hydrocortisone between 2013 and 2018. We compared patients who received low dose hydrocortisone (50 mg every 6 h) versus high dose hydrocortisone (100 mg every 8 h) on the primary outcome of shock reversal. RESULTS: 319 patients (low dose group, n = 134 and high dose group, n = 185) were included. In the multivariate regression model, high-dose steroids were associated with shock reversal [OR (95% CI) = 2.278 (1.063-4.880), p = 0.034]. This was not confirmed in the propensity score matched analysis [OR (95% CI) =2.202 (0.892-5.437), p = 0.087]. High dose steroids were associated with a lower need for additional vasopressor therapy (22% vs. 34%, p = 0.012) and lower shock recurrence (6.7% vs. 16%, p = 0.013), which was confirmed with propensity score matching. CONCLUSIONS: Low and high dose hydrocortisone have similar rates of shock reversal in septic shock patients. Hydrocortisone 100 mg every 8 h may reduce rates of recurrence of shock and reduce the need for additional vasopressors.