Small volume vacuum phlebotomy tubes: a controlled before-and-after study of a patient blood management initiative in an Australian adult intensive care unit.

BACKGROUND: Patients admitted to intensive care units (ICUs) undergo multiple blood tests. Small volume vacuum phlebotomy tubes (SVTs) provide an important blood conservation measure. SVTs reduce summative blood loss and may reduce odds of transfusion. We aimed to determine whether low volume blood sampling using SVTs for routine diagnostic purposes translates to decreased fall in haemoglobin concentration, and examine downstream effects on anaemia and need for transfusion during ICU admission. STUDY DESIGN AND METHODS: A single-centre, controlled before-and-after study, evaluating a unit-wide changeover from conventional volume vacuum phlebotomy tubes (CVTs) to SVTs on April 2015. All ICU patients admitted for > 48 hours during the 12 months before and after the intervention were included in multivariate and univariate analysis. Groups were stratified into short admissions (2-7 days) and long admissions (> 7 days). RESULTS: A total of 318 patients were analysed. For short admissions, SVTs decreased fall in haemoglobin concentration (unstandardized coefficient, -6.7; P = 0.001) and episodes of severe anaemia (odds ratio, 0.37, P = 0.02). There were no changes to haemoglobin concentration in long admissions. No effects on need for transfusion were observed (short admissions, P = 0.05; long admissions, P = 0.11). SVTs reduced daily sampling volumes by 50% with no increase in laboratory error (short admissions, P = 0.61; long admissions, P = 0.98). A moderate correlation existed between blood draws and fall in haemoglobin concentration (short admissions, r = 0.5; long admissions, r = 0.32). CONCLUSION: SVTs reduce sampling volume without increasing laboratory error. Follow-on effects include reduced fall in haemoglobin concentration and severe anaemia. These correlations are absent in long admissions.

Incidence and cost of stress ulcer prophylaxis after discharge from the intensive care unit: a retrospective study.

OBJECTIVE: To describe current patterns in initiation and cessation of proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) in intensive care units, and to assess the costs associated with inappropriate (non-evidence-based) SUP. DESIGN, SETTING AND PARTICIPANTS: Retrospective observational study in five ICUs in Western Australia. We assessed the medical records of consecutive patients admitted to the ICUs between September 2013 and January 2015. Patients aged < 18 years were excluded. RESULTS: We included 531 patients in the study. Of the 184 patients in whom PPIs were initiated for SUP in the ICU, 90 (48.9%) were still taking the therapy at the time of discharge from hospital. A documented indication for ongoing therapy was present in only nine patients (10%). We assumed a 10-year life expectancy after ICU discharge and that most patients continued taking a PPI, and calculated an additional cost of $180.20 per patient admitted to the ICU. This was based only on unnecessary PPI costs (ignoring costs of managing additional adverse events). The direct cumulative annual cost to the WA health system of PPIs continued unnecessarily for patients at discharge from hospital is estimated to be $250 800 for each year they continue to receive them. CONCLUSION: A substantial proportion of patients prescribed SUP in the ICU continue receiving this therapy at hospital discharge despite no clear indication. In addition to potential adverse clinical effects, this is associated with major direct and indirect cost implications.

Paradoxical and severe hypotension in response to adrenaline infusions in massive quetiapine overdose.

Atypical antipsychotics (quetiapine, olanzapine, risperidone and clozapine) are increasingly prescribed in Australia, and emergency departments report growing rates of overdose of these agents. As these drugs are comparatively new, the spectrum of toxicity may be unfamiliar to critical care physicians. Severe hypotension is a recognised consequence of quetiapine poisoning. We describe three patients with massive quetiapine overdose who developed significant hypotension resistant to fluid resuscitation. In each case, blood pressure fell dramatically after commencement of adrenaline infusions. Haemodynamic stability was restored when noradrenaline was substituted for adrenaline. The pharmacodynamics of quetiapine and the literature on overdose are reviewed. We present these cases to broaden the knowledge of physicians treating quetiapine overdose and to publicise the potential deleterious interaction with adrenaline. We recommend use of noradrenaline in preference to adrenaline in pharmacological management of shock in these patients.