Parenteral Nutrition Total Energy Dosing and Risk for Central Line-Associated Bloodstream Infection: A Case-Control Study.

Background: Central line-associated bloodstream infection (CLABSI) is a complication of central venous access devices used for parenteral nutrition (PN). PN overfeeding is associated with increased adverse effects; however, whether risk for CLABSI is influenced by PN dosing is uncertain. Objective: The purpose of the study was to assess differences in CLABSI risk associated with recommended total energy dosing in hospitalized adult patients receiving PN. Methods: A case-control study was conducted in a single United States Veterans Health Administration health system to assess the potential CLABSI risk factor of weight-based PN kilocalorie dosing. Hospitalized adult patients who developed CLABSI while receiving PN were identified and compared to a control group of patients who did not develop CLABSI. The exposures evaluated were overfeeding, defined as greater than 30 kcal/kg/day, and underfeeding, defined as less than 20 kcal/kg/day. Results: Twenty-nine cases of CLABSI were identified and compared with 274 controls. Odds of CLABSI were significantly higher in patients receiving greater than 30 kcal/kg/day (OR, 3.63; 95% CI, 1.55-8.48; P < .01). No significant difference in odds was found for patients receiving less than 20 kcal/kg/day (OR, .74; 95% CI, 0.21-2.57; P = .63). Conclusion: Increased risk for CLABSI in hospitalized adult patients receiving PN was found to be associated with overfeeding, but not underfeeding. These results may aid clinicians in the management of patients requiring PN and in the generation of hypothesis for future investigations.

Clinical Pharmacy Specialist Collaborative Management and Prescription of Diabetes Medications with Cardiovascular Benefit.

BACKGROUND: Involvement of Clinical Pharmacy Specialists (CPS) in the care of patients with diabetes mellitus (DM) has been demonstrated to be beneficial. Whether this positive impact applies to increased use of cardiovascular risk-reducing medications is less well established. OBJECTIVE: To determine the association of CPS co-management on the prescription of diabetes medications with proven cardiovascular benefits for patients with DM and established cardiovascular disease in the primary care setting. METHODS: This retrospective cohort study evaluated patients in a Veterans Affairs health-system in primary care settings from February 1, 2019, through January 31, 2020. Patients were included if they had type 2 DM treated with at least one medication and had CVD. Patients were grouped into two cohorts for comparison, those with CPS co-management and those without. The primary outcome was the proportion of patients in each group with new prescriptions for empagliflozin or liraglutide initiated during the study timeframe. RESULTS: In total, 8058 patients were found eligible for inclusion in the study. Clinical co-management by a CPS was provided to 2099 patients. Study medications were prescribed, approved, and initiated in 596 patients during the study period, including 391 (18.6%) in the CPS group and 205 (3.4%) in the non-CPS group (P < .001). CONCLUSION: This study showed CPS involvement is associated with increased prescribing of diabetes medications with proven cardiovascular benefits.

Risk Factors for Hypoglycemia During Treatment of Hyperglycemic Crises.

Objective: Diabetic ketoacidosis and hyperosmolar hyperglycemic state are life-threatening hyperglycemic crises often requiring intensive care unit (ICU) management. Treatment includes intravenous (IV) insulin with a transition to subcutaneous (SC) insulin upon resolution. Hypoglycemia is a common complication associated with treatment of hyperglycemic crises, but risk factors have not been well established. This study aimed to assess risk factors associated with hypoglycemia during treatment for hyperglycemic crises. Methods: This case-control study included ICU patients admitted with hyperglycemic crises at a single Veterans Affairs health system from 1 January 2013 to 31 March 2020. Patients who developed hypoglycemia during insulin treatment were compared with a control group. Odds of hypoglycemia were assessed based on risk factors, including BMI, comorbidities, and type of SC insulin used. Results: Of the 216 cases of hyperglycemic crises included, hypoglycemia occurred in 61 cases (44 on SC insulin, 11 on IV insulin, and 6 on both). Odds for hypoglycemia were significantly higher for underweight patients (odds ratio 4.52 [95% CI 1.05-19.55]), type 1 diabetes (4.02 [2.09-7.73]), chronic kidney disease (1.94 [1.05-3.57]), those resumed on the exact chronic SC insulin regimen following resolution (2.91 [1.06-7.95]), and patients who received NPH versus glargine insulin (5.13 [1.54-17.06]). No significant differences were seen in the other evaluated variables. Conclusion: This study found several factors associated with hypoglycemia during hyperglycemic crises treatment, many of which are not addressed in consensus statement recommendations. These findings may help ICU clinicians prevent complications related to hyperglycemic crisis management and generate hypotheses for future studies.

Coronavirus Disease 2019-Related Extensive Thrombosis in a Patient Receiving Therapeutic Anticoagulation With Dabigatran.

Introduction and Objective: Coronavirus disease 2019 (COVID-19) is associated with respiratory failure and a hypercoagulable state. Studies have shown the use of oral anticoagulants, specifically dabigatran, can significantly decrease mortality from COVID-19. Dabigatran is an oral direct thrombin inhibitor commonly used for nonvalvular atrial fibrillation and for the treatment or prevention of venous thromboembolism. The association of COVID-19-related extensive thrombosis while receiving full therapeutic anticoagulation with dabigatran has not been well-established in current literature. Case Report: We present a 73-year-old male patient with a history of persistent atrial fibrillation anticoagulated with dabigatran presenting with an active COVID-19 infection admitted to the intensive care unit. On hospital day 7, he developed extensive arterial and venous thromboembolisms. To our knowledge, this is the first published case of COVID-19-related extensive thrombosis while receiving full therapeutic anticoagulation with dabigatran. Discussion: Guidelines recommend prophylactic or therapeutic-dose anticoagulation with unfractionated heparin or low-molecular weight heparin for all patients if no contraindications exist; however, recommendations for the use of therapeutic oral anticoagulants have not been well established. Further studies are warranted to establish appropriate use of oral anticoagulants in the setting of COVID-19. Conclusion: Evidence from this report suggests clinicians should closely monitor patients at risk for hypercoagulability regardless of the anticoagulation therapy the patient may be receiving. Additionally, evidence from this case suggests a possible inferiority in the anticoagulation ability of dabigatran in patients with active COVID-19.

Severe hyperglycemia following transition from octreotide to lanreotide in a patient with enterocutaneous fistula receiving parenteral nutrition.

Somatostatin analogues, suchas octreotide and lanreotide, are commonly used in the management of enterocutaneous fistula. We report a case of severe and prolonged hyperglycemia that occurred in a patient after receiving a one-time dose of lanreotide, who had previously been stable on octreotide and did not have a history of diabetes mellitus. Management of the patient's hyperglycemia while receiving parenteral nutrition is described.

Comparison of Adverse Events With Vancomycin Diluted in Normal Saline vs Dextrose 5.

BACKGROUND: IV vancomycin is widely used for infections caused by Gram-positive bacteria; however, nephrotoxicity is commonly associated with its use. Clinical trials have shown an increased incidence of acute kidney injury (AKI) using normal saline (NS) for fluid resuscitation. This study evaluated differences in AKI and other patient outcomes associated with vancomycin diluted in NS compared with dextrose 5% in water (D5W). METHODS: This retrospective cohort study conducted at a single US Department of Veterans Affairs hospital included veterans who received vancomycin for at least 48 hours between July 1, 2015 and June 30, 2020. This study compared adverse events (AEs) of patients receiving vancomycin diluted in either NS or D5W. The primary outcome was incidence of AKI. Secondary outcomes included incidence of hyperglycemia, hyperchloremia, hypernatremia, metabolic acidosis, in-hospital mortality, and 30-day posthospitalization mortality. RESULTS: The study included 123 patients in each group (N = 246). The percentage of AKI was 22.8% in the D5W group compared with 14.6% the NS group (P = .14). There were no significant differences in the rates of hyperglycemia, hyperchloremia, hypernatremia, or metabolic acidosis between the 2 groups. In-hospital mortality and 30-day posthospitalization mortality were similar between the groups. CONCLUSIONS: This study comparing the AEs of IV vancomycin diluted in NS and D5W found no significant differences in AKI or other patient outcomes. These study results do not suggest the crystalloid used to dilute IV vancomycin is associated with differences in nephrotoxicity or other relevant AEs.

A Comparison Between Cefepime and Piperacillin-Tazobactam in the Management of Septic Shock.

Introduction Septic shock is defined as a dysregulated host response to infection characterized by hemodynamic instability. Concern for the increased risk of acute kidney injury (AKI) with piperacillin-tazobactam in combination with vancomycin may prompt more use of alternative broad-spectrum antipseudomonal beta-lactam antibiotics, such as cefepime. This study assessed whether cefepime was associated with improved outcomes compared to piperacillin-tazobactam in patients with septic shock. Methods This retrospective cohort study included veterans treated for septic shock between September 1, 2008, and August 31, 2018. This study compared cefepime and piperacillin-tazobactam as initial antibiotic management for septic shock. Outcomes included AKI, Clostridioides difficile infection (CDI), hospital length of stay, intensive care unit mortality, and mortality within 30 days of hospitalization. Results In total, 240 patients were included in this study (120 in each cohort). The proportion of AKI was 60.0% in the piperacillin-tazobactam cohort compared to 58.3% in the cefepime cohort (p = 0.90). Mortality was significantly higher in the cefepime cohort. There were no significant differences in CDI or hospital length of stay. Conclusion The results of this study do not suggest that the use of the antipseudomonal beta-lactam antibiotic used in the initial management of septic shock is associated with differences in the AKI or CDI. The higher mortality observed with cefepime may warrant further investigation.

Evaluation of Acute Postoperative Pain Management During an Injectable Opioid Shortage.

BACKGROUND: Drug product shortages, including injectable opioids, are common and have the potential to adversely affect patient care. OBJECTIVE: To evaluate the impact of an injectable opioid shortage for hospitalized adult patients in the acute postoperative setting. METHODS: A single-center, retrospective cohort study of noncritically ill hospitalized, postoperative patients requiring opioids for acute pain management was conducted. Patient cohorts were compared preshortage and postshortage for proportion of total intravenous (IV) opioids used, proportions of specific pain medications used, subjective pain scores, 30-day mortality, respiratory depression, need for opioid reversal, hospital length of stay, and opioid equivalent doses. RESULTS: A total of 275 patients were included, 130 patients in the preshortage cohort and 145 in the postshortage cohort. The proportion of total IV opioid doses was lower in the postshortage cohort versus the preshortage cohort (16.6% vs 20.5%; P < 0.01). Specific medications used were significantly different between the cohorts. The proportion of severe pain scores was lower in the postshortage cohort versus the preshortage cohort (55.6% vs 58.5%; P = 0.04). No significant differences were seen in the overall proportion of nonopioid analgesic use, 30-day mortality, respiratory depression, need for emergent opioid reversal, hospital length of stay, or opioid equivalent doses between cohorts. CONCLUSION AND RELEVANCE: In hospitalized, postoperative adults, an injectable opioid shortage was associated with significant decreases in IV opioid use and severe pain scores but no significant differences in nonopioid analgesic use, safety outcomes, or opioid equivalent doses. These results may assist clinicians in developing strategies for injectable opioid shortages and generating hypotheses for future studies.

Impact of a Clinical Decision-Support Tool on Venous Thromboembolism Prophylaxis in Acutely Ill Medical Patients.

Background: Adherence to guideline-based venous thromboembolism (VTE) prophylaxis recommendations is often inadequate. Effective improvement strategies are needed. Objective: The purpose of this quality improvement initiative was to increase use of the facility's preferred pharmacologic VTE prophylaxis, reduce unnecessary VTE prophylaxis use, and reduce use of pharmacologic VTE prophylaxis in high bleeding risk patients, in accordance with guideline-based recommendations. Methods: Clinical pharmacists spearheaded the development and implementation of a clinical decision-support tool (CDST) integrated within a Veterans Health Administration electronic health record (EHR). The CDST focused on VTE prophylaxis in acutely ill medical patients and guided prescribers to guideline-based recommendations. Following review and approval, the CDST underwent activation in the EHR. A subsequent intervention occurred, year 2 post-intervention, which embedded this CDST into the EHR admission process and admission menus. A drug message was added in the EHR to alert prescribers that low-molecular-weight heparin was the preferred agent. Measures were evaluated pre-intervention, year 1 post-intervention, and year 2 post-intervention. Results: After intervention, there were statistically significant increases in the proportion of patients receiving the facility's preferred pharmacologic VTE prophylaxis agent, enoxaparin, and a statistically significant decrease in the proportion of unwarranted VTE prophylaxis. The proportion of inappropriate pharmacologic VTE prophylaxis in high bleeding risk patients decreased, but this result did not reach statistical significance. Conclusion: The improvements observed suggest the beneficial role of CDSTs integrated into the EHR to increase adherence to guideline-based VTE prophylaxis recommendations.

Intravenous Insulin Infusion Protocol Compared With Subcutaneous Insulin for the Management of Hyperglycemia in Critically Ill Adults.

Background: The use of an intravenous insulin infusion protocol (IIP) is recommended for management of hyperglycemia in the intensive care unit (ICU); however, limited evidence of comparison has been made with subcutaneous (SC) insulin regimens. Objective: This study aims to evaluate the safety and effectiveness of an IIP compared with SC insulin regimens in an ICU patient sample since the implementation of an IIP using a computerized clinical-decision support tool. Methods: This investigation was a retrospective cohort study of patients who were treated for hyperglycemia while admitted to any of the ICUs at a Veterans Affairs Medical Center. Patients who were treated with either an IIP or a scheduled SC insulin regimen between May 1, 2015, and May 25, 2016, were included for evaluation. Results: Blood glucose (BG) was within the normoglycemia range (70-180 mg/dL) for 63.0% of the measurements in patients treated with an IIP (n = 171) compared with 45.7% in those treated with SC insulin regimens (n = 121; P < 0.01). Overall, patients managed with an IIP had a lower proportion of hypoglycemic BG measurements (1.2% vs 2.1%, P < 0.01), a lower proportion of hyperglycemic BG measurements (35.8% vs 52.2%, P < 0.01), and a lower mean BG (172.4 vs 194.3 mg/dL, P < 0.01). Conclusion and Relevance: The results of this study suggest that an IIP in a sample of adult ICU patients was associated with better BG control and lower occurrence of hypoglycemia compared with SC insulin regimens.

Integration of Around-the-Clock Clinical Pharmacy Specialists Into the Critical Care Team Can Increase Safety of Hyperglycemic Crisis Management.

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve the safety of hyperglycemic crisis management at a Veterans Affairs Medical Center by making clinical pharmacy specialists available to the critical care team 24 hours/day.

Quality improvement initiative to reduce adverse effects associated with parenteral nutrition overfeeding.

OBJECTIVE: Parenteral nutrition (PN) overfeeding is a potential risk factor in the development of infections and other complications including hyperglycaemia, refeeding syndrome and liver dysfunction. This study was conducted to evaluate the impact of a quality improvement initiative to reduce PN overfeeding. DESIGN: Retrospective cohort study of a quality improvement initiative. SETTING: A health system comprised of two US Department of Veterans Affairs medical centres. PATIENTS: Patients receiving PN. INTERVENTIONS: Methods to reduce overfeeding included the use of standardised PN products with lower dextrose to amino acid ratios, reduced use of intravenous lipid emulsion (ILE), and use of adjusted body weights or guideline-recommended predictive equations for energy requirements. MAIN OUTCOME MEASURES: The primary outcome measures were the doses of kilocalories, amino acids and ILE in each cohort. The proportions of patients developing complications before and after the intervention were evaluated. RESULTS: The mean maximum total daily kilocalorie dose was 30.2 kcal/kg/day in the preintervention group (n=86) vs 23.4 kcal/kg/day in the postintervention group (n=62) (p<0.001). More patients in the postintervention group received reduced ILE during the first week of PN therapy compared with the preintervention group (p<0.001). The mean maximum total daily amino acid dose in each group was not significantly different. Significantly fewer cases of central line-associated bloodstream infections, hyperglycaemia and liver dysfunction were observed in the postintervention group. CONCLUSIONS: A quality improvement initiative to reduce PN overfeeding was effective in reducing kilocalorie and ILE doses while maintaining similar amino acid doses. Observed complications were reduced following the intervention.

A Bedside Computerized Decision-Support Tool for Intravenous Insulin Infusion Management in Critically Ill Patients.

Intravenous (IV) insulin infusions using a validated protocol are the recommended method for blood glucose control in critically ill patients. Computerized decision-support tools improve quality over manual paper-based protocols. However, nonproprietary computerized tools targeting the recommended blood glucose range of 140-180 mg/dL are not readily available. A bedside computerized decision-support tool was developed at a US Department of Veterans Affairs health system to assist the nursing staff with the management of patients requiring IV insulin infusion. Initial evaluation showed that the tool was useful in the safe and effective management of an IV insulin infusion protocol for blood glucose control targeting the updated blood glucose range.

Impact of a Pharmacy-Cardiology Collaborative Practice on Dofetilide Safety Monitoring.

BACKGROUND: Limited studies have been published examining dofetilide's postmarketing use and its recommended monitoring. OBJECTIVE: To evaluate the impact of a collaborative pharmacy-cardiology antiarrhythmic drug (AAD) monitoring program on dofetilide monitoring. METHODS: This retrospective cohort study was performed to assess if a novel monitoring program improved compliance with dofetilide-specific monitoring parameters based on the Food and Drug Administration's Risk Evaluation and Mitigation Strategy. RESULTS: A total of 30 patients were included in the analysis. The monitoring parameters evaluated included electrocardiogram, serum potassium, serum magnesium, and kidney function. The primary outcome evaluated was the composite of these dofetilide monitoring parameters obtained in each cohort. In the standard cohort, 245 of 352 (69.6%) monitoring parameters were completed versus 134 of 136 (98.5%) in the intervention group ( P < 0.05). CONCLUSION: A collaborative pharmacy-cardiology AAD monitoring program was associated with a significant improvement in dofetilide monitoring. This improvement could potentially translate into enhanced patient safety outcomes, such as prevention of adverse drug reactions and decreased hospitalizations.

Zinc deficiency in a parenteral nutrition-dependent patient during a parenteral trace element product shortage.

Parenteral nutrition product shortages are common and place vulnerable patients at risk for nutrient deficiencies. This case report describes a parenteral nutrition-dependent patient who was found to have zinc deficiency during a parenteral nutrition product shortage. The management of the patient's zinc deficiency is described.

Clinical experience with ranolazine in a veteran population with chronic stable angina.

BACKGROUND: Efficacy of ranolazine in the treatment of chronic stable angina (CSA) has been established; however, pivotal trials did not require the optimization of conventional antianginal drug therapy (CADT) prior to use in a veteran population. OBJECTIVE: To determine whether ranolazine, when added to optimized doses of CADT, improves angina in a veteran population with CSA and refractory symptoms. METHODS: In an observational retrospective study, 35 patients prescribed ranolazine and having a baseline Seattle Angina Questionnaire (SAQ) administered at a Veterans Affairs medical center in Gainesville, FL, were evaluated. Patients who were prescribed ranolazine by a provider from outside the institution and did not obtain a baseline SAQ were excluded. The primary outcome measure was the change in SAQ scores from baseline to 1 and 3 months after initiation of ranolazine treatment. Secondary measures included clinically significant QTc interval prolongation (>500 msec or an increase of at least 60 msec from baseline), adverse drug reactions, discontinuation rates, and drug-drug interactions. RESULTS: The addition of ranolazine to optimized CADT was associated with improvement in all dimensions of the SAQ scores at 1 and 3 months compared to baseline scores (p < 0.001 for all dimensions). Mean changes in SAQ dimension scores at 1 and 3 months, respectively, were as follows: physical limitation, +9.86 and +11.94; angina stability, +39.29 and +32.69; angina frequency, +26.79 and +25.38; treatment satisfaction, +11.38 and +10.66; and disease perception, +16.85 and +18.59. Improvments in all dimensions, except treatment satisfaction, were clinically significant as defined by set criteria. Of the 7 patients whose ranolazine dosages were increased to 1000 mg twice daily, only 2 patients were able to maintain treatment at that dosage. CONCLUSIONS: Ranolazine added to optimized doses of CADT demonstrated an improvement in angina symptoms when given to a veteran population with persistent CSA.