Comparison of sustained rate control in atrial fibrillation with rapid ventricular rate: Metoprolol vs. Diltiazem.

OBJECTIVE: The objective of this study was to compare sustained rate control with intravenous (IV) diltiazem vs. IV metoprolol in acute treatment of atrial fibrillation (AF) with rapid ventricular rate (RVR) in the emergency department (ED). METHODS: This retrospective chart review at a large, academic medical center identified patients with AF with RVR diagnosis who received IV diltiazem or IV metoprolol in the ED. The primary outcome was sustained rate control defined as heart rate (HR) < 100 beats per minute without need for rescue IV medication for 3 h following initial rate control attainment. Secondary outcomes included time to initial rate control, HR at initial control and 3 h, time to oral dose, admission rates, and safety outcomes. RESULTS: Between January 1, 2016 and November 1, 2018, 51 patients met inclusion criteria (diltiazem n = 32, metoprolol n = 19). No difference in sustained rate control was found (diltiazem 87.5% vs. metoprolol 78.9%, p = 0.45). Time to rate control was significantly shorter with diltiazem compared to metoprolol (15 min vs. 30 min, respectively, p = 0.04). Neither hypotension nor bradycardia were significantly different between groups. CONCLUSIONS: Choice of rate control agent for acute management of AF with RVR did not significantly influence sustained rate control success. Safety outcomes did not differ between treatment groups.

Resource Utilization After Snakebite Severity Score Implementation into Treatment Algorithm of Crotaline Bite.

BACKGROUND: Crotaline envenomation clinical manifestations vary considerably among patients. Current recommendations for treatment with Crotalidae polyvalent immune Fab require assessment of envenomation control. Determining control of envenomation, particularly when patients are evaluated by different providers in separate clinical settings, can be difficult. OBJECTIVE: To determine if a difference in total vials of Crotalidae antivenin therapy exists between pre-protocol and post-Snakebite Severity Score (SSS) protocol. METHODS: Retrospective medical record review at an academic medical and regional Level I trauma center. Resource utilization in patients with a diagnosis of "snakebite" was compared between patients treated pre- and post-SSS protocol implementation. RESULTS: One hundred forty-six patients were included in the evaluation. One hundred twenty-seven (87.0%) patients received antivenin, n = 80 (90.9%) in the pre-protocol group and n = 47 (81.0%) in the post-protocol group. Median total number of antivenin vials per patient was lower in the post-protocol group than the pre-protocol group, 16 (10-24 interquartile range) vs. 12 (10-16 interquartile range), p = 0.006. This decreased utilization correlates to an approximate $13,200 savings per patient. Hospital and intensive care unit length of stay, opioid use, incidence of blood product transfusion, need for surgical intervention, or need for intubation were not different between groups. CONCLUSIONS: A snakebite protocol with SSS utilization to guide antivenin administration results in significantly decreased antivenin therapy in snakebite patients without increase in other health care utilization.

Clinical Pharmacy Discharge Counseling Service and the Impact on Readmission Rates in High-Risk Patients.

Background: A number of patient safety and transition of care initiatives have highlighted the benefits of incorporating a clinical pharmacist in the discharge medication process. Numerous studies have identified the prominent and consequential role of medication therapy errors occurring at hospital discharge. Objective: The objective of this study was to evaluate the effects of a discharge medication counseling service on readmission rates, emergency department (ED) visits, and days to first readmission or ED visit in patients deemed high risk for hospital readmission. Methods: A retrospective chart review was conducted from October 2014 to December 2014 in adult patients admitted to a general medicine unit and identified as being at high risk for readmission. Endpoints were compared between patients who received discharge counseling (study group) and those who did not (control group). Results: Eighty-nine high-risk patient charts were reviewed. Forty-four patients were in the study group and 45 patients were in the control group. There were no differences between the baseline characteristics of both groups. There were no differences between the study and control groups in 30-day readmission rates (18.2% vs 26.7%; P = .45) and in 30-day ED visits (4.6% vs 11.1%; P = .43). The number of days to first readmission or ED visit between the study and control groups was 22 versus 12 (P = .26). Conclusion: Although no statistical difference was found between groups in this study, integration of a clinical pharmacist as part of an interdisciplinary approach in the discharge medication process resulted in numerical improvements in outcomes. Additional investigation is warranted to further highlight the potential benefits of this service.

Effect of Body Weight on Hemodynamic Response in Patients Receiving Fixed-Dose Vasopressin for Septic Shock.

BACKGROUND: Fixed-dose vasopressin is an adjunctive therapy to norepinephrine (NE) to raise mean arterial pressure (MAP) and decrease NE requirements in patients with septic shock. It is unknown if weight affects hemodynamic response to vasopressin or if a weight-based vasopressin strategy is superior to fixed dosing. OBJECTIVE: The primary objective was to evaluate effect of body weight on response to vasopressin as measured by change in MAP 1 hour post-vasopressin initiation. METHODS: A single-center, retrospective study was performed in patients with septic shock. Baseline characteristics, catecholamine and vasopressin requirement, response to therapy, and adverse events were collected. RESULTS: Forty patients were included who received a fixed-dose vasopressin in addition to catecholamine infusions. No correlation was found in the primary outcome of change in MAP at 1 hour after vasopressin initiation compared with vasopressin dose relative to patient weight or body mass index (BMI). Change in MAP at 6 and 12 hours was not significant. In the obese population (n = 9), there was a significant negative correlation between BMI and change in MAP at 6 hours (correlation coefficient r = -0.951; P = 0.0009). Linear regression analysis confirmed that vasopressin dose relative toweight was independently associated with change in MAP at 1, 6, and 12 hours, whereas changes in NE dosing were not. CONCLUSION: Increasing weight-based dosing of vasopressin did not correlate with change in MAP when used with catecholamine vasopressors in septic shock. However, fixed-dose vasopressin may not be sufficient in obese septic shock patients with a BMI ≥30 kg/m(2).

Risk of thromboembolic events after protocolized warfarin reversal with 3-factor PCC and factor VIIa.

Bleeding events and life-threatening hemorrhage are the most feared complications of warfarin therapy. Prompt anticoagulant reversal aimed at replacement of vitamin K-dependent clotting factors is essential to promote hemostasis. A retrospective cohort study of warfarin-treated patients experiencing a life-threatening hemorrhage treated with an institution-specific warfarin reversal protocol (postimplementation group) and those who received the prior standard of care (preimplementation group) was performed. The reversal protocol included vitamin K, 3-factor prothrombin complex concentrate, and recombinant factor VIIa. Demographic and clinical information, anticoagulant reversal information, and all adverse events attributed to warfarin reversal were recorded. A total of 227 patients were included in final analysis, 109 in the preimplementation group and 118 in the postimplementation group. Baseline patient characteristics were similar in both groups, with the exception of higher average Sequential Organ Failure Assessment scores in the postimplementation group (P = .0005). The most common indication for anticoagulation reversal was intraparenchymal hemorrhage. Prereversal international normalized ratios (INRs) were similar in both groups. Attainment of INR normalization to less than 1.4 was higher, and rebound INR was lower in the postimplementation group (P < .0001; P = .0013). Thromboembolic complications were significantly higher in the postimplementation group (P = .003). Elevated baseline Sequential Organ Failure Assessment score and mechanical valve as an indication for anticoagulation were independently associated with thrombotic complications (P = .005). A warfarin reversal protocol consisting of 3-factor prothrombin complex concentrate, recombinant factor VIIa, and vitamin K more consistently normalized INR values to less than 1.4 as compared to the prior standard of care in a diverse patient population. This success came at the cost of a 2-fold increase in risk of thromboembolic complications.

Comparison of cefazolin versus oxacillin for treatment of complicated bacteremia caused by methicillin-susceptible Staphylococcus aureus.

Contrary to prior case reports that described occasional clinical failures with cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infections, recent studies have demonstrated no difference in outcomes between cefazolin and antistaphylococcal penicillins for the treatment of MSSA bacteremia. While promising, these studies described low frequencies of high-inoculum infections, such as endocarditis. This retrospective study compares clinical outcomes of cefazolin versus oxacillin for complicated MSSA bacteremia at two tertiary care hospitals between January 2008 and June 2012. Fifty-nine patients treated with cefazolin and 34 patients treated with oxacillin were included. Osteoarticular (41%) and endovascular (20%) sources were the predominant sites of infection. The rates of clinical cure at the end of therapy were similar between cefazolin and oxacillin (95% versus 88%; P=0.25), but overall failure at 90 days was higher in the oxacillin arm (47% versus 24%; P=0.04). Failures were more likely to have received surgical interventions (63% versus 40%; P=0.05) and to have an osteoarticular source (57% versus 33%; P=0.04). Failures also had a longer duration of bacteremia (7 versus 3 days; P=0.0002), which was the only predictor of failure. Antibiotic selection was not predictive of failure. Rates of adverse drug events were higher in the oxacillin arm (30% versus 3%; P=0.0006), and oxacillin was more frequently discontinued due to adverse drug events (21% versus 3%; P=0.01). Cefazolin appears similar to oxacillin for the treatment of complicated MSSA bacteremia but with significantly improved safety. The higher rates of failure with oxacillin may have been confounded by other patient factors and warrant further investigation.

Vasopressin Associated With an Increase in Return of Spontaneous Circulation in Acidotic Cardiopulmonary Arrest Patients.

BACKGROUND: During respiratory and metabolic acidosis, the vasoconstrictive effects of epinephrine may be blunted, whereas the response to vasopressin remains unchanged. The impact of this effect during advanced cardiac life support (ACLS) remains unclear. OBJECTIVE: Determine if vasopressin therapy in combination with epinephrine was associated with improved outcomes in patients with cardiac arrest compared to epinephrine alone. The primary outcome was difference in rate of return of spontaneous circulation (ROSC). Secondary outcomes included evaluation of rates of ROSC for patients with an initial pH <7.2 and by initial pulseless rhythm. METHODS: Single-center, retrospective review conducted from July 2010 to July 2012. Patients ≥18 years of age with documented cardiac arrest requiring ACLS and vasopressor therapy were included. RESULTS: A total of 101 patients met inclusion criteria. There was no difference in rate of ROSC (56% vs 60%, P = 0.68) or survival to hospital discharge (9% vs 5%, P = 0.46) between patients who received vasopressin in combination with epinephrine (n = 43) compared to epinephrine alone (n = 58). Subgroup analysis of ROSC in patients with an arterial pH of <7.2 (n = 35) showed an increased rate of ROSC (63% vs 37%, P = 0.01) in the vasopressin plus epinephrine group versus the epinephrine alone group, respectively. Subgroup analysis by initial cardiac rhythm showed no difference in rate of ROSC. CONCLUSIONS: Vasopressin in combination with epinephrine demonstrated improved ROSC in cardiac arrest patients with initial arterial pH <7.2 compared with epinephrine alone, without improving survival to hospital discharge.

Use of propofol-containing versus benzodiazepine regimens for alcohol withdrawal requiring mechanical ventilation.

BACKGROUND: When chronic, excessive alcohol intake is abruptly halted, patients are at risk for developing life-threatening alcohol withdrawal syndrome (AWS). Benzodiazepines have established efficacy, yet some patients' symptoms persist despite treatment with high doses. OBJECTIVES: The study objective was to compare time to resolution of AWS symptoms in mechanically ventilated patients receiving propofol-containing versus benzodiazepine infusions. METHODS: This study was a retrospective cohort analysis of adult patients with ICD-9 codes for AWS who required mechanical ventilation for AWS symptoms. RESULTS: A total of 1637 records were reviewed, and 64 were included. Propofol-containing regimens were used in 46 cases (72%), whereas benzodiazepine infusion monotherapy accounted for 18 cases (28%). Patients were predominantly male (97%), with a mean age of 45 years. Lorazepam-equivalent benzodiazepine doses given prior to intubation were greater in patients receiving propofol infusion (56 vs 15 mg, P = .03). Time to resolution of AWS symptoms for propofol- and benzodiazepine-treated patients was 8 and 7 days, respectively (P = .34). Median hospital and intensive care unit lengths of stay were similar (9 vs 10 days and 4 vs 4 days, respectively; P > .05 for both comparisons), as were days of mechanical ventilation (4 vs 3 days, P = .98). Patients in the benzodiazepine infusion monotherapy group required numerically increased amounts of benzodiazepine bolus doses while on continuous sedation, compared with patients receiving propofol infusion (36 vs 10 mg, P = .06). CONCLUSIONS: Propofol and Benzodiazepine-treated patients with AWS requiring mechanical ventilation experienced similar days of AWS symptoms, length of stay, and mechanical ventilation.

Propofol for benzodiazepine-refractory alcohol withdrawal in a non-mechanically ventilated patient.

Long-term alcohol use confers neurochemical changes in response to alcohol's exogenous inhibitory effects. Downregulation and decreased sensitivity of γ-aminobutyric acid receptors render benzodiazepines less effective at controlling psychomotor agitation. Propofol has been reported to have successfully relieved alcohol withdrawal syndrome (AWS) symptoms in part because of activation of γ-aminobutyric acid channels in combination with antagonism of excitatory amino acids such as N-methyl-D-aspartate. Successful use of propofol in refractory AWS in patients with endotracheal intubation and mechanical ventilation has been reported. We present a case of resolution of AWS symptoms in a benzodiazepine-refractory, nonintubated, non-mechanically ventilated alcohol withdrawal patient with low-dose, continuous-infusion propofol.

Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis.

BACKGROUND: The use of intravenous bicarbonate in diabetic ketoacidosis (DKA) may be considered for patients with a pH less than 6.9 according to the American Diabetes Association. The impact of this therapy on resolution of acidosis in patients with DKA is unclear. OBJECTIVE: To determine whether the use of intravenous bicarbonate therapy was associated with improved outcomes in patients with severe DKA who were seen in the emergency department. METHODS: This review was conducted from 2007 to 2011 in the emergency department of a tertiary teaching hospital. Adults diagnosed with DKA with an initial pH less than 7.0 were included. Patients were stratified into 2 groups based on receipt of intravenous bicarbonate. The primary study outcome was time to resolution of acidosis, defined as return to pH greater than 7.2. Secondary outcomes included length of stay; continuous infusion insulin use; and intravenous fluid, po tas si um, and insulin requirements within the first 24 hours of hospital admission, beginning upon admittance to the emergency department. We also conducted a subgroup analysis of patients with an initial pH less than 6.9. RESULTS: There was no significant difference in time to resolution of acidosis (8 hours vs 8 hours; p = 0.7) or time to hospital discharge (68 hours vs 61 hours; p = 0.3) between patients who received intravenous bicarbonate (n = 44) compared with those who did not (n = 42). The median dose of intravenous bicarbonate was 100 mEq (100-150) for patients who received intravenous bicarbonate. Insulin and fluid requirements in the first 24 hours were significantly higher in patients who received intravenous bicarbonate compared with those who did not (100 units vs 86 units; p = 0.04 and 7.6 L vs 7.2 L; p = 0.01, respectively). There was no significant difference in hours of continuous insulin infusion (27 hours vs 26 hours; p = 0.09) or potassium requirements in the first 24 hours of hospital stay (135 mEq vs 120 mEq; p = 0.84). CONCLUSIONS: Intravenous bicarbonate therapy did not decrease time to resolution of acidosis or time to hospital discharge for patients with DKA with an initial pH less than 7.0.

Retrospective analysis of levetiracetam compared to phenytoin for seizure prophylaxis in adults with traumatic brain injury.

BACKGROUND: Phenytoin is standard of care for seizure prophylaxis following traumatic brain injury (TBI). Levetiracetam, an alternative antiepileptic drug, is utilized for seizure prophylaxis despite limited data supporting its use. OBJECTIVE: Our primary outcome was post-TBI seizure activity measured by electroencephalogram (EEG) for levetiracetam versus phenytoin. Secondary outcomes were length of intensive care unit (ICU) stay, requirement for additional antiepileptic drugs (AED), and drug and monitoring costs. METHODS: A retrospective review was performed of patients admitted to neurosurgical or surgical trauma ICU. Adult patients with at least 1 day of EEG monitoring were included. Patients were excluded if they had history of epilepsy, prior TBI, less than 48 hours of AED therapy, or additional AED prior to EEG monitoring. RESULTS: A total 90 patients met inclusion criteria, with 18 receiving levetiracetam and 72 receiving phenytoin. Prevalence of EEG-confirmed seizure activity was similar between the levetiracetam and phenytoin groups (28% vs 29%; P = .99). ICU length of stay (13 vs 18 days; P = .28), time to EEG-confirmed seizure activity (4 vs 6 days; P = .24), and duration of seizure prophylaxis (9 vs 14 days; P = .18) were also similar. The median daily cost of levetiracetam therapy was $43 compared to $55 for phenytoin therapy and monitoring (P = .08). When all anticonvulsant therapy and monitoring were included, costs were lower for the levetiracetam group ($45 vs $83; P = .02). CONCLUSION: Levetiracetam may provide an alternative treatment option for seizure prevention in TBI patients in the ICU. Total antiepileptic drug and monitoring costs were lower for levetiracetam patients.

Management of an oral ingestion of transdermal fentanyl patches: a case report and literature review.

Purpose. Fentanyl is available as a transdermal system for the treatment of chronic pain in opioid-tolerant patients; however, it carries a black box warning due to both the potency of the product and the potential for abuse. In this report, we describe a case of transbuccal and gastrointestinal ingestion of fentanyl patches and the management of such ingestion. Summary. A 32-year-old man was brought to the emergency department (ED) via emergency medical services for toxic ingestion and suicide attempt. The patient chewed and ingested two illegally purchased transdermal fentanyl patches. In the ED, the patient was obtunded, dizzy and drowsy. Initial vital signs showed the patient to be afebrile and normotensive with a heart rate of 63, respiratory rate of 16, and oxygen saturation of 100% on 2 liters nasal cannula after administration of 2 milligrams of intravenous naloxone. The patient was treated with whole bowel irrigation and continuous intravenous naloxone infusion for approximately 48 hours without complications. Conclusion. Despite numerous case reports describing oral ingestion of fentanyl patches, information on the management of such intoxication is lacking. We report successful management of such a case utilizing whole bowel irrigation along with intravenous push and continuous infusion naloxone.

Pravastatin versus simvastatin for prevention of contrast-induced nephropathy.

Contrast-induced nephropathy (CIN) is associated with long-term morbidity, mortality, and increased health care costs. It has been suggested that statins have pleiotropic effects countering inflammatory and oxidative stress involved in CIN. Several studies support this theory; however, previously published studies have not evaluated the potential differences between statins in reducing the incidence of CIN. The purpose of this retrospective, single-center trial was to compare the incidence of CIN in patients receiving simvastatin or pravastatin therapy undergoing percutaneous coronary intervention (PCI). A total of 261 patients were included (145 received simvastatin and 116 received pravastatin) with the majority undergoing elective PCI. The population was predominantly male (65%), Hispanic (65%), and diabetic (62%), with a mean age of 59 years and a low-density lipoprotein (LDL) of 85 mg/dL. No significant differences were found between groups for risk factors or prophylactic strategies (eg, hydration). Contrast-induced nephropathy occurred in 26 patients (17.9%) in the simvastatin group versus 10 (8.6%) in the pravastatin group (P < .05). No patients required dialysis as a result of contrast administration. Acute kidney injury (AKI) occurred in 21 patients (14.5%) in the simvastatin group compared to 8 (6.9%) in the pravastatin group (P < .05). In multivariate analysis, the difference between statins remained an independent predictor for the development of CIN. In conclusion, patients on pravastatin had a significantly lower incidence of CIN compared to patients on simvastatin.

Immune reconstitution inflammatory syndrome after cessation of the tumor necrosis factor alpha blocker adalimumab in cryptococcal pneumonia.

Tumor necrosis factor alpha antagonists have proven efficacious for a variety of autoimmune-mediated diseases. However, recent data have highlighted the risk of invasive fungal infections with their use. These agents are typically discontinued when infectious complications occur during therapy; however, the immune reconstitution inflammatory syndrome (IRIS) may be seen after drug cessation. We describe the 1st case of IRIS secondary to cryptococcal pneumonia after cessation of adalimumab.

Continuous versus intermittent infusion of oxacillin for treatment of infective endocarditis caused by methicillin-susceptible Staphylococcus aureus.

Infective endocarditis (IE) is the fourth leading cause of life-threatening infection in the United States and imposes significant morbidity and mortality. The American Heart Association guidelines for the diagnosis and treatment of IE do not address continuous-infusion (CI) oxacillin. This retrospective study compares outcomes between CI oxacillin and intermittent-infusion (II) oxacillin in the treatment of IE caused by methicillin-susceptible Staphylococcus aureus (MSSA). A total of 709 medical records were reviewed for inpatients with definitive IE treated between 1 January 2000 and 31 December 2007. Continuous data were analyzed by Student's t test or the Wilcoxon rank sum test. The chi-square test or Fisher's exact test was used to compare nominal data. A multivariate logistic model was constructed. One hundred seven patients met eligibility criteria for inclusion into the study. Seventy-eight patients received CI oxacillin, whereas 28 received II oxacillin. CI and II groups were similar with respect to 30-day mortality (8% versus 10%, P = 0.7) and length of stay (20 versus 25 days, P = 0.4) but differed in 30-day microbiological cure (94% versus 79%, P = 0.03). Sixty-three patients received synergistic gentamicin, whereas 44 did not. The gentamicin and no-gentamicin groups were similar with respect to 30-day mortality (11% versus 4%, P = 0.2) and 30-day microbiological cure (90% versus 89%, P = 0.8); however, times to defervescence (4 versus 2 days, P = 0.02) were significantly different. CI oxacillin is an effective alternative to II oxacillin for the treatment of IE caused by MSSA and may improve microbiological cure. This convenient and pharmacodynamically optimized dosing regimen for oxacillin deserves consideration for patients with IE caused by MSSA.