Treatment of Candida auris during extracorporeal life support: A case report.

With rates of ECMO utilization on the rise, prevention of nosocomial infections is of paramount importance. Candida auris, an emerging highly pathogenic multidrug resistant fungus, is of particular concern as it is associated with persistent colonization of environmental surfaces, inability to be recognized by many diagnostic platforms, inconsistent laboratory susceptibility results, and high mortality rates. We describe a case of C. auris in a VV-ECMO patient successfully managed with a combination of anidulafungin, amphotericin B, and flucytosine.

Efficacy and safety of factor Xa inhibitors in low body weight patients.

STUDY OBJECTIVE: The purpose of this study is to provide evidence for the safety and efficacy of factor Xa inhibitors in patients with a weight ≤60 kg or BMI < 18.5 kg/m2 . DESIGN: Multicenter, retrospective, cohort study. SETTING: Twenty-two Ascension Health hospitals. PATIENTS: Low-body-weight adult patients (weight ≤ 60 kg or BMI < 18.5 kg/m2 ) receiving treatment for atrial fibrillation or venous thromboembolism. INTERVENTION: Factor Xa inhibitors (apixaban or rivaroxaban) or warfarin. MEASUREMENTS AND MAIN RESULTS: This study included 2538 patients between the factor Xa inhibitors (n = 1695) and warfarin (n = 843) groups with a mean weight of 53.5 ± 5.5 kg and BMI of 20.7 ± 3.1 kg/m2 . No significant difference in time to major bleeding was noted after controlling for potential confounders (HR 1.03, 95% CI 0.70-1.53, p = 0.87); similar results were seen following propensity score matching. Thromboembolism (5.3% vs. 6.2%, p = 0.38), composite major + clinically relevant nonmajor bleeding (9.8% vs. 11.5%, p = 0.18), and all-cause mortality (10.7% vs. 12.8%, p = 0.12) were similar between patients receiving factor Xa inhibitors versus warfarin. CONCLUSION: No differences in safety or effectiveness were noted between factor Xa inhibitors versus warfarin. These findings provide encouraging evidence to support the use of factor Xa inhibitors in low-body-weight patients.

Venous Thromboembolism Prophylaxis in Low Body Weight Critically Ill Patients.

OBJECTIVE: To compare bleeding and thromboembolic events in low body weight patients receiving reduced-dose venous thromboembolism (VTE) prophylaxis versus standard-dose VTE prophylaxis. DESIGN: Multicenter, retrospective, cohort study. SETTING: Five Ascension Health Hospitals. PATIENTS: Adult, critically ill, low body weight (≤50 kg) patients who received either reduced-dose VTE prophylaxis (n = 140) or standard-dose VTE prophylaxis (n = 279) for at least 48 h. INTERVENTION: Reduced-dose prophylaxis (enoxaparin 30 mg daily or heparin 5000 units every 12 h subcutaneously) or standard-dose prophylaxis (enoxaparin 40 mg daily, enoxaparin 30 mg every 12 h, or heparin 5000 units every 8 h subcutaneously). MEASUREMENTS AND MAIN RESULTS: A total of 419 patients were included with a mean weight of 45.1 ± 4.2 kg in the standard-dose group and 44.0 ± 5.1 kg in the reduced-dose prophylaxis group (P = .02). The primary endpoint, composite bleeding, was significantly lower in patients receiving reduced-dose prophylaxis (5% vs 12.5%, P = .02). After adjusting for confounding factors, results remained consistent demonstrating reduced composite bleeding with reduced-dose prophylaxis (odds ratio: 0.36, 95% confidence interval: 0.14-0.96). Major bleeding events occurred in 3.6% of reduced-dose patients compared with 8.6% in standard-dose patients (P = .056). Clinically relevant nonmajor bleeding (5.4% vs 2.9%, P = .24) and VTE (2.2% vs 0%, P = .08) events were similar between groups. CONCLUSIONS: A reduced-dose VTE prophylaxis strategy in low body weight, critically ill patients was associated with a lower risk of composite bleeding and similar rate of thromboembolism.

Hydrocortisone versus vasopressin for the management of adult patients with septic shock refractory to norepinephrine: A multicenter retrospective study.

STUDY OBJECTIVE: Significant practice variation exists when selecting between hydrocortisone and vasopressin as second line agents in patients with septic shock in need of escalating doses of norepinephrine. The goal of this study was to assess differences in clinical outcomes between these two agents. DESIGN: Multicenter, retrospective, observational study. SETTING: Ten Ascension Health hospitals. PATIENTS: Adult patients with presumed septic shock receiving norepinephrine prior to study drug initiation between December 2015 and August 2021. INTERVENTION: Vasopressin (0.03-0.04 units/min) or hydrocortisone (200-300 mg/day). MEASUREMENTS AND MAIN RESULTS: A total of 768 patients were included with a median (interquartile range) SOFA score of 10 (8-13), norepinephrine dose of 0.3 mcg/kg/min (0.1-0.5 mcg/kg/min), and lactate of 3.8 mmol/L (2.4-7.0 mmol/L) at initiation of the study drug. A significant difference in 28-day mortality was noted favoring hydrocortisone as an adjunct to norepinephrine after controlling for potential confounding factors (OR 0.46 [95% CI, 0.32-0.66]); similar results were seen following propensity score matching. Compared to vasopressin, hydrocortisone initiation was also associated with a higher rate of hemodynamic responsiveness (91.9% vs. 68.2%, p < 0.01), improved resolution of shock (68.8% vs. 31.5%, p < 0.01), and reduced recurrence of shock within 72 h (8.7% vs. 20.7%, p < 0.01). CONCLUSIONS: Addition of hydrocortisone to norepinephrine was associated with a lower 28-day mortality in patients with septic shock, compared to the addition of vasopressin.

Enteral Sedation in Patients Requiring Mechanical Ventilation During an Intravenous Analgesic and Sedative Shortage.

Background: There is a paucity of data evaluating the use of enteral sedation in mechanical ventilation. A sedative shortage resulted in the use of this approach. Purpose: To evaluate the feasibility of using enteral sedatives to decrease intravenous (IV) analgesia and sedative requirements. Materials/Methods: This single-center, retrospective, observational study compared two groups of patients admitted to the ICU who were mechanically ventilated. One group received a combination of enteral and IV sedatives and the second group received IV monotherapy. Linear mixed model (LMM) analyses were performed to assess the impact of enteral sedatives on IV fentanyl equivalents, IV midazolam equivalents, and propofol. Mann-Whitney U tests were performed on percent of days at goal for Richmond Agitation and Sedation Scale (RASS) and critical care pain observation tool (CPOT) scores. Results: One hundred and four patients were included. The average cohort age was 62 years and 58.7% were male. The median length of mechanical ventilation was 7.1 days and the median length of stay was 11.9 days. The LMM estimated that enteral sedatives reduced IV fentanyl equivalents received per patient by an average of 305.6 mcg/day (P = .04), although did not significantly decrease midazolam equivalents or propofol. There was no statistically significant difference in CPOT scores (P = .57 and P = .46 respectively), however RASS scores in the enteral sedation group were more often at goal (P = .03); oversedation occurred more in the non-enteral sedation group (P = .018). Conclusion: Enteral sedation may be a possible way to decrease IV analgesia requirements during periods of shortage.

Risk of bleeding with factor Xa inhibitors versus unfractionated heparin in patients with acute kidney injury.

STUDY OBJECTIVE: To compare bleeding and thromboembolic events in patients receiving therapeutic doses of apixaban or rivaroxaban versus unfractionated heparin (UFH) in patients with acute kidney injury (AKI). DESIGN: Single-center, retrospective, observational study. SETTING: Ascension St. John Hospital in Detroit, Michigan. PATIENTS: Hospitalized adult patients who received therapeutic doses of factor Xa inhibitors (n = 250) or UFH (n = 250) for at least 24 h in the setting of AKI. MEASUREMENTS AND MAIN RESULTS: After adjusting for confounding factors, patients who received a factor Xa inhibitor experienced a lower risk of composite major and clinically relevant nonmajor bleeding (CRNMB) events compared with UFH (OR: 0.57, 95% CI: 0.34-0.94; p = 0.03). There was a significantly decreased risk of CRNMB events in the factor Xa inhibitor group (OR: 0.55, 95% CI: 0.33-0.91, p = 0.02); however, no significant differences in major bleeding or venous thromboembolism (VTE) were noted. CONCLUSIONS: Our results suggest that it may be preferable to continue patients in AKI on factor Xa inhibitors versus transitioning to UFH due to the lower risk of bleeding events.

Management of Venous Thromboembolism in Morbid Obesity With Rivaroxaban or Warfarin.

BACKGROUND: Rivaroxaban is a first-line option for the management of venous thromboembolism (VTE). However, limited data are available regarding its effectiveness in morbidly obese patients. OBJECTIVE: To evaluate rates of thrombosis and bleeding in morbidly obese patients receiving rivaroxaban or warfarin for VTE. METHODS: A multicenter, retrospective cohort study was conducted to compare rates of bleeding and thrombosis in patients receiving rivaroxaban versus warfarin for acute VTE. Patients were included if they were older than 18 years and had a body mass index (BMI) greater than 40 kg/m2 or weight greater than 120 kg. The primary effectiveness outcome was hazard of VTE recurrence; the primary safety outcome was hazard of major bleeding. Patients were followed for up to 12 months. RESULTS: A total of 1281 patients were identified for acute VTE and were included in this study with 487 patients receiving rivaroxaban and 785 receiving warfarin. The average cohort age was 57.6 ± 14.6 years, and the average weight was 136.4 ± 27.2 kg. After controlling for confounding factors, the use of rivaroxaban was not associated with an increased hazard of VTE events when compared with warfarin (hazard ratio [HR] = 0.69, 95% confidence interval [CI]: 0.42-1.08, P = 0.12) or major bleeding (HR = 1.29, 95% CI: 0.66-2.30, P = 0.52). CONCLUSION AND RELEVANCE: No difference was observed in obese patients with weight >120 kg or BMI >40 kg/m2 receiving rivaroxaban or warfarin for VTE treatment in hazard of VTE or major bleeding. Either agent may be considered an appropriate treatment option in this population.

In-hospital venous thromboembolism: are glucocorticoids a prime suspect?

The objective of the study was to determine whether glucocorticoid use is associated with an increased incidence of in-hospital VTE. We conducted a case-control study of patients with an in-hospital VTE from October 2015 to December 2019. Adult patient cases were identified by ICD-10 codes for acute venous thromboembolism. Controls were selected from all patients without a VTE diagnosis and matched by hospital length of stay and admission type (medical/surgical). Patients were excluded if they had a history of VTE, received therapeutic anticoagulation, or were pregnant. All patients were evaluated to determine the presence or absence of glucocorticoid exposure. Glucocorticoid dose, duration, and route of administration were assessed for patients with steroid exposure. Overall, 78 patients with VTE and 234 controls were included. Receipt of glucocorticoids within the preceding 90 days was similar between the VTE cases and controls (39.7 vs. 38.9%, P  = 0.89). No differences were noted with regard to oral (21.8 vs. 19.2%, P = 0.62), intravenous (30.8 vs. 29.1%. P = 0.774), or inhaled (6.4 vs. 10.3%, P = 0.31) routes of administration between VTE case and control patients. Cumulative prednisone equivalent doses were similar between cases and controls (877 ±â€Š1366 vs. 697 ±â€Š1963 mg, P = 0.435). The risk of in-hospital venous thromboembolism was not influenced by glucocorticoid exposure within the past 90 days. These results were consistent across all routes of administration, exposure time, and steroid dose. Blood Coagul Fibrinolysis 33:000-000 Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

Cisplatin-induced nephrotoxicity in an outpatient setting.

BACKGROUND: The use of cisplatin is limited by the development of nephrotoxicity, with an incidence approaching 30%. It is unclear if a risk prediction score can effectively predict the development of nephrotoxicity throughout all cycles of cisplatin therapy among outpatients. METHODS: Retrospective, observational study evaluating adult patients receiving cisplatin in outpatient infusion centers from January 2009 to November 2019 (n = 186). A risk prediction score consisting of patient age, cisplatin dose, hypertension, and serum albumin was calculated to predict the risk of cisplatin-induced nephrotoxicity. RESULTS: The incidence of nephrotoxicity was 23.7% overall, with 8.1% of patients developing cisplatin-induced nephrotoxicity after the first dose. Patients who developed nephrotoxicity had a higher mean risk prediction score compared to patients who did not have nephrotoxicity (4.0 ± 2.0 versus 2.9 ± 2.1, p = 0.004, respectively). Multivariate logistic regression demonstrated each 1-point increase in the risk prediction score increased the odds of nephrotoxicity by 26.5% (OR: 1.27; 95% CI: 1.02-1.57, p = 0.034). Presence of diabetes mellitus increased the odds of cisplatin-induced nephrotoxicity (OR 3.66; 95% CI: 1.43-9.33, p = 0.007), whereas receipt of greater than or equal to 1 liter of 0.9% sodium chloride was protective, decreasing the odds of developing nephrotoxicity by 25%. CONCLUSION: By identifying patients at the highest risk of cisplatin-induced nephrotoxicity, providers can individualize risk reduction strategies. The use of a risk prediction model successfully predicted the risk of nephrotoxicity throughout all cycles of cisplatin in an outpatient setting.

Impact of a clinical decision support tool targeting QT-prolonging medications.

PURPOSE: To evaluate the impact of a newly implemented clinical decision support (CDS) tool targeting QT interval-prolonging medications on order verification and provider interventions. METHODS: A multicenter, retrospective quasi-experimental study was conducted to evaluate provider response to CDS alerts triggered during ordering of QT-prolonging medications for adult patients. The primary outcome was the proportion of orders triggering QTc alerts that were continued without intervention during a specified preimplementation phase (n = 49) and during a postimplementation phase (n = 100). Patient risk factors for QTc prolongation, provider alert response, and interventions to reduce the risk of QTc-associated adverse events were evaluated. RESULTS: The rate of order continuation without intervention was 82% in the preimplementation phase and 37% in the postimplementation phase, representing an 55% reduction in continued verified orders following implementation of the QT-focused CDS tool. Most alerts were initially responded to by the prescriber, with pharmacist intervention needed in only 33% of cases. There were no significant differences in patient QTc-related risk factors between the 2 study groups (P = 0.11); the postimplementation group had a higher proportion of patients using at least 2 QTc-prolonging medications (48%, compared to 26% in the preimplementation group; P = 0.02). CONCLUSION: Implementation of the CDS tool was associated with a reduction in the proportion of orders continued without intervention in patients at high risk for QTc-related adverse events.

Assessment of Anticoagulation in Patients Receiving Ultrasound-Assisted Catheter-Directed Thrombolysis for Treatment of Pulmonary Embolism.

BACKGROUND: Ultrasound-assisted, catheter-directed thrombolysis (USAT) has emerged as a popular treatment option for submassive pulmonary embolism (PE). The optimal strategy for transitioning patients from full-intensity to reduced-intensity heparin during the procedure has yet to be established. OBJECTIVE: The goal of this study was to evaluate the anticoagulation management in patients receiving catheter-directed thrombolysis with USAT. METHODS: A retrospective chart review was conducted of patients who received USAT for the treatment of PE. Institutional review board approval was obtained. The primary objective was to determine the proportion of patients with a therapeutic activated partial thromboplastin time (aPTT) prior to and during tissue-plasminogen activator (tPA) infusion. Secondary outcomes included heparin requirements, the rate of bleeding complications, and the appropriateness of long-term venous thromboembolism management. RESULTS: A therapeutic aPTT value was achieved in 32 patients (54.2%) prior to USAT and 35 patients (59.3%) during tPA infusion. Heparin requirements were reduced from 15.1 ± 4.1 to 12.8 ± 4.2 U/kg/h for patients who achieved a therapeutic aPTT both prior to and during tPA infusion. Bleeding occurred in 34.4% of patients and tended to be minimal (20.3%) or minor (10.9%). The majority of patients were discharged on a direct oral anticoagulant (63%), followed by warfarin (32%) and enoxaparin (5%). Conclusion and Relevance: To our knowledge, this is the first study that has assessed heparin management in the setting of USAT. The results of these data may aid in empirically dose adjusting unfractionated heparin to ensure safe and effective anticoagulation for patients receiving USAT.

Regadenoson versus Dipyridamole: A Comparison of the Frequency of Adverse Events in Patients Undergoing Myocardial Perfusion Imaging.

STUDY OBJECTIVE: To compare the frequency of adverse events in patients undergoing myocardial perfusion imaging (MPI) with either regadenoson or dipyridamole. DESIGN: Single-center, retrospective cohort study. SETTING: Large community teaching hospital. PATIENTS: A total of 568 adults who underwent single-photon emission tomography MPI with either regadenoson (284 patients) or dipyridamole (284 patients) as a vasodilator agent, following an institution conversion from regadenoson to dipyridamole in the MPI protocol on July 15, 2013, for cost-saving purposes. MEASUREMENTS AND MAIN RESULTS: Data were collected from the patients' electronic medical records. The primary endpoint was the composite occurrence of any documented adverse event in each group. Secondary endpoints were individual components of the primary endpoint, reason for termination of the MPI examination (protocol completion or premature end due to an adverse event), use of an interventional agent to an treat adverse event, and cost-related outcomes. A higher proportion of patients in the regadenoson group experienced an adverse event than those who received dipyridamole (84.9% vs 56.7%, p<0.0001). None of the patients in either group required early MPI study termination due to an adverse event. No significant differences were noted between groups regarding use of aminophylline or other interventions to treat adverse events. The overall drug cost savings in the postconversion dipyridamole group was $51,526. CONCLUSION: Dipyridamole was associated with fewer adverse events than regadenoson in patients undergoing MPI. Dipyridamole offers a safe and cost-effective alternative to regadenoson for cardiac imaging studies.

Can a Short Video Improve Apixaban Knowledge in an Inpatient Setting?

PURPOSE: To increase patient knowledge about apixaban (Eliquis, Bristol-Myers Squibb) using an educational video delivered in an urban inpatient setting. METHODS: This prospective, quasi-experimental study evaluated knowledge gain and retention in patients receiving apixaban after viewing a short educational video. Knowledge was assessed with a questionnaire immediately before, immediately after, and one month following the educational video. RESULTS: After 33 patients watched the video, scores increased by 19.7% from the pre-test to the immediate post-test time point (95% confidence interval [CI], 14.5-24.9; P < 0.001). Patients previously receiving apixaban or another anticoagulant were less likely to improve scores compared with new patients (P < 0.05). Twenty-two of the 33 patients (66.7%) completed the one-month follow-up. No difference in scores from pre-test to one month post-test were noted (6.4%; 95% CI, 1.6-14.5; P = 0.11). CONCLUSION: The apixaban educational video led to improvements in short-term knowledge; however, patients did not retain this knowledge at one month. Future studies should seek ways to improve long-term knowledge retention.

Assessment of Postoperative Pain Control with an Elastomeric Pain Pump Following Cardiothoracic Surgery.

OBJECTIVE: To assess the effectiveness of local anesthesia, delivered via elastomeric pump to manage pain in patients undergoing cardiothoracic surgery. METHODS: A retrospective, comparative analysis evaluating adult cardiothoracic surgery patients (by median sternotomy) who received continuous infusion bupivacaine + traditional methods of pain control (N = 100) or traditional pain control alone (N = 100) from July 2011-October 2013. The primary efficacy end point was total postoperative opioid requirements for 96 hours following surgery. Secondary end points included postoperative pain scores, nonopioid analgesic requirements for 96 hours after surgery, and frequency of postoperative adverse events. RESULTS: Demographic characteristics were similar between both groups. No difference was noted in overall opioid utilization for the first 96 hours postoperatively between the two groups ( P = 0.36). Similar pain scores were reported by patients in both groups for 96 hours following surgery, with the highest pain scores reported during the first 24 hours following surgery ( P = 0.37). No difference between groups was noted in utilization of ketorolac or acetaminophen. Frequency of postoperative adverse events, including the use of antiemetic agents for nausea and vomiting, was similar in between both groups. CONCLUSION: The use of elastomeric pumps in patients undergoing cardiothoracic surgery for reducing postoperative opioid consumption and pain may not be as beneficial as previously reported.

Vasopressor and Inotropic Management Of Patients With Septic Shock.

Numerous studies have evaluated the role of vasopressors and inotropes in the management of septic shock. This review assesses available evidence for the use of specific vasopressors in the management of septic shock. Use of adjunctive vasopressor therapy is also evaluated, examining the potential value of individual agents. Lastly, inotropic agents are evaluated for use in patients with myocardial dysfunction.

Evaluation of procedure-related bleeding risk in patients receiving bivalirudin during percutaneous coronary intervention.

BACKGROUND: Bivalirudin has historically been considered an attractive anticoagulant during percutaneous coronary intervention (PCI) because of reduced bleeding complications reported by early trials. Bivalirudin use during PCIs has been a subject of controversy because of conflicting data and recent findings. OBJECTIVE: To evaluate the clinical characteristics of patients receiving bivalirudin to determine if an opportunity to improve use exists based on risk of procedure-related bleeding. METHODS: This was a single-center, retrospective, observational study (n = 100) of all adult patients who received bivalirudin during cardiac catheterization at St John Hospital and Medical Center from June to August 2013. The risk of bleeding complications associated with PCI was estimated using a clinical risk algorithm developed from the National Cardiovascular Data Registry (NCDR). RESULTS: Treatment with bivalirudin was safe and effective. Of the 100 patients who received bivalirudin, only 34% were identified as having a high risk of procedure-related bleeding according to the NCDR clinical risk algorithm. There was no incidence of stent thrombosis noted and only 1 case of provisional glycoprotein IIb/IIIa inhibitor use. No episodes of Thrombolysis in Myocardial Infarction (TIMI) major bleeding were noted in the study population; however, 1 patient met TIMI minor bleeding criteria. Limitations of this study include small sample size and retrospective nature of the study. CONCLUSION: Opportunities to establish a more cost-effective use of bivalirudin may exist through implementation of protocols incorporating the NCDR risk assessment model.

The effect of a hypoglycemia treatment protocol on glycemic variability in critically ill patients.

INTRODUCTION: Hypoglycemia and glucose variability are independently associated with increased mortality in septic, surgical, and mixed intensive care unit (ICU) patients. Treatment of hypoglycemia with dextrose 50% can overcorrect blood glucose levels and increase glucose variability. The purpose of this study is to evaluate the effect of a hypoglycemia treatment protocol focused on minimizing glucose variability in critically ill patients. METHODS: This retrospective analysis was conducted at a 772-bed community teaching hospital in Detroit, Michigan. A standardized nursing-driven hypoglycemia treatment protocol specific to critically ill patients was implemented. Glucose variability, amount of dextrose administered, subsequent glucose monitoring, hypoglycemia recurrence, and mortality were compared between pre- and postprotocol groups. RESULTS: The coefficient of variability of blood glucose in the postprotocol group (n = 53) was decreased compared with the preprotocol group (n = 52), 40.9% versus 49.3%, respectively (P = .048). Dextrose usage was significantly reduced between groups (21.2 g preprotocol vs 11.5 g postprotocol; P < .001). The time to first blood glucose check was 36 minutes after protocol implementation compared to 61 minutes before the protocol (P = .003). Finally, the incidence of continued hypoglycemia following dextrose administration and ICU mortality was similar between groups. CONCLUSIONS: Implementation of the hypoglycemia treatment protocol described led to a reduction in glucose variability, while still providing a safe and effective way to manage hypoglycemia in critically ill patients.

Efficacy and safety of analgosedation with fentanyl compared with traditional sedation with propofol.

OBJECTIVES: To compare the efficacy and safety of analgosedation with fentanyl versus traditional sedation with propofol in critically ill patients receiving mechanical ventilation. METHODS: Retrospective, observational study evaluating adult critically ill patients on mechanical ventilation at a community teaching hospital who received continuous infusion fentanyl (n=50) or propofol (n=50) from September 2011-March 2013. RESULTS: Median duration of mechanical ventilation was similar between patients receiving propofol and fentanyl infusions (46.7 hr vs 46.0 hr, p=0.19). No difference was noted in median intensive care unit length of stay between groups (p=0.42). A larger percentage of patients receiving propofol required rescue opioids compared with patients receiving fentanyl (56% vs 34%, p=0.04). Furthermore, patients receiving propofol required significantly more rescue opioid therapy during the course of mechanical ventilation as calculated by fentanyl equivalents (150 µg vs 100 µg, p=0.03). No difference in the rate of intensive care unit delirium was noted between groups (fentanyl 23% vs propofol 27%, p=0.80). CONCLUSION: Analgosedation with fentanyl appears to be a safe and effective strategy to facilitate mechanical ventilation. This regimen does not appear to affect duration of mechanical ventilation when compared with propofol, but may allow for more optimal pain management in critically ill patients.