Ultrasound-Assisted Catheter-Directed Thrombolysis for the Management of Pulmonary Embolism: A Single Center Experience in a Community Hospital.

Current guidelines recommend anticoagulation alone for low-risk pulmonary embolism (PE) with the addition of systemic thrombolysis for high-risk PE. However, treatment recommendations for intermediate-risk PE are not well-defined. Due to bleeding risks associated with systemic thrombolysis, ultrasound-assisted catheter-directed thrombolysis (USAT) has evolved as a promising treatment modality. USAT is thought to decrease the rate of major bleeding by using localized delivery with lower thrombolytic dosages. Currently, there is little guidance on the implementation of USAT in the real-world clinical setting. This study was designed to evaluate our experience with USAT at this single community hospital with a newly initiated Pulmonary Embolism Response Team (PERT). All patients identified by the PERT with an acute PE diagnosed by a computed tomography (CT) scan from January 2021 to January 2023 were included. During the study period, there were 89 PERT activations with 40 patients (1 high-risk and 37 intermediate-risk PE) receiving USAT with alteplase administered at a fixed rate of 1 mg/h per catheter for 6 h. The primary efficacy outcome was the change in Pulmonary Embolism Severity Index (PESI) score within 48 h after USAT. The primary safety outcome was major bleeding within 72 h. The mean age was 57.4 ± 17.4 years and 50% (n = 20) were male, 17.5% (n = 7) had active malignancy, and 20% (n = 8) had a history of prior deep vein thrombosis (DVT) or PE. The mean PESI score decreased from baseline to 48 h post-USAT (84.7 vs 74.9; p = 0.025) and there were no major bleeding events. The overall hospital length of stay was 7.5 ± 9.8 days and ICU length of stay was 2.2 ± 2.8 days. This study outlined our experience at this single community hospital which resulted in an improvement in PESI scores and no major bleeding events observed.

Pharmacodynamic Characteristics of Nephrotoxicity Associated With Vancomycin Use in Children.

BACKGROUND: Limited studies incorporating population-based pharmacokinetic modeling have been conducted to determine pharmacodynamic indices associated with nephrotoxicity during vancomycin exposure in children. METHODS: A retrospective cohort analysis was conducted from September 2003 to December 2011 at 2 hospitals. Nephrotoxicity was defined as an increase in serum creatinine concentration (SCr) by ≥0.5 mg/dL, or ≥50% increase in baseline SCr, either persisting for ≥2 consecutive days. A 1-compartment model with first-order kinetics was used in NONMEM 7.2 to estimate trough concentrations (Cmin) and area under the curve over 24 hours (AUC). Univariate, classification and regression tree (CART), and multivariate analyses were conducted to identify factors contributing to nephrotoxicity. RESULTS: The analyses included 680 pediatric subjects with 1576 vancomycin serum concentrations. Based on univariate analysis, median Cmin (14.2 [interquartile range, IQR, 7.1-25.4] vs 8.4 [IQR, 5.5-12.4] mcg/mL; P = .001) and AUC (544 [IQR, 359-801] vs 378 [IQR, 304-494]; P < .001) were significantly higher in the nephrotoxic group compared with the non-nephrotoxic group. Using CART, we discovered that subjects with doses ≥60 mg/kg per day and AUC >1063 mg-h/L had a significantly higher occurrence of nephrotoxicity (P = .005). Adjusting for intensive care unit stay and concomitant nephrotoxic drugs, steady-state vancomycin Cmin ≥15 mcg/mL (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 1.1-5.8; P = .028) and AUC ≥800 mg-h/L (aOR, 3.7; 95% CI, 1.2-11.0; P = .018) were associated with increased risk of nephrotoxicity. CONCLUSIONS: Our study describes the pediatric exposure-nephrotoxicity relationships for vancomycin. Vancomycin Cmin ≥15 mcg/mL and AUC ≥800 mg-h/L in children are independently associated with a > 2.5-fold increased risk of nephrotoxicity and may provide justification for use of alternative antibiotics in selected situations.

Vancomycin monitoring in children using bayesian estimation.

BACKGROUND: Optimal monitoring of vancomycin in children needs evaluation using the exposure target with area under the curve (AUC) of the serum concentrations versus time over 24 hours. Our study objectives were to: (1) compare the accuracy and precision of vancomycin AUC estimations using 2 sampling strategies-1 serum concentration sample (1S, near trough) versus 2 samples (2S, near peak and trough) against the rich sample (RS) method; and (2) determine the performance of these strategies in predicting future AUC against an internal validation sample (VS). METHODS: This was a retrospective cohort study using population-based pharmacokinetic modeling with Bayesian post hoc individual estimations in nonlinear mixed effects modeling (version 7.2). Pediatric subjects 3 months-21 years of age who received vancomycin ≥48 hours and had more than 3 drug samples within the first ≤96 hours of therapy were enrolled. Outcome measures were the accuracy, precision, and internal predictive performance of AUC estimations using 2 monitoring strategies (ie, 1S versus 2S) against the RS (which was derived from modeling all serum vancomycin concentrations obtained anytime during therapy) and VS (from serum concentrations obtained after 96 hours of therapy). RESULTS: Analysis included 138 subjects with 712 vancomycin serum concentrations. Median age was 6.1 (interquartile range, 2.2-12.2) years, weight 22 (13-38) kg, and baseline serum creatinine 0.37 (0.30-0.50) mg/dL. Both accuracy and precision were improved with the 2S, compared with 1S, for AUC estimations (-2.0% versus -7.6% and 10.3% versus 12.8%, respectively) against the RS. Improved accuracy and precision were also observed for 2S when evaluated against VS in predicting future AUC. CONCLUSIONS: Compared with 1S, the 2S sampling strategy for vancomycin monitoring improved accuracy and precision in estimating and predicting future AUC. Evaluating 2 drug concentrations in children may be prudent to ensure adequate drug exposure.

Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists.

BACKGROUND: Transfer of medication information during transitions in care is crucial to preventing medication errors. Few studies evaluate patients' self-reported personal medication lists. OBJECTIVES: To assess completeness of personal medication lists and identify factors associated with incomplete personal lists and discrepancies between personal and clinic medication lists. METHODS: We analyzed patients' personal medication lists at an academic hospital preoperative clinic from January 2010 to October 2010. Completeness of personal medication lists was measured as reporting the name, dose, and frequency for all prescription and nonprescription medications or dietary supplements. Discrepancies between personal and clinic medication lists were measured as omitted medications or differing directions. RESULTS: Among 94 patients meeting inclusion criteria, 82 (87%) personal medication lists were evaluated. Most personal lists were incomplete (56%; 46/82), missing information for at least one medication reported; 94% (77/82) of personal lists had at least one discrepancy with clinic medication lists (median 4 discrepancies per patient list). On multivariate analyses, taking 10 or more medications (adjusted odds ratio [OR] = 3.52; 95% CI = 1.37 to 9.08) and being divorced, widowed, or single (adjusted OR = 3.10; 95% CI = 1.05 to 9.12) were independent predictors of incomplete personal medication lists. Taking 10 or more medications (adjusted OR = 3.44; 95% CI = 1.35 to 8.78) was also associated with higher rates of medication discrepancies. CONCLUSIONS: Patients' self-reported personal medication lists are often incomplete and have discrepancies with clinic medication lists. Interventions are needed to improve medication information transfer between patients, providers and healthcare systems.