Hypocalcemia in trauma patients receiving massive transfusion.

BACKGROUND: Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium is vital for coagulation, but hypocalcemia commonly occurs during massive transfusion due to citrate and serum calcium chelation. This study was conducted to determine the incidence of hypocalcemia and severe hypocalcemia in trauma patients who receive massive transfusion and to compare characteristics of patients with severe versus nonsevere hypocalcemia. MATERIALS AND METHODS: This was a retrospective study of trauma patients who received massive transfusion between January 2009 and November 2013. The primary outcome was the incidence of hypocalcemia (ionized calcium [iCa] < 1.12 mmol/L) and severe hypocalcemia (iCa < 0.90 mmol/L). Secondary outcomes included calcium monitoring, calcium replacement, and correction of coagulopathy. RESULTS: There were 156 patients included; 152 (97%) experienced hypocalcemia, and 111 (71%) had severe hypocalcemia. Patients were stratified into iCa ≥ 0.90 (n = 45) and iCa < 0.90 (n = 111). There were no differences in demographics or baseline laboratories except the severe hypocalcemia group had higher baseline activated partial thromboplastin time (29.7 [23.7-50.9] versus 25.8 [22.3-35.9], P = 0.003), higher lactic acid (5.8 [4.1-9.8] versus 4.0 [3.1-7.8], P = 0.019), lower platelets (176 [108-237] versus 208 [169-272], P = 0.003), and lower pH (7.14 [6.98-7.28] versus 7.23 [7.14-7.33], P = 0.019). Mortality was higher in the severe hypocalcemia group (49% versus 24%, P = 0.007). Patients in the iCa < 0.90 group received more blood products (34 [23-58] versus 22 [18-30] units, P < 0.001), and calcium chloride (4 [2-7] versus 3 [1-4] g, P = 0.002), but there was no difference in duration of MTP or final iCa. Neither group reached a median iCa > 1.12. CONCLUSIONS: Hypocalcemia is common during MTP, and vigilant monitoring is warranted. Research is needed to effectively manage hypocalcemia during massive transfusion.

Prevalence and Risk Factors for Iatrogenic Opioid Withdrawal in Medical Critical Care Patients.

Opioids are the mainstay of pain management and sedation in critically ill patients, which can lead to the development of physiologic tolerance and dependency. The prevalence of iatrogenic opioid withdrawal syndrome (IWS) is reported as 17-32% in the ICU; however, limited evidence exists for the medical ICU patient population. OBJECTIVES: To identify the and risk factors for IWS in adult patients admitted to critical care medicine services who received greater than or equal to 24 hours of continuous opioid infusion therapy. DESIGN SETTING AND PARTICIPANTS: A prospective, observational study was conducted in a tertiary care hospital in adult medical ICU patients. Ninety-two patients who received greater than or equal to 24 hours of continuous opioid infusions were included in the study. MAIN OUTCOMES AND MEASUREMENTS: Patients were assessed daily after opioid infusion discontinuation using the Clinical Opiate Withdrawal Scale (COWS) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) opioid withdrawal criteria for a maximum of 5 days. The primary outcome was the prevalence of IWS of moderate severity or greater using COWS. Secondary outcomes included the prevalence of IWS diagnosis of any severity based on COWS, the prevalence of IWS diagnosis based on a positive DSM-V score, and the identification of potential risk factors for developing IWS of any severity. RESULTS: Four hundred forty-seven patients received greater than or equal to 24 hours of continuous opioid therapy. Of these, 385 were excluded, leaving 92 patients included in the final analysis. Except for a higher prevalence of psychiatric history in the IWS-positive group, baseline characteristics were similar. Overall, 11 patients (12%) developed IWS of moderate severity or greater, based on COWS. The IWS-positive group also had longer durations of opioid infusions, higher cumulative opioid infusion doses, higher mean daily doses, and higher infusion rates at any given time. The concomitant use of dexmedetomidine (38.3 vs 15.6%, p = 0.014) and benzodiazepines (63.8 vs 37.8%, p = 0.021) during or after the opioid infusion were significantly higher in the IWS-positive group compared with the IWS-negative group. No significant differences were found between the two groups for scheduled or as needed opioids after cessation of the opioid infusion. Continuous opioid infusions greater than or equal to 72 hours and total daily dose greater than or equal to 1,200 µg were found to be independent predictors for the development of iatrogenic opioid withdrawal via logistic regression. CONCLUSIONS AND RELEVANCE: Approximately one in every eight patients receiving continuous infusion opioid for greater than 24 hours while mechanically ventilated in the medical ICU will develop IWS of moderate severity or greater; this increases to one in three patients diagnosed with DSM-V criteria or any level of IWS severity. Patients receiving opioid infusions greater than or equal to 72 hours, or a total daily fentanyl dose of greater than or equal to 1,200 µg (~ 50 µg/hr) are at a higher risk for developing IWS and should be monitored as part of clinical practice when opioid infusions are discontinued.

Early intravenous ibuprofen decreases narcotic requirement and length of stay after traumatic rib fracture.

Pain control after traumatic rib fracture is essential to avoid respiratory complications and prolonged hospitalization. Narcotics are commonly used, but adjunctive medications such as nonsteroidal anti-inflammatory drugs may be beneficial. Twenty-one patients with traumatic rib fractures treated with both narcotics and intravenous ibuprofen (IVIb) (Treatment) were retrospectively compared with 21 age- and rib fracture-matched patients who received narcotics alone (Control). Pain medication requirements over the first 7 hospital days were evaluated. Mean daily IVIb dose was 2070 ± 880 mg. Daily intravenous morphine-equivalent requirement was 19 ± 16 vs 32 ± 24 mg (P < 0.0001). Daily narcotic requirement was significantly decreased in the Treatment group on Days 3 through 7 (P < 0.05). Total weekly narcotic requirement was significantly less among Treatment patients (P = 0.004). Highest and lowest daily pain scores were lower in the Treatment group (P < 0.05). Hospital length of stay was 4.4 ± 3.4 versus 5.4 ± 2.9 days (P = 0.32). There were no significant complications associated with IVIb therapy. Early IVIb therapy in patients with traumatic rib fractures significantly decreases narcotic requirement and results in clinically significant decreases in hospital length of stay. IVIb therapy should be initiated in patients with traumatic rib fractures to improve patient comfort and reduce narcotic requirement.

Measures to improve safety of an elastomeric infusion system for pain management.

PURPOSE: Measures to improve the safe implementation and utilization of an elastomeric infusion system for pain management are described. SUMMARY: Due to the multiple safety concerns associated with the use of the On-Q infusion systems (I-Flow Corporation, Lake Forest, CA) in a community-based teaching institution, a multidisciplinary team of physicians, pharmacists, clinical nurses, nurse educators, and computer informatics personnel was formed to develop a standardized policy and procedure to ensure the safe use of On-Q pumps. The policy addressed several problems concerning prescribing, dispensing, administration, and monitoring of these pumps. The patient care policy for use of On-Q pumps dictates how the pumps are stocked, ordered, dispensed, administered, and monitored and the drugs approved for use in the pumps. Education bulletins, a summary of the new policy and procedure, and a formal presentation of the policy and procedure to unit-based nurse educators were provided. The focus was on a consistent message of safety by reiterating the problems described with these pumps in the literature and in the health care system itself. The physicians ordering the devices have provided positive feedback regarding the simplified ordering process and standardization of the pumps, medications, and concentrations. Both dispensing pharmacists and bedside nurses have noted that the orders are clearly communicated via the computerized system. The addition of documentation in the computer system and education regarding potential signs and symptoms of adverse events with the medication used with the pumps was greatly appreciated by the nursing staff. CONCLUSION: A health care system instituted measures to enhance the safety of using an elastomeric infusion system for pain management.

Diazepam as a component of goal-directed sedation in critically ill trauma patients.

PURPOSE: Limited information addressing the safety and efficacy of diazepam in the intensive care unit, particularly in trauma patients, is available. The purpose of this study is to evaluate the safety and efficacy of diazepam when used in routine clinical practice as a component of a goal-directed sedation regimen in critically ill trauma patients. MATERIAL AND METHODS: This is a prospective observational evaluation of adult trauma patients admitted to an intensive care unit with orders for as-needed midazolam or lorazepam followed by scheduled diazepam. Medication administration and Sedation-Agitation Scale scores were recorded. RESULTS: Twenty-four patients were evaluated. The most common diazepam dosage was 10 mg every 6 hours, and individual doses ranged from 5 to 30 mg. Sedation-Agitation Scale scores were recorded a median of 20 times per day (interquartile range, 15-24), and the majority (68%) were in the target range. No diazepam-related adverse events were observed. CONCLUSIONS: Based on this limited sample, the use of diazepam as a component of goal-directed therapy appears safe and effective in providing adequate sedation in critically ill trauma patients using an average dosage of 40 mg/d.