Evaluation of a pharmacy managed heparin protocol for extracorporeal membrane oxygenation patients.

INTRODUCTION: Unfractionated heparin is the preferred anticoagulant in extracorporeal membrane oxygenation (ECMO) patients. However, there is a lack of consensus on its titration and monitoring. The objective of this study was to describe the efficacy and safety of a pharmacy managed heparin protocol utilizing activated partial thromboplastin time (aPTT) in comparison to our standard physician-managed activated clotting time (ACT)-based anticoagulation in ECMO patients. METHODS: Patients administered a heparin drip while on ECMO were included in the study. The primary endpoints were the incidence of hemorrhagic and thrombotic complications. RESULTS: A total of 122 adult patients were identified who were on ECMO with heparin anticoagulation; sixty-one patients were managed with each of the physician-managed ACT and pharmacy managed aPTT protocols. No statistically significant difference was observed between the physician ACT and the pharmacy aPTT groups in overall hemorrhagic (69% vs 80%, p=0.145) or thrombotic complications (41% vs 39%, p=0.853). CONCLUSION: There was a similar rate of thrombotic and bleeding events between the two study groups. A pharmacy managed heparin protocol utilizing aPTT monitoring appears to be a safe and effective method of providing anticoagulation in adult ECMO patients.

Antipsychotic use and diagnosis of delirium in the intensive care unit.

INTRODUCTION: Delirium is an independent risk factor for prolonged hospital length of stay (LOS) and increased mortality. Several antipsychotics have been studied for the treatment of intensive care unit (ICU) delirium that has led to a high variability in prescribing patterns for these medications. We hypothesize that in clinical practice the documentation of delirium is lower than the incidence of delirium reported in prospective clinical trials. The objective of this study was to document the incidence of delirium diagnosed in ICU patients and to describe the utilization of antipsychotics in the ICU. METHODS: This was a retrospective, observational, cohort study conducted at 71 United States academic medical centers that reported data to the University Health System Consortium Clinical Database/Resource Manager. It included all patients 18 years of age and older admitted to the hospital between 1 January 2010 and 30 June 2010 with at least one day in the ICU. RESULTS: Delirium was diagnosed in 6% (10,034 of 164,996) of hospitalizations with an ICU admission. Antipsychotics were administered to 11% (17,764 of 164,996) of patients. Of the antipsychotics studied, the most frequently used were haloperidol (62%; n = 10,958) and quetiapine (31%; n = 5,448). Delirium was associated with increased ICU LOS (5 vs. 3 days, P < 0.001) and hospital LOS (11 vs. 6 days, P < 0.001), but not in-hospital mortality (8% vs. 9%, P = 0.419). Antipsychotic exposure was associated with increased ICU LOS (8 vs. 3 days, P < 0.001), hospital LOS (14 vs. 5 days, P < 0.001) and mortality (12% vs. 8%, P < 0.001). Of patients with antipsychotic exposure in the ICU, absence of a documented mental disorder (32%, n = 5,760) was associated with increased ICU LOS (9 vs. 7 days, P < 0.001), hospital LOS (16 vs. 13 days, P < 0.001) and in-hospital mortality (19% vs. 9%, P < 0.001) compared to patients with a documented mental disorder (68%, n = 12,004). CONCLUSIONS: The incidence of documented delirium in ICU patients is lower than that documented in previous prospective studies with active screening. Antipsychotics are administered to 1 in every 10 ICU patients. When administration occurs in the absence of a documented mental disorder, antipsychotic use is associated with an even higher ICU and hospital LOS, as well as in-hospital mortality.

Comparison of dexmedetomidine versus propofol for sedation in mechanically ventilated patients after cardiovascular surgery.

Many cardiovascular surgeries are fast-tracked to extubation and require short-term sedation. Dexmedetomidine and propofol have very different mechanisms of action and pharmacokinetic profiles that make them attractive sedative agents in this patient population. Recently, there has been increased use of dexmedetomidine in the intensive care unit (ICU), but few studies exist or have been published directly comparing both agents in this setting. We conducted a retrospective cohort study with patients admitted to the ICU after cardiovascular surgery from January through June 2011. Adult patients who underwent coronary artery bypass and/or cardiac valve surgery received either dexmedetomidine or propofol continuous infusion for short-term sedation after cardiovascular surgery. The primary end point was time (hours) on mechanical ventilation after surgery. Secondary end points included ICU length of stay (LOS), hospital LOS, incidence of delirium, and requirement of a second sedative agent. A total of 352 patients met study inclusion criteria, with 33 enrolled in the dexmedetomidine group and 319 in the propofol group. Time on mechanical ventilation was shorter in the dexmedetomidine group (7.4 hours vs. 12.9 hours, P = .042). No difference was seen in ICU or hospital LOS. The need for a second sedative agent to achieve optimal sedation (24% vs. 27%, P = .737) and incidence of delirium (9% vs. 7.5%, P = .747) were similar between both groups. Sedation with dexmedetomidine resulted in a significant reduction in time on mechanical ventilation. However, no difference was seen in ICU or hospital LOS, incidence of delirium, or mortality.

PF4/heparin antibody testing and treatment of heparin-induced thrombocytopenia in the intensive care unit.

BACKGROUND: The diagnosis of heparin-induced thrombocytopenia (HIT) may be challenging in critically ill patients, as heparin exposures are ubiquitous, and thrombocytopenia is common. Unwarranted ordering and incorrect interpretation of heparin antibody tests can expose a patient to adverse drug events and imposes a significant economic burden on our health care system. METHODS: A prospective, observational study was performed over 4 months on all adult patients located in 5 intensive care units, with a heparin antibody test ordered. RESULTS: A platelet factor 4/heparin enzyme-linked immunosorbent assay (ELISA) test was ordered in 131 patients. In total, 110 patients had a low 4Ts score (0-3), and of these 103 had a negative ELISA result. In patients with a low 4Ts score, 0 (0%) of 110 had an optical density value >1.0. One hundred twenty-nine patients (98%) had another possible cause of thrombocytopenia identified. CONCLUSION: In critically ill patients, low 4Ts scores indicate a low probability of HIT, and heparin antibody testing in these patients is not useful.

Evaluation of empiric antibiotic use in surgical sepsis.

BACKGROUND: We performed an evaluation of antimicrobial guidelines for patients with surgical sepsis. METHODS: The purpose of this study was to validate current empiric antibiotic recommendations in our sepsis protocol based on the suspected site of infection. The primary objective was to assess the appropriateness of empiric antibiotic recommendations and to determine if initial empiric antibiotics provided adequate coverage compared with sensitivity data (accuracy). Secondary end points included antibiotic protocol compliance, intensive care unit (ICU)-free days, and mortality. RESULTS: Appropriate antibiotics were prescribed in 82% of patients. Of the culture-positive patients, 72% received accurate antibiotics. ICU-free days were greater for patients in the compliant group (14.5 vs 8.4; P = .014). Hospital mortality was greater in patients who were noncompliant with protocol recommendations (22% vs 17%; P = .44). CONCLUSIONS: Our current antibiotic guidelines provide appropriate and accurate antimicrobial coverage. Noncompliance with the antibiotic protocol resulted in fewer ICU-free days and increased hospital mortality in surgical sepsis patients.