Brian P. McKinzie

Efficacy of Short-Course, Low-Dose Corticosteroid Therapy for Acute Pulmonary Sarcoidosis Exacerbations

Background:Although corticosteroids are the drug of choice for acute exacerbations of pulmonary sarcoidosis, the dose and duration of therapy is not standardized. We reviewed the short-term treatment outcome (median duration = 21 days) of 36 patients with acute exacerbations of pulmonary sarcoidosis using low-dose corticosteroid therapy (20 mg or less of daily prednisone equivalent). To the best of our knowledge, this is the shortest period of time over which the treatment of pulmonary sarcoidosis with corticosteroids has been assessed. Methods:Patients were identified retrospectively from an institution-approved database. Patient symptoms and spirometry were obtained from chart review. Additional clinical data were obtained from chart and database review. Results:Follow-up visits occurred a median of 21 days after the date of the exacerbation (mean 25 ± 3 standard error of mean). The average prednisone dose was 19 mg ± 0.4 standard error of mean. Patients had significant improvement in spirometry on this low-dose treatment regimen by the time of their short-term follow-up (forced vital capacity percent predicted improved from 68 to 82 [P < 0.0001] and was not significantly different from baseline; forced expiratory volume in 1 second percent predicted improved from 57 to 72 [P < 0.0001] and was not significantly different from baseline). Pulmonary symptoms also improved. Conclusions:Treatment of acute exacerbations of pulmonary sarcoidosis with 20 mg prednisone for a median of 21 days improved spirometry back to baseline and improved clinical symptoms. These data suggest that this corticosteroid dose can be safely used initially, and an attempt at tapering can be considered within the first month.

Safety and efficacy of heparin or enoxaparin prophylaxis in blunt trauma patients with a head abbreviated injury severity score >2

BACKGROUND Timing and type of chemoprophylaxis (CP) that should be used in patients with traumatic brain injury (TBI) remains unclear. We reviewed our institutions experience with low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in TBI. METHODS The charts of all TBI patients with a head abbreviated injury severity score >2 (HAIS) and an intensive care unit length of stay >48 hours admitted during a 42-month period between 2006 and 2009 were reviewed. CP was initiated after intracranial hemorrhage was considered stable. We reviewed all operative notes and radiologic reports in these patients to analyze the rate of significant intracranial hemorrhagic complications, deep venous thrombosis, or pulmonary embolus. RESULTS A total of 386 patients with TBI were identified; 158 were treated with LMWH and 171 were treated with UFH. HAIS was significantly different between the LMWH (3.8 ± 0.7) and UFH (4.1 ± 0.7) groups; the time to initiation of CP was not. The UFH group had a significantly higher rate of deep venous thrombosis and pulmonary embolus. Progression of ICH that occurred after the initiation of CP was significantly higher in the UFH-treated patients (59%) when compared with those treated with LMWH (40%). Two patients in the UFH group required craniotomy after the initiation of CP. CONCLUSION LMWH is an effective method of CP in patients with TBI, providing a lower rate of venous thromboembolic and hemorrhagic complications when compared with UFH. A large, prospective, randomized study would better evaluate the safety and efficacy of LMWH in patients suffering blunt traumatic brain injury.

Clinical Management Strategies and Implications for Parenteral Nutrition Drug Shortages in Adult Patients

Drug shortages affect every aspect of patient care, including and especially, nutrition therapy. The purpose of this review is to discuss current parenteral nutrition–related drug shortages, including causes and duration of the disruptions, and provide recommendations for managing specific nutritional shortages that minimize negative patient care outcomes. A general framework for the management of current and future shortages is presented.

Nutritional Supplements in Critical Illness

Poor nutritional intake during critical illness can contribute to increased morbidity and mortality. Although nutrition strategies for critically ill patients attempt to provide essential macronutrients, recent evidence suggests that certain micronutrients and supplements may improve wound healing and decrease infectious and inflammatory complications. This review will focus on mechanism of action, adverse effects and drug interactions reported in the literature, and appropriate dosing and outcomes data for specific nutritional supplements in various critically ill adult populations.

Pharmacologic Stress Gastropathy Prophylaxis May Not Be Necessary in At-Risk Surgical Trauma ICU Patients Tolerating Enteral Nutrition.

Objective: Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis. Design: A retrospective cohort study of records from 2008 to 2013. Setting: Adult patients in a single-center STICU were included. Patients: Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention. Intervention: Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation. Measurements and Main Results: A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US

Effect of Subcutaneous Unfractionated Heparin Prophylaxis on Activated Partial Thromboplastin Time: A Retrospective Evaluation ☆ ☆☆ ★ ★★ ☆☆☆

121/patient stay were realized. Conclusion: Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.

Evaluation of glucose variability when converting from insulin infusion to basal-bolus regimen in a surgical-trauma intensive care unit

STUDY OBJECTIVE Characterize the incidence of elevated aPTT results in patients treated with prophylactic, subcutaneous unfractionated heparin (UFH). DESIGN Retrospective, cohort analysis. SETTING Single-center, university hospital. MEASUREMENTS Evaluation of 257 patients with activated partial thromboplastin time (aPTT) testing both prior to and following subcutaneous (SC) unfractionated heparin (UFH) therapy. MAIN RESULTS Evaluated patients received UFH 5000 units every 8 hours. Baseline aPTT values were within the normal range (mean±SD, 32.0±8.5 seconds). After initiation of UFH, aPTT values increased (mean±SD, 37.6±15.2 seconds). After 24 hours of SC UFH, mean aPTT values (mean±SD, 38.6±15.5) exceeded the normal laboratory range (23.3-35.7 seconds). An elevated aPTT result after UFH was associated with baseline aPTT, length of therapy, and weight-based UFH dose. A significant association was not identified between aPTT elevation and age, race, sex, history of liver disease, type of admission, or transfusion of blood products. CONCLUSIONS Treatment with UFH resulted in a small, but significant, increase in aPTT.

Evaluating the risk profile of quetiapine in treating delirium in the intensive care adult population: A retrospective review

PURPOSE This study aimed to identify predictive factors resulting in glucose values greater than 200 mg/dL in patients with trauma transitioned from an insulin infusion to a basal-bolus subcutaneous insulin regimen. MATERIALS AND METHODS Thirty-nine patients with trauma on goal enteral nutrition in the intensive care unit receiving an insulin infusion for at least 48 hours and transitioned to a basal-bolus regimen were retrospectively identified. RESULTS Ten patients had hyperglycemic events after transition. Hyperglycemia was significantly associated with increased age (42 [17] years vs 56 [13] years, P=.02), admission glucose (128 [39] mg/dL vs 214 [91] mg/dL, P=.015), and insulin drip rate 48 hours before transition (87 [38] units/d vs 127 [49] units/d, P=.012). There was no difference between groups with respect to injury severity, demographics, or physiologic parameters. Multiple regression analysis revealed that increased age (odds ratio [OR], 1.215 [1.000-1.477]; P=.05), increased admission blood glucose (OR, 1.053 [1.006-1.101]; P=.025), and higher insulin infusion rates 48 hours before transition (OR, 1.061 [1.009-1.116]; P=.020) predisposed patients to severe hyperglycemic episodes. CONCLUSIONS Older patients with trauma and patients with higher blood glucose on admission are more likely to experience severe hyperglycemia when transitioned to basal-bolus glucose control. Higher insulin infusion rates at 48 hours before transition are also associated with severe hyperglycemia.

Making the Transition from Student to Resident: A Method to Individualize a PGY1 Program

Purpose: Dosing regimens of quetiapine to treat delirium in critically ill patients are titrated to effect, and may utilize doses higher than previously reported. This study aimed to assess the safety of quetiapine for this indication. Materials and methods: A retrospective medical chart review was conducted, identifying 154 critically ill adults that were initiated on quetiapine to treat delirium and monitored for QTc prolongation. Results: The median average daily dose was 150 mg (79–234) and median max dose was 225 mg (100–350). The overall range was 25–800 mg daily. The time to peak dose was 3 days (1–8). Patients with QTc prolongation were significantly older (age 54 ± 11 vs 45 ± 17 years (p = 0.002)) and with higher baseline QTc (454 ± 33 vs 442 ± 30 (p = 0.045)). Regression analysis revealed only dose as a significant factor (OR = 1.006 (1.003–1.009) (p < 0.001)). Conclusion: The dose of quetiapine has very little correlation with QTc and change from baseline. A small number of side effects were observed. Overall, titrating quickly to large doses of quetiapine is safe for treating delirium. HighlightsDose of quetiapine has very little correlation with extent of QTc prolongation.Dose of quetiapine has very little correlation with change from baseline QTc.Titrating quickly to high doses of quetiapine is safe for treating delirium.

Pharmacy residency training measured through a standardized knowledge test

A Postgraduate Year One (PGY1) resident’s concerns, limitations, and strengths may be self-identified early in the residency year but are reliant on self-awareness and insight. Program directors commonly find difficulty in identifying a resident’s specific knowledge deficits at the beginning of the program. A standardized resident examination can identify limitations early in training and these results can be incorporated into a tailored resident development plan. A total of sixty-two PGY1 residents completed the examination pre- and post-training over a five-year timespan. Scores increased in most core disciplines in each of the five years, indicating an overall improvement in resident knowledge throughout their PGY1 year. The approach of utilizing the scores for the resident’s individualized plan allows for customization to ensure that the resident addresses knowledge gaps where necessary.