Cesar Alaniz

Relationship Between Hyperglycemia and Infection in Critically Ill Patients

Hyperglycemia is a common problem encountered in hospitalized patients, especially in critically ill patients and those with diabetes mellitus. Uncontrolled hyperglycemia may be associated with complications such as fluid and electrolyte disturbances and increased infection risk. Studies have demonstrated impairment of host defenses, including decreased polymorphonuclear leukocyte mobilization, chemotaxis, and phagocytic activity related to hyperglycemia. Until 2001, hyperglycemia (blood glucose concentrations up to 220 mg/dl) had been tolerated in critically ill patients not only because high blood glucose concentrations were believed to be a normal physiologic reaction in stressed patients and excess glucose is necessary to support the energy needs of glucose‐dependent organs, but also because the true significance of short‐term hyperglycemia was not known. Recent clinical data show that the use of intensive insulin therapy to maintain tight blood glucose concentrations between 80 and 110 mg/dl decreases morbidity and mortality in critically ill surgical patients. Intensive insulin therapy minimizes derangements in normal host defense mechanisms and modulates release of inflammatory mediators. The principal benefit of intensive insulin therapy is a decrease in infection‐related complications and mortality. Further research will define which patient populations will benefit most from intensive insulin therapy and firmly establish the blood glucose concentration at which benefits will be realized.

Amino Acid Requirements in Critically Ill Patients with Acute Kidney Injury Treated with Continuous Renal Replacement Therapy

Acute kidney injury in critically ill patients is often a complication of an underlying condition such as organ failure, sepsis, or drug therapy. In these patients, stress‐induced hypercatabolism results in loss of body cell mass. Unless nutrition support is provided, malnutrition and negative nitrogen balance may ensue. Because of metabolic, fluid, and electrolyte abnormalities, optimization of nutrition to patients with acute kidney injury presents a challenge to the clinician. In patients treated with conventional intermittent hemodialysis, achieving adequate amino acid intake can be limited by azotemia and fluid restriction. With the use of continuous renal replacement therapy (CRRT), however, better control of azotemia and liberalization of fluid intake allow amino acid intake to be maximized to support the patients metabolic needs. High amino acid doses up to 2.5 g/kg/day in patients treated with CRRT improved nitrogen balance. However, to our knowledge, no studies have correlated increased amino acid intake with improved outcomes in critically ill patients with acute kidney injury. Data from large, prospective, randomized, controlled trials are needed to optimize the dosing of amino acids in critically ill patients with acute kidney injury who are treated with CRRT and to study the safety of high doses and their effects on patient morbidity and survival.

Chemoprophylaxis for Venous Thromboembolism in Otolaryngology

IMPORTANCE Venous thromboembolism (VTE) causes significant morbidity and mortality in surgical patients. Despite strong evidence that thromboprophylaxis reduces the incidence VTE, guidelines for prophylaxis in otolaryngology are not well established. Key to the development of VTE prophylaxis recommendations are effective VTE risk stratification and evaluation of the benefits and harms of prophylaxis. OBJECTIVE To evaluate the effectiveness and safety of VTE chemoprophylaxis among a population of otolaryngology patients stratified by risk. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 3498 adult patients admitted for otolaryngologic surgery at a single-institution academic tertiary care medical center between September 1, 2003, and June 30, 2010. INTERVENTIONS Patients were stratified into 2 groups based on whether they received VTE chemoprophylaxis. MAIN OUTCOMES AND MEASURES Incidence of VTE and bleeding-related complications within 30 days after surgery. RESULTS Of 1482 patients receiving VTE chemoprophylaxis, 18 (1.2%) developed a VTE compared with 27 of 2016 patients (1.3%) who did not receive prophylaxis (P = .75). Patients with Caprini VTE risk scores greater than 7 were less likely to have a VTE with perioperative chemoprophylaxis (5.3% vs 10.4%; P = .06). Of patients with VTE chemoprophylaxis, 3.5% developed a bleeding complication compared with 1.2% of patients without prophylaxis (P < .001). Bleeding complications were associated with concomitant use of antiplatelet medications and chemoprophylaxis. Among patients undergoing free tissue transfer, chemoprophylaxis significantly decreased the incidence of VTE (2.1% vs 7.7%; P = .002) and increased bleeding complications (11.9% vs 4.5%; P = .01). In all other patients, VTE chemoprophylaxis did not significantly influence the likelihood of VTE (1.0% vs 0.6%; P = .12) or bleeding (1.5% vs 0.9%; P = .15). CONCLUSIONS AND RELEVANCE Effectiveness and safety of VTE chemoprophylaxis differed between patient subgroups, defined by Caprini risk score and by procedure. Effectiveness was most evident in patients with high Caprini risk scores and microvascular free tissue reconstruction. Bleeding complications were associated with VTE chemoprophylaxis administered in close proximity to potent antiplatelet therapy. The Caprini risk assessment model appears to be an effective tool to stratify otolaryngology patients by risk for VTE. Patients undergoing free tissue reconstruction merit further study before developing recommendations for VTE prophylaxis because of their higher risk of both VTE and bleeding.

Impact of a critical pathway on inpatient management of diabetic ketoacidosis

To assess the management of diabetic ketoacidosis (DKA) and evaluate if introduction of a critical pathway improves management, we studied adults admitted with DKA to the Medicine and Critical Care Services in a US teaching hospital. Patients admitted with DKA in 1997 before implementation of the critical pathway were the control group (n=72). In 1998, housestaff and nurses in the emergency department (ED) and on the General Medicine and Critical Care Services were instructed in the use of the critical pathway. Patients admitted with DKA during 1998 (n=77) were the intervention group. Length of stay (LOS), hospital cost, adherence to guidelines, and medical outcomes to be avoided were compared, and regression analyses were performed to correlate processes and outcomes of care. Mean LOS and variability in LOS decreased during the intervention period, especially in patients treated without endocrinology consultation (EC) (5.2 +/- 10.6 vs. 2.4 +/- 2.1 days, P=0.01), and hospital cost and variability in cost tended to decrease (

Vancomycin Versus Linezolid in the Treatment of Methicillin-Resistant Staphylococcus aureus Nosocomial Pneumonia: Implications of the ZEPHyR Trial

6441 +/- 15,204 vs.

Role of unit-specific combination antibiograms for improving the selection of appropriate empiric therapy for gram-negative pneumonia.

3625 +/- 3478, P=0.24). More intervention subjects received the recommended intravenous fluid volume (88 vs. 71%, P=0.013), education in sick-day management (77 vs. 54%, P=0.006), and EC (38 vs. 21%, P=0.03). Insulin management was not changed. We conclude that implementation of a DKA critical pathway reduced practice variation and was associated with shorter LOS and a trend toward decreased cost. Some processes of care were improved but many require additional interventions.

Does body weight impact the efficacy of vasopressin therapy in the management of septic shock

In 2003, a retrospective trial comparing linezolid versus vancomycin in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) showed improved survival in the linezolid group. This ted to the ZEPHyR (Linezolid in the Treatment of Subjects with Nosocomial Pneumonia Proven to Be Due to Methicillin-Resistant Staphylococcus aureus) trial comparing linezolid versus vancomycin for MRSA pneumonia, which showed a benefit for linezolid with respect to clinical response but without a survival advantage. Limitations of the study included unbalanced treatment groups at baseline and number of patients excluded to reach the per-protocol group. Results of the ZEPHyR trial do not support routine use of linezolid for the treatment of MRSA pneumonia

Combination Therapy for the Treatment and Prevention of Hepatic Encephalopathy

In an effort to improve the selection of appropriate empiric gram-negative therapy for pneumonia, we examined intensive care unit-specific combination antibiograms. These antibiograms were able to predict appropriate empiric gram-negative therapy. Empiric combination therapy based on unit-specific combination antibiograms may aid in the selection of therapy for gram-negative pneumonia.

Apparent Argatroban Resistance in a Patient with Elevated Factor VIII Levels

BACKGROUND Vasopressors used for the management of septic shock are often dosed according to body weight. Use of vasopressin for physiologic replacement in patients with septic shock is usually administered as a standard non-weight-based dose. We hypothesized that the efficacy of vasopressin may be influenced by body weight. PURPOSE The primary objective was to determine if the effects of vasopressin on other vasopressor dosing requirements is related to body weight. Secondary objectives included evaluation of blood pressure and heart rate after the start of vasopressin infusion. METHODS A retrospective, cohort study in a large academic health center was conducted. Sixty-four adult inpatients with septic shock (26 medical intensive care unit and 38 surgical intensive care unit) who required vasopressor administration including vasopressin therapy were included. Dosing requirements of vasopressors were captured 1 hour before and during the hour of vasopressin initiation and 2 and 4 hours later. Other information collected during the study period included blood pressure, mean arterial pressure, and heart rate. RESULTS Most of the patients (n = 61) received vasopressin at a dose of 0.04 U/min. Changes in vasopressor dosing were significantly correlated with weight-adjusted vasopressin at 2 hours (correlation coefficient = -0.36, P = .03) and 4 hours (correlation coefficient = -0.46, P < .001). Use of vasopressin was associated with significant increases in systolic blood pressure, diastolic blood pressure, and mean arterial pressure at each time point compared with baseline. CONCLUSIONS Effects of vasopressin on catecholamine dosing requirements in the setting of septic shock may be influenced by body weight. Prospective studies are needed to examine weight-based dosing of vasopressin in this setting.

Continuous Infusion of Pantoprazole with Octreotide Does Not Improve Management of Variceal Hemorrhage

OBJECTIVE: To evaluate the efficacy and safety of combination therapy for the treatment and prevention of hepatic encephalopathy (HE). DATA SOURCES: A PubMed MEDLINE search was conducted (1947-June 2012) using the key terms lactulose, lactitol, nonabsorbable disaccharide, metronidazole, rifaximin, neomycin, probiotics, and hepatic encephalopathy. Searches were limited to include articles published in English. STUDY SELECTION AND DATA EXTRACTION: Study selection included published trials, case reports, and case series of humans with HE who were treated with combination therapy of rifaximin, lactulose, lactitol, metronidazole, neomycin, and/or probiotics. DATA SYNTHESIS: Only 6 studies that evaluated the benefits of combination drug therapy in the treatment or prevention of HE were available for review. Four studies addressed the treatment of HE, 2 found no significant difference between lactulose/neomycin versus placebo or rifaximin/lactulose, 1 assessed the use of rifaximin/lactulose without a control group, and the fourth found no significant difference between lactulose/probiotics versus either drug alone, although each group showed improvement from baseline. In the 2 prevention trials, both of which stemmed from the same data, the combination of rifaximin/lactulose was superior to lactulose alone, showing significant improvement in mental status, blood ammonia levels, and health-related quality of life and reductions in HE recurrence and hospitalization. Currently, there are no available clinical studies evaluating dual antibiotic therapy, metronidazole with nonabsorbable disaccharides, or antibiotics with probiotics. CONCLUSIONS: The evidence evaluating the use of combination therapy for the treatment of HE does not support its widespread use. The combination of rifaximin and lactulose may be considered in the treatment of HE and in patients refractory to monotherapy. The combination of rifaximin and lactulose should be considered for the prevention of HE, especially after the second episode of HE recurrence.