Christine Ahrens

Effect of low-calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: a randomized, controlled trial.

Objective:To determine the effect of a low-calorie parenteral nutrition (PN) regimen on the incidence and severity of hyperglycemia and insulin requirements. Design:Prospective, randomized, clinical trial. Setting:Urban, university-affiliated, level-I trauma center. Patients:Consecutive surgical patients requiring PN. Interventions:Patients were randomized to receive either a low-calorie PN formulation (20 nonprotein kilocalories per kg per day) or a standard PN formulation (30 nonprotein kilocalories per kg per day). Lipid-derived calories were standardized to 1000 kilocalories three times weekly for all patients; consequently, the number of calories varied only by the amount of carbohydrate administered. Protein requirements were individualized on the basis of estimated metabolic stress. Hyperglycemia was defined as a blood glucose level ≥200 mg/dL. Measurements and Main Results:Forty patients were evaluated (low-calorie PN, n = 20; standard PN, n = 20). Demographics of the two groups were similar. The incidence of hyperglycemic events was significantly lower in the low-calorie group (0% [0–0.5] vs. 33.1% [0–58.4]; p = .001]. Additionally, the severity of hyperglycemia was also lower in the low-calorie group (mean glucose area under the curve = 118 ± 22 [mg·hr]/dL vs. 172 ± 44 [mg·hr]/dL; p < .001). This resulted in lower average daily insulin requirements (0 [0–0] units vs. 10.9 [0–25.6] units; p < .001.). The only predictor of hyperglycemia was a dextrose administration rate >4 mg/kg/min. Conclusions:Administration of a low-calorie PN formulation resulted in fewer and less-severe hyperglycemic events and lower insulin requirements. PN regimens should not exceed a dextrose administration rate of 4 mg/kg/min to avoid hyperglycemic events.

A Review of Recombinant Factor VII for Refractory Bleeding in Nonhemophilic Trauma Patients

BACKGROUND Recombinant factor VII (rFVII) is an attractive agent to control refractory, coagulopathic bleeding in patients following major surgery. The purpose of this review is to evaluate the published experiences of rFVII in adult, nonhemophilic, surgical and trauma patients. METHODS A computerized literature search was conducted to identify articles pertaining to rFVII use for refractory bleeding in adult, nonhemophilic, surgical patients. The selected articles were reviewed and the applicable data was analyzed. RESULTS A total of 117 patients were found in 8 case series and 24 case reports. Overall, rFVII was effective in restoring hemostasis in 99/117 (85%) patients with 76/99 (77%) surviving to hospital discharge. In trauma patients, hemostasis was achieved in 20/26 (77%) patients and 17/20 (85%) survived. There were 5 (4%) thromboembolic events observed in the 117 cases and much disparity was noted with the initial dose. Severe acidosis affected the activity of rFVII. CONCLUSION Recombinant factor VII is an effective therapeutic agent for achieving hemostasis in nonhemophilic surgical patients. Published clinical experiences, however, are limited to small case series and case reports.

Prehemorrhage statin use and the risk of vasospasm after aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE Aneurysmal SAH is often followed by delayed ischemic deficits attributable to cerebral vasospasm. Recent studies suggest a positive impact of statin therapy on the incidence of vasospasm. This study was designed to assess whether a history of prior use of statin therapy was associated with a lower risk of vasospasm in patients with SAH. METHODS We performed a comprehensive retrospective review of patients with aneurysmal SAH between 1997 and 2004. Clinical demographics and imaging data for all patients were reviewed, and a logistic regression analysis was performed to identify the predictors of cerebral vasospasm, defined as a combination of clinical signs with radiographic confirmation. RESULTS Three hundred eight patients were included. Mean age was higher in the group receiving statins (64 +/- 12 vs 54 +/- 12 years). Hunt and Hess scores and treatment modality were not significantly different between the groups. Vasospasm was observed in 31% of patients not taking a statin (n = 282) vs 23% taking a statin (n = 26), without achieving statistical significance. Discontinuation of the statin did not affect risk of vasospasm. CONCLUSIONS Use of a statin prior to an aneurysmal SAH trended to reduce the incidence of subsequent vasospasm, without achieving statistical significance.

Discontinuation of vasopressin before norepinephrine increases the incidence of hypotension in patients recovering from septic shock: a retrospective cohort study.

PURPOSE There are little data regarding the discontinuation of vasoactive medications in patients recovering from septic shock. We designed this retrospective cohort study to evaluate the incidence of hypotension based on the order of removal of norepinephrine (NE) and vasopressin (AVP) in patients receiving concomitant NE and AVP infusions for the treatment of septic shock. MATERIALS AND METHODS Consecutive patients receiving concomitant NE and AVP infusions for septic shock admitted to the intensive care units of a tertiary care academic medical center were evaluated. RESULTS Of 50 included patients, the first vasoactive medication discontinued was NE in 32 patients and AVP in 18 patients. The groups had similar Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores at shock onset and at the time of discontinuation of the first agent. Five patients who had NE discontinued first (16%) versus 10 patients who had AVP discontinued first (56%) developed hypotension within 24 hours (unadjusted relative risk, 3.6; 95% confidence interval, 1.5-4.5; P = .008). In a multivariate analysis, only discontinuation of AVP first was independently associated with hypotension (adjusted relative risk, 5.9; 95% confidence interval, 1.7-21.0; P = .006). CONCLUSIONS Discontinuation of AVP before NE may lead to a higher incidence of hypotension in patients recovering from septic shock receiving concomitant AVP and NE.

Neurotoxicity of commonly used hepatic drugs.

Neurologic complications are common side-effects of immunosuppressive medications used in the prevention of graft rejection after organ transplantation. The medications most commonly encountered include the calcineurin inhibitors and mycophenolate mofetil. Depression is the most commonly encountered neurotoxicity; however, severe but rare adverse neurological effects related to these therapies have been reported. Interferons, ribavirin, and protease inhibitors are therapeutic options commonly encountered in the treatment of hepatitis. Nucleoside analogs such as adefovir dipivoxil and entecavir carry significant risks for the development of lactic acidosis and hepatic dysfunction; however, most common adverse effects to these therapies in general are mild. While the mechanisms of action are poorly elucidated, they are discussed along with treatment strategies.

Antimicrobial Monotherapy versus Combination Therapy for the Treatment of Complicated Intra-Abdominal Infections

It is unknown if β‐lactam monotherapy is sufficient for complicated intra‐abdominal infections or if broader coverage is required, such as with vancomycin. This study sought to determine the clinical outcomes of piperacillin/tazobactam (PIP/TAZ) monotherapy compared to combination therapy with vancomycin and PIP/TAZ for complicated intra‐abdominal infections among patients within a surgical intensive care unit (ICU).

Evolution of Cerebral Atrophy in a Patient with Super Refractory Status Epilepticus Treated with Barbiturate Coma

Introduction. Status epilepticus is associated with neuronal breakdown. Radiological sequelae of status epilepticus include diffusion weighted abnormalities and T2/FLAIR cortical hyperintensities corresponding to the epileptogenic cortex. However, progressive generalized cerebral atrophy from status epilepticus is underrecognized and may be related to neuronal death. We present here a case of diffuse cerebral atrophy that developed during the course of super refractory status epilepticus management despite prolonged barbiturate coma. Methods. Case report and review of the literature. Case. A 19-year-old male with a prior history of epilepsy presented with focal clonic seizures. His seizures were refractory to multiple anticonvulsants and eventually required pentobarbital coma for 62 days and midazolam coma for 33 days. Serial brain magnetic resonance imaging (MRI) showed development of cerebral atrophy at 31 days after admission to our facility and progression of the atrophy at 136 days after admission. Conclusion. This case highlights the development and progression of generalized cerebral atrophy in super refractory status epilepticus. The cerebral atrophy was noticeable at 31 days after admission at our facility which emphasizes the urgency of definitive treatment in patients who present with super refractory status epilepticus. Further research into direct effects of therapeutic coma is warranted.

Institutional care paths: Development, implementation, and evaluation

PURPOSE The Cleveland Clinic experience with care paths, including their creation and implementation, challenges overcome during development and testing, and outcomes of selected care path evaluations, is described. SUMMARY Care paths are tools to assist healthcare professionals in practicing evidence-based medicine. The Cleveland Clinic health system has implemented or is developing approximately 100 care paths, including care paths designed to optimize management of sepsis and septic shock and to promote timely use of i.v. tissue plasminogen activator and correct dosing of antithrombotics and statins in patients with stroke. Key steps in successful care path initiatives include (1) identifying key stakeholders, (2) achieving stakeholder consensus on a standardized approach to disease or condition management, (3) cultivating provider awareness of care paths, (4) incorporating care path tools into the electronic health record and workflow processes, and (5) securing the resources to develop, implement, and maintain care paths. Electronic health records facilitate the use of and adherence to care paths. After care path implementation, revisions are typically needed due to unexpected issues not initially identified and to optimize care path features and support resources for clinical practice. Ongoing evaluation is required to determine whether an implemented care path is producing the intended patient and quality performance outcomes. CONCLUSION Care paths provide a standardized approach to treatment or prevention of a disease or condition, reducing unnecessary variability and expense while promoting optimal, cost-effective patient care.

1313: Bleeding from Disseminated Intravascular Coagulation after Prothrombin Complex Concentrate

Introduction: Prothrombin complex concentrates (PCCs) have been used to treat life threatening bleeding associated with oral vitamin K antagonists. The major concern with PCC use has been the risk of thrombotic complications, such as myocardial infarction, venous thromboembolism, stroke, and dissemi