Christopher A. Paciullo

Multidrug-Resistant Organism Infections in Patients with Left Ventricular Assist Devices

Left ventricular assist devices improve survival prospects in patients with end-stage heart failure; however, infection complicates up to 59% of implantation cases. How many of these infections are caused by multidrug-resistant organisms is unknown. We sought to identify the incidence, risk factors, and outcomes of multidrug-resistant organism infection in patients who have left ventricular assist devices. We retrospectively evaluated the incidence of multidrug-resistant organisms and the independent risk factors associated with them in 57 patients who had permanent left ventricular assist devices implanted at our institution from May 2007 through October 2011. Outcomes included death, transplantation, device explantation, number of subsequent hospital admissions, and number of subsequent admissions related to infection. Infections were categorized in accordance with criteria from the Infectious Diseases Council of the International Society for Heart and Lung Transplantation. Multidrug-resistant organism infections developed in 18 of 57 patients (31.6%)-a high incidence. We found 3 independent risk factors: therapeutic goal (destination therapy vs bridging), P=0.01; body mass index, P=0.04; and exposed velour at driveline exit sites, P=0.004. We found no significant differences in mortality, transplantation, or device explantation rates; however, there was a statistically significant increase in postimplantation hospital admissions in patients with multidrug-resistant organism infection. To our knowledge, this is the first report in the medical literature concerning multidrug-resistant organism infection in patients who have permanent left ventricular assist devices.

Ketamine in adult cardiac surgery and the cardiac surgery Intensive Care Unit: an evidence-based clinical review.

Ketamine is a unique anesthetic drug that provides analgesia, hypnosis, and amnesia with minimal respiratory and cardiovascular depression. Because of its sympathomimetic properties it would seem to be an excellent choice for patients with depressed ventricular function in cardiac surgery. However, its use has not gained widespread acceptance in adult cardiac surgery patients, perhaps due to its perceived negative psychotropic effects. Despite this limitation, it is receiving renewed interest in the United States as a sedative and analgesic drug for critically ill-patients. In this manuscript, the authors provide an evidence-based clinical review of ketamine use in cardiac surgery patients for intensive care physicians, cardio-thoracic anesthesiologists, and cardio-thoracic surgeons. All MEDLINE indexed clinical trials performed during the last 20 years in adult cardiac surgery patients were included in the review.

Management of hypertensive emergency and urgency.

Severe hypertension is a frequent condition among patients presenting to emergency departments. Historically, this has been referred to as a hypertensive crisis. In addition, these hypertensive crises have been further divided into either hypertensive emergencies or urgencies depending on the presence or absence of target organ damage, respectively. The management differs between these crises in both the rapidity of blood pressure correction and the medications used. Hypertensive emergencies must be treated immediately with intravenous antihypertensive medications. However, hypertensive urgencies may be treated with oral antihypertensive agents to reduce the blood pressure to baseline or normal over a period of 24–48 hr. Appropriate identification, evaluation, and treatment of these conditions are of great importance in the emergency department to prevent progression of organ damage and death. The purpose of this article is to provide an overview of the hypertensive crises and their management.

Effect of positive perioperative donor and recipient respiratory bacterial cultures on early post‐transplant outcomes in lung transplant recipients

It is standard practice to administer prophylactic antibiotics post lung transplantation. However, no studies have evaluated the impact of culture positivity. The purpose of this study was to evaluate early post‐transplant outcomes of culture‐positive and culture‐negative lung transplant (LT) recipients and the appropriateness of the empiric regimens used.

Methylene blue for postcardiopulmonary bypass vasoplegic syndrome: A cohort study

Background: Methylene blue (MB) has been used to treat refractory hypotension in a variety of settings. Aims: We sought to determine whether MB improved blood pressure in postcardiopulmonary bypass (CPB) vasoplegic syndrome (VS) in a complex cardiac surgery population. Furthermore, to determine variables that predicted response to MB. Setting and Design: This was conducted in a tertiary care medical center; this study was a retrospective cohort study. Materials and Methods: Adult cardiac surgery patients who received MB for post-CPB VS over a 2-year period were studied. Mean arterial blood pressure (MAP) and vasopressor doses were compared before and after MB, and logistic regression was used to model which variables predicted response. Results: Eighty-eight patients received MB for post-CPB VS during the study period. MB administration was associated with an 8 mmHg increase in MAP (P = 0.004), and peak response occurred at 2 h. Variables that were associated with a positive drug response were deep hypothermic circulatory arrest during surgery and higher MAP at the time of drug administration (P = 0.006 and 0.02). A positive response had no correlation with in-hospital mortality (P = 0.09). Conclusions: MB modestly increases MAP in cardiac surgery patients with VS. Higher MAP at the time of drug administration and surgery with deep hypothermic circulatory arrest predict a greater drug response.

Multiple mini-interviews for pharmacy residency candidates

We read with interest the recent article by Oyler et al.[1][1] describing the incorporation of the multiple mini-interview (MMI) technique into their postgraduate year 1 (PGY1) pharmacy practice residency interview process. We implemented the MMI into our own PGY1 interview process in February 2014

Coagulation and complications of left ventricular assist device therapy: a primer for emergency nurses.

Implantation of left ventricular assist devices (LVADs) is becoming more common with the advancement of mechanical circulatory support technology and the continued insufficient number of organ donors available for heart transplantation. Modern LVADs provide a mechanically induced, nonpulsatile, continuous blood flow that drastically alters the hemodynamic and coagulation profile of patients using these devices. In addition to the risk of bleeding and thrombotic events, LVAD support can also lead to arrhythmias and infection. Although LVAD therapy can prolong life, the majority of patients will experience an adverse event following implantation and many of these complications can result in emergency department visits. By understanding the pathophysiology and management of LVAD complications, emergency nurses will be able to provide prompt and quality care for this unique patient population.

Moderate-to-Large Increases in Perioperative Serum Sodium Concentration Associated With Adverse Neurologic Events After Continuous Flow Left Ventricular Assist Device Implantation

OBJECTIVE It was hypothesized that preoperative hyponatremia is associated with increased 30-day mortality after left ventricular assist device placement, and that large increases in sodium concentration are associated with adverse neurologic events and 30-day mortality. DESIGN Data were collected retrospectively on all patients having continuous flow left ventricular assist device implantation between January 1, 2009 and March 31, 2013. Preoperative variables, operative variables, and perioperative sodium concentrations were recorded. Both 30-day mortality and 72-hour adverse neurologic events (stroke or seizure) were recorded as primary outcome variables. Preoperative sodium and Δ sodium (postoperative sodium-preoperative sodium) were analyzed as tests for 30-day mortality and adverse neurologic events using receiver operating characteristic curves. Both crude and adjusted logistic regression analyses were used to estimate odds ratios for the outcome variables. SETTING Tertiary care academic medical center. PARTICIPANTS Patients having durable continuous flow left ventricular assist device placement. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 88 patients, 30-day mortality was 14% (12 of 88) and the rate of perioperative stroke or seizure was 9% (8 of 88). There were 3 strokes and 5 tonic-clonic seizures. Preoperative sodium was a poor discriminative test for 30-day mortality and stroke or seizure (AUC=0.47 and 0.57, respectively). Δ sodium was a poor discriminative test for 30-day mortality, but a fair discriminative test for stroke or seizure (AUC=0.55 and 0.78, respectively). Δ sodium was a good discriminative test for seizure alone (AUC=0.82) and a fair discriminative test for stroke alone (AUC=0.70). It also increased the odds of stroke or seizure significantly, even when adjusting for possible confounders. CONCLUSIONS Moderate-to-large increases in sodium concentration during left ventricular assist device placement appear to be associated with adverse postoperative neurologic events. Preoperative hyponatremia has no relationship with 30-day mortality or adverse perioperative neurologic events.

Alteplase for the Treatment of Pulmonary Embolism: A Review.

Pulmonary embolism can present with a wide range of symptoms, from asymptomatic to cardiac arrest, making diagnosis challenging. Alteplase is a fibrinolytic that is indicated for the treatment of pulmonary embolism in intermediate- and high-risk patients. Controversy exists as to the patient population that will benefit most from fibrinolytic therapy, as well as the proper dose and administration technique. The patients risk of bleeding should be weighed against the potential benefits of treatment in light of the clinical presentation because of the high mortality rate associated with pulmonary embolism. Nurses at the bedside must monitor for signs of bleeding when alteplase is administered. Fibrinolytic therapy will frequently be started in the emergency department, and the nurse must ensure that alteplase is administered in a safe and effective manner. This review discusses the clinical evidence for alteplase in pulmonary embolism and its specific role in treatment.