Eric Bondarsky

Extended Versus Short-Course Corticosteroid Taper Regimens in the Management of Chronic Obstructive Pulmonary Disease Exacerbations in Critically Ill Patients:

Background: Previous literature has suggested that a short course of corticosteroids is similarly effective as an extended course for managing an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, there are limited data regarding the optimal corticosteroid regimen in critically ill patients and the dosing strategies remain highly variable in this population. Methods: This retrospective cohort study evaluated patients with AECOPD admitted to the intensive care unit within a 2-year period. Patients were divided into short-course (≤5 days) or extended-course (>5 days) corticosteroid taper groups. The primary end point was treatment failure, defined as the need for intubation, reintubation, or noninvasive mechanical ventilation. Secondary end points included the duration of mechanical ventilation, hospital and intensive care unit length of stay, and adverse events. Results: Of the 151 patients who met the inclusion criteria, 94 received an extended taper and 57 received a short taper. Treatment failure occurred in 3 patients, who were all in the extended taper group (P = .17). In a propensity score-matched cohort, the hospital length of stay was 7 days in the short taper group compared to 11 days in the extended taper group (P < .0001). No differences in adverse events were observed. Conclusion: A short-course corticosteroid taper in critically ill patients with AECOPD is associated with reduced hospital length of stay and decreased corticosteroid exposure without increased risk of treatment failure. A prospective randomized trial is warranted.

1906: VALPROIC ACID-INDUCED THROMBOCYTOPENIA LEADING TO ALVEOLAR HEMORRHAGE.

Learning Objectives: The incidence rate of thrombocytopenia related to valproic acid (VPA) use is about 5–18%. We describe a unique case of acute hypoxic respiratory failure due to VPA-induced alveolar hemorrhage. A 23-year-old man with a history of hemodialysis-dependent end-stage renal disease secondary to Alport’s syndrome and seizure disorder related to a previous subdural hemorrhage presented with hemoptysis and acute hypoxic respiratory failure requiring intubation. Methods: The patient’s platelet count was 33,000 cells/uL on admission (87,000 cells/uL five days prior; 150,000 cells/uL four months prior). The patient had been taking VPA for three months prior to admission and his dose was increased in the preceding week from 22.5g weekly to 35g weekly. VPA level was therapeutic upon admission. Initial chest x-ray showed bilateral diffuse opacities. The remainder of the workup was unrevealing, including blood and respiratory cultures, anti-glomerular basement membrane antibody, anti-double stranded DNA, anti-neutrophil cytoplasmic antibody (ANCA), rheumatoid factor, antinuclear antibody (ANA), complement levels, Coombs test and peripheral smear. Disseminated intravascular coagulation was ruled out. Bronchoscopy revealed blood originating in the left lower lobe. Thrombocytopenia and hemoptysis persisted despite several platelet transfusions, dexamethasone, desmopressin and broad-spectrum antibiotics. The patient’s hypoxia resolved with ultrafiltration of 10kg over several days. Levetiracetam was started while VPA was tapered off with improvement of the platelet count (peak 121,000 cells/uL) and hemoptysis. Results: Although a rare complication, this case highlights the importance of considering VPA-induced alveolar hemorrhage despite therapeutic VPA levels. Patients receiving VPA should have careful monitoring of their platelet count.