Jeffrey J. Bruno

Herbal Use among US Elderly: 2002 National Health Interview Survey

BACKGROUND: Use of herbal products among the elderly is an important concern for healthcare professionals. The presence of polypharmacy and multiple comorbidities places the elderly at high risk for herb—drug and herb—disease interactions. Limited data exist regarding herbal use among the US elderly population. OBJECTIVE: To evaluate the incidence of and attitudes toward herbal use in a nationally representative sample of US elderly patients ⩾65 years of age. METHODS: We performed a descriptive analysis of public domain data collected in the 2002 National Health Interview Survey. Statistical analyses were conducted through use of SUDAAN software with Taylor series linearization for variance estimation. RESULTS: Analysis of weighted data revealed that 12.9% ± 0.5% (mean ± SE) of US elderly people had used an herbal supplement within the past 12 months. Use was greatest among individuals 65–69 years of age, females, Hispanic and non-Hispanic ethnic minorities, and respondents with a greater income, higher education level, or more positive self-reported health status. Among elderly people purchasing over-the-counter and prescription drugs, herbal use was 13.9% ± 0.6% and 12.8% ± 0.6%, respectively. Glucosamine, echinacea, and garlic supplements represented the most common herbals used. Benefit from combined herbal and conventional therapy was the most common reason cited for use; however, 50.9% ± 2.2% of users did not discuss herbal therapy with a medical professional. Several theoretical herb—disease interactions were identified. CONCLUSIONS: The use of herbal products among the US elderly has risen over the past 5 years, whereas discussion of such use with medical professionals remains suboptimal.

Intensive Care Unit Delirium

Once considered a benign iatrogenic consequence of intensive care unit (ICU) admission, ICU delirium is now recognized as a prominent disorder that negatively affects patient morbidity and mortality. The primary goal in the detection and treatment of ICU delirium is to ensure the safety of the patient and caregiver(s). Most critically ill patients possess 1 or more risk factors for the development of delirium; therefore, interventions that target delirium assessment and prevention are essential. This article highlights some of the recent data that have emerged regarding ICU delirium, including its definition, incidence, risk factors, diagnostic tools, and treatment.

US practitioner opinions and prescribing practices regarding corticosteroid therapy for severe sepsis and septic shock

PURPOSE The aim of this study was to examine opinions and practices of US critical care practitioners (USCCPs) toward corticosteroid therapy in adult patients with severe sepsis or septic shock. MATERIALS AND METHODS A multicenter, electronic survey of USCCP members of the Society of Critical Care Medicine was conducted between March 18 and July 31, 2009. RESULTS A total of 542 USCCPs responded to the survey. The majority (83%) do not commonly use corticosteroids in adult patients with severe sepsis; however, up to 81% report use of corticosteroids for septic shock. Twenty-eight percent believe that corticosteroids reduce mortality in septic shock, whereas 27% do not and 45% are unsure. The decision to initiate therapy is based, more often, on a patients clinical status (65%) vs serum cortisol analysis (35%). Hydrocortisone is the most common corticosteroid prescribed (93%), with a median dosage of 200 mg/d and administration via intermittent intravenous injection. The Corticosteroid Therapy of Septic Shock trial had a large impact on survey respondents, with 62% reporting a practice change. Among the 19% of practitioners who do not prescribe corticosteroids, the most common reason was lack of proven survival benefit. CONCLUSIONS Corticosteroids are commonly used by USCCPs in adult patients with septic shock; however, criteria used to initiate therapy and opinions regarding their impact vary.

First-dose pharmacokinetics of aminoglycosides in critically ill haematological malignancy patients

The primary objective of this study was to determine the volume of distribution (Vd) (L/kg) of intravenous aminoglycosides (AGs) in critically ill haematological malignancy patients. Secondary objectives were to determine the body weight (actual, ideal, adjusted or lean) that yields the most precise estimate of Vd when normalised in L/kg as well as the frequency that current first-dose strategies result in post-distributional peak concentrations (C(peak)) within the target range (tobramycin 16-24 mg/L; amikacin 32-48 mg/L). In total, 58 AG doses were included (tobramycin, n = 34; amikacin, n = 24). Median Vd was 0.38 L/kg normalised per the most precise dose weight, which was actual body weight (ABW). The median dose was 445 mg (5.8 mg/kg ABW) for tobramycin and 1200 mg (13.8 mg/kg ABW) for amikacin. Target C(peak) (tobramycin 20mg/L; amikacin 40 mg/L) was achieved in only 25% of all AG episodes, with 4% exceeding the target and 71% falling below the target. Twenty-four organisms were isolated in the study sample; target C(peak) achievement (tobramycin 20 mg/L; amikacin 40 mg/L) would yield a peak:minimum inhibitory concentration of 10 in 75% and 52% of organisms, respectively. In conclusion, an increased Vd of AGs was identified in this critically ill haematological malignancy patient sample, and current dosing yielded a suboptimal C(peak) in the majority of patients.

Stress-related mucosal bleeding in critically ill oncology patients

Objective. To determine the incidence of stress-related mucosal bleeding (SRMB) in a critically ill oncology population receiving stress ulcer prophylaxis (SUP) with either a histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI). Design. Single-center, prospective, observational study. Setting. Fifty-two bed medical-surgical intensive care unit of an academic oncology institution. Patients. A convenience sample of 100 medical and surgical critically ill oncology patients who received intensive care for more than 24 hours and at least one dose of a H2RA or PPI for prevention of SRMB. Interventions. None. Measurements and Main Results. Patients were followed throughout their intensive care unit stay for the development of an overt and/or clinically significant gastrointestinal (GI) bleed. More patients received a PPI (n = 81) in contrast to a H2RA (n = 19) for SUP. Overall, 94 patients (94%) had at least one risk factor for a SRMB with four patients (4%) experiencing an event (overt bleed, n=3; clinically significant bleed, n =1). All cases of GI bleeding occurred in patients receiving a PPI. No ICU deaths were considered directly related to a GI bleed. Conclusions. The incidence of SRMB among high-risk critically ill oncology patients receiving SUP appears low; further, large-scale trials are needed to confirm this finding. J Oncol Pharm Practice (2009) 15: 9—16.

Probable Nonconvulsive Status Epilepticus With the Use of High-Dose Continuous Infusion Ceftazidime

Multidrug resistant (MDR) bacterial infections are a major concern of health care providers due to their increasing incidence and associated mortality. In some cases, few or no antibiotics have preserved activity. Beta-lactam administration via continuous infusion can optimize time over minimum inhibitory concentration (MIC). In some cases, use of high-dose continuous infusion (HDCI) may be necessary to achieve serum levels in excess of nonsusceptible MIC values. The use of HDCI beta-lactams is not without risk, specifically neurotoxic adverse effects, which appear dose related. We describe a 64-year-old male who experienced myoclonus and nonconvulsive status epilepticus while receiving HDCI ceftazidime for treatment of multidrug resistant Pseudomonas aeruginosa bacteremia. This report serves as a cautionary example of the potential toxicities associated with HDCI beta-lactams and supports the importance of risk–benefit analysis prior to and during treatment. Additionally, the use of serum drug level monitoring may be necessary to better prevent or predict toxicity.

Development of a combination antibiogram for Pseudomonas aeruginosa bacteremia in an oncology population

Purpose Development of a combination antibiogram to identify combinations of antibiotics that have the highest likelihood of attaining one active agent in the empiric management of presumed Pseudomonas aeruginosa bacteremia. Methods Patients with cancer and P. aeruginosa bacteremia from January 1 to December 31, 2012 were included in this analysis. The primary outcome was identification of effective combinations of beta-lactam and non-betalactam agents. An effective combination was defined as one which achieved in-vitro activity to greater than or equal to 85% of isolates collected. Furthermore, the addition of the non-beta-lactam agent was required to increase the in-vitro activity by at least 5% over beta-lactam monotherapy. Multiple secondary outcomes were evaluated. Results One hundred and twenty-three P. aeruginosa isolates were included from 99 patients. Single agent beta-lactam sensitivities ranged from 72.4 to 79.7%. Combination regimen sensitivities ranged from 73.5 to 96.7%. All combination regimens that included a beta-lactam plus an aminoglycoside were found to be effective per the study definition. Independent risk factors for MDR P. aeruginosa were receipt of intravenous (IV) antibiotics within 90 days and hospital length of stay (LOS) greater than or equal to five days. Increasing the number of antibiotics received was associated with a decrease in survival to hospital discharge. Conclusions Effective combination regimens included all beta-lactam aminoglycoside regimens. Receipt of IV antibiotics within 90 days and hospital LOS greater than or equal to five days were independent risk factors for MDR isolates.

Effects of Immune-Enhancing Enteral Nutrition on Mortality and Oxygenation in Acute Lung Injury and Acute Respiratory Distress Syndrome: A Meta-Analysis:

Purpose The contribution of the immune system to the pathogenesis of acute respiratory distress syndrome (ARDS) has led to a recent interest in the use of immune-enhancing enteral nutrition as a treatment modality. The purpose of this meta-analysis was to determine the effectiveness of immune-enhancing enteral nutrition as compared with standard enteral nutrition, with respect to mortality and change in oxygenation status, in patients with acute lung injury (ALI)/ARDS. Methods A systematic review was conducted of randomized controlled trials comparing immune-enhancing enteral nutrition with standard enteral nutrition in adult intensive care unit (ICU) patients with ALI/ARDS. Data were combined in a meta-analysis with STATA SE version 9.2 (StataCorp) using a random effects model. Results Three studies fulfilled inclusion criteria, totaling 411 patients. These studies demonstrated a statistically significant relative risk (RR) for in-hospital mortality, favoring patients who received immune-enhancing enteral nutrition (RR, 0.58; 95% confidence interval [CI], 0.42-0.79). With respect to change in oxygenation status, a statistically significant standardized mean difference (SMD) was observed at day 4 (SMD, 1.97; 95% CI, 0.27-3.67), favoring the immune-enhancing enteral nutrition group. At study day 7, the SMD did not reach statistical significance (SMD, 1.71; 95% CI, −0.13 to 3.56). Conclusions Oxygenation and mortality benefits of immune-enhancing enteral nutrition in adult ICU patients with ALI/ARDS have been shown in individual trials and meta-analyses. Subsequent clinical trials and meta-analyses are required to fully elucidate the role of immune-enhancing enteral nutrition in this patient population.

Possible pentostatin-induced symptomatic hyponatremia

Pentostatin is an adenosine deaminase inhibitor used in the treatment of hairy cell leukemia and T‐cell lymphomas. A 27‐year‐old man with refractory cutaneous T‐cell lymphoma developed severe hyponatremia 3 days after completing his first cycle of pentostatin therapy. Shortly after hospital admission, he became disoriented and was admitted to the medical intensive care unit and treated with a combination of hypertonic saline, intravenous diuretics, and fluid restriction to reestablish normal sodium homeostasis. The mechanism by which pentostatin may have induced hyponatremia in this patient is unknown; clinical and laboratory findings represented both extrarenal sodium loss and syndrome of inappropriate antidiuretic hormone. Clinicians should be aware of the possible development of life‐threatening symptomatic hyponatremia in patients receiving pentostatin.

962: USE OF ORDER SETS TO IMPROVE SEDATION AND ANALGESIA PRACTICES IN AN ONCOLOGY INTENSIVE CARE UNIT.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) stratified by response to iNO therapy. We hypothesized that iNO response (20% OI decrease in 6 hours) was associated with survival and duration of mechanical ventilation. Methods: Retrospective observational study of a cohort of children with ARDS (Berlin definition) admitted to the Children’s Hospital of Philadelphia PICU July 2011-June 2016 and exposed to iNO within 3 days of ARDS onset. Cox proportional hazard evaluated association between iNO response and mortality. Competing risk regression assessed association between iNO response and duration of ventilation, with successful extubation as primary outcome and death as competing risk. Models were adjusted for potential confounders. Results: 161 patients met inclusion criteria and were classified as responders (n=98) or nonresponders (n=63). There was no difference between groups in demographics, evidence of pulmonary hypertension, or ARDS etiology/severity. Cox regression showed no association between iNO response and mortality. However, competing risk regression demonstrated iNO response to be associated with shorter duration of mechanical ventilation (SHR 1.65, 95% CI 1.18–2.30, p=0.003), after adjusting for severity of illness/hypoxemia, and immunocompromise. Responders also had significantly less exposure to extracorporeal membrane oxygenation (ECMO, 6% vs 17%, p=0.034) and high-frequency oscillatory ventilation (HFOV, 26% vs 41%, p=0.039). Conclusions: While response to iNO was not associated with mortality, it correlated with shorter duration of ventilation and reduced exposure to ECMO and HFOV. Future trials of iNO in pediatric ARDS should stratify analyses by oxygenation response to iNO.