Kara L. Birrer

Hypocalcemia in trauma patients receiving massive transfusion

BACKGROUND Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium is vital for coagulation, but hypocalcemia commonly occurs during massive transfusion due to citrate and serum calcium chelation. This study was conducted to determine the incidence of hypocalcemia and severe hypocalcemia in trauma patients who receive massive transfusion and to compare characteristics of patients with severe versus nonsevere hypocalcemia. MATERIALS AND METHODS This was a retrospective study of trauma patients who received massive transfusion between January 2009 and November 2013. The primary outcome was the incidence of hypocalcemia (ionized calcium [iCa] < 1.12 mmol/L) and severe hypocalcemia (iCa < 0.90 mmol/L). Secondary outcomes included calcium monitoring, calcium replacement, and correction of coagulopathy. RESULTS There were 156 patients included; 152 (97%) experienced hypocalcemia, and 111 (71%) had severe hypocalcemia. Patients were stratified into iCa ≥ 0.90 (n = 45) and iCa < 0.90 (n = 111). There were no differences in demographics or baseline laboratories except the severe hypocalcemia group had higher baseline activated partial thromboplastin time (29.7 [23.7-50.9] versus 25.8 [22.3-35.9], P = 0.003), higher lactic acid (5.8 [4.1-9.8] versus 4.0 [3.1-7.8], P = 0.019), lower platelets (176 [108-237] versus 208 [169-272], P = 0.003), and lower pH (7.14 [6.98-7.28] versus 7.23 [7.14-7.33], P = 0.019). Mortality was higher in the severe hypocalcemia group (49% versus 24%, P = 0.007). Patients in the iCa < 0.90 group received more blood products (34 [23-58] versus 22 [18-30] units, P < 0.001), and calcium chloride (4 [2-7] versus 3 [1-4] g, P = 0.002), but there was no difference in duration of MTP or final iCa. Neither group reached a median iCa > 1.12. CONCLUSIONS Hypocalcemia is common during MTP, and vigilant monitoring is warranted. Research is needed to effectively manage hypocalcemia during massive transfusion.

Measures to improve safety of an elastomeric infusion system for pain management

PURPOSE Measures to improve the safe implementation and utilization of an elastomeric infusion system for pain management are described. SUMMARY Due to the multiple safety concerns associated with the use of the On-Q infusion systems (I-Flow Corporation, Lake Forest, CA) in a community-based teaching institution, a multidisciplinary team of physicians, pharmacists, clinical nurses, nurse educators, and computer informatics personnel was formed to develop a standardized policy and procedure to ensure the safe use of On-Q pumps. The policy addressed several problems concerning prescribing, dispensing, administration, and monitoring of these pumps. The patient care policy for use of On-Q pumps dictates how the pumps are stocked, ordered, dispensed, administered, and monitored and the drugs approved for use in the pumps. Education bulletins, a summary of the new policy and procedure, and a formal presentation of the policy and procedure to unit-based nurse educators were provided. The focus was on a consistent message of safety by reiterating the problems described with these pumps in the literature and in the health care system itself. The physicians ordering the devices have provided positive feedback regarding the simplified ordering process and standardization of the pumps, medications, and concentrations. Both dispensing pharmacists and bedside nurses have noted that the orders are clearly communicated via the computerized system. The addition of documentation in the computer system and education regarding potential signs and symptoms of adverse events with the medication used with the pumps was greatly appreciated by the nursing staff. CONCLUSION A health care system instituted measures to enhance the safety of using an elastomeric infusion system for pain management.

Diazepam as a component of goal-directed sedation in critically ill trauma patients.

PURPOSE Limited information addressing the safety and efficacy of diazepam in the intensive care unit, particularly in trauma patients, is available. The purpose of this study is to evaluate the safety and efficacy of diazepam when used in routine clinical practice as a component of a goal-directed sedation regimen in critically ill trauma patients. MATERIAL AND METHODS This is a prospective observational evaluation of adult trauma patients admitted to an intensive care unit with orders for as-needed midazolam or lorazepam followed by scheduled diazepam. Medication administration and Sedation-Agitation Scale scores were recorded. RESULTS Twenty-four patients were evaluated. The most common diazepam dosage was 10 mg every 6 hours, and individual doses ranged from 5 to 30 mg. Sedation-Agitation Scale scores were recorded a median of 20 times per day (interquartile range, 15-24), and the majority (68%) were in the target range. No diazepam-related adverse events were observed. CONCLUSIONS Based on this limited sample, the use of diazepam as a component of goal-directed therapy appears safe and effective in providing adequate sedation in critically ill trauma patients using an average dosage of 40 mg/d.

Nebulized Colistin for the Treatment of Multidrug-Resistant Gram-Negative Pneumonia

Purpose To describe the use of nebulized colistin (colistimethate sodium) for the treatment of multidrug-resistant gram-negative infections. Specific aims were to identify dose and frequency of nebulized colistin therapy currently used, to assess clinical and microbiological efficacy, and to assess the prevalence of adverse events resulting from colistin therapy. Methods A retrospective chart review was performed at a tertiary care, level I trauma center and teaching hospital. The review included examination of 29 courses of colistin therapy administered to 24 adults receiving at least 24 hours of nebulized colistin for the treatment of gram-negative pneumonia. Results Demographic, medication, adverse event, and outcome data were collected for the duration of colistin therapy. Colistin was administered to patients with multidrug-resistant infections caused by gram-negative organisms. Many patients had a history of exposure to multiple antibiotics or drug allergies. Resistance to colistin was observed in 3 of 18 isolates with available susceptibility data. Determining the prevalence of adverse events was difficult because of the use of multiple medications. Many patients had missed antibiotic doses. A 25% mortality rate was observed. Conclusion The findings of this study serve to demonstrate the use of nebulized colistin for treatment of multidrug-resistant gram-negative pneumonia in patients without cystic fibrosis; to raise concern with regard to the large number of missed antibiotic doses; and to emphasize the need for further investigation by a larger, prospective, randomized trial.

Haloperidol Use in Acute Traumatic Brain Injury: A Safety Analysis

Background: The association of delirium with poor outcomes creates a complex picture in traumatic brain injury patients by exacerbating an already increased risk for neurobehavioral sequelae. Haloperidol is commonly used for agitation and delirium; however, adverse events are concerns associated with its use in traumatic brain injury patients. The objective of this study was to assess the safety of haloperidol for the management of agitation and delirium in acute traumatic brain injury. Methods: A retrospective cohort study was conducted of adult ICU patients admitted from January 2007 to October 2009 with traumatic brain injury and admission Glasgow Coma Score ≤ 12. Incidence of complications (seizures, neuroleptic malignant syndrome, QTc prolongation, extrapyramidal symptoms, hematologic disturbances) and haloperidol prescribing patters were assessed. Results: A total of 101 patients were included (56 non-haloperidol, 45 haloperidol). There was no difference in types of brain injury. Haloperidol was initiated on average day 8 of admission, and the median daily dose was 9 mg for a median duration of 4 days. The haloperidol group received more analgesics (morphine equivalents) [714 vs. 252 mg, p<0.001], and more patients in the haloperidol group received benzodiazepines compared to non-haloperidol group [98% vs. 79%, p=0.005]. There was no significant increase in adverse events associated with haloperidol use. Patients in the haloperidol group who developed complications received a higher mean daily dose [p=0.013]. There was no difference in length of mechanical ventilation but the haloperidol group had a longer hospital length of stay. Conclusion: Treatment of agitation and delirium with haloperidol in acute traumatic brain injury patients is not associated with an increased incidence of complications.

881: IMPACT OF AN EMERGENCY DEPARTMENT PHARMACIST ON THE MANAGEMENT OF ACUTE ISCHEMIC STROKE

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) adverse events; specifically no episodes of QTc prolongation or extrapyramidal side effects. In addition, patients evaluated had an overall decrease in their levels of agitation, improved sedation scores (RASS), and decreases in the dose and duration of sedatives/analgesics required. Conclusions: Based upon these results, haloperidol continuous infusion appears to be a safe and effective option for the management of refractory ICU agitation/delirium in patients that had a poor response to standard medication therapies. Larger studies are needed to confirm these results.

1066: THE INCIDENCE OF HYPOCALCEMIA IN TRAUMA PATIENTS RECEIVING MASSIVE TRANSFUSION PROTOCOL

Learning Objectives: Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium (Ca) is vital to the coagulation pathway, but hypocalcemia (hypoCa) is common during MTP due to citrate and serum Ca binding. There is a paucity of data describing the incidence and clinical significance of hypoCa during MTP. This study was conducted to determine the incidence of hypoCa in trauma patients who receive MTP. We hypothesized that hypoCa is common during MTP and may perpetuate coagulopathy. Methods: This was a retrospective study of consecutive trauma patients who received MTP between Jan 2009 and Dec 2013. Data was collected from admission through 24 hours after discontinuation of MTP or death. Patients were excluded for incomplete records and age <18 years. Demographics, injury severity score, fluid and blood product administration, ionized Ca (iCa), and Ca replacement were collected. HypoCa was defined as iCa <1.12 mmol/L and severe hypoCa as iCa <0.90 mmol/L. Results: A total of 172 MTP patients were identified and 156 included. Of these, 91(58%) survived and 65(42%) expired. There were no differences in demographics or baseline labs except non-survivors (Non-S) had higher PT (19.9 ± 17 vs. 13.2 ± 4, p<0.01) and aPTT (59.9 ± 40 vs. 33.6 ± 31, p<0.01), lower pH (7.09 ± 0.2 vs. 7.18 ± 0.2, p<0.01), and received more blood products (52 ± 41 vs. 34 ± 24 units, p<0.01). There was no difference in fluid administered between groups. HypoCa occurred in 90(99%) survivors (S) and 62(95%) Non-S (p=0.3). Severe hypoCa occurred more frequently in Non-S vs. S [54(83%) vs. 57(63%), p<0.01]. Non-S received more total Ca replacement (5.4 ± 4.4 vs. 3.9 ± 3.3 gm, p=0.01) and were more likely to have uncorrected coagulopathy at the end of MTP (18.5% vs. 1.1%, p<0.01). Multivariate logistic regression was performed using baseline PT, aPTT, pH, temperature, total blood units and severe hypoCa to predict failure of coagulopathy reversal. Only temperature and aPTT were significant predictors (p=0.04, p=0.03, respectively). Conclusions: HypoCa is common during MTP, but severe hypoCa was not a predictor of coagulopathy reversal.

Critical Care Therapeutics - Use of Hypertonic 7.5% Sodium Chloride (NaCl) Solution in Patients with Traumatic Brain Injuries; Trauma: Antibiotics in Open Fractures; Sedation Update: Time for a Change?

This feature examines the impact of pharmacologic interventions on the treatment of the critically ill patient — an area of health care that has become increasingly complex. Recent advances in drug therapy (including evolving and controversial data) for adult intensive-care-unit patients will be reviewed and assessed in terms of clinical, humanistic, and economic outcomes. Direct questions or comments to Sandra Kane-Gill, PharmD, MSc, at kanesl@upmc.edu.