Lisa Hall Zimmerman

Effects of vitamin D deficiency in critically ill surgical patients.

BACKGROUND The incidence of vitamin D deficiency in critically ill patients is reported to be up to 50%, with a 3-fold increase in predicted mortality, but limited data exist concerning vitamin D deficiency in critically ill surgical patients. METHODS Sixty-six adult surgical intensive care unit patients who had 25-hydroxyvitamin D serum levels evaluated from January 2010 to February 2011 were prospectively identified. Patients were divided into groups according to vitamin D level (<20 vs ≥20 ng/mL). RESULTS Of the 66 patients evaluated, 49 (74%) had vitamin D levels < 20 ng/mL, and 17 (26%) had vitamin D levels ≥ 20 ng/mL. Patients with vitamin D levels < 20 versus ≥ 20 ng/mL had longer lengths of hospital stay. Lengths of intensive care unit stay were clinically longer, although not significant. Infection rates tended to be higher (P = .09), and a higher incidence of sepsis was seen in the patients with vitamin D levels < 20 ng/mL. CONCLUSIONS Vitamin D levels < 20 ng/mL have a significant impact on length of stay, organ dysfunction, and infection rates. More data are needed on the value of supplementation to improve these outcomes.

Causes and Consequences of Critical Bleeding and Mechanisms of Blood Coagulation

Pharmacists who practice in the critical care setting require a solid background on the causes and consequences of bleeding, as well as the mechanisms of hemostasis. This article provides an overview of these topics. Bleeding and outcomes as a result of surgery and trauma, from medical and pharmacologic causes, and in obstetrics and gynecology are discussed. Patients with brain trauma, those with inherited and acquired bleeding disorders, and patients undergoing therapeutic anticoagulation are addressed, as these are populations at special risk for severe bleeding. Bleeding events as a result of hypothermia, acidosis, and disseminated intravascular coagulation are also discussed, as is the pathophysiology of massive blood loss. Traditional and newer cell‐based models of coagulation mechanisms are described and compared. Application of this information in pharmacy practice will help ensure that therapies to manage and arrest blood loss are used appropriately in a wide variety of clinical scenarios.

Impact of minimizing diagnostic blood loss in the critically ill

BACKGROUND The use of a small-volume phlebotomy tube (SVPT) versus conventional-volume phlebotomy tube (CVPT) has led to a decrease in daily blood loss. Blood loss due to phlebotomy can lead ultimately to decreased rates of anemia and blood transfusions, which can be important in the critically ill patient. METHODS We compared SVPT vs CVPT retrospectively in critically ill adult patients age ≥18 years admitted to a surgical intensive care unit for ≥48 hours. CVPT were evaluated from January 2011 to May 2011 and SVPT from June 2012 to October 2012. RESULTS Amount of blood drawn for laboratory tests and transfusions were evaluated in 248 patients (116 SVPT vs 132 CVPT). When compared with CVPT, total blood volume removed (mean ± SD) with SVPT was less overall, 174 ± 182 mL vs 299 ± 355 mL, P = .001. Daily blood draws also were less, 22.5 ± 17.3 mL vs 31.7 ± 15.5 mL, P < .001. The units of packed red blood cells given were not significant, 4.4 ± 3.6 units vs 6.0 ± 8.2 units, P = .16. CONCLUSION The use of SVPT blood sampling led to a decreased amount of blood drawn. Strategies that use SVPT in a larger cohort also may decrease the number of transfusions in selected patients. Every effort should be made to use SVPT.

Twelve hundred abscesses operatively drained: An antibiotic conundrum?

BACKGROUND The incidence of soft tissue infections from antimicrobial-resistant pathogens is increasing. This study evaluated the epidemiology of operatively drained soft tissue abscesses. METHODS This retrospective study evaluated 1,200 consecutive patients from 2002 to 2008 who underwent incision and drainage (I&D) in the main operating room. Patients were excluded for perirectal or hidradenitis infections. RESULTS Of 1,200 consecutive cases with an I&D, 1,005 patients had intraoperative cultures. The 1,817 positive isolates included gram-positive aerobes (1,180 [65%]), gram-negative aerobes (207 [11%]), anaerobes (416 [23%]), and fungi (14 [1%]). The most prevalent organism was Staphylococcus aureus, 30% (536), with 80% (431) being methicillin-resistant S aureus (MRSA). MRSA was the predominant organism in all except the breast abscesses. Anaerobes were identified primarily in the breast in diabetics, and in trunk and extremity abscesses in intravenous drug users. The most frequently prescribed empiric antibiotic was ampicillin/sulbactam (66%). The initial empiric antibiotic did not cover MRSA (82%; P < .001), resistant gram-negative aerobes (24%), and anaerobes (26%). CONCLUSION Gram-positive aerobes plus anaerobes represented approximately 80% of the pathogens in our series, with the anaerobic rates being underestimated. Empiric antibiotics should cover MRSA and anaerobes in patients with superficial abscesses drained operatively.

Impact of evaluating antibiotic concentrations in abdominal abscesses percutaneously drained

BACKGROUND Appropriate antibiotic therapy and prompt drainage are essential for optimal results with abdominal abscesses. METHODS In this prospective study, 47 abdominal abscesses from 42 patients over 2 years who had percutaneous drainage were evaluated. Antibiotic concentrations were evaluated from the abscess fluid and correlated with clinical and microbiologic cure. RESULTS Only 23% of patients had appropriate antibiotic selection with optimal concentrations for the bacteria recovered. Piperacillin/tazobactam, cefepime, and metronidazole provided adequate concentrations in all except the largest abscesses, whereas fluconazole required higher doses in all abscesses. Vancomycin and ciprofloxacin levels were inadequate in most abscesses. With gram-negative aerobes, the use of appropriate antibiotics resulted in a relatively higher incidence of presumed eradication (100% [4 of 4] vs 75% [9 of 12], P = .26). With ≥ 3 organisms identified, clinical failure was significant (58% vs 13%, P = .01). CONCLUSIONS For optimal treatment, abdominal abscesses require prompt drainage and properly selected antibiotics at adequate doses. Essential information can be obtained from abscess cultures and their antibiotic concentrations.

896: ANTICOAGULATION VARIABILITY WITH HEPARIN IN PATIENTS RECEIVING EXTRACORPOREAL MEMBRANE OXYGENATION

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Anticoagulation is required during extracorporeal membrane oxygenation (ECMO) to prevent thrombosis and clotting of the ECMO circuit with unfractionated heparin being used most commonly. Established dosing and targets are limited and protocols vary between institutions. This study evaluates the effectiveness and safety of two heparin dosing strategies in critically ill patients receiving ECMO. Methods: This IRB approved, retrospective study evaluated critically ill adult patients who received anticoagulation with heparin while on ECMO 10/2012–6/2017. Protocol A (PA) targets PTT 45–60 seconds and protocol B (PB) targets PTT 60–80 seconds. Both protocols utilized the same weight-based adjustment strategy. Time to therapeutic PTT, thrombosis and bleeding rates were assessed. Results: Of the 59 patients who received ECMO, 36 (23PA, 13PB) met inclusion with a mean age of 60 ± 10 years and APACHE II of 26 ± 7. Primary ECMO was venous-atrial with a duration of 175 ± 92 hrs. Heparin was initiated 1.0 ± 0.6 days from the start of ECMO and continued 138.5 ± 95.7 hrs. Both protocols initiated heparin at 10 units/kg/hr resulting in more median dose adjustments in PB (3PB vs 2PA, p = 0.02). Time to target PTT was achieved faster with PA (11PA vs 36PB, hrs, p = 0.02), and more likely to sustain target PTT (55%PA vs 22%PB, p = 0.008). Resultant PTTs were 63.5 ± 29.2 with heparin 10–12 units/kg/hr and 43.5 ± 11.6 sec with < 10 units/kg/hr. Of the 248 PTTs in PA, 55% met target PTT with a mean dose of 12.5 ± 4.3 unit/kg/hr. Of the 142 PTTs in PB, 22% met target PTT with a mean dose of 12.7 ± 4.7. Bleeding and thrombotic events were similar between protocols. Conclusions: In ECMO patients, prompt attainment of therapeutic anticoagulation with heparin is important to the ECMO circuit viability. Patients initiated on PA (PTT target 45–60 secs) achieved therapeutic PTTs faster than patients targeting PTTs 60–80 secs. Heparin dosing protocols should be optimized to obtain targeted PTTs promptly.

1541: IMPACT OF TRANEXAMIC ACID ON TRANSFUSIONS PRE- VS POST-PROTOCOL IMPLEMENTATION IN TRAUMA PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) blood loss and more exposed to RBC transfusions. In this subgroup analysis, we address the question whether fresh RBC units are safer than standard delivery RBC units in perioperative intensive care unit (ICU) patients enrolled in ABLE. Methods: The ABLE randomized controlled trial included 2510 ICU patients who had a request for a first RBC transfusion in the 1st week in ICU, and an anticipated length of mechanical ventilation of 48 hours. We included perioperative patients, but excluded elective cardiac surgeries and trauma. Participants were randomised to receive either RBC stored ≤7 days or standard issue RBC. The primary outcome was 90-day all-cause mortality. Results: 172 perioperative patients were randomized to the fresh and 151 to the standard group which overall represents 13.3% of the ABLE population. Baseline data were similar. The length of storage was 7.2 ± 6.4 in fresh and 20.6 ± 8.4 days in standard group (P<0.0001). The 90-day mortality was 29.7% and 28.5%, respectively (absolute risk difference: 0.012: -0.088,0.111; p=0.817). Similar results were obtained in per protocol and sensitivity analysis. The same trend against fresh blood was observed for most secondary outcomes, including 6-month mortality and nosocomial infection even after adjustment for age, country and APACHE score. Conclusions: Our subgroup analysis of ABLE study demonstrated no superiority in fresh blood (≤7 days) compared to standard blood in perioperative critically ill adults, consistently with the ABLE study, in all primary and secondary outcomes. RBC delivered according to the first-in first-out (FIFO) principle is safe and there is no justification to recommend fresh blood in this population.

609: ARE WE PROVIDING ADEQUATE ANALGESIA & SEDATION TO CRITICALLY ILL, MECHANICALLY VENTILATED PATIENTS?

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263: IMPACT OF INDUCED HYPOTHERMIA ON CARDIAC ARREST SURVIVAL AND ASSOCIATED INITIAL RHYTHM

in 15 (83%) and SC in 3 (17%). MRI findings showed cortical injury alone in 50% of C vs 33% of SC (NS), cortical and subcortical in 50% C vs 67% SC, and subcortical alone or no injury in none. Good outcome was obtained in 0% C vs 33% SC. Of note, the single patient with SC myoclonus by EEG and good outcome had multifocal cortical injury on MRI. Conclusions: This pilot study found that patients after cardiac arrest classified into “cortical” or “subcortical” types of myoclonus based on EEG data were similar regarding distribution of MRI abnormalities. Additional research is warranted to explain the variable presentations and outcomes associated with myoclonus after cardiac arrest.