Manasa Murthy

Bivalirudin in pediatric patients maintained on extracorporeal life support.

Objective: Anticoagulation with heparin is standard of care for patients maintained on extracorporeal life support. Very limited evidence exists for the use of alternative anticoagulants during extracorporeal life support. Patients with heparin-induced thrombocytopenia, heparin resistance, and evidence of significant thrombosis while on heparin may be candidates for alternative anticoagulation. The objective of this analysis is to present evidence for the use of bivalirudin during extracorporeal life support in pediatric patients. Design: Case series. Setting: University of California, Davis Medical Center. Patients: Twelve critically ill, pediatric patients receiving bivalirudin for anticoagulation during extracorporeal life support. Interventions: None. Measurements and Main Results: Twelve patients meeting entry criteria received bivalirudin during the study period. The median patient age was 8 days (range, 1 d to 6 yr). Eight patients were neonates. Eight patients were male. Nine patients were supported with venoarterial extracorporeal life support. Median duration of extracorporeal life support was 226 hours (range, 111–913) and median time on bivalirudin was 92 hours (range, 60–230). Bivalirudin bolus doses were administered to select patients without bleeding complications. The maintenance dose that corresponded with initial target activated partial thromboplastin time ranged from 0.045 to 0.48 mg/kg/hr with a median rate of 0.16 mg/kg/hr. The median dose for days 1, 3, and 5 was 0.135, 0.175, and 0.267 mg/kg/hr, respectively. The correlation (r2) between dose adjustment and activated partial thromboplastin time response was 0.264. Conclusions: This is the largest case series describing the use of a direct thrombin inhibitor in pediatric extracorporeal life support patients. The maintenance dose range reflected considerable inter-patient variability. There was an observed increase in dose requirements with time. Bivalirudin, with close monitoring, is a potential option for pediatric patients on extracorporeal life support who have developed heparin-induced thrombocytopenia, heparin resistance, or significant thrombosis while on heparin.

Length of Stay Comparison between Rivaroxaban and Warfarin in the Treatment of Pulmonary Embolism: Results from a Real-World Observational Cohort Study

Background. Trials have shown that novel oral anticoagulants may decrease length of stay versus warfarin. A comparison of length of stay in the treatment of pulmonary embolism (PE) has not been performed outside post hoc analysis of a large clinical trial. Objective. To evaluate if rivaroxaban decreases length of stay compared to warfarin plus enoxaparin in the treatment of PE. Methods. This was a multicenter, retrospective, observational cohort study. Patients were identified based on discharge diagnosis of PE and were excluded if they received anticoagulants prior to admission and had additional indications for anticoagulation or reduced creatinine clearance. The primary endpoint was length of stay. Secondary endpoints included time from initial dose of oral anticoagulant to discharge and length of stay comparison between subgroups. Results. Inclusion criterion was met by 158 patients (82 warfarin, 76 rivaroxaban). The median length of stay was 4.5 days (interquartile range [IQR], 2.7, 5.9) in the warfarin group and 1.8 days (IQR, 1.2, 3.7) in the rivaroxaban group (P < 0.001). Time interval from first dose of oral anticoagulant to discharge was shorter with rivaroxaban (P < 0.001). Conclusions. Patients given rivaroxaban had decreased length of stay versus those given warfarin plus enoxaparin for the treatment of PE.

697: ANTIBIOTIC CHOICE FOR INTRA-ABDOMINAL INFECTIONS DUE TO AMPC BETA- LACTAMASE-PRODUCING ORGANISMS

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: A wide range of Enterobacteriaceae produce AmpC beta-lactamases, which confer resistance to penicillins and most cephalosporins. Recent studies have established cefepime (CEF) as an effective treatment option for AmpC beta-lactamase producing organisms; however, the efficacy of beta-lactam/betalactamase inhibitors is unclear. The objective of this study is to determine if there is a difference in outcomes for patients with intra-abdominal infections (IAI) caused by AmpC beta-lactamase producing organisms treated with CEF with or without metronidazole (MET) vs. piperacillin/tazobactam (PT). Methods: This multicenter, retrospective cohort study included adults with at least one IAI culture positive for an AmpC betalactamase producing organism that received CEF + MET or PT as definitive therapy and undergone at least one source control procedure. The primary outcome was the composite of surgical-site infections, recurrent IAIs, or death. Secondary outcomes included differences in the individual components of the composite outcome, length of stay from index source control procedure, microbiologic failure, length of antibiotic treatment, time to clinical resolution, and incidence of Clostridium difficile infection. Results: Of 736 charts reviewed, 119 included patients met inclusion criteria. Eighty-one patients received CEF + MET and 38 received PT. Baseline characteristics between groups were similar; median patient age and SOFA scores were 48 years and 3.7, respectively. There was no difference in the primary composite, which consisted only of treatment failure, between CEF + MET or PT groups (35% vs. 26.7%; p = 0.14). There were no significant differences in secondary outcomes other than microbiological failure which was significantly higher in the CEF + MET group vs. the PT group (17% vs. 0%; p = 0.01). In the CEF group, poor outcomes were predominately seen in patients who did not receive MET (24% of cases). Conclusions: No difference between CEF + MET vs. PT for treatment of IAIs caused by potential AmpC beta-lactamase–producing organisms. An adequately-powered study is necessary to further investigate these results.

1410: IMPACT OF NOREPINEPHRINE DOSING STRATEGY IN ACHIEVING GOAL MAP IN OBESE PATIENTS WITH SEPTIC SHOCK

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) met severe sepsis criteria (2 SIRS + admission diagnosis of infection + 1 sign of organ dysfunction) at triage. Three nurse-led evidence-based interventions were identified to improve sepsis care: 1) Application of a nursing sepsis protocol; 2) Comprehensive and intensive nursing education; and 3) Use of a severe sepsis triage screening tool. Posters, badge tags, and reward pins were also utilized to strengthen timely interventions. The interventions were introduced to the ED on December 14, 2015. Post-intervention data was collected in the immediate six months after introducing the interventions. Results: A total of 109 patients met the severe sepsis criteria and were reviewed for outcomes. There was a significant difference in mean time to antibiotics pre-intervention (n=46, mean 168.9 minutes) compared to post-intervention (n=63, mean 87.1 minutes) (t=5.3, p<.0001). A reduction in mortality was also witnessed; from 17.4% pre-intervention, to 9.5% post-intervention. The proportion of septic patients receiving their antibiotics in the ED pre and post interventions was improved by almost 22% (78.3% vs. 100%). Conclusions: A significant decrease in time to antibiotics was observed after implementing the interventions. There was also a notable decrease in mortality. Early intervention in the ED clearly improved outcomes. Importantly, nursing can play a significant role in reducing the time to antibiotics.