Mary Beth Shirk

Intrapleural Alteplase in a Patient with Complicated Pleural Effusion

OBJECTIVE: To report the intrapleural use of alteplase in a patient diagnosed with complicated pleural effusion (CPE). CASE SUMMARY: A 62-year-old white woman admitted with respiratory distress and hypotension developed a right-sided multi-loculated pleural effusion. Thoracentesis and chest tube drainage were not successful in resolving the effusion. In an attempt to increase the drainage of the pleural effusion, alteplase 16 mg was administered into the pleural cavity via the chest tube on 6 consecutive days. As a result, the volume drained from the patients chest tube increased, there was improvement on the chest X-ray, and she did not require surgical intervention. DISCUSSION: While streptokinase and urokinase have been shown to be useful adjuncts to chest tube drainage in the treatment of complicated pleural effusion and empyema, there have been no reports on the use of intrapleural alteplase. This report demonstrates that intrapleural administration of alteplase is a useful adjunct to tube drainage in resolving CPE. CONCLUSIONS: This patients CPE resolved when intrapleural alteplase was used as an adjunct to chest tube drainage and antibiotics. Controlled trials need to be conducted to investigate fully the efficacy, dosing, and safety of intrapleural alteplase in the treatment of patients with CPE and empyema.

Thromboembolic Events During Continuous Vasopressin Infusions: A Retrospective Evaluation

Background: Published guidelines suggest that vasopressin has a role in shock treatment, although its safety has not been adequately evaluated in a clinical setting. Vasopressin causes platelet aggregation and has been associated with the release of factor VIII coagulant and von Willebrand factor. Objective: To compare the incidence of venous thromboembolism (VTE) in patients with a diagnosis of shock who received vasopressin with those who did not receive vasopressin for hemodynamic support. Methods: A retrospective, single-center, cohort study was conducted at an academic, tertiary care center with 350 patients with a diagnosis of shock. Patients from the intensive care unit were randomly selected and separated into 2 groups for comparison of those receiving only catecholamines with those receiving vasopressin with or without catecholamines for hypotension. Patients with diabetes insipidus or variceal hemorrhage and those with any documented history of VTE were excluded. The primary outcome, VTE occurrence, was defined as a positive Doppler ultrasound, spiral computed tomography, or documented diagnosis in the discharge records. Frequency and type of risk factors for VTE were compared between the 2 study arms. A risk factor modeling approach was performed, using logistic regression to identify potential confounders and effect modifiers in the relationship between vasopressin and VTE. Results: There were 175 patients in each arm of the study. The crude incidence of VTE was 7.4% and 8% in the vasopressin and catecholamine groups, respectively (p = 0.84). No significant difference in the incidence of deep venous thrombosis (vasopressin 5.1%, control 7.4%; p = 0.51) or pulmonary embolism (vasopressin 2.3%, control 0.6%; p = 0.37) was found between groups. After adjusting for covariates, there was no statistically significant difference in the incidence of VTE between the 2 arms (p = 0.72). Conclusions: This investigation provides initial evidence that vasopressin infusions do not increase the risk of VTE in patients with shock.

Evaluation of Pharmacist Impact on Culture Review Process for Patients Discharged from the Emergency Department

Background Accurate and timely review of microbiological test results is a core component of antimicrobial stewardship. There is documented success of these programs in the inpatient setting; however, emergency department (ED) patients are typically not included in these initiatives. Objectives To assess the impact of an emergency medicine pharmacist (EMP)–facilitated review process of positive microbiological test results from patients discharged from the ED as measured by time to positive result review and number of indicated interventions completed. Methods This was a retrospective study that compared EMP-facilitated to ED charge nurse (CN)–facilitated physician review of randomly selected positive microbiological test results. Groups were compared concurrently within the time frame of July 1, 2012 through December 31, 2012. Results One hundred seventy-eight positive microbiological test results were included (EMP, n = 91; CN, n = 87). The median (IQR) time to initial review was 3 (1.0–6.3) hours for the EMP and 2 (0.3–5.5) hours for the CN group (p = .35). Four percent (1/25) of indicated interventions were not completed in the EMP group versus 47% (14/30) in the CN group (p = .0004). Conclusion An EMP was significantly less likely to miss an intervention when indicated with no difference in time to review of positive microbiological results. These findings support the role of the EMP in antimicrobial stewardship in the ED.

Characterization of drug overdoses in an Ohio incarcerated population.

Abstract Context: Literature exists about drug overdose following release of recently incarcerated individuals and mortality among prisoners in the United States, but little information exists about drug overdoses in the imprisoned population. Objective: This study aims to quantify and describe prisoner medication overdose requiring inpatient admission or assessment at a tertiary care facility and to assess the associated hospital charges. Materials and methods: A single-center, retrospective cohort study was conducted on all Ohio Department of Rehabilitation and Correction inmates who presented to The Ohio State University Wexner Medical Center with drug overdose between 15 October 2011 and 14 October 2014. Demographic information, overdose substances, exposure reason, clinical effects, lengths of stay, outcomes, and hospital charges were collected. Results: Of the 130 patients included in the study, there were 100 intentional overdoses, 7 unintentional overdoses, 3 adverse drug reactions, and 20 unknown intentions. The most common drug in prisoner overdose was phenytoin (n = 29, 22%). While anticonvulsants were the most common drug class overall, anticonvulsants, antidepressants, and cardiovascular medications accounted for equal numbers of intensive care unit (ICU) admissions. Most patients exhibited multiple symptoms on arrival, most commonly neurologic, cardiovascular, and gastrointestinal symptoms. Patients were seen from 21 of the 28 Ohio Department of Rehabilitation and Correction facilities, of which five facilities, that largely house minimum and medium security prisoners, accounted for 61% of patients sent to our institution. The total sum of charges was

PANCURONIUM: NEUROMUSCULAR BLOCKING AGENT OF CHOICE FOR THE CRITICALLY ILL?: 604

2,606,942 with 55% of charges from ICU stays. Conclusion: Our study shows that drug overdoses within our incarcerated population were largely intentional overdoses of anticonvulsants, cardiovascular drugs, and antidepressants. Opportunities exist to target intentional drug overdoses that accounted for 80% of prisoner overdoses for potential cost-savings.

Unlabeled uses of nebulized medications

Introduction: According to the “SCCM Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient,” pancuronium (P) can be used appropriately in the majority of ICU patients. Hypothesis: P is not the appropriate Neuromuscular Blocking Agent (NMBA) in the majority of ICU patients in our university, tertiary care center. Methods: A pharmacist review of continuous infusion NMBAs was performed to determine the appropriateness and frequency of each agent being used in the MICU, SICU, CCU, and BMT. MUE guidelines dictated agent selection based on the presence of renal insufficiency (UO<25ml/hr x 8hrs or CrCl<50ml/min), liver dysfunction (2x ULN AST, ALT, ALP, or bili), high dose steroids (1-1.5mg/kg/day of prednisone equivalents), or cardiac risk (HR>100bpm or arrhythmogenic risk). Recommended agents were vecuronium (V), cis-atracurium (C), and P. Results: 34 patients (mean age 50yrs) were evaluated between Aug 2003 and Feb 2004. All patients received continuous infusion benzodiazepine±opioid or propofol or had a documented Ramsay score >3 prior to paralysis. Mean APACHE II score on admission was 33. 38% of patients had renal insufficiency, 24% had liver dysfunction, 18% received high dose steroids, and 82% had a baseline HR >100bpm. Patients received C, V, and P 56, 41, and 3% of the time, respectively. C was the appropriate agent in 53% and V was appropriate in 47% of patients. P was not appropriate for use in any patient. The mean baseline HR in our patient sample was 113bpm. P was commonly not chosen in this patient population because of the high incidence of cardiac disease in our ICU population and the arrhythmogenic potential of the medication. Conclusions: Critically ill patients frequently have cardiac disease and are predisposed to cardiac arrhythmias. Although P is recommended for the majority of patients in the SCCM guidelines, it was not an appropriate choice in our patient population due to the incidence of vagolysis and increased heart rate with this agent. A review of the SCCM Clinical Practice Guidelines is recommended.