Nancy Bair

Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: physician and nurse adherence.

Objective: To determine physician and nurse adherence with sedative, analgesic, and neuromuscular blocking agent guidelines in the management of mechanically ventilated patients in a medical intensive care unit. Design: Prospective cohort study. Subjects: One hundred consecutively admitted patients to a medical intensive care unit who required mechanical ventilatory support. A sample of 29 nurses, residents, and attending physicians were interviewed regarding their attitudes and perceptions of the guidelines. Measurement: Data were collected from concurrent medical records and included the following: demographic characteristics; clinical variables; physician prescriptions of sedative, analgesic, and/or neuromuscular blocking agents; nurse administration of these medications; documentation of monitoring; and assessment of patient hemodynamic status and behaviors. A semistructured interview was elicited from both nurses and physicians about their rationale for the use or nonuse of the guidelines. Results: Patients ranged in age from 24 to 87 yrs, mean 60.7 (±15.3) yrs. Admission Acute Physiology and Chronic Health Evaluation III scores ranged from 36 to 192, mean 93.8 (±30.5) and median 88. Length of mechanical ventilatory support ranged from 1 to 112 days, mean 14.8 (±20.0) days, and median 8 days; medical intensive care unit length of stay ranged from 1 to 46 days, with a mean of 9.8 (±8.1) days and a median of 8 days. Of the 100 patients, 47% died, 28% returned home, and 25% were discharged to a nursing facility. Eighty‐five patients were administered one or more sedative, analgesic, and/or neuromuscular blocking agent, range 1‐9 drugs, mean 2.5 (±1.5) drugs. Physicians prescribed 14 different medications; the most commonly administered drug was lorazepam (n = 71), followed by morphine (n = 39). Physicians and nurses had partial or total adherence to the guidelines in 58% of patients. The initial choice of the drug followed the guidelines in 60% of patients; the overall guideline was followed in 23% of patients. The most common rationales for nonadherence to the guidelines stated by both physicians and nurses were patient‐specific factors, resident guideline learning curve, and physician medication preferences. Conclusion: Most patients required treatment for agitated behaviors. The majority of treatment regimens partially or totally adhered to the guidelines. Factors such as patient‐specific disease states, resident guideline learning curve, and physician preferences of medications may have decreased adherence. Improving adherence to the guidelines is essential to assess their effectiveness in improving clinical outcomes.

Causes and Circumstances of Death in Pulmonary Arterial Hypertension

RATIONALE The causes and circumstances surrounding death are understudied in patients with pulmonary arterial hypertension (PAH). OBJECTIVES We sought to determine the specific reasons and characteristics surrounding the death of patients with PAH. METHODS All deaths of patients with pulmonary hypertension (PH) followed in the Cleveland Clinic Pulmonary Vascular Program were prospectively reviewed by the PH team. A total of 84 patients with PAH (age 58 ± 14 yr; 73% females) who died between June 2008 and May 2012 were included. MEASUREMENTS AND MAIN RESULTS PH was determined to be the direct cause of death (right heart failure or sudden death) in 37 (44%) patients; PH contributed to but did not directly cause death in 37 (44%) patients; and the death was not related to PH in the remaining cases (n = 7; 8.3%). In three (3.6%) patients the final cause of death could not be adequately assessed. Most patients died in a healthcare environment and most received PH-specific therapies. In our cohort, 50% of all patients with PAH and 75.7% of those who died of right heart failure received parenteral prostanoid therapy. Less than half of patients had advanced healthcare directives. CONCLUSIONS Most patients with PAH in our cohort died of their disease; however, right ventricular failure or sudden death was the sole cause of death in less than half of patients.

Prevalence and characteristics of restless legs syndrome in patients with pulmonary hypertension.

BACKGROUND Patients with pulmonary hypertension (PH) have an increased prevalence of risk factors for restless legs syndrome (RLS). We performed a cross-sectional study to determine the prevalence and characteristics of RLS in this population. METHODS Patients filled out two questionnaires during a visit: (1) a diagnostic tool for RLS, based on the core clinical features; and (2) a 10-question rating scale used to assess severity. Data were obtained by medical record review with regard to demographics, characteristics of PH and known RLS risk factors. RESULTS Restless legs syndrome was found in 43.6% (24 of 55) (mean age +/- SD: 49 +/- 14 years; 41 women, 14 men) of patients and 54% of these had moderate or severe RLS. Patients with RLS were younger but gender differences were not appreciated. Presence of RLS did not correlate with measures of PH severity; however, patients with RLS were more likely to have a better 6-minute walk distance (p = 0.015) and lower BNP level (p = 0.07) and less likely to be WHO Class IV or require oxygen during the 6-minute walk test. Patients with a history of hypothyroidism (67%; p = 0.04) and those on opioids for relief of leg pain (69%) were more likely to have RLS. CONCLUSIONS Patients with PH had a very high prevalence of RLS and most had moderate or severe symptoms. RLS was more common in more active patients and those who were hypothyroid or on opioids for relief of leg pain. Patients with PH should be screened for RLS because good treatment options are available.

Subcutaneous to Intravenous Prostacyclin Analog Transition in Pulmonary Hypertension

Introduction: Prostacyclin analogs are Food and Drug Administration–approved therapies for the treatment of pulmonary arterial hypertension and can be administered by inhalational, intravenous (IV), or subcutaneous (SQ) routes. Because there are limited data to guide the transition between SQ to IV prostacyclin analogs, we describe our experience. Methods: We performed a retrospective review of patients with pulmonary hypertension diagnosed by right heart catheterization, who underwent transition from SQ to IV prostacyclin analogs. Results: We included 7 patients with pulmonary arterial hypertension and 2 with chronic thromboembolic pulmonary hypertension in this retrospective study. Median (interquartile range) age was 54 (39–63) years, and 67% were women. The reasons for the SQ to IV switch were site pain (n = 6, 67%), major surgery (n = 2, 22%), and septic shock (n = 1, 11%). SQ treprostinil was converted to IV treprostinil (n = 5, 56%) or IV epoprostenol (n = 4, 44%). When SQ treprostinil was converted to IV treprostinil, the initial mean (range) dose decreased from 84.9 (36.5–167) to 70.8 (24–114) ng·kg−1·min−1. When SQ treprostinil was converted to IV epoprostenol, the dose decreased from 24.5 (17.5–30) to 13.3 (9–20) ng·kg−1·min−1. The patient transitioned from SQ to IV treprostinil in the context of septic shock died a month after hospitalization. No deteriorations were observed in the remaining patients during the first year. Conclusions: Under careful monitoring, SQ treprostinil was transitioned to IV treprostinil or epoprostenol without complications. Dosing downadjustment was needed in some patients who were switched over from SQ to IV prostacyclin analogs.

Subdural hematomas in pulmonary arterial hypertension patients treated with protacyclin analogs

Prostacyclin analogs therapy has been associated with development of thrombocytopenia. Little is known whether this treatment increases the risk of intracranial hemorrhage in pulmonary artery hypertension (PAH) patients. We queried the Cleveland Clinic billing database to identify cases of nontraumatic sudural hematoma (SDH) in patients with PAH. We identified those individuals who were receiving prostacyclin analogs therapy at the time of the neurological event and assessed whether these patients were also taking antiplatelet or anticoagulation therapies. We identified three cases of nontraumatic SDH in 856-patient-year of prostacylin analog treatment. All patients were women, had low normal platelet counts or thrombocytopenia, and were concomitantly receiving anticoagulation therapy in the appropriate therapeutic anticoagulation range. All three patients were managed conservatively and had no neurologic sequelae. Nontraumatic acute subdural hematoma is a rare event in patients with PAH treated with prostacyclin analogs. All affected patients were concomitantly receiving anticoagulation therapy.