Nick Lonardo

Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients.

RATIONALE Mechanically ventilated intensive care unit (ICU) patients are frequently managed using a continuous-infusion sedative. Although recent guidelines suggest avoiding benzodiazepines for sedation, this class of drugs is still widely used. There are limited data comparing sedative agents in terms of clinical outcomes in an ICU setting. OBJECTIVES Comparison of propofol to midazolam and lorazepam in adult ICU patients. METHODS Data were obtained from a multicenter ICU database (2003-2009). Patient selection criteria included age greater than or equal to 18 years, single ICU admission with single ventilation event (>48 h), and treatment with continuously infused sedation (propofol, midazolam, or lorazepam). Propensity score analysis (1:1) was used and mortality measured. Cumulative incidence and competing risk methodology were used to examine time to ICU discharge and ventilator removal. MEASUREMENTS AND MAIN RESULTS There were 2,250 propofol-midazolam and 1,054 propofol-lorazepam matched patients. Hospital mortality was statistically lower in propofol-treated patients as compared with midazolam- or lorazepam-treated patients (risk ratio, 0.76; 95% confidence interval [CI], 0.69-0.82 and risk ratio, 0.78; 95% CI, 0.68-0.89, respectively). Competing risk analysis for 28-day ICU time period showed that propofol-treated patients had a statistically higher probability for ICU discharge (78.9% vs. 69.5%; 79.2% vs. 71.9%; P < 0.001) and earlier removal from the ventilator (84.4% vs. 75.1%; 84.3% vs. 78.8%; P < 0.001) when compared with midazolam- and lorazepam-treated patients, respectively. CONCLUSIONS In this large, propensity-matched ICU population, patients treated with propofol had a reduced risk of mortality and had both an increased likelihood of earlier ICU discharge and earlier discontinuation of mechanical ventilation.

Ventricular Tachycardia Associated with High‐Dose Chronic Loperamide Use

Loperamide is an antidiarrheal medication deemed by the U.S. Food and Drug Administration as safe enough to be sold as an over‐the‐counter medicine. Unlike other μ‐opioid receptor agonists, loperamide acts specifically in the myenteric plexus in the gastrointestinal tract, making the potential for abuse low and reports of toxicity extremely rare. We present a case of a patient previously in good health who developed episodes of cardiac pauses, nonsustained ventricular tachycardia, and eventually runs of sustained ventricular tachycardia with hemodynamic instability. She required cardiopulmonary resuscitation, multiple cardioversions, and placement of a pacemaker. Her medical history was remarkable only for type 2 diabetes and chronic postcholecystectomy diarrhea. Metformin was the only prescription medication she was taking at the time of presentation. However, she reported that she had been taking an entire bottle of Equate brand loperamide (144 mg) daily for ~2 years. Loperamide overdoses associated with ventricular arrhythmias have been reported, but this is the first case to describe a serious ventricular arrhythmia associated with long‐term use of a high dose of loperamide. Chronic overtreatment with loperamide may induce life‐threatening arrhythmias.

Outcomes When Using Adjunct Dexmedetomidine with Propofol Sedation in Mechanically Ventilated Surgical Intensive Care Patients

Objective: Compare the duration of mechanical ventilation between patients receiving sedation with continuous infusions of propofol alone or combination with the use of dexmedetomidine and propofol. Design: Retrospective, propensity matched (1:1) cohort study, employing eight variables chosen a priori for matching. Timing of exposure to dexmedetomidine initiation was incorporated into a matching algorithm. Setting: Level 1, university-based, 32-bed, adult, mixed trauma and surgical intensive care unit (SICU). Continuous sedation was delivered according to a protocol methodology with daily sedation vacation and spontaneous breathing trials. Choice of sedation agent was physician directed. Patients: Between 2010 and 2014, 149 SICU patients receiving mechanical ventilation for >24 h received dexmedetomidine with propofol. Propensity matching resulted in 143 pair cohorts. Interventions: Dexmedetomidine with propofol or propofol alone. Measurements and Main Results: There was no statistical difference in SICU length of stay (LOS), with a median absolute difference of 5.3 h for propofol alone group (p = 0.43). The SICU mortality was not statistically different (RR = 1.002, p = 0.88). Examining a 14-day period post-treatment with dexmedetomidine, on any given day (excluding days 1 and 14), dexmedetomidine with propofol-treated patients had a 0.5% to 22.5% greater likelihood of being delirious (CAM-ICU positive). In addition, dexmedetomidine with propofol-treated patients had a 4.5% to 18.8% higher likelihood of being above the target sedation score (more agitated) compared to propofol-alone patients. Conclusions: In this propensity matched cohort study, adjunct use of dexmedetomidine to propofol did not show a statistically significant reduction with respect to mechanical ventilation (MV) duration, SICU LOS, or SICU mortality, despite a trend toward receiving fewer hours of propofol. There was no evidence that dexmedetomidine with propofol improved sedation scores or reduced delirium.

1576: DOES THE ADDITION OF DEXMEDETOMIDINE TO PROPOFOL SEDATION REDUCE DURATION OF MECHANICAL VENTILATION?

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Burns > 20% total body surface area (TBSA) are associated with hypovolemic shock and release of inflammatory mediators, which can lead to production of reactive oxygen species that propagate shock by increased vascular permeability. Aggressive fluid resuscitation is paramount to minimize end organ damage in severe burns. Fluid resuscitation is initiated based on burn size with Lactated Ringer’s solution (LR) and titrated to a goal urine output (UOP) of 30–50 mL/hr. At the University of Utah Burn Center, albumin is added at a ratio of 1/3 albumin to 2/3 LR if UOP goals are not met. High-dose ascorbic acid (AA) may also be added if patients are failing resuscitation. Ascorbic acid is a free radical scavenger that may reduce vascular permeability by inactivating reactive oxygen species. Despite reported benefits of AA during resuscitation, concerns for osmotic diuresis and risk for renal injury have limited widespread use in burn centers. Methods: We conducted a case-control study to analyze the impact of AA in reducing fluid requirements and the risk for renal injury during the first 24 hours of resuscitation. All-cause mortality was assessed as a secondary outcome. All adult and pediatric patients admitted between 2008 and 2016 with an order for high-dose AA were evaluated for inclusion. Results: Sixty-two patients were included, with 31 in both AA and control groups. Patients were matched based on age (2–77 years), burn size (18–91%), inhalation injury (52% and 39%), and gender (56% male). There were no statistical differences in the baseline characteristics. Average 24-hour fluid resuscitation was 5.9 ± 2.9 mL/kg/%TBSA for AA and 5.1 ± 2.7 mL/ kg/%TBSA for control (P = 0.16). Ten AA patients and 5 control patients developed renal injury (P = 0.24). There were no differences in all-cause mortality, and 8 patients in each group expired during the study time period. Conclusions: Adjunctive use of AA did not reduce fluid resuscitation or increase the risk for renal injury in the first 24 hours of resuscitation. Additionally, there were no differences in mortality between the AA or control groups.

Implementing the Use of Pharmacist Progress Notes in a Surgical ICU

Background Critical care pharmacists are established and valuable members of the critical care team, however there is rarely written evidence of their daily involvement in the patients electronic medical record (EMR). Documentation in the EMR has the advantage of ensuring a seamless pass-off and provides an opportunity to capture the pharmacists cognitive and clinical impact in a way that traditional systems of tracking “interventions” fail to do. We investigated implementation of pharmacist progress notes in a surgical intensive care unit (ICU) and their utility in measuring pharmacist activity. Methods Daily pharmacist progress notes written in a surgical ICU over a period of 2 months were reviewed. Each pharmacist action identified through progress note review was quantified and scored by an independent reviewer using a newly developed scoring system, the clinical impact score (CIS). This was developed as a way to quantify pharmacist actions and to classify those actions by clinical impact. Results Four hundred sixty-two daily pharmacist progress notes were reviewed over a 2-month period. There were 1,055 actions identified that resulted in a therapy change. Four of these actions resulted in the potential avoidance of a sentinel event. Of patients with at least 5 progress notes (n = 44), the majority of pharmacist actions occurred on ICU day 1. Conclusion The results of this descriptive study demonstrate that the implementation of daily pharmacist progress notes is feasible in an advanced practice setting, and the pharmacists contribution to patient care may be obtained through review of this documentation in the patients medical record. The critical care pharmacists daily involvement in patient care most commonly results in optimization of pharmacotherapy and avoidance of drug misadventure.