Rolla T. Sweis

A Comparison of the Effects of Etomidate and Midazolam on Hospital Length of Stay in Patients With Suspected Sepsis: A Prospective, Randomized Study

STUDY OBJECTIVE Etomidate, a widely used induction agent for rapid sequence intubation in the emergency department (ED), causes measurable adrenal suppression after a single bolus dose. The clinical significance of this adrenal suppression in patients with sepsis remains controversial. We seek to determine the difference in hospital length of stay between patients with suspected sepsis who receive either etomidate or midazolam during intubation in our ED. METHODS We performed a prospective, double-blind, randomized study of patients with suspected sepsis who were intubated in our ED during an 18-month period. Eligible patients who were critically ill and were suspected of having sepsis were randomized to receive either etomidate or midazolam before intubation. RESULTS A total of 122 patients were enrolled; 59 received midazolam and 63 received etomidate. Two patients in the etomidate group were lost to follow-up. Patient baseline characteristics were similar between groups. There were no significant differences in median hospital length of stay (9.5 versus 7.3 days), ICU length of stay (4.2 versus 3.1 days), or ventilator days (2.8 versus 2.1) between patients who received midazolam and those who received etomidate, respectively. Inhospital mortality was 21 of 59 (36%; 95% confidence interval 24% to 49%) for patients who received midazolam and 26 of 61 (43%; 95% confidence interval 30% to 56%) for patients who received etomidate. For patients who survived to hospital discharge, the median length of stay was 11.3 days in the midazolam group versus 11.8 days in the etomidate group; for patients who died, the median length of stay was 2.9 days in the midazolam group versus 3.3 days in the etomidate group. CONCLUSION Patients with suspected sepsis and who received a single bolus dose of etomidate for rapid sequence intubation showed no significant increase in hospital length of stay compared with patients who received a single bolus dose of midazolam.

A Prospective Observational Study of the Effect of Etomidate on Septic Patient Mortality and Length of Stay

OBJECTIVES Etomidate is known to cause adrenal suppression after single-bolus administration. Some studies suggest that when etomidate is used as an induction agent for intubation of septic patients in the emergency department (ED), this adrenal suppression leads to increased mortality, vasopressor requirements, and length of hospital stay. The authors sought to determine differences in the in-hospital mortality and hospital length of stay (LOS) between septic patients given etomidate and patients given alternative or no induction agents for rapid-sequence intubation in our ED. METHODS This was a nonrandomized, prospective observational study of all patients meeting sepsis criteria who were intubated in an ED over a 9-month period. Times of patient presentation, intubation, admission, discharge, and/or death were recorded, as well as the intubation agent used, if any, and corticosteroid use. The authors also recorded relevant laboratory and demographic variables to determine severity of illness using the Mortality in Emergency Department Sepsis (MEDS) score. Mortality and survivor LOS between the patients given etomidate and those given alternative or no induction agents were compared. RESULTS A total of 106 patients with sepsis were intubated over the study period. Of these, 74 patients received etomidate, while 32 patients received ketamine, benzodiazepines, propofol, or no induction agents. Age in years (median = 78; interquartile range [IQR] = 67 to 83), gender (45% male), MEDS score (median = 13; IQR = 10 to 15), and receipt of supplemental corticosteroids (56%) were statistically similar between the two groups. In-hospital mortality of patients given etomidate (38%; 95% confidence interval [CI] = 28% to 49%) was similar to those receiving alternatives (44%; 95% CI = 28% to 61%). Surviving patients had a median hospital LOS after receiving etomidate of 10 days compared to those receiving alternatives (7.5 days; p = 0.08). CONCLUSIONS No statistically significant increase in hospital LOS or mortality in patients given etomidate for rapid-sequence intubation was found. Suggestions that the use of etomidate for intubation in the ED be abandoned are not supported by these data.

Automated Dispensing Cabinet Alert Improves Compliance with Obtaining Blood Cultures Before Antibiotic Administration for Patients Admitted with Pneumonia

BACKGROUND A Centers for Medicare & Medicaid Services (CMS) pneumonia quality measures with particular impact on the emergency department (ED) is blood cultures prior to antibiotic administration for patients admitted with pneumonia. A study was conducted to measure the impact of an automated dispensing cabinet (ADC) alert on improving compliance with the quality measure of obtaining blood cultures prior to giving antibiotics for patients admitted with pneumonia and who have blood cultures ordered. METHODS The pre-post study involved ED adult patient with an admitting diagnosis of pneumonia from October 2007 through September 2008. The intervention consisted of a series of questions in the ED medication ADC regarding blood culture orders and antibiotic administration. Patients with an admitting diagnosis of pneumonia were identified through a search of the ED electronic health record (EHR). The proportion of patients in whom blood cultures were obtained prior to antibiotic administration in the pre- (October 2007-March 2008) and postintervention (April 2008-September 2008) periods were compared. The chi-square test was used to test for statistical significance. RESULTS Some 951 patients with pneumonia were identified during the study period, 426 pre- and 525 postintervention. Compliance with obtaining blood cultures prior to antibiotic administration was 84% (205/245, 95% confidence interval [CI]: 79%-88%) and 95% (275/291, 95% CI: 92%-97%) in the pre and postintervention periods, respectively (p <. 001). CONCLUSIONS In this population of patients with pneumonia, a series of questions in an ADC improved compliance with the quality measure regarding the obtaining of blood cultures prior to administering antibiotics to patients in whom blood cultures are requested.

A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings.

The available routes of administration commonly used for medications and fluids in the acute care setting are generally limited to oral, intravenous, or intraosseous routes, but in many patients, particularly in the emergency or critical care settings, these routes are often unavailable or time-consuming to access. A novel device is now available that offers an easy route for administration of medications or fluids via rectal mucosal absorption (also referred to as proctoclysis in the case of fluid administration and subsequent absorption). Although originally intended for the palliative care market, the utility of this device in the emergency setting has recently been described. Specifically, reports of patients being treated for dehydration, alcohol withdrawal, vomiting, fever, myocardial infarction, hyperthyroidism, and cardiac arrest have shown success with administration of a wide variety of medications or fluids (including water, aspirin, lorazepam, ondansetron, acetaminophen, methimazole, and buspirone). Device placement is straightforward, and based on the observation of expected effects from the medication administrations, absorption is rapid. The rapidity of absorption kinetics are further demonstrated in a recent report of the measurement of phenobarbital pharmacokinetics. We describe here the placement and use of this device, and demonstrate methods of pharmacokinetic measurements of medications administered by this method.

Further characterization of the influence of crowding on medication errors.

Study Objectives: Our prior analysis suggested that error frequency increases disproportionately with Emergency department (ED) crowding. To further characterize, we measured this association while controlling for the number of charts reviewed and the presence of ambulance diversion status. We hypothesized that errors would occur significantly more frequently as crowding increased, even after controlling for higher patient volumes. Materials and Methods: We performed a prospective, observational study in a large, community hospital ED from May to October of 2009. Our ED has full-time pharmacists who review orders of patients to help identify errors prior to their causing harm. Research volunteers shadowed our ED pharmacists over discrete 4- hour time periods during their reviews of orders on patients in the ED. The total numbers of charts reviewed and errors identified were documented along with details for each error type, severity, and category. We then measured the correlation between error rate (number of errors divided by total number of charts reviewed) and ED occupancy rate while controlling for diversion status during the observational period. We estimated a sample size requirement of at least 45 errors identified to allow detection of an effect size of 0.6 based on our historical data. Results: During 324 hours of surveillance, 1171 charts were reviewed and 87 errors were identified. Median error rate per 4-hour block was 5.8% of charts reviewed (IQR 0-13). No significant change was seen with ED occupancy rate (Spearmans rho = –.08, P = .49). Median error rate during times on ambulance diversion was almost twice as large (11%, IQR 0-17), but this rate did not reach statistical significance in univariate or multivariate analysis. Conclusions: Error frequency appears to remain relatively constant across the range of crowding in our ED when controlling for patient volume via the quantity of orders reviewed. Error quantity therefore increases with crowding, but not at a rate greater than the expected baseline error rate that occurs in uncrowded conditions. These findings suggest that crowding will increase error quantity in a linear fashion.