Susan Hamblin

Beta-blockers and Traumatic Brain Injury: A Systematic Review, Meta-analysis, and Eastern Association for the Surgery of Trauma Guideline

OBJECTIVE To determine if beta-(β)-blockers improve outcomes after acute traumatic brain injury (TBI).Objective: To determine if beta-(&bgr;)-blockers improve outcomes after acute traumatic brain injury (TBI). Background: There have been no new inpatient pharmacologic therapies to improve TBI outcomes in a half-century. Treatment of TBI patients with &bgr;-blockers offers a potentially beneficial approach. Methods: Using MEDLINE, EMBASE, and CENTRAL databases, eligible articles for our systematic review and meta-analysis (PROSPERO CRD42016048547) included adult (age ≥ 16 years) blunt trauma patients admitted with TBI. The exposure of interest was &bgr;-blocker administration initiated during the hospitalization. Outcomes were mortality, functional measures, quality of life, cardiopulmonary morbidity (e.g., hypotension, bradycardia, bronchospasm, and/or congestive heart failure). Data were analyzed using a random-effects model, and represented by pooled odds ratio (OR) with 95% confidence intervals (CI) and statistical heterogeneity (I2). Results: Data were extracted from 9 included studies encompassing 2005 unique TBI patients with &bgr;-blocker treatment and 6240 unique controls. Exposure to &bgr;-blockers after TBI was associated with a reduction of in-hospital mortality (pooled OR 0.39, 95% CI: 0.27–0.56; I2 = 65%, P < 0.00001). None of the included studies examined functional outcome or quality of life measures, and cardiopulmonary adverse events were rarely reported. No clear evidence of reporting bias was identified. Conclusions: In adults with acute TBI, observational studies reveal a significant mortality advantage with &bgr;-blockers; however, quality of evidence is very low. We conditionally recommend the use of in-hospital &bgr;-blockers. However, we recommend further high-quality trials to answer questions about the mechanisms of action, effectiveness on subgroups, dose-response, length of therapy, functional outcome, and quality of life after &bgr;-blocker use for TBI.

Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions.

BACKGROUND Concerted management of the traumatic hemothorax is ill-defined. Surgical management of specific hemothoraces may be beneficial. A comprehensive strategy to delineate appropriate patients for additional procedures does not exist. We developed an evidence-based algorithm for hemothorax management. We hypothesize that the use of this algorithm will decrease additional interventions. METHODS A pre-/post-study was performed on all patients admitted to our trauma service with traumatic hemothorax from August 2010 to September 2013. An evidence-based management algorithm was initiated for the management of retained hemothoraces. Patients with length of stay (LOS) less than 24 hours or admitted during an implementation phase were excluded. Study data included age, Injury Severity Score, Abbreviated Injury Scale chest, mechanism of injury, ventilator days, intensive care unit (ICU) LOS, total hospital LOS, and interventions required. Our primary outcome was number of patients requiring more than 1 intervention. Secondary outcomes were empyema rate, number of patients requiring specific additional interventions, 28-day ventilator-free days, 28-day ICU-free days, hospital LOS, all-cause 6-month readmission rate. Standard statistical analysis was performed for all data. RESULTS Six hundred forty-two patients (326 pre and 316 post) met the study criteria. There were no demographic differences in either group. The number of patients requiring more than 1 intervention was significantly reduced (49 pre vs. 28 post, p = 0.02). Number of patients requiring VATS decreased (27 pre vs. 10 post, p < 0.01). Number of catheters placed by interventional radiology increased (2 pre vs. 10 post, p = 0.02). Intrapleural thrombolytic use, open thoracotomy, empyema, and 6-month readmission rates were unchanged. The “post” group more ventilator-free days (median, 23.9 vs. 22.5, p = 0.04), but ICU and hospital LOS were unchanged. CONCLUSION Using an evidence-based hemothorax algorithm reduced the number of patients requiring additional interventions without increasing complication rates. Defined criteria for surgical intervention allows for more appropriate utilization of resources. Level of Evidence Therapeutic study, level IV.

Method of Hypertonic Saline Administration: Effects on Osmolality in Traumatic Brain Injury Patients

Hypertonic saline (HTS) is an effective therapy for reducing intracranial pressure (ICP). The ideal method of administration is unknown. The purpose of this study was to evaluate the method of HTS infusion and time to goal osmolality. A retrospective cohort analysis was conducted in severe TBI patients with ICP monitoring in place who received 2 doses of HTS. Patients were divided into bolus versus continuous infusion HTS cohorts. The primary outcome was median time to goal osmolality. Secondary outcomes included percentage of patients reaching goal osmolality, percent time at goal osmolality, mean cerebral perfusion pressure (CPP) and ICP, ICU length of stay, and mortality. Safety outcomes included rates of hyperchloremia, hypernatremia, and acute kidney injury (AKI). 162 patients were included with similar baseline characteristics. Time to goal osmolality was similar between cohorts (bolus 9.78h vs. continuous 11.4h, p=0.817). A significant difference in the percentage of patients reaching goal osmolality favoring the continuous group was found (93.9% vs 73.3%, p=0.003). The continuous group was maintained at goal osmolality for a higher percentage of osmolality values after reaching goal (80% vs. 50%, p=0.032). No difference was seen in CPP, ICP, length of stay and mortality. Rates of hypernatremia were similar, but significant higher rates of hyperchloremia (0.77vs 1.58 events per HTS days, p<0.001) and AKI (0% vs 12.9%, p=0.025) were observed in the continuous cohort. Although no difference in time to goal osmolality was observed, continuous HTS was associated with a higher percentage of patients achieving goal osmolality.

150: IMPACT OF DOSE-CAPPING ON TIME TO THERAPEUTIC ANTI-XA LEVELS FOR WEIGHT-BASED UNFRACTIONATED HEPARIN

Learning Objectives: The polypharmacy of illicit drugs can make the clinical diagnosis of an overdose challenging. We describe 3 patients with reported heroin use whose presentation was, instead, consistent with a β-adrenergic toxidrome from clenbuterol adulterated heroin. Methods: A 19, 21, and 25-year-old patient arrived to the emergency department after intravenous injection of heroin. In minutes they experienced palpitations, chest pain, shortness of breath, and vomiting. Patients were alert and tachycardic (mean HR 150 bpm) with normal blood pressures. After several hours, the cohort developed hypotension (mean MAP 50 mmHg). Studies revealed hypokalemia, hypomagnesemia, hyperglycemia, and lactic acidosis. Toxicology screens were positive for opiates, cocaine, THC. β-agonist toxicity from clenbuterol was suspected. All had elevated troponins (mean peak troponin 2.1 ng/mL). Electrocardiograms displayed dynamic ST depressions and prolonged QTc > 500 ms. Echocardiograms revealed normal systolic function. Treatment included IV fluids, lorazepam, aspirin. B-antagonists were withheld because of cocaine exposure. Urine clenbuterol, reported 2 weeks later, was positive in all patients. Results: Clenbuterol is a long acting β2 agonist. Toxicity has been reported from adulterated heroin and anabolic supplements. The β2 toxidrome consists of tachycardia, hypotension, hypokalemia, hyperglycemia, and lactic acidosis. Clenbuterol associated myocardial ischemia has been reported in young patients with normal coronary arteries on cardiac catheterization. Treatment consists of IV fluids and β-adrenergic antagonists. In the scenario of a tainted heroin overdose, it is important to differentiate β-agonist cardiotoxicity with tachycardia and hypotension, from cocaine cardiotoxicity where treatment with β-antagonists may be detrimental and benzodiazepine administration is preferred. Clenbuterol testing is not readily available, thus, recognizing the β-agonist toxidrome is critical to provide targeted therapy.

Perceptions of critical care pharmacists participating in a formal mentor–mentee program

Mentor–mentee relationships should be symbiotic and can yield multiple benefits for both participants, including improved publishing success, job retention and satisfaction, and exposure to new opportunities.[1][1],[2][2] The Clinical Pharmacy and Pharmacology (CPP) Section of the Society of

1113: HYPERTONIC SALINE AND ACUTE KIDNEY INJURY IN TRAUMATIC BRAIN INJURY

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) to promote antimicrobial stewardship. Commonly this includes vancomycin to empirically cover methicillin-resistant Staphylococcus aureus (MRSA). This study assessed the impact and necessity of adding vancomycin to IAI treatment regimens. Methods: A post hoc analysis of the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial was performed. Patients who received piperacillin/tazobactam (P/T) and/or ertapenem, meropenem and imipenem were included with categorization into two groups based on presence or absence of vancomycin. Univariate and multivariate analysis compared the effect of including vancomycin on the composite outcome (recurrent IAI, surgical site infection, SSI or mortality) and individual components. Results: The cohort included 344 patients who received P/T and/or a carbapenem with 110 (32%) of these patients receiving vancomycin. The majority of the patients received P/T (>75%). Isolation of MRSA occurred in only 8 (2.3%) patients (1 received vancomycin). Vancomycin use resulted in a different occurrence of the composite outcome, 32.7% vs. 20.9% for vancomycin and no vancomycin, respectively (p=0.02), but patients prescribed vancomycin, values represented as mean (SD), had higher APACHE II scores-13.1 (6.6) vs. 9.4 (5.7), p<0.0001; extended length of stay-12.6 (10.2) vs. 8.6 (8.0) days, p<0.001; and prolonged antibiotic courses-9.1 (8.0) vs. 7.1 (4.9) days, p=0.02. After risk adjustment in a multivariate model, no significant difference existed for the composite outcome or the individual components: recurrent IAI (OR=1.50 p=0.23), SSI (OR=1.55, p=0.31) or mortality (OR=1.02, p=0.99) relative to vancomycin utilization. Conclusions: This post hoc analysis reveals that addition of vancomycin occurred in nearly a third of cases, more often in sicker patients. However, no appreciable difference in recurrent IAIs, SSIs or mortality were demonstrated suggesting limited utility for adding vancomycin to IAI treatment regimens.