Xi Liu-DeRyke

Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society

The risk of death from venous thromboembolism (VTE) is high in intensive care unit patients with neurological diagnoses. This is due to an increased risk of venous stasis secondary to paralysis as well as an increased prevalence of underlying pathologies that cause endothelial activation and create an increased risk of embolus formation. In many of these diseases, there is an associated risk from bleeding because of standard VTE prophylaxis. There is a paucity of prospective studies examining different VTE prophylaxis strategies in the neurologically ill. The lack of a solid evidentiary base has posed challenges for the establishment of consistent and evidence-based clinical practice standards. In response to this need for guidance, the Neurocritical Care Society set out to develop and evidence-based guideline using GRADE to safely reduce VTE and its associated complications.

Hypocalcemia in trauma patients receiving massive transfusion

BACKGROUND Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium is vital for coagulation, but hypocalcemia commonly occurs during massive transfusion due to citrate and serum calcium chelation. This study was conducted to determine the incidence of hypocalcemia and severe hypocalcemia in trauma patients who receive massive transfusion and to compare characteristics of patients with severe versus nonsevere hypocalcemia. MATERIALS AND METHODS This was a retrospective study of trauma patients who received massive transfusion between January 2009 and November 2013. The primary outcome was the incidence of hypocalcemia (ionized calcium [iCa] < 1.12 mmol/L) and severe hypocalcemia (iCa < 0.90 mmol/L). Secondary outcomes included calcium monitoring, calcium replacement, and correction of coagulopathy. RESULTS There were 156 patients included; 152 (97%) experienced hypocalcemia, and 111 (71%) had severe hypocalcemia. Patients were stratified into iCa ≥ 0.90 (n = 45) and iCa < 0.90 (n = 111). There were no differences in demographics or baseline laboratories except the severe hypocalcemia group had higher baseline activated partial thromboplastin time (29.7 [23.7-50.9] versus 25.8 [22.3-35.9], P = 0.003), higher lactic acid (5.8 [4.1-9.8] versus 4.0 [3.1-7.8], P = 0.019), lower platelets (176 [108-237] versus 208 [169-272], P = 0.003), and lower pH (7.14 [6.98-7.28] versus 7.23 [7.14-7.33], P = 0.019). Mortality was higher in the severe hypocalcemia group (49% versus 24%, P = 0.007). Patients in the iCa < 0.90 group received more blood products (34 [23-58] versus 22 [18-30] units, P < 0.001), and calcium chloride (4 [2-7] versus 3 [1-4] g, P = 0.002), but there was no difference in duration of MTP or final iCa. Neither group reached a median iCa > 1.12. CONCLUSIONS Hypocalcemia is common during MTP, and vigilant monitoring is warranted. Research is needed to effectively manage hypocalcemia during massive transfusion.

Measures to improve safety of an elastomeric infusion system for pain management

PURPOSE Measures to improve the safe implementation and utilization of an elastomeric infusion system for pain management are described. SUMMARY Due to the multiple safety concerns associated with the use of the On-Q infusion systems (I-Flow Corporation, Lake Forest, CA) in a community-based teaching institution, a multidisciplinary team of physicians, pharmacists, clinical nurses, nurse educators, and computer informatics personnel was formed to develop a standardized policy and procedure to ensure the safe use of On-Q pumps. The policy addressed several problems concerning prescribing, dispensing, administration, and monitoring of these pumps. The patient care policy for use of On-Q pumps dictates how the pumps are stocked, ordered, dispensed, administered, and monitored and the drugs approved for use in the pumps. Education bulletins, a summary of the new policy and procedure, and a formal presentation of the policy and procedure to unit-based nurse educators were provided. The focus was on a consistent message of safety by reiterating the problems described with these pumps in the literature and in the health care system itself. The physicians ordering the devices have provided positive feedback regarding the simplified ordering process and standardization of the pumps, medications, and concentrations. Both dispensing pharmacists and bedside nurses have noted that the orders are clearly communicated via the computerized system. The addition of documentation in the computer system and education regarding potential signs and symptoms of adverse events with the medication used with the pumps was greatly appreciated by the nursing staff. CONCLUSION A health care system instituted measures to enhance the safety of using an elastomeric infusion system for pain management.

Current and Future Treatment Considerations in the Management of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a type of hemorrhagic stroke that can cause significant morbidity and mortality. Although guidelines have been published to help direct the care of these patients, there is insufficient quality literature regarding the medical and pharmacological management of patients with aSAH. Treatment is divided into 3 categories: supportive therapy, prevention of complications, and treatment of complications. There are numerous pharmacological therapies that are targeted at prevention and treatment of the neurological and medical complications that may arise. Rebleeding, hydrocephalus, cerebral vasospasm, and seizures are the most common neurological complications while the most common medical complications include hyponatremia, pulmonary edema, cardiac arrhythmias, neurogenic stunned myocardium, fever, anemia, infection, hyperglycemia, and venous thromboembolism. Risk factors, clinical presentation, diagnosis, pathophysiology, as well as initial management, prevention, and treatment of complications will be the focus of this discussion.

Possible removal of topiramate by continuous renal replacement therapy

BACKGROUND Topiramate is primarily renally eliminated and requires dosage adjustment based upon renal function. While there is data to suggest drug removal during intermittent hemodialysis (IHD), little is known regarding its clearance and dosing during continuous renal replacement therapy (CRRT). CASE DESCRIPTION We describe a 59-year-old man with refractory status epilepticus who was started on continuous venovenous hemodiafiltration (CVVHDF) for acute renal failure while receiving topiramate with a series of serum concentrations to assess for removal during CVVHDF. CONCLUSION Our data suggest clinically important amounts of topiramate are removed by CRRT, and higher topiramate dosage may be needed for these patients instead of the current recommended 50% of normal dosage. Unfortunately, there is no antiepileptic drug dosing recommendation when used during CRRT due to the paucity of data. This case highlights a need for research evaluating the effect of CRRT on AED elimination in order to optimize therapy for seizure control.

Management of Spontaneous Nontraumatic Intracranial Hemorrhage

Intracerebral hemorrhage (ICH) is one of the most devastating subtypes of stroke and is characterized by spontaneous extravasation into the parenchymal tissue of the brain. Although advances in critical care have improved, there is no intervention currently available that has shown to alter the outcome of patients who have suffered acute ICH. Therefore, management is largely supportive. Treatment strategies are aimed at limiting hematoma enlargement, seizures, and cerebral edema, as well as other ICU-related complications such as deep venous thrombosis, hyperglycemia, and fever. This review will outline the key pharmacological management strategies in patients with ICH and highlight the most current American Heart Association/American Stroke Association (AHA/ASA) guidelines for management published in 2007.

Medical Management of Variceal Hemorrhage

Gastroesophageal variceal hemorrhage is a major complication of portal hypertension in 50% to 60% of patients with liver cirrhosis and is a frequent cause of mortality in these patients. The prevalence of variceal hemorrhage is approximately 5% to 15% yearly, and early variceal rebleeding has a rate of occurrence of 30% to 40% within the first 6 weeks. More than 50% of patients who survive after the first bleeding episode will experience recurrent bleeding within 1 year. Management of gastroesophageal varices should include prevention of initial and recurrent bleeding episodes and control of active hemorrhage. Therapies used in the management of gastroesophageal variceal hemorrhage may include pharmacologic therapy (vasoactive agents, nonselective b-blockers, and antibiotic prophylaxis), endoscopic therapy, transjugular intrahepatic portosystemic shunt, and shunt surgery. This article focuses primarily on pharmacologic management of acute variceal hemorrhage.

Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Executive Summary of Evidence-Based Guidelines: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine

PRELIMINARY REMARKSGuideline LimitationsPractice guidelines are not intended as absolute requirements. The use of the practice guidelines does not, in anyway, project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstanc

Haloperidol Use in Acute Traumatic Brain Injury: A Safety Analysis

Background: The association of delirium with poor outcomes creates a complex picture in traumatic brain injury patients by exacerbating an already increased risk for neurobehavioral sequelae. Haloperidol is commonly used for agitation and delirium; however, adverse events are concerns associated with its use in traumatic brain injury patients. The objective of this study was to assess the safety of haloperidol for the management of agitation and delirium in acute traumatic brain injury. Methods: A retrospective cohort study was conducted of adult ICU patients admitted from January 2007 to October 2009 with traumatic brain injury and admission Glasgow Coma Score ≤ 12. Incidence of complications (seizures, neuroleptic malignant syndrome, QTc prolongation, extrapyramidal symptoms, hematologic disturbances) and haloperidol prescribing patters were assessed. Results: A total of 101 patients were included (56 non-haloperidol, 45 haloperidol). There was no difference in types of brain injury. Haloperidol was initiated on average day 8 of admission, and the median daily dose was 9 mg for a median duration of 4 days. The haloperidol group received more analgesics (morphine equivalents) [714 vs. 252 mg, p<0.001], and more patients in the haloperidol group received benzodiazepines compared to non-haloperidol group [98% vs. 79%, p=0.005]. There was no significant increase in adverse events associated with haloperidol use. Patients in the haloperidol group who developed complications received a higher mean daily dose [p=0.013]. There was no difference in length of mechanical ventilation but the haloperidol group had a longer hospital length of stay. Conclusion: Treatment of agitation and delirium with haloperidol in acute traumatic brain injury patients is not associated with an increased incidence of complications.

Temperature Management in Acute Neurologic Injury To Cool or Not to Cool

Therapeutic hypothermia is becoming an important intervention following acute neurologic injury despite inconclusive results concerning efficacy. This enthusiasm primarily stems from a lack of other effective interventions in this population. With the increase in the use of therapeutic hypothermia, several practical issues must be considered when initiating this intervention. Clinical pharmacists can play an important role in anticipating and addressing some complications such as shivering, slow drug metabolism, and infection. This review will discuss the available literature concerning the efficacy of therapeutic hypothermia in various neurologic injuries, as well as the most common adverse events associated with it.