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Garrigue P, Reber M, Perinel-Ragey S, Launay M. Personalized Amoxicillin Therapy in a Critically Ill Patient Undergoing Renal Replacement Therapy: A Grand Round. Ther Drug Monit 2024:00007691-990000000-00244. [PMID: 38950121 DOI: 10.1097/ftd.0000000000001242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/02/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND The case study discusses a complex scenario involving the use of amoxicillin in a critically ill patient undergoing intermittent renal replacement therapy.Severe infections are complicated by septic shock and organ failure, requiring urgent and effective antibiotic treatment. METHODS The patient's comorbidities, including obesity and acute kidney injury, required careful consideration of the amoxicillin dosing strategies. RESULTS Therapeutic drug monitoring is critical for dose adjustment during treatment. CONCLUSIONS This case highlights the importance of a collaborative approach between clinicians and therapeutic drug monitoring consultants to optimize antibiotic therapy for critically ill patients with renal impairment.
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Affiliation(s)
| | - Margot Reber
- Médecine Intensive Réanimation G, CHU de Saint-Etienne, Saint Etienne, France; and
| | - Sophie Perinel-Ragey
- Médecine Intensive Réanimation G, CHU de Saint-Etienne, Saint Etienne, France; and
| | - Manon Launay
- Médecine Intensive Réanimation G, CHU de Saint-Etienne, Saint Etienne, France; and
- Centre Régional de Pharmacovigilance, CHU Nord de St Etienne, Saint Etienne, France
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Hassouneh WB, Al-Ghazawi MA, Saleh MI, Najib N. Population Pharmacokinetics of Dasatinib in Healthy Subjects. Pharmaceuticals (Basel) 2024; 17:671. [PMID: 38931339 PMCID: PMC11206811 DOI: 10.3390/ph17060671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/05/2024] [Accepted: 05/07/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Dasatinib is one of the tyrosine kinase inhibitors. The main use of these agents is inhibition of cancerous cell proliferation. The therapeutic importance of tyrosine kinase inhibitors raises the necessity of many types of investigations, especially the pharmacokinetic analysis of these drugs in humans. This analysis, along with other investigations and clinical research, will contribute to the overall knowledge of the drug. This study focused on the population pharmacokinetics of dasatinib. The objective of the study was to investigate the sources of the variability of dasatinib in a population pharmacokinetics study in healthy participants. METHODS We utilized 4180 plasma observations from 110 subjects who were administered SPRYCEL® on two separate occasions under fasting conditions; data from 20% of the subjects (22 subjects) were extracted for the purpose of internal model evaluation and data from 88 subjects were used in modeling. The model was evaluated by visual predictive check of three different datasets. A two-compartmental model with first order absorption and transit compartment was considered the simplest base model to describe the data based on the corrected Bayesian information criterion evaluation. Covariates were tested through conditional sampling for the stepwise approach-screening procedure in Monolix 2020R1 version. Conditional sampling for the stepwise approach was used to include the correlated covariates within the base model in the forward inclusion step and then to eliminate them backwardly to ensure that the key covariates were kept in the model at the final stage. RESULTS The effect of body mass index on the absorption rate constant was considered as significant covariate in the final established model. Visual predictive check for simulations, 20% of the original dataset (internal dataset) and an external dataset demonstrated the appropriateness of the final model. CONCLUSIONS Population pharmacokinetic modeling was performed to describe dasatinib pharmacokinetics in healthy subjects. Body mass index was considered as a factor that might be used in the future along with studies on patients to adjust the dosing regimens. KEY POINTS Dasatinib is classified as a highly variable drug; this variability was demonstrated in the study by the effect of body mass index on the absorption rate constant.
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Affiliation(s)
- Walaa B. Hassouneh
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman 11942, Jordan; (W.B.H.); (M.I.S.)
| | - Mutasim A. Al-Ghazawi
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman 11942, Jordan; (W.B.H.); (M.I.S.)
| | - Mohammad I. Saleh
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman 11942, Jordan; (W.B.H.); (M.I.S.)
| | - Naji Najib
- International Pharmaceutical Research Center, Amman 11196, Jordan;
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3
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Thomas M, Elhindi J, Kamaladasa K, Sirisena T. Antiarrhythmic preferences and outcomes post DC cardioversion for atrial fibrillation, an Australian rural perspective. Aust J Rural Health 2024. [PMID: 38766693 DOI: 10.1111/ajr.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Direct current cardioversion (DCCV) remains one of the recommended management strategies for symptomatic atrial fibrillation (AF). Antiarrhythmic drugs (AAD) are prescribed post procedure to maintain sinus rhythm (SR). Limited literature exists on the AAD prescribing practices and their efficacy, post-DCCV in rural Australia. OBJECTIVE The primary aim was to determine the preferred AAD post-DCCV and the factors affecting AAD prescribing practices. The secondary aim was to assess the efficacy of the AAD in maintaining SR. DESIGN A retrospective observational audit of patients with non-valvular AF who underwent successful elective DCCV for symptomatic AF, during 2015-2020 at a regional hospital in New South Wales (NSW) (Dubbo Base Hospital). Patients were followed up for a duration of 12 months post-DCCV. RESULTS 233 patients underwent successful DCCV during the study duration. Amiodarone was the preferred AAD of choice post-DCCV followed by sotalol and flecainide, respectively (36.5% vs. 27.8% vs. 1.3%). 35.2% patients were not prescribed AAD. Amiodarone and sotalol had similar but modest efficacies and neither were superior to no AAD, in maintaining SR 12 months post-DCCV (AF recurrence rate 61.5% vs. 68.2% vs. 71.6% respectively, p = 0.37). Antecedent cerebrovascular accident (CVA), pulmonary disease, smoking, prior treatment with digoxin, diuretics and left ventricular (LV) dysfunction were factors that influenced AAD prescribing practices. CONCLUSION The study demonstrates equal efficacies of amiodarone, sotalol and no AAD in maintaining SR 12 months post-DCCV. Prescribing practices post-DCCV at Dubbo Base Hospital differ from observed national trends and guidelines. AAD prescription requires a multifaceted approach with a key consideration to prioritise safety over efficacy, being mindful of challenges in delivering optimal healthcare in a rural setting.
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Affiliation(s)
- Martin Thomas
- Department of Cardiology, Dubbo Base Hospital, Dubbo, New South Wales, Australia
- Department of Intensive Care Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - James Elhindi
- Research and Education Network, Western Sydney Local Health District, Westmead, New South Wales, Australia
| | - Kanishka Kamaladasa
- Department of Cardiology, Dubbo Base Hospital, Dubbo, New South Wales, Australia
| | - Tilak Sirisena
- Department of Cardiology, Dubbo Base Hospital, Dubbo, New South Wales, Australia
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Harris TD, Farrar JE, Byerly S, Filiberto DM, Dickerson RN. Evaluation of a Novel Enteral Phosphorus Therapy with Enteral Nutrition during a National Intravenous Sodium Phosphate Shortage. Nutrients 2024; 16:1394. [PMID: 38732640 PMCID: PMC11085910 DOI: 10.3390/nu16091394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
The purpose of this study was to evaluate the efficacy and safety of intragastric administration of small volumes of sodium enema solution containing phosphorus as phosphorus replacement therapy in critically ill patients with traumatic injuries who required continuous enteral nutrition. Adult patients (>17 years of age) who had a serum phosphorus concentration <3 mg/dL (0.97 mmol/L) were evaluated. Patients with a serum creatinine concentration >1.4 mg/dL (124 µmol/L) were excluded. Patients were given 20 mL of saline enema solution intragastrically, containing 34 mmol of phosphorus and mixed in 240 mL water. A total of 55% and 73% of patients who received one (n = 22) or two doses (n = 11) had an improvement in the serum phosphorus concentration, respectively. The serum phosphorus concentration increased from 2.5 [2.1, 2.8] mg/dL (0.81 [0.69, 0.90] mmol/L) to 2.9 [2.2, 3.0] mg/dL (0.94 [0.71, 0.97 mmol/L) for those who received two doses (p = 0.222). Excluding two patients with a marked decline in serum phosphorus by 1.3 mg/dL (0.32 mmol/L) resulted in an increase in the serum phosphorus concentration from 2.3 [2.0, 2.8] mg/dL (0.74 [0.65, 0.90] mmol/L) to 2.9 [2.5, 3.2] mg/dL (0.94 [0.81, 1.03] mmol/L; n = 9; p = 0.012). No significant adverse effects were noted. Our data indicated that intragastric phosphate administration using a small volume of saline enema solution improved the serum phosphorus concentrations in most patients.
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Affiliation(s)
- Tinia D. Harris
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA
| | - Julie E. Farrar
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Dina M. Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Roland N. Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Gouju J, Jourdan C, Legeay S. [An online tool to personalize the drug-doses for obese adults]. Therapie 2024; 79:379-392. [PMID: 37865563 DOI: 10.1016/j.therap.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Between 1975 and 2014, the number of people suffering from obesity tripled, reaching 17% of the adult population in France and more than 35% in the United States. Obesity is defined by a Body Mass Index (BMI)>30kg/m2 and characterized by a significant accumulation of adipose tissue responsible for the increase in weight. This accumulation leads to physiological changes capable of modifying the pharmacokinetics of drugs, which can lead to the administration of inappropriate doses. For this reason, some significant dosage adjustments are necessary for obese patients. However, data on these adaptations are not easily accessible and sometimes complex to implement in practice. AIM To perform a new online tool allowing to calculate and propose an adjusted dose of a drug that should be administered to an obese patient. METHOD (i) carrying out an extensive bibliographic research according to the PRISMA methodology; and (ii) the development of a new website site proposing an adjusted dose for obese patients. RESULTS Firstly, 49 reviews concerning the dose adaptation have been evaluated and, secondly, 319 articles have been selected. Among them, 204 articles have been included in the database to justify the adjusted dose of 84 drugs and administration methods including antibiotics, antifungals, anticoagulants or even cancer drugs. This database is available online through a calculator on the website named Adapt'Obese. Thus, with the sex, height and weight of an obese patient, Adapt'Obese proposes a personalized and adjusted dose of the drug to administer. PERSPECTIVES Other drugs will be added soon, and functional improvements are planned, with the aim of adapting the dosages in obese patients, as for patients with renal insufficiency.
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Affiliation(s)
- Julien Gouju
- Inserm U1066, MINT, CNRS 6021, SFR-ICAT 4208, IBS, CHU d'Angers, université d'Angers, 49933 Angers, France; CHU d'Angers, 49933 Angers, France.
| | | | - Samuel Legeay
- Inserm U1066, MINT, CNRS 6021, SFR-ICAT 4208, IBS, CHU d'Angers, université d'Angers, 49933 Angers, France
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Eisler P, Zimmermann S, Henningsson R. Interpectoral and Pectoserratus Plane Block vs. Local Anesthetic Infiltration for Partial Mastectomy: A Prospective Randomized Trial. Pain Res Manag 2024; 2024:9989997. [PMID: 38550709 PMCID: PMC10977337 DOI: 10.1155/2024/9989997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/16/2024] [Accepted: 03/07/2024] [Indexed: 04/02/2024]
Abstract
Background Patients undergoing breast surgery are at risk of severe postoperative pain. Several opioid-sparing strategies exist to alleviate this condition. Regional anesthesia has long been a part of perioperative pain management for these patients. Aim This randomized study examined the benefits of interpectoral and pectoserratus plane block (IPP/PSP), also known as pectoralis nerve plain block, compared with advanced local anesthetic infiltration. Methods We analyzed 57 patients undergoing partial mastectomy with sentinel node dissection. They received either an ultrasound-guided IPP/PSP block performed preoperatively by an anesthetist or local anesthetic infiltration performed by the surgeon before and during the surgery. Results Pain measured with the numerical rating scale (NRS) indicated no statistically significant difference between the groups (IPP/PSP 1.67 vs. infiltration 1.97; p value 0.578). Intraoperative use of fentanyl was significantly lower in the IPP/PSP group (0.18 mg vs 0.21 mg; p value 0.041). There was no statistically significant difference in the length of stay in the PACU (166 min vs 175 min; p value 0.51). There were no differences in reported postoperative nausea and vomiting (PONV) between the groups. The difference in postoperative use of oxycodone in the PACU (p value 0.7) and the use of oxycodone within 24 hours postoperatively (p value 0.87) was not statistically significant. Conclusions Our study showed decreased intraoperative opioid use in the IPP/PSP group and no difference in postoperative pain scores up to 24 hours. Both groups reported low postoperative pain scores. This trial is registered with NCT04824599.
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Affiliation(s)
- Patryk Eisler
- Department of Anesthesia and Intensive Care, Central Hospital Karlstad, Karlstad, Sweden
- Department of Anesthesia, Spital Grabs, Grabs, Switzerland
| | - Stephan Zimmermann
- Department of Anesthesia and Intensive Care, Central Hospital Karlstad, Karlstad, Sweden
| | - Ragnar Henningsson
- Department of Anesthesia and Intensive Care, Central Hospital Karlstad, Karlstad, Sweden
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Gorham J, Taccone FS, Hites M. Therapeutic Drug Monitoring of Antimicrobials in Critically Ill Obese Patients. Antibiotics (Basel) 2023; 12:1099. [PMID: 37508195 PMCID: PMC10376599 DOI: 10.3390/antibiotics12071099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Obesity is a significant global public health concern that is associated with an elevated risk of comorbidities as well as severe postoperative and nosocomial infections. The treatment of infections in critically ill obese patients can be challenging because obesity affects the pharmacokinetics and pharmacodynamics of antibiotics, leading to an increased risk of antibiotic therapy failure and toxicity due to inappropriate dosages. Precision dosing of antibiotics using therapeutic drug monitoring may help to improve the management of this patient population. This narrative review outlines the pharmacokinetic and pharmacodynamic changes that result from obesity and provides a comprehensive critical review of the current available data on dosage adjustment of antibiotics in critically ill obese patients.
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Affiliation(s)
- Julie Gorham
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
| | - Maya Hites
- Clinic of Infectious Diseases, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
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Population Pharmacokinetics/Pharmacodynamics and Clinical Outcomes of Meropenem in Critically Ill Patients. Antimicrob Agents Chemother 2022; 66:e0084522. [PMID: 36226944 PMCID: PMC9664862 DOI: 10.1128/aac.00845-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Several pathophysiological changes can alter meropenem pharmacokinetics in critically ill patients, thereby increasing the risk of subtherapeutic concentrations and affecting therapeutic outcomes. This study aimed to characterize the population pharmacokinetic (PPK) parameters of meropenem, evaluate the relationship between the pharmacokinetic/pharmacodynamic index of meropenem and treatment outcomes, and evaluate the different dosage regimens that can achieve 40%, 75%, and 100% of the dosing interval for which the free plasma concentrations remain above the MIC of the pathogens (fT>MIC) targets. Critically ill adult patients treated with meropenem were recruited for this study. Five blood samples were collected from each patient. PPK models were developed using a nonlinear mixed-effects modeling approach, and the final model was subsequently used for Monte Carlo simulations to determine the optimal dosage regimens. A total of 247 concentrations from 52 patients were available for analysis. The two-compartment model with linear elimination adequately described the data. The mean PPK parameters were clearance (CL) of 4.8 L/h, central volume of distribution (VC) of 11.4 L, peripheral volume of distribution (VP) of 14.6 L, and intercompartment clearance of 10.5 L/h. Creatinine clearance was a significant covariate affecting CL, while serum albumin level and shock status were factors influencing VC and VP, respectively. Although 75% of the drug-resistant infection patients had fT>MIC values of >40%, approximately 83% of them did not survive the infection. Therefore, 40% fT>MIC might not be sufficient for critically ill patients, and a higher target, such as 75 to 100% fT>MIC, should be considered for optimizing therapy. A 75% fT>MIC could be reached using approved doses administered via a 3-h infusion.
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Puyade M, Brunet F, Carolina R, Fergusson N, Makedonov I, Freedman MS, Atkins H. Autologous Hematopoietic Stem Cell Transplantation for Multiple Sclerosis, the Ottawa Protocol. Curr Protoc 2022; 2:e437. [PMID: 35594180 DOI: 10.1002/cpz1.437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Autologous hematopoietic stem cell transplantation (aHSCT) is increasingly used to treat patients with highly active multiple sclerosis (MS) refractory to disease-modifying therapy. Briefly, cyclophosphamide and filgrastim are used to mobilize autologous hematopoietic stem cells (HSC) into the circulation. HSC are harvested by leukapheresis, purified using a CD34 immunomagnetic selection process, and cryopreserved. Busulphan, cyclophosphamide, and rabbit anti-thymocyte globulin are used to destroy the patient's autoreactive immune system, followed by infusion of the previously collected HSC, which reconstitute a naïve and self-tolerant immune system. Many MS patients experience durable remissions with no evidence of new disease activity following aHSCT. Treatment-related toxicity is rare, but potentially life-threatening complications necessitate appropriate patient selection by MS neurologists and HSCT physicians. AHSCT must be performed with a highly trained multidisciplinary team expert to minimize morbidity and mortality. We present the current aHSCT procedure for an MS indication at The Ottawa Hospital, developed from our program's 20-year experience. © 2022 Wiley Periodicals LLC. Basic Protocol 1: Candidate selection Basic Protocol 2: Autologous hematopoietic stem cell mobilization, collection, purification, and cryopreservation Basic Protocol 3: Autologous hematopoietic stem cell transplantation Basic Protocol 4: Supportive care following recovery from aHSCT (Beyond 100 days) Basic Protocol 5: Ongoing evaluation of multiple sclerosis.
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Affiliation(s)
- Mathieu Puyade
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Centre d'Investigation Clinique (CIC)-1402, CHU de Poitiers, Poitiers, France
| | - Francis Brunet
- Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rush Carolina
- Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ontario
| | | | | | - Mark S Freedman
- Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ontario.,Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Harold Atkins
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ontario.,Ottawa Hospital Research Institute, Ottawa, Ontario
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Population Pharmacokinetics of Amikacin in Patients on Veno-Arterial Extracorporeal Membrane Oxygenation. Pharmaceutics 2022; 14:pharmaceutics14020289. [PMID: 35214022 PMCID: PMC8879580 DOI: 10.3390/pharmaceutics14020289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 12/04/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support leads to complex pharmacokinetic alterations, whereas adequate drug dosing is paramount for efficacy and absence of toxicity in critically ill patients. Amikacin is a major antibiotic used in nosocomial sepsis, especially for these patients. We aimed to describe amikacin pharmacokinetics on V-A ECMO support and to determine relevant variables to improve its dosing. All critically ill patients requiring empirical antimicrobial therapy, including amikacin for nosocomial sepsis supported or not by V-A ECMO, were included in a prospective population pharmacokinetic study. This population pharmacokinetic analysis was built with a dedicated software, and Monte Carlo simulations were performed to identify doses achieving therapeutic plasma concentrations. Thirty-nine patients were included (control n = 15, V-A ECMO n = 24); 215 plasma assays were performed and used for the modeling process. Patients received 29 (24–33) and 32 (30–35) mg/kg of amikacin in control and ECMO groups, respectively. Data were best described by a two-compartment model with first-order elimination. Inter-individual variabilities were observed on clearance, central compartment volume (V1), and peripherical compartment volume (V2). Three significant covariates explained these variabilities: Kidney Disease Improving Global Outcomes (KDIGO) stage on amikacin clearance, total body weight on V1, and ECMO support on V2. Our simulations showed that the adequate dosage of amikacin was 40 mg/kg in KDIGO stage 0 patients, while 25 mg/kg in KDIGO stage 3 patients was relevant. V-A ECMO support had only a secondary impact on amikacin pharmacokinetics, as compared to acute kidney injury.
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Busse D, Simon P, Schmitt L, Petroff D, Dorn C, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Comparative Plasma and Interstitial Tissue Fluid Pharmacokinetics of Meropenem Demonstrate the Need for Increasing Dose and Infusion Duration in Obese and Non-obese Patients. Clin Pharmacokinet 2021; 61:655-672. [PMID: 34894344 PMCID: PMC9095536 DOI: 10.1007/s40262-021-01070-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A quantitative evaluation of the PK of meropenem, a broad-spectrum β-lactam antibiotic, in plasma and interstitial space fluid (ISF) of subcutaneous adipose tissue of obese patients is lacking as of date. The objective of this study was the characterisation of meropenem population pharmacokinetics in plasma and ISF in obese and non-obese patients for identification of adequate dosing regimens via Monte-Carlo simulations. METHODS We obtained plasma and microdialysate concentrations after administration of meropenem 1000 mg to 15 obese and 15 non-obese surgery patients from a prospective clinical trial. After characterizing plasma- and microdialysis-derived ISF pharmacokinetics via population pharmacokinetic analysis, we simulated thrice-daily (TID) meropenem short-term (0.5 h), prolonged (3.0 h), and continuous infusions. Adequacy of therapy was assessed by the probability of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) analysis based on time unbound concentrations exceeded minimum inhibitory concentrations (MIC) on treatment day 1 (%fT > MIC) and the sum of PTA weighted by relative frequency of MIC values for infections by pathogens commonly treated with meropenem. To avoid interstitial tissue fluid concentrations below MIC for the entire dosing interval during continuous infusions, a more conservative PK/PD index was selected (%fT > 4 × MIC). RESULTS Adjusted body weight (ABW) and calculated creatinine clearance (CLCRCG_ABW) of all patients (body mass index [BMI] = 20.5-81.5 kg/m2) explained a considerable proportion of the between-patient pharmacokinetic variability (15.1-31.0% relative reduction). The ISF:plasma ratio of %fT > MIC was relatively similar for MIC ≤ 2 mg/L but decreased for MIC = 8 mg/L over ABW = 60-120 kg (0.50-0.20). Steady-state concentrations were 2.68 times (95% confidence interval [CI] = 2.11-3.37) higher in plasma than in ISF, supporting PK/PD targets related to four times the MIC during continuous infusions to avoid suspected ISF concentrations constantly below the MIC. A 3000 mg/24 h continuous infusion was sufficient at MIC = 2 mg/L for patients with CLCRCG_ABW ≤ 100 mL/min and ABW < 90 kg, whereas 2000 mg TID prolonged infusions were adequate for those with CLCRCG_ABW ≤ 100 mL/min and ABW > 90 kg. For MIC = 2 mg/L and %fT> MIC = 95, PTA was adequate in patients over the entire investigated range of body mass and renal function using a 6000 mg continuous infusion. A prolonged infusion of meropenem 2000 mg TID was sufficient for MIC ≤ 8 mg/L and all investigated ABW and CLCRCG_ABW when employing the PK/PD target %fT > MIC = 40. Short-term infusions of 1000 mg TID were sufficient for CLCRCG_ABW ≤ 130 mL/min and distributions of MIC values for Escherichia coli, Citrobacter freundii, and Klebsiella pneumoniae but not for Pseudomonas aeruginosa. CONCLUSIONS This analysis indicated a need for higher doses (≥ 2000 mg) and prolonged infusions (≥ 3 h) for obese and non-obese patients at MIC ≥ 2 mg/L. Higher PTA was achieved with prolonged infusions in obese patients and with continuous infusions in non-obese patients. TRIAL REGISTRATION EudraCT: 2012-004383-22.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Ayad AE, Salman OH, Ibrahim AMF, Al-Taher WAM, Mishriky AM, Pergolizzi JV, Viswanath O, Urits I, Rekatsina M, Peppin JF, Paladini A, Varrassi G. A Response to: Letter to the Editor regarding "Influences of Gender on Intravenous Nalbuphine Actions After Major Abdominal Surgery: A Multicenter Study". Pain Ther 2021; 10:1783-1786. [PMID: 34431072 PMCID: PMC8586306 DOI: 10.1007/s40122-021-00305-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/06/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Amany E Ayad
- Department of Anesthesia ICU and Pain, Cairo University, Cairo, 11566, Egypt
| | - Ossama H Salman
- Department of Anesthesiology, South Valley University, Qena, 83511, Egypt
| | | | | | - Adel M Mishriky
- Department of Community Medicine, Suez Canal University, Ismailia, 41511, Egypt
| | | | - Omar Viswanath
- Department of Anesthesiology, University of Arizona, Phoenix, AZ, 85003, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MS, USA
| | | | - John F Peppin
- College of Osteopathic Medicine, Pikeville University, c, KT, USA
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13
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Jiang J, Zhang J, Liu Y, Xu D, Peng Z. Urine Output Calculated Using Actual Body Weight May Result in Overestimation of Acute Kidney Injury for Obese Patients. Shock 2021; 56:737-743. [PMID: 33927136 PMCID: PMC8519162 DOI: 10.1097/shk.0000000000001789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/07/2021] [Indexed: 11/26/2022]
Abstract
GOAL The derived hourly urine output (UO) indexed by body weight is one of the major criteria for the diagnosis of acute kidney injury (AKI). However, it is unclear whether actual body weight (ABW) or ideal body weight (IBW) should be used. This study aims to explore whether UO calculation based on ABW might lead to overestimation of AKI. METHOD AKI patients identified in the Medical Information Mart for Intensive Care III database by different components of the Kidney Disease Improving Global Outcomes guidelines and different definitions of body weight were retrospectively studied. Hospital and 90-day mortality were compared to decide whether different patient groups had the same outcome. RESULTS In the cohort of 14,725 patients, AKI was identified in 4,298 (29.19%) and 3,060 (20.78%) patients respectively when ABW or IBW was used (P < 0.01). Multivariate logistic regression revealed that AKI patients identified by UO calculated from ABW had similar hospital and 90-day mortality to that of patients with no evidence of AKI. Whereas AKI patients identified by serum creatinine changes, or those identified by both ABW and IBW, had twice higher the risks of hospital death and about 1.5 times higher the risks of 90-day death compared with thoese with no evidence of AKI. Results were confirmed in two separate sensitivity analyses where patients whose admission creatinine levels were within the normal reference ranges and patients identified as sepsis were studied. CONCLUSIONS Calculating hourly body weight normalized UO using ABW may lead to underestimation of UO and overestimation of AKI.
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Affiliation(s)
- Jun Jiang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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14
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Sohn JT. Comment: The Safety of Continuous Infusion Propofol in Mechanically Ventilated Adults With Coronavirus Disease 2019. Ann Pharmacother 2021; 56:626-627. [PMID: 34496671 DOI: 10.1177/10600280211043505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, 52727, Republic of Korea
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15
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Babariya SP, Vivero A, Peedin A, Karp JK. Therapeutic plasma exchange in patients with severe obesity (BMI >40): A survey of practices in the United States. J Clin Apher 2021; 36:802-807. [PMID: 34355813 DOI: 10.1002/jca.21931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND The prevalence of obesity in the United States is estimated at 42.4% and expected to increase over the next decade. Therefore, understanding how to best perform certain medical procedures on severely obese (SO) patients is a necessity. This study presents results on the current methods of performing therapeutic plasma exchange (TPE) on SO patients. This paper aims to contribute to the existing literature by providing new insights into calculating plasma volume (PV) for TPE in SO patients. METHODS Blood Bank/Apheresis Directors at all institutions with pathology residency and/or blood banking/transfusion medicine fellowship programs were asked to complete a 5-question online survey about their institutional policies regarding TPE in SO patients. Survey data were analyzed to determine if institutions have policies in place to calculate PV in SO patients. RESULTS Out of the 144 institutions contacted, 45 (31%) completed the survey. Nine (20%) institutions had a policy to calculate PV differently for SO patients, 7 (16%) reported a specific body mass index (BMI) above which they alter PV calculation, and 7 (16%) reported a maximum volume exchanged in SO patients. CONCLUSION A minority of responding institutions had specific policies in place to calculate PV for TPE in SO patients. Practice patterns for calculating PV for TPE in SO patients varied, with some institutions adjusting PV calculations and others setting a maximum volume to be exchanged regardless of BMI. These findings highlight the need for establishing a clear method of calculating PV in SO patients.
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Affiliation(s)
| | - Angelica Vivero
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexis Peedin
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Julie Katz Karp
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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16
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Mellon G, Hammas K, Burdet C, Duval X, Carette C, El-Helali N, Massias L, Mentré F, Czernichow S, Crémieux AC. Population pharmacokinetics and dosing simulations of amoxicillin in obese adults receiving co-amoxiclav. J Antimicrob Chemother 2021; 75:3611-3618. [PMID: 32888018 DOI: 10.1093/jac/dkaa368] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pneumonia, skin and soft tissue infections are more frequent in obese patients and are most often treated by co-amoxiclav, using similar dosing regimens to those used for non-obese subjects. No data are available on amoxicillin pharmacokinetics among obese subjects receiving co-amoxiclav. MATERIALS AND METHODS Prospective, single-centre, open-label, non-randomized, crossover pharmacokinetic trial having enrolled obese otherwise healthy adult subjects. A first dose of co-amoxiclav (amoxicillin/clavulanate 1000/200 mg) was infused IV over 30 min, followed by a second dose (1000/125 mg) administered orally, separated by a washout period of ≥24 h. We assayed concentrations of amoxicillin by a validated ultra HPLC-tandem MS technique. We estimated population pharmacokinetic parameters of amoxicillin by non-linear mixed-effect modelling using the SAEM algorithm developed by Monolix. RESULTS Twenty-seven subjects were included in the IV study, with 24 included in the oral part of the study. Median body weight and BMI were 109.3 kg and 40.6 kg/m2, respectively. Amoxicillin pharmacokinetics were best described by a two-compartment model with first-order elimination. Mean values for clearance, central volume, intercompartmental clearance and peripheral volume were, respectively, 14.6 L/h, 9.0 L, 4.2 L/h and 6.4 L for amoxicillin. Oral bioavailability of amoxicillin was 79.7%. Amoxicillin Cmax after oral administration significantly reduced with weight (P = 0.013). Dosing simulations for amoxicillin predicted that most of the population will achieve the pharmacodynamic target of fT>MIC ≥40% with the regimen of co-amoxiclav 1000/200 mg (IV) or 1000/125 mg (oral) q8h for MICs titrated up to 0.5 mg/L (IV) and 1 mg/L (oral). CONCLUSIONS Pharmacokinetic/pharmacodynamic goals for amoxicillin can be obtained in obese subjects.
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Affiliation(s)
- G Mellon
- AP-HP, Tropical and Infectious Diseases department, Hôpital Saint-Louis, Paris, France
| | - K Hammas
- CIC-EC 1425, INSERM, F-75018 Paris, France.,AP-HP, Hôpital Bichat, DEBRC, F-75018 Paris, France
| | - C Burdet
- CIC-EC 1425, INSERM, F-75018 Paris, France.,AP-HP, Hôpital Bichat, DEBRC, F-75018 Paris, France.,Université de Paris, IAME, INSERM, F-75018 Paris, France
| | - X Duval
- CIC-EC 1425, INSERM, F-75018 Paris, France.,Université de Paris, IAME, INSERM, F-75018 Paris, France
| | - C Carette
- AP-HP, Nutrition department, Hôpital Georges-Pompidou, Paris, France
| | - N El-Helali
- Microbiology Laboratory, Hôpital Paris Saint Joseph, Paris, France
| | - L Massias
- Université de Paris, IAME, INSERM, F-75018 Paris, France.,AP-HP, Toxicology Laboratory, Hôpital Bichat, Paris, France
| | - F Mentré
- CIC-EC 1425, INSERM, F-75018 Paris, France.,AP-HP, Hôpital Bichat, DEBRC, F-75018 Paris, France.,Université de Paris, IAME, INSERM, F-75018 Paris, France
| | - S Czernichow
- AP-HP, Nutrition department, Hôpital Georges-Pompidou, Paris, France.,Université de Paris, CRESS, INSERM, INRA, F-75004 Paris, France
| | - A-C Crémieux
- AP-HP, Tropical and Infectious Diseases department, Hôpital Saint-Louis, Paris, France
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17
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Hattar L, Assaker JP, Aoun J, Price LL, Carrozza J, Jaber BL. Revising the Maximal Contrast Dose for Predicting Acute Kidney Injury following Coronary Intervention. Am J Nephrol 2021; 52:328-335. [PMID: 33827080 DOI: 10.1159/000515382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/19/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The maximal allowable contrast dose (MACD = 5 × body weight/serum creatinine) is an empiric equation that has been used and validated in several studies to mitigate the risk of contrast-induced acute kidney injury (CI-AKI). However, coefficient 5 (referred to as factor K) was empirically devised and never disputed. The aim of this study was to refine the MACD equation for the prediction of CI-AKI following percutaneous coronary interventions (PCIs). METHODS This is a single-center, retrospective cohort study of adults undergoing PCI. Electronic medical records were reviewed to identify patients who underwent PCI between 2010 and 2019, derived from the National Cardiovascular Data Registry Cath-PCI registry for our hospital. Factor K (defined as contrast volume × serum creatinine/body weight) was calculated for every patient. A receiver operating characteristic (ROC) curve was constructed, and the Youden index was used to identify the optimal cut-off value for factor K in predicting severe (stages 2-3) CI-AKI. RESULTS Of the 3,506 patients undergoing PCI, 255 (7.2%) developed CI-AKI, and 68 (26.7%) of the 255 experienced severe AKI. Factor K predicted all-stage CI-AKI (area under the ROC curve 0.649; 95% CI 0.611, 0.686) but had better performance for predicting severe (stages 2-3) AKI (0.736; 95% CI 0.674, 0.800). The optimal cut-off value for factor K in predicting severe CI-AKI was 2.5, with a corresponding sensitivity of 68.7% and specificity of 70.5%. On subgroup analyses, optimal cut-off values for factor K for high-risk groups were not significantly different from those of low-risk groups. CONCLUSION Our study indicates that factor K in the MACD equation is an independent risk factor for the development of severe CI-AKI, with an optimal cut-off value of 2.5. If our findings are validated, the MACD equation should be revised to incorporate the coefficient of 2.5 instead of 5.
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Affiliation(s)
- Laith Hattar
- Department of Medicine, St. Elizabeth's Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Jean-Pierre Assaker
- Department of Medicine, St. Elizabeth's Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Joe Aoun
- Department of Medicine, St. Elizabeth's Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Cardiology, DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Lori Lyn Price
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA
| | - Joseph Carrozza
- Department of Medicine, St. Elizabeth's Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, St. Elizabeth's Medical Center, Boston, Massachusetts, USA
| | - Bertrand L Jaber
- Department of Medicine, St. Elizabeth's Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
- Division of Nephrology, St. Elizabeth's Medical Center, Boston, Massachusetts, USA
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18
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Moon TS, Van de Putte P, De Baerdemaeker L, Schumann R. The Obese Patient: Facts, Fables, and Best Practices. Anesth Analg 2021; 132:53-64. [PMID: 32282384 DOI: 10.1213/ane.0000000000004772] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The prevalence of obesity continues to rise worldwide, and anesthesiologists must be aware of current best practices in the perioperative management of the patient with obesity. Obesity alters anatomy and physiology, which complicates the evaluation and management of obese patients in the perioperative setting. Gastric point-of-care ultrasound (PoCUS) is a noninvasive tool that can be used to assess aspiration risk in the obese patient by evaluating the quantity and quality of gastric contents. An important perioperative goal is adequate end-organ perfusion. Standard noninvasive blood pressure (NIBP) is our best available routine surrogate measurement, but is vulnerable to greater inaccuracy in patients with obesity compared to the nonobese population. Current NIBP methodologies are discussed. Obese patients are at risk for wound and surgical site infections, but few studies conclusively guide the exact dosing of intraoperative prophylactic antibiotics for them. We review evidence for low-molecular-weight heparins and weight-based versus nonweight-based administration of vasoactive medications. Finally, intubation and extubation of the patient with obesity can be complicated, and evidence-based strategies are discussed to mitigate danger during intubation and extubation.
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Affiliation(s)
- Tiffany S Moon
- From the Department of Anesthesiology and Pain, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Roman Schumann
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, Massachusetts
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19
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Derendorf H, Heinrichs T, Reimers T, Lebert C, Brinkmann A. Calculated initial parenteral treatment of bacterial infections: Pharmacokinetics and pharmacodynamics. GMS INFECTIOUS DISEASES 2020; 8:Doc17. [PMID: 32373442 PMCID: PMC7186811 DOI: 10.3205/id000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the third chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter features the pharmacokinetic and pharmacodynamics properties of the most frequently used antiinfective agents.
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Affiliation(s)
- Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Tobias Reimers
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Alexander Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Germany
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20
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Nikitopoulou I, Kampisiouli E, Jahaj E, Vassiliou AG, Dimopoulou I, Mastora Z, Tsakiris S, Perreas K, Tzanela M, Routsi C, Orfanos SE, Kotanidou A. Ghrelin alterations during experimental and human sepsis. Cytokine 2019; 127:154937. [PMID: 31830702 DOI: 10.1016/j.cyto.2019.154937] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 10/24/2019] [Accepted: 11/19/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Ghrelin is a hormone mainly produced by cells of the gastric mucosa, which has been shown to possess anti-inflammatory and immunomodulatory properties. The objective of the study was to investigate ghrelin levels during sepsis, as well as in an experimental sepsis model. METHODS All consecutive admissions to the ICU of a tertiary hospital in Athens, Greece were screened for eligibility during the study. Thirty four non-septic patients upon ICU admission who subsequently developed sepsis were enrolled. Clinical data and scores were recorded, and blood samples were obtained at baseline (upon ICU admission), and at sepsis development. Total and active ghrelin, leptin, and cytokines were measured. Moreover, lipopolysaccharide (LPS) was administered to mice in order to induce endotoxemia and at specified time points, blood and tissue samples were collected. RESULTS In patients, serum total and active ghrelin concentrations were significantly elevated in sepsis compared to baseline (553.8 ± 213.4 vs 193.5 ± 123.2, p < 0.001; 254.3 ± 70.6 vs 56.49 ± 16.3, p < 0.001). Active ghrelin levels at the sepsis stage were inversely correlated with SOFA score and length of stay in the ICU (p = 0.023 and p = 0.027 respectively). In the mouse endotoxemia model ghrelin levels were elevated following LPS treatment, and the same trend was observed for leptin, TNFα and IL-6. Ghrelin administration managed to reduce IL-6 levels in mouse serum and in BALF. Pulmonary expression of ghrelin and its receptor GHSR1a was found decreased in LPS-treated mice. CONCLUSIONS In a well-defined cohort of ICU patients, we have demonstrated that active and total ghrelin increase in sepsis. The same is true for the experimental sepsis model used in the study. The inverse correlation of active ghrelin levels with SOFA score and length of ICU stay among septic patients is indicative of a potential protective role of active ghrelin during the septic process.
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Affiliation(s)
- I Nikitopoulou
- GP Livanos and M Simou Laboratories, 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - E Kampisiouli
- 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - E Jahaj
- 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - A G Vassiliou
- GP Livanos and M Simou Laboratories, 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - I Dimopoulou
- 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - Z Mastora
- 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - S Tsakiris
- GP Livanos and M Simou Laboratories, 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - K Perreas
- GP Livanos and M Simou Laboratories, 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - M Tzanela
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - C Routsi
- 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - S E Orfanos
- GP Livanos and M Simou Laboratories, 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece; 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece; 2nd Department of Critical Care, Medical School, National & Kapodistrian University of Athens, "Attikon" Hospital, Haidari, Athens, Greece.
| | - A Kotanidou
- GP Livanos and M Simou Laboratories, 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece; 1st Department of Critical Care & Pulmonary Services, Medical School, National & Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
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22
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Propofol infusion syndrome: a structured literature review and analysis of published case reports. Br J Anaesth 2019; 122:448-459. [PMID: 30857601 DOI: 10.1016/j.bja.2018.12.025] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/26/2018] [Accepted: 12/20/2018] [Indexed: 12/31/2022] Open
Abstract
Propofol infusion syndrome is a rare, potentially fatal condition first described in children in the 1990s and later reported in adults. We provide a narrative review of what is currently known about propofol infusion syndrome, including a structured analysis of all published case reports; child and adult cases were analysed separately as propofol is no longer used for long-term sedation in children. The review contains an update on current knowledge of the pathophysiology of this condition along with recommendations for its diagnosis, prevention, and management. We reviewed 108 publications documenting 168 cases of propofol infusion syndrome. We evaluated clinical features and analysed factors influencing mortality in child and adult cases using separate multivariate analysis models. We used separate multiple linear regression models to analyse relationships between cumulative dose of propofol and the number of features seen and organ systems involved. Lipidaemia, fever, and hepatomegaly occurred more frequently in children than in adults, whilst rhabdomyolysis and hyperkalaemia were more frequent in adults. Mortality from propofol infusion syndrome is independently associated with fever and hepatomegaly in children, and electrocardiogram changes, hypotension, hyperkalaemia, traumatic brain injury, and a mean propofol infusion rate >5 mg kg-1 h-1 in adults. The cumulative dose of propofol was associated with an increased number of clinical features and the number of organ systems involved in adult cases only. Clinicians should consider propofol infusion syndrome in cases of unexplained metabolic acidosis, ECG changes, and rhabdomyolysis. We recommend early consideration of continuous haemofiltration in the management of propofol infusion syndrome.
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23
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Schmidt JJ, Strunk AK, David S, Bode-Böger SM, Martens-Lobenhoffer J, Knitsch W, Scherneck S, Welte T, Kielstein JT. Single- and multiple-dose pharmacokinetics and total removal of colistin in critically ill patients with acute kidney injury undergoing prolonged intermittent renal replacement therapy. J Antimicrob Chemother 2019; 74:997-1002. [DOI: 10.1093/jac/dky511] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/05/2018] [Accepted: 11/13/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Julius J Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Ann-Kathrin Strunk
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Stefanie M Bode-Böger
- Institute of Clinical Pharmacology, Otto von-Guericke-University of Magdeburg, Magdeburg, Germany
| | - Jens Martens-Lobenhoffer
- Institute of Clinical Pharmacology, Otto von-Guericke-University of Magdeburg, Magdeburg, Germany
| | - Wolfgang Knitsch
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Stephan Scherneck
- Institute of Pharmacology, Toxicology and Clinical Pharmacy, Technical University of Braunschweig, Braunschweig, Germany
| | - Tobias Welte
- Department of Pulmonary Medicine, Hannover Medical School, Hannover, Germany
| | - Jan T Kielstein
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
- Medical Clinic V
- Nephrology
- Rheumatology
- Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
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24
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Mirkov S, Lyseng-Williamson KA. Appropriate drug dosages in obese patients. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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25
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Dickerson RN. Metabolic support challenges with obesity during critical illness. Nutrition 2018; 57:24-31. [PMID: 30153576 DOI: 10.1016/j.nut.2018.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/14/2018] [Accepted: 05/21/2018] [Indexed: 12/21/2022]
Abstract
Adiposity-based chronic disease, critical illness, and nutrition therapy increase the risk for overfeeding and worsened nutritional and clinical outcomes. Hypocaloric, high-protein nutrition therapy provides critically ill obese patients the opportunity to achieve net protein anabolism with a reduced risk for overfeeding-related complications. The intent of this review is to discuss the impact of obesity on clinical outcomes, describe the consequences of obesity that increase complications associated with nutrition therapy, provide the framework to develop a hypocaloric, high-protein regimen, review the scientific evidence to support this mode of therapy, and discuss its limitations. Practical suggestions for patient monitoring are also provided.
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Affiliation(s)
- Roland N Dickerson
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee.
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26
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Katayama S, Koyama K, Goto Y, Koinuma T, Tonai K, Shima J, Wada M, Nunomiya S. Body weight definitions for evaluating a urinary diagnosis of acute kidney injury in patients with sepsis. BMC Nephrol 2018; 19:101. [PMID: 29716530 PMCID: PMC5930934 DOI: 10.1186/s12882-018-0895-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 04/12/2018] [Indexed: 12/25/2022] Open
Abstract
Background We hypothesized that the use of actual body weight might lead to more frequent misdiagnosis of acute kidney injury (AKI) than when ideal body weight is used in underweight and/or obese patients. We examined which definition of body weight is most effective in establishing a urinary diagnosis of AKI in septic patients. Methods Consecutive patients aged ≥ 20 years admitted to the intensive care unit of a university hospital between June 2011 and December 2016 were analyzed. Sepsis was defined in accordance with the Sepsis-3 criteria. AKI was defined as a urinary output of < 0.5 mL/kg/6h during intensive care unit stay. Patients were divided into one of four body mass index-based classes. The severity of illness and 90-day mortality were compared across the body mass index subgroups in patients diagnosed using the actual body weight or ideal body weight. Results Of 5764 patients, 569 septic patients were analyzed. One hundred and fifty-three (26.9%) and 140 (24.6%) patients were diagnosed as having AKI using actual body weight and ideal body weight, respectively. There were no significant differences in the severity of illness among these groups. Also, 90-day mortality did not differ significantly among these groups. According to body mass index, 90-day mortality significantly differed in patients diagnosed using their actual body weights (underweight vs. normal vs. overweight vs. obese: 76.7% vs. 39.5% vs. 26.0% vs. 35.7%, P = 0.033). Conclusion Generally, using actual body weight to calculate the weight-adjusted hourly urine output for diagnosing AKI increased the sensitivity compared to ideal body weight, irrespective of the severity of illness in septic patients. Delayed diagnosis, however, was more common among underweight patients in this situation, and clinicians should be cautious when diagnosing urinary AKI using actual body weight.
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Affiliation(s)
- Shinshu Katayama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Kansuke Koyama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yuya Goto
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Toshitaka Koinuma
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Ken Tonai
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Jun Shima
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Masahiko Wada
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shin Nunomiya
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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The impact of body mass index on post resuscitation survival after cardiac arrest: A meta-analysis. Clin Nutr ESPEN 2018; 24:47-53. [DOI: 10.1016/j.clnesp.2018.01.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 01/28/2018] [Indexed: 12/19/2022]
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Abstract
ZusammenfassungPatienten der bariatrischen Chirurgie sind eine Hochrisikogruppe für venöse Thromboembo-lien. Die aktuellen Leitlinien der AWMF (Deutschland), NICE (Großbritannien) und der ACCP (USA) werden vorgestellt, und es erfolgt eine Diskussion der Literatur zum Thema. Frühmobilisation und physikalische Methoden sind die Basismaßnahmen zur Thromboseprophylaxe für alle Patienten. Zusätzlich ist in der Regel eine medikamentöse Prophylaxe indiziert. Mittel der Wahl sind heute niedermolekulare Heparine. Evidenz-basierte Dosisempfehlungen für bariatrische Patienten liegen nicht vor. Wir empfehlen eine viertel therapeutische Dosis von niedermolekularen Heparinen ohne Gewichts-Obergrenze einmal täglich s.c. Der Beginn soll am Tag vor der OP sein. Alternative ist Fondaparinux in einer Fixdosis von 1 x 2,5 mg s.c. Gegen das Thrombose- muss individuell das Blutungsrisiko abgewogen werden.
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Pépin JL, Timsit JF, Tamisier R, Borel JC, Lévy P, Jaber S. Prevention and care of respiratory failure in obese patients. THE LANCET RESPIRATORY MEDICINE 2017; 4:407-18. [PMID: 27304558 DOI: 10.1016/s2213-2600(16)00054-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/25/2016] [Accepted: 01/28/2016] [Indexed: 12/14/2022]
Abstract
With the increase in the global prevalence of obesity, there is a parallel rise in the proportion of obese patients admitted to intensive care units, referred for major surgery or requiring long-term non-invasive ventilation (NIV) at home for chronic respiratory failure. We describe the physiological effect of obesity on the respiratory system mainly in terms of respiratory mechanics, respiratory drive, and patency of the upper airways. Particular attention is given to the prevention and the clinical management of respiratory failure in obese patients with a main focus on invasive and NIV in intensive care during the perioperative period and long-term use of NIV on return home. We also address other aspects of care of obese patients, including antibiotic dosing and catheter-related infections.
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Affiliation(s)
- Jean Louis Pépin
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France.
| | - Jean François Timsit
- IAME, INSERM UMR 1137, Paris Diderot University, Paris, France; Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University and Bichat Hospital, Paris, France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean Christian Borel
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Patrick Lévy
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, University of Montpellier, Saint Eloi Teaching Hospital, Montpellier, France; Centre National de la Recherche Scientifique (CNRS 9214), Institut National de la Santé et de la Recherche Medicale (INSERM U-1046), Montpellier University, Montpellier, France
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Xiong Y, Fukuda T, Knibbe CAJ, Vinks AA. Drug Dosing in Obese Children: Challenges and Evidence-Based Strategies. Pediatr Clin North Am 2017; 64:1417-1438. [PMID: 29173794 DOI: 10.1016/j.pcl.2017.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
With the alarming increase of obesity in children, pediatricians are increasingly being confronted with difficult dosing decisions. Many drug labels do not provide specific dosing instructions for children who are obese. In this article, we describe the physiologic parameters altered by obesity and their influences on drug disposition and effect. We review the principles of allometry, and the key pharmacokinetic parameters that can be used to derive age appropriate dosing regimens. Last, we illustrate how appropriate weight descriptors can be selected, and how important PK parameters can be extrapolated for dosing in obese children when pediatric pharmacokinetic information is available.
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Affiliation(s)
- Ye Xiong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St Antonius Hospital, PO Box 2500, Nieuwegein 3430 EM, The Netherlands; Division of Pharmacology, Leiden Academic Center for Drug Research, Faculty of Science, Leiden University, PO Box 9502, 2300 RA, Leiden, The Netherlands
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229-3039, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Park G, Shayani S, Stiller T, Wang S, Yuan S. Dose capping of plerixafor in patients weighing more than 100 kg at one vial led to successful mobilization outcomes and significant cost savings. Transfusion 2017; 58:323-329. [PMID: 29134662 DOI: 10.1111/trf.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Plerixafor is frequently used as an adjunct agent to improve mobilization of peripheral blood stem cells in many clinical settings. However, its high cost (>$8000 per single-use 24-mg vial) is a significant concern. The manufacturer-recommended dose is 0.24 mg/kg. Therefore, patients weighing more than 100 kg would require a second vial, thus doubling the drug cost per dose. We implemented a policy of capping the dose of plerixafor at 24 mg, or one vial, for patients weighing more than 100 kg. This retrospective study compares the mobilization of patients more than 100 kg who received capped doses, with historical control patients who received full, uncapped doses. STUDY DESIGN AND METHODS Consecutive, eligible patients weighing more than 100 kg who received capped (n = 47) and full doses of plerixafor (n = 40) were identified. Plerixafor was given up-front, as a rescue agent due to suboptimal mobilization, or during remobilization. Baseline characteristics and mobilization data were collected and compared. RESULTS Patients in the two groups showed comparable baseline characteristics. They collected similar total numbers of CD34+ cells/kg (median, 4.08 × 106 vs. 3.36 × 106 CD34+ cells/kg; p = 0.86) and achieved comparable collection success rates as defined by collecting more than 2.0 × 106 CD34+ cells/kg (98% vs. 90%, p = 0.21). However, patients who received capped doses required only half of the number of vials of plerixafor (median, 3 vials vs. 6 vials; p < 0.0001). CONCLUSION Dose capping plerixafor at 24 mg for patients more than 100 kg is a cost-effective strategy, which achieved comparable mobilization outcomes and reduced the total number of vials of plerixafor used by half.
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Affiliation(s)
- Gabriel Park
- Department of Pharmacy Services, City of Hope National Medical Center, Duarte, California
| | - Sepideh Shayani
- Department of Pharmacy Services, City of Hope National Medical Center, Duarte, California
| | - Tracey Stiller
- Division of Biostatistics, Department of Information Sciences, City of Hope National Medical Center, Duarte, California
| | - Shirong Wang
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, City of Hope National Medical Center, Duarte, California
| | - Shan Yuan
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, City of Hope National Medical Center, Duarte, California
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Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy/tolerability of a culture-guided approach in the eradication of Helicobacter pylori and identify factors associated with antibiotic resistance/treatment failure. PATIENTS AND METHODS This retrospective single-center study included patients who underwent culture-guided treatment for H. pylori infection, after two ineffective eradication attempts, between October 2012 and December 2016. We assessed the following demographic and clinical data of the patients: sex, age, BMI, alcohol and tobacco consumption, history of dyspepsia, peptic ulceration and first-degree relatives with gastric cancer, antibiotic susceptibility results, treatment composition, tolerability, and success. The treatment success was confirmed by a monoclonal stool antigen test. RESULTS Culture-guided treatment was performed in 42 patients (57% women, mean age±SD: 48.9±11.4 years). The rates of antibiotic resistance were as follows: clarithromycin 86%, metronidazole 67%; levofloxacin 52%, tetracycline 2%, and amoxicillin and rifampicin 0%. Double resistance to clarithromycin and metronidazole was found in 59.5% of the patients. Most patients showed resistance to less than three antibiotics, but 31% were resistant to three or more. Intention-to-treat and per-protocol eradication rates were 59.5 and 61.5%. Adverse events occurred in 15 (35.7%) patients, but only two (4.8%) patients did not complete treatment because of adverse events. Only age more than 50 years was associated with resistance to three or more antibiotics. Having a first-degree relative with gastric cancer was associated with treatment failure and having a BMI of at least 25 kg/m protected from failure. CONCLUSION Third-line culture-guided treatment often fails to eradicate H. pylori infection. We need to find factors other than in-vitro antibiotic resistance to explain these suboptimal results.
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 321] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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Budiansky AS, Margarson MP, Eipe N. Acute pain management in morbid obesity – an evidence based clinical update. Surg Obes Relat Dis 2017; 13:523-532. [DOI: 10.1016/j.soard.2016.09.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/06/2016] [Accepted: 09/08/2016] [Indexed: 01/13/2023]
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Hepatotoxicity in Obese Versus Nonobese Patients With Acetaminophen Poisoning Who Are Treated With Intravenous N-Acetylcysteine. Am J Ther 2017; 23:e714-9. [PMID: 24263163 DOI: 10.1097/01.mjt.0000434043.62372.00] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is limited information regarding the outcomes associated with acetaminophen (APAP) poisoning in obese individuals. It is possible that patients who are obese are more susceptible to APAP-induced liver injury, thereby diminishing the efficacy of antidotes such as N-acetylcysteine (NAC). We evaluated the outcomes associated with APAP poisoning in obese versus nonobese adults who are treated with intravenous (IV) NAC. This was a retrospective cohort study conducted in a tertiary care, academic medical center. Adult patients with APAP toxicity, who were treated with IV NAC between June 2005 and August 2012, were included. The patients were categorized into 2 groups based on their body mass index (BMI): (1) obese (BMI ≥ 30.0 kg/m) versus (2) nonobese (BMI 18.5-24.9 kg/m). The primary outcome measure was the proportion of patients who developed hepatotoxicity (aspartate aminotransferase or alanine aminotransferase >1000 IU/L). A total of 80 patients were included in the final cohort (40 in each group). The median BMI for the obese and nonobese groups was 34.5 kg/m [interquartile range (IQR) 31.4-40.2] and 22.4 kg/m (IQR 21.2-23.9), respectively (P < 0.001). Other than more white patients being present in the nonobese group, there were no other baseline differences between groups with regard to demographics, liver function tests, or coagulation studies. Obese patients received a median IV NAC dose of 291.5 mg/kg (IQR 270.8-300.7) compared with 300 mg/kg (IQR 287.8-301.9) in the nonobese group (P = 0.07). Hepatotoxicity occurred in 27.5% of the obese patients and 37.5% of the nonobese patients (P = 0.34). No adverse drug effects were noted in either group. Obese and nonobese patients being treated with IV NAC for APAP toxicity experienced similar rates of hepatotoxicity.
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Adams C, Tucker C, Allen B, McRae A, Balazh J, Horst S, Johnson D, Ferreira J. Disparities in hemodynamic resuscitation of the obese critically ill septic shock patient. J Crit Care 2017; 37:219-223. [DOI: 10.1016/j.jcrc.2016.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 10/01/2016] [Accepted: 10/02/2016] [Indexed: 01/23/2023]
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Dickerson RN, Patel JJ, McClain CJ. Protein and Calorie Requirements Associated With the Presence of Obesity. Nutr Clin Pract 2017; 32:86S-93S. [PMID: 28388369 DOI: 10.1177/0884533617691745] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Obesity compounds the metabolic response to critical illness and increases the risk for overfeeding complications due to its comorbidities. Hypocaloric, high-protein nutrition therapy affords the hospitalized patient with obesity the opportunity to achieve net protein anabolism with a reduced risk of overfeeding complications. The intent of this review is to provide the theoretical framework for development of a hypocaloric high-protein regimen, scientific evidence to support this mode of therapy, and unique considerations for its use in specialized subpopulations. Macronutrient goals and practical suggestions for patient monitoring are given.
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Affiliation(s)
- Roland N Dickerson
- 1 Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - Jayshil J Patel
- 2 Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Craig J McClain
- 3 Departments of Medicine and Pharmacology & Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Abstract
Prescribing antibiotics is an essential component of initial therapy in sepsis. Early antibiotics are an important component of therapy, but speed of administration should not overshadow the patient-specific characteristics that determine the optimal breadth of antimicrobial therapy. Cultures should be drawn before antibiotic therapy if it does not significantly delay administration. Combination antibiotic therapy against gram-negative infections is not routinely required, and combination therapy involving vancomycin and piperacillin/tazobactam is associated with an increase in acute kidney injury. Emergency practitioners should be aware of special considerations in the administration and dosing of antibiotics in order to deliver optimal care to septic patients.
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Affiliation(s)
- Michael G Allison
- Critical Care Medicine, St. Agnes Hospital, 900 South Caton Avenue, Baltimore, MD 21229, USA
| | - Emily L Heil
- Department of Pharmacy, University of Maryland Medical Center, 29 South Greene Street, Room 400, Baltimore, MD 21201, USA
| | - Bryan D Hayes
- Department of Emergency Medicine, University of Maryland Medical Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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Obata Y, Mizogami M, Nyhan D, Berkowitz DE, Steppan J, Barodka V. Pilot Study: Estimation of Stroke Volume and Cardiac Output from Pulse Wave Velocity. PLoS One 2017; 12:e0169853. [PMID: 28060961 PMCID: PMC5218503 DOI: 10.1371/journal.pone.0169853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/22/2016] [Indexed: 02/01/2023] Open
Abstract
Background Transesophageal echocardiography (TEE) is increasingly replacing thermodilution pulmonary artery catheters to assess hemodynamics in patients at high risk for cardiovascular morbidity. However, one of the drawbacks of TEE compared to pulmonary artery catheters is the inability to measure real time stroke volume (SV) and cardiac output (CO) continuously. The aim of the present proof of concept study was to validate a novel method of SV estimation, based on pulse wave velocity (PWV) in patients undergoing cardiac surgery. Methods This is a retrospective observational study. We measured pulse transit time by superimposing the radial arterial waveform onto the continuous wave Doppler waveform of the left ventricular outflow tract, and calculated SV (SVPWV) using the transformed Bramwell-Hill equation. The SV measured by TEE (SVTEE) was used as a reference. Results A total of 190 paired SV were measured from 28 patients. A strong correlation was observed between SVPWV and SVTEE with the coefficient of determination (R2) of 0.71. A mean difference between the two (bias) was 3.70 ml with the limits of agreement ranging from -20.33 to 27.73 ml and a percentage error of 27.4% based on a Bland-Altman analysis. The concordance rate of two methods was 85.0% based on a four-quadrant plot. The angular concordance rate was 85.9% with radial limits of agreement (the radial sector that contained 95% of the data points) of ± 41.5 degrees based on a polar plot. Conclusions PWV based SV estimation yields reasonable agreement with SV measured by TEE. Further studies are required to assess its utility in different clinical situations.
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Affiliation(s)
- Yurie Obata
- Division of Cardiac Anesthesia, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Maki Mizogami
- Department of Anesthesiology and Reanimatology, University of Fukui, Fukui, Japan
| | - Daniel Nyhan
- Division of Cardiac Anesthesia, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Dan E. Berkowitz
- Division of Cardiac Anesthesia, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Jochen Steppan
- Division of Cardiac Anesthesia, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Viachaslau Barodka
- Division of Cardiac Anesthesia, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- * E-mail:
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Newman D, Scheetz MH, Adeyemi OA, Montevecchi M, Nicolau DP, Noskin GA, Postelnick MJ. Serum Piperacillin/Tazobactam Pharmacokinetics in a Morbidly Obese Individual. Ann Pharmacother 2016; 41:1734-9. [PMID: 17726066 DOI: 10.1345/aph.1k256] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To report pharmacokinetic alterations and optimal dosing of piperacillin/tazobactam in an obese patient. Case Summary: A 39-year-old morbidly obese (weight 167 kg, body mass index 50 kg/m2) man was treated with piperacillin/tazobactam 3.375 g every 4 hours for recurrent cellulitis. The wound culture grew Groups A and B Streptococcus and rare Pseudomonas aeruginosa. Blood samples were obtained at steady-state from a peripheral venous catheter at 0, 0.5, 1, 2, 3, and 4 hours after the start of the infusion. Population pharmacokinetics were generated from a previously published data set. The serum concentrations of piperacillin/tazobactam obtained in the patient were compared with the 95% confidence interval from the representative population. Pharmacokinetic parameters such as maximal serum concentration, minimal serum concentration, average steady-state concentration, half-life, elimination rate constant, volume of distribution (Vd), clearance, area under the curve at steady-state, and percent of time greater than the minimum inhibitory concentration (%t>MIC) were calculated and qualitatively compared between the sample and the population. Discussion: Substantial differences were noted in both the absolute values at the times of sample collection and the overall concentration-versus-time profile of both compounds. The morbidly obese individual compared with the population demonstrated a reduced average serum steady-state concentration: 39.8 mg/L versus 123.6 mg/L, an increased Vd: 54.3 L versus 12.7 L, and an increased half-life: 1.4 hours versus 0.6 hours, respectively. The %t>MIC of piperacillin for the patient, assuming MICs of 2, 4, 8, 16, 32, 64, and 128 mg/L, was 100%. 100%, 90.9%, 55.4%. 19.9%, 0%, and 0%, respectively. Conclusions: Pathogens with elevated MICs may require altered dosing schemes with piperacillin/tazobactam. Future studies are warranted to assess increased dosages, more frequent dosing intervals, or continuous infusion dosing schemes for obese individuals with serious infections.
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Affiliation(s)
- Diane Newman
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL 60611, USA
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Does Obesity Predispose Medical Intensive Care Unit Patients to Venous Thromboembolism despite Prophylaxis? A Retrospective Chart Review. Crit Care Res Pract 2016; 2016:3021567. [PMID: 27994886 PMCID: PMC5141306 DOI: 10.1155/2016/3021567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/26/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Obesity is a significant issue in the critically ill population. There is little evidence directing the dosing of venous thromboembolism (VTE) prophylaxis within this population. We aimed to determine whether obesity predisposes medical intensive care unit patients to venous thromboembolism despite standard chemoprophylaxis with 5000 international units of subcutaneous heparin three times daily. Results. We found a 60% increased risk of venous thromboembolism in the body mass index (BMI) ≥ 30 kg/m2 group compared to the BMI < 30 kg/m2 group; however, this difference did not reach statistical significance. After further utilizing our risk model, neither obesity nor mechanical ventilation reached statistical significance; however, vasopressor administration was associated with a threefold risk. Conclusions. We can conclude that obesity did increase the rate of VTE, but not to a statistically significant level in this single center medical intensive care unit population.
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Unanswered questions about VTE prophylaxis in critically ill obese patients. Intensive Care Med 2016; 42:1506-7. [PMID: 27412435 DOI: 10.1007/s00134-016-4431-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
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43
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Idrees U, Londner M. Pharmacotherapy Overview of Seizure Management in the Adult Emergency Department. J Pharm Pract 2016. [DOI: 10.1177/0897190005280050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Seizures are a common cause of emergency department visits, and approximately 28% of epilepsy patients present to an emergency department annually for treatment. This article will provide an overview of the pharmacotherapeutic management of seizures and anticonvulsant therapy for patients who present to the adult emergency department, including practical information for pharmacists covering or cross-covering this practice area. The benzodiazepines are reviewed as a class, including dosing strategies, pharmacodynamic considerations, and advantages and disadvantages of lorazepam, diazepam, and midazolam. Indications for the use of phenytoin and fosphenytoin will be reviewed, as well as dosing, adverse effects, and cost-effectiveness data. In addition, dosing, administration, pharmacokinetics, and adverse effects of phenobarbital, carbamazepine, and valproate will be discussed. Clinical indications for serum anticonvulsant concentration monitoring and subsequent calculation of loading doses from serum concentrations are reviewed. Since status epilepticus is a life-threatening emergency, its therapeutic management is reviewed, including the use of continuous infusion midazolam, pentobarbital, and propofol. There are many opportunities for clinical pharmacists to collaborate with other members of the health care team to optimize efficacy and minimize adverse effects of anticonvulsant agents in the emergency department setting.
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Affiliation(s)
- Umbreen Idrees
- Departments of Pharmacy Services and Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland,
| | - Michael Londner
- Department of Emergency Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Dietch ZC, Duane TM, Cook CH, O'Neill PJ, Askari R, Napolitano LM, Namias N, Watson CM, Dent DL, Edwards BL, Shah PM, Guidry CA, Davies SW, Willis RN, Sawyer RG. Obesity Is Not Associated with Antimicrobial Treatment Failure for Intra-Abdominal Infection. Surg Infect (Larchmt) 2016; 17:412-21. [PMID: 27027416 DOI: 10.1089/sur.2015.213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Obesity and commonly associated comorbidities are known risk factors for the development of infections. However, the intensity and duration of antimicrobial treatment are rarely conditioned on body mass index (BMI). In particular, the influence of obesity on failure of antimicrobial treatment for intra-abdominal infection (IAI) remains unknown. We hypothesized that obesity is associated with recurrent infectious complications in patients treated for IAI. METHODS Five hundred eighteen patients randomized to treatment in the Surgical Infection Society Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated. Patients were stratified by obese (BMI ≥30) versus non-obese (BMI≥30) status. Descriptive comparisons were performed using Chi-square test, Fisher exact test, or Wilcoxon rank-sum tests as appropriate. Multivariable logistic regression using a priori selected variables was performed to assess the independent association between obesity and treatment failure in patients with IAI. RESULTS Overall, 198 (38.3%) of patients were obese (BMI ≥30) versus 319 (61.7%) who were non-obese. Mean antibiotic d and total hospital d were similar between both groups. Unadjusted outcomes of surgical site infection (9.1% vs. 6.9%, p = 0.36), recurrent intra-abdominal infection (16.2% vs. 13.8, p = 0.46), death (1.0% vs. 0.9%, p = 1.0), and a composite of all complications (25.3% vs. 19.8%, p = 0.14) were also similar between both groups. After controlling for appropriate demographics, comorbidities, severity of illness, treatment group, and duration of antimicrobial therapy, obesity was not independently associated with treatment failure (c-statistic: 0.64). CONCLUSIONS Obesity is not associated with antimicrobial treatment failure among patients with IAI. These results suggest that obesity may not independently influence the need for longer duration of antimicrobial therapy in treatment of IAI versus non-obese patients.
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Affiliation(s)
- Zachary C Dietch
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Therese M Duane
- 3 Department of Surgery, Virginia Commonwealth University , Richmond, Virginia
| | - Charles H Cook
- 4 Department of Surgery, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - Patrick J O'Neill
- 5 Department of Surgery, Maricopa Integrated Health System , Phoenix, Arizona
| | - Reza Askari
- 6 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Lena M Napolitano
- 7 Department of Surgery, University of Michigan , Ann Arbor, Michigan
| | - Nicholas Namias
- 8 Department of Surgery, University of Miami Miller School of Medicine , Miami, Florida
| | - Christopher M Watson
- 9 Department of Surgery, University of South Carolina , Columbia, South Carolina
| | - Daniel L Dent
- 10 Department of Surgery, University of Texas Health Science Center at San Antonio , San Antonio, Texas
| | - Brandy L Edwards
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Puja M Shah
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Christopher A Guidry
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Stephen W Davies
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Rhett N Willis
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Robert G Sawyer
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia.,2 Division of Patient Outcomes, Policy and Population Research, Department of Public Health Sciences, The University of Virginia Health System , Charlottesville, Virginia
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Bouquegneau A, Vidal-Petiot E, Moranne O, Mariat C, Boffa JJ, Vrtovsnik F, Scheen AJ, Krzesinski JM, Flamant M, Delanaye P. Creatinine-based equations for the adjustment of drug dosage in an obese population. Br J Clin Pharmacol 2016; 81:349-61. [PMID: 26531818 DOI: 10.1111/bcp.12817] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/21/2015] [Accepted: 10/24/2015] [Indexed: 12/30/2022] Open
Abstract
AIM For drug dosing adaptation, the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend using estimated glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, after 'de-indexation' by body surface area (BSA). In pharmacology, the Cockcroft-Gault (CG) equation is still recommended to adapt drug dosage. In the context of obesity, adjusted ideal body weight (AIBW) is sometimes preferred to actual body weight (ABW) for the CG equation. The aim of the present study was to compare the performance of the different GFR-estimating equations, non-indexed or de-indexed by BSA for the purpose of drug-dosage adaptation in obese patients. METHODS We analysed data from patients with a body mass index (BMI) higher than 30 kg m(-2) who underwent a GFR measurement. eGFR was calculated using the CKD-EPI and Modification of Diet in Renal Disease (MDRD) equations, de-indexed by BSA, and the CG equation, using either ABW, AIBW or lean body weight (LBW) for the weight variable and compared with measured GFR, expressed in ml min(-1). RESULTS In our population of obese patients, use of the AIBW instead of the ABW in the CG equation, markedly improved the overall accuracy of this equation [57% for CGABW and 79% for CGAIBW (P < 0.05)]. For high BMI (over 40 kg m(-2)), the accuracy of the CG equations is no different when using LBW than when using AIBW. The MDRD and CKD-EPI equations de-indexed by the BSA also performed well, with an overall higher accuracy for the MDRD de-indexed equation [(80% and 76%, respectively (P < 0.05)]. CONCLUSIONS The de-indexed MDRD equation appeared to be the most suitable for estimating the non-indexed GFR for the purpose of drug dosage adaptation in obese patients.
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Affiliation(s)
- Antoine Bouquegneau
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Emmanuelle Vidal-Petiot
- Department of Renal Physiology, Hôpital Bichat, AP-HP and Paris Diderot University, Paris, France
| | - Olivier Moranne
- Department of Nephrology-Dialysis-Transplantation, CHU Nice, Nice, France
| | - Christophe Mariat
- Department of Nephrology, University Jean Monnet, Saint-Etienne, France
| | | | - François Vrtovsnik
- Department of Nephrology, Hôpital Bichat, AP-HP and Paris Diderot University, Paris, France
| | - André-Jean Scheen
- Department of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Jean-Marie Krzesinski
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Martin Flamant
- Department of Renal Physiology, Hôpital Bichat, AP-HP and Paris Diderot University, Paris, France
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
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Radosevich JJ, Patanwala AE, Erstad BL. Norepinephrine Dosing in Obese and Nonobese Patients With Septic Shock. Am J Crit Care 2016; 25:27-32. [PMID: 26724290 DOI: 10.4037/ajcc2016667] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Whether or not norepinephrine infusions for support of hemodynamic status in patients with septic shock should be weight based is unknown. This situation is particularly pertinent in patients who are extremely overweight or obese. OBJECTIVE To compare dosing requirements and effect of norepinephrine on blood pressure in obese and nonobese patients with septic shock. METHODS In a retrospective cohort study, data on adult patients with septic shock who received norepinephrine infusion for support of hemodynamic status in a tertiary care, academic medical center were analyzed. Patients were categorized as obese (body mass index ≥ 30) or nonobese (body mass index < 30). The primary outcome was dosing requirements of norepinephrine at 60 minutes after the start of the infusion. The secondary outcome was the log-transformed ratio of mean arterial pressure to norepinephrine. RESULTS The final cohort consisted of 100 obese and 100 nonobese patients. Mean norepinephrine infusion rate at 60 minutes was 0.09 (SD, 0.08) μg/kg per minute in the obese group and 0.13 (SD, 0.14) μg/kg per minute in the nonobese group (P = .006). The non-weight-based dose at 60 minutes was 9 μg/min in obese patients and 8 μg/min in nonobese patients (P = .72). The log transformed mean arterial pressure to norepinephrine ratio at 60 minutes was 2.5 (SD, 0.9) in obese patients and 2.5 (SD, 0.8) in nonobese patients (P = .54) CONCLUSIONS: Compared with nonobese patients, obese patients with septic shock require lower weight-based doses of norepinephrine and similar total norepinephrine doses.
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Affiliation(s)
- John J. Radosevich
- John J. Radosevich is a clinical pharmacist, critical care, Pharmacy Department, St Joseph’s Hospital and Medical Center, Phoenix, Arizona. Asad E. Patanwala is an associate professor and Brian L. Erstad is a professor and department head, Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Asad E. Patanwala
- John J. Radosevich is a clinical pharmacist, critical care, Pharmacy Department, St Joseph’s Hospital and Medical Center, Phoenix, Arizona. Asad E. Patanwala is an associate professor and Brian L. Erstad is a professor and department head, Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Brian L. Erstad
- John J. Radosevich is a clinical pharmacist, critical care, Pharmacy Department, St Joseph’s Hospital and Medical Center, Phoenix, Arizona. Asad E. Patanwala is an associate professor and Brian L. Erstad is a professor and department head, Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
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Maseda E, Gimenez MJ, Gilsanz F, Aguilar L. Basis for selecting optimum antibiotic regimens for secondary peritonitis. Expert Rev Anti Infect Ther 2015; 14:109-24. [PMID: 26568097 DOI: 10.1586/14787210.2016.1120669] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Adequate management of severely ill patients with secondary peritonitis requires supportive therapy of organ dysfunction, source control of infection and antimicrobial therapy. Since secondary peritonitis is polymicrobial, appropriate empiric therapy requires combination therapy in order to achieve the needed coverage for both common and more unusual organisms. This article reviews etiological agents, resistance mechanisms and their prevalence, how and when to cover them and guidelines for treatment in the literature. Local surveillances are the basis for the selection of compounds in antibiotic regimens, which should be further adapted to the increasing number of patients with risk factors for resistance (clinical setting, comorbidities, previous antibiotic treatments, previous colonization, severity…). Inadequate antimicrobial regimens are strongly associated with unfavorable outcomes. Awareness of resistance epidemiology and of clinical consequences of inadequate therapy against resistant bacteria is crucial for clinicians treating secondary peritonitis, with delicate balance between optimization of empirical therapy (improving outcomes) and antimicrobial overuse (increasing resistance emergence).
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Affiliation(s)
- Emilio Maseda
- a Anesthesiology and Surgical Critical Care Department , Hospital Universitario La Paz , Madrid , Spain
| | | | - Fernando Gilsanz
- a Anesthesiology and Surgical Critical Care Department , Hospital Universitario La Paz , Madrid , Spain
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Pediatric Obesity: Pharmacokinetics and Implications for Drug Dosing. Clin Ther 2015; 37:1897-923. [DOI: 10.1016/j.clinthera.2015.05.495] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/14/2015] [Accepted: 05/19/2015] [Indexed: 02/01/2023]
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Johnston CT, Maish GO, Minard G, Croce MA, Dickerson RN. Evaluation of an Intravenous Potassium Dosing Algorithm for Hypokalemic Critically Ill Patients. JPEN J Parenter Enteral Nutr 2015; 41:796-804. [PMID: 26304602 DOI: 10.1177/0148607115602885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The intent of this study was to evaluate the safety and efficacy of an intravenous (IV) potassium (K) dosing algorithm for hypokalemic critically ill trauma patients. METHODS Adult patients, admitted to the trauma intensive care unit from June 2010 to October 2012 and who received IV K therapy according to a standardized dosing algorithm, were retrospectively evaluated. Patients who received IV K during resuscitation or following initiation of nutrition therapy, IV fluids containing >20 mEq/L of potassium, or medications known to alter K homeostasis or those with an arterial pH change >0.1, diarrhea, hypomagnesemia, renal impairment, or morbid obesity were excluded. RESULTS In total, 715 patients were reviewed to obtain 100 evaluable patients. Serum K for patients with mild depletion (serum K, 3.5-3.9 mEq/L, n = 74) remained unchanged at 0.0 ± 0.3 mEq/L ( P = ns) following 46 ± 8 mEq. Serum K increased by 0.4 ± 0.3 mEq/L ( P = .001) following 78 ± 18 mEq during moderate depletion (serum K, 3-3.4 mEq/L). None of the patients experienced hyperkalemia (serum K, >5.2 mEq/L) postinfusion. The presence of traumatic brain injury (TBI) blunted the response to IV K for mild K depletion as only 26% had an increase in serum K compared with 55% of patients without TBI ( P = .025). CONCLUSIONS The Nutrition Support Service-guided IV K dosing algorithm was safe for patients with mild and moderate hypokalemia and efficacious for those with moderate hypokalemia. Further study in patients with severe hypokalemia (serum K, <3 mEq/L) is warranted.
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Affiliation(s)
- Corry T Johnston
- 1 Department of Pharmacy, University of Maryland Baltimore Washington Medical Center, Baltimore, Maryland, USA
| | - George O Maish
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Gayle Minard
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Martin A Croce
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Roland N Dickerson
- 3 Department of Clinical Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Brancaccio A, Giuliano C, McNorton K, Delgado G. Impact of a phenytoin loading dose program in the emergency department. Am J Health Syst Pharm 2015; 71:1862-9. [PMID: 25320136 DOI: 10.2146/ajhp140039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The use of a combined physician-and pharmacist-directed phenytoin loading dose program in an emergency department (ED) was evaluated. METHODS This single-center, observational, preimplementation-postimplementation study evaluated adult patients who received a phenytoin loading dose in the ED. The primary outcome compared the proportion of optimal phenytoin loading doses in the preimplementation and postimplementation groups. The postimplementation group was further stratified into pharmacist- and prescriber-dosing groups. Other outcomes evaluated included the numbers of appropriate serum phenytoin concentrations measured, adverse drug reactions (ADRs), and recurrence of seizures within 24 hours of loading dose administration in the preimplementation and postimplementation groups. RESULTS There was no difference in the proportion of optimal phenytoin loading doses between the preimplementation and postimplementation groups (50% versus 62%, respectively; p=0.19). When stratified by individual groups, the rate of optimal phenytoin loading doses increased by 64% in the postimplementation pharmacist group (50% versus 82%, p=0.007), while the rate in the prescriber-dosing group remained relatively unchanged (50% versus 49%, p=0.91). The number of appropriate serum phenytoin concentrations significantly improved in the postimplementation versus preimplementation group (65% versus 40%, p=0.025). Rates of ADRs and recurrence of seizures did not differ across the study groups. CONCLUSION No change in the percentage of optimal phenytoin loading doses in the ED was observed after implementation of a combined pharmacist- and physician- dosing program. When stratified into pharmacist or prescriber dosing, the pharmacist-led dosing program significantly improved the proportion of patients who received optimal phenytoin loading doses.
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Affiliation(s)
- Adam Brancaccio
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
| | - Christopher Giuliano
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC.
| | - Kelly McNorton
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
| | - George Delgado
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
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