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Zheng L, Alshaer MH, Peloquin C, Venugopalan V, Alnuaimat HM, Converse M. Cefepime pharmacokinetics in adult extracorporeal membrane oxygenation patients. Pulm Pharmacol Ther 2024; 84:102271. [PMID: 38008397 DOI: 10.1016/j.pupt.2023.102271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/25/2023] [Accepted: 11/21/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND The impact of extracorporeal membrane oxygenation (ECMO) on the pharmacokinetics/dynamics (PK/PD) of beta-lactam antibiotics have not been well studied in general, but cefepime specifically has the least amount of data. We aimed to investigate whether ECMO alters the PK of cefepime in adult intensive care unit (ICU) patients. METHODS This single-center, retrospective case-control study evaluated cefepime therapeutic drug monitoring (TDM) results from ECMO patients that were matched 1:1 with TDM results in non-ECMO patients for drug regimen and renal function. The primary outcome was the difference in PK/PD of cefepime in ECMO compared with non-ECMO ICU patients. Secondary outcomes included hospital length of stay, treatment failure, superinfection, bacterial resistance, and survival to discharge. RESULTS Eighty-two patients were included with 44 matched cefepime concentrations in each group. ECMO patients had higher free maximum concentrations (fCmax) (p = 0.003), lower free minimum concentration (fCmin)/1x minimum inhibitory concentration (MIC) ratios (p = 0.040), and lower attainment of free Cmin/4x MIC (p = 0.010). There were no differences between the groups for free Cmin, time above 1xMIC or 4x MIC, and pharmacokinetic parameters (ke, half-life, and Vd). Of those who survived to discharge, hospital length of stay was longer in the ECMO group (p < 0.001). Patients on ECMO were more likely to experience treatment failure (p = 0.036). The incidence of bacterial resistance, superinfection, or survival were similar among the groups. CONCLUSION These data suggest that more aggressive empiric dosing may be warranted in patients on ECMO. Therapeutic drug monitoring and future prospective studies would provide more evidence to guide decision making regarding dose adjustments.
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Affiliation(s)
- Lily Zheng
- Department of Pharmacy Services, University of Florida Health Jacksonville North, 15255 Max Leggett Pkwy, Jacksonville, FL, USA.
| | - Mohammad H Alshaer
- Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Medical Science Bldg Rm P4 05, 1600 SW Archer Rd., Gainesville, FL, USA
| | - Charles Peloquin
- Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Medical Science Bldg Rm P4 05, 1600 SW Archer Rd., Gainesville, FL, USA
| | - Veena Venugopalan
- Pharmacotherapy & Translational Research, University of Florida College of Pharmacy, Medical Science Bldg Rm P4 05, 1600 SW Archer Rd., Gainesville, FL, USA
| | - Hassan M Alnuaimat
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, 1505 SW Archer Road, Gainesville, FL, USA
| | - Maureen Converse
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, USA
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Graboyes SDT, Owen PS, Evans RA, Berei TJ, Hryniewicz KM, Hollis IB. Review of anticoagulation considerations in extracorporeal membrane oxygenation support. Pharmacotherapy 2023; 43:1339-1363. [PMID: 37519116 DOI: 10.1002/phar.2857] [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: 01/27/2023] [Revised: 06/10/2023] [Accepted: 06/16/2023] [Indexed: 08/01/2023]
Abstract
Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno-arterial (VA) and veno-venous (VV) ECMO, there are still significant hemocompatibility-related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA-ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.
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Affiliation(s)
- Sydney D T Graboyes
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, California, USA
| | - Phillip S Owen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Rickey A Evans
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Theodore J Berei
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Katarzyna M Hryniewicz
- Heart Failure Section, Minneapolis Heart Institute at Abbot Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
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Bourgault AM. Clinical Nurses Encouraged to Write for Publication. Crit Care Nurse 2023; 43:8-11. [PMID: 37001874 DOI: 10.4037/ccn2023262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Affiliation(s)
- Annette M Bourgault
- Annette Bourgault is Editor of Critical Care Nurse. She is an Associate Professor at the University of Central Florida in Orlando and a Nurse Scientist with Orlando Health. Dr Bourgault can be reached at
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Procaccini DE, Roem J, Ng DK, Rappold TE, Jung D, Gobburu JVS, Bembea MM. Evaluation of acquired antithrombin deficiency in paediatric patients supported on extracorporeal membrane oxygenation. Br J Clin Pharmacol 2023. [PMID: 36850024 DOI: 10.1111/bcp.15703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 03/01/2023] Open
Abstract
AIMS There remains a paucity of literature regarding best practice for antithrombin (AT) monitoring, dosing and dose-response in paediatric extracorporeal membrane oxygenation (ECMO) patients. METHODS We conducted a retrospective cohort study at a quaternary care paediatric intensive care unit in all patients <18 years of age supported on ECMO from 1 June 2011 to 30 April 2020. Adverse events and outcomes were characterized for all ECMO runs. AT activity and replacement were characterized and compared between two clinical protocols. AT activities measured post- vs. pre-AT replacement were compared in order to characterize a dose-response relationship. RESULTS The final cohort included 191 patients with 201 ECMO runs and 2028 AT activity measurements. The median AT activity was 65% (interquartile range [IQR], 51-82) and 879 (43.3%) measurements met the criteria of deficient. The overall median AT dose and increase in AT activity were 50.6 units/kg/dose (IQR, 39.5-67.2) and 23.5% (IQR, 9.8-36.0), respectively. In the protocol that restricted AT activity measurements to clinical scenarios concerning for heparin resistance, there was significantly higher dosing in conjunction with significantly fewer overall administrations. Approximately one third of AT activity remained deficient after repletion. There was no difference in mechanical complications, reasons for discontinuation of ECMO support, time on ECMO or survival between protocols. CONCLUSIONS There was a high prevalence of AT deficiency in paediatric ECMO patients. An AT replacement protocol based on evaluating heparin resistance is associated with fewer AT administrations, with similar circuit and patient outcomes. Further data are needed to identify optimal dosing strategies.
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Affiliation(s)
- David E Procaccini
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jennifer Roem
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas E Rappold
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dawoon Jung
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Sheasby J, Krais S, Do M, Hall A, Pace H, Myers DP, George TJ. An Interprofessional Approach to Mobilizing Patients With COVID-19 Receiving Extracorporeal Membrane Oxygenation. AACN Adv Crit Care 2022; 33:262-273. [PMID: 36067264 DOI: 10.4037/aacnacc2022293] [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: 11/01/2022]
Abstract
OBJECTIVE To assess survival outcomes with the intervention of an interprofessional mobilization program for patients with COVID-19 who were receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). DESIGN Preintervention and postintervention retrospective cohort study. METHODS Survival outcomes of nonmobilized, adult patients (n = 16) with COVID-19 who were receiving VV-ECMO (May 2020 through December 2020) were compared with those of 26 patients who received a mobility care plan (January 2021 through November 2021). In the preintervention group, full sedation and paralysis were used. In the postintervention group, an early mobilization strategy involving interprofessional collaboration was introduced. RESULTS The postintervention group had improved survival (73.1% vs 43.8%; P < .04); fewer days of receiving paralytics, fentanyl, and midazolam (P < .01 for all); but more days of dexmedetomidine, morphine, and ketamine administration (P < .01 for all). Concomitantly, more patients in the postintervention cohort received oral or transdermal analgesics, oral anxiolytics, and oral antipsychotics (P < .01 for all), and also required more VV-ECMO cannula adjustments (P = .03). CONCLUSION Early mobilization of patients with COVID-19 who were receiving VV-ECMO improved survival rates but led to more cannula adjustments.
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Affiliation(s)
- Jenelle Sheasby
- Jenelle Sheasby is ECMO Coordinator, Baylor Scott & White The Heart Hospital, 1100 Allied Drive, Plano, TX 75093
| | - Suzanne Krais
- Suzanne Krais is Chief Nursing Officer, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Monica Do
- Monica Do is Clinical Pharmacist, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Amy Hall
- Amy Hall is Senior Physical Therapist, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Holland Pace
- Holland Pace is Senior Occupational Therapist, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - David P Myers
- David P. Myers is Staff Pulmonologist, Pulmonary Critical Care Medicine, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Timothy J George
- Timothy J. George is Surgical Director of Mechanical Circulatory Support, Baylor Scott & White The Heart Hospital, Plano, Texas
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Aiello SR, Flores S, Coughlin M, Villarreal EG, Loomba RS. Antithrombin use during pediatric cardiac extracorporeal membrane oxygenation admission: insights from a national database. Perfusion 2020; 36:138-145. [PMID: 32650697 DOI: 10.1177/0267659120939758] [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] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The frequency of extracorporeal membrane oxygenation in pediatric patients continues to increase, especially in patients with complex congenital heart disease. Providing adequate anticoagulation is necessary for patients on extracorporeal membrane oxygenation and is achieved with adequate heparin administration. Antithrombin is administered to potentiate heparin's effects. However, the efficacy of antithrombin supplementation is unclear and a clear clinical benefit has not been established. We present a large retrospective study examining the effects of antithrombin on pediatric patients receiving extracorporeal membrane oxygenation. METHODS Data for this study were obtained from the Pediatric Health Information System and Pediatric Health Information System+ databases from 2004 to 2015. Pediatric patients receiving extracorporeal membrane oxygenation with a congenital heart disease diagnosis were included and divided into groups that did or did not utilize antithrombin. For all admissions, the following were captured: age of admission, gender, year of admission, length of stay, billed charges, inpatient mortality, the presence of specific congenital malformations of the heart, specific cardiac surgeries, and comorbidities. RESULTS A total of 9,193 admissions were included and 865 (9.4%) utilized antithrombin. Between groups, there were significantly different frequencies of co-morbidities, cardiac lesion types and antithrombin usage over the study period. There were significantly lower odds in the antithrombin group of venous thrombosis. Antithrombin was not significantly associated with hemorrhage; however, antithrombin was associated with increased inpatient mortality and a decrease in length of stay and billed charges. CONCLUSION Antithrombin administration is associated with increased mortality, a shorter length of stay, and decreased billing cost. Recently, antithrombin usage has been decreasing-potentially due to the reported lack of clinical benefit. Together, these results reinforce that antithrombin may not be indicated for all pediatric extracorporeal membrane oxygenation patients.
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Affiliation(s)
- Salvatore R Aiello
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
| | - Saul Flores
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Megan Coughlin
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Enrique G Villarreal
- Cardiac Intensive Care Unit, Section of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School, Chicago, IL, USA
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