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Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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So M, Tsai H, Swaminathan N, Bartash R. Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e72. [PMID: 36483373 PMCID: PMC9726551 DOI: 10.1017/ash.2022.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 06/17/2023]
Abstract
Antimicrobial therapies are essential tools for transplant recipients who are at high risk for infectious complications. However, judicious use of antimicrobials is critical to preventing the development of antimicrobial resistance. Treatment of multidrug-resistant organisms is challenging and potentially leads to therapies with higher toxicities, intravenous access, and intensive drug monitoring for interactions. Antimicrobial stewardship programs are crucial in the prevention of antimicrobial resistance, though balancing these strategies with the need for early and frequent antibiotic therapy in these immunocompromised patients can be challenging. In this review, we summarize 5 frequently encountered transplant infectious disease stewardship challenges, and we suggest strategies to improve practices for each clinical syndrome. These 5 challenging areas are: asymptomatic bacteriuria in kidney transplant recipients, febrile neutropenia in hematopoietic stem cell transplantation, antifungal prophylaxis in liver and lung transplantation, treatment of left-ventricular assist device infections, and Clostridioides difficile infection in solid-organ and hematopoietic stem-cell transplant recipients. Common themes contributing to these challenges include limited data specific to transplant patients, shortcomings in diagnostic testing, and uncertainties in pharmacotherapy.
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Affiliation(s)
- Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, United States
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Abstract
PURPOSE OF REVIEW The use of durable ventricular assist devices (VAD) to manage end-stage heart failure is increasing, but infection remains a leading cause of morbidity and mortality among patients with VAD. In this review, we synthesize recent data pertaining to the epidemiology, diagnosis, management, and prevention of VAD infections, discuss transplant considerations in patients with VAD infections, and highlight remaining knowledge gaps. We also present a conceptual framework for treating clinicians to approach these infections that draws on the same principles that guide the treatment of analogous infections that occur in patients without VAD. RECENT FINDINGS Despite advances in device design, surgical techniques, and preventative interventions, more than a third of VAD recipients still experience infection as an adverse outcome. Positron emission tomography has emerged as a promising modality for identifying and characterizing VAD infections. High-quality data to support many of the routine therapeutic strategies currently used for VAD infections-including suppressive antibiotic therapy, surgical debridement/device exchange, and novel antimicrobials for emerging multidrug-resistant organisms-remain limited. Although pre-transplant VAD infection may impact some early transplant outcomes, transplantation remains a viable option for patients with most types of VAD infection. Standardized definitions of VAD infection applied to large registry datasets have yielded key insights into the epidemiology of infectious complications among VAD recipients, but more prospective studies are needed to evaluate the effectiveness of existing and novel diagnostic and therapeutic strategies.
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Affiliation(s)
- Varun K Phadke
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.
| | - Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
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Hall SF, Athans V, Wanek MR, Wang L, Estep JD, Williams B. Evaluation of a hospital-wide vancomycin-dosing nomogram in patients with continuous-flow left ventricular assist devices. Int J Artif Organs 2020; 44:411-417. [PMID: 33222593 DOI: 10.1177/0391398820975037] [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: 01/22/2023]
Abstract
INTRODUCTION Hemodynamic derangements due to heart failure are associated with alterations in pharmacokinetics. Although use of mechanical circulatory support mitigates such derangements, little evidence is available regarding pharmacokinetics in patients with LVADs. A previous pharmacokinetic analysis of vancomycin among patients with LVADs observed a reduced volume of distribution and clearance compared with estimates based on population kinetics. METHODS A total of 28 adult patients with LVADs hospitalized between January 2014 and May 2018 who received vancomycin through a pharmacist dosing consult were included. Internal medicine patients without heart failure receiving vancomycin were enrolled in a 2:1 fashion to make a control group. Exclusion criteria were unstable renal function, ESRD, acute decompensation, cardiac surgery within the preceding 5 days, or weight >110 kg. RESULTS No difference was observed in the proportion achieving goal trough (64% of LVAD patients vs 71% control patients, p = 0.50). However, mean trough was significantly higher among LVAD patients (23.4 mg/L vs 17.7 mg/L, p = 0.017). Furthermore, there was a significant difference in the distribution of trough levels (p = 0.025) with LVAD patients being more likely to attain levels >25 mg/L (32% vs 14%) and less likely to have troughs <10 mg/L (4% vs 14%). A numerically greater number of LVAD patients experienced nephrotoxicity but this did not reach statistical significance (32% vs 18%, p = 0.14). CONCLUSION The use of vancomycin in LVAD patients may result in higher trough levels when compared to internal medicine patients. Increased monitoring or conservative dosing may be warranted to improve safety and efficacy.
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Affiliation(s)
- Sylvie F Hall
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Vasilios Athans
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Lu Wang
- Department of Quantitative Health Services, Cleveland Clinic, Cleveland, OH, USA
| | - Jerry D Estep
- George M. and Linda H. Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, OH, USA
| | - Brad Williams
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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Sherwin J, Thompson E, Hill KD, Watt K, Lodge AJ, Gonzalez D, Hornik CP. Clinical pharmacology considerations for children supported with ventricular assist devices. Cardiol Young 2018; 28:1082-1090. [PMID: 29991374 PMCID: PMC6299825 DOI: 10.1017/s1047951118001075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The ventricular assist device is being increasingly used as a "bridge-to-transplant" option in children with heart failure who have failed medical management. Care for this medically complex population must be optimised, including through concomitant pharmacotherapy. Pharmacokinetic/pharmacodynamic alterations affecting pharmacotherapy are increasingly discovered in children supported with extracorporeal membrane oxygenation, another form of mechanical circulatory support. Similarities between extracorporeal membrane oxygenation and ventricular assist devices support the hypothesis that similar alterations may exist in ventricular assist device-supported patients. We conducted a literature review to assess the current data available on pharmacokinetics/pharmacodynamics in children with ventricular assist devices. We found two adult and no paediatric pharmacokinetic/pharmacodynamic studies in ventricular assist device-supported patients. While mechanisms may be partially extrapolated from children supported with extracorporeal membrane oxygenation, dedicated investigation of the paediatric ventricular assist device population is crucial given the inherent differences between the two forms of mechanical circulatory support, and pathophysiology that is unique to these patients. Commonly used drugs such as anticoagulants and antibiotics have narrow therapeutic windows with devastating consequences if under-dosed or over-dosed. Clinical studies are urgently needed to improve outcomes and maximise the potential of ventricular assist devices in this vulnerable population.
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Affiliation(s)
- Jennifer Sherwin
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Kevin D. Hill
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kevin Watt
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Andrew J. Lodge
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Tunney RK, Whyte K, DeAntonio HJ. Lidocaine toxicity in the setting of HeartMate
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left ventricular assist device. J Clin Pharm Ther 2018; 43:733-736. [DOI: 10.1111/jcpt.12717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/14/2018] [Indexed: 11/28/2022]
Affiliation(s)
- R. K. Tunney
- East Carolina Heart Institute at ECU Greenville NC USA
- Campbell University College of Pharmacy & Health Sciences Buies Creek NC USA
| | - K. Whyte
- East Carolina Heart Institute at ECU Greenville NC USA
- UNC Eshelman School of Pharmacy Chapel Hill NC USA
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Nicholson JD, Kaakeh Y. Pharmacotherapy considerations for long-term management of patients with left ventricular assist devices. Am J Health Syst Pharm 2018; 75:755-766. [PMID: 29802111 DOI: 10.2146/ajhp170317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Yaman Kaakeh
- Purdue University College of Pharmacy, West Lafayette, IN
- Indiana University School of Medicine, West Lafayette, IN
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