2043. T2-Candida (T2MR) vs. Β-D-Glucan (BDG) for Preemptive Antifungal Stewardship in the Intensive Care Unit (ICU)

Background

Timely empiric antifungal therapy is essential in the management of candidemia but must be weighed with the risks of overuse. The purpose of this study was to compare preemptive antifungal therapy and outcomes following a negative T2MR or BDG test result among ICU patients.

Methods

IRB-approved, quasi-experiment in a four hospital system, May 2014–October 2017. T2MR implemented November 2015. Inclusion: preemptive anidulafungin (AFG), negative blood culture(s) and either a negative BDG by system guideline interpretation or T2MR. Exclusions: transplant, neutropenia, or another documented indication for antifungals. Primary endpoint: days of preemptive AFG. Secondary outcomes: ICU and hospital length of stay, incidence of invasive candidiaisis after discontinuation of preemptive therapy, reinitiation of antifungal therapy in the index admission, and inpatient mortality. Early discontinuation defined as single dose only.

Results

A total of 179 patients included: BDG n = 79, T2MR n = 100. Median age: BDG 63 (50, 71); T2MR 59 (50, 70). Baseline SOFA score: 8 (6,11) BDG; 12 (8,15) T2MR. Candida score ≥ 3: 43 and 41%, respectively. Preemptive AFG: 2 (1,5) days BDG and 1 (1,2) days T2MR (P < 0.001). Subsequent proven candidemia: 2 (2.5%) BDG; 1 (1%) T2MR. Antifungal reinitiated: 13 (17%) BDG; 12 (12%) T2MR. Mortality: 35 (44%) BDG, 59 (59%) T2MR, P = 0.07. AFG was discontinued early in 91 (51%) patients. T2MR was the only characteristic associated with early D/C (Table 1).

Conclusion

T2MR testing facilitates use of early preemptive echinocandin therapy in ICU patients and minimizes unnecessary prolonged therapy when compared with use of BDG.

Disclosures

G. Alangaden, T2 Biosystems: Speaker’s Bureau, Educational grant and Speaker honorarium.

Evaluation of a dedicated pharmacist staffing model in the medical intensive care unit

PURPOSE

Published studies have shown that pharmacists on medical rounds reduce the incidence of preventable adverse drug events (ADEs). However, the impact of a dedicated pharmacist who provides consistent patient care in a critical care unit remains to be evaluated.

OBJECTIVE

To determine the impact of a pharmacist who is permanently assigned to the medical intensive care unit (MICU) on the incidence of preventable ADEs, drug charges, and length of stay (LOS) in the MICU.

DESIGN

A randomized, experimental versus historical control group design was used. Preventable ADEs were identified and validated by 2 pharmacists and a critical care physician. Information about MICU drug charges and LOS were obtained from the hospital administrative database.

RESULTS

The intervention group had fewer occurrences of ADEs (10 ADEs/1,000 patient days) when compared to the control group (28 ADEs/1,000 patient days) at a significance level of .03. No significant differences were found between the 2 groups in MICU drug charges and LOS. The vast majority of the 596 documented recommended interventions (99%) were accepted by the medical team. Nutrition monitoring, medication indicated but not prescribed, and dosage modification were the top 3 problems identified by the pharmacist.

CONCLUSION

The addition of a dedicated critical care pharmacist to the MICU medical team improves the safe use of medication. The services of a dedicated critical care pharmacist should be expanded to include weekend hours to ensure the benefits of improved medication safety.

Heavy metal in the intensive care unit: a review of current literature on trace element supplementation in critically ill patients

Trace elements are essential for many physiologic processes. In recent years, supplementation has been studied for a variety of indications, including glycemic control, wound healing, antioxidant effect, and anemia. Critical illness, especially states such as burns, traumas, and septic shock, is associated with inflammatory and oxidative stress, immune dysfunction, and malnutrition. In these patients, enteral and parenteral nutrition or pharmaceutical supplementation is used to provide essential macronutrients, including trace elements. The purpose of this review is to describe trace element supplementation, including iron, copper, chromium, manganese, selenium, and zinc, and highlight their mechanism, pharmacology, outcome data, and adverse effects.

Opportunity for Pharmacy Intervention on an Urban Teaching Hospital Rapid Response Team: A Pilot Study

Background:

The role of a rapid response team (RRT) or medical emergency team is to bring the expertise of specialists trained in critical care to patients on general medicine and surgical wards who are rapidly deteriorating and to treat them accordingly. The involvement of pharmacists on cardiopulmonary resuscitation teams has been reported. However, the role of a pharmacist member of an RRT has not been extensively researched.

Objective:

To identify the role of a pharmacist on an RRT and categorize types of pharmacist interventions during cardiopulmonary resuscitation and initial patient assessments.

Methods:

This pilot study documented interventions made by the pharmacist on our RRT over a 1-month period. The pharmacist assisted the RRT with evaluations of patients during assessments and cardiopulmonary resuscitations and provided specialized medical information based on our current organizational standards of practice.

Results:

The pharmacist attended 34 consultations and 8 resuscitations during cardiopulmonary arrests. There were 96 interventions made during 34 RRT assessments—2.6 interventions per assessment. The most common interventions were treatment recommendations (29%), dosing recommendations (15%), and procuring medications for emergent use (12%). In both the treatment and dosing categories, antibiotic recommendations were the most common.

Conclusions:

The pharmacist member of the RRT had the opportunity for intervention on every patient seen by the team. The most common areas for intervention are treatment and dosing recommendations involving antibiotics, as well as providing and preparing emergent medications.

Implementing Sepsis Quality Initiatives in a Multiprofessional Care Model

Studies of acute myocardial infarction, trauma, and stroke have resulted in improved outcomes through earlier diagnosis and application of therapy at the most proximal stage of hospital presentation. Most critical therapies for these diseases are frequently instituted prior to admission to an ICU. This systems-based approach to the sepsis patient has been lacking. To change this paradigm, a trial comparing early goal-directed therapy (EGDT) versus standard care was performed using specific criteria for the early identification of high-risk sepsis patients and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression, and increased metabolic demands. One decade later, EGDT has been shown to modulate inflammation, decrease the progression of organ failure, improve microcirculatory function, and decrease health resource consumption and mortality. A standard operating procedure beginning with EGDT for severe sepsis and septic shock is a hospital-wide initiative.

Resuscitation bundle compliance in severe sepsis and septic shock: improves survival, is better late than never

While clinicians' management of severe sepsis and septic shock has been positively influenced by a number of clinical research studies in the last decade, challenges remain regarding early hemodynamic optimization as envisioned in the Surviving Sepsis Campaign's (SSC) resuscitation bundle (RB). We examined the impact of a hospital-wide continuous quality improvement (CQI) initiative on patients presenting with severe sepsis and septic shock, and the impact of the sepsis RB on patient outcomes when completed beyond the 6-hour recommendation period. The study was an 18-month, prospective cohort study enrolling patients who met the definition of severe sepsis or septic shock. Compliance with the hemodynamic components of the sepsis RB was defined as achieving goal mean arterial pressure (MAP) ≥ 65 mm Hg, central venous pressure (CVP) ≥ 8 mm Hg, and central venous oxygen saturation (ScvO₂) ≥ 70%. Compliance was assessed at 6 hours and 18 hours after diagnosis of severe sepsis or septic shock. In all, 498 patients with severe sepsis and/or septic shock were evaluated to determine the upper limit of the range of hours that compliance with the RB would still improve outcomes. Using 18 hours as a marker, Compliers at 18 hrs and Non-Compliers at 18 hrs were compared. There were 202 patients who had the RB completed in less than or equal to 18 hours. There were 296 patients who did not complete the RB at 18 hours. The Compliers at 18 hrs had a significant 10.2% lower hospital mortality 37.1% (22% relative reduction) compared to the Non-Compliers at 18 hrs hospital mortality of 47.3% (P < .03). When the two groups were adjusted for differences in baseline illness severity, the Compliers at 18 hrs had a greater reduction in predicted mortality of 26.8% versus 9.4%, P < 0.01.

CONCLUSIONS

Initiating the sepsis RB for patients with severe sepsis and/or septic shock decreased mortality. A CQI initiative that monitored the implementation in real-time allowed for improvement in compliance and efficacy of the bundle on outcomes. Multiple studies have shown that compliance to the RB within 6 hours lowers hospital mortality. This study uniquely shows that when bundle completion is extended to 18 hours, the mortality reduction remains significant.

Pharmacists on Rounding Teams Reduce Preventable Adverse Drug Events in Hospital General Medicine Units

BACKGROUND

Previous studies found that medication errors result from lack of sufficient information during the prescribing step. Therefore, it is proposed that having a pharmacist available when patients are evaluated during the rounding process may reduce the likelihood of preventable adverse drug events (ADEs). The objectives of this study were to evaluate the impact of having a pharmacist participate with a physician rounding team on preventable ADEs in general medicine units and to document pharmacist interventions made during the rounding process.

METHODS

A single-blind, standard care-controlled study design was used to compare patients receiving care from a rounding team including a pharmacist with patients receiving standard care (no pharmacist on rounding team). Patients admitted to and discharged from the same general medicine unit were included in the study. The main outcome measure of this study was preventable ADEs. Patient records were randomly selected and evaluated by a blinded process involving independent senior pharmacist specialists and a senior staff physician. Interventions made by the pharmacists in the treatment group were documented.

RESULTS

The rate of preventable ADEs was reduced by 78%, from 26.5 per 1000 hospital days to 5.7 per 1000 hospital days. There were 150 documented interventions recommended during the rounding process, 147 of which were accepted by the team. The most common interventions were (1) dosing-related changes and (2) recommendations to add a drug to therapy.

CONCLUSION

Pharmacist participation with the medical rounding team on a general medicine unit contributes to a significant reduction in preventable ADEs.

Magnesium sulfate therapy after aneurysmal subarachnoid hemorrhage

OBJECT

Vasospasm remains a significant source of neurological morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH), despite advances in current medical, surgical, and endovascular therapies. Magnesium sulfate therapy has been demonstrated to be both safe and effective in preventing neurological complications in obstetrical patients with eclampsia. Evidence obtained using experimental models of brain injury, cerebral ischemia, and SAH indicate that Mg may also have a role as a neuroprotective agent. The authors hypothesize that MgSO4 therapy is safe, feasible, and has a beneficial effect on vasospasm and, ultimately, on neurological outcome following aneurysmal SAH.

METHODS

A prospective randomized single-blind clinical trial of high-dose MgSO4 therapy following aneurysmal SAH (Hunt and Hess Grades II-IV) was performed in 40 patients, who were enrolled within 72 hours following SAH and given intravenous MgSO4 or control solution for 10 days. Serum Mg++ levels were maintained in the 4 to 5.5 mg/dl range throughout the treatment period. Clinical management principles were the same between groups (including early use of surgery or endovascular treatment, followed by aggressive vasospasm prophylaxis and treatment). Daily transcranial Doppler (TCD) ultrasonographic recordings were obtained, and clinical outcomes were measured using the Glasgow Outcome Scale (GOS). The patients' GOS scores and the TCD recordings were analyzed using the independent t-test. Forty patients were enrolled in the study: 20 (15 female and five male patients) received treatment and 20 (11 female and nine male patients) comprised a control group. The mean ages of the patients in these groups were 46 and 51, respectively, and the mean clinical Hunt and Hess grades were 2.6 +/- 0.68 in the MgSO4 treatment group and 2.3 +/- 0.73 in the control group (mean +/- standard deviation [SD], p = 0.87). Fisher grades were similar in both groups. Mean middle cerebral artery velocities were 93 +/- 27 cm/second in MgSO4-treated patients and 102 +/- 34 cm/second in the control group (mean +/- SD, p = 0.41). Symptomatic vasospasm, confirmed by angiography, occurred in six of 20 patients receiving MgSO4 and in five of 16 patients receiving placebo. Mean GOS scores were 3.8 +/- 1.6 and 3.6 +/- 1.5 (mean +/- SD, p = 0.74) in the treatment and control groups, respectively. Significant adverse effects from treatment with MgSO4 did not occur.

CONCLUSIONS

Administration of high-dose MgSO4 following aneurysmal SAH is safe, and steady Mg++ levels in the range of 4 to 5.5 mg/dl are easily maintained. This treatment does not interfere with neurological assessment, administration of anesthesia during surgery, or other aspects of clinical care. We observed a trend in which a higher percentage of patients obtained GOS scores of 4 or 5 in the group treated with MgSO4, but the trend did not reach a statistically significant level. A larger study is needed to evaluate this trend further.

Adrenal insufficiency in high-risk surgical ICU patients

STUDY OBJECTIVES

To examine the incidence and response to treatment of adrenal insufficiency (AI) in high-risk postoperative patients.

DESIGN

Prospective observational case series.

SETTING

Large urban tertiary-care surgical ICU (SICU).

PARTICIPANTS

Adults > 55 years of age who required vasopressor therapy after adequate volume resuscitation in the immediate postoperative period.

INTERVENTIONS

Each patient underwent a cosyntropin (ACTH) stimulation test; at the discretion of the clinical team, some patients were empirically given hydrocortisone (100 mg IV q8h for three doses) before serum cortisol values became available.

MEASUREMENTS

Adrenal dysfunction (AD), defined as serum cortisol < 20 microg/dL at all time points, with Delta cortisol (60 min post-ACTH minus baseline) of < or = 9 microg/dL; functional hypoadrenalism (FH), defined as serum cortisol < 30 microg/dL at all time points or Delta cortisol (60 min post-ACTH minus baseline) < or = 9 microg/dL; and AI, as the presence of either AD or FH.

RESULTS

One hundred four patients were enrolled with a mean age (SD) of 65.2 +/- 16.9 years. AI (AD plus FH) was found in 34 of 104 patients (32.7%): AD was found in 9 patients (8.7%), FH in 25 patients (24%), and normal adrenal function in 70 patients (67.3%). The absolute eosinophil count was significantly higher in the combined AD and FH groups compared with the group with normal adrenal function (p < 0.05). Forty-six of 104 patients (44.2%) received hydrocortisone; 29 (63%) could be weaned from treatment with vasopressors within 24 h. This beneficial effect of hydrocortisone reached statistical significance in the FH group when compared with untreated patients (p < 0.031); a similar trend was seen in the AD group (p = 0.083). Mortality was also lower in the hydrocortisone-treated AI patients (5 of 23 [21%] vs 5 of 11 [45%] in those not receiving hydrocortisone; p < 0.01).

CONCLUSION

There is a high incidence of AI among SICU patients > 55 years of age with postoperative hypotension requiring vasopressors. There is also a significant association between hydrocortisone replacement therapy, resolution of vasopressor requirements, and improved survival.

Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit

OBJECTIVE

To establish the validity and reliability of a new sedation scale, the Motor Activity Assessment Scale (MAAS).

DESIGN

Prospective, psychometric evaluation.

SETTING

Sixteen-bed surgical intensive care unit (SICU) of a 937-bed tertiary care, university-affiliated teaching hospital.

PATIENTS

Twenty-five randomly selected, adult, mechanically ventilated, nonneurosurgical patients who were admitted to the SICU > or = 12 hrs after surgery and were not receiving neuromuscular blockers.

INTERVENTION

Four hundred assessments (eight per patient) were completed consecutively but independently, in pairs, at standardized times (both day and night) by two nurses who were preselected for each assessment from a pool of 32 pretrained SICU nurses.

MEASUREMENTS AND MAIN RESULTS

To estimate validity, paired assessments (four/patient) compared the MAAS result with the subjective assessment using a 10-cm visual analog sedation scale, the percent change in blood pressure and heart rate from the previous 4-hr baselines, and the number of recent agitation-related sequelae. To estimate reliability, paired assessments (four/patient) measured correlation between assessments of the same type (e.g., MAAS-MAAS). Generalized estimating equations, which accounted for the four repeated measures in each patient, supported MAAS validity by finding a linear trend between MAAS and the visual analog scale (p < .001), blood pressure (p < .001), heart rate (p < .001), and agitation-related sequelae (p < .001) end points. The MAAS (kappa = 0.83 [95% confidence interval, 0.72 to 0.94]) was found to be more reliable than subjective assessment using the visual analog scale (intraclass correlation coefficient = 0.32 [95% confidence interval, 0.05 to 0.55]).

CONCLUSIONS

The MAAS is a valid and reliable sedation scale for use with mechanically ventilated patients in the SICU. Further studies are warranted regarding the effect of MAAS implementation in our SICU on patient outcomes, such as quality of sedation and length of mechanical ventilation, as well as the use of the MAAS in other patient populations (e.g., medical).

Determination of gentamicin pharmacokinetics by bioelectrical impedance in critically ill adults

This investigation compares the accuracy of calculating gentamicin pharmacokinetic parameters by a noninvasive body composition technique (bioelectrical impedance analysis; BIA) with an empiric method, against the two-point method as the criterion standard. A prospective concurrent open label design was used. The 32 medical and surgical intensive care unit beds at Henry Ford Hospital, a not-for-profit, university-affiliated teaching hospital, served as the setting. Twenty critical ill adults, Therapeutic Index Scoring System (TISS) = 4, who required gentamicin as part of their normal course of therapy for gram-negative bacillary infections, were evaluated. Gentamicin Vd and k were calculated by three methods. After measurement of body composition parameters by BIA, previously derived gentamicin dosing equations were used to predict gentamicin volume of distribution (Vd) and elimination rate constant (k) (BIA method). Empiric estimates of these parameters (Vd = 0.3L/kg and k derived from creatinine clearance) were compared with the BIA parameters against a criterion standard Vd and k determined from a two-point sampling of gentamicin serum concentrations. Measurements of BIA parameters and gentamicin serum concentrations were made in duplicate with coefficients of variation, < or = 2% and < or = 3%, respectively. The BIA and empiric methods produced resultant pharmacokinetic parameters (Vd and k) not different than those measured by the two-point method. There were no statistically significant differences in mean error (bias), or mean squared error (precision) for both Vd and k assessed by the empiric or BIA methods.(ABSTRACT TRUNCATED AT 250 WORDS)

Bar-code technology applied to drug-use evaluation

Bar-code technology was used to determine: (1) patterns in histamine H2-receptor antagonist use and (2) the occurrence of adverse drug effects and drug interactions associated with the use of these agents in critically ill patients. Patients at Henry Ford Hospital (Detroit) receiving histamine H2-receptor antagonists over a two-month period were evaluated. Clinical information was collected in the intensive care units by using a bar-code system. The data-capture menu was based on drug-use-evaluation criteria for H2-receptor antagonists. Data collected in the scanning wands were uploaded into a computer database and were analyzed at the end of the study. Data were collected for 207 patients. Cimetidine was the predominant H2-receptor antagonist used, and the predominant indication was stress-ulcer prophylaxis. Dosing trends followed accepted guidelines for cimetidine dosage adjustment in renal and hepatic failure. Two drug interactions and six adverse drug reactions occurred. Pharmacists made 92 recommendations to the medical staff regarding modification in therapy, involving 32% of the patients. Data collection required an average of 10 minutes per day each for three pharmacists. H2-receptor antagonist use patterns were evaluated in intensive care units through the application of bar-code technology. The speed and efficiency of this automated tool facilitated collection of a large amount of data.

Individualizing nutrition in patients with acute respiratory failure requiring mechanical ventilation

Provision of adequate nutrition is recognized as a therapeutic necessity to maintain inspiratory muscle strength and prevent weaning failures in patients with acute respiratory failure requiring mechanical ventilation. Total caloric needs are empirically estimated by calculation of basal energy expenditure and modified by correction factors for concurrent levels of stress. Energy requirements can vary considerably from empiric estimations and may be better defined by indirect calorimetry that measures oxygen consumption and carbon dioxide production. Protein constituents are initiated empirically until patient-specific urea nitrogen excretion is available. The addition of fat emulsion as 20-50 percent of total daily calories limits lipogenesis, prevents excessive carbon dioxide production, and provides a volume-concentrated caloric source to fluid-restricted patients. Manipulation of nutrient composition can improve or impair ventilatory weaning and nutritional rehabilitation. The significance of substrate utilization is reviewed and recommendations for establishing nutritional regimens for mechanically ventilated adults with acute respiratory failure are provided.