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Study Objective: To compare guideline-based fluid resuscitation and need for respiratory support escalation in septic patients with pulmonary hypertension (PH) to those without PH., Design: Single-center, retrospective cohort study., Setting: Tertiary care academic medical center in Detroit, Michigan., Patients: Adult patients with or without PH hospitalized and diagnosed with sepsis from November 1, 2013 through December 31, 2019. Patients with sepsis were assigned to one of two groups based on a previous PH diagnosis or no PH diagnosis., Intervention: None., Measurements and Main Results: The primary outcome was incidence of respiratory support escalation within 72 h from sepsis time zero. Respiratory support escalation included high-flow nasal cannula, bilevel positive airway pressure, or intubation. One-hundred and four patients were included with 52 patients in each study group. Patients with PH were more likely to require escalation of respiratory support compared to non-PH patients (32.7% vs. 11.5%; p = 0.009). Fewer patients with PH received 30 mL/kg of crystalloid within 6 h of time zero compared with non-PH patients (3.8% vs. 42.3%; p < 0.001). Vasopressor initiation was more common in patients with PH compared with the non-PH group (40.4% vs. 19.2%; p = 0.018). PH diagnosis was the only independent predictor of respiratory support escalation., Conclusions: During initial sepsis management when compared with patients without PH, patients with PH had increased instances of respiratory support escalation within 72 h of sepsis time zero despite lower fluid resuscitation volumes., (© 2023 Pharmacotherapy Publications, Inc.)

Objectives: The Centers for Medicare and Medicaid Services Severe Sepsis and Septic Shock Management Bundle (SEP-1) assesses antibiotic administration, lactate measurement, and blood culture collection within 3 h of severe sepsis onset. The impact of the SEP-1 3-hour bundle among patients with severe sepsis is not extensively described. This investigation aimed to describe the impact of 3-hour bundle compliance on 28-day in-hospital mortality in patients with severe sepsis., Study Design: This was a retrospective, propensity adjusted, nested case-control study assessing the impact of compliance with a 3-hour sepsis bundle among patients with severe sepsis., Setting: This study was conducted at a large, academic, tertiary care medical center in Detroit, Michigan from July 1, 2017 to December 31, 2019., Patients: Cases were defined as those suffering 28-day in-hospital mortality. Controls were defined as those surviving at or discharged by 28 days. Patients were separated based on 3-hour bundle compliance or noncompliance. Nested and overall cohorts were assessed. Severe sepsis time zero was manually validated. Patients with shock, requiring vasopressors within 8 h of time zero, or those not meeting SEP-1 inclusion criteria were excluded., Intervention: The primary outcome was the propensity adjusted odds of 28-day in-hospital mortality among 3-hour bundle compliant versus noncompliant patients. Secondary outcomes included mortality for individual bundle element compliance, progression to septic shock, and predictors of mortality according to logistic regression., Results: A total of 325 compliant and 325 noncompliant patients were included. The median Sequential Organ Failure Assessment (SOFA) score was three in each group. There was no difference in propensity adjusted odds of mortality among those compliant versus noncompliant with the 3-hour bundle (odds-ratio [OR] 1.039; 95% CI: 0.721-1.497; p = 0.838) or with individual bundle elements. SOFA score and female sex were predictors of mortality., Conclusions: Three-hour bundle compliance did not impact 28-day in-hospital mortality in patients with severe sepsis. Further research is needed to understand the impact of 3-hour bundle compliance on mortality in severe sepsis., (© 2022 Pharmacotherapy Publications, Inc.)

Purpose: Evidence-based guideline recommendations for vancomycin dosing recently shifted from a trough-based strategy to an area under the curve (AUC) approach. While several AUC dosing methods exist, the optimal approach has not been determined. Literature characterizing time requirements for various vancomycin dosing strategies remains limited., Methods: A time and motion study was conducted to measure the time spent by clinical pharmacists dosing vancomycin using an AUC nomogram. Pharmacists who dosed and monitored vancomycin for adult patients on the general medical ward (GMW) or intensive care unit (ICU) of a large academic medical center consented to study participation. Vulnerable patients and vancomycin orders for surgical infection prophylaxis were excluded. The primary outcome was the median amount of time clinical pharmacists dedicated to vancomycin-related clinical activities during an 8-hour weekday shift. Secondary outcomes included the proportion of patients prescribed vancomycin at the beginning of each shift and factors contributing to greater than average time spent on vancomycin-related responsibilities., Results: Seven clinical pharmacists collected data on 178 vancomycin orders. The estimated amount of time a clinical pharmacist spent on daily vancomycin responsibilities averaged 10.45 minutes (interquartile range [IQR], 6.94-15.8 minutes). The overall median time requirement per vancomycin assessment was 3.45 minutes (IQR, 1.95-6.7 minutes). The only factor independently associated with prolonged dosing time was follow-up dosing from a previous day., Conclusion: The study elucidated time requirements associated with an AUC nomogram-based vancomycin dosing approach. This data could be used to compare time requirements associated with other existing vancomycin dosing strategies, which may help healthcare systems determine the optimal AUC dosing method for their specific practice model., (© American Society of Health-System Pharmacists 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Impella devices are percutaneously inserted ventricular assist devices which require a continuous purge solution that contains heparin to prevent pump thrombosis and device failure. We describe 2 patients with heparin-induced thrombocytopenia (HIT) supported with an Impella device utilizing an argatroban-based purge solution. Case 1 involved an 83-year-old female with biventricular failure which resulted in right ventricle Impella support. The purge solution was changed to include argatroban due to concern of device clotting in the setting of HIT. Case 2 involved a 55-year-old male with worsening cardiogenic shock which resulted in left ventricle Impella support. Due to decreased purge flow rates and concerns for clotting, argatroban was added to the purge solution. Both patients' total argatroban regimens were monitored and adjusted by pharmacy, resulting in therapeutic anticoagulation without any major bleeding or thrombotic events. Subsequently, a protocol was designed and implemented. These case reports appear to demonstrate the safe and effective use of argatroban purge solutions for the necessary anticoagulation with an Impella device. Further studies are needed to confirm these results and determine the optimal dosing regimen.