Search

Abstract Background Data to support the use of specific vasopressors in septic shock are limited. Since angiotensin II (AT2) was approved by the Food and Drug Administration in 2017, multiple mechanistically distinct vasopressors are available to treat septic shock, but minimal data exist regarding which patients are most likely to benefit from each agent. Renin and dipeptidyl peptidase 3 (DPP3) are components of the renin–angiotensin–aldosterone system which have been shown to outperform lactate in predicting sepsis prognosis, and preliminary data suggest they could prove useful as biomarkers to guide AT2 use in septic shock. Methods The DARK-Sepsis trial is an investigator-initiated industry-funded, open-label, single-center randomized controlled trial of the use of AT2 versus standard of care (SOC) vasopressor therapy in patients admitted to the intensive care unit (ICU) with vasodilatory shock requiring norepinephrine ≥ 0.1 mcg/kg/min. In both groups, a series of renin and DPP3 levels will be obtained over the first 24 h of treatment with AT2 or SOC. The primary study outcome will be the ability of these biomarkers to predict response to vasopressor therapy, as measured by change in total norepinephrine equivalent dose of vasopressors at 3 h post-drug initiation or the equivalent timepoint in the SOC arm. To determine if the ability to predict vasopressor response is specific to AT2 therapy, the primary analysis will be the ability of baseline renin and DPP3 levels to predict vasopressor response adjusted for treatment arm (AT2 versus control) and Sequential Organ Failure Assessment (SOFA) scores. Secondary outcomes will include rates of acute kidney injury, need for mechanical ventilation and kidney replacement therapy, lengths of stay in the ICU and hospital, ICU and hospital mortality, and rates of prespecified adverse events. Discussion With an armamentarium of mechanistically distinct vasopressor agents now available, sub-phenotyping patients using biomarkers has the potential to improve septic shock outcomes by enabling treatment of the correct patient with the correct vasopressor at the correct time. However, this approach requires validation in a large definitive multicenter trial. The data generated through the DARK-Sepsis study will prove crucial to the optimal design and patient enrichment of such a pivotal trial. Trial registration ClinicalTrials.gov NCT05824767. Registered on April 24, 2023.

Objective. Describe continuous infusion (CI) ketamine practices in pediatric intensive care units (PICUs) and evaluate its effect on pain/sedation scores, exposure to analgesics/sedatives, and adverse effects (AEs). Methods. Multicenter, retrospective, observational study in children

Empagliflozin is a sodium glucose cotransporter-2 inhibitor that inhibits renal glucose reabsorption through an insulin-independent mechanism. This class of drugs is used in the management of type 2 diabetes. A 49-year-old female with type 2 diabetes treated with empagliflozin presented to the emergency department in diabetic ketoacidosis (DKA). This case report details the series of events leading to the diagnosis of drug-induced DKA, which led to a change in the patient’s diagnosis from type 2 diabetes to type 1 diabetes.

Objective During March 2020 in the United States, demand for sedatives increased by 91%, that for analgesics rose by 79%, and demand for neuromuscular blockers increased by 105%, all owing to the number of COVID-19 cases requiring invasive mechanical ventilation (MV). We hypothesize that analgesic and sedative requirements decrease following tracheotomy in this patient population. Methods In this cross-sectional study, we conducted a retrospective chart review to identify patients with COVID-19 who underwent tracheotomy (T) at an academic medical center between March 2020 and January 2021. We used a paired Student t -test to compare total oral morphine equivalents (OMEs), total lorazepam equivalents, 24-hour average dexmedetomidine dosage in μg/kg/hour, and 24-hour average propofol dosage in μg/kg/minute on days T−1 and T+2 for each patient. Results Of 50 patients, 46 required opioids before and after tracheotomy (mean decrease of 49.4 mg OMEs). Eight patients required benzodiazepine infusion (mean decrease of 45.1 mg lorazepam equivalents. Fifteen patients required dexmedetomidine infusion (mean decrease 0.34 μg/kg/hour). Seventeen patients required propofol (mean decrease 20.5 μg/kg/minute). Conclusions When appropriate personal protective equipment is available, use of tracheotomy in patients with COVID-19 who require MV may help to conserve medication supplies in times of extreme shortages.

The purpose of this article is to summarize pharmacotherapy related emergency medicine (EM) literature indexed in 2023. Articles were selected utilizing a modified Delphi approach. The table of contents from pre-determined journals were reviewed and independently evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by paired authors. Pharmacotherapy-related publications deemed to be GRADE 1A and 1B were reviewed by the collective group for inclusion in the review. In all, this article summarizes and provides commentary on the potential clinical impact of 13 articles, 6 guidelines, and 5 meta-analyses covering topics including guideline releases and updates on rapid sequence intubation in the critically ill, managing cardiac arrest or life-threatening toxicity due to poisoning, and management of major bleeding following trauma. Also discussed are ongoing controversies surrounding fluid resuscitation, time and treatment modalities for ischemic stroke, steroid use in community-acquired pneumonia, targeted blood product administration, and much more. [ABSTRACT FROM AUTHOR]

IMPORTANCE:. The response of ICU patients to continuously infused ketamine when it is used for analgesia and/or sedation remains poorly established. OBJECTIVES:. To describe continuous infusion (CI) ketamine use in critically ill patients, including indications, dose and duration, adverse effects, patient outcomes, time in goal pain/sedation score range, exposure to analgesics/sedatives, and delirium. DESIGN, SETTING, AND PARTICIPANTS:. Multicenter, retrospective, observational study from twenty-five diverse institutions in the United States. Patients receiving CI ketamine between January 2014 and December 2017. MAIN OUTCOMES AND MEASURES:. Chart review evaluating institutional and patient demographics, ketamine indication, dose, administration, and adverse effects. Pain/sedation scores, cumulative doses of sedatives and analgesics, and delirium screenings in the 24 hours prior to ketamine were compared with those at 0–24 hours and 25–48 hours after. RESULTS:. A total of 390 patients were included (median age, 54.5 yr; interquartile range, 39–65 yr; 61% males). Primary ICU types were medical (35.3%), surgical (23.3%), and trauma (17.7%). Most common indications were analgesia/sedation (n = 357, 91.5%). Starting doses were 0.2 mg/kg/hr (0.1–0.5 mg/kg/hr) and continued for 1.6 days (0.6–2.9 d). Hemodynamics in the first 4 hours after ketamine were variable (hypertension 24.0%, hypotension 23.5%, tachycardia 19.5%, bradycardia 2.3%); other adverse effects were minimal. Compared with 24 hours prior, there was a significant increase in proportion of time spent within goal pain score after ketamine initiation (24 hr prior: 68.9% [66.7–72.6%], 0–24 hr: 78.6% [74.3–82.5%], 25–48 hr: 80.3% [74.6–84.3%]; p < 0.001) and time spent within goal sedation score (24 hr prior: 57.1% [52.5–60.0%], 0–24 hr: 64.1% [60.7–67.2%], 25–48 hr: 68.9% [65.5–79.5%]; p < 0.001). There was also a significant reduction in IV morphine (mg) equivalents (24 hr prior: 120 [25–400], 0–24 hr: 118 [10–363], 25–48 hr: 80 [5–328]; p < 0.005), midazolam (mg) equivalents (24 hr prior: 11 [4–67], 0–24 hr: 6 [0–68], 25–48 hr: 3 [0–57]; p < 0.001), propofol (mg) (24 hr prior: 942 [223–4,018], 0–24 hr: 160 [0–2,776], 25–48 hr: 0 [0–1,859]; p < 0.001), and dexmedetomidine (µg) (24 hr prior: 1,025 [276–1,925], 0–24 hr: 285 [0–1,283], 25–48 hr: 0 [0–826]; p < 0.001). There was no difference in proportion of time spent positive for delirium (24 hr prior: 43.0% [17.0–47.0%], 0–24 hr: 39.5% [27.0–43.8%], 25–48 hr: 0% [0–43.7%]; p = 0.233). Limitations to these data include lack of a comparator group, potential for confounders and selection bias, and varying pain and sedation practices that may have changed since completion of the study. CONCLUSIONS AND RELEVANCE:. There is variability in the use of CI ketamine. Hemodynamic instability was the most common adverse effect. In the 48 hours after ketamine initiation compared with the 24 hours prior, proportion of time spent in goal pain/sedation score range increased and exposure to other analgesics/sedatives decreased.

Empagliflozin is a sodium glucose cotransporter-2 inhibitor that inhibits renal glucose reabsorption through an insulin-independent mechanism. This class of drugs is used in the management of type 2 diabetes. A 49-year-old female with type 2 diabetes treated with empagliflozin presented to the emergency department in diabetic ketoacidosis (DKA). This case report details the series of events leading to the diagnosis of drug-induced DKA, which led to a change in the patient’s diagnosis from type 2 diabetes to type 1 diabetes.

This study aimed to describe pneumococcal polysaccharide vaccine-23 (PPSV23) vaccination use in high-risk pediatric patients with chronic heart disease (CHD). This was a single-center retrospective cohort study. Patients were included if they were aged 2–18 years and were diagnosed with CHD. The primary outcome was PPSV23 vaccination. Secondary outcomes included missed opportunities and the incidence of infections. Three hundred ninety-two patients were included; the mean age was 8.8 years. Only 40 patients (10.2%) had documentation of PPSV23 vaccination. Patients had a median number of three clinic visits in 2019. There were 114 cases of pneumonia documented in patients before receiving PPSV23 and one case reported after PPSV23 vaccination. PPSV23 vaccination in high-risk pediatric patients with CHD was low, with many documented missed opportunities for vaccination. This may be attributed to the PPSV23 not being a routine vaccination on the pediatric schedule. [ABSTRACT FROM AUTHOR]

The purpose of this article is to summarize pharmacotherapy related emergency medicine (EM) literature indexed in 2022. Articles were selected utilizing a modified Delphi approach. The table of contents from pre-determined journals were reviewed and independently evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by paired authors, with disagreements adjudicated by a third author. Pharmacotherapy-related publications deemed to be GRADE 1A and 1B were reviewed by the group for inclusion in the review. In all, this article summarizes and provides commentary on the potential clinical impact of 13 articles, 4 guidelines, and 3 meta-analyses covering topics including anticoagulant reversal, tenecteplase in acute ischemic stroke, guideline updates for heart failure and aortic aneurysm, magnesium in atrial fibrillation, sedation in mechanically ventilated patients and pain management strategies in the Emergency Department (ED), and tranexamic acid use in epistaxis and GI bleed. [ABSTRACT FROM AUTHOR]

This article highlights the most relevant emergency medicine (EM) pharmacotherapy publications indexed in 2021. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies via the GRADE system. After review of journal table of contents GRADE 1A and 1B articles were reviewed by authors. Twenty articles, 2 guidelines, 2 position papers, and 2 meta-analysis were selected for full summary. Articles included in this review highlight acute agitation management, acute appendicitis treatment, sexually transmitted infection updates, optimizing sepsis management and treatment, updates for the ideal thrombolytic agent in acute ischemic stroke and endovascular therapy candidates, indications for tranexamic acid, calicium for out of hospital cardiac arrest, optimial inotrope for cardiogenic shock, awareness during rapid sequence intubation paralysis, comparison of propofol or dexmedetomidine for sedation, treatment of cannabis hyperemsis syndrome, and prophylactic use of diphenhydramine to reduce neuroleptic side effects. Selected articles are summarized to include design, results, limitations, conclusions and impact. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to describe and compare the public's change in awareness and perceptions of, willingness to use, willingness to pay, and interest in insurance coverage for community pharmacist prescriptive authority services and point of care testing over a time span of 14 years.Methods: This was a retrospective review of anonymous questionnaires administered by student pharmacists in 2004 and in 2018. Questionnaires were administered to individuals who presented to University of New Mexico College of Pharmacy sponsored health fair screenings and at various community pharmacies throughout the state of New Mexico (NM).Results: In total, 545 (2004) and 659 (2017-2018) participants completed the questionnaire. Awareness of community pharmacist clinical services increased from 2004 to 2018. In 2018, awareness of newer prescriptive authority services provided by pharmacists in NM was low relative to the services assessed in previous years. Most respondents indicated a willingness to use and pay for pharmacist-provided clinical services and felt that pharmacists should receive compensation by their insurance for these services. Trust in pharmacist advice grew from 2004 to 2018.Conclusion: Overall rates of awareness of community pharmacist clinical services were low with the exception of immunizations; however, most participants indicated interest in and willingness to use these services. Most participants believed pharmacists should receive reimbursement from insurance companies for clinical services and were also willing to pay a copay or out-of-pocket cost for these services. [ABSTRACT FROM AUTHOR]

The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician. [ABSTRACT FROM AUTHOR]

Background: Previous studies of thyroid stimulating hormone (TSH) levels in Emergency Department (ED) patients largely have centered on patients with atrial fibrillation (AF). In our ED patients with AF as well as patients with Psychiatric diagnoses (psych) are screened. The purpose of the present study was to compare TSH levels in the 2 groups. Our hypotheses were that an abnormal TSH and/or AF predicted the need for hospital admission and that TSH is more likely decreased in AF and increased in psych patients.Methods: Our goal in the study was to compare the use of TSH testing in two ED populations, AF vs. psych patients. The study was a cross sectional cohort of AF vs. psych patients who had TSH levels drawn in the ED over a two year period. Our laboratory ranges were used to determine high vs. low TSH. Two chart examiners collected data after a training process. Charts were reviewed extracting demographic data, TSH levels, outcome (admit vs. discharge), history of AF, thyroid disease, psych diagnoses, presence of CHF, diabetes, hypertension. We compared AF vs. Psych groups using chi square and t-tests for parametric data. Odds ratios were calculated for comparisons between the 2 groups. For non-parametric data Mann Whitney U was used. A logistic regression was performed with the outcome of admission vs. discharge to find predictors of hospital admission. Kappa was calculated for inter-rater agreement. An a priori power analysis showed 80% power with 2 groups of 100 with an absolute difference of 20% between the 2 groups.Results: 252 patients were included, 101 with AF and 152 Psych. Demographics differed in age only with AF patients being older. Mean TSH for AF vs. 2.4 for AF, 2.9 for psych (NS) with no differences in percentages with high or low TSH in the 2 groups. Fifty-three patients had abnormal TSH levels (21%), 27% of AF and 17% of Psych patients (NS). There were significant differences in incidence of CHF, DM, HTN, and tachycardia with more in the AF group (P < 0.001). Significantly more of the psych patients had a history of hypothyroidism (OR 2.28). Our logistic regression showed that taking into account demographics including age, the only predictors of admission were the presence of CHF (aOR 18.6) and having a diagnosis of AF (aOR 4.0).Conclusion: There were no differences in TSH levels between the 2 groups. Twenty-one percent had an abnormal level. CHF and AF predicted hospital admission on regression analysis. Many with these AF or Psych diagnoses had abnormal ED TSH levels that could be useful in diagnosis, maintenance, or continuous treatment for their conditions diagnoses. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The objective of the study was to compare errors in the emergency department (ED) with pharmacists present (PPs) for resuscitations and traumas vs with pharmacists absent (PAs). Our hypothesis was that errors would be significantly fewer during PP than PA times. We also hypothesized that times with PP would affect patients greater when disposition was to more critical areas (intensive care unit, or ICUs). Methods: The study was conducted during a 3-month period in 2009 in a level 1 trauma center with an emergency medicine residency. This was a cross-sectional cohort study comparing a prospective analysis of patients during the time (10 hour/day) with PP and a retrospective review of the time on the same days (14 hours/day) with PA. Demographics of age, race, and sex were recorded. Patient disposition was either ICU, operating room, non-ICU wards, observation unit, or discharge. Main outcome was errors recorded including medications given but not ordered, medication ordered but not given, and time delays for medications. For demographics and prevalence, descriptive statistics and percentages were used. Percent differences and 95% confidence intervals (CIs) and χ 2 were derived. Logistic regression used predictor variables of age, race, sex, disposition, and presence or absence of pharmacists. An a priori power analysis was performed. The study was powered at 80% with 186 subjects per group (PP vs PA), to find a difference of 20% between the 2 groups in percent of medical errors. Results: There were 694 patients included in the 3-month period. A total of 242 presented during PP times and 452 during PA times. There were 383 (55%) male, 301 (43%) female, and 10 (2%) unknown sex. Mean age was 45 ± 18 years in PP group and 48 ± 20 years in PA group (P, nonsignificant). There was no difference in ethnicity between groups. There were 6 (3%) patients with errors recorded during PP times and 137 (30%) with errors recorded during PA times (difference, 27%; 95% CI, 23-32). Controlling for age, race, sex, and disposition, medical errors were 13.5 times more likely during PA than during PP times (adjusted odds ratio, 13.5; 95% CI, 5.7-31.9). Conclusion: With pharmacists absent, over 13 times more errors are recorded in our ED than with pharmacists present. An on-site pharmacist in the ED may be helpful in reducing medical errors. [Copyright &y& Elsevier]

Objective: Overall medication-related errors in the emergency department (ED) are 13.5 times more likely to occur in the absence of an emergency medicine pharmacist (EMP). Although the effectiveness of pharmacist-driven renal dosing adjustment has been studied in the intensive care unit, data are lacking in the ED setting. The aim of our study was to evaluate the appropriateness of antibiotic dosing when an EMP is physically present in the ED compared to when absent.Methods: This was a retrospective cohort study of patients treated in a level I trauma center with 75 adult and 12 pediatric beds and an annual census of 90000 patients. The study period was from March 1 to September 30, 2014. An EMP was physically present in the ED from 11:00 to 01:30 and absent from 01:31 to 10:59. Male and female patients 18years and older were considered for inclusion if cefazolin, cefepime, ciprofloxacin, piperacillin-tazobactam, or vancomycin was ordered. The primary outcome was the composite rate of correct antibiotic dose and frequency. Statistics included a multivariable logistic regression using age, sex, presence of EMP, and creatinine clearance as independent predictors of correct antibiotic use.Results: A total 210 cases were randomly chosen for evaluation, half during times when EMPs were present and half when they were absent. There were 130 males (62%) with an overall mean age of 54±18years. Overall, 178 (85%) of 210 of the antibiotic orders were appropriate, with 95% appropriate when an EMP was present compared to 74% when an EMP was absent (odds ratio, 6.9; 95% confidence interval, 2.5-18.8). In a logistic regression model, antibiotic appropriateness was independently associated with the presence of the EMP and creatinine clearance.Conclusion: Antibiotics that require renal and/or weight dosing adjustment are 6.5 times more likely to be appropriate in the ED when an EMP is present. Prevalence of antibiotic dosing error is related to both the presence of EMPs and the degree of renal impairment. [ABSTRACT FROM AUTHOR]

Background: Troponin elevation can be caused by etiologies other than acute coronary syndromes (ACS). Our hypothesis was that elevated troponins occur more frequently in non-ACS cases but that ACS cases (type 1 ST-elevation myocardial infarction [STEMI] and type 1 non-STEMI [NSTEMI]) have significantly higher troponin elevations.Methods: This was a cross-sectional cohort analysis of a random subset of all patients with elevated troponins (defined as ≥0.06 ng/mL) over a 1-year period from July 2013 to June 2014. The first positive troponin I and the peak were used in this study. All included patients had medical record reviews looking for whether our cardiologists or hospitalists attributed the elevated troponin to an ACS (NSTEMI or STEMI) or non-ACS cause. Non-ACS causes were categorized as infection, cancer, renal diseases, cardiovascular disease, pulmonary disease, trauma, cardiac arrest, neurologic disease, hypertension, or other. Data were extracted by 2 investigators on the cause of the elevated troponin. Three sessions to educate data extractors were arranged and methods of data extraction discussed, then a 5% sample was reevaluated by the other extractor to determine interrater agreement measures. Parametric data were evaluated with t test and analysis of variance. Dichotomous variables were compared using χ(2) test. Troponin data were evaluated using nonparametric Kruskal-Wallis or Mann-Whitney U. A logistic regression model was created with variables selected a priori to evaluate the predictive ability of these variables in differentiating ACS vs non-ACS causes of elevated troponin.Results: We evaluated 458 randomly selected patients from 1317 unique cases of all patients with initial elevated troponins at least 0.06 mg/mL during the study period. There was 84% interrater agreement in the 5% sampling. Seventy-nine percent had a non-ACS cause of elevated troponin, and the average initial positive troponin I level was significantly lower in the non-ACS cases (0.14; 95% confidence interval [CI], 0.08-0.37) than those with documented STEMI (10.2; 95% CI, 0.75-20.1) or NSTEMIs (0.4; 95% CI, 0.13-1.7). In the non-ACS group, the median initial troponin was 0.14 ng/mL (0.08-0.37 ng/mL). Peak troponin levels were highest in STEMI, next NSTEMI, and lowest in non ACS causes. The most frequent subgroups in the non-ACS group were non-ACS cardiovascular, infectious, renal, or hypertensive causes. In a linear regression model adjusting for age and sex, higher troponin levels had higher odds of being related to ACS causes (adjusted odds ratio, 1.4; 95% CI, 1.2-1.6) than non-ACS causes.Conclusion: The etiology for most initial elevated troponin I levels in a randomly selected population is the result of non-ACS causes. As initial + troponin levels increased, they were more likely associated with ACS causes than with non-ACS causes. Average initial + and peak troponin values were highest in STEMIs, next highest in NSTEMIs, and lowest overall in non-ACS causes. [ABSTRACT FROM AUTHOR]

Objective: Describe continuous infusion (CI) ketamine practices in pediatric intensive care units (PICUs) and evaluate its effect on pain/sedation scores, exposure to analgesics/sedatives, and adverse effects (AEs)., Methods: Multicenter, retrospective, observational study in children <18 years who received CI ketamine between 2014 and 2017. Time spent in goal pain/sedation score range and daily cumulative doses of analgesics/sedatives were compared from the 24 hours (H) prior to CI ketamine to the first 24H and 25-48H of the CI. Adverse effects were collected over the first 7 days of CI ketamine., Results: Twenty-four patients from 4 PICUs were included; median (IQR) age 7 (1-13.25) years, 54% female ( n  = 13), 92% intubated ( n  = 22), 25% on CI vasopressors ( n  = 6), and 33% on CI paralytics ( n  = 8). Ketamine indications were analgesia/sedation ( n  = 21, 87.5%) and status epilepticus ( n  = 3, 12.5%). Median starting dose was 0.5 (0.48-0.70) mg/kg/hr and continued for a median of 2.4 (1.3-4.4) days. There was a significant difference in mean proportion of time spent within goal pain score range (24H prior: 74% ± 14%, 0-24H: 85% ± 10%, and 25-48H: 72% ± 20%; p =0.014). A significant reduction in median morphine milligram equivalents (MME) was seen (24H prior: 58 (8-195) mg vs. 0-24H: 4 (0-69) mg and p =0.01), but this was not sustained (25-48H: 24 (2-246) mg and p =0.29). Common AEs were tachycardia (63%), hypotension (54%), secretions/suctioning (29%), and emergence reactions (13%)., Conclusions: Ketamine CI improved time in goal pain score range and significantly reduced MME, but this was not sustained. Larger prospective studies are needed in the pediatric population., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this article., (Copyright © 2024 Christine M. Groth et al.)

Background: Urinary tract infections (UTIs) are commonly treated in the emergency department (ED), and unfortunately, resistance to first-line agents is increasing., Objectives: To characterize treatment of pyelonephritis in a nationally representative sample of ED patients and to identify patient- and treatment-specific factors associated with receiving initial inactive antibiotics., Methods: We conducted a multicentre, observational cohort study utilizing the Emergency Medicine PHARMacotherapy Research NETwork (EMPHARM-NET), comprising 15 geographically diverse US EDs. All patients ≥18 years of age with a diagnosis of pyelonephritis between 2018 and 2020 were included. The primary endpoint was the proportion of patients who received initial inactive empirical antibiotic therapy and to identify predictive factors of inactive antibiotic therapy., Results: Of the 3714 patients evaluated, 223 had culture-positive pyelonephritis. Median patient age was 50.1 years and patients were mostly female (78.3%). Overall, 40.4% of patients received an IV antibiotic, most commonly ceftriaxone (86.7%). The most frequently prescribed antibiotics were cefalexin (31.8%), ciprofloxacin (14.3%), cefdinir (13.5%) and trimethoprim/sulfamethoxazole (12.6%). Overall, 10.3% of patients received initial inactive therapy. After adjustment in a multivariable analysis, long-acting IV antibiotic was predictive of inactive therapy (OR 0.23, 95% CI 0.07-0.83)., Conclusions: In our prospective, multicentre observational study, we found that only 40.4% of patients with pyelonephritis received empirical IV antibiotics in the ED, contributing to inactive therapy. Receipt of long-acting IV antibiotics was independently associated with a decreased rate of initial inactive therapy. This reinforces guideline recommendations to administer long-acting IV antibiotics empirically in the ED upon suspicion of pyelonephritis., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

There is limited literature evaluating the use of nebulized albuterol in the management of hyperkalemia. The objective was to evaluate the efficacy of insulin alone compared with the addition of nebulized albuterol for the treatment of hyperkalemia. This is a retrospective, single-center evaluation of adult patients with hyperkalemia attending the Emergency Department of a large urban academic medical center. Consecutive patients with a potassium level of >5 mmol/L were included. Patients without a repeat potassium level within 4 hours of medication administration, those receiving hemodialysis before a repeat serum potassium, or those that had a hemolyzed blood sample were excluded. The primary outcome was the change in potassium level within 4 hours in patients who received insulin monotherapy versus patients who received insulin and albuterol. The secondary outcomes included hospital length of stay, intensive care unit (ICU) admission, and mortality. Out of the 204 patients, 141 received insulin, whereas 63 received insulin and nebulized albuterol. There was no difference in the change in potassium level between the insulin and the insulin and nebulized albuterol groups (0.85 ± 0.6 vs 0.96 ± 0.78 mmol/L; P = .36). There was no difference in median hospital length of stay (8.6 days, IQR 13.2 days, vs 5.6 days, IQR 8.2 days; P = .09), ICU admission (31.9% vs 38.1%; P = .39), and all-cause mortality (14.9% vs 17.5%; P = .64). In this retrospective analysis, the addition of albuterol to insulin for the treatment of hyperkalemia did not result in a greater change in potassium level within 4 hours of therapy., (© 2023, The American College of Clinical Pharmacology.)

The aim of this study is to evaluate and describe the utilization and safety of 4F-PCC in a nonanticoagulated, surgical patient population at an academic, tertiary care center. This retrospective, single-center chart review evaluated nonanticoagulated adult patients at least 18 years of age who had at least one dose of 4F-PCC administered between 1 January 2017 and 30 September 2022 for a surgical or peri-procedural indication. Hemostatic efficacy following 4F-PCC administration was the primary outcome, assessed by subsequent blood product administration and hemoglobin and hematocrit reduction. Secondary outcomes included an assessment of thrombotic events within 30 days post-4F-PCC administration, in-hospital mortality, and the length of hospital stay. A total of 71 patients met the inclusion criteria, with 61 patients receiving 4F-PCC for cardiac surgery and 10 patients for other intraoperative or peri-procedural indications. The mean total 4F-PCC dose was 25.0 U/kg. For the primary outcome of hemostatic efficacy, 81% of patients had excellent hemostasis; however, blood product administration was reported in 95.8% of patients post-4F-PCC. Thromboembolic events occurred in 10 (14.1%) patients and 21.1% of patients expired prior to discharge in the total cohort. Off-label 4F-PCC use in nonanticoagulated patients is reported despite a lack of robust guidance for use. Following 4F-PCC administration, hemostatic efficacy based on hemoglobin and hematocrit changes was observed; however, blood product use was frequent, and 4F-PCC administration was not without risks, including thromboembolic complications such deep vein thrombosis (DVT), pulmonary embolism, and stroke. Further studies are needed to validate the off-label administration of 4F-PCC in nonanticoagulated patients., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Early post-traumatic seizures occur within 7 days following a traumatic brain injury and may lead to additional brain damage and poor outcomes. Levetiracetam or phenytoin is often used for seizure prophylaxis in this patient population, but valproic acid may be an appropriate therapeutic alternative in patients with concomitant agitation. Evidence for the use of valproic acid for both early post-traumatic seizure prophylaxis and agitation is limited. The purpose of this study is to examine the safety and efficacy of valproic acid for both early post-traumatic seizure prophylaxis and agitation. Methods : This single-center, retrospective case series includes 18 patients who received valproic acid for both early post-traumatic seizure prophylaxis and agitation. Efficacy for early post-traumatic seizure prophylaxis is assessed by the incidence of seizures within 7 days of injury. Efficacy for agitation is assessed by changes in Riker Sedation-Agitation Scale scores during valproic acid therapy. The safety of valproic acid is defined by the incidence of selected adverse events. Results: Among 18 patients with traumatic brain injuries receiving valproic acid for both early post-traumatic seizures and agitation, one patient experienced a seizure during the period of prophylaxis and thrombocytopenia was the most common adverse event. Conclusion: In this small cohort of patients, valproic acid appears be a potential option to prevent early post-traumatic seizures in patients with traumatic brain injuries and concomitant agitation with minimal adverse effects. Randomized, controlled studies are needed to further investigate the role of valproic acid for this indication, including standards for dosing regimens, serum drug monitoring, and the relationship between valproic acid treatment and mortality., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Introduction: An estimated 38 million people are living with human immunodeficiency virus (HIV) worldwide. Pharmacists are well positioned to provide care to patients with HIV, but gaps in HIV education among pharmacists exist. Recognizing the need to educate and prepare future pharmacists, a 2-credit advanced HIV elective course was created for Doctor of Pharmacy students at Washington State University College of Pharmacy and Pharmaceutical Sciences in the United States, and Masters of Clinical Pharmacy students from University of Western Cape School of Pharmacy in South Africa. Methods: Course topics included diagnosis and treatment of HIV in children and adults, management of common comorbidities, pre-exposure prophylaxis, pharmacogenetic applications, and antiretroviral drug-drug interactions. Course effectiveness was evaluated using student examination results. Student perceptions were evaluated using pre- and post-course self-assessments involving abilities, confidence, and attitudes toward caring for people living with HIV. Results: Student pharmacists demonstrated competency in HIV knowledge, demonstrated skills in application to clinical-based scenarios, and reported significantly improved confidence and abilities as well as positive changes in attitudes toward people with HIV. Conclusion: This course contributed to student learning across different student cohorts in an institutional program in the United States including successful execution of distance learning and clinical application for students at a program in South Africa.

Objective: The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) remains one of the most important targets for neurocritical care. Advances in monitoring technology have facilitated a more thorough understanding of the pathophysiology and therapeutic approaches, but interventions are generally limited to either systemic therapies or passive CSF drainage. The authors present a novel approach that combines a multimodal monitoring bolt-based system with an irrigating ventricular drain capable of delivering intrathecal medications and describe their early experience in patients with aSAH., Methods: The authors performed a retrospective review of cases treated with the combined Hummingbird multimodal bolt system and the IRRAflow irrigating ventriculostomy., Results: Nine patients were treated with the combined multimodal bolt system with irrigating ventriculostomy approach. The median number of days to clearance of the third and fourth ventricles was 3 days in patients with obstructive intraventricular hemorrhage. Two patients received intrathecal alteplase for intraventricular hemorrhage clearance, and 2 patients received intrathecal nicardipine as rescue therapy for severe symptomatic angiographic vasospasm., Conclusions: Combined CSF drainage, irrigation, multimodality monitoring, and automated local drug delivery are feasible using a single twist-drill hole device. Further investigation of irrigation settings and treatment approaches in high-risk cases is warranted.

The 2011 Infectious Diseases Society of America guidelines for treatment of uncomplicated urinary tract infections (UTIs) recommend non-β-lactam antibiotics for empiric therapy. However, increasing Escherichia coli and Klebsiella spp. resistance to first-line antibiotic therapies has necessitated the need for alternative agents. Based on local antibiogram data, cephalexin has become the preferred oral antibiotic for empiric treatment of UTIs at our institution. The purpose of this single-center retrospective review was to assess clinical outcomes of patients discharged from the emergency department (ED) who received cephalexin for the treatment of uncomplicated UTIs. The primary outcome of this study was to assess the proportion of patients with clinical success 30 days after discharge from the ED. Patients were excluded if they were <18 years of age, received ≥10 days of cephalexin, received antibiotics for any indication other than uncomplicated UTI, received antibiotics within 60 days of their ED visit, or had structural abnormalities. A total of 264 patients were included for evaluation, and 214 patients (81.1%) met the criteria for clinical success. Overall, 28 (10.6%) patients required a change in antibiotics based on cultures and sensitivities, 18 (6.8%) patients returned for nonresolving or worsening symptoms, and 4 (1.5%) patients required both a change in antibiotics and returned for nonresolving or worsening symptoms. Short courses of twice-daily cephalexin appear to be a safe and effective option for the empiric treatment of uncomplicated UTIs., (© 2022, The American College of Clinical Pharmacology.)

Objective: The Advisory Committee on Immunization Practices recommends the pneumococcal polysaccharide vaccine (PPSV23) following the pneumococcal conjugate vaccine (PCV13) for pediatric patients aged 2 to 18 years with high-risk medical conditions. The PPSV23 is not a routine immunization for all pediatric patients and children who meet criteria for high-risk conditions may not consistently receive the PPSV23 vaccine, despite current recommendations. The goal of this study was to determine PPSV23 -vaccination rates in the high-risk pediatric patients with type 1 or type 2 diabetes., Methods: A single-center retrospective cohort study was conducted. Patients were included if they were 2 to 18 years of age on January 1, 2019, with a diagnosis of diabetes, and had ≥1 encounters within the health care system in 2019. The primary outcome was PPSV23 vaccination rates in the high-risk diabetic pediatric population. Secondary outcomes included identifying missed opportunities for vaccinations and the incidence of invasive pneumococcal infections., Results: A total of 366 patients met criteria for study inclusion. Patients had a mean age of 13.3 years and were predominantly white (69.8%). A total of 32 (8.7%) patients had documentation of PPSV23 vaccination. Baseline characteristics were comparable between the two groups. There were 32 cases of pneumonia charted before patients received the PPSV23 and one case reported after patients received the PPSV23 vaccination., Conclusions: PPSV23 vaccination rates were low in this high-risk diabetic pediatric group, with many -documented missed opportunities for vaccination. This may be attributed to the vaccine not being a -routinely recommended for all pediatric patients., (Copyright. Pediatric Pharmacy Association. All rights reserved. For permissions, email: membership@pediatricpharmacy.org.)

Evidence supporting intravenous-to-oral (IV-to-PO) antibiotic deescalation for uncomplicated streptococcal bloodstream infections (BSIs) are limited. The objective of this study was to compare clinical outcomes of patients treated with IV-only versus IV-to-PO antibiotic therapy for uncomplicated streptococcal BSIs. This was a single-center, retrospective study of patients aged ≥18 years who received treatment for uncomplicated streptococcal BSIs from January 2017 to December 2019. Patients were excluded if they had a polymicrobial BSI, endocarditis, osteomyelitis, septic arthritis, or received antibiotic therapy for >14 days. The primary outcome was clinical failure, defined as persistent bacteremia, recurrence of bacteremia, or mortality at 30 days. Secondary outcomes included length of hospital stay, all-cause readmissions, development of Clostridioides difficile infection, and adverse antibiotic reactions. There were 98 patients who met the inclusion criteria: 51 patients in the IV-to-PO therapy group and 47 patients who received IV-only antibiotics. Streptococcus pneumoniae and beta-hemolytic streptococci were the most common pathogens. Patients received an average of 4.4 days of IV antibiotics before being stepped down to an oral agent. Hospital length of stay (6.3 vs 12.6 days; P < .001) and total antibiotic duration of therapy (11.8 vs 13.9 days; P = .002) were significantly shorter in patients receiving IV-to-PO therapy. There were no clinical failures observed in patients who received IV-to-PO antibiotic therapy. IV-to-PO step-down therapy for uncomplicated streptococcal BSIs was not associated with worse clinical outcomes compared to patients receiving IV-only antibiotic therapy., (© 2022, The American College of Clinical Pharmacology.)

Purpose: The pathophysiology and hemodynamic management of acute spinal cord injuries, including the use of intravenous and enteral vasoactive agents, are reviewed., Summary: Spinal cord injuries are devastating neurological insults that in the acute setting lead to significant hemodynamic disturbances, including hypotension and bradycardia, that are influenced by the level of injury. High thoracic (usually defined as at or above T6) and cervical injuries often manifest with hypotension and bradycardia due to destruction of sympathetic nervous system activity and unopposed vagal stimulation to the myocardium, whereas lower thoracic injuries tend to result in hypotension alone due to venous pooling. Initial management includes maintaining euvolemia with crystalloids and maintaining or augmenting mean arterial pressure with the use of intravenous vasoactive agents to improve neurological outcomes. Choice of vasopressor should be based on patient-specific factors, particularly level of injury and presenting hemodynamics. This review includes the most recent literature on intravenous vasopressors as well as the limited evidence supporting the use of enteral vasoactive agents. Enteral vasoactive agents may be considered, when clinically appropriate, as a strategy to wean patients off of intravenous agents and facilitate transfer outside of the intensive care unit., Conclusion: The hemodynamic management of acute spinal cord injuries often requires the use of vasoactive agents to meet mean arterial pressure goals and improve neurological outcomes. Patient-specific factors must be considered when choosing intravenous and enteral vasoactive agents., (© American Society of Health-System Pharmacists 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Uropathogen resistance, fluoroquinolone-resistance (FQR), and extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. The primary aim of our study was to determine the prevalence of FQR from a geographically diverse sample of United States emergency departments (EDs)., Methods: We conducted a multi-center, observational cohort study using a network of 15 geographically diverse US EDs. All patients ≥18 years of age with the primary or secondary diagnosis of urinary tract infection (UTI) in the ED identified using International Classification of Diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or UTI from 2018 to 2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with FQR Escherichia coli., Results: Among 3779 patients who met inclusion criteria, median age was 62.9 years (interquartile range [IQR]: 41-77.6) and 76.3% were female. The most common diagnoses were complicated (41.2%) and uncomplicated cystitis (40.3%). E. coli was the most common pathogen (63.2%), followed by Klebsiella pneumoniae (13.2%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 7.4%, ranging from 3.6% to 11.6% by site. Previous IV or oral antimicrobial use in the past 90-days and history of a multi-drug resistant pathogen were associated with FQ-resistant E. coli (odds ratio [OR] 2.68, 95% confidence interval [CI]: 2.04-3.51, and OR 6.93, 95% CI: 4.95-9.70, respectively). Of the patients who had FQ-resistant E. coli or an ESBL-producing uropathogen isolated, 116 (37.1%) and 61 (36.7%) did not have any documented risk factors for resistance., Conclusion: FQ-resistant E. coli is widely prevalent across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments., (© 2022 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Background: Group A Streptococcus (GAS) pharyngitis is the most common bacterial cause of acute pharyngitis and is often over treated with unnecessary antibiotics. The purpose was to evaluate if implementation of a rapid antigen detection test (RADT) for GAS would reduce the number of inappropriately prescribed antibiotics for adult patients presenting with symptoms of pharyngitis. Methods: This was a retrospective cohort study of adult urgent care clinic patients pre- and post-implementation of a GAS RADT. We included patients who had a diagnosis of GAS identified via ICD-10 codes and either a throat culture, GAS RADT, or antibiotic prescribed for GAS. Antibiotic prescribing was assessed as appropriate or inappropriate based on testing and IDSA guideline recommendations. Thirty-day follow-up visits related to pharyngitis or the prescribed antibiotics was also evaluated. Results: A total of 1734 patients were included; 912 and 822 in the pre- and post-implementation groups, respectively. Following implementation of the GAS RADT, there was an increase in the number of antibiotics prescribed for GAS (43.4% vs 59.1%, P  < .001) as well as an increase in appropriate prescribing (67.6% vs 77.5%, P  < .001). More 30-day pharyngitis-related follow-up visits were seen in the pre-intervention group (12.5% vs 9.3%, P  = .03). Conclusion: Implementation of a RADT for GAS pharyngitis was associated with an increase in both the overall number of antibiotic prescriptions for GAS and the proportion of appropriately prescribed antibiotics. There was also a reduction in follow up visits related to GAS pharyngitis, however educational efforts to further increase appropriate prescribing is needed., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Purpose: Epoprostenol and treprostinil are prostacyclins indicated for the treatment of pulmonary arterial hypertension (PAH). Although there is literature describing the conversion of intravenous (IV) epoprostenol to IV treprostinil or IV treprostinil to oral treprostinil, there is little data on the direct conversion of IV epoprostenol to oral treprostinil. In this case, we describe the direct conversion of IV epoprostenol to oral treprostinil without an intermediary conversion to IV treprostinil., Summary: A 39 year-old female with PAH was admitted for altered mental status and self-removal of her peripherally inserted central catheter (PICC) used for IV epoprostenol. Given the unplanned hospitalization, absence of a dedicated central line for IV prostacyclin therapy, and concern the patient may remove a future subcutaneous line, the patient was transitioned to oral treprostinil. Of note, despite triple PAH therapy, the patient was unable to reach a low risk group based on her prognostic risk assessment. A right heart catheterization four months prior found severe PAH with a pulmonary arterial pressure of 79/32 mmHg (mean, 49 mmHg) and pulmonary vascular resistance of 10.6 Wood units. To expedite the transition, the patient was directly converted from IV epoprostenol to oral treprostinil without an intermediary conversion to IV treprostinil. A target oral treprostinil dose of 5 mg TID was calculated based on 110% of the IV epoprostenol dose (19 ng/kg/min) utilizing the conversion recommended by the medication manufacturer. Every 8 hours, IV epoprostenol was decreased by 2 ng/kg/min and oral treprostinil was increased by 0.5 mg. The target oral treprostinil dose of 5 mg TID was reached 72 hours after conversion initiation. Three hours after the final titration, the patient was discharged home on room air., Conclusion: In this case, rapid transition from IV epoprostenol to oral treprostinil was achieved in 72 hours without reported adverse effects., (© American Society of Health-System Pharmacists 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Seizures are a common manifestation of toxic exposures requiring immediate and possibly ongoing management. Guidelines recommend benzodiazepines as first-line therapy for toxic seizures; however, there is a paucity of literature regarding optimal secondary treatment. We systematically evaluated the available literature for second-line treatment of toxic seizures., Methods: We searched PubMed, Embase, PsychINFO, Cochrane Library, Web of Science, Google Scholar, and International Pharmaceutical Abstracts from inception through August of 2018, following PRISMA Guideline. The MESH terms focused on identifying treatments for seizures induced by drugs or other potentially toxic substances. We excluded the articles if they involved animals, had seizures resulting from alcohol withdrawal, were case reports, or not peer-reviewed. Our primary outcome was seizure termination and/or suppression by the second-line agent as agreed upon by two authors. We used descriptive statistics for analysis., Results: We identified six case series that met inclusion and exclusion criteria. Included case series contained nine to 235 patient cases each. The most common xenobiotic exposures were bupropion, isoniazid, and anti-psychotics. The description of seizure type and duration was diverse. First-line treatments were primarily benzodiazepines. Secondary treatments included propofol, barbiturates, phenytoin, valproic acid, and levetiracetam. Patient outcomes differed, attributable to any of the following: mixed toxic substances, drug-drug interactions, inability to control seizures, or toxicity of the anti-epileptic drugs (AED) themselves. Few cases specifically discussed the success of secondary treatment administration to suppress or terminate seizures., Conclusions: Available literature discussing second-line treatment for toxic seizures is of poor quality with high heterogeneity. Although the majority of articles used similar second-line agents, it is difficult to compare the efficacy of the regimens. Additional studies are necessary to identify the most efficacious second-line therapies in toxic seizures.

Introduction: Patients evaluated after sexual assault may benefit from nonoccupational postexposure prophylaxis (nPEP) to prevent infection with HIV, yet multiple barriers may prohibit nPEP delivery. The IN-STEP (Integrating nPEP after Sexual Trauma in Emergency Practice) project was designed to improve access to HIV screening and prevention for patients evaluated in the emergency department (ED) of our academic hospital after a sexual assault., Methods: The IN-STEP team identified and addressed four key areas for improvement: (1) training of ED providers to perform nPEP assessments; (2) access to HIV testing in the ED; (3) provision of nPEP medications, using a patient-centered approach; and (4) continuity of care between the ED and follow-up sites in the community. Improvements were implemented using parallel plan-do-study-act cycles corresponding to these four key areas., Results: IN-STEP resulted in significant systems improvements in HIV screening, prevention, and continuity of care. This program not only improved the care of patients affected by sexual assault but also those evaluated for HIV due to other indications., Conclusions: Involvement of a multidisciplinary leadership team, clear delineation of a patient-centered project focus, and coordination across four parallel areas for improvement were useful for completing this complex effort., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 National Association for Healthcare Quality.)

Purpose: To evaluate the effect of time to tranexamic acid administration on blood product usage in trauma patients and to assess the potential benefit of initiating a protocol for field administration by ground ambulance personnel., Methods: Adult patients with traumatic injuries who received 1 g of tranexamic acid during the period January 2014 through June 2016 were retrospectively identified via review of automated dispensing cabinet and electronic medical record data and cross-referencing with the New Mexico Trauma Registry. Exclusion criteria included tranexamic acid use for nontrauma indications, previous admission for trauma during the study period, and a lack of pertinent information regarding the time, type, or severity of trauma in available records. The primary outcome was blood product use (aggregate of units of platelets, packed red blood cells [pRBCs], and fresh frozen plasma [FFP]) in the first 24 hours of hospital admission., Results: The analysis included 107 patient cases, with a median transport time of 20 minutes (range, 7-103 minutes); 73% of reported transport times were less than 30 minutes. All patients received a loading dose of tranexamic acid in the hospital, with the exception of 2 patients who received tranexamic acid in the field. Administration of a tranexamic acid loading dose was documented within 3 hours for 90.7% of patients, with a mean time to administration of 91.9 minutes. A mean (SD) total of 14.8 (16.0) units of blood products (range, 0-91 units) were administered, consisting of a mean (SD) of 8.0 (8.4) units of pRBCs (range, 0-48 units), 5.6 (7.5) units of FFP (range, 0-38 units), and 1.2 (1.7) units of platelets (range, 0-7 units). Time to tranexamic acid administration did not affect blood product usage in the first 24 hours of admission after adjusting for potential confounders., Conclusion: Earlier administration of tranexamic acid was not associated with a decrease in use of blood products. This finding, paired with the relatively short ground transport times typical for our institution, makes it unlikely that field administration of tranexamic acid would benefit the evaluated patient population., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)