scholarly journals Patient Predictors of Dexmedetomidine Effectiveness for Sedation in Intensive Care Units

2014 ◽  
Vol 23 (2) ◽  
pp. 160-165 ◽  
Author(s):  
Pamela L. Smithburger ◽  
Randall B. Smith ◽  
Sandra L. Kane-Gill ◽  
Philip E. Empey
Keyword(s):  
Intensive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Multiple Logistic Regression Analysis ◽  
Patient Characteristics ◽  
Specific Patient ◽  
Academic Medical ◽  
Adequate Sedation ◽  
Effective Sedation ◽  
At Home

Background Dexmedetomidine, a selective α2-adrenergic receptor agonist, is increasingly used as a sedative in intensive care despite variations in patients’ responses. Objectives To determine the effectiveness of dexmedetomidine as a sedative and specific patient characteristics that play a role in adequate sedation with dexmedetomidine. Methods A 6-month, pilot, prospective observational study was performed in a medical intensive care unit at an academic medical center. Patients receiving dexmedetomidine were followed up until use of the drug was stopped and they were classified as nonresponders or responders. Effective sedation was defined as a score of 3 to 4 on the Sedation Agitation Scale after the administration of dexmedetomidine. Patient characteristics, laboratory values, home and inpatient medications, and dexmedetomidine dosing information were collected to identify predictors of clinical response. Results During the 6-month study period, 38 patients received dexmedetomidine. The drug was ineffective as a sedative in 19 patients (50%) and effective in 11 (29%). Effectiveness could not be assessed in 8 patients because of clinical confounders. According to standard multiple logistic regression analysis, successful sedation was more likely in patients with a lower score on the Acute Physiology and Chronic Health Evaluation II (Odds Ratio [OR] 0.81; 95% CI, −0.39 to −0.03) and patients who took antidepressants at home (OR 10.27; 95% CI, 0.23 to 4.43) than in patients who had a higher score or did not take antidepressants at home. Conclusions Effective sedation with dexmedetomidine is variable.

scholarly journals Determining Inappropriate Medication Alerts from “Inaccurate Warning” Overrides in the Intensive Care Unit

2018 ◽  
Vol 09 (02) ◽  
pp. 268-274 ◽  
Author(s):  
Christine Rehr ◽  
Adrian Wong ◽  
Diane Seger ◽  
David Bates
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Drug Allergy ◽  
Medical Center ◽  
Inappropriate Medication ◽  
Academic Medical Center ◽  
Patient Characteristics ◽  
Valuable Resource ◽  
Provider Behavior ◽  
Academic Medical

Objective This article aims to understand provider behavior around the use of the override reason “Inaccurate warning,” specifically whether it is an effective way of identifying unhelpful medication alerts. Materials and Methods We analyzed alert overrides that occurred in the intensive care units (ICUs) of a major academic medical center between June and November 2016, focused on the following high-significance alert types: dose, drug-allergy alerts, and drug–drug interactions (DDI). Override appropriateness was analyzed by two independent reviewers using predetermined criteria. Results A total of 268 of 26,501 ICU overrides (1.0%) used the reason “Inaccurate warning,” with 93 of these overrides associated with our included alert types. Sixty-one of these overrides (66%) were identified to be appropriate. Twenty-one of 30 (70%) dose alert overrides were appropriate. Forty of 48 drug-allergy alert overrides (83%) were appropriate, for reasons ranging from prior tolerance (n = 30) to inaccurate ingredient matches (n = 5). None of the 15 DDI overrides were appropriate. Conclusion The “Inaccurate warning” reason was selectively used by a small proportion of providers and overrides using this reason identified important opportunities to reduce excess alerts. Potential opportunities include improved evaluation of dosing mechanisms based on patient characteristics, inclusion of institutional dosing protocols to alert logic, and evaluation of a patient's prior tolerance to a medication that they have a documented allergy for. This resource is not yet routinely used for alert tailoring at our institution but may prove to be a valuable resource to evaluate available alerts.

Hemodynamic Effects of Ketamine Compared With Propofol or Dexmedetomidine as Continuous ICU Sedation

2021 ◽  
pp. 106002802110510
Author(s):  
Evan Atchley ◽  
Eljim Tesoro ◽  
Robert Meyer ◽  
Alexia Bauer ◽  
Mark Pulver ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical ◽  
Clinically Significant ◽  
Critically Ill Adults ◽  
Icu Sedation ◽  
Ill Adults ◽  
Positive Effect

Background Ketamine has seen increased use for sedation in the intensive care unit. In contrast to propofol or dexmedetomidine, ketamine may provide a positive effect on hemodynamics. Objective The objective of this study was to compare the development of clinically significant hypotension or bradycardia (ie, negative hemodynamic event) between critically ill adults receiving sedation with ketamine and either propofol or dexmedetomidine. Methods This was a retrospective cohort study of adults admitted to an intensive care unit at an academic medical center between January 2016 and January 2021. Results Patients in the ketamine group (n = 78) had significantly less clinically significant hypotension or bradycardia compared with those receiving propofol or dexmedetomidine (n = 156) (34.6% vs 63.5%; P < 0.001). Patients receiving ketamine also experienced smaller degree of hypotension observed by percent decrease in mean arterial pressure (25.3% [17.4] vs 33.8% [14.5]; P < 0.001) and absolute reduction in systolic blood pressure (26.5 [23.8] vs 42.0 [37.8] mm Hg; P < 0.001) and bradycardia (15.5 [24.3] vs 32.0 [23.0] reduction in beats per minute; P < 0.001). In multivariate logistic regression modeling, receipt of propofol or dexmedetomidine was the only independent predictor of a negative hemodynamic event (odds ratio [OR]: 3.3, 95% confidence interval [CI], 1.7 to 6.1; P < 0.001). Conclusion and Relevance Ketamine was associated with less clinically relevant hypotension or bradycardia when compared with propofol or dexmedetomidine, in addition to a smaller absolute decrease in hemodynamic parameters. The clinical significance of these findings requires further investigation.

Abstract 16125: Impact of COVID-19 on Echocardiography Volume at a Large Academic Medical Center

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Merilyn S Varghese ◽  
Jordan B Strom ◽  
Sarah Fostello ◽  
Warren J Manning
Keyword(s):  
Patient Outcomes ◽  
Hospital Admissions ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical ◽  
Hospital Systems ◽  
The Impact ◽  
At Home

Introduction: COVID-19 has significantly impacted hospital systems worldwide. The impact of statewide stay-at-home mandates on echocardiography volumes is unclear. Methods: We queried our institutional echocardiography database from 6/1/2018 to 6/13/2020 to examine rates of transthoracic (TTE), stress (SE), and transesophageal echocardiograms (TEE) prior to and following the COVID-19 Massachusetts stay-at-home order on March 15, 2020. Results: Among 36,377 total studies performed during the study period, mean weekly study volume dropped from 332 + 3 TTEs/week, 30 + 1 SEs/week, and 21 + 1 TEEs/week prior to the stay-at-home order (6/1/2018-3/15/2020) to 158 + 13 TTEs/week, 8 + 2 SEs/week, and 8 + 1 TEEs/week after (% change, -52%, -73%, and -62% respectively, all p < 0.001 when comparing volume prior to March 15 versus after). Weekly TTEs correlated strongly with hospital admissions throughout the study period (r = 0.93, 95% CI 0.89-0.95, p < 0.001) ( Figure ). Outpatient TTEs declined more than inpatient TTEs (% change, -74% vs. -39%, p <0.001). As of 3 weeks following the cessation of the stay-at-home order, TTE, SE, and TEE weekly volumes have increased to 73%, 66%, and 81% of pre-pandemic levels, respectively. Conclusions: Echocardiography volumes fell precipitously following the Massachusetts stay-at-home order, strongly paralleling declines in overall hospitalizations. Outpatient TTEs declined more than inpatient TTEs. Despite lifting of the order, echocardiography volumes remain substantially below pre-pandemic levels. The impact of the decreased use of echocardiographic services on patient outcomes remains to be determined.

scholarly journals 2424. Shedding of Viable Clostridiodes difficile in Patients Admitted to a Medical Intensive Care Unit

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S837-S838
Author(s):  
Vincent B Young ◽  
Micah Keidan ◽  
Rachel D Yelin ◽  
Thelma E Dangana ◽  
Pamela B Bell ◽  
...  
Keyword(s):  
Intensive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Secondary Analysis ◽  
Icu Patients ◽  
Specific Pcr ◽  
Patient Admissions ◽  
Academic Medical ◽  
Healthcare Associated ◽  
Record Review

Abstract Background Hospitalized patients are at risk of colonization with a range of healthcare-associated bacterial pathogens, including C. difficile. In patients admitted to intensive care units (ICUs), in whom C. difficile infection (CDI) is associated with increased morbidity and mortality. To understand the risk for acquisition of C. difficile and development of CDI, we monitored ICU patients daily for shedding of C. difficile by culture. Methods We conducted a secondary analysis of daily rectal/fecal swab samples collected from medical ICU patients of a 720-bed academic medical center in Chicago, IL. Selective culture for C. difficile was performed on swab samples from patients who had 2 or more samples obtained using selective media. Confirmation of putative C. difficile isolates was done by specific PCR assays for the 16S rRNA-encoding gene and the toxin genes tcdA, tcdB, cdtA and cdtB. Clinical testing for CDI was performed using the Xpert® C. difficile PCR assay (Cepheid). Clinical and demographic metadata were collected at bedside and by electronic medical record review. Results Culture was attempted on 2106 swab samples from 451 patients (486 ICU admissions) (Figure 1). A mean of 4.33 samples was obtained from each patient. C. difficile was isolated from 211 (10%) samples from 79 patients (Table 1). The first sample was positive by culture for 48 (9.9%) of patient admissions to the ICU. 31 (6.4%) patients who were initially negative by culture had a subsequent sample from which C. difficile was isolated. Persistence of culture-positivity varied from patient to patient (Figure 2). Of 80 patients who were tested for CDI based on physician suspicion, 12 patients had a positive Cepheid PCR test; 9 had diarrhea and were treated for CDI. Conclusion Surveillance for shedding of C. difficile by daily culture reveals that patients admitted to the ICU can shed the pathogen intermittently without attributable disease. This can be in the form patients who are admitted carrying the organism as well as those who appear to acquire the organism during their stay. It is unclear whether patient or microbiome factors underlie the differences seen in patterns of shedding. Furthermore, intermittent shedding may reflect multiple episodes of exposure to C. difficile spores and asymptomatic shedding without stable colonization. Disclosures All authors: No reported disclosures.

scholarly journals Impact of Changes in Urine Culture Ordering Practice on Antimicrobial Utilization in Intensive Care Units at an Academic Medical Center

2016 ◽  
Vol 37 (4) ◽  
pp. 448-454 ◽  
Author(s):  
Mohamed Sarg ◽  
Greer E. Waldrop ◽  
Mona A. Beier ◽  
Emily L. Heil ◽  
Kerri A. Thom ◽  
...  
Keyword(s):  
Intensive Care ◽  
Urine Culture ◽  
Medical Center ◽  
Academic Medical Center ◽  
Intervention Group ◽  
Antimicrobial Use ◽  
Post Intervention ◽  
Icu Patients ◽  
Antimicrobial Utilization ◽  
Academic Medical

OBJECTIVETo assess antimicrobial utilization before and after a change in urine culture ordering practice in adult intensive care units (ICUs) whereby urine cultures were only performed when pyuria was detected.DESIGNQuasi-experimental studySETTINGA 700-bed academic medical centerPATIENTSPatients admitted to any adult ICUMETHODSAggregate data for all adult ICUs were obtained for population-level antimicrobial use (days of therapy [DOT]), urine cultures performed, and bacteriuria, all measured per 1,000 patient days before the intervention (January–December 2012) and after the intervention (January–December 2013). These data were compared using interrupted time series negative binomial regression. Randomly selected patient charts from the population of adult ICU patients with orders for urine culture in the presence of indwelling or recently removed urinary catheters were reviewed for demographic, clinical, and antimicrobial use characteristics, and pre- and post-intervention data were compared.RESULTSStatistically significant reductions were observed in aggregate monthly rates of urine cultures performed and bacteriuria detected but not in DOT. At the patient level, compared with the pre-intervention group (n=250), in the post-intervention group (n=250), fewer patients started a new antimicrobial therapy based on urine culture results (23% vs 41%, P=.002), but no difference in the mean total DOT was observed.CONCLUSIONA change in urine-culture ordering practice was associated with a decrease in the percentage of patients starting a new antimicrobial therapy based on the index urine-culture order but not in total duration of antimicrobial use in adult ICUs. Other drivers of antimicrobial use in ICU patients need to be evaluated by antimicrobial stewardship teams.Infect. Control Hosp. Epidemiol. 2016;37(4):448–454

The impact of formulary restriction on the relative consumption of carbapenems in intensive care units at an academic medical center

2019 ◽  
Vol 40 (9) ◽  
pp. 1056-1058
Author(s):  
Jacob W. Pierce ◽  
Andrew Kirk ◽  
Kimberly B. Lee ◽  
John D. Markley ◽  
Amy Pakyz ◽  
...  
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
Medical Center ◽  
Academic Medical Center ◽  
Interrupted Time Series ◽  
Interrupted Time Series Analysis ◽  
Surgical Intensive Care ◽  
Academic Medical ◽  
The Impact ◽  
Formulary Restriction

AbstractAntipseudomonal carbapenems are an important target for antimicrobial stewardship programs. We evaluated the impact of formulary restriction and preauthorization on relative carbapenem use for medical and surgical intensive care units at a large, urban academic medical center using interrupted time-series analysis.

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