RESUMEN
BACKGROUND: Standard low-molecular-weight heparin dosing may be suboptimal for venous thromboembolism prophylaxis. We aimed to identify independent predictors of subprophylactic Xa (subXa) levels in trauma patients treated under a novel early chemoprophylaxis algorithm. METHODS: A retrospective analysis of trauma patients from July 2016 to June 2017 who received enoxaparin 40 mg twice daily and had peak Xa levels drawn was performed. Patients were divided into cohorts based on having a subXa (<0.2 IU/mL) or prophylactic (≥0.2 IU/mL) Xa level. RESULTS: In all, 124 patients were included, of which 38 (31%) had subXa levels, and 17 (14%) had Xa levels greater than 0.4 IU/mL. Of the subXa cohort, 35 (92%) had their dosage increased, and the repeat Xa testing that was done in 32 revealed that only 75% reached prophylactic levels. The median time to the initiation of chemoprophylaxis was 21.9 hours (interquartile range [IQR], 11.45-35.07 hours). Patients who were defined as having lower risk of having a complication as a result of bleeding had a shorter time to starting prophylaxis than those at higher risk (18.39 hours [IQR 5.76-26.51 hours] vs. 29.5 hours [IQR 16.23-63.07 hours], p < 0.01).There was no difference in demographics, weight, body mass index, creatinine, creatinine clearance, injury severity score, type of injury, weight-based dose, time to chemoprophylaxis, or bleeding complications between the cohorts. No independent predictors of subXa level were identified on multivariable logistic regression. CONCLUSIONS: A significant number of trauma patients fail to achieve prophylactic Xa levels. Intrinsic factors may prevent adequate prophylaxis even with earlier administration and higher dosing of low-molecular-weight heparin. LEVEL OF EVIDENCE: Therapeutic, level IV.
Asunto(s)
Anticoagulantes/uso terapéutico , Enoxaparina/uso terapéutico , Factor Xa/metabolismo , Tromboembolia Venosa/prevención & control , Heridas y Lesiones/complicaciones , Adulto , Anticoagulantes/administración & dosificación , Enoxaparina/administración & dosificación , Femenino , Hemorragia/etiología , Humanos , Almacenamiento y Recuperación de la Información , Masculino , Persona de Mediana Edad , Factores de Riesgo , Factores de Tiempo , Tromboembolia Venosa/etiologíaRESUMEN
BACKGROUND: We evaluated the role of serial catheter-directed bronchoalveolar lavage (CDBAL) in the diagnosis and management of pneumonia in ventilated surgical intensive care unit patients. METHODS: Intubated surgical intensive care unit patients were prospectively evaluated with serial CDBALs from September 1, 2012, to May 31, 2013. Initial CDBALs were performed if patients developed the following signs of pneumonia: white blood cell count greater than 11 or less than 4, temperature greater than 38.5°C or less than 36°C, qualitative purulent sputum, worsening oxygenation, or new infiltrate on plain chest x-ray. Subsequent CDBALs were performed every 4 days. Pneumonia was diagnosed using a Clinical Pulmonary Infection Score of greater than 6 and CDBAL cultures with greater than or equal to 10 colony-forming units of pathogenic organisms. Patients were also evaluated for sustained (≥48 hours) respiratory deterioration (increased FIO2 or positive end-expiratory pressure) corresponding to the National Healthcare Safety Network definition of ventilator-associated event (VAE). RESULTS: A total of 159 patients were intubated for 5 days or longer, of whom 80 patients were diagnosed with clinical pneumonia. Of these patients, 67 had serial CDBALs performed, and 81 ventilator-associated pneumonias (VAPs) were diagnosed in these patients. Of the patients with VAP, 16 also met the National Healthcare Safety Network criteria for VAE. Patients with VAP that had sustained respiratory deterioration demonstrated resolution of their compromise 60 hours (interquartile range [IQR], 41-107 hours) after starting antibiotics. Of the patients with pneumonia, 66 (81%) had resolution of the pathogenic bacteria in subsequent CDBAL cultures or were extubated within 4 days (IQR, 4-5 days) after starting antibiotics. The duration of antibiotic therapy in this group was 8 days (IQR, 7-9 days). The remaining 15 patients had multiple positive serial CDBAL cultures that isolated the same organism despite antibiotic treatment. The duration of antibiotic therapy was 14 days (IQR, 10-19 days) in these patients. The culture results were used to adjust antibiotic regimens a median of one time (IQR, 1-2 times) in 13 (87%) and two or more times in 6 (40%) of these patients. CONCLUSION: Serial CDBALs help guide antibiotic treatment duration in patients with pneumonia and VAE. Patients with sustained hypoxia or persistent bacterial growth may require prolonged therapy. LEVEL OF EVIDENCE: Diagnostic test, level III. Therapeutic study, level IV.