RESUMEN

OBJECTIVES: Provide a multiorganizational statement to update the statement from a paper in 2000 about critical care pharmacy practice and makes recommendations for future practice. DESIGN: The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting, and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. MAIN RESULTS: There are 82 recommendation statements: forty-four original recommendations and 38 new recommendation statements. Thirty-four recommendations were made for patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations are in the domain of training and education and eight recommendations regarding professional development. CONCLUSIONS: The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.

Asunto(s)

Cuidados Críticos/organización & administración , Enfermedad Crítica , Unidades de Cuidados Intensivos/organización & administración , Servicio de Farmacia en Hospital/organización & administración , Rol Profesional , Humanos , Mejoramiento de la Calidad , Sociedades Médicas , Sociedades Farmacéuticas

RESUMEN

OBJECTIVES: To provide a multiorganizational statement to update recommendations for critical care pharmacy practice and make recommendations for future practice. A position paper outlining critical care pharmacist activities was last published in 2000. Since that time, significant changes in healthcare and critical care have occurred. DESIGN: The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. MAIN RESULTS: There are 82 recommendation statements: 44 original recommendations and 38 new recommendation statements. Thirty-four recommendations represent the domain of patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations were made in the domain of training and education and eight recommendations regarding professional development. CONCLUSIONS: Critical care pharmacists are essential members of the multiprofessional critical care team. The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.

Asunto(s)

Cuidados Críticos/organización & administración , Enfermedad Crítica , Unidades de Cuidados Intensivos/organización & administración , Servicio de Farmacia en Hospital/organización & administración , Rol Profesional , Mejoramiento de la Calidad , Sociedades Médicas , Sociedades Farmacéuticas

RESUMEN

OBJECTIVES: Provide a multiorganizational statement to update the statement from a paper in 2000 about critical care pharmacy practice and make recommendations for future practice. DESIGN: The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-System Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (>66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting, and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. MAIN RESULTS: There are 82 recommendation statements: forty-four original recommendations and 38 new recommendation statements. Thirty-four recommendations were made for patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations are in the domain of training and education and eight recommendations regarding professional development. CONCLUSIONS: The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.

Asunto(s)

Cuidados Críticos , Servicio de Farmacia en Hospital , Enfermedad Crítica , Humanos , Farmacéuticos , Rol Profesional , Mejoramiento de la Calidad

RESUMEN

Ketamine is an anesthetic known globally both for its potent dissociative properties and potential for abuse. More recently, ketamine demonstrates utility in a variety of disease states such as treatment-resistant depression, status asthmaticus, and acute agitation. In addition, ketamine has been shown to demonstrate various effects at different doses, which adds to its pharmacological benefit. As these new indications continue to come to light, it is important to stay current with the dosing for these indications as well as the adverse effects associated with ketamine's use. This review highlights the history and mechanism of ketamine as well as addressing the use of the different dosing ranges of ketamine.

Asunto(s)

Anestésicos Disociativos/administración & dosificación , Relación Dosis-Respuesta a Droga , Servicio de Urgencia en Hospital , Ketamina/administración & dosificación , Humanos

RESUMEN

BACKGROUND: It is standard practice to administer prophylactic antibiotics post lung transplantation. However, no studies have evaluated the impact of culture positivity. The purpose of this study was to evaluate early post-transplant outcomes of culture-positive and culture-negative lung transplant (LT) recipients and the appropriateness of the empiric regimens used. METHODS: Adult patients who received an LT at Emory University Hospital between January 1, 2010 and August 31, 2015 were reviewed and stratified into three groups: (i) culture-positive appropriate empiric treatment, (ii) culture-positive inappropriate empiric treatment, and (iii) culture-negative. Antibiotics were defined as appropriate if bacteria were sensitive to the empiric regimen. The primary endpoint was 30-day mortality. Secondary endpoints included hospital length of stay (LOS), intensive care unit (ICU) LOS, percent neutrophil count in a bronchoalveolar lavage (BAL) sample, presence of airway ischemia, and appropriateness of the empiric antibiotic regimen. RESULTS: Nine, zero, and four patients died within 30 days in the culture-positive appropriate (n = 113), culture-positive inappropriate (n = 5), and culture-negative groups (n = 29) (P = .564) respectively. The median hospital LOS was 19, 16, and 15 days respectively. Median ICU LOS was 6, 5, and 7 respectively. The respective percent neutrophil counts in the BAL fluid were 79, 83, and 65. The presence of airway ischemia was only documented in eight patients, all in the culture-positive appropriate group. CONCLUSION: We did not identify an association between antibiotic appropriateness and 30-day mortality, hospital LOS, or ICU LOS in post-LT recipients.

Asunto(s)

Bacterias/aislamiento & purificación , Líquido del Lavado Bronquioalveolar/microbiología , Trasplante de Pulmón/efectos adversos , Complicaciones Posoperatorias/epidemiología , Infecciones del Sistema Respiratorio/epidemiología , Adolescente , Adulto , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Profilaxis Antibiótica/efectos adversos , Profilaxis Antibiótica/métodos , Bacterias/efectos de los fármacos , Lavado Broncoalveolar/estadística & datos numéricos , Líquido del Lavado Bronquioalveolar/citología , Niño , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Neutrófilos , Periodo Perioperatorio , Complicaciones Posoperatorias/microbiología , Complicaciones Posoperatorias/prevención & control , Infecciones del Sistema Respiratorio/microbiología , Infecciones del Sistema Respiratorio/prevención & control , Estudios Retrospectivos , Factores de Tiempo , Donantes de Tejidos/estadística & datos numéricos , Receptores de Trasplantes/estadística & datos numéricos , Resultado del Tratamiento , Adulto Joven

RESUMEN

BACKGROUND: Methylene blue (MB) has been used to treat refractory hypotension in a variety of settings. AIMS: We sought to determine whether MB improved blood pressure in postcardiopulmonary bypass (CPB) vasoplegic syndrome (VS) in a complex cardiac surgery population. Furthermore, to determine variables that predicted response to MB. SETTING AND DESIGN: This was conducted in a tertiary care medical center; this study was a retrospective cohort study. MATERIALS AND METHODS: Adult cardiac surgery patients who received MB for post-CPB VS over a 2-year period were studied. Mean arterial blood pressure (MAP) and vasopressor doses were compared before and after MB, and logistic regression was used to model which variables predicted response. RESULTS: Eighty-eight patients received MB for post-CPB VS during the study period. MB administration was associated with an 8 mmHg increase in MAP (P = 0.004), and peak response occurred at 2 h. Variables that were associated with a positive drug response were deep hypothermic circulatory arrest during surgery and higher MAP at the time of drug administration (P = 0.006 and 0.02). A positive response had no correlation with in-hospital mortality (P = 0.09). CONCLUSIONS: MB modestly increases MAP in cardiac surgery patients with VS. Higher MAP at the time of drug administration and surgery with deep hypothermic circulatory arrest predict a greater drug response.

Asunto(s)

Puente Cardiopulmonar , Inhibidores Enzimáticos/uso terapéutico , Azul de Metileno/uso terapéutico , Complicaciones Posoperatorias/tratamiento farmacológico , Vasoplejía/tratamiento farmacológico , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndrome , Resultado del Tratamiento

RESUMEN

PURPOSE: The need for venous thromboembolism prophylaxis is well accepted in the intensive care unit (ICU) and supported by a variety of guideline recommendations. Several studies have highlighted poor adherence to these recommendations, but it is unknown why this discrepancy exists. The aim of this study is assess the prevalence of pharmacoprophylaxis and characterize the practice of withholding prophylaxis. MATERIALS AND METHODS: Multicenter, cross-sectional study conducted in adults admitted to a Georgia ICU at participating institutions on March 12, 2014. Data were collected on eligible patients regarding need for and omission of pharmacoprophylaxis. RESULTS: Three hundred sixty-four patients across 9 institutions were included in the study. Patients had a mean age of 58 years and a median Sequential Organ Failure Assessment score of 5. Physical activity was completely bedridden or restricted in 87% of the cohort. Forty-five percent of patients were not receiving pharmacoprophylaxis. The most common reasons for withholding prophylaxis were receipt of mechanical prophylaxis, recent surgery or central nervous system bleed, and thrombocytopenia. Over 16% of the cohort was inappropriately not receiving thromboprophylaxis. Patients with an elevated international normalized ratio had lower odds of receiving prophylaxis (0.2). CONCLUSIONS: Venous thromboembolism prophylaxis is commonly omitted in ICU patients, and reasons for omission vary. An elevated international normalized ratio is associated with withholding of pharmacologic prophylaxis.

Asunto(s)

Anticoagulantes/uso terapéutico , Vías Clínicas , Adhesión a Directriz , Unidades de Cuidados Intensivos/normas , Tromboembolia Venosa/tratamiento farmacológico , Anticoagulantes/administración & dosificación , Cuidados Críticos , Estudios Transversales , Femenino , Georgia , Hospitalización , Humanos , Relación Normalizada Internacional , Masculino , Persona de Mediana Edad , Puntuaciones en la Disfunción de Órganos , Prevalencia , Factores de Riesgo

RESUMEN

Extracorporeal membrane oxygenation (ECMO) is an established therapy in the management of patients with refractory cardiogenic shock or acute respiratory failure. In this report, we describe the rapid development and implementation of an organized ECMO program at a facility that previously provided ad hoc support. The program provides care for patients within the Emory Healthcare system and throughout the Southeastern United States. From September 2014 to February 2015, 16 patients were treated with either venovenous or venoarterial ECMO with a survival to decannulation of 53.3% and survival to intensive care unit discharge of 40%. Of the 16 patients, 10 were transfers from outside facilities of which 2 were remotely cannulated and initiated on ECMO support by our ECMO transport team. Complications included intracerebral hemorrhage, bleeding from other sites, and limb ischemia. The results suggest that a rapidly developed ECMO program can provide safe transport services and provide outcomes similar to those in the existing literature. Key components appear to be an institutional commitment, a physician champion, multidisciplinary leadership, and organized training. Further study is required to determine whether outcomes will continue to improve.

Asunto(s)

Oxigenación por Membrana Extracorpórea , Adulto , Anciano , Oxigenación por Membrana Extracorpórea/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Respiratoria/terapia , Choque Cardiogénico/terapia

RESUMEN

Left ventricular assist devices improve survival prospects in patients with end-stage heart failure; however, infection complicates up to 59% of implantation cases. How many of these infections are caused by multidrug-resistant organisms is unknown. We sought to identify the incidence, risk factors, and outcomes of multidrug-resistant organism infection in patients who have left ventricular assist devices. We retrospectively evaluated the incidence of multidrug-resistant organisms and the independent risk factors associated with them in 57 patients who had permanent left ventricular assist devices implanted at our institution from May 2007 through October 2011. Outcomes included death, transplantation, device explantation, number of subsequent hospital admissions, and number of subsequent admissions related to infection. Infections were categorized in accordance with criteria from the Infectious Diseases Council of the International Society for Heart and Lung Transplantation. Multidrug-resistant organism infections developed in 18 of 57 patients (31.6%)-a high incidence. We found 3 independent risk factors: therapeutic goal (destination therapy vs bridging), P=0.01; body mass index, P=0.04; and exposed velour at driveline exit sites, P=0.004. We found no significant differences in mortality, transplantation, or device explantation rates; however, there was a statistically significant increase in postimplantation hospital admissions in patients with multidrug-resistant organism infection. To our knowledge, this is the first report in the medical literature concerning multidrug-resistant organism infection in patients who have permanent left ventricular assist devices.

Asunto(s)

Bacterias/aislamiento & purificación , Farmacorresistencia Bacteriana Múltiple , Insuficiencia Cardíaca/terapia , Corazón Auxiliar/efectos adversos , Infecciones Relacionadas con Prótesis/microbiología , Función Ventricular Izquierda , Adulto , Anciano , Antibacterianos/uso terapéutico , Bacterias/efectos de los fármacos , Índice de Masa Corporal , Remoción de Dispositivos , Femenino , Georgia/epidemiología , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Readmisión del Paciente , Diseño de Prótesis , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/mortalidad , Infecciones Relacionadas con Prótesis/terapia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

Pulmonary embolism can present with a wide range of symptoms, from asymptomatic to cardiac arrest, making diagnosis challenging. Alteplase is a fibrinolytic that is indicated for the treatment of pulmonary embolism in intermediate- and high-risk patients. Controversy exists as to the patient population that will benefit most from fibrinolytic therapy, as well as the proper dose and administration technique. The patient's risk of bleeding should be weighed against the potential benefits of treatment in light of the clinical presentation because of the high mortality rate associated with pulmonary embolism. Nurses at the bedside must monitor for signs of bleeding when alteplase is administered. Fibrinolytic therapy will frequently be started in the emergency department, and the nurse must ensure that alteplase is administered in a safe and effective manner. This review discusses the clinical evidence for alteplase in pulmonary embolism and its specific role in treatment.

Asunto(s)

Fibrinolíticos/uso terapéutico , Embolia Pulmonar/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Servicio de Urgencia en Hospital , Humanos

RESUMEN

Ketamine is a unique anesthetic drug that provides analgesia, hypnosis, and amnesia with minimal respiratory and cardiovascular depression. Because of its sympathomimetic properties it would seem to be an excellent choice for patients with depressed ventricular function in cardiac surgery. However, its use has not gained widespread acceptance in adult cardiac surgery patients, perhaps due to its perceived negative psychotropic effects. Despite this limitation, it is receiving renewed interest in the United States as a sedative and analgesic drug for critically ill-patients. In this manuscript, the authors provide an evidence-based clinical review of ketamine use in cardiac surgery patients for intensive care physicians, cardio-thoracic anesthesiologists, and cardio-thoracic surgeons. All MEDLINE indexed clinical trials performed during the last 20 years in adult cardiac surgery patients were included in the review.

Asunto(s)

Analgésicos , Procedimientos Quirúrgicos Cardíacos , Cuidados Críticos/métodos , Medicina Basada en la Evidencia/métodos , Ketamina , Adulto , Humanos , Unidades de Cuidados Intensivos

RESUMEN

OBJECTIVE: It was hypothesized that preoperative hyponatremia is associated with increased 30-day mortality after left ventricular assist device placement, and that large increases in sodium concentration are associated with adverse neurologic events and 30-day mortality. DESIGN: Data were collected retrospectively on all patients having continuous flow left ventricular assist device implantation between January 1, 2009 and March 31, 2013. Preoperative variables, operative variables, and perioperative sodium concentrations were recorded. Both 30-day mortality and 72-hour adverse neurologic events (stroke or seizure) were recorded as primary outcome variables. Preoperative sodium and Δ sodium (postoperative sodium-preoperative sodium) were analyzed as tests for 30-day mortality and adverse neurologic events using receiver operating characteristic curves. Both crude and adjusted logistic regression analyses were used to estimate odds ratios for the outcome variables. SETTING: Tertiary care academic medical center. PARTICIPANTS: Patients having durable continuous flow left ventricular assist device placement. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 88 patients, 30-day mortality was 14% (12 of 88) and the rate of perioperative stroke or seizure was 9% (8 of 88). There were 3 strokes and 5 tonic-clonic seizures. Preoperative sodium was a poor discriminative test for 30-day mortality and stroke or seizure (AUC=0.47 and 0.57, respectively). Δ sodium was a poor discriminative test for 30-day mortality, but a fair discriminative test for stroke or seizure (AUC=0.55 and 0.78, respectively). Δ sodium was a good discriminative test for seizure alone (AUC=0.82) and a fair discriminative test for stroke alone (AUC=0.70). It also increased the odds of stroke or seizure significantly, even when adjusting for possible confounders. CONCLUSIONS: Moderate-to-large increases in sodium concentration during left ventricular assist device placement appear to be associated with adverse postoperative neurologic events. Preoperative hyponatremia has no relationship with 30-day mortality or adverse perioperative neurologic events.

Asunto(s)

Corazón Auxiliar/efectos adversos , Enfermedades del Sistema Nervioso/sangre , Atención Perioperativa/métodos , Complicaciones Posoperatorias/sangre , Sodio/sangre , Adulto , Anciano , Biomarcadores/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/diagnóstico , Enfermedades del Sistema Nervioso/epidemiología , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

Advanced experiential education represents the culmination of a pharmacy student's training, where students can apply the knowledge they have learned in the classroom to real patients. Unfortunately, opportunities for students to provide the direct patient care recommended by pharmacy organizations and accrediting bodies are lacking. Additionally, academic health systems that can provide these experiences for students are experiencing hardships that have stalled the expansion of postgraduate training programs and services. Formal cooperation between unaffiliated colleges of pharmacies and academic health systems has the potential to increase the number of experiential students completing rotations in an academic environment, expand postgraduate education training programs, enhance the development of resident educators, increase research and scholarly opportunities, and expand clinical pharmacy services. This article describes the formation of a unique joint initiative between a private academic health system without a college of pharmacy and a private college of pharmacy without a hospital. The successful cultivation of the relationship has resulted in professional growth at both institutions and can be implemented at other sites around the country to synergize the efforts of academic health systems and colleges of pharmacy.

Asunto(s)

Entrevistas como Asunto/métodos , Selección de Personal , Residencias en Farmacia/métodos , Criterios de Admisión Escolar , Femenino , Humanos , Masculino

RESUMEN

Implantation of left ventricular assist devices (LVADs) is becoming more common with the advancement of mechanical circulatory support technology and the continued insufficient number of organ donors available for heart transplantation. Modern LVADs provide a mechanically induced, nonpulsatile, continuous blood flow that drastically alters the hemodynamic and coagulation profile of patients using these devices. In addition to the risk of bleeding and thrombotic events, LVAD support can also lead to arrhythmias and infection. Although LVAD therapy can prolong life, the majority of patients will experience an adverse event following implantation and many of these complications can result in emergency department visits. By understanding the pathophysiology and management of LVAD complications, emergency nurses will be able to provide prompt and quality care for this unique patient population.

Asunto(s)

Anticoagulantes/administración & dosificación , Enfermería de Urgencia , Corazón Auxiliar/efectos adversos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Educación Continua en Enfermería , Humanos

RESUMEN

OBJECTIVE: To report the pharmacokinetic and pharmacodynamic properties of vancomycin in 4 patients undergoing high-volume continuous venovenous hemofiltration (CVVH). CASE SUMMARY: Data from 4 patients prescribed high-volume CVVH for acute renal failure treated with vancomycin were analyzed. Vancomycin plasma concentrations were measured 4 and 24 hours after the end of a 1-hour vancomycin infusion. The mean therapy fluid rate on initiation of vancomycin was 56.2 mL/kg/h (range 48.0-65.5). The mean loading dose of vancomycin was 18.3 mg/kg (range 14.7-19.7). Median vancomycin concentration 4 hours after the dose was 18.1 mg/L (range 13.1-30.0). At 24 hours after the dose, only 1 patient had a detectable vancomycin concentration (5.2 mg/L). DISCUSSION: There was a large variability in the clearance of vancomycin in this patient population. Current strategies for dosing vancomycin may lead to subtherapeutic trough concentrations. Vancomycin dosing in this patient population should be based on a detailed assessment of the CVVH prescription, vancomycin concentrations, and clinical needs and response. CONCLUSIONS: An initial vancomycin dose of 20-25 mg/kg with frequent monitoring and adjustment is recommended for patients receiving high-volume CVVH.

Asunto(s)

Antibacterianos/farmacocinética , Vancomicina/farmacocinética , Lesión Renal Aguda/sangre , Lesión Renal Aguda/terapia , Adulto , Anciano , Antibacterianos/administración & dosificación , Antibacterianos/sangre , Femenino , Hemofiltración , Humanos , Masculino , Persona de Mediana Edad , Vancomicina/administración & dosificación , Vancomicina/sangre

RESUMEN

STUDY OBJECTIVE: To assess the correlation between the chromogenic factor X assay and the international normalized ratio (INR) in patients transitioning from argatroban to warfarin therapy. DESIGN: Retrospective medical record review. SETTING: Academic medical center and community-based teaching hospital. PATIENTS: One hundred thirty-nine patients who had chromogenic factor X levels measured during the transition from argatroban to warfarin therapy between January 1, 2006, and July 31, 2010. MEASUREMENTS AND MAIN RESULTS: The correlation between chromogenic factor X levels and INRs during the transition period was assessed by calculating the sensitivity, specificity, positive predictive value, and negative predictive value for chromogenic factor X levels that were less than or equal to 45% in predicting a therapeutic INR (2.0-3.5). Patients received an average of 4.4 doses of warfarin before argatroban was discontinued. In 60 patients (43.2%), chromogenic factor X levels were subtherapeutic at the time of argatroban discontinuation. Chromogenic factor X levels could predict a therapeutic INR with a sensitivity of 63.2%, a specificity of 80%, a positive predictive value of 93.5, and a negative predictive value of 32.3. In patients who received 5 or more days of warfarin overlap with argatroban, the sensitivity of chromogenic factor X levels to predict an INR greater than 2.0 was 78.2%, with a specificity of 77.8%, a positive predictive value of 95.6, and a negative predictive value of 36.8. The correlation of chromogenic factor X levels and a therapeutic INR was 18.1%; however, this poor correlation may have been due to increases in the INR values of the patients who received less than 5 days of warfarin overlap with argatroban. During the transition period, nine patients developed thrombi and eight patients experienced clinically significant bleeding. CONCLUSION: Measuring chromogenic factor X levels is recommended before transitioning patients from argatroban to warfarin therapy. Patients should receive at least 5 days of overlap with warfarin and have a chromogenic factor X level of 45% or less before discontinuing argatroban.

Asunto(s)

Anticoagulantes/administración & dosificación , Coagulación Sanguínea/efectos de los fármacos , Factor X/análisis , Relación Normalizada Internacional , Ácidos Pipecólicos/administración & dosificación , Warfarina/administración & dosificación , Centros Médicos Académicos , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Arginina/análogos & derivados , Compuestos Cromogénicos , Bases de Datos Factuales , Esquema de Medicación , Registros Electrónicos de Salud , Hospitales de Enseñanza , Humanos , Masculino , Persona de Mediana Edad , Ácidos Pipecólicos/efectos adversos , Ácidos Pipecólicos/uso terapéutico , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sensibilidad y Especificidad , Sulfonamidas , Warfarina/efectos adversos , Warfarina/uso terapéutico

RESUMEN

OBJECTIVE: Patients recovering from cardiothoracic surgery are known to be at increased risk of heparin-induced thrombocytopenia. Postoperatively, if heparin-induced thrombocytopenia is suspected, heparin is discontinued immediately and an alternative anticoagulant, such as the direct thrombin inhibitor argatroban, is administered. Current data regarding the safety and efficacy of argatroban in the postoperative cardiothoracic surgical patient in the intensive care setting are limited. METHODS: Data were collected retrospectively from January 1, 2007, to December 31, 2010, from patients tested for antiplatelet factor 4/heparin antibodies on clinical suspicion of heparin-induced thrombocytopenia after cardiothoracic surgery. We evaluated the use of argatroban as a therapeutic agent for the postoperative treatment of suspected heparin-induced thrombocytopenia by comparing thrombotic and bleeding events, platelet dynamics, antiplatelet factor 4/heparin antibody titer, and clinical probability score between patients who did and did not receive argatroban. RESULTS: Eighty-seven patients were included; 47 patients (54%) were treated with argatroban, and 40 patients (46%) were not treated with argatroban. There was no association between argatroban therapy and bleeding, mortality, length of stay, or pretreatment thrombotic events. Among all patients, antiplatelet factor 4/heparin antibody titer and clinical probability score were higher in patients treated with argatroban. CONCLUSIONS: Clinical suspicion of heparin-induced thrombocytopenia as detected by clinical probability score and thrombotic complications should prompt immediate cessation of heparin and initiation of an alternative anticoagulant such as argatroban. The results from this study demonstrate that argatroban should be considered without increased risk for adverse events, including bleeding, in the cardiothoracic intensive care unit after surgery.

Asunto(s)

Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Procedimientos Quirúrgicos Cardíacos , Heparina/efectos adversos , Unidades de Cuidados Intensivos , Ácidos Pipecólicos/administración & dosificación , Procedimientos Quirúrgicos Torácicos , Trombocitopenia/prevención & control , Anticuerpos/sangre , Anticoagulantes/inmunología , Arginina/análogos & derivados , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Sustitución de Medicamentos , Georgia , Hemorragia/inducido químicamente , Heparina/inmunología , Humanos , Ácidos Pipecólicos/efectos adversos , Factor Plaquetario 4/inmunología , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Sulfonamidas , Procedimientos Quirúrgicos Torácicos/efectos adversos , Trombocitopenia/inducido químicamente , Trombocitopenia/diagnóstico , Trombocitopenia/inmunología , Trombosis/inducido químicamente , Trombosis/inmunología , Trombosis/prevención & control , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

Severe hypertension is a frequent condition among patients presenting to emergency departments. Historically, this has been referred to as a hypertensive crisis. In addition, these hypertensive crises have been further divided into either hypertensive emergencies or urgencies depending on the presence or absence of target organ damage, respectively. The management differs between these crises in both the rapidity of blood pressure correction and the medications used. Hypertensive emergencies must be treated immediately with intravenous antihypertensive medications. However, hypertensive urgencies may be treated with oral antihypertensive agents to reduce the blood pressure to baseline or normal over a period of 24-48 hr. Appropriate identification, evaluation, and treatment of these conditions are of great importance in the emergency department to prevent progression of organ damage and death. The purpose of this article is to provide an overview of the hypertensive crises and their management.

Asunto(s)

Servicio de Urgencia en Hospital/organización & administración , Hipertensión/fisiopatología , Hipertensión/terapia , Antihipertensivos/uso terapéutico , Humanos , Hipertensión/tratamiento farmacológico