Category: Pharmacology & Therapeutics
Keywords: Milrinone, dobutamine, insulin, pumps (PubMed Search)
Posted: 5/4/2019 by Ashley Martinelli
(Updated: 8/14/2024)
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Continuous home infusion therapies of medications such as insulin, milrinone, dobutamine, and pulmonary hypertension medication such as treprostinil are becoming more common. As a result, you may see these patients present to the emergency room and need to know the basics for checking the pump.
These questions are very important to determine if you will need to order a replacement infusion bag and run it on a hospital infusion pump, or if the patient can safely remain on their pump during the initial medical evaluation.
Category: Pharmacology & Therapeutics
Keywords: bleeding, epistaxis, tranexamic acid (PubMed Search)
Posted: 3/2/2019 by Ashley Martinelli
(Updated: 8/14/2024)
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Mechanism of Action | Tranexamic Acid (TXA) is an antifibrinolytic agent that is a competitive inhibitor of plasminogen activation, and a non-competitive inhibitor of plasmin Inhibits the breakdown of fibrin mesh allowing clot formation
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When is it Indicated? | Epistaxis/Oral Bleeds/Fistula Bleeds
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Trauma
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Adverse Reactions |
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Category: Pharmacology & Therapeutics
Keywords: hypoglycemia, hyperkalemia (PubMed Search)
Posted: 2/2/2019 by Ashley Martinelli
(Updated: 8/14/2024)
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Scott NL, Klein LR, Cales E, Driver BE. Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department. Am J Emerg Med. 2019;37(2):209-213.
Category: Pharmacology & Therapeutics
Keywords: naloxone, overdose (PubMed Search)
Posted: 12/3/2018 by Ashley Martinelli
(Updated: 8/14/2024)
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Providing naloxone to patients at risk for opioid overdose is now standard of care. A retrospective study evaluated the rate of naloxone obtainment after standardizing the process for prescribing naloxone in the emergency department and dispensing from the hospital outpatient pharmacy.
55 patients were prescribed naloxone. Demographics: mean age 48 years old, 75% male, 40% primary diagnosis of heroin diagnosis, 45.5% were prescribed other prescriptions.
Outcomes:
Barriers identified included lack of ED dispensing program, cost of medication, even though cost is minimal and can be waived, and likely multifactorial reasons why patients did not present to pharmacy as instructed.
Take Home Points:
Verdier M, Routsolias JC, Aks SE. Naloxone prescriptions from the emergency department: An initiative in evolution. Am J Emerg Med. 2018;37(1)164-165.
Category: Pharmacology & Therapeutics
Keywords: Clonidine, opioid withdrawal (PubMed Search)
Posted: 10/6/2018 by Ashley Martinelli
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Clonidine is an alpha-2 agonist commonly used to treat hypertension. Clonidine can also be used to mitigate symptoms of opioid withdrawal as it easily crosses the blood brain barrier and reduces sympathetic effects.
When using clonidine for acute withdrawal or blood pressure control, oral tablets are the preferred route. Clonidine transdermal patches have slow absorption and take 2-3 days for the effect to be seen. Once removed, clonidine patches can provide therapeutic levels for up to 20 hours.
Bottom Line: If clonidine is needed acutely for your patient, select oral tablets and titrate to effect.
Catapres-TTS [package insert] Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT, August 2016.
Category: Infectious Disease
Keywords: clostridium difficile, antibiotics, vancomycin (PubMed Search)
Posted: 8/4/2018 by Ashley Martinelli
(Updated: 8/14/2024)
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Clinical Definition | Treatment | |
Initial episode, non-severe | WBC ≤ 15,000 AND SCr <1.5 |
If above agents unavailable, metronidazole PO 500mg 3x daily
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Initial episode, severe | WBC ≥ 15,000 OR SCr >1.5 |
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Initial episode, fulminant | Hypotension, shock, ileus, megacolon |
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First Recurrence |
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McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66(7):e1-e48.
PMID: 29562266
Category: Pharmacology & Therapeutics
Keywords: steroids, infection, leukocytosis (PubMed Search)
Posted: 6/2/2018 by Ashley Martinelli
(Updated: 8/14/2024)
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Steroids induce leukocytosis through the release of cells from bone marrow and the inhibition of neutrophil apoptosis. This effect typically occurs within the first two weeks of steroid treatment.
Leukocyte elevation is commonly used in the diagnosis of septic patients; however, this can be hard to discern in patients on concomitant steroid therapy.
A retrospective cohort study of adult patients presenting with fevers and a diagnosis of pneumonia, urinary tract infection, bacteremia, cellulitis, or COPD exacerbation was conducted to determine the maximal level of WBC within the first 24h of admission between patients on acute, chronic, or no steroid treatment.
Results: maximal WBC levels (p< 0.001)
· Acute steroid therapy: 15.4 ± 8.3 x 10 9/L
· Chronic steroid therapy: 14.9 ± 7.4 x 10 9/L
· No steroid therapy: 12.9 ± 6.4 x 10 9/L
An increase in WBC of 5 x 10 9/L can be found in acute and chronic steroid use when presenting with an acute infection and fever.
Frenkel A, Kachko E, Cohen K, Novak V, Maimon N. Estimations of a degree of steroid inducted leukocytosis in patients with acute infections. Am J Emerg Med. 2018;36(5):749-753.
Category: Critical Care
Keywords: sepsis (PubMed Search)
Posted: 3/31/2018 by Ashley Martinelli
(Updated: 8/14/2024)
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Bottom Line: Implement sepsis protocols as soon as sepsis is suspected prior to the end of the 3 hour treatment window.
Category: Infectious Disease
Keywords: sepsis, pseudomonas (PubMed Search)
Posted: 2/3/2018 by Ashley Martinelli
(Updated: 8/14/2024)
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Debating between cefepime or piperacillin/tazobactam for your septic patient? Use this table to help you decide.
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| Cefepime | Piperacillin/Tazobactam |
Gram Negative Spectrum | Pseudomonas aeruginosa | Yes | Yes |
Aerobic gram negative organisms | E. coli Klebsiella sp. Proteus mirabilis M catarrhalis H. influenza | E. coli Klebsiella sp. Proteus mirabilis M. catarrhalis H. influenza | |
Anerobic gram negative organisms | No | B. fragilis
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Gram Positive Spectrum | MRSA | No | No |
Aerobic gram positive organisms | MSSA CoNS Group A Strep S. pneumoniae
| MSSA CoNS Group A Strep S. pneumoniae E. faecalis | |
Anaerobic gram positive organisms | P. acnes Peptostreptococci | P. acnes Peptostreptococci Clostridium sp. | |
Infection Site Concerns | CNS Penetration | Yes | No1 |
Urine Penetration | Yes | Yes | |
Lung Penetration | Yes | Low2 | |
Dosing Frequency (Normal Renal Function) | Q8h | Q6h |
1. Tazobactam CNS penetration is limited, thus limiting antipseudomonal activity in the CNS
2. Low pulmonary penetration, may not achieve therapeutic levels in patients with critical illness
Take home points:
-Piperacillin/tazobactam differs in spectrum with its ability to cover enterococcus and anaerobes. Consider for sepsis with gastrointestinal source
-Cefepime can be used for CNS infections and readily achieves therapeutic concentrations in the lungs. Metronidazole can be added to ensure anaerobic organism coverage.
-Piperacillin/tazobactam should be dosed every 6 hours in patients with normal renal function to achieve therapeutic concentration.
1. Gilbert, D. N., Chambers, H. F., Eliopoulos, G. M., Saag, M. S., & Pavia, A. T. (2016). Sanford guide to antimicrobial therapy 2016. 46th edition. Sperryville, VA, USA: Antimicrobial Therapy, Inc.
2. Nau R, Kinzig-Schippers M, Sörgel F, et al. Kinetics of piperacillin and tazobactam in ventricular cerebrospinal fluid of hydrocephalic patients.?Antimicrobial Agents and Chemotherapy. 1997;41(5):987-991.
3. Felton T, McCalman K, Malagon I, et al. Pulmonary penetration of piperacillin and tazobactam in critically ill patients. Clinical pharmacology and therapeutics. 2014;96(4):438-448. doi:10.1038/clpt.2014.131.
4. Boselli E, Breilh D, Duflo F, et al. Steady-state plasma and intrapulmonary concentrations of cefepime administered in continuous infusion critically ill patients with severe nosocomial pneumonia. Critical Care Medicine.2003;31:2102-2106.
Category: Infectious Disease
Keywords: c. difficile, antibiotic (PubMed Search)
Posted: 12/2/2017 by Ashley Martinelli
(Emailed: 12/6/2017)
(Updated: 12/6/2017)
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Community-associated Clostridium difficile infection (CA-CDI) represents 41% of all CDI cases annually. The association of specific outpatient exposures was assessed in a case control study by Guh, et al. They reviewed the CDC’s active surveillance reporting from 10 states through the Emerging Infections Program (Maryland participates).
Cases: ≥18, + C. difficile stool specimen collected as an outpatient or within 3 days of hospitalization, with no overnight stay in a health care facility in the prior 12 weeks, and no prior CDI diagnosis
Controls: matched 1:1 for age and sex within the same surveillance catchment area as the case patient on the date of the collection specimen. Exclusion criteria: prior diagnosis of CDI, diarrheal illness, overnight stay in health care facility in the prior 12 weeks
Data Collection: telephone interview, standardized questionnaire or comorbidities, medication use, outpatient health care visits, household and dietary exposures in the prior 12 weeks
Results: 452 participants (226 pairs), over 50% were ≥ 60 years of age, 70.4% female, and 29% were hospitalized within 7 days of diagnosis, no patients developed toxic megacolon or required colectomy.
Cases had more health care exposures, including the emergency department (11.2% vs 1.4% p <0.0001), urgent care (9.9% vs 1.8%, p=0.0003). In addition, cases also reported higher antibiotic exposures (62.2% vs 10.3%, p<0.0001) with statistically significant higher exposure to cephalosporins, clindamycin, fluoroquinolones, metronidazole, and beta-lactam and/or beta-lactamase inhibitor combination. The most common antibiotic indications were ear or sinus infections, URI, SSTI, dental procedure, and UTI. No differences were found in household or dietary exposures.
Take-home point: This study highlighted the risk for CA-CDI infection for patients presenting to an ED and reiterates that exposures to fluoroquinolones, cephalosporins, beta-lactam and/or beta-lactamase inhibitor combinations, and clindamycin significantly increases the risk of CA-CDI infection. Reducing unnecessary outpatient antibiotic prescribing may prevent further CA-CDI. 36% of case patients did not have any antibiotic or outpatient health care exposure; therefore, additional risk factors may exist.
Alice Y Guh, Susan Hocevar Adkins, Qunna Li, Sandra N Bulens, Monica M Farley, Zirka Smith, Stacy M Holzbauer, Tory Whitten, Erin C Phipps, Emily B Hancock, Ghinwa Dumyati, Cathleen Concannon, Marion A Kainer, Brenda Rue, Carol Lyons, Danyel M Olson, Lucy Wilson, Rebecca Perlmutter, Lisa G Winston, Erin Parker, Wendy Bamberg, Zintars G Beldavs, Valerie Ocampo, Maria Karlsson, Dale N Gerding, L Clifford McDonald; Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study, Open Forum Infectious Diseases, Volume 4, Issue 4, 1 October 2017, ofx171, https://doi.org/10.1093/ofid/ofx171
Category: Pharmacology & Therapeutics
Keywords: antipyretic, sepsis, fever (PubMed Search)
Posted: 10/7/2017 by Ashley Martinelli
(Emailed: 10/10/2017)
(Updated: 8/14/2024)
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Fever occurs in 40% of patients with sepsis. Historically, there has been conflicting evidence of whether patient outcomes improve with antipyretic therapy.
A recent large meta-analysis assessed the effect of antipyretic therapy on mortality of critically ill septic patients. The analysis included 8 randomized studies (1,531 patients) and 8 observational studies (17,432 patients) that assessed mortality of septic patients with and without antipyretic therapy.
The authors found no difference in mortality at 28 days or during hospital admission. There was also no difference in shock reversal, heart rate, or minute ventilation.
As expected, they found a statistically significant reduction in posttreatment body temperature (-0.38°C, 95% IC -0.63 to -0.13) in patients who received antipyretic therapy. NSAIDs and cooling therapies were more effective than acetaminophen, however no agent or dosing information was provided and only one study included physical cooling therapies.
Bottom Line: Antipyretic therapies do not reduce mortality in patients with sepsis, but they may improve patient comfort by reducing body temperature.
Drewry AM, et al. Antipyretic therapy in critically ill septic patients: a systematic review and meta-analysis. Crit Care Med 2017;45:806-813.
Category: Gastrointestional
Keywords: Gastroparesis, haloperidol (PubMed Search)
Posted: 8/5/2017 by Ashley Martinelli
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Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements.
In Depth:
Study Design: single-center, retrospective review, case-matched to prior visit for gastroparesis
Patients:
52 patients with previously diagnosed diabetic gastroparesis by gastric motility study who presented to the ED for gastroparesis treatment
Groups:
Haloperidol administered visit
Haloperidol NOT administered visit (most recent visit, >7 days prior to haloperidol visit)
Results:
Baseline characteristics: median age 32 (21-57), 62% (32/52) female
Statistically significant reduction in hospital admissions for the haloperidol visit: (5/52 [10%] [CI 3-21%]) vs the non-haloperidol visit (14/52 [27%] [CI 16-41%]) p=0.02
Statistically significant reduction in opioid administration during the haloperidol visit: 6.75 ME (IQR 7.93) vs 10.75 ME (IQR 12) p=0.009
No difference in ED LOS, hospital LOS or need for additional antiemetics/prokinetics
No dystonic reactions, akathesia, excessive sedation, or cardiovascular complications in patients who received haloperidol
Limitations:
Small, single-center, retrospective study that only included patients with diabetic gastroparesis
Only intramuscular administration was studied
Baseline QT not reported
Young patient population, no description of comorbidities or home medications
Conclusions:
Haloperidol may be considered as an adjunctive therapy in patients with diabetic gastroparesis for its antiemetic and analgesic properties. Prospective studies are necessary to confirm findings.
Ramirez R, Salcup P, Croft B, Darracq MA. Am J Emerg Med 2017;35:1118-1120.