Insulin via continuous intravenous infusion (ICII) is a standard of care for treating patients with diabetic ketoacidosis (DKA). Once DKA is resolved, ICII is transitioned to subcutaneous therapy. However, recent guidelines recommend continuation of home dose subcutaneous basal insulin (HDBI) in patients with DKA. The objective of this study was to evaluate outcomes in patients who received early vs delayed HDBI.This is a retrospective cohort study of patients ≥16 years old admitted to the medical intensive care unit between 1 July 2012 and 30 June 2015 with a primary diagnosis of DKA who received ICII and HDBI. Patients were stratified into early or delayed groups if they received HDBI before or after resolution of DKA, respectively. The primary outcome was incidence of transitional failure, defined as resumption of ICII or recurrence of DKA after initial ICII discontinuation.A total of 106 admissions were included for analysis; 33 (31.1%) received early HDBI. The incidence of transitional failure was similar between the early and delayed groups (OR, 0.60; 95% CI, 0.26 to 1.44; P = 0.72). In the early group, ICII duration was shorter at 13.8 hours [interquartile range (IQR), 10.1 to 16.5] vs 17.1 hours (IQR, 12.6 to 21.1; P = 0.04), with a trend toward lower rates of hypoglycemia (OR, 0.41; 95% CI, 0.16 to 1.05; P = 0.058).There was no significant difference in incidence of transitional failure between early and delayed HDBI. Early HDBI was associated with a shorter duration of ICII and a trend toward less hypoglycemia. A prospective analysis is needed to confirm these findings.
Background: Both parametric and nonparametric methods have been proposed to support model-informed precision dosing (MIPD). However, which approach leads to better models remains uncertain. Using open-source software, these 2 statistical approaches for model development were compared using the pharmacokinetics of vancomycin in a challenging subpopulation of class 3 obesity. Methods: Patients on vancomycin at the University of Vermont Medical Center from November 1, 2021, to February 14, 2023, were entered into the MIPD software. The inclusion criteria were body mass index (BMI) of at least 40 kg/m 2 and 1 or more vancomycin levels. A parametric model was created using nlmixr2/NONMEM, and a nonparametric model was created using Pmetrics. Then, a priori and a posteriori predictions were evaluated using the normalized root mean squared error (nRMSE) for precision and the mean percentage error (MPE) for bias. The parametric model was evaluated in a simulated MIPD context using an external validation dataset. Results: In total, 83 patients were included in the model development, with a median age of 56.6 years (range: 24–89 years), and a median BMI of 46.3 kg/m 2 (range: 40–70.3 kg/m 2 ). Both parametric and nonparametric models were 2-compartmental, with creatinine clearance and fat-free mass as covariates to clearance and volume parameters, respectively. The a priori MPE and nRMSE for the parametric versus nonparametric models were −6.3% versus 2.69% and 27.2% versus 30.7%, respectively. The a posteriori MPE and RMSE were 0.16% and 0.84%, and 13.8% and 13.1%. The parametric model matched or outperformed previously published models on an external validation dataset (n = 576 patients). Conclusions: Minimal differences were found in the model structure and predictive error between the parametric and nonparametric approaches for modeling vancomycin class 3 obesity. However, the parametric model outperformed several other models, suggesting that institution-specific models may improve pharmacokinetics management.
Introduction: This study aims to describe the clinical success and duration of antimicrobial therapy in patients with inferior vena cava (IVC) filters who develop a blood stream infection (BSI). Hypothesis: BSI could be treated with antimicrobial therapy alone without the need for filter removal. Methods: An 11-year retrospective, cohort study was conducted at our institution on all patients 18 years and older with BSI complicated by IVC filter presence. Patients were identified by ICD-9 codes (IVC filter placement, sepsis or BSI). Patients were excluded if they were neutropenic, pregnant, developed BSI before filter placement, if BSI was deemed a contaminant by the attending provider, or if blood cultures were negative. A medical record review was completed on included patients. Results: There were 1,223 patients who received an IVC filter during the study period; 173 patients were also coded for sepsis or BSI. 69 (39.9%) patients met inclusion criteria. The population was primarily male (68.1%), and mean 53.9 (SD 17.7) years old. The most common reason for admission was trauma (36.2%), followed by gastrointestinal complications (15.9%). The patients received an IVC filter due to contraindications to anticoagulant therapy (63.8%), development of venous thromboembolism despite prophylaxis or treatment (24.6%), or being deemed high risk for pulmonary embolism development (11.6%). The BSI isolates were primarily Staphylococcal species (50.0%), followed by Enterococal species (21.0%) and Enterobacter cloacae (13.0%). The median (IQR) time to BSI development after IVC filter placement was 18.0 days (6.2-73.0). The median (IQR) duration of antimicrobial therapy for all BSI episodes was 13.4 days (9.7-19.0). There were 31 recurrences and only 1 relapse with C. albicans after treatment. There were 115 organisms isolated in 100 separate BSI episodes. No IVC filters were removed as part of BSI treatment. Conclusions: BSI after IVC filter placement was a relatively uncommon occurrence. We found that bacterial BSI could be successfully treated with approximately 14 days of therapy without removing the IVC filter. More studies are needed to define the appropriate treatment course for patients with fungal BSI.
Introduction: Trauma patients often require rapid sequence intubation (RSI) for airway maintenance. Etomidate, an RSI sedative, was previously associated with an increased risk of acute respiratory distress syndrome (ARDS) in an urban trauma population. Methods: A retrospective, observational study of adult trauma patients admitted from 6/2009 to 12/2012 who received RSI and were maintained on mechanical ventilation (MV) for at least 48 hours was conducted. Patients placed on comfort measures, received CPR in the field, had cardiogenic shock, or used steroids chronically were excluded. Patients were identified using an in-hospital trauma database and grouped based on whether they received etomidate (etomidate) or any other sedative (other) for RSI. Patient characteristics and ALI/ARDS risk factors were collected through medical record review. One intensivist and one anesthesiologist, blinded to group, reviewed chest radiographs to assess for findings consistent with ALI/ARDS, in concordance with the American-European Consensus Conference definition. The primary outcome was the development of ALI within 48 hours of intubation when comparing etomidate with other for RSI. Secondary outcomes included development of ARDS, MV duration, and ICU and hospital length of stay. Results: During the study period, 192 patients met inclusion criteria, and 108 (56.2%) received etomidate for RSI, while 84 (43.8%) received other. The emergency department Glasgow Coma Scale score was lower in the etomidate group (8.4 vs 10.5, p=0.004), otherwise patients had similar characteristics. No differences were noted in risk factors for development of ALI including blood products, initial tidal volumes used, or 48-hour fluid resuscitation between groups. Development of ALI (11.1% vs 20.2%, p=0.106) and ARDS (10.1% vs 15.5%, p=0.210) were similar between etomidate and other, respectively. No significant differences in secondary outcomes were noted. Conclusions: Etomidate use in a rural trauma population did not appear to be associated with an increased incidence of ALI or other outcomes.
Topical vancomycin may be an effective intervention to decrease the risk of postoperative surgical site infections (SSIs). The primary objective of this study was to evaluate the impact of topical vancomycin with intravenous (IV) cefazolin compared with IV cefazolin alone on the incidence of SSI in instrumented multilevel spinal fusion (MLSF) surgery.This was a retrospective cohort study of patients 18 years and older who underwent instrumented MLSF surgery between January 1, 2010, and July 31, 2014. Patients who underwent anterior cervical diskectomy and fusion, had spine surgery within 3 months prior to index case, received antibiotics other than IV cefazolin prior to surgery, or had preoperative length of stay longer than 5 days were excluded. SSIs were identified using Centers for Disease Control and Prevention National Healthcare Safety Network definitions. Summary statistics were computed. Variables found to be associated with increased risk of SSI through univariate analysis were included in a multivariate analysis.Among 326 patients, 29 (8.9%) developed an SSI. Univariate analysis showed a trend toward decreased SSI incidence in the cohort receiving topical vancomycin with IV cefazolin compared with IV cefazolin alone, although this was not statistically significant ([6/116] 5.2% vs [23/210] 11.0%, p = 0.08). Topical vancomycin was associated with a protective effect against SSI in the multivariate analysis (odds ratio [OR] 0.26, p = 0.02). Significant risk factors for the development of SSI included female sex (OR 3.3, p = 0.01), increasing invasiveness score (p < 0.01), and diabetes mellitus (OR 5.1, p < 0.01).Topical vancomycin administered in addition to IV cefazolin was associated with a decreased risk of SSI in high-risk MLSF patients. Female patients and those with diabetes mellitus were at higher risk of developing postsurgical infection. Further prospective studies are needed to confirm these results and to define the most clinically effective dose of topical vancomycin in this patient population.
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