Compliance with guidelines for treating sepsis.
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Aged↗
Biomedical subjects
Jeffrey F Barletta
Publications and source records attributed to Jeffrey F Barletta.
Estimation of creatinine clearance in end-stage liver disease.
BACKGROUND: Estimation of renal function in patients with end-stage liver disease (ESLD) is complicated by several factors. OBJECTIVE: To develop a practical and relatively inexpensive method for estimating creatinine production and clearance in patients with ESLD. METHODS: Serum creatinine concentrations and urinary excretion of creatinine were measured in 27 patients with moderate-to-severe liver disease with the goal of developing equations to predict creatinine clearance from serum creatinine. Subjects were studied during an initial evaluation for a liver transplant program. Two 24 hour urine specimens were collected along with 3 serum samples over a 2 day evaluation period. Serum and urine creatinine concentrations were determined using both a modified Jaffé (autoanalyzer) method and an HPLC method. The data were analyzed using nonlinear mixed-effects modeling. RESULTS: Considering both statistical criteria and physiological conventions through allometric scaling theory, creatinine clearance (mL/min) in males can be estimated as (80/serum creatinine) x (actual body weight/70)0.75. For females, the same equation is valid, but the result is multiplied by 0.661. A simplified equation without the exponent is presented, along with equations that are appropriate when an HPLC assay is used for greater specificity. CONCLUSIONS: These equations offer potential for improved estimation of creatinine clearance in patients with liver impairment; however, they need further validation using an independent group of subjects.
Algorithms↗
Medication errors and patient complications with continuous renal replacement therapy.
Continuous renal replacement therapy (CRRT) is commonly used for renal support in the intensive care unit. While the risk of medication errors in the intensive care unit has been described, errors related specifically to CRRT are unknown. The purpose of this study is to characterize medication errors related to CRRT and compare medication errors that occur with manually compounded solutions versus commercially available solutions. We surveyed three separate internet-based, pediatric list serves that are commonly used for communications for programs utilizing CRRT. Data regarding CRRT practices and medication errors were recorded. Medication errors were graded for degree of severity and compared between programs using manually compounded dialysis solutions versus commercially available dialysis solutions. In a survey with 31 program responses, 18 reported medication errors. Two of the 18 were related to heparin compounding, while 16/18 were due to solution compounding errors. Half of the medication errors were classified as causing harm, two of which were fatal. All medication errors were reported by programs that manually compounded their dialysis solutions. Medication errors related to CRRT are associated with a high degree of severity, including death. Industry-based, commercially available solutions can decrease the occurrence of medication errors due to CRRT.
Child↗
Albumin for fluid resuscitation: implications of the Saline versus Albumin Fluid Evaluation.
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Albumins↗
Effect of low-calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: a randomized, controlled trial.
OBJECTIVE: To determine the effect of a low-calorie parenteral nutrition (PN) regimen on the incidence and severity of hyperglycemia and insulin requirements. DESIGN: Prospective, randomized, clinical trial. SETTING: Urban, university-affiliated, level-I trauma center. PATIENTS: Consecutive surgical patients requiring PN. INTERVENTIONS: Patients were randomized to receive either a low-calorie PN formulation (20 nonprotein kilocalories per kg per day) or a standard PN formulation (30 nonprotein kilocalories per kg per day). Lipid-derived calories were standardized to 1000 kilocalories three times weekly for all patients; consequently, the number of calories varied only by the amount of carbohydrate administered. Protein requirements were individualized on the basis of estimated metabolic stress. Hyperglycemia was defined as a blood glucose level > or = 200 mg/dL. MEASUREMENTS AND MAIN RESULTS: Forty patients were evaluated (low-calorie PN, n = 20; standard PN, n = 20). Demographics of the two groups were similar. The incidence of hyperglycemic events was significantly lower in the low-calorie group (0% [0-0.5] vs. 33.1% [0-58.4]; p = .001]. Additionally, the severity of hyperglycemia was also lower in the low-calorie group (mean glucose area under the curve = 118 +/- 22 [mg x hr]/dL vs. 172 +/- 44 [mg x hr]/dL; p < .001). This resulted in lower average daily insulin requirements (0 [0-0] units vs. 10.9 [0-25.6] units; p < .001.). The only predictor of hyperglycemia was a dextrose administration rate >4 mg/kg/min. CONCLUSIONS: : Administration of a low-calorie PN formulation resulted in fewer and less-severe hyperglycemic events and lower insulin requirements. PN regimens should not exceed a dextrose administration rate of 4 mg/kg/min to avoid hyperglycemic events.
Area Under Curve↗
A review of recombinant factor VII for refractory bleeding in nonhemophilic trauma patients.
BACKGROUND: Recombinant factor VII (rFVII) is an attractive agent to control refractory, coagulopathic bleeding in patients following major surgery. The purpose of this review is to evaluate the published experiences of rFVII in adult, nonhemophilic, surgical and trauma patients. METHODS: A computerized literature search was conducted to identify articles pertaining to rFVII use for refractory bleeding in adult, nonhemophilic, surgical patients. The selected articles were reviewed and the applicable data was analyzed. RESULTS: A total of 117 patients were found in 8 case series and 24 case reports. Overall, rFVII was effective in restoring hemostasis in 99/117 (85%) patients with 76/99 (77%) surviving to hospital discharge. In trauma patients, hemostasis was achieved in 20/26 (77%) patients and 17/20 (85%) survived. There were 5 (4%) thromboembolic events observed in the 117 cases and much disparity was noted with the initial dose. Severe acidosis affected the activity of rFVII. CONCLUSION: Recombinant factor VII is an effective therapeutic agent for achieving hemostasis in nonhemophilic surgical patients. Published clinical experiences, however, are limited to small case series and case reports.
Cost-Benefit Analysis↗
Hypocholesterolemia in sepsis and critically ill or injured patients.
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Animals↗
Bioavailability of gatifloxacin by gastric tube administration with and without concomitant enteral feeding in critically ill patients.
OBJECTIVE: Sequential intravenous-to-oral antimicrobial therapy with highly bioavailable antiinfective agents such as the fluoroquinolones may improve patient safety and decrease cost of infection management. However, physiologic changes associated with critical illness may alter drug absorption, distribution, and clearance, and concomitant enteral feeding may decrease fluoroquinolone bioavailability. We evaluated the effect of critical illness and concomitant gastric tube feeding on gatifloxacin bioavailability. DESIGN: Prospective, randomized, single-dose, two-way crossover, pharmacokinetic study. SETTINGA tertiary, level-one, trauma center. PATIENTS: Sixteen critically ill patients (baseline Acute Physiology and Chronic Health Evaluation II score >or=16) tolerating enteral nutrition administered by gastric tube (NG) for >or=12 hrs were randomized to receive gatifloxacin concurrently with continuous tube feeding or with interrupted tube feeds. Patients with renal insufficiency or those receiving concomitant fluoroquinolone therapy or postpyloric feeding were excluded. Patients received gatifloxacin 400 mg either by the intravenous or NG route followed by the alternative dosage form after a 72-hr washout period. MEASUREMENTS AND MAIN RESULTS: Serial serum gatifloxacin concentrations (from 5 mins to 24 hrs) were analyzed using a validated high-performance liquid chromatography method. Bioavailability was determined as the ratio of NG/intravenous area under the concentration-time curve (AUC infinity ) measured by the trapezoidal method. Although there was no difference in the bioavailability between NG (AUC infinity : 38.0 [range 20.1 to 48.5] microg x h/mL) and intravenous (AUC infinity : 39.5 [range 24.1 to 63.1] microg x h/mL, p =.60) gatifloxacin (bioavailability: 98.5% [range 61.1% to 119.7%]), a wide variability was observed in three of eight patients (>30% reduction in bioavailability). Concomitant gastric tube feeding did not affect gatifloxacin bioavailability (interrupted tube feeds: 98.5% [range 61.1% to 119.7%]; continuous tube feeding: 109.0% [range 86.2% to 142.1%]; p =.42). Neither a period nor differential carryover effect was observed. CONCLUSIONS: Although concomitant tube feeding did not affect gatifloxacin bioavailability, critical illness resulted in significant variability that may complicate the role of gatifloxacin in sequential intravenous-to-oral therapy. More research is needed to identify those patients in whom gatifloxacin bioavailability is reduced and for whom an empirical increase in gatifloxacin dose should be considered.
APACHE↗
Stress ulcer prophylaxis in trauma patients.
INTRODUCTION: A number of issues concerning stress ulcer prophylaxis remain unresolved despite numerous randomized, controlled trials and several meta-analyses. The role of stress ulcer prophylaxis, particularly in trauma patients, is further complicated by the lack of trials utilizing clinically important bleeding as an endpoint. Given the lack of consensus regarding stress ulcer prophylaxis in trauma patients, prescribing practices at Level I trauma centers in the United States were assessed. MATERIALS AND METHODS: A survey was developed that contained questions related to institutional prescribing and evaluation of stress ulcer prophylaxis. The survey was intended to delineate these practices at the 188 Level I trauma centers (at the time of the present survey) in the United States. RESULTS: One hundred and nineteen surveys were returned, yielding a response rate of 63%. Eighty-six percent stated that medications for stress ulcer prophylaxis are used in a vast majority of trauma patients admitted to the intensive care unit. Sixty-five percent stated that there is one preferred medication. For these institutions, histamine-2-blockers were the most popular at 71%. Thirty-nine percent stated that greater than 50% of patients remain on stress ulcer prophylaxis following discharge from the intensive care unit. CONCLUSION: The lack of consensus with regards to appropriate stress ulcer prophylaxis is apparent in this survey of Level I trauma centers. For those institutions with a preferred agent, histamine-2-blockers were most common.
Anti-Ulcer Agents↗
Characteristics of prophylactic antibiotic strategies after penetrating abdominal trauma at a level I urban trauma center: a comparison with the East guidelines.
BACKGROUND: Antibiotic prophylaxis, along with surgical intervention, is a key component in reducing infection in patients after penetrating abdominal trauma (PAT). Recent guidelines from the Eastern Association for the Surgery of Trauma (EAST) recommend that prophylaxis for < or = 24 hours is adequate for most patients. We compared antibiotic prophylaxis practices after PAT at our institution with EAST guidelines, quantified the incidence of infection, and identified risk factors for infection. METHODS: This study was a retrospective review of patients with PAT requiring a therapeutic laparotomy between July 1998 and January 2001. RESULTS: Antibiotic prophylaxis met EAST guidelines criteria in 21 of 97 patients (22%). There was a trend toward higher infection rates (18 of 76 vs. 3 of 21; = 0.273) when prophylaxis exceeded EAST recommendations. Multivariate analysis revealed blood transfusions to be the only predictor of infection (odds ratio, 6.9; 95% confidence interval, 2.42-19.95). CONCLUSION: Despite prophylactic antibiotic use often exceeding EAST criteria, many patients still developed infection. Blood transfusion was the only significant risk factor for infection.
Abdominal Injuries↗
Tachyphylaxis associated with continuous cisatracurium versus pancuronium therapy.
STUDY OBJECTIVES: To compare dosing requirements over time among patients receiving continuous cisatracurium versus pancuronium therapy, and to identify factors that may account for changes in pancuronium versus cisatracurium infusion requirements over time. DESIGN: Retrospective, comparative cohort analysis. SETTING: A tertiary level 1 trauma center. PATIENTS: Forty-five consecutive adult patients who were admitted to intensive care units at our institution from January 1998-August 2000 and received continuous cisatracurium or pancuronium therapy for at least 48 hours. MEASUREMENTS AND MAIN RESULTS: Dosing requirements of patients treated with pancuronium or cisatracurium were recorded over time throughout the treatment period. Factors that could affect dosing requirements of a neuromuscular blocking agent (NMBA) were stratified as time invariant (admitting service, acute physiology and chronic health evaluation II score, duration of mechanical ventilation, pressure control ventilation, baseline hepatic or renal insufficiency, thermal injury, train-of-four assessment, and concurrent drug administration or disorders affecting neuromuscular transmission) or time variant (concurrent sedation and narcotic analgesia therapy; serum magnesium, potassium, and creatinine concentrations; arterial pH level; temperature; peak airway pressure; and partial pressure of oxygen:fraction of inspired oxygen ratio). Hierarchical linear modeling was used to compare the dosing requirements and to identify confounders affecting the relationship. The infusion rate escalation for the cisatracurium group was greater (0.39 microg/kg/min; 95% confidence interval [CI] 0.22-0.56; 23 patients) than for the pancuronium group (-0.06 microg/kg/min; 95% CI -0.24-0.12; 22 patients; p<0.001) and was associated with an average daily cost/patient significantly higher (p<0.001) with cisatracurium ($258+/-$114) than pancuronium ($11+/-$5). Confounder analysis revealed that only the admitting service and the number of times the NMBA infusion was suspended because no twitch was detected differed between groups. Neither of these confounders significantly affected the temporal relationship between cisatracurium and pancuronium infusion rates. CONCLUSION: Dosing requirements increase over time at a significantly greater rate for cisatracurium than pancuronium infusions. Tachyphylaxis with cisatracurium is associated with substantial drug-related costs and is not accounted for by various disease-, patient-, and therapy-related factors. Further investigation is required to elucidate the mechanisms and risk factors underlying this phenomenon.
Adult↗