Background: Broad-spectrum antibiotic agents are utilized for complicated intra-abdominal infection (cIAI); however, the need for empiric methicillin-resistant Staphylococcus aureus (MRSA) coverage is not clear as the incidence of MRSA cIAI is rare. Patients and Methods: A single-center, retrospective, pre- and post-cohort study of adults admitted to the surgical intensive care unit (SICU) with cIAI between March 1, 2021, to May 1, 2023, was conducted. Historically, the SICU utilized vancomycin for all cIAI; however, in April 2022, the preferred regimen was changed to either piperacillin-tazobactam with vancomycin added for patients with MRSA risk factors or for Enterococcus spp. coverage in cefepime- or levofloxacin-based regimens for penicillin-allergic patients. The primary outcome was number of vancomycin days of therapy (DOT) per 1,000 patient days. Categoric and continuous variables were analyzed with chi-square and Fisher exact tests. Results: A total of 142 SICU encounters were included, 64 in the pre-cohort and 78 in the post-cohort. There was no difference in median vancomycin DOT per 1,000 patient days (14 days [interquartile range or IQR 5-21]; 16 days [IQR 8-17] p = 0.522) between the pre- and post-cohort. There was a significant reduction in the number of patients given vancomycin after the protocol change (90.6%; 76.9%, p = 0.042). A significant increase in piperacillin-tazobactam exposure was also observed (48.4%; 82.1%, p < 0.001) in the post-cohort aligning with our institutional practice change. Conclusions: In critically ill surgical patients with cIAI, the implementation of an antimicrobial stewardship guideline did not reduce vancomycin DOT per 1,000 patient days, however, it did result in a significant reduction in vancomycin exposure.

Introduction: Magnesium (mag) deficiency occurs in up to 65% of patients in the intensive care unit and up to 20% of all hospitalized patients. Magnesium replacement dosing varies due to the lack literature. In 2019, our institution switched to a fixed dose of magnesium sulfate intravenous (IV) 4g for all IV doses of magnesium for treatment of hypomagnesemia including ICU and renal impairment patients. Methods: This is a retrospective, single-center, IRB approved study at a large tertiary referral hospital from 1/2018 to 8/2019. Patients were divided into two groups: pre (1/2018–6/2018) & post (1/2019–8/2019) implementation of fixed dose mag protocol. The pre group received an initial mag replacement of 2g IV and the post group received mag IV 4g for hypomagnesemia. Patients were included if they received mag IV 2g or 4g dose (depending on the time period) and excluded for lack of follow-up levels. The primary endpoint was mag level at 48h. Secondary outcomes included incidence of mag toxicity and total grams of mag in a 96 hour period. A subgroup analysis of patients with impaired renal function was conducted. Statistics were performed in SPSS version 28. Results: A total of 2,440 patients were included with 934 in the 2g cohort and 1506 in the 4g cohort. The cohorts were similar with 40% of the patients having a eGFR < 60 mL/min/1.73m2 and 7% with an eGFR < 15 mL/min/1.73m2. The 4g cohort had a statistically significant higher mag level at 48h (1.91 mg/dL vs 1.98 mg/dL, p=0.001), 24h (1.97 mg/dL vs 2.19 mg/dL, p=0.001), 72h (1.90 mg/dL vs 1.98 mg/dL, p=0.001), and 96h (1.88 mg/dL vs 1.96 mg/dL, p=0.001) compared to the 2g cohort. The 2g cohort required significantly more doses of mag vs the 4g cohort (mean doses/patient: 1.97 vs. 1.70, p=0.001), and received fewer grams (mean grams/patient: 3.98g vs 6.44g, p=0.001). No patients in the 2g and one in the 4g cohort had a mag level > 4.5 mg/dL, but did not have any signs of toxicity upon chart review. In the subgroup analysis of renal impairment, there were no differences in mag levels at any time point. Conclusions: Using a fixed dose magnesium IV 4g doses instead of 2g doses led to statistically significant higher levels, but may not be clinically significant. This protocol appears safe for ICU patients, and patients with renal impairment.

Purpose We sought to determine the correlation between the Numeric Rating Scale (NRS) and Critical-Care Pain Observation Tool (CPOT) to determine whether clinical factors modified the relationship between NRS and CPOT assessments. Materials and Methods We included nonventilated adults admitted to the MICU or SICU who could self-report pain and had at least 3 paired NRS and CPOT assessments. We performed Spearman correlation to assess overall correlation and performed proportional odds logistic regression to evaluate whether the relationship between NRS and CPOT assessments was modified by clinical factors. Results Nursing staff performed NRS and CPOT assessments every 4 h in 1302 patients, leading to 61,142 matched assessments. We found that the NRS and CPOT have a Spearman correlation coefficient of 0.56 and an intraclass correlation coefficient of 0.32 in intensive care unit patients. Factors that modified the relationship between the NRS and CPOT included the presence of delirium (P < .001) and lower mean daily Richmond Agitation Sedation Scale (<0.001). Conclusions The correlation coefficient between the NRS and the CPOT was found to be 0.56. The presence of delirium, decreased level of arousal, modified the relationship between the NRS and CPOT. Self-reported and behavioral pain assessments cannot be used interchangeably in critically ill adults.

1Vanderbilt University Medical Center, Brentwood, TN 2Vanderbilt University Medical Center, Nashville, TN

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 605 doi: 10.1097/01.ccm.0000811164.70898.ea

Stollings, Joanna; Rumbaugh, Kelli; Wang, Li; Hayhurst, Christina; Pandharipande, Pratik; Ely, Wes; Hughes, Christopher Author Information

Schmidt, Lauren; Mulherin, Diana; Rumbaugh, Kelli; Weavind, Lisa; Seidner, Douglas Author Information

Mangan, Brendan1; Hamblin, Susan2; Rumbaugh, Kelli1; Dennis, Bradley1 Author Information

IntroductionVasopressin is recommended for management of septic shock refractory to fluid challenge and norepinephrine. Controversy exists over when to add vasopressin to norepinephrine treatment. Due to the rising cost of vasopressin and the lack of mortality benefit, the surgical intensive care unit (SICU) at Vanderbilt University Medical Center implemented a protocol for vasopressin use with the purpose of decreasing utilization and cost.ObjectiveThe purpose of this study was to characterize vasopressin utilization and evaluate adherence to this protocol.MethodsThrough a retrospective, observational analysis, adult patients admitted to the SICU who received vasopressin during the 11 months before and after protocol implementation in August 2015 were identified. The primary outcome was vasopressin usage per patient. Secondary outcomes included norepinephrine use, vasopressin cost, and protocol adherence.ResultsDuring the pre‐ and post‐protocol periods, 144 of 1788 admitted patients (8%) and 119 of 1845 admitted patients (6%) received vasopressin, respectively. The total duration of vasopressin infusion during hospitalization was similar before and after protocol implementation (20 vs 18 hours, P = 0.526), but vasopressin was both added and discontinued when norepinephrine was infusing at a higher rate (added at 12 vs 18 mcg/min, P < 0.001; discontinued at 0.5 vs 6.0 mcg/min, P < 0.001). Norepinephrine was infused for a longer duration post protocol implementation (31 vs 57 hours, P < 0.001). After implementation, a protocol violation occurred in 59 patients (50%); however, 59% of these were related to vasopressin initiation in the operating room. Thirty‐two patients (27%) experienced a SICU‐related violation, with the most common type being discontinuation of norepinephrine prior to vasopressin.ConclusionImplementation of a vasopressin utilization protocol in a SICU resulted in more selective usage of vasopressin and a similar duration of infusion when it was utilized. Protocol adherence was nearly 75%, exposing some opportunities for continued education and improvement.

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

PURPOSE:Persistent elevation of prothrombin time (PT) and International Normalized Ratio (INR) values in a patient receiving daptomycin is reported.SUMMARY:A morbidly obese 51-year-old man was hospitalized for evaluation for surgical intervention for gallstone pancreatitis and biliary obstruction. Previously prescribed warfarin therapy was withheld due to suspected coagulopathy and an elevated INR (5.1), and warfarin reversal was initiated. After undergoing partial cholecystectomy on hospital day 6, the patient developed sepsis and was treated with i.v. meropenem and daptomycin for vancomycin-resistant Enterococcus infection. Warfarin therapy, which had been resumed after cholecystectomy, was again discontinued on hospital day 12. On the eighth day of daptomycin therapy, the INR remained elevated (2.6) even though the patient had no warfarin exposure for 9 days. On hospital day 21, thromboelastography (TEG) indicated normal whole blood coagulation. Other anticoagulation markers normalized, but the INR remained elevated until daptomycin was discontinued. Daptomycin has been shown to falsely prolong the INR when specific laboratory reagents are used for PT and INR testing, but the specific reagent used in this case has not been previously implicated.CONCLUSION:Daptomycin therapy appeared to cause a false and substantial INR elevation in a patient who had been receiving warfarin. Results of TEG suggested that the INR elevation was an artifact of a drug-laboratory interaction and did not represent an anticoagulated state. The patient's INR normalized after linezolid was substituted for daptomycin.

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Background: The optimal duration of antimicrobial therapy for treatment of complicated intra-abdominal infections (cIAI) in critically ill surgical patients is unknown. Recent evidence suggests that a short (four-day) course of therapy may be effective, however data in severely critically ill patients are limited.Patients and Methods: A single-center, retrospective, cohort study was conducted at a tertiary academic medical center. Adult patients admitted to the surgical intensive care unit (SICU) with cIAI between December 2011 and July 2015 were enrolled. Patients undergoing transplantation and those with less than 24 h in the SICU were excluded. Patients were divided into two groups, short (<= 7 d) and long (> 7 d) antimicrobial therapy. The primary outcome was treatment failure, which was defined as a composite of recurrent cIAI, secondary extra-abdominal infection, and/or in-hospital mortality from any cause. Categorical and continuous data were analyzed with chi(2) and Mann-Whitney U tests, respectively. Binary logistic regression was performed to determine factors associated with treatment failure and mortality.Results: Of 1,679 patients screened, 240 were included, 103 in the short and 137 in the long group. Patients in the short and long groups received a median of 5 and 14 d of therapy, respectively (p < 0.001). Treatment failure occurred less frequently with a short duration of therapy (39% versus 63%, p < 0.001) and it occurred two days sooner after source control in patients receiving the shorter courses of antimicrobial therapy (short, median 6 d, interquartile range [IQR] 3-9; long, 8 d, IQR 6-14; p < 0.001). Logistic regression demonstrated that a long duration of therapy was associated with treatment failure (odds ratio [OR] 2.186, 95% confidence interval [CI] 1.251-3.820, p = 0.006), but not with mortality (OR 0.738, 95% CI 0.329-1.655, p = 0.461).Conclusions: In critically ill surgical patients with cIAI, a short duration of antimicrobial therapy after source control resulted in similar outcomes to previously published studies, providing support for the safety of this approach in critically ill patients.

Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Hart, Heather; Wells, Nancy; Rumbaugh, Kelli; Huggins, Elizabeth; Flinn, Sarah; Stollings, Joanna; Pandharipande, Pratik; Ely, Wes

Background:Clostridium difficile causing clinical disease of the small bowel is reported rarely in the literature, but may be increasing in incidence as overall Clostridium difficile infection (CDI) rates increase across the country. Common risk factors that have been reported in the literature for C. difficile enteritis include inflammatory bowel disease (IBD), recent antibiotic use, and gastrointestinal surgery. We report a unique case of C. difficile enteritis involving the small bowel with necrosis and perforation in the absence of common risk factors. Case Presentation: A 57-year-old African American female with no prior surgical history presented with acute abdominal pain with diarrhea and was found to have CDI. On hospital day eight, the patient de-compensated suddenly. She was found to have a small bowel perforation in the proximal jejunum with pathology demonstrating CDI involving the small bowel. Conclusion:Clostridium difficile infection involving the small bowel is being reported increasingly and can lead to perforation, especially in immunocompromised patients. Whereas C. difficile enteritis has been described previously involving the small bowel, this case is unique because the patient did not have any of the strongest risk factors for CDI and presented with acute necrosis and perforation of the jejunum.