LaPlante, Reid; Nicolosi, Christian; Daniel-McCalla, Shawnee; Parbuoni, Kristine Author Information

Introduction: Targeted temperature management (TTM) is frequently used for the prevention of secondary injury in subarachnoid hemorrhage, intracranial hemorrhage and ischemic stroke. Shivering is common in patients undergoing TTM and causes detrimental effects on systemic oxygen consumption, brain tissue oxygenation and intracranial pressure. After standard of care for the management of shivering, limited data on the use of dantrolene has been reported with potential efficacy, although the prevalence of adverse events is unknown. The goal of this study is to evaluate the safety and efficacy of dantrolene for refractory shivering in patients undergoing TTM. Methods: A retrospective review was completed of patients admitted to the neurocritical care unit that received continuous dantrolene for this indication. Data extracted included TTM modality, neurologic injury type with associated severity score, and bedside shivering assessment scale (BSAS) score 6 hrs before, during and 6 hrs after dantrolene. Also collected included dantrolene dose, duration, route and potential adverse effects related to dantrolene. Results: 30 patients met inclusion with 24 admitted for a neurologic injury of aneurysmal subarachnoid hemorrhage with median Hunt Hess score of 4 (IQR 3-4.25) and modified Fisher scale score of 3 (IQR 3-4). Appropriate initial dosing weight was utilized in 60% of patients and 93.3% underwent TTM using an Arctic SunTM. The median duration of dantrolene therapy was 3 days (IQR 1.25-4.75). BSAS decreased from 6 hrs prior to dantrolene with a median score of 2 (IQR 1-3) to 1 (IQR 0-2) and 0.5 (IQR 0-1) at 6 and 36 hrs post dantrolene. 43.3% of patients experienced an adverse event related to the dantrolene infusion. Infiltration and transaminitis were the most common, both accounting for 38.5% of events. Conclusions: Dantrolene use for refractory shivering exhibited a trend in decreasing BSAS signaling potential efficacy, though additional evaluation is needed to fully assess. A large portion of patients encountered an adverse event attributable to dantrolene. Based on this evidence, it is recommended that dantrolene be administered via only central venous catheter for refractory shivering and daily liver function panels should be monitored during administration to prevent infiltration and transaminitis.

Numerous patients have cultures pending at discharge which, if not addressed, may delay diagnosis and initiation of appropriate antimicrobials. The purpose of the study is to evaluate the appropriateness of discharge antimicrobial therapy and result documentation in patients with positive cultures finalized post-discharge. This was a cross-sectional cohort study of patients admitted from July 1 to December 31, 2019 with positive sterile-site microbiologic cultures finalized post-discharge. Pertinent inclusion and exclusion factors were admission ≥ 48 h and non-sterile sites, respectively. The primary objective was to determine the frequency of discharged patients warranting antimicrobial changes based on finalized cultures. Secondary objectives included prevalence and timeliness of result documentation and rates of 30-day readmission, among intervention warranted versus not warranted. Chi-squared or Fisher’s exact tests were used as appropriate. Binary multivariable logistic regression was completed for 30-day readmission stratified by infectious disease (ID) involvement due to the potential for effect modification. A total of 208 of 768 patients screened were included. Most patients were discharged from a surgical service (45.7

PURPOSE:Targeted temperature management (TTM), including normothermia and therapeutic hypothermia, is used primarily for comatose patients with return of spontaneous circulation after cardiac arrest or following neurological injury. Despite the potential benefits of TTM, risks associated with physiological alterations, including electrolyte shifts, may require intervention.SUMMARY:This review describes the normal physiological balance of electrolytes and temperature-related alterations as well as the impact of derangements on patient outcomes, providing general recommendations for repletion and monitoring of key electrolytes, including potassium, phosphate, and magnesium.CONCLUSION:Frequent monitoring and consideration of patient variables such as renal function and other risk factors for adverse effects are important areas of awareness for clinicians caring for patients undergoing TTM.

Abstract Background Half of patients have cultures pending at discharge. Failure to address these results may delay diagnosis and time to appropriate antimicrobials. The purpose of the study is to evaluate appropriateness of antimicrobial therapy and result documentation in patients with positive cultures finalized post-discharge. Methods Retrospective cohort study of patients from 7/2019-12/2019 with positive sterile-site microbiologic cultures finalized post-discharge. Pertinent inclusion and exclusion factors were admission ≥48 hours and non-sterile sites, respectively. The primary objective was to determine the frequency of discharged patients warranting antimicrobial intervention based on finalized culture results. Secondary objectives included incidence and timeliness of result documentation and rates of 30-day hospital readmission, among intervention warranted vs not warranted. Chi-squared or Fisher’s exact tests were used as appropriate. Binary multivariable logistic regression was completed for 30-day hospital re-admission stratified by infectious disease (ID) team involvement. Results 208 of 768 patients screened were included. Most patients were discharged from a surgical service (45.7%); deep tissue and blood were the most common culture sites (29.3%). Antimicrobial intervention was warranted in 36.5% of patients (n=76). Rates of result documentation were overall low (35.5%). Time to documentation of results was significantly shorter in patients warranting intervention compared to those who did not, but hospital readmission was higher (Table 1). Finally, result documentation in patients not being followed by ID was associated with decreased odds of 30-day readmission (OR 0.19, 95% CI, 0.07-0.53) (Table 2). Conclusion A significant number of patients with cultures finalized post-discharge warranted antimicrobial intervention. Acknowledgment of final culture data can decrease the risk of 30-day hospital readmission, especially in patients not followed by ID. Quality improvement efforts should focus on methods to improve documentation and follow-up of pending cultures to improve patient outcomes. Disclosures Kimberly C. Claeys, PharmD, BioFire Diagnostics: Honoraria|La Jolla Pharmaceuticals: Advisor/Consultant.