Abstract Objectives Evaluate if peripheral administration of 3% hypertonic saline (HTS) provides timely treatment with a rate of infusion-related adverse events at or below what is reported in the literature. Methods This was a single-center, retrospective study conducted in a large academic medical center in New York City. Eligible patients were inpatients receiving either 2% or 3% HTS for severe hyponatremia, elevated intracranial pressure, or cerebral edema. The primary outcome was incidence of infusion-related adverse events. Secondary endpoints included achievement of appropriate sodium correction, incidence of over-correction, length of time from ordering to medication administration, and incidence of osmotic demyelination syndrome (ODS). Main Results A total of 199 patients were included in analysis (85 in the 3% HTS group and 114 in the 2% HTS group). No difference was found between groups for rate of infusion related adverse events or incidence of sodium overcorrection groups (0 vs 1 [0.9%]; p = 0.39). Significantly more patients in the 3% HTS group received intermittent administration (p < 0.001), whereas more patients in the 2% HTS group received a continuous infusion (p < 0.001). There were no reports of ODS in either group. No difference in length of time to administration was found between groups. Conclusion Our study, one of the largest to evaluate peripheral administration of 3% HTS, found that it is not associated with an increase in infusion related adverse events or sodium overcorrection versus 2% HTS. Peripheral administration should be recommended to provide timely treatment for patients requiring HTS.

Evaluate if peripheral administration of 3

Abstract Introduction The majority of patients in the intensive care unit (ICU) are at risk for at least one electrolyte abnormality and critically ill patients are the most vulnerable population to the effects of suboptimal electrolyte levels. These patients have unique characteristics impacting implications of the electrolyte disturbances and management. Areas Covered In the ICU, magnesium, potassium, calcium, phosphorous, and sodium are the most commonly encountered electrolytes that can be abnormal in the critically ill. Critical illness both is affected by and affects disturbances of these electrolytes which can result in more severe illness, longer duration of mechanical ventilation, increased dialysis support, longer length of stay, and increased mortality. Often, patients have multiple imbalances that require correction. Removal or mitigation of the cause should be undertaken whenever possible and should be concurrent with any therapeutic management used to correct the electrolyte imbalance. Selection of medication to correct electrolyte imbalances should be undertaken according to available evidence and drug-specific characteristics that impact medication delivery in the critically ill. Electrolyte disturbances, measurements, and corrections are ubiquitous in the ICU. Published literature on the management of electrolytes in the critically ill is limited. Management should consider factors unique to the critically ill when selecting optimal treatment approach and it is essential to individualize treatment to a patient’s unique needs and adapt management to the patient’s chancing clinical situation.

Background Breakthrough seizures and status epilepticus require urgent management. Administration of intravenous push (IVP) levetiracetam has been demonstrated to be safe as compared to intravenous piggyback (IVPB). This transition can potentially offer faster time to administration and reduced drug and material cost. The objective of this study was to observe safety of administration in patients receiving levetiracetam via IVP compared to IVPB in acute care settings. Methods This is a multi-center, observational, retrospective cohort study of 1214 adult patients who received levetiracetam pre- and post-implementation of IVP over a 6 month timespan. Primary outcome was time from order verification to administration of urgent first-time doses. Secondary outcomes included time to administration of loading doses and cost. Safety outcome was infusion site related reactions. Results Time from order verification to administration of urgent first-time doses pre- and post-implementation of IVP administration was reduced from 61 minutes to 47 minutes (P=0.0002). Infusion site related reactions were observed in 6 out of 5432 doses in the IVPB arm and in 5 out of 4700 doses in the IVP arm (P=1). Total estimated cost was $76,171.96 for the 5449 IVPB total doses and $11,484.33 for the 4721 IVP total doses. Conclusions Transition from IVPB to IVP administration reduced time from order verification to administration of urgent first-time doses with both administrations having similar incidence of infusion site related reactions. Cost savings and improved workflow were observed. Levetiracetam administered via IVP may be considered as a safe alternative method of administration in the acute care setting.

Enoxaparin is a hydrophilic drug with obesity having little effect on its apparent volume of distribution, therefore patients with obesity receiving standard 1 mg/kg dosing may be at a higher risk of supratherapeutic dosing. Conversely, dose reducing patients with obesity could place already at risk patients at higher risk of a thrombotic event. Data and recommendations are variable for the most appropriate weight-based dose of therapeutic enoxaparin in obese patients, particularly those a weight > 100 kg or a body mass index (BMI) ≥ 40 kg/m2. The purpose of this systematic review was to globally evaluate these data to surmise optimal dosing recommendations for patients with obesity. A systematic review of English language studies was conducted and identified articles via Pubmed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) searches. Studies were included if they reported therapeutic enoxaparin use in adult patients with a BMI ≥ 40 kg/m2 or body weight > 100 kg and the percentage of patients achieving a therapeutic anti-Xa based on a weight-based dose or the weight-based dose required to produce a therapeutic anti-Xa level. Therapeutic attainment of anti-Xa levels were assessed across enoxaparin weight-based dosing categories including a very low dose group: < 0.75 mg/kg, low dose group: 0.75–0.85 mg/kg, and standard dose group: ≥ 0.95 mg/kg. Rates of bleeding and thrombosis were also evaluated. A total of eight studies were included. For anti-Xa level assessment, 682 patients were included. A total of 62 2. This review identified eight studies that assessed therapeutic enoxaparin dosing in patients with a BMI ≥ 40 kg/m2 or > 100 kg and determined that patients with a reduced dosing regimen (0.75–0.85 mg/kg) achieved goal anti-Xa levels 66 3. Rates of bleeding occurred in 3.6 4. Use of a reduced weight-based dose of enoxaparin (0.75–0.85 mg/kg) may result in more obese patients with a BMI ≥ 40 kg/m2 or body weight > 100 kg achieving goal anti-Xa levels than full weight-based dosing. 5. Prospective randomized-controlled trials are required to verify clinical outcomes in this population.

Introduction: Loading doses of 20 mg/kg of levetiracetam are commonly employed for refractory status epilepticus however, recent studies utilizing higher loading doses of 40-60 mg/kg have prompted a change in practice. This study aims to establish whether higher loading doses of levetiracetam lead to more rapid cessation of status epilepticus and reduced need for additional antiepileptic drugs. Methods: This was an IRB-approved, single-center, retrospective cohort study of patients admitted to a tertiary care academic medical center between April and September 2021. Patients were included if they were > 18 years of age and received levetiracetam as a loading-dose for cessation of status epilepticus. Patients were excluded if levetiracetam was administered for seizure prophylaxis. The primary outcome was unsuccessful seizure termination, defined as a requirement of an additional loading dose or an increase in maintenance doses of levetiracetam. Secondary outcomes included ICU and hospital length of stay, mortality, and need for third line treatment. Results: Of 390 patients screened for inclusion, 206 met inclusion criteria and were included in the primary analysis. Amongst patients who received a loading < 20 mg/kg, 50% had a diagnosis of epilepsy prior to admission, compared to 37.3% in the 20-40 mg/kg group and 42% in the ≥ 40 mg/kg group. Rates of ICU admission were 20%, 37.3% and 36.3%, respectively (p = 0.163). There was a statistically significant difference in ICU (3.5, 8.9, 13.5; p = 0.03) and hospital length of stay (13.1, 22.5, 30.7, p = 0) among groups. The primary outcome, unsuccessful seizure termination, was 13.8% in the < 20 mg/kg group, 12% in the 20-40 mg/kg group, and 34% in the > 40 mg/kg group. The rates of third-line therapy administration in each group was 5% vs. 13.3% vs. 22%, respectively. Conclusions: Among patients treated with loading-doses of levetiracetam > 40 mg/kg, there was a statistically significant increase in maintenance dose of levetiracetam and a trend towards more frequent administration of third-line agents. There was a longer ICU length of stay among patients administered >40 mg/kg loading dose which could have led to increased monitoring and increases in maintenance dosing of levetiracetam among that population.

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Introduction: First-line hemodynamic support and the vasopressor of choice for septic shock is norepinephrine. There is considerable variability in practice and a paucity of data regarding when to add vasopressin or corticosteroids, and in what sequence. Defining which agent to administer secondarily to norepinephrine for escalation of hemodynamic support could reduce unnecessary adverse events from central line utilization, decrease adverse drug events, and may result in more economic management of patients. Methods: This is a single-center, retrospective cohort study of patients admitted to the intensive care unit (ICU) between October 2020 and January 2021. Patients were included if > 18 years of age and received norepinephrine plus either vasopressin or corticosteroids as second-line support for septic shock. Patients were excluded if they were on corticosteroids prior to admission. The primary outcome was the percentage of patients who required escalation of hemodynamic support after receipt of a second-line agent within 2 hours. Secondary outcomes included ICU length of stay (LOS), hospital LOS, in-hospital mortality, total hours on vasopressors, acute kidney injury (AKI), need for dialysis and/or renal replacement therapy, superinfection > 48 hours from time zero, and central line utilization. Results: Of 1287 patients screened for inclusion, 142 patients were included in the primary analysis. Eighty-three patients received vasopressin first, 43 patients received corticosteroids first, and 13 patients received both vasopressin and corticosteroids at the same time. For the primary outcome, 15.7%, 32.6%, 7.7% required escalation of norepinephrine within 2 hours, respectively. Respectively, mortality rates were 62.7%, 65.1%, and 76.9%. Central line utilization was on average 12.5 days, 6.6 days, and 5 days among the respective groups. Conclusions: There exists a lack of data when examining the utilization of vasopressin and corticosteroids as second-line add-on agents in septic shock. There was a higher mortality rate than expected among the population who received both corticosteroids and vasopressin at the same time. Central line utilization was lower in those who received corticosteroids first and for those who received both at the same time.

What is Known and Objective Sevelamer is an insoluble polymer indicated for the management of hyperphosphatemia in patients with chronic kidney disease (CKD). The package inserts for both tablet formulations recommend the tablets be administered whole. Due to whole tablets being sometimes inadvertently crushed and the significantly increased cost of sevelamer packets, we evaluated the safety and feasibility of crushed sevelamer tablets for enteral feeding tube administration. Methods A single-centre retrospective chart review was performed. All adult ICU patients prescribed sevelamer carbonate between 1 January 2015 and 31 July 2019 were included if they received at least one dose of a sevelamer tablet or packet, whereas they had an enteral feeding tube in place. The primary outcome was the incidence of an obstructed enteral feeding tube or need for replacement, as defined as the number of occurrences over the total numbers of doses administered. The secondary outcome was the change in phosphorus levels from time of sevelamer initiation to discontinuation or patient discharge. Results A total of 14 obstructions were reported, four in the tablet arm and ten in the packet arm (0.4% tablet arm, 0.5% packet arm;P = .5931). Of these, four (29%) required tube replacement and were followed by sevelamer discontinuation. Two (14%) were documented to be due to increased tube feeds and esomeprazole. Six (43%) cases required tube replacement, but no issues arose upon continuation. Only one of the obstructions resulted in a recurrent tube occlusion. What is New and Conclusion Sevelamer tablets may be crushed and administered via enteral feeding tubes, provided clear instruction on tablet preparation is included. Oral administration in dysphagic patients requires further evaluation with clear protocols for preparation and administration.

Abstract Background Accurately predicting the presence of a carbapenem resistant enterobacterales (CRE) in hospitalized patients presents itself as an opportunity that would support timely initiation of CRE active agents. The aim of this study is to determine how reliably the existing risk prediction models identify patients likely to require empiric anti-CRE treatment, preliminary results of which are presented herein. Methods A systematic search identified all existing CRE prediction models for validation in our patient population. Medical records of hospitalized patients within the Mount Sinai Health System in New York were subsequently reviewed. Data was gathered on model predictors, baseline demographics, clinical information, microbiology results, antibiotic utilization history and index infection. Besides calculating the AUROC, the main outcome of our study was to establish optimal prediction score cutoffs and false positive rates (FPR) where corresponding model performance maintains a false negative rate (FNR) of < 10%, < 20% and < 30%, respectively. Results 12 models were retained for validation. We identified 106 patients, 41 of which were treated for a CRE infection. Previous admission, organ transplantation, CKD, infection type, and carbapenem use were baseline variables that significantly differed between the groups treated for a CRE or non-CRE related infection (Table 1). The models ability to discriminate varied as evidenced by the AUROC range of 0.5 to 0.77 (Figure 1), suggesting the Seligmen et al. model as the overall best. When evaluated at the pre-specified FNR intervals of < 10%, < 20% and < 30%, the model by Lodise et al., Seligman et al., and Vazquez-Guillamet et al. produced the best FPR, respectively (Table 2). Table 1. Baseline characchteristics Table 2. Model Performance Figure 1. AUROCs Conclusion Discriminative ability of the risk prediction models showed varying performance. The model by Lodise et al. appears to be most useful when a low risk level is deemed acceptable for failure rate, while at a moderate to high risk of missing a CRE case (20% and 30% FNR), the methods by Seligman and Vazquez-Guillamet et al. are most desirable as they minimize the chance of over-treatment. Additional work to increase sample size and to evaluate the models inter-rater reliability is currently on going. Disclosures All Authors: No reported disclosures

INTRODUCTION: In early March 2020, COVID-19 spread in New York City This paper shows trends of rising cases of DKA associated with a worsening COVID-19 pandemic in New York City With the potential for such a large number of DKA patients, our institution found a need for revised glycemic management protocol We discuss how a multidisciplinary team designed a protocol to care for patients with COVID-19 infection and DKA METHODS: Five of The Mount Sinai Health System's EDs are on a shared electronic health record system (Epic Systems, Verona, WI) Deidentified visit data extracted for routine quality review was made available for analysis We looked at total visits and select visit diagnoses related to DKA through March, April and May 2019 and compared those counts to the same period in 2020 Our protocol was developed by stakeholders in a multidisciplinary hospital team We focused on the basic tenets of DKA management: insulin therapy, fluid resuscitation, and electrolyte repletion RESULTS: A total of 93,218 visits were recorded across the five EDs from March 1-May 31, 2019 During that period there were 106 diagnoses of DKA made in the EDs (0 114% of visits) Across the same period in 2020 there were 59,009 visits, and 214 diagnoses of DKA (0 363% of visits) This coincides with the height of the Sars-CoV-2 pandemic in New York City To address this surge, our protocol decreased the frequency of fingerstick monitoring, with changes to insulin dosing allowing admission to non-ICU beds We transitioned from a provider-driven protocol to a nurse-driven protocol to avoid treatment delays due to order placement Insulin infusion rate charts were created to provide nurses guidance on dosing modifications To minimize ARDS risk, our protocol's fluid replacement recommendations lowered resuscitation and replacement rate volumes, adjusting based on provider reassessment Lab values were monitored every 3-4 hours CONCLUSIONS: There is a correlation between the rise of the Sars-CoV-2 pandemic in New York City and a net rise in patients diagnosed with diabetic ketoacidosis We believe our DKA protocol will facilitate safe and effective management of patients with COVID-19 and DKA, reducing the healthcare burden associated with protocols that necessitate frequent treatment modifications and ICU-level care

PURPOSE:Nearly half of intensive care unit (ICU) patients will develop delirium. Antipsychotics are used routinely for the management of ICU delirium despite limited reliable data supporting this approach. The unwarranted continuation of antipsychotics initiated for ICU delirium is an emerging transitions of care concern, especially considering the adverse event profile of these agents. We sought to evaluate the magnitude of this issue across 6 centers in New Jersey and describe risk factors for continuation.METHODS:This multicenter, retrospective study examined adult ICU patients who developed ICU delirium from June 2016 to June 2018. Patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission.RESULTS:Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital.CONCLUSION:The continuation of antipsychotics for the management of delirium during transitions of care was a common practice across ICUs in New Jersey. Several risk factors for continuation of antipsychotics were identified. Efforts to reduce unnecessary continuation of antipsychotics at transitions of care are warranted.

BACKGROUND:Atrial fibrillation (AF) frequently develops during critical illness. In septic shock complicated by rapid AF, the use of phenylephrine may be advantageous secondary to its β-1 sparing properties. However, evidence supporting this strategy is lacking.OBJECTIVE:The purpose of this study is to determine the clinical effect on rate control of transitioning norepinephrine to phenylephrine in septic shock patients who develop AF with a rapid ventricular response (RVR).METHODS:A single-center retrospective study of septic shock patients admitted to the medical or surgical intensive care unit (ICU) who developed AF with RVR (heart rate >110 beats per minute [bpm]). Patients who were switched to phenylephrine were compared to those who remained on norepinephrine. The primary end point was sustained achievement of rate control. A time-varying Cox proportional hazards model was used to assess the primary end point.RESULTS:A total of 67 patients were included in the study, of which 28 were switched to phenylephrine. Baseline characteristics were similar between groups. The unadjusted hazard ratio for achieving rate control was significant at 1.99 (95% confidence interval [CI]: 1.19-3.34; P < .01) for the phenylephrine group. The adjusted hazard ratio was 1.75 (95% CI: 0.86-3.53; P = .12). There were no statistically significant differences in mortality or ICU length of stay.CONCLUSION:Our study suggests a potential clinical effect on achieving rate control when switching to phenylephrine cannot be excluded. It remains unclear if there is a benefit on mortality or length of stay outcomes in critically ill patients.

Background: In response to the devastating effects of the coronavirus disease 2019 pandemic, several vaccine prototypes have been developed, with the Pfizer/BioNTech (BNT162b2) platform being the first to receive emergency use authorization. Although taken to market on an unprecedented timeline, the safety profile of the drug during clinical trials was shown to be favorable. Shortly after release, reports from the Centers for Disease Control and Prevention demonstrated a higher-than-average rate of anaphylaxis to the vaccine that has been the cause for concern for safety officials and the general public alike. Here, we present a unique case of protracted anaphylaxis in a recipient of the BNT162b2. Case Summary: The patient is a 55-year-old female with a history of multiple allergic reactions who presented with respiratory distress and hives after receiving the first dose of the BNT162b2, despite premedication with IV steroids and diphenhydramine. The refractory nature of her reaction was demonstrated by edema of her tongue (visualized on nasolaryngoscopy), requiring an epinephrine infusion for nearly 3 days. She was discharged from the hospital with instructions not to receive the second dose of the vaccine. Conclusion: Although the exact etiology of anaphylaxis secondary to this messenger RNA-based vaccine is not completely clear, our literature search and review of the patient’s course support either polyethylene glycol versus other excipient-related allergy as a possible cause. Based on the protracted nature to our patient’s anaphylaxis, critical care management for patients with a true anaphylactic reaction to BNT162b2 may require monitoring for an extended period of time.

Abstract Background The 2018 Society of Critical Care Medicine guidelines on the “Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU” advocate for protocol-based analgosedation practices. There are limited data available to guide which analgesic to use. This study compares outcomes in patients who received continuous infusions of fentanyl or hydromorphone as sedative agents in the intensive care setting. Methods This retrospective cohort study evaluated patients admitted into the medical intensive care unit, the surgical intensive care unit, and the cardiac intensive care unit from April 1, 2017, to August 1, 2018, who were placed on continuous analgesics. Patients were divided according to receipt of fentanyl or hydromorphone as a continuous infusion as a sedative agent. The primary endpoints were ICU length of stay and time on mechanical ventilation. Results A total of 177 patients were included in the study; 103 received fentanyl as a continuous infusion, and 74 received hydromorphone as a continuous infusion. Baseline characteristics were similar between groups. Patients in the hydromorphone group had deeper sedation targets. Median ICU length of stay was eight days in the fentanyl group compared to seven days in the hydromorphone group (p = 0.11) and median time on mechanical ventilation was 146.47 hours in the fentanyl group and 122.33 hours in the hydromorphone group (p = 0.31). There were no statistically significant differences in the primary endpoints of ICU length of stay and time on mechanical ventilation between fentanyl and hydromorphone for analgosedation purposes. Conclusion No statistically significant differences were found in the primary endpoints studied. Patients in the hydromorphone group required more tracheostomies, restraints, and were more likely to have a higher proportion of Critical Care Pain Observation Tool (CPOT) scores > 2.

Haberlein, Megan1; Shariff, Rayhan1; Hickey, Sean1; Schwab, Alfred1; Manasia, Anthony1; Leibner, Evan1; Illuzzi, Ella1; Radparvar, Sara1 Author Information

Dixit, Deepali; Patel, Krina; Adams, Christopher; Radparvar, Sara; Cardinale, Maria; Andrews, Liza Author Information