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Knox H, Edwin SB, Giuliano C, Paxton RA. Venous Thromboembolism Prophylaxis in Low Body Weight Critically Ill Patients. J Intensive Care Med 2024; 39:493-498. [PMID: 38111295 DOI: 10.1177/08850666231217693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
OBJECTIVE To compare bleeding and thromboembolic events in low body weight patients receiving reduced-dose venous thromboembolism (VTE) prophylaxis versus standard-dose VTE prophylaxis. DESIGN Multicenter, retrospective, cohort study. SETTING Five Ascension Health Hospitals. PATIENTS Adult, critically ill, low body weight (≤50 kg) patients who received either reduced-dose VTE prophylaxis (n = 140) or standard-dose VTE prophylaxis (n = 279) for at least 48 h. INTERVENTION Reduced-dose prophylaxis (enoxaparin 30 mg daily or heparin 5000 units every 12 h subcutaneously) or standard-dose prophylaxis (enoxaparin 40 mg daily, enoxaparin 30 mg every 12 h, or heparin 5000 units every 8 h subcutaneously). MEASUREMENTS AND MAIN RESULTS A total of 419 patients were included with a mean weight of 45.1 ± 4.2 kg in the standard-dose group and 44.0 ± 5.1 kg in the reduced-dose prophylaxis group (P = .02). The primary endpoint, composite bleeding, was significantly lower in patients receiving reduced-dose prophylaxis (5% vs 12.5%, P = .02). After adjusting for confounding factors, results remained consistent demonstrating reduced composite bleeding with reduced-dose prophylaxis (odds ratio: 0.36, 95% confidence interval: 0.14-0.96). Major bleeding events occurred in 3.6% of reduced-dose patients compared with 8.6% in standard-dose patients (P = .056). Clinically relevant nonmajor bleeding (5.4% vs 2.9%, P = .24) and VTE (2.2% vs 0%, P = .08) events were similar between groups. CONCLUSIONS A reduced-dose VTE prophylaxis strategy in low body weight, critically ill patients was associated with a lower risk of composite bleeding and similar rate of thromboembolism.
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Affiliation(s)
- Helena Knox
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | - Stephanie B Edwin
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
- Department of Pharmacy, Wayne State University, Eugene Applebaum Applebaum College of Pharmacy and Health Sciences, Detroit, MI, USA
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Zoma L, Paxton RA, Dehoorne M, Giuliano C. Comparing Post-operative Opioid Consumption before and after a Patient-Controlled Analgesia Shortage: A Re-evaluation of Safety and Effectiveness. J Pain Palliat Care Pharmacother 2023; 37:272-277. [PMID: 37669436 DOI: 10.1080/15360288.2023.2250334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/19/2023] [Accepted: 08/06/2023] [Indexed: 09/07/2023]
Abstract
This retrospective cohort study aimed to compare post-surgical opioid consumption before and after a PCA (patient-controlled analgesia) shortage. The study evaluated patients who received PCA vs. nurse-administered opioid analgesia (non-PCA). Two hundred and twenty-four patients ≥18 years who were initiated on analgesia within 24 h of surgery were included. The primary outcome was opioid consumption in average daily oral morphine milliequivalents (MME). The results showed that patients in the PCA group had increased MME consumption (162 ± 100.4 vs. 70.7 ± 52.8, p < 0.01), increased length of hospital stay (4.2 vs. 3.2 days, p < 0.01), and increased frequency of nausea (33 vs. 17.9%, p < 0.01). After controlling for confounding factors, the PCA group utilized significantly more opioids (84.6 MME/day, p < 0.01) than the non-PCA group. There was no difference in pain AUC/T (0.19 ± 0.07 vs. 0.21 ± 0.08, p = 0.07) and average opioid prescribing upon discharge (150 [77.5-360] vs. 90 [77.5-400], p = 0.64) between the PCA group and non-PCA group, respectively. These results question the routine use of PCA in post-operative patients due to the increased risk of opioid consumption, longer length of hospital stay, and higher incidence of nausea.
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Affiliation(s)
- Lena Zoma
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | | | - Michelle Dehoorne
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Science, Wayne State University, Ascension St. John Hospital, Detroit, MI, USA
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Aprilliano B, Giuliano C, Paxton RA, Edwin SB. Risk of bleeding with factor Xa inhibitors versus unfractionated heparin in patients with acute kidney injury. Pharmacotherapy 2023; 43:129-135. [PMID: 36588500 DOI: 10.1002/phar.2759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVE To compare bleeding and thromboembolic events in patients receiving therapeutic doses of apixaban or rivaroxaban versus unfractionated heparin (UFH) in patients with acute kidney injury (AKI). DESIGN Single-center, retrospective, observational study. SETTING Ascension St. John Hospital in Detroit, Michigan. PATIENTS Hospitalized adult patients who received therapeutic doses of factor Xa inhibitors (n = 250) or UFH (n = 250) for at least 24 h in the setting of AKI. MEASUREMENTS AND MAIN RESULTS After adjusting for confounding factors, patients who received a factor Xa inhibitor experienced a lower risk of composite major and clinically relevant nonmajor bleeding (CRNMB) events compared with UFH (OR: 0.57, 95% CI: 0.34-0.94; p = 0.03). There was a significantly decreased risk of CRNMB events in the factor Xa inhibitor group (OR: 0.55, 95% CI: 0.33-0.91, p = 0.02); however, no significant differences in major bleeding or venous thromboembolism (VTE) were noted. CONCLUSIONS Our results suggest that it may be preferable to continue patients in AKI on factor Xa inhibitors versus transitioning to UFH due to the lower risk of bleeding events.
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Affiliation(s)
- Bianca Aprilliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA.,Department of Pharmacy, Wayne State University Eugene Applebaum Applebaum College of Pharmacy and Health Sciences, Detroit, Michigan, USA
| | | | - Stephanie B Edwin
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
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DeBiase C, Giuliano CA, Doshi M, Ganoff M, Alexander Paxton R. Enoxaparin versus unfractionated heparin for venous thromboembolism prophylaxis in renally impaired ICU patients. Pharmacotherapy 2021; 41:424-429. [PMID: 33641194 DOI: 10.1002/phar.2518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/25/2021] [Accepted: 02/13/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Intensive care unit (ICU) patients with renal insufficiency are more likely to develop venous thromboembolism and are at an increased risk for bleeding. There is conflicting data on whether enoxaparin or unfractionated heparin (UFH) is preferred for preventing thromboembolism in this population. Therefore, the purpose of this study was to evaluate the safety of prophylactic enoxaparin versus UFH in ICU patients with renal impairment. METHODS We conducted a single-center, retrospective cohort study of ICU patients with renal impairment who received venous thromboembolism prophylaxis with either enoxaparin or UFH. Patients were included if they were at least 18 years of age, had renal impairment (acute kidney injury, severely decreased renal function, or end-stage renal disease), and an ICU length of stay ≥72 h. The primary outcome was the proportion of patients experiencing a major bleeding event, including fatal bleed, symptomatic bleed in a critical area, or bleeding causing a ≥2 g/dl decrease in hemoglobin leading to a transfusion of ≥2 units of packed red blood cells. RESULTS A total of 460 patients were included in the study. Of these, 231 received enoxaparin and 229 received UFH. In the unadjusted analysis, there was no difference in major bleeding events observed with enoxaparin compared to UFH (29.4% vs. 22.3%; p = 0.08) or rates of venous thromboembolism (4.3% vs. 3.5%; p = 0.64), respectively. After adjusting for confounding factors, enoxaparin showed a significant increase in major bleeding (OR: 1.84; 95% CI: 1.11 - 3.04; p = 0.02). CONCLUSION Thromboprophylaxis with enoxaparin in critically ill patients with renal impairment was associated with an increased risk of major bleeding compared to UFH.
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Affiliation(s)
| | - Christopher A Giuliano
- Ascension St. John Hospital, Detroit, MI, USA.,Eugene Applebaum College of Pharmacy, Wayne State University, Detroit, MI, USA
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Masse J, Giuliano CA, Brown S, Paxton RA. Association Between the Use of Long-Acting Insulin and Hypoglycemia in Nondiabetic Patients in the Surgical Intensive Care Unit. J Intensive Care Med 2016; 33:317-321. [PMID: 27821581 DOI: 10.1177/0885066616677030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this study was to examine the association between long-acting insulin and hypoglycemia in nondiabetic surgical intensive care patients. METHODS This single-center, retrospective cohort study evaluated glycemic control in nondiabetic critically ill surgical patients receiving long-acting insulin plus sliding scale versus those receiving sliding scale alone. Patients were matched based on sliding scale order and type of surgery. The primary outcome was the proportion of patients who experienced hypoglycemia (glucose values <70 mg/dL). Secondary outcomes included comparing the distribution of glycemic events in the 2 groups and describing the proportion of patients transferred out of the intensive care unit on long-acting insulin who experienced hypoglycemia. RESULTS One hundred twenty patients met the study criteria. Hypoglycemia was significantly higher in the long-acting insulin plus sliding scale group compared to those receiving sliding scale alone (17 [28.3%] patients vs 8 [13.3%] patients; P = .047). After adjusting for body mass index, renal failure, age, and Acute Physiology and Chronic Health Evaluation II, the odds of hypoglycemia were 4.1 times higher for patients receiving long-acting insulin and sliding scale compared to those receiving sliding scale alone ( P = .02). There were more hypoglycemic events (42 vs 20; P = .05) and hyperglycemic events (313 vs 135; P = .02) in the long-acting insulin group. CONCLUSION This study demonstrated higher rates of hypoglycemia associated with the utilization of long-acting insulin in nondiabetic surgical intensive care patients. Risk of hypoglycemia should be weighed against possible benefits in this population.
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Affiliation(s)
- Jordan Masse
- 1 Department of Pharmacy, St. John Hospital and Medical Center, Detroit, MI, USA
| | - Christopher Alan Giuliano
- 1 Department of Pharmacy, St. John Hospital and Medical Center, Detroit, MI, USA.,2 Department of Pharmacy Practice, Wayne State University, Detroit, MI, USA
| | - Sara Brown
- 1 Department of Pharmacy, St. John Hospital and Medical Center, Detroit, MI, USA
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Arnold P, Paxton RA, McNorton K, Szpunar S, Edwin SB. The effect of a hypoglycemia treatment protocol on glycemic variability in critically ill patients. J Intensive Care Med 2013; 30:156-60. [PMID: 24277155 DOI: 10.1177/0885066613511048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Hypoglycemia and glucose variability are independently associated with increased mortality in septic, surgical, and mixed intensive care unit (ICU) patients. Treatment of hypoglycemia with dextrose 50% can overcorrect blood glucose levels and increase glucose variability. The purpose of this study is to evaluate the effect of a hypoglycemia treatment protocol focused on minimizing glucose variability in critically ill patients. METHODS This retrospective analysis was conducted at a 772-bed community teaching hospital in Detroit, Michigan. A standardized nursing-driven hypoglycemia treatment protocol specific to critically ill patients was implemented. Glucose variability, amount of dextrose administered, subsequent glucose monitoring, hypoglycemia recurrence, and mortality were compared between pre- and postprotocol groups. RESULTS The coefficient of variability of blood glucose in the postprotocol group (n = 53) was decreased compared with the preprotocol group (n = 52), 40.9% versus 49.3%, respectively (P = .048). Dextrose usage was significantly reduced between groups (21.2 g preprotocol vs 11.5 g postprotocol; P < .001). The time to first blood glucose check was 36 minutes after protocol implementation compared to 61 minutes before the protocol (P = .003). Finally, the incidence of continued hypoglycemia following dextrose administration and ICU mortality was similar between groups. CONCLUSIONS Implementation of the hypoglycemia treatment protocol described led to a reduction in glucose variability, while still providing a safe and effective way to manage hypoglycemia in critically ill patients.
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Affiliation(s)
- Patrick Arnold
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA.
| | | | - Kelly McNorton
- Department of Pharmacy, St. John Hospital and Medical Center, Detroit, MI, USA
| | - Susan Szpunar
- Department of Medical Education, St. John Hospital and Medical Center, Detroit, MI, USA
| | - Stephanie B Edwin
- Department of Pharmacy, St. John Hospital and Medical Center, Detroit, MI, USA
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