The annual congress of the Society of Critical Care Medicine was held from Jan. 17 to 21 in Phoenix and attracted more than 5,500 participants from around the world, including nurses, pharmacists, physicians, respiratory therapists, students, and other health care practitioners. The conference highlighted recent advances in critical care medicine, with presentations and abstracts mainly focusing on the management of critically ill patients.
In one study, Jeffrey Barletta, Pharm.D., of the Midwestern University College of Pharmacy in Glendale, Ariz., and colleagues found that critically ill patients who were exposed to two or more days of proton pump inhibitor (PPI) therapy had a two-fold increase in risk for Clostridium difficile infection.
“We’ve revealed duration of PPI therapy as a significant risk factor for the acquisition of nosocomial Clostridium difficile in critically ill patients,” Barletta said. “This risk became evident after only two days of therapy. Clinicians should consider alternative forms of acid suppressive therapy for indications like stress ulcer prophylaxis given the short exposure time that is associated with this significant adverse event.”
In another study, Hermang Yadav, M.D., of the Mayo Clinic in Rochester, Minn., and colleagues evaluated the risk of acute respiratory distress syndrome (ARDS) following bone marrow transplant (BMT) over an eight year period. The study included 2,635 patients undergoing hematopoietic stem cell transplantation.
“We identified that the overall incidence of ARDS is 5 percent in the year following transplant. Patients undergoing allogeneic transplantation are much more likely to get ARDS than those who undergo autologous transplantation — around 16 versus 3 percent,” Yadav said.
The investigators also found that the mortality associated with ARDS in the post-transplant setting is exceedingly high.
“At one year following transplant, 67 percent of those who develop ARDS will have died, compared to 12 percent of those who do not develop ARDS. Those who undergo allogeneic transplantation generally fare worse: 72 percent of allogeneic transplants who develop ARDS during a hospital admission will die during that hospitalization alone. The mortality in those with ARDS following autologous transplantation is still substantial, but lower, with an in-hospital mortality of 38 percent,” Yadav said. “ARDS is a frequent and devastating complication following BMT, dramatically influencing patient survival. Patients undergoing allogeneic hematopoietic stem cell transplantation have a higher incidence of ARDS and worse outcomes, when compared to those undergoing autologous BMT. Our findings highlight an urgent need to better understand the risk factors underlying ARDS in this population, thereby facilitating the future development and implementation of effective prevention strategies.”
Cassie Barton, M.D., of the Oregon Health & Science University in Portland, and colleagues observed an elevated risk of thrombosis associated with a novel anticoagulation reversal program utilizing weight-based prothrombin complex concentrate and fixed-dose activated recombinant factor VII in patients receiving warfarin therapy. This protocol is no longer used in clinical practice.
“We found a surprisingly high rate of thrombotic complications with the protocol, affecting 28 percent of patients. Deep vein thrombosis was the most common complication. Also, we found that despite the protocol achieving our international normalized ratio (INR) goals, with an average post-reversal INR of 0.9 from a pre-reversal INR of ~3.5, about half of our patients also received an average of two units of fresh frozen plasma,” said Barton. “We looked for risk factors for thrombotic complications and found that male sex and use of a concomitant anticoagulant such as enoxaparin were risk factors for thrombosis.”
Sadeq A. Quraishi, M.D., of Harvard Medical School and Massachusetts General Hospital in Boston, and colleagues found that giving a single large dose of vitamin D3 (400,000 IU) was safe and could rapidly improve vitamin D status in patients with severe sepsis or septic shock.
“We also showed that this improvement in vitamin D status was associated with a significant increase in the expression of an endogenous antimicrobial peptide known as cathelicidin. Cathelicidin not only circulates systemically, but is also expressed at key barrier sites in the body such as the skin, gut, and lungs — which are all potential gateways for devastating infections that can result in severe sepsis or septic shock,” Quraishi said. “Given that anywhere from 50 to 90 percent of critically ill patients may have low vitamin D status, screening and aggressive vitamin D repletion in addition to providing other timely therapeutic interventions may be a cost-effective strategy to improve outcomes in intensive care unit (ICU) patients.”
Pamela L. Smithburger, Pharm.D., of the University of Pittsburgh, and colleagues found that the use of an interprofessional, multi-modal, non-pharmacological intervention was effective in decreasing ICU delirium.
“We demonstrated a greater than 40 percent reduction in the percentage of ICU length of stay spent delirious after protocol implementation. After we controlled for risk factors of delirium, the use of our protocol resulted in a 57 percent decreased risk in the chances of developing delirium,” Smithburger said. “Based upon our results and success, our protocol was disseminated through our entire health system to be used in all of the ICUs. Further investigations include the analysis of the health system data in diverse populations.”
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