2025 Southeastern Residency Conference

Title: Comparison in Clinical Outcomes with Lorazepam vs. Midazolam use in Patients Admitted to a Community Hospital for Alcohol Withdrawal


Authors: Caitlin Ferguson, Stephen Melton


Background: Alcohol withdrawal is an urgent medical condition which occurs when an individual disrupts or discontinues regular alcohol consumption. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a widely used tool for assessing the severity of alcohol withdrawal symptoms and guiding treatment (1). Current guidelines state longer acting benzodiazepines are preferred due to clinical benefits and longer duration of action (2). Recent drug shortages have led to a shift toward using alternative medications such as midazolam in place of the traditional protocolized lorazepam. By comparing outcomes of each benzodiazepine, healthcare providers can make informed decisions about treatment alternatives.  


Methods: Baptist Health Lexington implemented a protocol to utilize midazolam in lieu of lorazepam during a period of drug shortage. This retrospective study analyzes local clinical outcome data comparing the use of lorazepam and midazolam in patients with alcohol withdrawal before and after the ASHP-designated lorazepam drug shortage in February 2023. Data will be analyzed via review of hospital electronic medical record six months prior and six months after the protocol initiation. The primary outcome is to evaluate the differences in hospital length of stay in number of days for each treatment regimen. The following secondary outcomes will also be assessed: maximum and average CIWA score, total number of lorazepam equivalents administered, and ICU length of stay. Appropriate statistical tests will then be analyzed to assess the clinical outcomes of the two medications. The data collected will be de-identified from individual patient charts and presented only in aggregate.  


Results: In progress 


Conclusions: In progress 

Title: 
Effects of selective serotonin reuptake inhibitors on stress ulcer bleeding in critically ill patients


Authors: 
Morgan Keller, Sabrina Croft, Joseph Crosby


Objective: 
To be presented in slides


Self Assessement Question: 
To be presented in slides


Background:
Critically ill patients in the intensive care unit have increased risk for gastrointestinal complications, including stress ulcers and bleeding due to physiological stress, mechanical ventilation, and pharmacological interventions such as anticoagulants and corticosteroids. Prophylactic treatments such as proton pump inhibitors and H2-receptor antagonists are commonly used to mitigate this risk. The aim of this study is to determine whether the use of selective serotonin reuptake inhibitors is associated with an increased incidence of gastrointestinal bleeding with critically ill patients.


Methods:
This retrospective, observational chart review evaluates adult patients who are critically ill and admitted to one of the St. Joseph’s/Candler intensive care units who are taking selective serotonin reuptake inhibitor medications compared to patients with a comparator ICD 10 code (NSTEMI I21.4) not taking selective serotonin reuptake inhibitor therapy. A computer-generated list identified patients who were admitted to one of the St. Joseph’s/Candler intensive care unit (ICU), coronary care unit (CCU), or neuro-intensive care unit (NICU) with selective serotonin reuptake inhibitor therapy in patient from August 1 2020-August 1 2024. Comparatively, a second computer-generated list identified patients who were admitted to one of the St. Joseph’s/Candler ICU, CCU, or NICU with ICD 10 code I21.4 from August 1 2020-August 1 2024. Subjects were then be reviewed for study inclusion or exclusion based on the aforementioned criteria, and Microsoft office excel was used to randomize patients and select 50 patients per treatment arm. Chart review was conducted to determine if the patient was diagnosed with a gastrointestinal bleed during their specific visit. All data was collected and analyzed through Microsoft office excel. Primary outcomes and input variables are summarized with means and standard deviations for continuous measures, and proportions and percentages for non-continuous measures. Any adjusted analysis conducted was through multivariable regression.


Results:
Among the 100 critically ill patients admitted to the ICU, CCU, or NICU unit at St. Joseph’s and Candler Hospital, nine (9%) of patients were found to have a gastrointestinal bleed. Of the 9 patients who had a gastrointestinal bleed, seven (77.8%) of the patients were not on selective serotonin reuptake inhibitor therapy (SSRI) whereas 2 (22.2%) were on SSRI therapy. Among the nine patients diagnosed with a gastrointestinal bleed, five patients were in the CCU, one patient in the NICU, one patient in the St. Joseph’s ICU, and two patients in the Candler ICU. 71 (71%) of patients were on stress ulcer prophylaxis with either proton pump inhibitors or histamine type-2 receptor antagonists and only one of these patients experienced a gastrointestinal bleed. 
The primary endpoint analysis demonstrated no statistically significant association between SSRI therapy and increased risk of gastrointestinal bleeding in critically ill patients admitted into intensive care units, (p-value of 0.08). The lack of statistical significance suggests other clinical factors may contribute to the numerically fewer patients who experienced gastrointestinal bleeding on selective serotonin reuptake inhibitor medications than those patients not on selective serotonin reuptake inhibitor therapy.


Conclusion:
Selective serotonin reuptake inhibitor therapy does not appear to significantly increase the risk of gastrointestinal bleeding in critically ill patients admitted to intensive care units. Despite the predisposing factors of these patients to gastrointestinal complications, the observed incidence of bleeding was not higher in patients receiving selective serotonin reuptake inhibitors compared to those not receiving selective serotonin reuptake inhibitors who were diagnosed with NSTEMI. Considering the study’s limitations of retrospective design and small sample size, further research with larger, multicenter data should explore the potential relationship of selective serotonin reuptake inhibitors and gastrointestinal bleeding risk in critically ill patients. 

Title: Optimizing Outpatient Antibiotic Therapy: Impact of Continuous Infusion Beta-Lactams and Vancomycin on Patient Adherence and Clinical Outcomes
 
Authors: Tarik Prince, Tyler Martin, Geren Thomas, Megan Mills
 
Objective: To compare the impact of continuous infusion (CI) versus intermittent infusion of beta-lactams and vancomycin in outpatient parenteral antibiotic therapy (OPAT) on patient adherence, clinical outcomes, and device-related complications, while assessing potential advantages of CI based on pharmacokinetic/pharmacodynamic principles.
 
Self-Assessment Question: How does continuous infusion (CI) of beta-lactams and vancomycin in OPAT compare to intermittent infusion in terms of patient adherence, clinical outcomes, and device-related complications? Provide at least one potential advantage of CI based on pharmacokinetic/pharmacodynamic principles.


Background: Beta-lactam antibiotics are widely used globally, and their bactericidal activity depends on optimizing pharmacokinetics by maximizing the fraction of time their concentration exceeds the minimum inhibitory concentration (fT>MIC). Continuous infusion (CI) over 24 hours has been demonstrated to improve fT>MIC, potentially leading to enhanced bacterial eradication, reduced resistance development, and lower relapse rates compared to intermittent infusion. While robust data exist for inpatient settings—showing reduced mortality, shorter hospital stays and improved clinical cure rates—the impact of CI in outpatient parenteral antibiotic therapy (OPAT) remains underexplored, especially concerning patient adherence and clinical outcomes. This study investigates CI versus intermittent infusion of beta-lactams and vancomycin in OPAT, focusing on treatment success, adherence rates, and device-related complications such as catheter occlusions and infections.
Methods: This prospective, quasi-experimental study evaluated patients discharged on CI antibiotics versus intermittent dosing. Inclusion criteria included adults (≥18 years) receiving OPAT with beta-lactam antibiotics for infections requiring prolonged therapy. Stability data for beta-lactams and vancomycin administered via CI through elastomeric devices were reviewed for compatibility with 24-hour CI. A dosing protocol was developed, detailing drug preparation, concentrations, device use, and patient monitoring. Patient adherence was assessed through self-reports (documenting missed doses), shipment tracking (confirming on-time medication delivery), and provider follow-ups (verifying compliance with administration schedules). Adherence was defined as 100% of prescribed doses received without missed or delayed doses. Secondary outcomes include clinical response, adverse effects, and hospital readmission rates within 30 days post-treatment completion. Data will be analyzed descriptively, with logistic regression for adherence predictors.
Results: An interim analysis was conducted, including six patients in the intermittent infusion group. The mean age was 71 years (range 51–90 years), with 67% of patients being male. The infections treated included osteomyelitis, urinary tract infection, Methicillin-Sensitive Staphylococcus aureus (MSSA) bacteremia, pneumonia, MSSA wound infection, and Pseudomonas aeruginosa wound infection. Adherence rates were 67%, with four patients adhering to therapy. Clinical response was achieved in 66% of patients, with no readmissions within 30 days post-discharge. Despite non-adherence in two patients, both achieved clinical cure. The most notable adverse event was a rash, which prompted a change in therapy. 
Conclusion: No definitive conclusions can be drawn at this time due to the small sample size and data available only for one arm of the study. Given the limited sample size, further research with a larger cohort is needed to explore factors influencing adherence and its potential impact on clinical outcomes. Data collection is ongoing for both the intermittent infusion and continuous infusion groups, and additional retrospective data may be required to strengthen these findings.

Title:
Efficacy and Safety of Reduced-dose Insulin for the Treatment of Hyperkalemia in the Emergency Department 
Authors:
Blake Henderson, PharmD; Cortney Storey, PharmD, MBA; Cassey Starnes, PharmD, BCPS; Kevin Sullivan, PharmD, BCCCP; Elsa Hendrick, 2026 PharmD candidate; Jessie Lipstreuer, PharmD, BCEMP
Objective:
The purpose of this study was to assess the efficacy and safety outcomes between patients treated with reduced-dose versus standard-dose insulin for the treatment of hyperkalemia in the emergency department
Self-Assesment Question:
What is the recommended standard IV insulin dose for the treatment of hyperkalemia in the emergency department?
Background:
Hyperkalemia is a common, potentially fatal electrolyte abnormality. Hyperkalemia occurs in 1% - 10% of hospitalized patients with up to 2% - 3% identified in the emergency department. Recent estimates have shown that hyperkalemia leads to more than 800,000 annual emergency department (ED) visits in the United States with a growing prevalence due to an aging population with associated comorbidities
Methods:
This single-center, retrospective, IRB-approved study evaluated adult patients who received intravenous (IV) insulin, either reduced dose of 5 units or standard of 10 units, for the treatment of hyperkalemia from January 1, 2020 to July 31, 2024. Exclusion criteria included patients who received IV insulin for indication other than hyperkalemia, missing repeat labs within 12 hours of insulin administration, and receipt of emergent dialysis prior to first repeat potassium. The primary outcome was median change in potassium, defined as change from baseline to first repeat potassium, then from 4-18 hours post administration of the first dose of IV insulin. Secondary efficacy outcomes included repeat IV insulin doses required for persistent hyperkalemia within 12 hours, change in blood glucose (BG) at 1, 6, and 12 hours post IV insulin, additional dextrose given within 12 hours of initial IV insulin, pathway compliance with appropriate initial insulin dose and initial appropriate dextrose given for patients with a BG < 250, and hospital length of stay. The primary safety outcomes included incidence of hypoglycemia (BG <70 mg/dL) and severe hypoglycemia (BG < 54 mg/dL). IV insulin. Data was sourced from the electronic medical record and collected using REDCap and statistical analysis was conducted using SPSS. Continuous data was assessed using Student’s t-test or Mann-Whitney U test. Categorical data was assessed using Chi-square test or Fisher’s exact test.
Results:
Forty-six patients were included in the standard dose insulin group and ninety patients were included in the reduced dose insulin group. The primary outcome, mean change in potassium, was not significantly different between both groups [95% CI: -0.296 to 0.236; p=0.83) or at 4-18 hours post IV insulin administration [95% CI: 0.429 to -7.346; p=0.43]. For secondary efficacy outcomes, there was no statistically significant difference in glucose levels at baseline [95% CI: -45.935 to 13.849; p=0.29), 6 hours [95% CI: -36.146 to 19.566; p=0.56], or at 12 hours post IV insulin administration [95% CI: -33.120 to 20.129; p=0.63]. For safety outcomes, no statistically significant difference was found in incidence of hypoglycemia (10 vs 22 patients, p = 0.52) or severe hypoglycemia (6 vs 10 patients, p = 0.91) in both groups.
Conclusions:
In this retrospective, observational study, there was no difference found in median reduction of potassium levels with standard dose IV insulin vs reduced dose IV insulin. No significant differences in secondary safety and efficacy outcomes were observed.

Title: Pharmacist Impact Within a Post-Intensive Care Clinic at a Safety Net Hospital 
Objective: To evaluate the impact of a critical care pharmacist in the Post-ICU Clinic (PIC).


Self Assessment Question: Describe the most common interventions made by the critical care pharmacist in the PIC clinic?


Authors: Alexandria Howell1, Sam Pournezhad1, Tarun Kapoor2, Nicole Herbst3, Marina Rabinovich1 

1. Grady Memorial Hospital; Atlanta, GA
2. Emory University Hospital, Atlanta, GA
3. Hershey Medical Center, Hershey, PA

Background: It is estimated more than half of intensive care unit (ICU) survivors are faced with a constellation of new symptoms following prolonged ICU stays. Post-ICU Syndrome is defined as new onset weakness, fatigue, cognitive decline, intrusive memories, and/or depression, and is associated with poor quality of life and increased risk of rehospitalization. ICU survivors require close follow-up with continuity of care to ensure all problems are appropriately addressed. Post-ICU Clinics have been established to combat these public health concerns; however, there are a limited number of clinics nationwide. The PIC at Grady Memorial Hospital is a multidisciplinary clinic consisting of a critical care clinical pharmacist, critical care physician, and physical medicine and rehabilitation physician. Pharmacists play a critical role in the clinic by evaluating the patient’s quality of life and ensuring optimization of medication regimens.  


Purpose: To describe and quantify the interventions made by critical care trained pharmacists in the post-ICU ambulatory setting. 


Methods: This was a single centered retrospective chart review study evaluating critical care trained pharmacist interventions in the PIC Clinic from June 2022 to July 2024. Patients were referred to the PIC clinic if they spent more than 4 days in the ICU and/or more than 48 hours mechanically ventilated. Adult patients evaluated by the clinical pharmacist during the PIC visit were included for study evaluation. The primary endpoint was the total number of pharmacist interventions and median number per patient. Secondary endpoints included types of medication interventions and medications classes with interventions. 
 
Results: One-hundred patients met inclusion criteria. More than half (53%) of patients were admitted to the medical ICU. The most common ICU diagnosis was respiratory failure (36%), followed by trauma (25%). Clinical pharmacists completed 254 interventions during the time period, with a median of 3 per patient (interquartile range [IQR] 1.8-4). The most common intervention was medication initiation (24%) followed by medication discontinuation (23%). Medication classes with the highest frequency of pharmacist interventions were analgesics (25%) followed by cardiac medications (22%). 
 
Conclusion: The critical care clinical pharmacist is a key member of the PIC by providing medication interventions with a median of 3 per patient. Medication interventions performed by the pharmacist may optimize patients’ pharmacotherapy regimens and quality of life but additional studies are needed. 
 

Title: Antidote Assessment in a Community Health System

Authors: Madison Owen, Rachel Rumbarger, Jon Oriet, Jonathan Worley

Objective: Identify antidote management trends to improve patient safety and outcomes.

Self Assessment Question: Which of the following is a key factor in improving patient outcomes related to antidote management?

Background: Antidotes are essential in the management patients with toxic exposures, as delays or unavailability can significantly increase morbidity and mortality. However, global deficiencies in antidote stocking arise due to infrequent use, limited education, inadequate awareness, supply chain interruptions, and constrained hospital resources. Expert consensus guidelines for antidote stocking in hospitals were updated in 2018 to address these challenges. Cone Health initially evaluated its antidote PAR (Periodic Automatic Replenishment) levels in 2018, based on these guidelines. Since then, changes in drug availability, the introduction of new antidotes, system expansions, and a lack of routine oversight necessitated a 2024 review. This review identified misalignments with updated guidelines, leading to system-wide inventory adjustments at emergency care locations. Changes were driven by guideline recommendations, usage patterns, waste considerations, and cost-effectiveness, leading to adjustments in PAR levels for 18 antidotes across multiple closely located sites. This study aimed to evaluate current antidote practices and assess whether recent inventory changes improved alignment with guidelines and patient care.

Methods: This was a multi-center, IRB-approved, retrospective study that evaluated patients who received a select antidote for a toxicological emergency at four hospitals and two free-standing emergency departments​ within Cone Health. Exclusion criteria included incomplete medical records, antidote use outside of toxicological emergencies, or patients treated in non-emergency settings. Utilizing the 2018 Expert Consensus Guidelines for Stocking of Antidotes in Hospitals That Provide Emergency Care and the in-house hospital vulnerability assessment updates and antidote indication and dosing updates, the inventory PAR levels for antidotes at Cone Health were updated, resulting in modifications to the PAR levels for digoxin immune fab, glucagon, and 16 other antidotes. A pre-post intervention design was used, with pre-intervention data collected from March 2018 through March 2024 and post-intervention data from April 2024 through February 2025. The primary objective was to assess the composite appropriateness of antidote utilization based on guideline recommendations, including dose accuracy and time to administration. Secondary objectives included evaluating individual metrics for dose and administration timing and determining the adequacy of current antidote inventory. Descriptive statistics were utilized for analysis.

Results: A total of 231 patients met inclusion criteria, with 128 in the pre-intervention group and 103 in the post-intervention group. Following antidote inventory adjustments, adherence to guideline-recommended dosing improved, with no cases of suboptimal dosing in the post-intervention group. For the composite primary outcome, optimal timing was achieved in 70% (90/128) of cases and optimal dosing in 97% (124/128) in the pre-intervention group, compared to 71% (73/103) and 100% (103/103), respectively, in the post-intervention group. Despite modifications to PAR levels, including increases for some antidotes, no instances of stock depletion leading to treatment delays were observed. Inventory adequacy was maintained across all emergency care sites.

Conclusion: Optimizing antidote inventory based on updated guideline recommendations improved adherence to dosing accuracy and administration time without compromising availability. The modest reduction in administration time suggests improved efficiency, though further enhancements could positively impact patient outcomes. These findings underscore the importance of routine antidote inventory assessments in improving patient safety and resource management. Future research should focus on prospective antidote utilization evaluation, identifying opportunities for optimization through order set utilization, and cost-effectiveness analysis to refine stocking strategies further.

Title: Evaluating the Use of Angiotensin II vs. Methylene Blue in the Management of Refractory Distributive Shock in Patients with Liver Failure  
Authors: Kaanan Shah, Marion Javellana, Peter Moran, Kendall Huntt, Alley Killian  
Background: Angiotensin II (AGII) and methylene blue (MB) are agents used in the management of refractory shock as adjunctive agents, typically in combination with catecholamines, vasopressin, and/or corticosteroids. However, many studies have excluded patients with liver failure. In liver failure, patients experience a high cardiac output and low systemic vascular resistance causing hypotension. These agents are thought to be beneficial in this setting as AGII activates angiotensin type 1 receptors thus increasing blood pressure and systemic vascular resistance and MB disrupts the cGMP signaling pathway leading to vasoconstriction. The purpose of this study is to compare the efficacy of AGII and MB in refractory shock in patients with liver failure.  
Methods: The institutional review board approved this single center, retrospective chart review study. Patients over the age of 18 that received AGII for at least 3 hours or a bolus dose of at least 1 mg/kg and/or a continuous infusion of MB between October 1, 2022 through September 16, 2024 were included. Patients were excluded if they had no documented liver failure, were pregnant, had active internal bleeding or cardiogenic shock, received intraoperative administration of the study agents or MB as an antidote. The primary outcome is the improvement of shock defined as a percent decrease in catecholamine and vasopressin requirement 3 hours after administration of the study agent based on norepinephrine equivalence. Secondary outcomes include percent decrease in catecholamine and vasopressin requirements at the 1-, 8-, and 24-hour marks post-initiation of the study agents, liberation from vasopressors, adverse events, length of ICU stay, and incidence of ICU mortality. Data from the primary and secondary outcomes were analyzed using intention-to-treat and continuous data was compared using the student t-test or Mann-Whitney U test to determine statistical significance.   
Results: Twenty-four patients were included, with five patients in the AGII group and 19 patients in the MB group. Vasopressor requirements decreased at the 3-hour mark after MB but increased after AGII, though not a statistically significant difference (-11.7 vs. +11.3; p = 0.783). Only 18 patients in the MB group and 4 patients in the AGII group survived to the 8-hour mark and there was an increase in NE equivalence with both MB and AGII (+ 9.9 vs. + 38.3; p = 0.731). Additionally, only 15 patients in the MB group and 3 patients in the AGII group survived to the 24-hour mark and patients in the MB group saw a decrease in NE equivalence while patients in the AGII group saw an increase (-15.1 vs. +71.8; p = 0.331). Mortality in the 94.7% in the MB group and 80% in the AGII group. One patient in each group was successfully liberated from vasopressors.     
Conclusions: AGII and MB are agents used to treat refractory shock. This study demonstrated MB’s potential benefit, compared to AGII, in managing shock in patients with liver failure with an initial reduction in vasopressor requirements. The lack of sustained response to the study agents could potentially be explained by the severity of hepatic dysfunction and associated vasodilatory shock. The two patients who were liberated from vasopressors received liver transplants. Limitations of this study include a small and unequal patient population, the retrospective, single-center nature of the study, and its local applicability. This highlights a need for further research on these agents in the management of shock in patients with liver failure in order to find a beneficial place in therapy for them.  

Title: Comparison of emergency department weight based levetiracetam dosing in patients with status epilepticus  
Authors: Zackery Moreo, Kelly Bodine, Olivia Morgan, John Patka  
Objective: Evaluate impact of levetiracetam dosing in the ED on need for subsequent antiseizure medications (ASMs)  
Self-Assessment Question: What is the optimal dose of levetiracetam in patients with SE? 
Background: Status epilepticus (SE) is defined as a seizure with five minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures. SE is a neurological emergency requiring immediate evaluation and management to prevent significant morbidity and mortality. Benzodiazepines are first line treatment for aborting seizure activity; however, in SE seizures may be refractory requiring second line treatment options. Guidelines for SE recommend the use of levetiracetam as a second line agent but, the dosing recommendations for levetiracetam vary. Other available studies have compared the use of levetiracetam at various doses to other antiseizure medications (ASMs), but few have compared the efficacy of different levetiracetam dosing strategies to each other. Due to this and the variation in guideline recommendations, dosing throughout the emergency department (ED) may differ. 
Methods: This was a retrospective cohort study of adult patients presenting to the ED with SE and received at least one dose of levetiracetam from January 2023 to December 2023. The primary outcome was percentage of patients requiring subsequent ASM’s 6-hours from initial levetiracetam dose. Secondary outcomes included the percentage of patients receiving guideline recommended dose of benzodiazepines, use of institutional order set, escalation of care (ICU admission or intubation). Primary and secondary outcomes were assessed utilizing Chi-Square analysis. 
Results: A total of 300 patients were screened, 253 patients met inclusion criteria and were included in the final analysis. There was a total of 145 patients in the levetiracetam ≥ 60 mg/kg group and 108 patients in the levetiracetam < 60 mg/kg group. Patients had median age of 60, majority were male (56.6%) and black (82%). Patients had a mean weight of 73.1 kg (±18.2) in ≥ 60 mg/kg group and 80.1 kg (±22.6) in the < 60 mg/kg group. Ninety-seven patients (66.9%) in the ≥ 60mg/kg group had a history of epilepsy and 96 (66.2%) were prescribed ASM prior to admission, and 62 (57.4

Title: Comparative Effects of 3% Sodium Chloride Continuous Infusion Versus Intermittent Boluses on Renal Outcomes


Authors: Abbygail Wilbourn, Braiden Sorgenfrei, Alex Ewing, Jenna Sorgenfrei, Michael Wagner


Objective: Identify hypertonic saline administration that leads to decreased adverse renal outcomes while achieving target serum sodium levels for intracranial pressure management.


Self Assessment Question: What strategy does the 2024 American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) guidelines recommend for ICP management in TBI?


Background: Cerebral edema, often resulting from traumatic brain injury (TBI), can lead to elevated intracranial pressure (ICP), which is associated with poorer outcomes. American College of Surgeons and Neurocritical Care Society guidelines recommend hyperosmolar therapy, such as hypertonic saline or mannitol, for managing elevated ICP; however, these guidelines primarily focus on bolus dosing, with limited data on continuous infusion strategies. This study aims to evaluate whether intermittent bolus therapy reduces the incidence of acute kidney injury (AKI) compared to continuous infusion of hypertonic saline, with the goal of improving safety and informing best practices for hyperosmolar therapy at a 864-bed academic medical center in South Carolina, USA.


Methods: This single-center, retrospective study at a 864-bed academic medical center in South Carolina, USA assessed trauma patients admitted to the ICU between January 2022 and December 2023 who received either intermittent boluses or continuous infusion of 3% sodium chloride for suspected elevated intracranial pressure (ICP). Primary outcomes included the combined incidence of acute kidney injury (AKI), hyperchloremia, and metabolic acidosis within 7 days, while secondary outcomes focused on individual complications, time to serum sodium goals, and major renal events. Data were collected through chart review and stored in REDCap, with approval from the institution’s IRB.


Results: A total of 88 patients were included (61 continuous infusion, 27 bolus). Continuous infusion patients were younger and had longer ICU stays (6.8 vs 4.8 days, p=0.02), though hospital stays were similar. Hypertonic saline exposure was higher in the continuous group, particularly on days 2–3 (p<0.001). The combined incidence of acute kidney injury, hyperchloremia, and metabolic acidosis was significantly higher in the continuous group (91.8% vs 66.7%, p=0.009), mainly due to hyperchloremia (p=0.002). Multivariate analysis confirmed infusion method as a significant predictor (aOR 0.19, p=0.03). Switching to sodium acetate occurred in 38 patients, more commonly in the infusion group but not statistically significant. Those who switched had higher hyperchloremia incidence after day 4 (p=0.0009). No differences were found in secondary outcomes.


Conclusion: Bolus therapy achieved similar time to target sodium levels while resulting in fewer electrolyte-related complications—particularly hyperchloremia—and a lower combined incidence of kidney injury, hyperchloremia, and metabolic acidosis compared to continuous infusion. These findings suggest that bolus therapy may be a safer and more favorable strategy for hypertonic saline administration.

Title: Evaluating the Safety and Efficacy of Vasopressin in Patients with Hemorrhagic Shock


Authors: Amanda Fisher, Martin Gordon, Sarah Frye


Objective: Evaluate the safety and efficacy of vasopressin on blood and fluid requirements in hemorrhagic shock.


Self-Assessment Question: True or false: In this study, patients who received vasopressin had significantly lower requirements of blood products compared to those who did not receive vasopressin.


Background: Hemorrhagic shock is associated with a high rate of mortality in the first 24 hours following injury. Management includes stopping the bleeding, aggressive fluid resuscitation, and preventing hypotension. Complications of fluid resuscitation include increased bleeding, acute respiratory distress (ARDS), hemodilution, and hypothermia. There is controversy over whether early initiation of vasopressors can reduce fluid requirements and restore hemodynamics. Arginine vasopressin (AVP) is a neuropeptide that is secreted in response to hypotension by the posterior pituitary. It is essential in maintaining vasomotor tone in hypovolemic and septic shock, and secretion is associated with vasoconstriction. In hemorrhagic shock, patients are at risk of AVP deficiency in the first 48 hours of injury. While not currently recommended by the Advanced Trauma Life Support guidelines, vasopressors can be used when blood pressure is unable to be maintained despite volume resuscitation and are addressed in the European guidelines. This study is designed to compare vasopressin used adjunctly with a catecholamine vasopressor to a catecholamine vasopressor alone on the cumulative volume of blood products infused in a 48-hour period in trauma patients admitted with hemorrhagic shock.


Methods: This was a single center, retrospective, cohort study that evaluated the safety and efficacy of utilizing vasopressin with catecholamine vasopressors on the cumulative volume of blood products in patients with hemorrhagic shock. Included patients had a diagnosis of hemorrhagic shock, received catecholamine vasopressors, and were treated in an adult critical care unit from January 2020 to January 2024.Patients were excluded if they received CPR on arrival or immediately prior to hemorrhagic shock diagnosis, those with “do not resuscitate” orders at the time of diagnosis, and those who had hemorrhagic shock due to a gastrointestinal bleed. The primary outcome of the study was the cumulative volume of blood products infused within 48 hours after diagnosis of hemorrhagic shock. Secondary outcomes included cumulative volume of crystalloid fluids, total vasopressor requirements, ICU length of stay, and 30-day mortality.


Results: A total of 63 patients met inclusion criteria with 15 patients in the vasopressin group and 48 in the vasopressor only group. Patients in the vasopressin group received 10 units of blood compared to 12 units of blood in the vasopressor only group (p=0.846). Those in the vasopressin group had higher cumulative vasopressor requirements over a 48-hour period (12,621 mcg norepinephrine equivalents vs 240.5 mcg norepinephrine equivalents, p=0.002) and had a longer duration of mechanical ventilation compared to the vasopressor only group (4 days vs 2 days, p=0.023). There were no significant differences in cumulative fluid, 30-day mortality, ICU and hospital length of stays, and adverse events.


Conclusion: This study demonstrated that the use of vasopressin did not decrease the volume of blood products utilized in hemorrhagic shock patients; however, patients receiving vasopressin had higher vasopressor requirements and required mechanical ventilation longer than those who received vasopressors alone.