2025 Southeastern Residency Conference

TITLE: Auto-verification Resulting in Medication Errors in the Emergency Department


AUTHORS: Courtney Ellison, Nichole Moore, Rachel Rossi, Christopher Whitman, Rachel Foster, Amanda Williams, and Maria Berec


BACKGROUND: Auto-verification is a process commonly utilized by hospitals to increase workflow. The Joint Commission and the American Society of Health-System Pharmacists (ASHP) provide standards to incorporate into auto-verification software, such as “do not verify” criteria, to ensure safety. Available literature has demonstrated the proficiency of auto-verification; however, limited studies have evaluated its safety. This study aimed to assess current medications auto-verified in a health system’s emergency department for the rate of errors and compare them to medications verified by a pharmacist while observing the differences in time of verification and time of administration of first doses.

METHODS: A multi-site retrospective cohort study of auto-verified adult and pediatric medication orders from July 2023 through September 2023 was conducted. Data for antibiotic and anticoagulant medication orders auto-verified in patients ≥ 19 years old and auto-verified pediatric (≤ 18 years old) orders were collected and compared to orders verified by pharmacists. Orders entered by pharmacists were excluded from the study. Medication order numbers were placed in a random list generator to identify comparator groups and evaluated based on medication, dose, frequency, indication, and if duplicates were present. Other data collected included patient demographics, location, time of ordering, time to verification, and time to administration. The primary endpoint was the rate of medication errors, which were classified based on the type of error. Secondary endpoints included near misses, average ordering, administration, and verification time. Fisher's exact test and relative risk ratios used to analyze the primary endpoint.

RESULTS: A total of 1,003 medication orders were retrospectively evaluated between July 2023 through September 2023. Comparator groups consisted of 251 samples per group: adult auto-verified antibiotics and anticoagulants, adult pharmacy-verified antibiotics and anticoagulants, and pediatric auto-verified medications, with 250 samples in the pediatric pharmacy-verified medications group. Thirty-two medication errors were identified among the adult auto-verified group, and 10 in the adult pharmacy-verified group. The rate of medication errors among the pediatric orders auto-verified and pharmacy-verified orders were 14 and 4, respectively. Incorrect dosing accounted for most errors identified among the auto-verified adult (50%; 16/32) and pediatric orders (79%; 11/14). For the primary endpoint there was a relative risk of 3.3 (95% CI 1.66 – 6.55; p=0.0003) for the adult population and a relative risk of 3.48 (95% CI 1.16 – 10.44; p=0.028) for the pediatric population. The average times to order verification were 13.2 minutes for adults and 6.9 minutes for pediatrics. The average times to administration for auto-verified orders were 29.1 minutes in adults and 18.6 minutes in pediatrics. Of all the medication errors identified, 21.7% (10/46) were considered near misses.

CONCLUSION: Auto-verification can provide proficient patient care in fast-paced settings where accuracy is vital. Periodic evaluation of this process is essential to evaluate the safety of present standards. Among medications auto-verified in the emergency department, there was a statistically significant difference compared to pharmacy-verified medications in adult and pediatric patients. Limitations identified were a small percentage of patients’ renal functions were evaluated among auto-verified orders (49% adults and 18% pediatrics), and most orders were one-time doses. The randomization process was considered a limitation because medications in the auto-verified groups were inconsistent with pharmacy-verified groups in terms of specific drugs. The results of this study will be utilized for quality improvement purposes for auto-verification criteria and safety evaluation of other drug classes commonly auto-verified.

Title: Evaluation of the Safety and Efficacy of Early Long-Acting Insulin in Diabetic Ketoacidosis

Authors: Emily Davis, McKenzie Hodges, Lauren Duty, Aayush Patel

Background: Diabetic ketoacidosis (DKA) is a life-threatening complication of uncontrolled diabetes mellitus. Hospital admissions for DKA have increased significantly, rising by 55% over the past decade. Treatment for lowering blood glucose and resolving acidosis in DKA is to administer short-acting insulin via continuous infusion. Once resolved, subcutaneous long-acting insulin is administered one to two hours prior to discontinuing the continuous infusion. This current standard of care is time-intensive, requires heightened monitoring, and is associated with rebound hyperglycemia as well as transition failure. Insulin glargine, a long-acting subcutaneous insulin, is conditionally recommended by the American Diabetes Association 2024 Consensus Report as an adjunct therapy to continuous IV insulin to reduce the duration of treatment and improve outcomes. Preliminary literature supports earlier administration of insulin glargine with continuous IV insulin for reducing time to DKA resolution and hospital length of stay without increasing hypoglycemia risk. However, there are uncertainties as to which patient population would benefit best from earlier long-acting insulin administration and what dose of insulin glargine to utilize. The purpose of this study was to determine the impact of administering insulin glargine within three hours of initiating continuous IV insulin in moderate to severe DKA patients.

Methods: This was a retrospective chart review conducted at Piedmont Columbus Regional Midtown of adult patients diagnosed with moderate or severe DKA who received continuous IV insulin and early insulin glargine. Early administration was defined as insulin glargine given within three hours of IV insulin initiation, whereas late administration was insulin glargine given at transition. The primary objective of this study was to compare the time to DKA resolution between patients who received early insulin glargine versus those who received late. The secondary objectives were to compare hospital length of stay, the rate of blood glucose decline, incidence of DKA reoccurrence, incidence of hypoglycemia, and incidence of hypokalemia in patients who received early insulin glargine versus those who received late. All outcomes were analyzed using student t-test or descriptive statistics. Patients were excluded if they presented with euglycemic DKA, were diagnosed with septic shock, required surgery within 48 hours of continuous IV insulin discontinuation, received continuous IV insulin for less than six hours, and/or received systemic steroids during admission.

Results: There was a total of 100 patients included in the study, 22 patients that received early insulin glargine and 78 that received late. Baseline characteristics were not significantly different between groups, with most patients having severe DKA and a history of type one diabetes. For the primary outcome of time to DKA resolution, the average time for late administration was 14.77 hours and 13.18 hours for early. The average time to DKA resolution was not significantly different between groups. For the secondary outcomes, average hospital length of stay was 2.99 days for late administration and 3.86 days for early. Average decrease in blood glucose per hour was significantly different with 35.94 for late administration and 53.42 for early. Incidence of DKA reoccurrence was significantly different with 26% of patients who received late administration and 4.5% of patients who received early. Incidence of rebound hyperglycemia was significantly different with 71% of patients who received late administration and 23% of patients who received early. Incidence of hypoglycemia was 13% of patients who received late administration and 14% of patients who received early. Incidence of hypokalemia was 56% of patients who received late administration and 50% of patients who received early.  

Conclusion: Early administration of long-acting insulin has the potential to mitigate DKA reoccurrence. Administering insulin glargine earlier in the treatment course had a similar safety profile to the current standard of care with no significant differences in hypoglycemia or hypokalemia. Further research is needed to fully determine the optimal timing of administration and dose of insulin glargine. 

Contact: Emily.Davis2@piedmont.org

Title: Evaluation of Venous Thromboembolism Prophylaxis in Conjunction with Low Dose Rivaroxaban in Hospitalized Patients
 
Authors: Kara Bamberger, Matt Wallace, Regan Wade
 
Background: Acute venous thromboembolism (VTE) is a common, preventable complication in hospitalized patients that contributes to significant morbidity and mortality. Current guidelines recommend the use of unfractionated heparin (UFH), low molecular weight heparin (LMWH), or fondaparinux for pharmacologic prophylaxis in hospitalized patients at risk of developing VTE. Alternatively, rivaroxaban, an oral factor Xa inhibitor, can be utilized as VTE prophylaxis at a dose of 10 mg daily. Rivaroxaban is also approved for the indications of stable coronary artery disease (CAD), recent acute coronary syndrome (ACS), and peripheral artery disease (PAD) at a lower dose of 2.5 mg twice daily, in conjunction with aspirin at doses less than 100 mg daily. However, its VTE prophylactic benefits at this dosing in hospitalized patients is unclear, making the need for additional pharmacologic VTE prophylaxis uncertain. At Vanderbilt University Medical Center (VUMC), the practice for mitigating VTE risk among these patients is not standardized. 
 
Methods: A retrospective, single-center cohort study was conducted to evaluate the safety and efficacy of administering pharmacologic VTE prophylaxis in conjunction with low dose rivaroxaban in hospitalized patients. Patients were eligible for inclusion if they were 18 years of age or older, admitted to VUMC for at least 24 hours, administered at least one dose of low dose rivaroxaban, and had an indication for VTE prophylaxis based on a PADUA prediction score of ≥4. Patients were excluded if they had established an VTE event prior to inclusion, were receiving or had an indication for therapeutic anticoagulation, or a contraindication to VTE prophylaxis. The primary outcome evaluated was a composite of new VTE events during hospitalization and clinically significant bleeding events. Secondary outcomes evaluated were hospital length of stay and the time to initiation of VTE prophylaxis after admission.
 
Results: In progress
 
Conclusions: In progress

Title: 
Efficacy and Safety of Bivalirudin Compared with Heparin Anticoagulation in Critically Ill Patients Requiring Venovenous Extracorporeal Membrane Oxygenation


Authors: 
Brianna R. Landrum; Nick Tran; Kayla A. Lawlor; Sagar B. Dave; Christina Creel-Bulos; Casey Miller; Jolie Gallagher


Objective: 
To evaluate the efficacy and safety of bivalirudin compared with heparin anticoagulation in critically ill patients requiring VV-ECMO.


Self Assessment Question: 
The ELSO General Guidelines currently recommend unfractionated heparin as the preferred
anticoagulant for patients requiring VV-ECMO.
a) True
b) False


Background: 
Extracorporeal membrane oxygenation (ECMO) is an invasive mechanical circulatory support
system that is utilized in the management of critically ill patients. Veno-venous ECMO (VV-ECMO) is primarily used for patients with respiratory failure, and anticoagulation is crucial to prevent thrombosis. Both unfractionated heparin (UFH) and bivalirudin are commonly used anticoagulants in ECMO; however, the data comparing these agents in VV-ECMO is sparse. Therefore, this study aims to evaluate the efficacy and safety of bivalirudin compared with heparin anticoagulation in critically ill patients requiring VV-ECMO.


Methods:
This retrospective study was conducted at Emory University Hospital (EUH), including adult
patients (≥18 years) who received VV-ECMO between January 2020 and April 2024. Patients who were anticoagulated with either UFH or bivalirudin within 24 hours of VV-ECMO cannulation were included. Exclusion criteria included pregnancy, history of factor deficiencies, history of Chronic Thromboembolic Pulmonary Hypertension (CTEPH), VA-ECMO cannulation, single-site cannulation, death or withdrawal of care within 24 hours of VV-ECMO cannulation, or ECMO managed at an outside hospital (OSH) for greater than 30 days. The primary outcome was the incidence of VV-ECMO circuit or oxygenator exchange. Secondary outcomes included time spent within the therapeutic anti-Xa and activated partial thromboplastin time (aPTT) ranges, ICU and hospital length of stay, duration of mechanical ventilation and VV-ECMO support, and the incidence of systemic thrombosis and post-decannulation thrombosis. Safety outcomes included the total volume of blood products transfused, the incidence of new hemorrhage, the occurrence of thrombocytopenia or heparin-induced thrombocytopenia (HIT), and mortality rates, including both inpatient and pre-decannulation mortality, as well as mortality at 28 days.


Results:
A total of 124 patients were included, with 75 receiving UFH and 49 receiving bivalirudin.
Baseline characteristics were similar between the two groups, though patients receiving bivalirudin had a higher Sequential Organ Failure Assessment (SOFA) score (10 for UFH vs. 12 for bivalirudin, p=0.007) and a larger number of patients with COVID-19 as a primary diagnosis [3 (0.04%) for UFH vs. 26 (53.06%) for bivalirudin]. There were no significant differences in the primary outcome of circuit or oxygenator exchange between the two groups (8.0% for UFH vs. 12.2% for bivalirudin, p=0.538). However, patients on bivalirudin spent a significantly greater proportion of time within the therapeutic aPTT range compared to UFH (58.5% vs. 33.3%, p<0.001). Secondary outcomes showed that patients in the bivalirudin group had significantly longer ICU and inpatient stays, as well as longer durations of mechanical ventilation and VV-ECMO. Both groups had similar rates of hemorrhage and thrombosis, but the bivalirudin group had a significantly higher rate of in-hospital (40.8% vs. 17.3%, p=0.004) and pre-decannulation mortality (36.7% vs. 16.0%, p=0.008).


Conclusion:
In patients receiving VV-ECMO, there was no difference in the rate of circuit or oxygenator
exchange between bivalirudin or UFH. Bivalirudin was associated with longer ICU and hospital length of stay, increased mechanical ventilation and ECMO duration, and higher in-hospital and pre-decannulation mortality compared to UFH. However, there were no differences in the rate of thrombosis or hemorrhage between the two anticoagulants. The observed differences in outcomes may be attributed to the higher severity of illness in the bivalirudin group, particularly among patients with COVID-19. Despite bivalirudin providing more predictable anticoagulation, these findings suggest that further research with larger, prospective studies and standardized anticoagulation protocols is needed to better define the optimal anticoagulant for VV-ECMO patients.

Title: Evaluation of a Pharmacist Driven Intensive Care Unit Bowel Regimen 
Authors: Rachael Weingarten, PharmD; Jessica Millen, PharmD, BCPS, BCCCP; Caitlin Edwards, PharmD 
Cone Health Moses Cone Hospital
Objective: To discuss and evaluate practice change surrounding the standardization of a pharmacist driven ICU bowel regimen 
Self-Assessment Question: True/False: A pharmacist-driven bowel regimen in the ICUs may lead to a decreased time to first bowel movement?
Background: Constipation is one of the most common gastrointestinal problems in critically ill patients affecting up to 80% of adults in the intensive care unit (ICU). Studies have found that constipation is associated with poor clinical outcomes including increased infection rates, ICU mortality, prolonged duration of mechanical ventilation, and length of ICU stay. In the ICU, opioids are the cornerstone treatment for moderate to severe pain and are notorious for causing constipation. Bowel care in the ICU is often neglected, and it is unclear whether bowel protocols can prevent downstream patient outcomes. Previously at Cone Health, there was no standardized bowel regimen for the prevention and treatment of constipation in critically ill patients. In April 2024 a pharmacist-driven bowel regimen was implemented in Moses Cone Memorial Hospital ICUs to manage different forms of constipation. The purpose of this study was to evaluate the impact of this pharmacist-driven standardized ICU bowel regimen management protocol for acute opioid-induced constipation in critically ill patients.
Results: A total of 87 patient charts were evaluated and 47 patients were included in the final analysis. A total of 20 patients were included in the pre-intervention group and 27 in the post-intervention group. The average age was younger at 58 years old in the pre-intervention group compared to 62 years old in the post-intervention group. There were more caucasian patients in the post-intervention group (56% vs. 45%) and more patients admitted to the cardiovascular ICU in the pre-intervention group (60% vs. 13%). The most common additional medication contributing to constipation was diuretic therapy in both groups. The number of days without a bowel movement was 5.29 in the pre-intervention group compared to 4.1 in the post-intervention group (p-value: 0.08). 2 patients in the pre-intervention group experienced diarrhea compared to 8 patients in the post-intervention group (p-value: 0.08). There was no statistically significant difference in any of the other secondary endpoints.  
Conclusion: A standardized pharmacist-driven ICU bowel regimen demonstrated a numerical trend toward a reduction in the number of days to achieve a bowel movement. 

TITLE: Feasibility and Impact of a Pharmacist-Driven Fosphenytoin Dosing and Monitoring Program 
AUTHORS: Tristan Underwood, Vince Buttrick, Erik Turgeon 
OBJECTIVE: Describe the benefits of implementing a pharmacist-driven fosphenytoin dosing and monitoring program.  
BACKGROUND: Fosphenytoin requires careful monitoring due to its narrow therapeutic range and complex pharmacokinetics. Studies have demonstrated that pharmacist-directed dosing programs can improve dosing accuracy, optimize serum levels, and reduce adverse events. The purpose of this study was to evaluate the impact of a pharmacist-driven fosphenytoin dosing and monitoring program on adherence to FDA approved fosphenytoin dosing and recommended lab monitoring for the treatment of seizures. 
METHODS: Data was collected for adult patients admitted to the hospital who received at least one dose of fosphenytoin between July 2023 – July 2024 and November 2024 – March 2025. The intervention was a pharmacist-driven, hospital-wide fosphenytoin dosing and monitoring program that included a fosphenytoin order panel and an automatic in-basket message notifying pharmacy of phenytoin levels. The primary endpoint was to compare adherence to FDA approved fosphenytoin dosing and recommended lab monitoring in the pre-implementation and post-implementation groups. The secondary endpoints included frequency of re-current seizures and number of fosphenytoin related pharmacist interventions. 
RESULTS: In progress.
CONCLUSIONS: In progress. 

Title: Comparison of Alteplase versus Tenecteplase for Treatment of Acute Ischemic Stroke at a Large Community Hospital


Authors: Abigail Edwards, Rachel Settle, Anne Astin, Anna-Kathryn Priest


Background: Although tenecteplase lacks FDA approval for acute ischemic stroke, the evidence available suggests tenecteplase is non-inferior to alteplase and potentially more efficacious in patients with large vessel occlusion strokes. The 2019 American Heart Association/American Stroke Association and 2023 European Stroke Organization Recommendations currently state that tenecteplase is a reasonable alternative over alteplase for use in acute ischemic stroke. In November 2023, the Baptist Health System transitioned to tenecteplase from alteplase for eligible patients with acute ischemic stroke. The purpose of this study is to compare the efficacy and safety of alteplase versus tenecteplase for acute ischemic stroke in the Baptist Health System.
 
Methods: This is an institutional review committee approved retrospective, single-center observational cohort study using electronic health records of adult patients 19 years of age or older within the Baptist Health System before and after the transition to tenecteplase for acute ischemic stroke. Patients were included if they had a documented NIHSS score and received either tenecteplase or alteplase for acute ischemic stroke. Data on tenecteplase was collected between November 2023 and June 2024, and an equal number of patients who received alteplase was collected in the months prior to the system-wide change.
 
Results: Of the 136 electronic medical records reviewed, 94 met inclusion criteria. The average change in NIHSS score was -4.5 in the tenecteplase group versus -3.9 in the alteplase group. There was a total of 5 bleeding events in the tenecteplase group versus 10 in the alteplase group. When comparing clinically significant bleeds ( ≥ 4 increase in NIHSS), tenecteplase had 1 while alteplase had 2 bleeding events that met criteria. Neither the tenecteplase or alteplase group had a documented angioedema event.
 
Conclusion: Our study found that tenecteplase had a similar efficacy compared to alteplase when used for acute ischemic stroke in the Baptist Health System. Tenecteplase also had a comparable, if not slightly better, safety profile.

Title: Evaluating Treatment Compliance and Effectiveness for Opioid Use Disorder Through a Pharmacy Developed Emergency Department-Initiated Buprenorphine Protocol 
Authors: Dana Thorvilson, Kevin Lynch, Charleen Melton, and Katie McLaurin 
Background: Opioid-involved overdose deaths accounted for 81,806 deaths in the United States in 2022, the most in any previous year, with 64.7% of deaths having at least one potential opportunity for intervention. With an increased number of opioid prescriptions and the emergence of synthetic opioids in the illicit market, emergency department (ED) visits for opioid overdoses, opioid withdrawal, complications of injection drug use and other opioid-related adverse events have escalated with an estimated one in every eighty ED visits in the United States. Naltrexone, methadone, and buprenorphine are Food and Drug Administration-approved medications for the treatment of opioid use disorder (OUD) and have been available for several decades; however, untreated OUD remains a public health problem. As the opioid crisis has worsened, the ED has become the front line and a crucial touchpoint for engaging patients in treatment for OUD and may be the only contact individuals with OUD have with the healthcare system. This study aims to evaluate the impact of a pharmacy developed, ED initiated buprenorphine or buprenorphine/naloxone protocol. 
Methods: An ED-based buprenorphine initiation protocol was approved for implementation at CaroMont Regional Medical Center (CRMC) on November 5th, 2024. This is a single-center, prospective cohort study that will be conducted from November 15

Title: Evaluation of Clinical Pharmacy Involvement in Emergency Department Culture Follow-up Services 


Authors: Leah J. Clark, Nicholas (Cade) Pritchett, Jason E. Dover, and Elizabeth W. Covington
Objective: At the conclusion of my presentation, the participant will be able to describe potential benefits of clinical pharmacist integration into culture follow-up services.
Self-Assessment Question: 
Which of the following best describes the impact of clinical pharmacist integration based on the results of this study?
A. Reduced 30-day re-hospitalization/ED re-visit
B. Reduced patient pick-up of follow-up prescription
C. Reduced fluoroquinolone prescribing for urine cultures
D. Reduced time to patient contact
 
Answer: D
Background: Recently, emergency departments (ED) have invested in programs such as microbiologic culture follow-up to ensure test results received post-discharge are followed up appropriately and in a timely manner. To preserve quality of care and improve workflow, pharmacists have been integrated into these services. Current literature mainly includes pre-post studies assessing culture follow-up services before and after pharmacist involvement.  The purpose of this study is to directly evaluate ED culture follow-up services between a main emergency department with pharmacy oversight compared to two externally located emergency departments without pharmacy oversight.
Methods: This single-center retrospective, observational study evaluated patients who had microbiology data resulting after discharge from the ED between August 2023- February 2024 at three EDs affiliated with East Alabama Health. Patients were excluded if they needed additional care, such as transfer or admission, or expired during their ED visit. A control group consisting of the external EDs (150 patients), where advanced practice providers independently manage culture follow-up, was compared to the main ED (150 patients), where clinical pharmacists are involved.  The primary outcome was time from culture result to first attempted patient contact. Secondary outcomes included callback intervention errors, time to initial culture review, and readmission rates. Categorical data were analyzed via chi-square or Fisher’s exact test. Continuous data were analyzed via student’s t-test or Mann-Whitney U test based upon distribution. Statistical significance was defined by a 2-tailed p-value < 0.05.
Results: Baseline characteristics were balanced between the groups with except for age and reason for ED visit. The median time from culture result to first attempted patient contact was 5.2 hours [1.7-27.3] in the main ED compared to 25.0 hours [5.8-57.6] for the external EDs (P < 0.001). The main ED also demonstrated fewer callback intervention errors, 8.7% versus 22.7% (P = 0.001), and shorter time to initial culture review, 3.1 hours [1.1-5.3] versus 8.8 hours [3.8-23.9] (P < 0.001). There was no difference in readmission or ED revisits.
Conclusion: There was a significant difference in time from culture result to first attempted patient contact with the integration of pharmacy services. Further research is needed to evaluate the impact pharmacy integration has on clinically relevant outcomes such as readmission.

Title: Time to Sedation Initiation after Rapid Sequence Intubation in Various Hospital Settings 


Authors: Danielle Wilson, Christen Freeman, Megan Heath


Background: Rapid sequence intubation (RSI) is a procedure for emergency airway management. Proper administration of induction and paralytic agents leads to quicker airway control and increases the rate of first pass success with an endotracheal tube. An induction agent, such as etomidate, propofol, or ketamine, is used to sedate the patient prior to paralysis and the RSI procedure itself. Rocuronium and succinylcholine are both paralytic agents, however rocuronium has a much longer duration of action and almost always outlasts the induction agent. There should be an urgency to start adequate sedation as soon as possible following intubation to minimize wakefulness with paralysis. The purpose of this study is to assess the time to sedation initiation (in minutes) following the administration of induction and paralytic agents for RSI in different areas of the hospital at DCH Regional Medical Center, including the emergency department (ED), medical-surgical units, and intensive care units (ICUs).


Methods: Patients were screened for inclusion from August 1, 2023 to July 31, 2024. Eligible participants included those ≥ 19 years of age who underwent RSI in the ED, a medical-surgical unit, or an ICU. Retrospective chart reviews were completed for the 150 patients that were included.


Results: The median time to sedation initiation after RSI was 16.5, 58, and 23minutes in the ED, medical-surgical units, and ICUs, respectively. Etomidate was the induction agent used most commonly (91.3%), and rocuronium was the paralytic agent used most commonly (87.3%). Induction agents were dosed appropriately about 80% of the time, however paralytic agents were only dosed appropriately about 30% of the time. Appropriate post-RSI sedation was initiated 72% of the time with continuous fentanyl and propofol infusions used together most often.


Conclusion: Overall, there is a gap between RSI agent administration and post-intubation sedation in each of the hospital settings evaluated. This gap is greater in the medical-surgical units likely due to the fact that continuous sedation is not available in those areas. With etomidate and rocuronium used most often, the gaps between RSI and post-intubation sedation raise a greater concern for patients having wakefulness with paralysis. While induction agents were often dosed correctly, dosing for paralytic agents appears to be an area for significant improvement. Lastly, the majority of patients were initiated on appropriate post-intubation sedation, however all patients need to receive deep sedation following RSI while the paralytic agent is still in effect.

Title: Safety and Efficacy of Alternative Insulin Dosing Strategies for the Management of Hyperkalemia


Authors: Savannah Small, Amanda Guffey, Erik Turgeon


Background: Hyperkalemia is a common electrolyte disorder that can lead to serious complications, and potentially life threatening cardiac arrythmias, if not managed appropriately. IV regular insulin is typically used in combination with other treatment strategies for the management of acute hyperkalemia due to its quick onset and modest duration. Current guidelines recommend administering insulin as an IV bolus of 10 units, typically in combination with 25-50g of dextrose to mitigate the risk of hypoglycemia. Despite coadministration with dextrose, 10 units of IV regular insulin given for the treatment of hyperkalemia, has been associated with significant rates of hypoglycemia. Some evidence suggests a lower incidence of hypoglycemia with comparable potassium lowering when utilizing 5 units as an IV bolus compared to 10 units of IV regular insulin.


Methods: Pre- and post-intervention chart review of hospital-wide hyperkalemia treatment encounters at a single-center, 607-bed teaching hospital in West Columbia, SC from October 2023 to April 2025. The intervention of this study is the modification of current hyperkalemia order sets from a default IV regular insulin dose of 10 units to a default of 5 units. This review will be utilized to compare the safety and efficacy of IV regular insulin administered at 5 units vs 10 units. The primary outcome is the incidence of clinically significant hypoglycemic events, defined as a blood glucose level less than 70 mg/dL, associated with IV insulin administration for the treatment of hyperkalemia. Secondary outcomes include potassium lowering effects of each IV insulin dosing strategy for the treatment of hyperkalemia and any relevant severe hypoglycemic events, defined as blood glucose levels less than 40 mg/dL. Hypoglycemic events and change in serum potassium levels were manually analyzed by the investigator through EHR-generated data and manual chart review.


Results: In progress.
Conclusion: In Progress.

Title: The Role of Lacosamide in the Treatment of Status Epilepticus within a Large, Academic Health-System
Authors: Mojibola Awe, Alexander Aubin, Krista Dumkow, Neha Naik, Chelsea Wamsley 


Background: Status epilepticus (SE) is a neurologic emergency that requires prompt treatment to prevent irreversible neurologic deterioration or death. There is variance in treatment strategy after first-line administration of benzodiazepines, due to lack of clinical data to support the use of a specific second-line antiseizure medication (ASM) in SE. Lacosamide (LCM) is an ASM with compelling attributes to be considered a second-line agent, including its ability to be administered as an undiluted intravenous push and its minimal drug interactions and adverse effects. This study aimed to evaluate the current role of LCM in the treatment of SE within a large, academic health-system. 
Methods: A multi-center retrospective chart review of patients admitted to Emory Healthcare hospitals between December 2020 and August 2024 was performed. Patients must have had a documented episode of SE and received at least one dose of intravenous LCM within the first 24 hours of admission to be included. The primary endpoint was the incidence of seizure termination within 6 hours of LCM administration without subsequent ASM use. Secondary outcomes reported include time from initial presentation to seizure cessation and LCM administration, incidence of LCM as the termination drug, cessation of seizure activity within an hour following LCM administration, and 24-hour seizure free period following LCM. Additional secondary outcomes reported include average LCM loading and maintenance dosing, incidence of mechanical ventilation, and time to mechanical ventilation from LCM administration.  
Results: Of 143 patients with a documented status epilepticus diagnosis code reviewed, 26 met inclusion criteria for this study. Among these patients, a majority were male with a median age of 60.5 years (IQR 53.5–67). Most patients required ICU admission (88.5%). Patients who were included had a past medical history of epilepsy (65.3%), stroke (30.8%), and alcohol/drug use (26.9%). Prior to hospitalization, 42.3% of patients were not on ASM; 38.5% were on levetiracetam monotherapy and 19.2% of patients were on multiple ASMs. Median time from admission to LCM administration was 156 minutes (IQR 149–165) and seizure cessation occurred at a median of 172 minutes (IQR 163–187) post-administration. LCM was effective in achieving seizure cessation within six hours without additional ASM in 19.2% of patients and served as the final ASM in 26.9% of cases. Across Emory Healthcare institutions, LCM was most frequently used as the second ASM for status epilepticus treatment (35%). A shorter time to LCM administration appeared to correlate with faster seizure cessation but did not impact the incidence of mechanical ventilation. 
Conclusions: LCM was identified as the final ASM administered in 26.9% of patients in this study, highlighting its potential role as a terminating agent for SE. However, this percentage is lower than findings from other studies which report intravenous LCM as the last ASM administered before seizure termination in 44% or more of cases. Additionally, LCM was most frequently used as the second ASM after benzodiazepines or levetiracetam for SE management across Emory Healthcare institutions. This trend may reflect an increasing recognition of LCM’s utility earlier in the SE treatment algorithm, particularly in situations where other ASMs may be contraindicated or less accessible. Furthermore, shorter time to LCM administration appeared to correlate with faster seizure cessation, suggesting the importance of early intervention. However, this correlation did not extend to the incidence of mechanical ventilation, indicating that other factors besides seizure cessation may influence this outcome.

Authors: Raja Munthe, Lisa Sagardia Shapiro, Raphaelle Lombardo, Fadi Nahab, Deborah Westover

Objective: To assess the door-to-needle times (DTN) of patients who meet eligibility criteria for thrombolytic administration prior to and post implementation of the use of tenecteplase in ischemic strokes.

Self Assessment Question: What is the recommended door-to-needle times for patients with an acute ischemic stroke receiving a thrombolytic?

Background: Acute ischemic strokes (AIS) is commonly treated with thrombolytics like Alteplase (ALT) and Tenecteplase (TNK). ALT has a long history of research supportive improved outcomes, but TNK, with advantages such as longer half-life, higher fibrin specificity, and simpler admnistration as a single bolus, is emerging as a promising alternative. While previous studies show comparable safety and effiacy between TNK and ALT, including similar rates of mortality and adverse events, TNK’s favorable pharmacokinetic profile & administration technique may improve key time intervals like door-to-needle (DTN) and door-to- puncture (DTP). Not all studies have shown uniform improvements, nor have they looked at the impact of TNK implementation across types of stroke centers. With TNK now the preferred thrombolytic within Emory Healthcare, as of April 2024, this study aims to evaluate TNK’s impact on stroke care process times, outcomes, and potential obstacles to implementation.

Methods: This is a multicenter retrospective, observational cohort study of consecutive patients selected from Emory’s Stroke Get-With-The-Guidelines Registry, which includes all patients who were suspected of having a stroke, between October 2023 to October 2024. Patients who were 18 years or older, suspected of ischemic stroke, and received thrombolytic therapy with either ALT or TNK within an Emory healthcare facility were included. Patients who were pregnant or received thrombolytics while already admitted inpatient were excluded from the study. The primary endpoint studied was DTN. Secondary outcomes included DTP times, door-in-door-out (DIDO) times, rates of serious adverse effects, such as serious bleeding events or hypersensitivity reactions (e.g. angioedema); hospital length of stay (LOS) and successful thrombectomy defined as TICI scores 2B or greater. DTN and DIDO times, rates of serious adverse events, and hospital LOS were analyzed with Mann-Whitney U tests.Categorical data will be analyzed using a Chi-square test with quantity-limited variables assessed using Fisher's exact tests.


Results: Of 3,511 patients recorded in Emory’s Stroke Get-With-the-Guidelines registry during the study period, 188 (5.2%) received thrombolytics, and 154 patients that met inclusion criteria were included in the study. Our results showed no significant difference in DTN times (56 vs. 53 minutes, p = 0.14), DIDO times (106 vs. 121 minutes, p = 0.45), DTP times (123 vs 104 minutes, p = 0.51) or serious adverse bleeding effects (p = 0.11, OR 1.1 [95% CI 0.4,3.2]) between the pre- and post-implementation cohorts. DTN times did not differ significant based on stroke center classification (p = 0.07) or between thrombolytics at each site and type of stroke center. Hospital LOS and rate of successful thrombectomy were also not significantly different.

Conclusion: There was no statistically significant difference in DTN or DIDO times between cohorts treated with ALT or TNK. These results suggest that the change in thrombolytics did not make significant impact on our ability to promptly administer thrombolytics or transfer patients to thrombectomy-capable centers. Additionally, there were no significant differences in serious adverse effects between cohorts suggesting similar safety profiles between ALT and TNK. Due to the lack of significant difference in stroke response, outcomes, or rate of serious adverse events, transitioning from ALT to TNK should focus on the ease of administration.

Title: Evaluation of Intravenous Insulin Infusions in the Treatment of Mild Diabetic Ketoacidosis (DKA)
 
Authors: Janna Lewis, Andrew Baxley, Carrie Harding, and Aayush Patel


Background: Diabetic ketoacidosis (DKA) is a serious complication of diabetes, characterized by hyperglycemia, metabolic acidosis, and ketosis, and contributing to over 500,000 annual hospital days. The standard treatment for DKA involves the administration of intravenous (IV) insulin infusions to restore normal blood glucose levels, suppress ketosis, and correct acidosis. This method allows for precise and rapid titration of insulin doses based on blood glucose and ketone monitoring. While insulin infusions are effective for managing DKA, our current practice presents several challenges, especially in mild DKA. Intensive monitoring of blood glucose and electrolytes requires significant resources, with a particular concern for hypokalemia. Additionally, transitioning patients from IV to subcutaneous (SQ) insulin can be problematic, leading to hyperglycemia and transition failures, if not executed correctly. Evidence supports the use of SQ insulin as an effective treatment for mild DKA, showing that it can achieve similar glycemic control to IV insulin while reducing the need for intensive monitoring. Studies have demonstrated that SQ insulin, when administered appropriately, leads to safe and effective treatment of mild DKA, with a lower risk of complications such as hypokalemia and hypoglycemia compared to IV insulin therapy. The purpose of our study is to assess the impact of IV insulin in the treatment of mild DKA, with the goal of guiding clinical decisions and improving resource utilization.
 
Methods: This retrospective chart review was conducted at Piedmont Columbus Regional Midtown, from April 1, 2024, to September 30, 2024. The primary objective is to evaluate the time to resolution of DKA, defined as BG < 200 mg/dL, serum bicarbonate ≥ 15 mEq/L or pH levels > 7.30 and anion gap ≤ 12. Secondary objectives include the duration of therapy, hospital length of stay, the incidence of hypoglycemia and hypokalemia, transitional failures, and the cost of administering IV insulin infusions. Patients included in this study were adults aged 18 years or older diagnosed with mild DKA. The diagnosis of mild DKA was defined based on standard criteria, including a blood glucose level > 200 mg/dL, arterial pH of 7.25 to 7.30 or serum bicarbonate levels of 15 to 18 mEq/L, with the presence of serum ketones. Primary and secondary objectives will be summarized using descriptive statistics.   
 
Results: This study found that the mean time to resolution of mild DKA was 10.9 hours, with an average insulin therapy duration was 17.08 hours. These results indicate a moderate treatment duration, highlighting the time required for metabolic stabilization in this patient population. In terms of safety, there were 4 patients that experienced hypoglycemia, 11 patients that experienced hypokalemia, and 2 patients experienced reoccurrence of DKA, which highlights the need for close monitoring. Additionally, from a cost perspective, the average hospital length of stay was 5 days, and the average direct treatment cost per patient was about 243 dollars. However, it’s important to note that this does not include hospitalization costs, additional medications, or other medical expenses, meaning the true cost burden of this treatment is likely much higher.
 
Conclusion: In conclusion, the findings suggest that while IV insulin is effective for mild DKA, it poses risks for hypokalemia and hypoglycemia, indicating the need for close monitoring and consideration of alternative treatments like subcutaneous insulin. At this time, our future directions include exploring the use of subcutaneous insulin for the treatment of mild DKA. Recent studies have demonstrated that subcutaneous insulin lispro is as effective as intravenous insulin in managing mild DKA. This alternative treatment offers comparable outcomes, including similar rates of blood glucose and ketone normalization. Given its efficacy and potential benefits, subcutaneous insulin presents a promising alternative for appropriate patients. 
 
Contact: Janna.Lewis@Piedmont.org

Title: Evaluation of Pharmacist-Driven Enoxaparin Dosing Using Anti-Xa Monitoring in Obese Trauma Patients


Authors: Kathleen White, Jacquelyn Crawford, Cameron Lanier, Austin Roe, Jess Brumit, Jen Tharp, Vera Wilson


Background: Obesity and trauma are both independent risk factors for the development of venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE). Enoxaparin (in the setting of adequate renal function) is the preferred agent for VTE prophylaxis in trauma patients by the Eastern Association for the Surgery of Trauma, Western Trauma Association, and American Association for Surgery of Trauma/ American College of Surgeons Comittee. Recent studies have suggested that weight-based dosing strategies may result in prophylactic concentrations more reliably than fixed dosing and that pharmacist-driven protocols are effective in adjusting enoxaparin based on levels to maintain prophylactic efficacy. While an association between higher BMI and subprophylactic enoxaparin dosing has been identified, data is still lacking to describe the prevalence and impact of weight-based dosing in obese trauma patients. Given increasing national trends in obesity and higher rates of obesity in the Appalachian region compared to the national average, we sought to evaluate the efficacy of this protocol in our population presenting to the Level 1 Trauma Center of the region.


Methods: This was a retrospective study conducted via chart review of adult (aged greater than or equal to 18) trauma patients presenting to Johnson City Medical Center in Johnson City, TN between October 1st, 2022 and May 1st, 2024. Patients were included if they met criteria for the weight-based protocol (trauma without traumatic brain injury or spinal cord injury, CrCl 30 mL/min and above, and weight of 50 kg or more), had received 2-3 consecutive doses of enoxaparin, and had at least one Xa level for evaluation. Patients were excluded if they did not meet the above criteria, were not on the protocol, pregnant, incarcerated, or reported therapeutic anticoagulation prior to hospital admission. The primary outcome is efficacy (frequency) of the protocol in achieving prophylactic Xa levels. Additional outcomes collected wil be incidence of VTE, incidence of International Society of Thrombosis and Hemostasis (ISTH) major bleeding, bleeding requiring blood product transfusion, length of ICU/ hospital stay, and mortality. Data will be analyzed using univariate and multivariate analysis as indicated. 


Results: In Progress


Conclusion: In Progress

TITLE: Impact of Maintenance Intravenous Fluid Prescribing in Hospitalized Patients at a Large Community Hospital During a National Shortage


AUTHORS: Sheniesa N Whitton, Susan E Smith, Sarah L Cassell, W Anthony Hawkins


OBJECTIVE: Evaluate the changes in prescribing practices related to maintenance intravenous fluids (mIVF) during a national shortage


SELF-ASSESSMENT QUESTION: Based on the point prevalence study, how did prescribing practices change during the IVF shortage?
a.MDs were more likely to prescribe IVF
b.IVF were administered with stop dates
c.IVF were ordered with a documented indication
d.All of the above


BACKGROUND: IVF are among the most prescribed therapies in hospitalized patients. Despite their widespread use, inappropriate prescribing of mIVF remains a concern due to its association with adverse outcomes, including fluid overload, electrolyte imbalances, and increased need for invasive interventions.
IVF therapy has evolved into distinct categories, including mIVF, which is administered to meet daily fluid and electrolyte requirements when oral intake is inadequate. However, data on mIVF prescribing patterns in hospitalized patients, particularly during national shortages, remain limited. The study aims to evaluate the impact of mIVF prescribing both before and during a national shortage.


METHODS: This IRB approved, point prevalence study included all hospitalized adult admitted on November 10, 2023 (before the shortage) and October 10, 2024 (during the shortage). Patients were excluded if they received IVF in the intensive care units (ICU) and emergency department (ED). The prevalence of mIVF was calculated by dividing the number of patients receiving IVF < 333 ml/hr by the total number of patients admitted on the dates of interest. The research team defined IVF as a type of crystalloid that does not contain protein and not used as diluent for medications and mIVF as any fluid running at a rate of < 333 mL/hr. Descriptive statistics were used and chi-square and Mann Whitney was used to determine p-value. P- value of < 0.05 suggest statistical significance.


RESULTS: The prevalence of mIVF use was 31.6% during the shortage compared to 30.7% before the shortage, indicating that overall mIVF use remained relatively stable, with a slight increase of less than 1%. Patients during the shortage were significantly more likely to have an indication documented for IVF administration compared to those before the shortage (60.7% vs. 46.3%, p = 0.011). The proportion of patients with a documented stop date for IVF orders was similar across both time points (58.5% vs. 55.9%, p = 0.661). Normal saline remained the most commonly used IVF during both time points (48.9% vs. 48.5%, p = 0.953), followed by lactated Ringer’s (36.3% vs. 44.9%, p = 0.152). The use of half normal saline was significantly more common during the shortage (5.2% vs. 0.7%, p = 0.030). Regarding prescriber type, MDs were the most frequent prescribers of IVF both during and before the shortage (83% vs. 76.5%), followed by nurse practitioners (6.7% vs. 12.5%) and DOs (6.7% vs. 1.5%). The distribution of prescriber types differed significantly between time points (p = 0.009). Most patients receiving IVF were also on a diet, with no significant difference between the two dates (87.4% vs. 88.2%, p = 0.587). The proportion of patients receiving diuretics was lower during the shortage (72.7% vs. 87.5%, p = 0.768), though this was not statistically significant. Loop diuretics were the most commonly used in both groups (4.4% vs. 5.1%, p = 0.364).


CONCLUSION: The overall prevalence of mIVF use remained consistent across both time points, with a slight, non-significant increase during the IVF shortage. This suggests an increased awareness and implementation of fluid stewardship practices. These trends, observed in a large community hospital, highlight the potential impact of supply challenges on clinical behavior and documentation practices.

TITLE: Evaluation of the current state of burnout among clinical pharmacists  
AUTHORS: S Kisala, S Boyko, R Hollis, K Quairoli, S Ye, A May  
OBJECTIVE: Determine the current prevalence of burnout and demographic characteristics among clinical pharmacists.  
SELF-ASSESSMENT QUESTION: What is the current prevalence of burnout among clinical pharmacists?   
BACKGROUND: The World Health Organization (WHO) categorized burnout as a syndrome officially added to the International Classification of Diseases, 10th revision (ICD-10) compendium in 2019. Burnout is characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment. The COVID-19 pandemic has significantly altered the healthcare landscape, potentially impacting burnout levels. While it has been widely studied among healthcare professionals, research on clinical pharmacists and clinical pharmacy specialists remains limited.  It is still being determined if the unique challenges clinical pharmacists face during and after the pandemic have influenced the prevalence and severity of burnout in this group. 
METHODOLOGY: This cross-sectional descriptive survey examined burnout among clinical pharmacists and clinical pharmacist specialists in the United States. Eligible participants were full-time pharmacists spending over 50% of their time in direct patient care, while those with less than one year of experience post-training or in part-time roles were excluded. A survey, developed using validated demographic and burnout assessment tools, including the Maslach Burnout Inventory (MBI), was reviewed by a focus group for clarity. Distribution initially targeted the Vizient Pharmacy Network but expanded to include the American Society of Health-System Pharmacists (ASHP) to ensure broader reach. The survey remained open from August 1 to September 19, 2024, with weekly reminders posted. Burnout was assessed using MBI-defined thresholds for emotional exhaustion, depersonalization, and personal achievement, with demographic and job-specific factors examined as potential contributors. Descriptive statistics summarized participant characteristics, and chi-square tests, along with odds ratios, were used to assess associations between burnout and relevant factors, with statistical significance set at p < 0.05. 
RESULTS: A total of 401 clinical pharmacists met the inclusion criteria and completed the survey, with most respondents being female (77.6%), white (82.8%), and having over 10 years of experience (65.3%). The overall burnout rate was 78%, with 30% of participants reporting high emotional exhaustion, 62% high depersonalization, and 54% low personal accomplishment. Burnout was present in one, two, and all three dimensions in 29%, 30%, and 19% of respondents, respectively. Emergency medicine pharmacists exhibited the highest burnout rates (94%), with 47% experiencing high emotional exhaustion, 81% high depersonalization, and 75% low personal accomplishment. Conversely, ambulatory care pharmacists exhibited lower rates of burnout (68%) overall, with 18% experiencing high emotional exhaustion, 55% high depersonalization, and 34% low personal accomplishment. Work 

Title: Efficacy of Olanzapine versus Quetiapine for ICU Related Agitation and Delirium 
 
Authors: Nina Casanova, Trisha Sharma, Jasleen Bolina, Neha Naik, Sagar Dave, Tu-Trinh Tran 
 
Background: Agitation and delirium are estimated to occur in 80% of critically ill patients admitted to the hospital; however, there is no gold standard of treatment. Initial management involves non-pharmacologic interventions and minimizing modifiable risk factors. While there is limited literature comparing atypical antipsychotics, critically ill patients experiencing agitation and delirium may benefit from their short-term use. This study aims to compare and evaluate the efficacy of olanzapine and quetiapine to treat agitation and delirium in the intensive care unit (ICU). 
 
Methods: This retrospective cohort analysis evaluated patients receiving either olanzapine or quetiapine for at least 24 hours with an indication of agitation, sedation, or anxiety. The study population included patients who were admitted to either a medical or surgical ICU at a tertiary medical center between August 1, 2022 and April 1, 2024. Patients were excluded if antipsychotic therapy was initiated prior to ICU admission or as a continuation of home therapy, if their antipsychotic was ordered as needed, or if they were pregnant or incarcerated. The primary outcome was the duration of delirium while on the antipsychotic, validated via CAM-ICU scores. Secondary outcomes included ICU length of stay, antipsychotic therapy duration, and incidence of antipsychotic discontinuation prior to ICU discharge. Patient and hospital course characteristics were described using medians and interquartile ranges (IQR) for continuous variables and percentages for categorical variables.  
 
Results: A total of 442 patients were reviewed for analysis. Data from 200 patients were analyzed, including 87 who received olanzapine and 113 who received quetiapine. Baseline characteristics were similar between the two groups. Risk factors for delirium prior to antipsychotic initiation included acute kidney injury (47% in olanzapine group vs. 52% in quetiapine group), alcohol use (14% vs. 12%), psychiatric diagnosis (20% vs. 19%), and prior benzodiazepine use at home (7% vs. 4%). The average duration of delirium was 5 days in both groups (p=0.447). The duration of antipsychotic therapy was similar in both groups at a median of 9 days for olanzapine and 8 days for quetiapine (p=0.510). Although a greater number of patients receiving quetiapine were mechanically ventilated at baseline than those receiving olanzapine, there was no statistically significant difference in overall duration of mechanical ventilation (64% vs. 44%). ICU length of stay was shorter for patients in the olanzapine group compared to the quetiapine group (11 vs. 14 days; p=0.043). Forty (46%) patients receiving olanzapine and forty-one (26%) patients receiving quetiapine were continued on their antipsychotic upon ICU discharge.  
 
Conclusion: This study provides insight into the pharmacological management of ICU agitation and delirium by comparing the use of olanzapine and quetiapine. While olanzapine and quetiapine may have different effects on medication use patterns and mechanical ventilation, both antipsychotics appear similarly effective and well-tolerated in managing ICU-related agitation and delirium. Further research is needed to optimize treatment strategies in order to determine appropriate drug selection and utilization.  
 
Contact email: nina.casanova@emoryhealthcare.org

Title: Impact of Surge Capacity on Time to Subsequent Dose of Antibiotics for Sepsis Patients in the Emergency Department
Authors: Stephanie Knode, Chelsie Sanders, Ginger Gamble, Amy Campbell; ECU Health Medical Center- Greenville, NC
 
Background/Purpose:
Antibiotics are a cornerstone of sepsis treatment, however there is no guidance on the impact of subsequent antibiotic delays on clinical outcomes. Previous studies have evaluated the impact of delays and discussed external factors that may influence these delays. No current studies have evaluated how surge capacity may impact delays in second dose antibiotics. Therefore, the objective of this study is to compare the impact of red/disaster capacity versus green/yellow capacity on delays in second dose antibiotics for sepsis patients in the emergency department.
 
Methods:
Eligible patients are 18 years or older with a diagnosis of sepsis who received at least two doses of the same intravenous antibiotic, with the first dose given in the emergency department. Antibiotics needed to have a 6-, 8-, or 12-hour administration frequency. Patients were excluded if they expired prior to the second dose of antibiotics, were pregnant or a prisoner, received their first dose of antibiotics prior to ED arrival, or if there was escalation or change in empiric coverage between the first and second dose of antibiotics. This study is a single-center, retrospective, observational review with patient data obtained through Vizient and capacity data through hospital operations.
 
Results:
The initial Vizient data pull identified 1292 patients potentially eligible for this study, of which 1000 patients were excluded. The most common reasons for exclusion were receipt of 24 hour dosed antibiotics and change in empiric antibiotics between the first and second dose. 292 patients who received 302 antibiotics were eligible for inclusion in this study. Baseline characteristics were similar between groups, including age, sex, weight, renal function, and the choice of empiric antibiotics. The primary outcome of incidence in delay of second dose antibiotics was seen in 130 patients (68.78%) in the green and yellow capacity group versus 66 patients (58.41%) in the red and internal disaster capacity group, with a p-value of 0.081. Hospital mortality, 7-, 30-, and 90-day mortality were not significantly different between groups, nor were need for mechanical ventilation, admission to an intensive care unit (ICU), or hospital and ICU lengths of stay.
 
Conclusions:
Red/disaster capacity did not have a significant impact on the incidence of second dose antibiotic delays versus green/yellow capacity for sepsis patients in the emergency department.

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.