2025 Southeastern Residency Conference

Title: Simplified Phenobarbital Versus Benzodiazepine Driven CIWA-Ar Protocol for Alcohol Withdrawal Syndrome 


Authors: Hyo Min Kim, Julie Willmon, Houda Dardari 


Background/Purpose: Treatment for alcohol withdrawal syndrome (AWS) targets disrupted pathways of GABA inhibition and NMDA receptor upregulation.1 According to the American Society of Addiction Medicine, benzodiazepines are first-line treatment for AWS. However, prolonged exposure to ethanol will result in tolerance to benzodiazepines.2 While benzodiazepines only work on GABA, phenobarbital offers a dual mechanism of action involving glutamate and GABA along with longer half-life for easier tapering.3 Literature suggests positive clinical outcomes from phenobarbital in AWS, but the ideal dosing is unknown.4 This study compares hospital length of stay (LOS) between a simplified phenobarbital regimen and the traditional benzodiazepine-driven CIWA protocol in patients admitted for AWS. Secondary outcomes include ICU LOS, need for adjunctive therapy, and incidence of adverse events. 


Methodology: This retrospective study analyzed patients admitted for AWS at AdventHealth Winter Park from November 1, 2022, to January 31, 2025. Patients received either a simplified phenobarbital dosing strategy or a traditional benzodiazepine-driven CIWA protocol. Exclusion criteria included age <18 years, pregnancy, discharge against medical advice within 24 hours, home phenobarbital use, or a history of porphyria. The phenobarbital regimen involved an initial IV loading dose of phenobarbital 5–8 mg/kg based on ideal body weight (IBW), or adjusted body weight if >130% IBW, administered as an infusion over 10–30 minutes in 100 mL normal saline. Additional doses of phenobarbital 65–130 mg IV push were given at physician discretion based on withdrawal symptoms. 

Title:
Impact of Ideal Versus Actual Body Weight on Analgesic and Sedative Requirements in Critically Ill Patients with Obesity
Authors:
Melanie Datt; Ashley Taylor; Christy Forehand; Emma Pearman; Allison Lopez; Brooke Smith
Objective:
Determine whether ideal body weight dosing of analgesic and sedative medication reduces opioid and sedative requirements in critically ill patients with obesity.
Self-Assessment Question:
True or False: Critically ill patients with obesity who received ideal body weight dosing of sedative medications had lower opioid requirements compared to those in the actual body weight group.
Background:
Analgosedation is the standard of care for managing pain and agitation in mechanically ventilated patients in the intensive care unit (ICU). Most sedative medications are lipophilic, including fentanyl, propofol, midazolam, dexmedetomidine, and ketamine. In patients with obesity, lipophilic drugs have an increased volume of distribution, leading to an increase in drug accumulation in the adipose tissue. This could cause an increase in adverse effects and oversedation. There is limited data about the appropriate dosing of these sedative medications in patients with obesity in the ICU, as a majority of the data is in the operative setting. This data is difficult to extrapolate to the critically ill patient since these patients differ both in their duration of sedation and severity of illness.  On February 1st, 2022, our institution changed to an ideal body weight (IBW) dosing strategy for continuous analgesic and sedative medications, including fentanyl, propofol, dexmedetomidine, and ketamine. This retrospective chart review was designed to determine whether utilizing IBW dosing for critically ill patients with obesity would result in decreased analgesic and sedative requirements compared to an actual body weight dosing strategy.
Methods:
This was a single-center, retrospective, observational chart review conducted at a 520-bed tertiary academic medical center. Critically-ill adult patients with a BMI greater than 30 kg/m² who received analgosedation with continuous fentanyl from January 1, 2020 – March 31, 2020 and January 1, 2024 – March 31, 2024 were permitted for inclusion. Patients were excluded from the study if admitted from an outside hospital, admitted to the Neurosciences ICU, or required sedation for elevated intracranial pressure or status epilepticus, or required deep sedation and/or neuromuscular blocking agents. Patients were also excluded if they were on mechanical circulatory support, had a history of opioid use disorder, were prescribed a long-acting oral opioid or fentanyl patch, or had a positive COVID-19 result. The primary outcome was cumulative morphine milligram equivalent (MME) requirements for the duration of fentanyl continuous infusion. Secondary outcomes included cumulative sedation requirements for the duration of continuous fentanyl infusion, cumulative daily benzodiazepine requirements (in midazolam equivalents), cumulative daily MME of as-needed (PRN) opioids, number of antipsychotic PRN doses, highest and lowest daily RASS and pain score, duration of mechanical ventilation, and ICU and hospital lengths of stay.
Results: 
Seventy-seven patients were included in the study, with 46 patients in the actual body weight (ABW) group and 31 patients in the ideal body weight (IBW) group. The median BMI was 35.3 in the ABW group and 34.9 in the IBW group. A majority of patients were admitted to the medical ICU in both groups. There was a statistically significant difference in the median cumulative MME requirements (931.2 vs. 537.9, p=0.037). For secondary outcomes, there was a statistically significant difference in median cumulative fentanyl infusion MME requirements (914.1 vs. 485.8, p=0.029), but there was no difference in the requirements of other sedative infusions (propofol, dexmedetomidine, ketamine, and midazolam). There were no differences in cumulative daily PRN benzodiazepine requirements (p=0.334) or PRN opioid MME requirements (p=0.196). For the highest and lowest daily RASS score, the medians were in the goal range of –2 to 0. There were no differences in duration of mechanical ventilation, ICU length of stay, or hospital length of stay.
Conclusion:
Utilizing an ideal body weight dosing strategy decreased cumulative opioid requirements (in MMEs) in critically ill patients with obesity without increased sedation or PRN opioid or benzodiazepine requirements.

Title: Evaluation and optimization of the post-operative colorectal surgery multimodal pain order set


Authors: Madison Pinke, Jerry Robinson


Background: According to guidance from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons, a multimodal pain management strategy for postoperative patients is recommended to reduce length of stay and have earlier return of bowel function. A multimodal pain regimen is defined as using multiple medications with difference mechanisms of pain control to act synergistically in order to enhance analgesic effect. Around 2016, Huntsville Hospital implemented a multimodal pain protocol for post-operative colorectal surgery patients as part of an enhanced recovery after the surgery process. However, this multimodal pain management protocol has not been updated since initiation and utilization rates of full multimodal approach appeared low. The purpose of this retrospective chart review is to evaluate the current use of pain management in post-operative colorectal patients, determining rate of compliance with defined order sets, and incorporating current literature-supported changes into updated orders to increase overall compliance. 


Methods: This single-center, pre-post implementation study evaluated the multimodal pain regimen ordered at Huntsville Hospital following surgery between June 2024 and August 2024. Patients in this study were 18 years or older and had an initiated “COLOREC Abdominal Surgery PostOp” order set. A chart review was completed for included patients. Data collected from the electronic health record (EHR) included: demographic information, surgeon, method of surgery, multimodal pain regimen ordered, multimodal pain regimen received by the patient, additional pain medications needed, bowel regimen ordered, hospital discharge status and length of stay. Once the pre-intervention data was collected, recommended changes were presented to the group of colorectal surgeons for inclusion in updated order sets. Planned post-implementation data collection will match pre-implementation data types and outcome differences. The primary endpoint was utilization rates of multimodal pain order set as defined by the percentage of patients who received a multimodal pain regimen. The secondary endpoint was length of stay (days). Descriptive statistics were used to analyze the data.


Results: Analysis of pre-implementation data revealed that complete multimodal pain regimens were not consistently utilized in GI colorectal surgery post-operative patient care. However, the data demonstrated that when multimodal pain regimens were implemented, there was a reduction in length of stay. Implementations went live April 9, 2025. 


Conclusion: Although post-implementation data remains limited due to recent initiation, the preliminary findings are encouraging as they are already demonstrating improved utilization. 

Title: Impact of Intravenous Push Administration of Levetiracetam in the Emergency Department
Authors: Allison Kump, Katlynn Bailey, Aubrie Hammond, Katie McLaurin, Samantha Pizzurro, Regan Porter
Objective: 

Title: Impact of a Novel Sepsis Diagnostic Test on the Prescribing Habits of Antimicrobials 
Authors: Monica Campbell, Emily Johnston, Hollis O'Neal, Christopher Thomas 
Objective: The objective of this study is to calculate de-escalation timing of antibiotics in septic patients prior to and after the use of a novel sepsis diagnostic test at our institution. 
Background: IntelliSep, an FDA approved rapid diagnostic and risk stratification test for sepsis has been used at Our Lady of the Lake Regional Medical Center (OLOLRMC) since August 2023. This test uses the biophysical abnormalities of leukocytes and associates this with detection of sepsis and the potential for impeding organ dysfunction. The purpose of this study is to examine the utilization of Intellisep to combat another prevalent issue, antimicrobial resistance. This study examines the utilization of IntelliSep on antimicrobial prescribing habits and compares time to appropriate de-escalation of antimicrobials, initiation of antimicrobials, and other relevant outcomes in presumed septic patients pre and post the use of IntelliSep.
Methods: This study is a single-center retrospective chart review. Patients included in the study are adult patients presenting to Our Lady of the Lake who received an IntelliSep Index Score (ISI). Based on the ISI, patients are classified as band 1, 2, or 3, with band one patients having a negative predictive value for sepsis of 97.5% based on previous studies. One hundred and ninety-five patients with ISI scores that were hidden from providers, and their treatment decisions, will be the control group compared to 400 total patients with ISI scores within the next year of initiation at our institution. A predetermined scoring system for classifying antimicrobials and their spectrum of activity will be used. In this scoring system, category one antimicrobials are the most narrow up to category three as the most broad. Category four medications are considered restricted antimicrobials at our institution. The primary outcome is time to de-escalation of antimicrobials based on this scoring system. Secondary outcomes include percent initiation of antimicrobials, total days of antimicrobial therapy, ICU and hospital lengths of stay, positive blood cultures within 72 hours of admission, and in-hospital mortality.
Results: Our primary outcome of time to de-escalation was 43.6 hours pre-intelliSep and 34.3 hours post-intelliSep in the overall category, and 22.8 hours and 22.1 hours for band 1, specifically. Number of patients initiated on antibiotics was 52 (67%) and 81 (41%) for band 1 patients pre and post-IntelliSep, respectively. Patients initiated on a broad-spectrum (3ab) regimen for band 1 were 32 (63%) and 28 (35%) for pre and post-intelliSep, respectively. 
Conclusion: Overall, we did not see a difference in our primary outcome for time to de-escalation of antibiotics. There was a statistically significant difference found in antibiotics started on arrival and patients initiated on a broad-spectrum regimen in our band 1 patients. These results are promising and overall point to a more appropriate usage of antimicrobials after the usage of IntelliSep, a diagnostic and risk stratification test for sepsis. 

Title: Effect of phenobarbital administration in the emergency department for alcohol withdrawal syndrome on length of stay
 
Authors: Payton Mueller, Wesley Arrison, and Megan Cavagnini
 
Background: Alcohol withdrawal syndrome results from a disruption in neurotransmitter homeostasis related to gamma-aminobutyric acid (GABA) and glutamate activity. Benzodiazepines are considered first-line treatment for alcohol withdrawal while phenobarbital is considered an adjuvant agent and is the preferred alternative for patients experiencing severe withdrawal. Studies show that phenobarbital leads to lower rates of mechanical ventilation, reduces symptoms of alcohol withdrawal, and decreases intensive care unit (ICU) admissions. The purpose of this study was to compare the effect of one-time doses of intravenous phenobarbital administered in the emergency department (ED) with standard care for alcohol withdrawal syndrome on hospital length of stay.
 
Methods: This was a retrospective observational cohort study of patients with alcohol withdrawal syndrome who presented to the emergency department between January 1, 2020 to December 31, 2024 at a two-hospital health system. This study included patients 18 years or older that presented to the hospital via the ED and received treatment for alcohol withdrawal. Patients were excluded if they received multiple doses of phenobarbital, if they received phenobarbital outside of the ED, or if they were transferred from outside hospitals. Patients were identified using a computer-generated list using diagnosis codes for alcohol withdrawal and orders for phenobarbital or the institution’s alcohol withdrawal protocol. Subjects were matched in a 2:1 ratio in the standard of care group to the phenobarbital group based on baseline characteristics, demographic information, and patient reported frequency of alcohol use. The primary outcome was hospital length of stay. Secondary outcomes included admission location, intensive care unit length of stay, escalations in care, benzodiazepine use, use of adjuvant agents for alcohol withdrawal, and intubation rates.
 
Results: There were 165 patients included in this analysis (55 patients in the phenobarbital group; 110 patients in the standard care group). There was no difference in median length of stay between the phenobarbital group and the standard care group (3 days vs 2 days; p = 0.251). There were 11 patients in the phenobarbital group and 11 patients in the standard care group that required ICU admission (20% vs 10%, p = 0.075). Patients in the phenobarbital required a median of 45 mg diazepam equivalents compared to 22.5 mg diazepam equivalents in the standard care group (p = 0.592). Additionally, 25 patients in the phenobarbital group and 26 patients in the standard care group required at least one adjuvant agent (45.5% vs 23.6%; p = 0.004). There were also no differences between the phenobarbital group and standard care group in admission location (p = 0.224), escalation in care (3.2% vs 2.8%; p = 1), and intubation rates (5.4% vs 0.9%; p = 0.108).
 
Conclusions: This study found no statistically significant difference in hospital length of stay between the phenobarbital group and the standard care group. Patients that received phenobarbital were more likely to receive additional adjuvant agents compared to the standard care group. Additional prospective studies are needed to assess the impact of one-time doses of phenobarbital in the emergency department on clinical and safety outcomes. 

Title: Evaluation of intravenous thrombolytic administration for acute ischemic stroke in patients with NIHSS score 0-5


Authors: Xuyen Nguyen, Parth Parikh, Morgan Weithman, Haley Smith, Jamie Wagner, Michael Loewe, Victoria Fontenot, Amy booth, Jamie Landry, Lynette 
Obey, and Greggory Davis


Objective: To evaluate the safety and efficacy of intravenous thrombolytic therapy in stroke patients with NIHSS 0-5 


Background: Approximately 87% of all stroke cases are acute ischemic stroke (AIS), and 13% are hemorrhagic. Current guidelines recommend intravenous 
thrombolytic (IVT) therapy in patients with AIS who present within 4.5 hours of severe or disabling symptoms. However, more than 50% of patients with AIS 
present with mild or minor symptoms (with a National Institute of Health Stroke Score, or NIHSS, of 0-5), and the guidelines do not have a strong 
recommendation for the use of IVT therapy in this patient population due to conflicting evidence. Therefore, this research project aims to determine the efficacy and safety of IVT therapy in patients with an initial NIHSS of 0-5.


Methods: A retrospective chart review was performed to identify patients admitted to the Franciscan Missionaries of Our Lady Health System and St. Dominic 
Jackson Memorial Hospital between 01/01/2020 and 12/31/2024. Patients were included if they were 18 years or older, presented within 4.5 hours with mild or minor stroke symptoms (NIHSS 0-5), AIS was confirmed by imaging, and patients received IVT therapy. Patients were divided based on their initial NIHSS into 
either NIHSS 3-5 or NIHSS 0-2 groups and were evaluated with a predetermined 2:1 ratio, due to fewer anticipated patients in the NIHSS 0-2 group. The primary 
endpoint was modified Rankin Scale (mRS) score of 0-1 at 90 days. Secondary endpoints include mortality at 90 days, in-hospital death, recurrent stroke, 
symptomatic intracranial hemorrhage, hemorrhagic transformation, early neurological deterioration, early neurological improvement, NIHSS 0 at discharge, mRS at 90 days, and time to IVT administration. 


Results: A total of 58 patients were included in this study, with 40 patients in the NIHSS 3-5 group and 18 patients in the NIHSS 0-2 group. 11 patients in the 0-2 group and 29 patients in the 3-5 group achieved mRS of 0-1 at 90 days. Overall, compared to patients in the NIHSS 0-2 group, the patients in the 3-5 group did not have a higher odd of having mrs 0-1 at 90 days, as shown by an adjusted odd ratio of 1.75, 95% confident interval of 0.52-5.79, and a p value of 0.4. No deaths were observed during hospital stay and at 90 days. Hemorrhagic conversion occurred in 5 (13%) of patients in the NIHSS 3-5 group and in 1 (5.6%) of patients in the NIHSS 0-2 group. Recurrent stroke occurred in 5 (13%) of patients in the NIHSS 3-5 group and did not occur in the NIHSS 0-2 group. Median time to IVT administration was 39 minutes in the NIHSS 3-5 group and 51 minutes in the NIHSS 0-2 group.

Conclusion: Among patients with NIHSS 0-5 treated with IVT therapy, there were no differences in functional outcome at 90 days between the NIHSS 3-5 group and the NIHSS 0-2 group. No meaningful differences in secondary outcomes were observed. In conclusion, further studies with a larger sample size are still needed to support an informed decision to administer IVT therapy in this patient population.

Title: Evaluation of Low-Dose Ketamine for Pain Managment in the Emergency Department: Impact on Opioid Requirements
Authors: Valery Cepeda, Emily Harman 
Objective:
Describe the use of pain-dose ketamine in the Emergency Department and impact on outpatient opioid requirements. 
Self-Assessment Question:
True or False: This study found the use of pain-dose ketamine resulted in lower MME requirements both in the ED and in outpatient prescriptions.
Background: 
Ketamine, traditionally used as a dissociative anesthetic for sedation and anesthesia, has gained attention for its off-label use in pain management. Its NMDA receptor antagonism provides effective analgesia, making it a promising alternative or adjunct to opioids, particularly when opioids are less effective or carry a high risk of adverse effects. This study aimed to evaluate whether low-dose (0.1-0.3 mg/kg IV) ketamine could reduce opioid requirements compared to opioids alone in emergency department (ED) patients. 
Methodology: 
This retrospective, observational cohort study included adult patients discharged from the ED who received either pain-dose ketamine or opioid medication for pain management or minor procedures at Northeast Georgia Medical Center between January 1, 2024 and June 30, 2024. The primary outcome was total opioid consumption in the ED, measured in morphine milligram equivalents (MMEs), in patients receiving pain-dose ketamine compared with those receiving opioids alone. Secondary outcomes included average change in pain scores during ED stay and total daily MME of opioid prescriptions issued at discharge. To control for confounding factors, patients were matched into 50 pairs based on similar demographic and clinical characteristics (age, gender, and indication for therapy), with one patient in each pair receiving only opioids (opioid-only group) and the other receiving ketamine plus/minus opioids (ketamine group). Data on demographics, medical history, dosing, adjunctive pain medications, and pain scores were collected, and statistical analyses were performed using descriptive and inferential methods, with statistical significance set at p<0.05. 
Results:  
A total of 133 patients met the inclusion criteria. One hundred patients were matched with 50 patients in the ketamine group and 50 in the opioid-only group. Baseline characteristics were similar between the two groups. For indication, 64% of the ketamine group received treatment for acute pain compared to 88% in the opioid-only group, while 36% of the ketamine group received treatment for procedural pain versus 12% in the opioid-only group. The ketamine group had a statistically significant higher total opioid consumption during the ED stay compared to the opioid-only group (median MME 17.5 [IQR 12-30] vs. median MME 12 [IQR 5-15]; p = 0.002). Change in pain score was greater in the ketamine group compared to the opioid group (median 0 [IQR 0–5] vs. median 0 [IQR 0–3.25]; p = 0.173). Additionally, the ketamine group demonstrated a statistically significant increase in daily MME requirements for outpatient opioid prescriptions (median MME  30 [IQR 25–39.5] vs. median MME 30 [IQR 20–38]; p = 0.041). 
Conclusion:  
This study found that ED patients receiving ketamine (plus/minus opioids) had higher total opioid requirements during their ED stay and required increased daily opioid doses at discharge compared to those receiving opioids alone. Pain score reductions were similar between the groups. The observed increase in MME requirements in the ketamine group may be attributable to its more frequent use for procedural sedation, as opposed to solely treating acute pain. Additional research is needed to better identify specific indications and optimal use of pain-dose ketamine in the emergency department.

Title: Impact of Vasopressin Initiation Timing on Outcomes of Septic Shock Patients Receiving Norepinephrine at a Large Community Hospital

Authors: Trish Elder, Mickala Thompson
 
Background: The Surviving Sepsis Campaign Guidelines 2021 recommend use of norepinephrine (NE) as the first-line vasopressor for adult patients with septic shock. If the mean arterial pressure (MAP) cannot be maintained above 65 mmHg with a low to moderate dose of NE (0.25-0.5 mcg/kg/min), vasopressin is recommended second-line. Several research studies have been conducted in recent years to address the ambiguity surrounding the most appropriate timeframe for initiation of vasopressin. Some study findings include an increased time to shock resolution and decreased length of ICU stay with early initiation of vasopressin. The purpose of this study is to assess the effect of vasopressin initiation timing on outcomes of septic shock patients receiving NE at Huntsville Hospital.

Methods: A retrospective, institutional review committee exempt, chart review was conducted to evaluate all non-pregnant patients 18 years or older with active vasopressin and NE infusion orders and a diagnosis of septic shock, between August 1, 2023 and March 31, 2025. Patients were excluded if they received other vasopressors prior to vasopressin, they were located in the Cardiovascular ICU (CVICU), or their NE infusion rates could not be determined. Data was collected from the electronic health record (EHR) and analyzed using descriptive statistics. The primary endpoints were NE dose at time of vasopressin initiation and time from shock presentation to vasopressin initiation. The secondary endpoints included MAP 6 hours post vasopressin initiation, NE dose 6 hours after vasopressin initiation, time to shock resolution and ICU LOS.
 
Results: A total of 58 patients were included in the study: 52 in the “pre-intervention” (PRE) group and 6 in the “post-intervention” (POST) group. The baseline characteristics were similar between groups, apart from race. The number of patients initiated on vasopressin when the dose of NE was >0.5 mcg/kg/min was higher in the PRE group than the POST group with 69% and 17%, respectively. The median dose of NE at time of vasopressin initiation was 0.7 mcg/kg/min in the PRE group and 0.37 mcg/kg/min in the POST group. Due to the high mortality rate in this patient population, the secondary endpoints, time to shock resolution and ICU length of stay had 11 patients in the PRE group and 2 patients in the POST group. Due to the sample size, these outcomes could not be adequately assessed.
 
Conclusion: The implementation of a new order comment on all NE orders demonstrated a positive trend in the reduction of the NE dose when vasopressin was initiated. A larger sample size is needed to fully assess outcomes such as time to shock resolution and ICU length of stay in this patient population. Other limitations included the retrospective study design and limitations of EHR capabilities that led to a delay in intervention implementation.

Association between medication-related needle sticks and delirium in the ICU
Shelby Wathen, Susan Smith, Abigail Powell, John Carr
St. Joseph’s/Candler Hospital
wathensh@sjchs.org 
 
Background
Delirium is a clinical syndrome that is frequently observed in critically ill adults in the intensive care unit (ICU.) Several risk factors have been identified that contribute to delirium. These risk factors include, but are not limited to; pain, older age, infection, catheters, fever, hypoxia, brain injury, sleep deprivation, and sedatives. One risk factor that has not been well established is the number of subcutaneous injections or point-of-care glucose (POCG) tests a patient receives. The purpose of this study is to determine if there is an association between medication-related needle sticks and delirium in the ICU.
Methods
This was a retrospective, observational analysis that included critically ill adult patients (18 years old) who were admitted to the ICU for 72 hours or more from January 1, 2020 to December 31, 2020. Patients were divided into groups based on those who experienced delirium and those who did not. Patients were excluded if their Richmond Agitation Sedation Scale (RASS) was -4 to -5, if they were admitted with an acute neurological diagnosis, cognitive impairment prior to admission, admission for alcohol withdrawal, or history of dementia. Baseline demographic data, number of subcutaneous injections, number of blood glucose checks, RASS score, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) score, length of hospital stay (LOS), length of ICU stay, and mortality were collected for each patient. The primary outcome was number of medication-related needle sticks per day in the ICU. Secondary outcomes were to determine the number of delirium-free days, all-cause mortality during the index hospitalization, LOS, and ICU LOS.
Results
A total of 404 patients were included in this study, 92 patients in the delirium group and 312 patients in the non-delirium group. The average number of subcutaneous injections and POCG tests per ICU day was 4.28 and 3.55 (p = <0.001) for the delirium and non-delirium groups, respectively. The average number of delirium-free ICU days was 8.5 in the delirium group and 5 in the non-delirium group (p = <0.001). The all-cause mortality rate was 40% in the delirium group and 19% in the non-delirium group (p = <0.001). Average LOS was 16 days and 9 days (p = <0.001) in the delirium and non-delirium groups, respectively  and average ICU LOS was 10 days and 5 days in the delirium and non-delirium groups, respectively (p = <0.001).
Conclusions
There was a statistically significant difference between medication-related needle sticks per day in the delirium group vs the non-delirium group. All-cause mortality rate, number of delirium-free days, average LOS, and average ICU LOS also had a statistically significant difference. More data in a larger, prospective trial is needed to determine if there is a true correlation between needle sticks and delirium.

Title: Optimizing Stress Ulcer Prophylaxis in Critically Ill Patients: A Pharmacist-Driven Approach to Discontinuation

Authors: Ciana Wallace, Sarah Adams, Jamie McCarthy 

Objective: To assess SUP medication management before and after the implementation of a standardized, pharmacist-driven guidance. 

Background: Stress ulcers are superficial ulcerations that typically occur in the fundus and body of the stomach due to hospitalization. Specifically, patients in the intensive care unit (ICU) are at higher risk for stress ulcer development. Frequently, stress ulcer prophylaxis (SUP) is initiated in the ICU but infrequently discontinued when no longer indicated. The purpose of this study was to reduce inappropriate SUP continuation during hospitalization and at discharge at Piedmont Athens Regional through implementation of a pharmacist guidance document for discontinuation. 

Methods: This is a single-center, pre-post interventional study on patients admitted to the medical or cardiac ICU and initiated on SUP. A standardized pharmacist-driven SUP guidance was developed to provide criteria for discontinuation of SUP and approved by critical care providers. The SUP guide was designed to discontinue SUP based on a lack of risk factors for stress ulcers. Patient charts were reviewed before and after the intervention of the SUP guide. The pre-intervention group included 50 randomly selected patients admitted between November 2023 and January 2024. The post-intervention group included 50 randomly selected patients admitted between November 2024 and January 2025. Patients ≥ 18 years of age with medical or cardiac ICU admission > 24 hours and on a proton pump inhibitor (PPI) or histamine-2-receptor antagonist (H2RA) were automatically included. The primary outcome was the number of days patients were continued on inappropriate SUP. The secondary outcome was the number of patients discharged on inappropriate SUP. Statistical analysis was completed using Microsoft Excel. Continuous data was analyzed using the Mann-Whitney U test and reported as median with interquartile range data. Categorical data was analyzed using the Chi-Square test and reported as a frequency. Statistical significance was assessed with a significance level of 0.05.

Results:  A total of 100 patients were included in the study with 50 patients in both the pre-intervention and post-intervention groups. There were no significant differences in the baseline characteristics between both groups. For the primary outcome, the post-intervention group had fewer days of inappropriate SUP continuation compared to the pre-intervention group (1.1 days vs 0.2 days (p = 0.04). The post-intervention group had fewer days of SUP continuation compared to the pre-intervention group (4.1 days vs 5.7 days, p = 0.03). There were less patients discharged from the ICU and CICU on SUP between the pre-intervention and post-intervention groups (76% vs 54%, p = 0.021). No statistically significant difference was found in the number of patients discharged from the hospital on SUP; however, there were less patients discharged overall between the pre-intervention and post-intervention groups (20% vs 14%, p = 0.424).

Conclusions: The study emphasizes the impactful role of pharmacists in optimizing SUP management with a clear reduction in both overall SUP continuation and inappropriate use. These results reinforce the value of implementing a standardized approach to routinely assess SUP appropriateness. Moving forward, incorporating this guidance into an institutional protocol could help ensure consistent practice and long-term improvements in SUP management.

Title: Assessment of the Implementation of a fixed dose PCC protocol

Authors: Loren Proctor, Patrick Blakenship, Kyle Allmond, Brad Crane, Madison Sullivan, and Joy Bussey

Background: In August 2023, Blount Memorial Hospital (BMH) undertook a significant change in its protocol for managing anticoagulation reversal by transitioning from a weight-based activated 4-factor prothrombin complex concentrate (FEIBA) to a fixed-dose inactivated 4-factor prothrombin complex concentrate (KCENTRA). For several years prior to this transition, FEIBA had been the preferred agent for reversing anticoagulation. Since its adoption in 2016, FEIBA had served as the cornerstone for managing patients in the Emergency Department (ED) who required urgent anticoagulation reversal due to its efficacy in counteracting the effects of anticoagulation. However, the decision was made to move to KCENTRA, a fixed-dose product known for its precision and reliability in critical interventions. Historically, BMH has seen a consistent need for 4-factor prothrombin complex concentrates, with approximately 2 to 3 patients in the ED each month requiring this type of intervention. The introduction of KCENTRA is expected to streamline the administration process and enhance the overall effectiveness of anticoagulation reversal, reflecting the hospital’s dedication to continuous improvement and patient safety in emergency care.

Methods: 
This is an IRB-approved, retrospective analysis study to evaluate the effects of the transition from weight-based activated 4-factor prothrombin complex concentrate (FEIBA) to a fixed-dose inactivated 4-factor prothrombin complex concentrate (KCENTRA) at BMH. A report will be generated for all patients who received 4-factor PCC for Xa inhibitor reversal in the ED. This includes documentation of the order submission to drug administration and the subsequent verification by the pharmacist. Additionally, there will be a collection and assessment of the financial aspects related to the administration of 4-factor PCC for Xa inhibitor reversal. 

The primary objective will compare the time from order submission to administration time between FEIBA and KCENTRA. As for the secondary objectives, evaluation of the duration from order submission to pharmacist verification, as well as the assessment of the financial impact of transitioning from a weight-based dosing regimen to a fixed dosing regimen will be analyzed.

Results: When comparing the time difference from order submission to administration time, it was found that weight-based dosing (FEIBA) was significantly faster than fixed-dose (KCENTRA) by 6 minutes. When comparing the time difference from order submission to pharmacist verification, it was found that weight-based dosing (FEIBA) was faster than fixed-dose (KCENTRA) by 1.3 minutes. However, when analyzing finances, it was found that fixed-dose (KCENTRA) surpassed weight-based dosing (FEIBA) due to its significant financial savings of $4,053 per patient. 

Conclusion: The data we collected in regard to order submission, administration time, and pharmacist verification all favored weight-based dosing (FEIBA). However, due to the significant financial savings with fixed-dose (KCENTRA), our institution continued with fixed-dose (KCENTRA) as the 4F-PCC of choice. 

Self-Assessment Question: True or False: When changing from FEIBA® to KCENTRA®, the financial impact was more beneficial.

TITLE: Impact of a Pharmacist Led Medication Adherence Team on A1c 
AUTHORS: Rion Poland; Niaima Geresu; Cindy Nee; Mary Katherine Cheeley 
 
BACKGROUND: Chronic diseases such as hypertension, diabetes, and heart disease account for over 85% of healthcare spending in the United States and remain leading causes of death and disability. While clinical trials have demonstrated that optimal medication adherence improves clinical outcomes, real-world data often reveal suboptimal adherence. Time constraints and staffing limitations often impede community pharmacists’ ability to effectively address medication adherence in a real-world setting. This study evaluates the effect of a pharmacist-led medication adherence program on clinical outcomes in patients with uncontrolled diabetes.
 
METHODS: This single-center, retrospective chart review included patients who had an A1c of 9% or higher and whose anti-diabetic medication(s) were 10 to 30 days past their refill due date at a Grady pharmacy between October 1, 2023, and March 31, 2024. Patients successfully contacted by a medication adherence pharmacist were assigned to the intervention group, while those who could not be reached were included in the control group. Patients without follow-up A1c values were excluded. The primary outcome assessed the difference in A1c change between the two groups. Secondary outcomes included the change in A1c from baseline within each group and the percentage of patients achieving an A1c goal of less than 9%.
 
RESULTS: A total of 391 patients were included in the study, with similar baseline characteristics between groups. The majority of patients were uninsured, on insulin therapy, and prescribed at least two antidiabetic medications. Within the intervention group, over 70% of patients were contacted once by the medication adherence pharmacist. Following the study period, over 25% of patients in both the intervention and control groups achieved an A1c below 9%, with rates of 27.4% and 26%, respectively. Regarding the primary outcome, the intervention group demonstrated a median A1c reduction of 0.7 (IQR: -0.5 to -2.2), while the control group experienced a median reduction of 0.75 (IQR: -0.8 to -1.9). The difference between groups was not statistically significant (p = 0.302). However, within-group analysis revealed a significant A1c reduction in both groups. In the intervention group, the median A1c decreased from 10.9 (IQR 9.8–12.5) to 10.2 (IQR 8.7–12) (p < 0.001). Similarly, the control group experienced a decrease from 11.0 (IQR 9.8–12.5) to 10.3 (IQR 8.8–11.9) (p = 0.0013). The median time between pre- and post-intervention A1c measurements was similar between groups, with the intervention group at 22 weeks (IQR 14.7–33.1) and the control group at 22.6 weeks (IQR 16.25–40.1).
 
CONCLUSION: While the pharmacist-led adherence intervention group was associated with a significant reduction in A1c, the degree of improvement did not differ significantly from the control group. These findings suggest that medication adherence pharmacists may positively influence patient outcomes; however, additional patient-specific factors likely contribute to A1c reduction. Future studies should explore social determinants of health, including socioeconomic status, housing stability, and provider follow-up, as potential barriers to improved adherence. Assessing these factors through patient surveys or adherence metrics, such as the percentage of days covered, may provide further insight. While additional strategies may refine adherence interventions, patient adherence remains a critical component of chronic disease management.

TITLE: The Variance of Distribution of Fluid Bolus in Patients Diagnosed with Sepsis and Septic Shock within the St. Joseph/Candler Health System
AUTHORS: Saralyn Hardin, Stephen McCall, Caitlyn Johnson
OBJECTIVE: To determine the St. Joseph/Candler Health System’s variation of distribution of fluid bolus volume given within three hours after sepsis or septic shock diagnosis from the standard of care (30mL/kg).
BACKGROUND: Currently the Surviving Sepsis guidelines recommend prompt fluid resuscitation with 30 milliliters per kilogram of crystalloid fluids within the first three hours of care for patients who are either hypotensive or have a lactate level > 4mmol in the absence of randomized control trials to support this recommendation. To our knowledge, there are no trials that include distribution of fluid volumes or categorical incidences manifested from fluid overload such as renal replacement therapy or diuretic administration beyond 72 hours in varying fluid bolus volumes.
METHODS: This was a retrospective, single-centered, observational, chart review of patients who have been admitted to St. Joseph’s or Candler Hospitals and diagnosed with sepsis or septic shock at the time of admission the fluid volume was evaluated with respect to patient ideal body weight in order to determine a health system distribution and variance from guideline recommended resuscitation of 30 mL/kg. Patients were further differentiated into groups based on variance from mean fluid bolus volume using standard Gaussian distribution. Using the health system’s software and a computer-generated list using MedMined™ services to identify patients with this diagnosis between April 1, 2023 and April 1, 2024, patients were reviewed for inclusion in the study.
RESULTS: Three hundred fifty patients were screened for eligibility with a total n=107. The average fluid bolus administered within three hours was found to be 1819.7 milliliters resulting in 29.3 milliliters per kilogram of ideal body weight with the average ideal body weight being 63.4 kilograms. Of the one hundred and seven patients there past medical history’s revealed 18 (17%) congestive heart failure, 21 (21%) chronic kidney disease, 67 (63%) hypertension and 48 (45%) diabetes mellitus. Four of the one hundred and seven patients included experienced an acute heart failure event during hospitalization with one having a past medical history of congestive heart failure. New renal replacement therapy was initiated in three of the one hundred and seven patients with only one patient having a past medical history of chronic kidney disease. There were 19 (18%) of the hundred and seven patients that required new diuretic use during hospitalization. Overall, there is a potential correlation between patients having a past medical history significant for congestive heart failure and fluid bolus given to adverse events. 
CONCLUSION: The overall fluid volume administered to patients during initial fluid resuscitation was comparable close to the guideline’s recommendations with all cause mortality of only eleven percent. However, there were comparable correlations between the total amount of fluid received and adverse events experienced by patients.  Considering the study’s limitations of small sample size, further research with larger, multicenter data should explore potential relationship between fluid bolus given after sepsis or septic shock diagnosis to adverse events.

1. Title: Effect of Methylene Blue on Vasopressor Requirements in Patients with Septic Shock
2. Resident Email: taylor.dodd2@hcahealthcare.com
3. Authors: Taylor Dodd, Stephanie Lesslie
4. Background: Septic shock is defined as a severe infection causing an abnormal immune response with the potential to progress to hypotension and organ failure. Vasopressors may be required to achieve mean arterial pressures sustainable to life. Methylene blue has shown promising data in improving hemodynamics through the inhibition of nitric oxide, a vasodilator released by the body in a shocked state. A 2023 trial found that early methylene blue administration in septic shock led to earlier vasopressor discontinuation and shorter hospital durations. Other studies have been conducted that have shown a reduction in vasopressor requirements and increased survival rates with the addition of methylene blue.    
5. Methods: This single-center, retrospective cohort study aimed to assess the change in vasopressor requirements in patients with septic shock that received methylene blue. Patients were included if they were 18 years old, admitted to the emergency department or intensive care unit at time of methylene blue administration, and used for the indication of sepsis or septic shock. Patients were excluded if they had contraindications to methylene blue, were pregnant, or incarcerated. The primary outcome was the change in vasopressor requirements 12 hours after administration of methylene blue. The secondary outcomes investigated were change in vasopressor requirements 6 and 24 hours after methylene blue administration, hospital and ICU length of stay, total number of methylene blue doses, mortality, and reported adverse effects.
6. Results: 
   In this descriptive study, 38 patients met inclusion criteria; 2 of which were excluded from this study. For the excluded patients, 1 was incarcerated and the other had a creatinine clearance < 15 mL/min. For the primary outcome of change in vasopressors 12 hours after methylene blue administration, we observed a decrease in vasopressor requirements of 17.5 mcg/minute, reported in norepinephrine equivalents.
   At the 6 hour time point after methylene blue administration, we observed a decrease in vasopressor requirements of 2.5 mcg/minute. There was a decrease in vasopressor requirements observed 24-hours after methylene blue administration of 14.0 mcg/minute. In the patients included, there was an all-cause mortality rate of 78%. The median ICU length of stay was 4 days and the median hospital length of stay was 5 days in patients that received methylene blue. There were no reported adverse effects reported in patients who received methylene blue.
7. Conclusion: Overall, our study observed that patients who received methylene blue had decreased vasopressor requirements at 6, 12 and 24 hours after administration. No adverse effects were identified.

Title: Optimization of Automated Dispensing Cabinets to Reduce Medication Errors in the Emergency Department


Authors:  Kelly Bodine, PharmD; Aubrey Murphy, PharmD; John Patka, PharmD, BCPS; Laurie Cavendish, PharmD, BCPS; Debbie Vigliotti, PharmD, LSSGB


Objective: To describe the utilization of automated dispensing cabinets to determine the safety of emergency medication dispensing practices and to address modifiable sources of potential medication errors. 


Self Assessment Question: How can automated dispensing cabinet usage be modified for safety?


Background: A medication error is a preventable event that may lead to inappropriate medication use or patient harm. Automated dispensing cabinets (ADCs) have eliminated a significant margin of human error; however, safety measures are lessened in the emergency department (ED) to provide for timely treatment of critical patients. Less restricted access, fewer verification checkpoints, and retrospective charting are a few of the barriers to medication safety that exist in the ED. Nationally recognized organizations have recommendations for ADC use to help mitigate safety barriers and risk points. With a variety of individuals accessing ADCs, passing along medications, and providing direct patient care in the Grady Memorial Hospital (GMH) ED, optimized ADC storage and dispensing conditions are needed to ensure best patient care. The purpose of this study was to describe the utilization of ADCs to determine the safety of emergency medication dispensing practices and to address modifiable sources of potential medication errors. 


Methods: Retrospective review of ADC utilization and practices in the ED of a single institution between January 1, 2024 and March 31, 2024. Reports were generated for three ADCs located in emergent patient-care areas using software from BD Pyxis™. ADC layouts were evaluated, taking into consideration pocket type and medications contained within the ADC, including high risk and sound-alike-look-alike medications based on ISMP guidance and GMH policies and procedures. Override data was evaluated, including number of overrides, user profession, and medications overridden. Results were utilized to modify and optimize ED ADCs for both safety and efficacy, such as moving medications to an alternative storage pocket type. Interventions were quantified as part of the primary analysis. Secondary analysis included evaluating the impact of any measurable outcomes for modifications made.  


Results: 1,375 overrides and 342 medications stored among the 3 Pyxis stations were assessed. This study found that 25% of medications stored were in matrix drawers, however very few were high-risk or SALAD medications. Due to this, minimal changes were recommended to Pyxis storage design. Of the 1,375 overrides, 37% were for high-risk medications. No changes were recommended to overridable medications due to the location of these Pyxis stations. Lastly, few high-risk and SALAD medications were associated with Pyxis safety alerts, and adjustment efforts focused on alert optimization. 


Conclusion: This study found that Pyxis station design was previously optimized for safety surrounding high-alert and SALAD medications. Ultimately, optimization of Pyxis alerts and override warnings were needed to improve safe medication practices. 

Title: Evaluation of Clinical Outcomes in Patients with AECOPD Receiving Systemic Corticosteroids

Authors: Ashley V. Adkins; Rachel Kile

Objective: Assess outcomes of cumulative corticosteroid dosing ≤ 200 mg compared to > 200 mg in patients admitted with or for AECOPD

Self Assessment Question: What is the most recent GOLD guideline-recommended corticosteroid regimen for AECOPD management

Background: 
Systemic corticosteroids have been shown to improve lung function, health-related quality of life,  decrease hospitalization duration, need for mechanical ventilation, treatment failure, readmission rates, and dyspnea in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommends using 40 mg of prednisone equivalent daily for 5 days (200 mg total prednisone equivalents), however, a standard dose of systemic corticosteroids across guidelines does not exist. Optimal doses of systemic corticosteroids for managing AECOPD vary, with prednisone and methylprednisolone commonly used. Both oral and intravenous administration of corticosteroids show similar outcomes regarding treatment failure, relapse, and mortality, with the IV route preferred for severe cases. Similar to dosing, there is no optimal duration of systemic corticosteroids in AECOPD; however, chronic use is generally avoided.

Methods: 
A retrospective review was conducted (n=164) to assess the impact of prednisone equivalent dosing less than or equal to 200 mg vs. greater than 200 mg on AECOPD-related outcomes. Patients aged ≥ 40 years who were hospitalized for AECOPD between August 1, 2023, and July 31, 2024, were included in the initial data analysis. Patients were excluded if they were not admitted, transferred from another facility before admission, had baseline or newly diagnosed comorbid lung conditions, left against medical advice, were admitted for hospice, or used corticosteroids in the past 30 days before admission. The primary outcome evaluated mean length of stay (LOS). Secondary outcomes included need for ICU transfer, respiratory failure, mean blood glucose readings >180 mg/dL,  requirement of rapid-acting insulin, mechanical ventilation, requirement of supplemental oxygen, inpatient mortality, and 30- and 60-day all-cause readmission rates.

Results:
Of the 164 patients with AECOPD included in the initial analysis, 100 patients met inclusion criteria. The included patients were divided into 2 separate arms:  prednisone equivalent dosing ≤ 200 mg (n= 18) vs. > 200 mg (n=82). There were no statistically significant differences between the two arms for baseline characteristics. The primary endpoint showed a statistically significant difference in the mean LOS between the prednisone equivalent dosing ≤ 200 mg vs. > 200 mg (3.56 days vs. 5.56 days, p= 0.0081). There were no statistical differences found between the two arms for secondary endpoints however, there was a numerically significant endpoint, including blood glucose abnormalities >180 mg/dL (27.8% vs. 41.4%). There was a statistically significant difference found between the average total days of inpatient corticosteroid use (3.11 vs. 5.5, p= 0.0029) and the average milligrams of inpatient prednisone equivalents used (149.472 vs. 613.089, p= 0.0001). No statistically significant differences were found between the different corticosteroid types or routes of administration used.

Conclusion:
Eighty-two percent of included patients received cumulative corticosteroid dosing above the GOLD guideline recommendation (> 200 mg prednisone equivalents) without clear evidence showing that conservative dosing ≤ 200 mg prednisone equivalents vs. higher doses > 200 mg prednisone equivalents makes a positive clinical difference on pre-specified outcomes. In conclusion, it is recommended to re-educate providers on the availability of the COPD order set, which limits the use of corticosteroids to GOLD guideline recommendations, and trial a pharmacist-driven intervention report for patients on more than 5 days of corticosteroid therapy when admitted for or with AECOPD. If these changes are implemented, a follow-up assessment would be warranted to compare findings to the same pre-specified outcomes as this review.

Title: Comparison of Clinical Outcomes in Hospitalized Patients Receiving Olive Oil-Based versus Soybean Oil-Based Lipid Emulsions with Parenteral Nutrition
Authors: 
Tilyn Digiacomo
Chris Wilson
Breanna Carter
Background: Intravenous lipid emulsions are an integral component of parenteral nutrition for the provision of essential fatty acids, linoleic acid and alpha-linolenic acid. Given the pro-inflammatory properties of linoleic acid, the advantage of linoleic-sparing formulations has been debated. Olive oil-based lipid emulsions contain one-third the amount of linoleic acid compared to its soybean oil-based counterpart, making its use potentially advantageous in critical illness, infection, and liver injury. Despite its vital role in parenteral nutrition, recommendations regarding the optimal lipid emulsion formulation are lacking. This study aims to compare clinical outcomes in patients receiving olive oil-based versus soybean oil-based lipid emulsions as a component of parenteral nutrition.
Methods: This was a single-center, retrospective, cohort study that included adult patients hospitalized at a large academic medical center. Patients had to be 18 years of age or older with confirmed receipt of either olive oil-based or soybean oil-based lipid emulsion as a component of parenteral nutrition. Patients were excluded from the study if they were receiving parenteral nutrition prior to hospitalization, duration of parenteral nutrition was less than three days, patients received both lipid emulsions, cirrhosis was noted on imaging or past medical history, baseline serum bilirubin was greater than 2 mg/dL, or baseline serum triglycerides were greater than 400 mg/dL. The primary endpoint of this study was parenteral nutrition-associated liver disease, defined as total bilirubin greater than 2 mg/dL or any of the following greater than 1.5 times the upper limit of normal in accordance with institution-specific values: aspartate aminotransferase, alanine transaminase, or alkaline phosphatase. Secondary outcomes include the incidence of hospital-acquired bloodstream infection, hypertriglyceridemia, and length of stay. Nominal data was analyzed utilizing Chi-square or Fisher’s exact test. Continuous data was analyzed utilizing Wilcoxon Rank Sum or Student’s t-test.
Results: In total, 200 patients were included in the final analysis with 100 patients in each group. The majority of patients were receiving parenteral nutrition for ileus or small bowel obstruction for a median duration of 8 to 9 days, respectively. Baseline demographics, including intensive care unit admission and mortality, were similar between groups. Parenteral nutrition-associated liver disease occurred in 35 patients in the olive oil-based group compared to 28 in the soybean oil-based group (35% vs. 28%; P = 0.29). There was no difference in hypertriglyceridemia, hospital-acquired bloodstream infection, or length of stay observed between lipid emulsions.
Conclusion: Among hospitalized patients receiving parenteral nutrition, there was no difference in the rate of parenteral nutrition-associated liver disease when comparing olive oil-based versus soybean oil-based lipid emulsions. Moreover, no difference in hypertriglyceridemia, length of stay, or hospital-acquired bloodstream infections were observed between groups. Study findings may be explained by confounding medications, critical illness, or shorter durations of parenteral nutrition. Future research should aim to examine similar outcomes among longer durations of parenteral nutrition.  

Title: Riluzole for Motor Recovery in Patients with Traumatic Spinal Cord InjuryAuthors: Autumn Locke, PharmD; Kenji Leonard, MD; April Quidley, PharmD, BCCCP, BCPS, FCCM, FCCP; Elizabeth Langenstroer, PharmD, BCCP

Objective: The purpose of this study was to determine the impact of riluzole on motor recovery function in patients with spinal cord injury.

Self-Assessment Question: Which statement best summarizes the findings of this study on riluzole for acute spinal cord injury?

Background: Studies on the effect of riluzole have demonstrated conflicting results in improving functional outcomes for patients with spinal cord injury. The most recent study demonstrates benefit only in cervical spinal cord injuries when considering motor recovery scores. This analysis aims to address the uncertainty of riluzole use in all types of spinal cord injuries and determine if there is improvement in functional motor scores with the use of riluzole.

Methods: This was a single-center, retrospective analysis at East Carolina University Health Medical Center (ECUHMC) of adult patients with a documented spinal cord injury admitted to the surgical intensive care unit (SICU) and transferred to ECUHMC inpatient rehabilitation facility. Patients that received riluzole from January 1, 2020 to December 31, 2023 were compared to standard of care prior to riluzole acquisition from January 1, 2018 to December 31, 2019. Data was obtained from electronic health records. The primary objective of this study was to compare the change in American Spinal Cord Association (ASIA) score from admission to discharge from inpatient rehabilitation.

Results:  A total of 129 patients were included in the analysis, with 85 patients in the post-riluzole group and 44 in the pre-riluzole group. Baseline characteristics between groups were similar; however, a significantly higher proportion of patients in the post-riluzole group received concomitant corticosteroids compared to those in the pre-riluzole group (29% vs. 7%; p = 0.007). Change in ASIA score from IPR admission to discharge, did not differ between groups (0 ± 0.605 vs. 0 ± 0.424; p = 0.9711).  Patients in the post-riluzole group demonstrated significantly higher mean arterial pressure (MAP) targets (82.83 mmHg vs. 80.78 mmHg; p = 0.035) and a longer ICU length of stay (8 days vs. 5 days; p = 0.017). Other secondary outcomes, including duration of MAP push, hospital length of stay, mortality, and change in Glasgow Coma Score showed no difference between groups. Riluzole administration was associated with a significant increase in alanine aminotransferase (ALT) levels from baseline (30 ± 55.43 units/L) to day 7 of therapy (45 ± 49.5 units/L)(p = 0.039). Multivariable regression analysis revealed that none of the variables assessed, including riluzole exposure, age, neurological injury level, and MAP range, were independently associated with increased motor function recovery.

Conclusion: Riluzole was not associated with a statistically significant improvement in motor recovery as measured by ASIA scores.

Dual Antiplatelet Strategies for Intracranial Aneurysms Treated with 
PipelineTM Flex Embolization Device with Shield TechnologyTM


Authors: Brian Shouse; Adam L. Wiss; Chris Larkin


Background:
Flow diverting stents are a common treatment for intracranial aneurysms, especially those that are wide-necked. While surface modifications to new generation flow diverting stents have sought to improve compatibility and mitigate thrombosis risk, dual antiplatelet therapy (DAPT) is recommended. Aspirin and clopidogrel are the most commonly utilized agents for initial DAPT regimens, but the optimal antiplatelet strategy remains unclear. Due to differences in the genetic variability and potency, among other factors, between oral P2Y12 antagonists, our institution often utilizes a platelet reactivity assay (PRA) to optimize the thrombosis and hemorrhage risk for patients requiring DAPT for flow diverting stents. For example, for patients in whom clopidogrel resistance is of concern, alternative DAPT strategies with ticagrelor or prasugrel, in addition to aspirin, may be utilized. Conversely, clopidogrel hyperresponders may be changed to a less intensive dosing regimen (i.e., <75 mg daily). However, the impact of the aforementioned DAPT regimens on thrombotic risk and hemorrhagic complications is not known. This study aimed to evaluate the impact of DAPT using aspirin and clopidogrel 75 mg once daily (standard) versus DAPT with aspirin combined with either an alternative clopidogrel dosage or ticagrelor (alternative) in patients with intracranial aneurysms treated with the Pipeline™ Flex device with Shield Technology™.


Methods: 
This was a single center, retrospective chart review of adult patients treated with PipelineTM Flex Embolization Device with Shield TechnologyTM at Ascension Saint Thomas Hospital West from March 1, 2021 to June 1, 2024. Patients were placed into one of two groups based on their discharge DAPT regimen. The primary outcome was the incidence and severity of thromboembolic events within 3 to 6 months on standard vs alternative dosing DAPT, which was defined by new clinical stroke or thrombus on imaging. Secondary outcomes included hospital readmission and death within 3 to 6 months of procedure. 


Results: 
Forty patients were included (standard n= 23, alternative n=17). Baseline characteristics were similar, with a median age of 59 years and 85% female. Ruptured aneurysms occurred in 39.1% of the standard group versus 23.5% of the alternative group. Among those with rupture, 66.6% in the standard group had a Hunt and Hess score ≥3, compared to 0% in the alternative group. In the standard group, the most common dual antiplatelet therapy (DAPT) regimen was aspirin plus clopidogrel 75mg daily (100%), whereas alternative regimens included clopidogrel 75mg every other day (64.7%)  or ticagrelor-based (17.7%). The most common standard DAPT regimen was aspirin plus clopidogrel 75 mg daily (100%), while alternative regimens included clopidogrel 75 mg every other day (64.7%) or ticagrelor-based therapy (17.7%). No significant differences were observed in the primary outcome of thromboembolic events at 3–6 months (4.3% vs. 11.8%, p=0.5647)  There were no significant differences in any secondary outcomes. 


Conclusion/Discussi

Title: Comparison of purge reliability between heparin- and bicarbonate-based purge solutions during Impella support
Author Names: Jessica Donald, Breanne Mefford, Bryan Love, Jenna Cox
 
Background: Impella heart pumps are temporary mechanical circulatory support (MCS) devices used beyond procedural settings in patients with cardiogenic shock to support heart function by unloading the right or left ventricle. A solution is utilized to suppress denatured protein or thrombus deposition within the purge gaps of the Impella device. Heparin-based purge solutions are recommended by the device manufacturer, who advises against the use of non-heparin anticoagulants within the purge solution. While direct thrombin inhibitors were initially explored as a purge solution option for patients with heparin-induced thrombocytopenia, pump failures and other complications have been documented with their use. Sodium bicarbonate has emerged as an alternative, stabilizing the pump without affecting systemic heparin levels, simplifying anticoagulation management. Although FDA-approved in April 2022 for patients intolerant to heparin, data related to its clinical use remains limited.


Methods: This retrospective, observational cohort study aims to assess the efficacy of a sodium bicarbonate-based purge solution as an alternative to heparin-based purge solutions for patients receiving Impella support. The primary outcome will focus on purge reliability, defined as a composite measure of: a 25% increase in purge pressure from baseline, and/or a 50% reduction in purge flow rate (for index flow rates >15 mL/hr) or a 30% reduction (for index flow rates ≤15 mL/hr). Secondary outcomes will include the individual components of the primary composite outcome, along with the use of alteplase in the purge solution, as well as variations in purge flow rates and pressures.
 
Results: In Progress
 
Conclusion: In Progress

Title: Evaluation of Desmopressin in Preventing Overcorrection of Hyponatremia Among Patients with Renal Dysfunction


Authors: Kelsea Mabie, Tara Kennell, Rajarshi Patel, Brooke Smith, Aaron Chase, Kelli Henry


Background: Hyponatremia is a common cause for hospital and intensive care unit (ICU) admission. Treatment strategies vary based on patient presentation and the presumed cause of hyponatremia, but center around sodium repletion, fluid balance management, and discontinuation of offending agents. Increasing serum sodium must be done in a slow, controlled fashion to prevent overcorrection which may cause adverse neurological effects, including osmotic demyelination syndrome (ODS). One method to prevent sodium overcorrection includes administering desmopressin to decrease free water loss via the kidneys, avoiding hemoconcentration and rapid increase in sodium. Studies have demonstrated desmopressin is a useful agent for this indication; however, there is limited evidence on the efficacy of desmopressin in the setting of renal dysfunction.  


Methods: This was a single center, retrospective cohort study at an academic medical center that received exemption from the institutional review board. Adult patients with a serum sodium <125 mEq/L who received one or more doses of intravenous (IV) desmopressin during their admission were included. Patients were excluded if they received desmopressin for a diagnosis of diabetes insipidus or hemorrhage. The primary outcome was the difference in rate of sodium overcorrection (>8 mEq/L) 24 hours after the first desmopressin dose in patients with renal dysfunction compared to those without renal dysfunction. Renal dysfunction was defined as creatinine clearance less than 30 mL/min. Secondary outcomes included rate of correction before and after desmopressin, proportion of patients achieving a sodium correction of 5–10 mEq/L within 24 hours of presentation, and rate of overcorrection at 24 and 48 hours after presentation. Outcomes were assessed with chi-squared, t-test, and Mann-Whitney U as appropriate. All patient demographics were categorized using mean and standard deviation or median and interquartile range.


Results: Sixty-five patients were included in this study with 14 patients (21.5%) having renal dysfunction. Forty-three (66.2%) patients were male, 54 (83.1%) were admitted to the ICU, and 17 (26.2%) received a home medication associated with hyponatremia. Baseline variables including age, sex, ICU admission, renal function, baseline sodium, weight, and fluid status were well-balanced between groups. Patients in the renal dysfunction group received significantly more milliequivalents of sodium through IV fluids compared to those without renal dysfunction (90.7 vs 284.2 mEq, p=0.001), which was primarily driven by 0.9% sodium chloride administration. There was no difference in the primary outcome of rate of overcorrection 24 hours after administration of desmopressin (9.8 vs 21.4%, p=0.476). The mean change in sodium 24 hours after desmopressin was similar between groups (2.43 vs 3 mEq/L, p=0.691), with no difference in rate of overcorrection at 24 hours (9.8 vs 28.6%, p=0.173) or 48 hours (5.9 vs 14.3%, p=0.632) after admission. Correction within goal range was similar between groups at 24 hours after admission (51.0 vs 50.0%, p=1.000) and after desmopressin administration (17.6 vs 28.6%, p=0.597). There were no differences in safety outcomes. 


Conclusion: Our study did not demonstrate a difference in overcorrection of sodium after desmopressin in those with impaired versus normal renal function. Overall, there was a low incidence of overcorrection, though this study was likely underpowered. The results did not reach statistical significance however, the observed differences in sodium overcorrection rates could suggest that renal dysfunction may not influence the clinical response to desmopressin. Future studies are warranted to determine the effect of renal dysfunction on safety and efficacy of desmopressin.  

Title: Retrospective review of food bolus resolution following pharmacologic treatment in a community hospital emergency department   


Authors: Abigail E. Hall; Taylor Servais; Rachel Langenderfer; Brittany NeSmith; Ryan Lally; Evan McDonald


Objective : Identify pharmacological options available for the treatment of food bolus impactions  


Self Assessment Question: For food bolus impactions, EGD remains the definitive treatment, but during the interim period which medications are available for treatment? (answers: Glucagon; Nitroglycerin)


Background: A food bolus is a medical emergency where food is impacted in the esophagus with a sudden onset of symptoms. The definitive treatment for food bolus is esophagogastroduodenoscopy (EGD), but pharmacotherapeutic management can be utilized in the interim to attempt resolution. The American Society for Gastrointestinal Endoscopy (ASGE) guideline for management of food impactions notes administration of intravenous (IV) glucagon to induce esophageal relaxation and aid with bolus passage, but use is associated with adverse events. Although the ASGE guidelines do not discuss effectiveness of oral nitroglycerin, case reports suggest it may be useful for the management of food bolus due to its ability to cause local smooth muscle relaxation.  The purpose of this study is to evaluate resolution of food bolus among patients treated with glucagon only, glucagon and nitroglycerin, and nitroglycerin only.


Methods: This is a retrospective cohort study of adult patients presenting to a St. Francis Emergency Department (ED) with a food bolus. Patients were included if they received intramuscular (IM) or IV glucagon or oral nitroglycerin. Patients were excluded if they did not have an identified food bolus or their treatment outcomes were not recorded. The primary outcome evaluated was resolution of food bolus following pharmacologic treatment. Secondary outcomes included need for hospital admission, performance of emergent EGD, and documented adverse effects. Data was collected from May 20, 2022 to November 30, 2024, retrieved from chart review via electronic medical records, and maintained confidentially.


Results: There were a total of 89 patients screened. Six of these patients were excluded based on proposed criteria. Eighty-three patients who received nitroglycerin or glucagon for the indication of food bolus within a St. Francis ED between May 20, 2022 and November 30, 2024 were included. Twenty-three (27.7%) patients had resolution with medication administration alone. Glucagon alone was administered to 43 patients, nitroglycerin alone was administered to 9 patients, and 31 patients received both nitroglycerin and glucagon.  Resolution of food bolus following medication administration occurred in 15 (34.9%), 3 (33.3%), 5 (16.1%) of patients respectively. The secondary outcome of requiring emergent EGD occurred in 60 patients following medication administration, and of these patients, all achieved resolution following EGD. There were eight patients requiring hospital admission. Of the patients that required admission four patients received glucagon alone, and four patients received glucagon and nitroglycerin. However, patients that were admitted were for the purposes of receiving an EGD or requiring monitoring after EGD. None of the patients experienced adverse effects of headache, flushing, or hypotension with either agent. Emesis was documented following the administration of glucagon or nitroglycerin in 19 (20.4%) and 4 (9.1%) of patients respectively. 


Conclusion: This retrospective cohort study evaluated the resolution of food bolus with the administration of nitroglycerin alone, glucagon alone, or glucagon and nitroglycerin administration. No agent was found to be superior for the resolution of food bolus. Medication administration resulted in a small portion of food bolus resolution, leading to most patients requiring EGD following medication administration. However, emesis was documented more frequently following glucagon administration than following nitroglycerin administration. With minimal occurrences of resolution following any medication administration, additional factors such as medication cost and adverse effect profile should be considered when choosing a pharmaceutical agent for the treatment of a food bolus.

Title: Evaluation of Rapid Sequence Intubation Agent Selection on Hemodynamics in Emergency Room Patients


Authors: Jaclyn Gruver, Thomas Neal, Tracey Bastian, Valerie Van Vickle


Background: Rapid sequence intubation (RSI) is the process of administering a sedative induction agent and a paralytic agent to assist endotracheal intubation. The goal of induction is to induce general anesthesia, which allows for the administration of paralytics and the facilitation of optimal intubating settings. Shock index (SI) has been used by some emergency departments as a clinical severity score. It is defined as heart rate (HR) divided by systolic blood pressure (SBP) and normally ranges from 0.5 to 0.7. An SI greater than 0.9 is linked to increased risk for decompensation and poor outcomes. The purpose of this study is to evaluate the impact of induction agent selection (etomidate, ketamine, and propofol) on peri-/post- intubation hemodynamics after RSI in Emergency Room (ER) patients.


Methods: This study was an Institutional Review Board approved, single-center, retrospective chart review evaluating patients aged 18 years and older who were intubated in the ER, received one of the induction agents for RSI (etomidate, ketamine, or propofol), and survived to hospital admission. Patients who were intubated in the ER from January 1, 2022 to August 31, 2024 were identified using data from a medication dispensing cabinet report for the intubation kit, which included the induction agents. The primary objective is to evaluate the differences in pre-intubation and post-intubation shock index between etomidate, ketamine, and propofol. Secondary endpoints include: incidence of bradycardia (HR < 60 bpm) within 30 minutes of intubation, tachycardia (HR > 100 bpm) within 30 minutes of intubation, hypertension (SBP > 140 mmHg or DBP > 90 mmHg) within 30 minutes of intubation, hypotension (SBP < 90 mmHg or DBP < 60 mmHg) within 30 minutes of intubation, treatment of hypotension within 30 minutes of intubation, and dose of agent used for RSI. The safety outcome is 28 day ventilator-free days (VFD).


Results: In progress.


Conclusion: In progress.

Title: Evaluation of Pseudoephedrine as Adjunctive Therapy in Acute Spinal Cord injuries


Authors: Gianna Antinone, Taylor Law, Amanda McKinney, Mary Massaro, John Gripentrog, Stephanie Scott, and A. Shaun Rowe


Objective: To evaluate the efficacy of pseudoephedrine as an adjunctive agent to IV vasopressors in acute spinal cord injuries 


Self Assessment Question: True/False: The addition of oral pseduoephedrine to IV vasopressors for MAP augmentation post-SCI resulted in a short duration of IV vasopressors.  Answer: False


Background: Spinal cord injury (SCI) is defined as acute traumatic damage to the spinal cord, resulting in temporary or permanent neurolgical damage. Neurogenic shock, defined as bradycardia and hypotension, is common within this population. The relative recommendation immediately after injury is to augment mean arterial pressure (MAP) to a goal of 85-90 mmHg for one week to adequately perfuse the spinal cord. Commonly used treatments for MAP augmentation include intravenous (IV) and oral vasopressors such as pseudoephedrine (PSE) and midodrine. This study evaluates the efficacy of pseudephedrine as an adjunctive agent to IV vasopressors in patients with acute spinal cord injuries. 


Methods: We performed a retrospective cohort study of trauma-surgical critical care patients at the University of Tennessee Medical Center from October 1, 2015, to January 1, 2024. Patients were included if 18 years of age and older, diagnosed with a spinal cord injury, and required IV vasopressor intiation upon admission to achieve a MAP goal > 85 mmHg for the first 5 days after injury. Patients were divided into two groups of either vasopressor monotherapy or vasopressor in combination with PSE to augment the goal MAP. The primary outcome of this study compared the time to IV vasopressor discontinuation between the two groups. Secondary outcomes included incidence of central line placement and duration, ICU and hospital length of stay, all-cause ICU and hospital mortality, successful discontinuation of IV vasopressors post-pseduoephedrine initiation, IV vasopressor re-initation within 24hrs of discontinuation, and incidence of bradycardia. 


Results: Among the 751 patients identified for inclusion, 201 patients met inclusion criteria, of which 136 patients received vasopressor monotherapy, whereas 65 patients received vasopressor plus adjunctive PSE to maintain MAP goals. The duration of IV vasopressors was 70 hours versus 106 hours in the adjunctive PSE group (p=0.0299). Central line placement, duration of central line placement, hospital and ICU length of stay, hospital mortality, and ICU mortality were similar between the two groups. 80.7% of patients has successful discontinuation of vasopressors once PSE was initated. The incidence of bradycardia was more prominent in the adjunctive PSE group (44.6%) compared to vasopressors alone (25.7%), p=0.0072. 


Conclusion: Although this study did not meet the primary outcome of reducting time to IV vasopressor discontinuation, this study demonstrated successful discontionuation of vasopressors post-PSE iniation in 80% of the study population who received PSE as adjunctive therapy. This study is limited by a small sample population and retrospective nature. 

1. Title: Valproic Acid Augmentation in Traumatic Brain Injury Related Agitation
2. Authors: Michelle Allsup, Peterson Worrell
3. Background: Traumatic brain injuries (TBIs) are a prevalent issue with many patients experiencing cognitive/behavioral symptoms such as agitation, impulsiveness, and irritability. TBIs were defined as subdural hematoma, subarachnoid hematoma, skull fractures, and cerebral contusion given that it was caused by a traumatic event, such as a fall or motor vehicular collision. The purpose of this study is to identify if valproic acid (VPA) augmentation has a significant difference in these patients’ agitation.
4. Methods: This retrospective, observational, cohort study included adult trauma patients admitted to the hospital diagnosed with TBI, and initiated on of VPA and/or quetiapine for agitation. Patients were excluded if they pregnant, incarcerated, and taking any of the following prior to admission – antipsychotics, mood stabilizers, or VPA. These patients were individually chart reviewed from July 31, 2024 to January 31, 2025. The primary outcome was the time to documented resolution, in days, of agitation and the length of time until dose reductions occurred. The secondary outcomes are the incidence of adverse drug reactions (ADR) and the incidence of valproic acid discontinuation due to an ADR or persistent ADRs. As needed medications were also evaluated prior to VPA initiation and after VPA initiation.
5. Results: A total of 8 patients were included in this IRB-approved study. The included patients were then split amongst themselves to examine the before VPA initiation and after VPA initiation. The primary outcome of time to documented resolution of agitation in the pre-VPA time period was a median of 0 days and in the post-VPA time period was 1.5 days. The length of time until dose reductions occurred in the pre-VPA time period was 0 days with quetiapine and in the post-VPA time period was 3.5 days with quetiapine and 0 days with VPA. There were no documented adverse events and no discontinuations due to ADRs. There was a total of 36 doses of as needed medications (haloperidol or lorazepam) given 72 hours prior to VPA initiation and a total of 20 doses of as needed medications given 72 hours after VPA initiation.
6. Conclusion: We observed that VPA may reduce agitation in patients post-TBI whose agitation was not controlled on quetiapine alone. We found that there were more frequent dose reductions of quetiapine on discharge. There was less use of as needed medications after VPA initiation than prior to VPA initiation. A larger sample size is needed to determine if valproic acid decreases agitation in TBI patients. This should be conducted in a multicenter, prospective, randomized controlled study. This will aid in fully evaluating the benefit of VPA for agitation in patients post-TBI.

Contact: Michelle Allsup at michelle.allsup@hcahealthcare.com with any questions.

Title: Evaluation of Appropriateness of Antibiotics Prescribed at ED Discharge for Urinary Tract Infections or Community Acquired Pneumonia in Medicare Patients 65+ 

Authors: Gabrielle Hopkins, Carlen Johnson, Nicole Gonzalez

Background: Antibiotics are some of the most prescribed medications in the Emergency Department. However, providers are often required to prescribe antibiotics prior to definitive culture results. Studies have shown that inappropriate prescribing may lead to patient harm, including adverse events, treatment failure, antimicrobial resistance, and hospital readmission. Community acquired pneumonia (CAP) and urinary tract infections (UTI) are among the top discharge diagnoses with the highest 30-day all-cause readmissions. This retrospective study aims to provide insight into ED discharge antibiotic prescribing patterns in Medicare patients 65+ for CAP or UTI at AdventHealth Central Florida Division (CFD) South campuses.

Method: The study was conducted as a retrospective chart review. Reports were populated through the electronic health record identifying Medicare patients 65 years at all AdventHealth CFD South campuses who were discharged from the ED with at least one antibiotic for CAP or UTI during the period of June 1, 2023 to June 30, 2024. Patients who were less than 65 years old, pregnant, incarcerated, discharged from the ED with CAP or UTI with no oral antibiotics, or had missing documentation were excluded from the study. De-identified patient data including demographics, antibiotic agent, antibiotic dose, duration of therapy, antibiotic appropriateness based on culture results, and markers of infection were collected for assessment. The primary outcome of this study was to evaluate the appropriateness of discharge ED antibiotic prescribing for CAP or UTI within the Medicare 65+ population. The antibiotic agent, dose, frequency, duration of therapy, and appropriateness of each agent based on culture results were assessed. The secondary outcome was inappropriate renal dosing associated with discharge antimicrobial treatment. Collected data was analyzed using descriptive statistics. 

Results: A total of 158 patients met the inclusion criteria and were included in data analysis. The median age was 78 years, the median weight was 72.5 kg, and the median height was 65 inches. The most common comorbidities included cardiac [131, (82%)], neurological [45,(28%)], and diabetes [38, (24%)]. Fifty-one patients diagnosed with UTI (34%) received ceftriaxone in the emergency department prior to discharge. Upon discharge, the most prevalent antimicrobial agent prescribed for UTI was cephalexin [65,(44%)] and most common organism identified was Escherichia coli [30, (18%)]. Cystitis was found to be the most common indication for antimicrobial therapy upon discharge [133 (84%)]. Nine (5.6%) patients were diagnosed with CAP. The most prevalent agent prescribed for CAP upon discharge was azithromycin [5, (55%)] and Mycoplasma pneumoniae [1 (11%] was identified to be the most common organism for CAP. The median duration of antimicrobial therapy was 7 days for UTI and 7 days for CAP. Further analysis revealed drug-bug mismatch in 22 (28%) patients, renal function mismatch in 87 (55%) patients and no microbiologic results in 40 (25%) patients.

Conclusion: Discharge antibiotic prescribing patterns varied amongst each CFD campus for Medicare 65+ patents who were discharged home on antimicrobial therapy for UTI or CAP. Twenty-eight percent (28%) of antibiotics prescribed at discharge did not appropriately treat the culture identified pathogens. Fifty-five percent (55%) of the antibiotics were dosed inappropriately based on renal function. This demonstrates an opportunity for pharmacist involvement to improve future patient care. Future directions include opportunities to improve rates of bug-drug match selection, education and resources for ED providers on proper antibiotic selection. Lastly, standardization of order sets for discharge antibiotics for patients discharged from all CFD EDs may improve appropriate discharge antibiotic prescribing. 

Self-Assessment Question: Which was the most common bacteria identified in patients with UTI? 
A. Staphylococcus aureus 
B. Escherichia coli 
C. Klebsiella pneumoniae 
D. Proteus mirabilis

• Title: Comparative Analysis of Sedation and Analgesia Requirements in Trauma Patients Presenting with a Positive Drug Toxicology Screen 
• Authors: Sydney Kermeen, Sarah Alimenti, Michael Honaker, Kenji Leonard, and Emily Whitehead
• Objective: Compare analgesia and sedation requirements in trauma patients requiring intubation after presenting with a positive urine drug screen (UDS) and/or serum ethanol level to patients presenting with a negative toxicology screen.
• Self Assessment Question: True or False: Due to impaired drug metabolism and increased drug tolerance, trauma patients acutely intoxicated with amphetamine, cocaine, PCP, MDMA, or ethanol may have higher opioid requirements during mechanical intubation?
• Background: Pre-injury illicit substance use and intoxication are predictors of ICU admission and increased analgesia and sedation requirements in patients admitted to the hospital following traumatic injuries. Literature evaluating analgesia and sedation in patients presenting with a positive toxicology screen is limited and further research is warranted to guide treatment.
• Methods: This was a single-center, retrospective, observational study including adult patients admitted to the surgical intensive care unit (SICU) who were intubated for at least 48 hours following a trauma and presented with either a positive urine drug screen (UDS) for cannabinoids, cocaine, amphetamines, phencyclidine, ecstasy and/or elevated serum ethanol level within the first 24 hours of admission.  Patients were excluded if they had withdrawal of care or were transferred out of the SICU within 48 hours of admission, utilized short acting opiates for at least 30 days or long-acting opiates as a home medication, had a pre-diagnosed psychiatric illness, or utilized pentobarbital, chemical paralysis, or extracorporeal membrane oxygenation during the study period. The control group included patients presenting with both a negative UDS and serum ethanol level. There were two comparator groups: group 1 with both a positive UDS and serum ethanol level, and group 2 with a positive UDS and negative serum ethanol level. The primary outcome was median daily dose of opioid requirements in morphine milligram equivalents until extubation, transfer from SICU, or 30 days. Some of the secondary outcomes included mean daily benzodiazepine use, mean daily dose of continuous sedation, utilization of adjunctive analgesia and sedation agents, length of mechanical ventilation, average daily pain scores, and percentage of time within goal sedation.
• Results: A total of 151 patients were included in the analysis, with 50 patients each in the UDS(-)/EtOH(-) and USD(+)/(-) groups and 51 patients in the UDS(+)/EtOH(+) group. Baseline characteristics and patient demographics between groups were similar between groups. There were no differences in median daily MME, LME, dexmedetomidine, or ketamine use between groups; however, intoxicated patients in the UDS(+)/EtOH(+) and UDS(+)/EtOH(-) used a significantly higher median dose of propofol (30.9 [21.5, 36.7] and 33.9 [22.7, 50.0]  vs 33.9 [13.7, 33.6] mcg/kg/min). UDS(+)/EtOH(+) and UDS(+)/EtOH(-) groups also used more adjunctive agents (66.7 % and 82.0% vs 46.0%, p=0.0008) and ERAS medications (45% and 47% vs 46%, p=0.0028). Additionally, intoxicated patients achieved lower RASS levels on continuous sedation compared to non-intoxicated patients (-1 [-2.0, 1.0] and -1 [-2.0, 1.0] vs -2 [-2.8, 1.0]). Of note, the incidence of mortality was higher in the non-intoxicated group (7% and 1% vs 11%, p=0.0101). There were no differences in duration of intubation, BPS scores, ICU LOS, hospital LOS, self extubation, or trach placement.
• Conclusion: Mechanically-ventilated patients with a positive UDS and/or serum ethanol level may not have higher MME or LME requirements. However, multimodal adjunctive analgesia and sedation methods may be warranted.
  
   sydney.kermeen@ecuhealth.org
  
  

Title: Angioedema Resolution: Evaluation of Low Dose and High Dose Steroids
Authors: Cristina V. Martinez, Evan C. Hardbeck, Nicholas Filk, Neha Naik, Maria C. CreelBulos, Jasleen K. Bolina 


Background: According to the Centers for Disease Control, angioedema affects approximately 110,000 patients annually in the United States. Angioedema is characterized by self-limited swelling of the mucosal tissues in the face and larynx. It can become life-threatening if airway obstruction occurs, requiring prompt emergency care. Angioedema can be classified as either hereditary or acquired. In hereditary cases, swelling occurs due to a bradykinin response, whereas in acquired cases, it is triggered by a histamine response. Bradykinin-mediated angioedema is initially treated with a C1- esterase inhibitor, while histamine-mediated angioedema is managed with corticosteroids, antihistamines, and epinephrine. While corticosteroids are commonly used to treat angioedema there is a notable gap in current literature on optimal dosing strategies. This retrospective review aims to evaluate steroid use in angioedema patients by comparing low dose and high dose regimens to elucidate current practices, trends, and outcomes in symptom resolution.


Methods: This multicenter, retrospective, observational study included patients aged 18 years or older, diagnosed with angioedema, who received more than one dose of corticosteroids over a two-year period. Patients were excluded from the study if they were known to be pregnant or incarcerated. Patients were stratified into four groups based on their initial steroid agent and the secondary steroid treatment to which they were transitioned. Groups 1 and 2 received an initial high dose of steroids followed by a low dose in Group 2 or remained on high dose in Group 1. Groups 3 and 4 received an initial low dose followed by a high dose in Group 3 or remained on a low dose in Group 4. High dose was defined as an equivalent dose of hydrocortisone equal or greater to 250 mg. The primary objective of this study was resolution of angioedema, defined as discontinuation or de-escalation of steroid therapy, de-escalation of oxygen therapy, or documentation of resolution of symptoms. Secondary objectives included adjuvant angioedema treatments used, oxygen requirements over two days, incidence of intubation, hospital length of stay, ICU length of stay, and adverse effects including infection and hyperglycemia post steroid initiation.


Results: A total of 66 patients were categorized into four groups based on initial and subsequent steroid doses. The median time to angioedema resolution in the high dose to high dose group (Group 1) and the high dose to low dose group (Group 2) was 2 days. The low dose to high dose group (Group 3) had the shortest resolution time, with a median time of one day. In the low dose to low dose group (Group 4), the median time to resolution was 2.5 days. Group 1 included all patients who required intubation, accounting for 15% of the total study population. ICU length of stays was longest at 3 days in Group 1 followed by 2.5 and 1.5 days in Group 2 and 4 respectively. Additionally, patients in the higher dose regimen groups experienced higher rates of hyperglycemia and infection when compared to regimens with lower doses.


Conclusion: This study highlights the gap in current guidance for the use of corticosteroid dosing strategies for angioedema. While high dose regimens are commonly used, practitioners should assess patient specific factors due to increased risk of adverse effects with higher dosing regimens. Transitioning to lower doses may provide a safer and equally effective alternative. This area of practice calls for future research to develop standardized guidelines to optimize corticosteroid use in angioedema treatment, ensuring both efficacy and safety for patients.