The primary objective is to identify and describe the complications associated with the use of intravenous lipid emulsion (ILE) therapy as an antidote for lipophilic drug toxicity. This study is a retrospective chart review of patients treated with ILE at two academic medical centers between 2005 and 2012. Based on previously reported complications, we hypothesized that pancreatitis, ARDS, and lipemiainduced laboratory interference might occur. Clinical definitions of these complications were defined a priori. Subjects treated with ILE who did not develop at least one complication were excluded. A total of nine patients were treated with ILE during the study period, six of whom experienced potential complications as a result of the ILE. Two patients developed pancreatitis, and four patients had lipemia-induced interference of interpretation of laboratory studies, despite ultracentrifugation. Laboratory interference precluded one patient from being an organ donor. Three patients developed ARDS; although temporally associated, a causal relationship between ILE and the development of ARDS cannot be clearly established. As ILE is increasingly used for less severe cases of drug toxicity, clinicians should be aware of potential complications associated with its use. A risk-benefit assessment for the use of ILE should be implemented on a case-by-case basis.

Abstract

There are no published studies that have compared quality outcomes of hospitalized poisoned patients primarily under the care of physician medical toxicologists to patients treated by non-toxicologists. We hypothesized that inpatients primarily cared for by medical toxicologists would exhibit shorter lengths of stay (LOS), lower costs, and decreased mortality. Patients discharged in 2010 and 2011 from seven hospitals within the same health care system and greater metropolitan area with Medicare severity diagnosis-related groups for "poisoning and toxic effects of drugs" with and without major comorbidities or complications (917 & 918, respectively) were identified from a Premier® database. The database contained severity-weighted comparisons between expected and observed outcomes for each patient. Outcome parameters were differences between expected and observed LOS, cost, and percent mortality. These were then compared among groups of patients primarily admitted and cared for by (1) medical toxicologists at one hospital (Banner Good Samaritan Medical Center, BGS), (2) non-toxicologists at BGS, and (3) non-toxicologists at six other hospitals. Records of 3,581 patients contained complete data for assessment of at least one outcome measure. Patients cared for by medical toxicologists experienced favorable differences in LOS, costs, and mortality compared with other patient groups (p<0.001). If patients cared for by non-toxicologists had experienced similar differences in observed over expected values for LOS, cost, and mortality as those cared for by medical toxicologists, there would have been a median savings of 1,483 hospital days, $4.269 million, and a significant decrease in mortality during the 2-year study period. Differences between observed and expected LOS, cost, and mortality in patients primarily cared for by medical toxicologists were significantly better than in patients cared for by non-toxicologists, regardless of facility. These data suggest that significant reductions in patient hospital days, costs, and mortality are possible when medical toxicologists directly care for hospitalized patients.

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Clinical trials involving liposomal bupivacaine and SABER-Bupivacaine indicate that both safely prolong analgesia, while decreasing opioid requirements when compared with placebo. However, additional clinical studies are necessary to better determine the efficacy and cost-effectiveness of these long-acting local anesthetic formulations.

Background Audiovisual streaming technologies allow detailed remote patient assessment and have been suggested to change management and enhance triage. The advent of wearable, head-mounted devices (HMDs) permits advanced teletoxicology at a relatively low cost. A previously published pilot study supports the feasibility of using the HMD Google Glass® (Google Inc.; Mountain View, CA) for teletoxicology consultation. This study examines the reliability, accuracy, and precision of the poisoned patient assessment when performed remotely via Google Glass®. Methods A prospective observational cohort study was performed on 50 patients admitted to a tertiary care center inpatient toxicology service. Toxicology fellows wore Google Glass® and transmitted secure, real-time video and audio of the initial physical examination to a remote investigator not involved in the subject's care. High-resolution still photos of electrocardiograms (ECGs) were transmitted to the remote investigator. On-site and remote investigators recorded physical examination findings and ECG interpretation. Both investigators completed a brief survey about the acceptability and reliability of the streaming technology for each encounter. Kappa scores and simple agreement were calculated for each examination finding and electrocardiogram parameter. Reliability scores and reliability difference were calculated and compared for each encounter. Results Data were available for analysis of 17 categories of examination and ECG findings. Simple agreement between on-site and remote investigators ranged from 68 to 100 % (median = 94 %, IQR = 10.5). Kappa scores could be calculated for 11/17 parameters and demonstrated slight to fair agreement for two parameters and moderate to almost perfect agreement for nine parameters (median = 0.653; substantial agreement). The lowest Kappa scores were for pupil size and response to light. On a 100-mm visual analog scale (VAS), mean comfort level was 93 and mean reliability rating was 89 for on-site investigators. For remote users, the mean comfort and reliability ratings were 99 and 86, respectively. The average difference in reliability scores between on-site and remote investigators was 2.6, with the difference increasing as reliability scores decreased. Conclusion Remote evaluation of poisoned patients via Google Glass® is possible with a high degree of agreement on examination findings and ECG interpretation. Evaluation of pupil size and response to light is limited, likely by the quality of streaming video. Users of Google Glass® for teletoxicology reported high levels of comfort with the technology and found it reliable, though as reported reliability decreased, remote users were most affected. Further study should compare patient-centered outcomes when using Electronic supplementary material The online version of this article

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