Background Standard venous thromboembolism (VTE) prophylaxis with enoxaparin results in inadequate protection in certain patients, with sub-therapeutic plasma anti-Xa levels associated with elevated VTE rates. We hypothesized that many trauma patients would be sub-therapeutic on the standard prophylactic dose of enoxaparin. Our goal was to adjust the enoxaparin dose to achieve target anti-Xa levels to take advantage of the drug based on its pharmacologic properties. Methods Patients admitted to the trauma service were included if they received at least 3 doses of prophylactic enoxaparin and underwent at least 2 screening venous duplex. Peak plasma anti-Xa levels ≤ 0.2 IU/ml were considered low and the dose was increased by 10mg bid until adequate anti-Xa levels were obtained. A strict screening venous duplex protocol was followed. Patients were excluded if they were diagnosed with a DVT prior to beginning enoxaparin or did not have correctly timed anti-Xa levels. Results Sixty-one trauma patients met inclusion criteria. There were 3 patients diagnosed with VTE (4.9%). Patients had a mean age of 45.9 years and were predominantly male (70.5%). Of the 61 patients, 18 (29.5%) had therapeutic anti-Xa levels on standard enoxaparin 30mg bid. Compared to patients who had therapeutic anti-Xa levels on enoxaparin 30mg bid, the 43 patients (70.5%) who were sub-therapeutic were more likely to be male, have larger body weight, and larger body surface area. There were no significant bleeding events in the group that received an enoxaparin dose adjustment. Conclusions A majority of patients had sub-therapeutic anti-Xa levels while on enoxaparin 30mg bid suggesting inadequate VTE prophylaxis. The need for routine use of a higher dose of prophylactic enoxaparin in trauma patients and the effects of routinely dose adjusting enoxaparin on VTE rates should be the study of future prospective, randomized trials.

Therapeutic/care management study, level II.

Objective. To assess the impact of high-fidelity patient simulation on pharmacy resident knowledge, confidence, and competency with advanced resuscitation algorithms and interventions.Design. An overview of the institutional cardiopulmonary arrest algorithm and a review of pertinent medications and calculations were presented to postgraduate year 1 (PGY1) pharmacy residents, followed by participation in 3 simulated clinical scenarios using a high-fidelity mannequin.Assessment. An improvement of pharmacy resident knowledge, confidence, and competency with advanced resuscitation skills was observed. In addition, pharmacy residents demonstrated high performance levels with skills requiring advanced competency and proactive interactions with the cardiac arrest team. Conclusion. Incorporating high-fidelity patient simulation into an advanced resuscitation training program can help pharmacy residents achieve competency through the active learning of practical skills.

Dexmedetomidine can be a safe and effective sedative agent for neurosurgical patients. A loading infusion should be avoided and higher maintenance doses may be required to ensure adequate sedation. Further studies are necessary to establish an optimal dosage regimen.

Background: An observational pilot study of 41 medical and surgical intensive care patients on infusion insulin at our own institution found that glycemic control rapidly deteriorated within 48 hours of stopping infusion insulin. This prompted the design and testing of a transition protocol. Methods: The transition protocol identified appropriate patients for subcutaneous (SC) insulin along with the insulin dose and schedule. A pharmacist‐hospitalist improvement team offered protocol guidance but adherence was left to the discretion of the provider. The primary endpoints were mean blood glucose the first and second day after stopping the insulin infusion and the number of patients with hypoglycemia (41‐70 mg/dL) and severe hypoglycemia (<40 mg/dL) during the 48‐hour transition. Secondary endpoints include severe hyperglycemia (>300 mg/dL), length of stay (LOS), re‐initiation of the infusion insulin, day‐weighted glucose mean 12 days following transition for patients with diabetes, and identification of a new diagnosis of diabetes. Results: Patients with diabetes transitioned by protocol (n = 33) had better glycemic control than those (n = 39) transitioned without the protocol (Day 1 population glucose mean of 168 mg/dL vs. 211 mg/dL [P<0.001], Day 2 means of 176 mg/dL vs 218 mg/dL [P<0.001]). Severe hypoglycemia occurred once in each group. There were 14 patients newly diagnosed with diabetes based on an A1c ≥6%. Patients with stress hyperglycemia maintained good glycemic control with correctional insulin only. Conclusion: Protocol adherence improved glycemic control, reduced unnecessary use of insulin, and identified patients with previously undiagnosed diabetes, without any increase in hypoglycemia. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

No abstract

Therapeutic study, level V.

Glucose control has repeatedly been shown to influence favorable outcomes in the surgical intensive care unit (ICU). Intensive insulin therapy has recently been associated with reduced infections complications in burn patients. However, traditional protocols are associated with rates of severe hypoglycemia as high as 19%. Two commercial computer glucose control programs have reported rates of severe hypoglycemia (glucose <50 mg/dl) of 0.6 and 0.4%. Recently, the authors' burn ICU adopted an intensive insulin computer-based protocol created at their institution and already successfully in use in their surgical ICU. The authors hypothesized that their protocol can be used effectively in the burn patient population without an increase risk of severe hypoglycemia. All patients admitted to the burn ICU have blood glucose (BG) values checked routinely. With two consecutive hyperglycemic values >200 mg/dl, patients are placed on a computer-based protocol intravenous insulin drip. Once initiated, BGs are tested hourly with adjustments made according to the computer protocol. Values recorded from January to December 2008 were abstracted from the database and analyzed. Thirty-one patients were treated using the computer glucose control protocol and 12,699 measurements were performed. There were eight measurements <50 mg/dl (0.07%). Seventy-six percent of values were within the target range of 90 to 150 mg/dl. Few patients had severe hyperglycemia with BG >300 mg/dl (0.2%). There were no adverse events associated with the hypoglycemic episode. The computer-based protocol is more effective than those previously used at the institution and provides safe, reliable results in the burn patients.