Severe alcohol withdrawal is not clearly defined, and limited data regarding management are available. Protocolized administration of benzodiazepines, in combination with phenobarbital, may reduce the need for mechanical ventilation and lead to shorter ICU stays. Propofol is a viable alternative for patients refractory to benzodiazepines; however, the role of other agents remains unclear. Randomized, prospective studies are needed to clearly define effective treatment strategies.
Background: Norepinephrine remains the first-line option to manage patients with circulatory shock. Limited evidence exists evaluating noncatecholamine compounds as first-line monotherapy for managing noncardiogenic shock. Objective: To compare vasopressin monotherapy with norepinephrine monotherapy for reversal of distributive and hemorrhagic shock. Methods: This was a retrospective cohort study including adult patients who were diagnosed with hypovolemic or septic shock, received fluids, and received norepinephrine or vasopressin monotherapy for at least 1 hour. Patients excluded lacked a clear diagnosis, were initiated on 2 or more vasopressors at once, or underwent cardiac surgery. The primary outcome was time to shock reversal. Secondary outcomes included mortality, lengths of stay, and safety end points. A multivariable Cox proportional hazards model was performed incorporating baseline and treatment variables. Results: A total of 85 and 160 patients were treated with vasopressin and norepinephrine, respectively. A decrease in time to shock reversal was observed in the vasopressin group (58.32 hours [95% CI, 50.88-66.00] vs 74.64 hours [95% CI, 60.96-88.32], P = 0.004). Mortality was lower in the vasopressin group (25% vs 41%, P = 0.01), and intensive care unit length of stay was longer (13 days [interquartile range, IQR = 7-19] vs 7 days [IQR = 5-9], P = 0.006). Remaining secondary outcomes were similar. The multivariable analysis revealed no difference in time to shock reversal. Conclusion and Relevance: First-line vasopressin exhibited faster time to distributive shock reversal in the unadjusted analysis but failed to maintain this difference in the multivariable analysis. These findings support safe use of vasopressin as first-line therapy or as an alternative to norepinephrine in distributive shock.
There are several validated insulin infusion protocols to help guide intravenous (IV) insulin dose titrations. However, when continued upward titration of insulin infusion is required to achieve glycemic control, little is known to guide how high the infusion rate can be increased without compromising safety and improving efficacy. The purpose of this study was to characterize patients requiring high-dose insulin infusions (rates >20 units/hour) for the management of hyperglycemia and determine the incidence at our institution. A retrospective chart review of all patients aged 18 years or older who received IV insulin infusion between 01/01/2016 and 07/31/2017 at Beaumont Hospital, MI resulted in 82 patients (2.9%) who received high-dose insulin infusion for the management of hyperglycemia. Average age was 62 years old and majority were Caucasian males. Most patients had hyperglycemia associated with risk factors such as: history of type 2 diabetes (71%), obesity (median body mass index (BMI) was 33.9 kg/m2), critical illness (89%), many were surgical patients (>50%), and a large proportion received vasopressors (79%) and corticosteroids (36%). The highest infusion rate observed was 80 units/hour, with a median infusion rate of 6.5 units/hour. Hypoglycemia (BG ≤ 70 mg/dl) was reported in 29% of patients and 11% had recurrent hypoglycemic episodes. Our findings suggest that the overall need for high-dose insulin infusion rates is very low. However, the incidence of hypoglycemia in these patients was substantially high and therefore concerning. Insulin is a high-alert medication requiring implementation of appropriate safety measures to prevent errors and careful investigation is warranted when used in high-doses. We recommend an insulin infusion “time-out” to assess the infusion site, the IV line and insulin bag before exceeding 20 units/hour. Furthermore, institutional policies for soft- and hard-maximum infusion parameters should be established to conserve use. Disclosure A.A. Feleke: None. R.C. Fuller: None. R. Ismail: None. M. Cadiz: None.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.