2011 December

The fallacy of the BUN:creatinine ratio in critically ill patients.

Nephrol Dial Transplant Start a Discussion »

Dec 312011

The fallacy of the BUN:creatinine ratio in critically ill patients.

Nephrol Dial Transplant. 2011 Dec 29;

Authors: Rachoin JS, Daher R, Moussallem C, Milcarek B, Hunter K, Schorr C, Abboud M, Henry P, Weisberg LS

Abstract
Background and objectivesAcute kidney injury (AKI) is common in critically ill patients and is associated with a high mortality rate. Pre-renal azotemia, suggested by a high blood urea nitrogen to serum creatinine (BUN:Cr) ratio (BCR), has traditionally been associated with a better prognosis than other forms of AKI. Whether this pertains to critically ill patients is unknown.MethodsWe conducted a retrospective observational study of two cohorts of critically ill patients admitted to a single center: a derivation cohort, in which AKI was diagnosed, and a larger validation cohort. We analyzed associations between BCR and clinical outcomes: mortality and renal replacement therapy (RRT).ResultsPatients in the derivation cohort (N = 1010) with BCR >20 were older, predominantly female and white, and more severely ill. A BCR >20 was significantly associated with increased mortality and a lower likelihood of RRT in all patients, patients with AKI and patients at risk for AKI. Patients in the validation cohort (N = 10?228) with a BCR >20 were older, predominantly female and white, and more severely ill. A BCR >20 was associated with increased mortality and a lower likelihood of RRT in all patients and in those at risk for AKI, BUN correlated with age and severity of illness.ConclusionsA BCR >20 is associated with increased mortality in critically ill patients. It is also associated with a lower likelihood of RRT, perhaps because of misinterpretation of the BCR. Clinicians should not use a BCR >20 to classify AKI in critically ill patients.

PMID: 22207331 [PubMed - as supplied by publisher]

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Disproportionate elevation of jugular venous pressure in pleural effusion.

Br J Hosp Med (Lond) Start a Discussion »

Dec 312011

Disproportionate elevation of jugular venous pressure in pleural effusion.

Br J Hosp Med (Lond). 2011 Oct;72(10):582-5

Authors: Jolobe OM

Abstract
Constrictive pericarditis is characterized by elevation in jugular venous pressure disproportionate to the severity of concurrent breathlessness. As pleural effusion may be an associated feature it is recommended that jugular venous pressure should be documented in all patients who present with pleural effusion.

PMID: 22041729 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Management of the hyperthermic patient.

Br J Hosp Med (Lond) Start a Discussion »

Dec 312011

Management of the hyperthermic patient.

Br J Hosp Med (Lond). 2011 Oct;72(10):571-5

Authors: Calvello EJ, Hu K, Khoujah D

Abstract
Undifferentiated body temperature of greater than 38 degreesC can herald a number of important clinical syndromes essential to diagnose besides just infectious aetiologies. This review examines the pathophysiology, clinical features and approach to the management of hyperthermia that will lead to appropriate diagnosis and treatment.

PMID: 22041727 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downstream of CPOE alerts.

J Am Med Inform Assoc Start a Discussion »

Dec 312011

Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downstream of CPOE alerts.

J Am Med Inform Assoc. 2011 Dec;18 Suppl 1:i45-i50

Authors: Miller AM, Boro MS, Korman NE, Davoren JB

Abstract
Objective To categorize the appropriateness of provider and pharmacist responses to warfarin critical drug-drug interaction (cDDI) alerts, assess responses and actions to the cDDI, and determine the occurrence of warfarin adverse drug events (ADE) after alerts. Design An 18-month, retrospective study of acute care admissions at a single Veterans Affairs medical center using computerized provider order entry (CPOE). Measurements Patients included had at least one warfarin cDDI alert. Chart reviews included baseline laboratory values and demographics, provider actions, patient outcomes, and associated factors, including other interacting medications and number of simultaneously processed alerts. Results 137 admissions were included (133 unique patients). Amiodarone, vitamin E in a multivitamin, sulfamethoxazole, and levothyroxine accounted for 75% of warfarin cDDI. Provider responses were clinically appropriate in 19.7% of admissions and pharmacist responses were appropriate in 9.5% of admissions. There were 50 ADE (36.6% of admissions) with warfarin; 80% were rated as having no or mild clinical effect. An increased number of non-critical alerts at the time of the reference cDDI alert was the only variable associated with an inappropriate provider response (p=0.01). Limitations This study was limited by being a retrospective review and the possibility of confounding variables, such as other interacting medications. Conclusion The large number of CPOE alerts may lead to inappropriate responses by providers and pharmacists. The high rate of ADE suggests a need for improved medication management systems for patients on warfarin. This study highlights the possibility of alert fatigue contributing to the high prevalence of inappropriate alert over-ride text responses.

PMID: 22037888 [PubMed - in process]

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Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED.

Am J Emerg Med Start a Discussion »

Dec 302011

Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED.

Am J Emerg Med. 2011 Dec 26;

Authors: Lee CC, Lee CH, Chuang MC, Hong MY, Hsu HC, Ko WC

Abstract
OBJECTIVES: To investigate the clinical impact of inappropriate empirical antibiotics on patient outcome and determine the risk factors for mortality in bacteremic adults who visited the emergency department (ED). METHODS: Bacteremic adults visiting the ED from January 2007 to June 2008 were identified retrospectively. Demographic characteristics, clinical conditions, bacteremic pathogens, antimicrobial agents, and outcomes were determined from chart records. RESULTS: The total of 454 eligible bacteremic adults were included in the analysis; excluded from the study were another 261 patients with contaminated blood cultures and 64 patients with ED stays of less than 24 hours. Among the included individuals, the mean age was 64.6 years, with a small predominance of males (230 patients, 50.7%). Of a total 494 bacteremic isolates, Escherichia coli (206, 41.7%) and Klebsiella species (81, 16.4%) were the most frequently encountered microorganisms. A lower 28-day mortality rate was demonstrated in bacteremic patients treated with appropriate antibiotics than that in those with inappropriate antibiotics or that in those with no antibiotic therapy, as judged by Kaplan-Meier survival curves (P = .01). Moreover, the differences among these three groups achieved higher significance (P = .002) in critically ill patients (Pittsburgh bacteremia scores of ?4 points). In multivariate analyses, inappropriate antibiotic therapy in the ED was associated independently with mortality at 28 days (odds ratio, 2.26; 95% confidence interval, 1.01-5.13; P = .04). CONCLUSIONS: For bacteremic adults visiting the ED, their outcomes were favorable following appropriate antibiotics, compared to treatment with inappropriate antibiotics or no antibiotics.

PMID: 22205015 [PubMed - as supplied by publisher]

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Hospital-level variation in the percentage of admissions originating in the emergency department.

Am J Emerg Med Start a Discussion »

Dec 302011

Hospital-level variation in the percentage of admissions originating in the emergency department.

Am J Emerg Med. 2011 Dec 26;

Authors: Studnicki J, Platonova EA, Fisher JW

Abstract
PURPOSE: Well over half of all US hospital patients are now admitted directly through the emergency department (ED) rather than scheduled through the admissions department by a referring member of the medical staff. This study sought to understand hospital-level variation in the percentage of admissions originating in the ED. BASIC PROCEDURES: This was a retrospective, cross-sectional analysis of 5 748 375 ED visits and 2 265 478 inpatient discharge occurring in 192 short-term acute Florida hospitals in calendar year 2005. MAIN FINDINGS: Hospitals with increasing percentages of patients admitted through the ED are smaller in scale with fewer admissions, beds, and smaller medical staffs but admit a higher percentage of their ED visits to the hospital. Patients in these hospitals are increasingly Hispanic, older, Medicare insured, and likely to represent a preventable ambulatory sensitive condition. CONCLUSIONS: The increasing rate of admissions from the ED department is a national trend, but there is substantial variation at the hospital level. In Florida, measures of hospital scale and an older population with some limitations in access to, or the quality of, primary care are the factors influencing hospital-level variation. Factors implicated in increased ED use such as ED visit acuity, lack of insurance, and race are not important contributory variables. The process of admission and, particularly, the role of the organized medical staff in this process are evolving, and the consequences of these changes require further research.

PMID: 22205007 [PubMed - as supplied by publisher]

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