Clinically relevant potential drug-drug interactions in intensive care patients: a large retrospective observational multicenter study

Purpose: Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all pDDIs are clinically relevant. Clinical decision support systems (CDSSs) warning for irrelevant pDDIs could result in alert fatigue and overlooking important signals. Therefore, our aim was to describe the frequency of clinically relevant pDDIs (crpDDIs) to enable tailoring of CDSSs to the ICU setting. Materials & methods: In this multicenter retrospective observational study, we used medication administration data to identify pDDIs in ICU admissions from 13 ICUs. Clinical relevance was based on a Delphi study in which intensivists and hospital pharmacists assessed the clinical relevance of pDDIs for the ICU setting. Results: The mean number of pDDIs per 1000 medication administrations was 70.1, dropping to 31.0 when con -sidering only crpDDIs. Of 103,871 ICU patients, 38% was exposed to a crpDDI. The most frequently occurring crpDDIs involve QT-prolonging agents, digoxin, or NSAIDs. Conclusions: Considering clinical relevance of pDDIs in the ICU setting is important, as only half of the detected pDDIs were crpDDIs. Therefore, tailoring CDSSs to the ICU may reduce alert fatigue and improve medication safety in ICU patients. ? 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).Perioperative Medicine: Efficacy, Safety and Outcome (Anesthesiology/Intensive Care

Clinically relevant potential drug-drug interactions in intensive care patients: A large retrospective observational multicenter study

Purpose: Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all pDDIs are clinically relevant. Clinical decision support systems (CDSSs) warning for irrelevant pDDIs could result in alert fatigue and overlooking important signals. Therefore, our aim was to describe the frequency of clinically relevant pDDIs (crpDDIs) to enable tailoring of CDSSs to the ICU setting. Materials & methods: In this multicenter retrospective observational study, we used medication administration data to identify pDDIs in ICU admissions from 13 ICUs. Clinical relevance was based on a Delphi study in which intensivists and hospital pharmacists assessed the clinical relevance of pDDIs for the ICU setting. Results: The mean number of pDDIs per 1000 medication administrations was 70.1, dropping to 31.0 when considering only crpDDIs. Of 103,871 ICU patients, 38% was exposed to a crpDDI. The most frequently occurring crpDDIs involve QT-prolonging agents, digoxin, or NSAIDs. Conclusions: Considering clinical relevance of pDDIs in the ICU setting is important, as only half of the detected pDDIs were crpDDIs. Therefore, tailoring CDSSs to the ICU may reduce alert fatigue and improve medication safety in ICU patients

Gastrointestinal actinomycosis: an unusual presentation with obstructive uropathy: report of a case and review of the literature

Gastrointestinal actinomycosis: an unusual presentation with obstructive uropathy: report of a case and review of the literature. de Feiter PW, Soeters PB. Department of Surgery, Division of Gastrointestinal Surgery, University Hospital Maastricht, Maastricht, the Netherlands. A 55-year-old female patient is described who had recurrent retroperitoneal infections without an apparent focus. After a protracted period of illness the infection proved to be caused by actinomycosis. An unusual feature of the inflammatory process consisted of obstruction of the ureters, ultimately resulting in destruction of the left kidney. Hydronephrosis resulting from inflammatory fibrosis has not been reported in the literature befor

Rectal Perforations After Barium Enema: A Review

PURPOSE: Rectal injuries during barium enema are rare but life-threatening complications. The last review about this subject was published more than ten years ago. In the present review, we present an overview on the subject andespecially focus on changes in treatment strategies anddevelopments of less risky visualization techniques. METHODS: A literature search was performed in the PubMed library using the key words-barium enema, complications, peritonitis, and rectal perforation-as well as related articles and other references obtained from these articles. RESULTS: The most frequent cause of perforation is iatrogenic and catheter-related. Other causes are related to weakness of the colorectal wall or obstruction. Five types of perforations have been described: 1) perforations of the anal canal below the levator; 2) incomplete perforations; 3) perforations into the retroperitoneum; 4) transmural perforations into adjacent viscera; 5) perforations into the free intraperitoneal cavity. Most incomplete perforations and one-half of the retroperitoneal perforations have minimal clinical signs. Intraperitoneal perforations lead to the most catastrophic course, starting with rectal bleeding and mild abdominal complaints. This is rapidly followed by progressive sepsis and peritonitis, and leads to a high mortality rate. Surgery is not always required for intramural or small retroperitoneal perforations. These can be treated conservatively and require surgical debridement only in case of large amounts of extravasation or abscesses. Surgical repair of large rectal mucosal lesions or anal sphincter lesions is advised. Perirectal abscesses require drainage. Intraperitoneal perforations with gross extravasation need immediate aggressive surgical treatment in a critical care setting, because the threat of shock is high. Intraperitoneal perforations, neglected perforations, gross barium extravasation, poorly prepared colon, and venous intravasation of barium are prognostically unfavorable. The severest late complication in intraperitoneal perforations is ileus. Meticulous technical performance of the barium enema is the most important factor in prevention. CONCLUSIONS: Rectal perforations after barium enema are rare. The overall mortality rate decreased in recent decades from approximately 50 to 35 percent as the result of advances in supportive and intensive care. Because of these advances, more aggressive surgical strategies were undertaken. With the advent of endoscopy, less barium enemas are performed. Consequently, the absolute incidence of complications has decreased. It is expected that in the future barium enemas will be replaced by more sensitive and less risky techniques, such as CT colonography and magnetic resonance colonography. AD - Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands

Tracheal compression caused by an innominate artery aneurysm after thoracic aortic aneurysm repair in a patient with Marfan disease

A 43-year-old man was admitted to the intensive care unit because of weaning impairment. His medical history revealed hypertension, marfan disease, bentall procedure, partial aortic arch replacement, and replacement of the aortic arch with bypasses to the left common carotid, proximal innominate, and left subclavian arteries. Now a thoracoabdominal aortic aneurysm (crawford extent ii) with dissection necessitated aortic replacement from the previous graft to the iliac bifurcation. Extubation attempts early after surgical intervention failed. After transfer to the intensive care unit, weaning was impaired by desaturation caused by sputum retention. Resistance during advancement of a suction tube into the trachea was noted. Bronchoscopy showed 90% stenosis caused by external compression. A computed tomographic (ct) scan (figure 1) visualized tracheal compression between the spinal column and the aneurysmatic innominate artery (maximal diameter of 3 cm). During reoperation, the innominate artery aneurysm was excluded, new bypasses to the right carotid and subclavian arteries were constructed, and fibrotic tissue compromising the patency of the trachea was transected. During the operation (positive-pressure ventilation), bronchoscopy revealed spontaneous deployment and a fully patent lumen. Five days postoperatively, bronchoscopy during spontaneous breathing (zero positive pressure) revealed tracheomalacia and a remaining stenosis of 60%. Several hours after extubation, coughing and increased inspiratory effort resulted in desaturation and stridor. Reintubation was necessary for another week. After 14 days, the patient was discharged from the hospital without stridor or dyspnea. A ct scan performed after 5 months showed persistent tracheomalacia with a diameter reduction of approximately 60% (figure 2). The patient was free of symptoms.download full-size imagefigure 1. Ct scan of the cervical region showing 90% tracheal stenosis caused by compression of the trachea between the spinal column and the aneurysmatic innominate artery (Ø 3 cm)

Successful treatment of Staphylococcus epidermidis prosthetic valve endocarditis with linezolid after failure of treatment with oxacillin, gentamicin, rifampicin, vancomycin, and fusidic acid regimens

We present a 49-y-old male, with a history of marfan's disease and aortic and mitral valve replacement surgery, who was operated for a type iii thoracoabdominal aneurysm. The postoperative course was compromized by a staphylococcus epidermidis mitral valve endocarditis, which was successfully treated only after intravenous linezolid was included in the therapy