41 research outputs found

    Bicarbonate-based Purge Solution As A Bleeding Reduction Strategy in Patients on Impella Support

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    Study: The Impella Catheters require a heparin-containing purge solution to maintain proper pump function by reducing the risk of biomaterial deposition in the purge gaps. A bicarbonate-based purge solution (BBPS) has been proposed as an alternative to a heparin-based purge solution. We review performance in patients supported to date with a BBPS (heparin-induced thrombocytopenia patients were excluded from this analysis). Methods: This review includes patients (n=26) supported using sodium bicarbonate (25 mEq/1L of D5W) in the purge from September 2020 to February 2021. These patients were supported with BBPS post-operatively where heparin in the purge was not desired or were transitioned to BBPS because of bleeding issues. Case data were collected from an internal database to develop the clinical narrative and cross-referenced against Impella Controller data logs to assess purge trends and pump function. Results: All pumps were switched to BBPS in the purge if not started with BBPS (Figure 1A). The average time to initiating BBPS was 1.6 days (excluding n=3 outliers where time to switching was \u3e15 days). The average duration of support with BBPS was 5 days and a maximum duration of 22 days (Figure 1B). Figure 1C shows clinical indications for use. Purge pressure and purge flow remained stable while on BBPS (Figure 1D). In conclusion, this preliminary experience suggests the feasibility of using BBPS to maintain purge patency, ensure pump motor reliability, reduce bleeding risk, and simplify anticoagulation management. Use of a BBPS may be a safe and effective alternative to heparin in the purge for patients in which heparin is contraindicated or not feasible. More patient experience and analysis are needed to evaluate how bicarbonate compares to heparin in the purge for all patients

    Bicarbonate Purge Solution to Support Impella Devices for Patients with Clinically Suspected or Confirmed Heparin-induced Thrombocytopenia

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    Study: The Impella catheter is a transvalvular, micro-axial left ventricular assist device that provides temporary mechanical circulatory support and requires a heparin-containing purge solution to reduce the risk of biomaterial deposition in the purge gaps and also maintain proper pump function. For patients with suspected or confirmed heparin-induced thrombocytopenia (HIT), direct thrombin inhibitors (DTI) have been proposed as an alternative to heparin in the purge, but have been associated with pump failure requiring temporary tPA in the purge solution to normalize pump function. In this report, we review HIT patients supported with a sodium bicarbonate-based purge solution (BBPS). Methods: Patients with suspected or confirmed HIT on Impella support using sodium bicarbonate (25 mEq in 1L D5W solution) in the purge from September 2020 to January 2021 were reviewed. Case data were obtained from Impella Quality (IQ) database for those supported with a BBPS and clinically suspected or confirmed HIT. Purge pressures and purge flows were evaluated from the Automated Impella Controller (AIC). Results: Ten patients were supported with a BBPS during this period. Impella support was begun either with no anticoagulant (n=5), DTI (n=2), or heparin (n=3) and then switched to BBPS. Impella run time using a BBPS ranged from 1-14 days; five pumps had a run time with a BBPS \u3e 10 days (Figure 1). Systemic DTI use was used in five cases along with a BBPS. No purge pathway thrombosis or bleeding events were observed, along with no changes in purge flow or purge pressures observed. In conclusion, preliminary experience suggests the use of BBPS in the setting suspected or confirmed HIT patients supported with an Impella is safe and effective and may provide a useful therapeutic option for heparin intolerant patients. Future work should investigate mechanisms and purge reliability of BBPS in this setting

    Mental workload and driving

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    International audienceThe aim of this review is to identify the most representative measures of subjective and objective mental workload in driving, and to understand how the subjective and objective levels of mental workload influence the performance as a function of situation complexity and driving experience, i.e., to verify whether the increase of situation complexity and the lack of experience increase the subjective and physiological levels of mental workload and lead to driving performance impairments. This review will be useful to both researchers designing an experimental study of mental workload and to designers of drivers' training content. In the first part, we will broach the theoretical approach with two factors of mental workload and performance, i.e., situation complexity and driving experience. Indeed, a low complex situation (e.g., highways), or conversely a high complex situation (e.g., town) can provoke an overload. Additionally, performing the driving tasks implies producing a high effort for novice drivers who have not totally automated the driving activity. In the second part, we will focus on subjective measures of mental workload. A comparison of questionnaires usually used in driving will allow identifying the most appropriate ones as a function of different criteria. Moreover, we will review the empirical studies to verify if the subjective level of mental workload is high in simple and very complex situations, especially for novice drivers compared to the experienced ones. In the third part, we will focus on physiological measures. A comparison of physiological indicators will be realized in order to identify the most correlated to mental workload. An empirical review will also take the effect of situation complexity and experience on these physiological indicators into consideration. Finally, a more nuanced comparison between subjective and physiological measures will be established from the impact on situation complexity and experience

    The Effect of Cardiovascular Credentialed Pharmacists on Process Measures and Outcomes in Myocardial Infarction and Heart Failure

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    Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108262/1/phar1444.pd

    Reimbursement mechanisms for glycoprotein IIb/IIIa-receptor inhibitors

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    A Trial of Automated Safety Alerts for Inpatient Digoxin Use with Computerized Physician Order Entry

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    Objective: Automated clinical decision support (CDS) has shown promise in improving safe medication use. The authors performed a trial of CDS, given both during computerized physician order entry (CPOE) and in response to new laboratory results, comparing the time courses of clinician behaviors related to digoxin use before and after implementation of the alerts. Design: Alerts were implemented to notify of the potential risk from low electrolyte concentrations or unknown digoxin or electrolyte concentrations during CPOE. Alerts were also generated in response to newly reported hypokalemia and hypomagnesemia in patients given digoxin. Measurements: Clinician responses to the alerts for six months were compared with responses to similar situations for six months prior to implementation. Results: During CPOE, checking for unknown serum values increased after implementation compared with control at one hour: 19% vs. 6% for digoxin, 57% vs. 9% for potassium, and 40% vs. 12% for magnesium as well as at 24 hours (p < 0.01 for all comparisons). Electrolyte supplementation increased with newly reported hypokalemia and hypomagnesemia after implementation at one hour: 35% vs. 6% and 49% vs. 5% for potassium and magnesium, respectively, as well as at 24 hours (p < 0.01 for all comparisons). During CPOE, supplementation for hypokalemia was not improved, whereas supplementation for hypomagnesemia improved at one hour (p < 0.05). Conclusion: Overall, the alerts improved the safe use of digoxin. During CPOE, alerts associated with missing levels were effective. For hypokalemia and hypomagnesemia, the alerts given during CPOE were not as effective as those given at the time of newly reported low electrolytes

    Frequency of “on-label” use of intravenous diltiazem for rate control in patients with acute-onset atrial fibrillation or atrial flutter

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    Background: Intravenous (IV) diltiazem is indicated for acute atrial fibrillation or flutter (AFF) but real-world dosing strategies often differ from labeling. Objective: To characterize “on-label” use of IV diltiazem in acute AFF. Methods: An IRB-approved, single-center, retrospective, observational design was utilized. Eligible patients had acute AFF with heart rate > 120 bpm and received IV diltiazem between June 2012 – June 2014. The primary outcome was frequency of on-label use of IV diltiazem, defined as use of at least one FDA-approved weight-based bolus dose followed by an infusion, if appropriate, in the absence of contraindications. Results: 300 patients were screened; 97 patients were included for analysis. IV diltiazem was used on-label in only 14 patients (14.4%). Of the 96 patients who received an initial diltiazem bolus, the median dose was significantly higher in patients for whom the diltiazem dose was on-label [17.5 mg (IQR 10-20 mg) vs. 10.0 mg (IQR 10-20 mg), p < 0.02). Twenty-nine patients (34.9%) in the off-label group had a therapeutic response to diltiazem alone compared to 8 patients (57.1%) in the on-label group (p = 0.11). More patients treated with off label diltiazem boluses required additional rate control medications (40.9% vs. 7.1%, p < 0.04). Conclusion: IV diltiazem was not used in accordance with FDA labeling in the majority of patients. For most patients, IV diltiazem doses were lower than recommended and many of these patients required additional rate control medications to achieve a therapeutic response. Patients with tachycardia due to acute AFF may benefit from improved IV diltiazem dosing strategies or the use of alternative rate-control agents (e.g. beta blockers)

    Reversal of Oral Anticoagulants: A Survey of Contemporary Practice Trends (ReACT)

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    This study evaluated practice patterns and factors influencing treatment decisions regarding urgent or emergent reversal of oral anticoagulants (OACs). A 30-question survey was electronically distributed to anticoagulation members of the Anticoagulation Forum. Questions were designed to capture practice trends in the reversal of warfarin, factor Xa inhibitors, and factor IIa inhibitors. Continuous and categorical data were analyzed to generate descriptive statistics. Open-ended questions were summarized by thematic categories. 173 responses were collected most from US-based pharmacists with direct patient care responsibilities. The majority of the respondents' institutions (90.2%) utilized a guideline or protocol for OACs reversal. Vitamin K (91.3%), activated charcoal (80.4%), and fresh frozen plasma (72.8%) were the most common reversal agents on formulary without restrictions. Most institutions (87.0%) reported having 4-factor prothrombin complex concentrate (4F-PCC) and idarucizumab on formulary, but most commonly (52.2%) with restrictions. Andexanet alfa was only reported on formulary at 35.9% of institutions. In contrast to current guideline recommendations, vitamin K (98.8%) was preferred over 4F-PCC and 4F-PCC (71.6%) was preferred over andexanet alfa as first-line agents used to reverse warfarin and factor Xa inhibitors, respectively. Weight-based dosing strategies for 4F-PCC were commonly utilized for different reversals (41.2%-59.4%). Cost, efficacy, and safety of 4F-PCC were identified as top facilitators and barriers for 4F-PCC adoption in practice. Our findings revealed that guideline recommendations for reversal of warfarin and factor Xa and IIa inhibitors are not followed by a majority of institutions. Studies are needed to investigate strategies to overcome barriers for implementing and following guideline recommendations
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