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Antipyretic effect of clonidine in intensive care unit patients: a nested observational study
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
Antipyretic effect of clonidine in intensive care unit patients: a nested observational study Majid Mokhtari ∗ , Mohammad Sistanizad, Maryam Farasatinasab Shahid Beheshti University of Medical Sciences (SBUMS), Iran Background Fever in ICU is usually an adaptive response to infection or inflammation. Pharmacological intervention is often required in addition to addressing the underlying causes of fever. Animal studies have examined the antipyretic effect of clonidine, however to our knowledge there are no clinical data available in humans. Objective To report possible antipyretic effect of clonidine in ICU patients. Methods The observation of antipyretic effect of clonidine was made during a single center randomized control trial, which was designed to study the effect of clonidine addition to the commonly used sedative agents, in mechanically ventilated ICU patients. Forty patients, 18 years or older on mechanical ventilation for 3 days or longer, were randomized in two groups of clonidine and placebo., In addition to the usual sedation/analgesia, patients in the clonidine arm received enteral clonidine in doses of 0.1 mg TID which was increased to 0.2 mg TID if hemodynamics remained stable. Vital signs, laboratory data, all cultures and daily intensive care unit events were recorded. Results The odds ratio of temperature higher than 38.3◦ C was 3.96 times higher in the placebo group, after adjustment for the illness severity and the time of follow up. (P=0.049). A lower temperature (0.52◦ C) was observed in the clonidine group after adjustment for the time of follow up (P=0.006). Conclusion Our report is the first of its kind in humans which demonstrates possible antipyretic properties of enteral clonidine in the critically ill intensive care unit patients. http://dx.doi.org/10.1016/j.aucc.2017.02.027 Impact of a therapeutic drug monitoring program on antibiotic prescribing with the intensive care unit: a single centre experience Stephan Morgan ∗ , K. McCann, S. Rudham Department of Intensive Care Unit, St Vincent’s Public Hospital, Sydney, New South Wales Introduction Pharmacokinetics of antibiotics are altered during critical illness and may lead to either under dosing with treatment failure or overdosing with potential toxicity. Study Objectives To review the impact of a TDM on antibiotic prescribing within a single Intensive Care Unit. Methods Antibiotic levels were collected between April-June 2016. Antibiotic plasma concentrations were defined according to local guidelines. Results 122 consecutive samples were obtained for analysis with 68 (56%) found to be outside the therapeutic range. Samples were categorized as either: sub-therapeutic (23/122 = 19%); therapeutic (54/122 = 44%); elevated (31/122 = 25%); toxic (14/122 = 11%).
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The proportion of dose alterations in each of the abnormal level groups was assessed: sub-therapeutic (3/23 = 13%); elevated (7/31 = 23%); toxic (6/14 = 42%). In total 16/122 (13%) of samples resulted in dose alteration. The proportion of patients on renal replacement therapy (RRT) was assessed in both the sub-therapeutic (6/23 = 26%) and toxic (9/14 = 64%) groups. These figures are in the context of a total proportion of samples taken whilst on renal replacement therapy of 51/122 = 41%. Conclusion Antibiotic levels were outside the therapeutic range in a significant number of patients with both sub-therapeutic and toxic levels being common. Of the abnormal levels only 13% of doses were altered but this figure rose to 42% in the context of toxic levels. Risk of toxicity was greater in patients receiving RRT and the frequency of sub-therapeutic levels was greater in the absence of reduced eGFR or established RRT. http://dx.doi.org/10.1016/j.aucc.2017.02.028 Exercise is delayed in critically ill patients: a five year observational study in an Australian tertiary intensive care unit Marc Nickels a,b,∗ , Leanne Aitken c,d,e , James Walsham d,f , Lisa Watson a , Steven McPhail b,g a
Intensive Care Unit and Physiotherapy Department, Princess Alexandra Hospital b School of Public Health & Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology c NHMRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Menzies Health Institute Queensland, Griffith University d Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia e School of Health Sciences, City University London, London, United Kingdom f School of Medicine, University Of Queensland g Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia Duration of bed rest among critically ill patients in ICU has been associated with development of persistent weakness that can last for more than five years. Commencing early exercise interventions in ICU is likely to reduce critically ill patients’ physical dysfunction. However, critically ill patients often experience prolonged periods of bed rest and inactivity. This study examined the timing of commencement of exercise interventions, including sitting out of bed and upright mobilisation, following physiological stability in critically ill patients and describes key clinical outcomes. Participants included consecutive patients admitted for >48 hours to a 25-bed Australian mixed medical and surgical adult ICU between July 2009 and June 2014. Time taken for patients to achieve neurological, cardiorespiratory and cardiovascular (physiological) stability was calculated and timing of initial sitting out of bed and upright mobilisation was recorded. A small number of patients (n=206, 6.0%) did not achieve physiological stability. A substantial proportion of patients (n=1377, 40.1%) did not complete any mobilisation or sitting activities. For patients (n=1851, 53.9%) who did undertake mobilisation or sitting activities, activity commenced a median (IQR) of 3.6 (2.0, 7.7) days after ICU admission. This represented a median (IQR) delay after physiological stability of 2.3 (1.3, 4.4) days for mobilisation
Antipyretic effect of clonidine in intensive care unit patients: a nested observational study Majid Mokhtari ∗ , Mohammad Sistanizad, Maryam Farasatinasab Shahid Beheshti University of Medical Sciences (SBUMS), Iran Background Fever in ICU is usually an adaptive response to infection or inflammation. Pharmacological intervention is often required in addition to addressing the underlying causes of fever. Animal studies have examined the antipyretic effect of clonidine, however to our knowledge there are no clinical data available in humans. Objective To report possible antipyretic effect of clonidine in ICU patients. Methods The observation of antipyretic effect of clonidine was made during a single center randomized control trial, which was designed to study the effect of clonidine addition to the commonly used sedative agents, in mechanically ventilated ICU patients. Forty patients, 18 years or older on mechanical ventilation for 3 days or longer, were randomized in two groups of clonidine and placebo., In addition to the usual sedation/analgesia, patients in the clonidine arm received enteral clonidine in doses of 0.1 mg TID which was increased to 0.2 mg TID if hemodynamics remained stable. Vital signs, laboratory data, all cultures and daily intensive care unit events were recorded. Results The odds ratio of temperature higher than 38.3◦ C was 3.96 times higher in the placebo group, after adjustment for the illness severity and the time of follow up. (P=0.049). A lower temperature (0.52◦ C) was observed in the clonidine group after adjustment for the time of follow up (P=0.006). Conclusion Our report is the first of its kind in humans which demonstrates possible antipyretic properties of enteral clonidine in the critically ill intensive care unit patients. http://dx.doi.org/10.1016/j.aucc.2017.02.027 Impact of a therapeutic drug monitoring program on antibiotic prescribing with the intensive care unit: a single centre experience Stephan Morgan ∗ , K. McCann, S. Rudham Department of Intensive Care Unit, St Vincent’s Public Hospital, Sydney, New South Wales Introduction Pharmacokinetics of antibiotics are altered during critical illness and may lead to either under dosing with treatment failure or overdosing with potential toxicity. Study Objectives To review the impact of a TDM on antibiotic prescribing within a single Intensive Care Unit. Methods Antibiotic levels were collected between April-June 2016. Antibiotic plasma concentrations were defined according to local guidelines. Results 122 consecutive samples were obtained for analysis with 68 (56%) found to be outside the therapeutic range. Samples were categorized as either: sub-therapeutic (23/122 = 19%); therapeutic (54/122 = 44%); elevated (31/122 = 25%); toxic (14/122 = 11%).
119
The proportion of dose alterations in each of the abnormal level groups was assessed: sub-therapeutic (3/23 = 13%); elevated (7/31 = 23%); toxic (6/14 = 42%). In total 16/122 (13%) of samples resulted in dose alteration. The proportion of patients on renal replacement therapy (RRT) was assessed in both the sub-therapeutic (6/23 = 26%) and toxic (9/14 = 64%) groups. These figures are in the context of a total proportion of samples taken whilst on renal replacement therapy of 51/122 = 41%. Conclusion Antibiotic levels were outside the therapeutic range in a significant number of patients with both sub-therapeutic and toxic levels being common. Of the abnormal levels only 13% of doses were altered but this figure rose to 42% in the context of toxic levels. Risk of toxicity was greater in patients receiving RRT and the frequency of sub-therapeutic levels was greater in the absence of reduced eGFR or established RRT. http://dx.doi.org/10.1016/j.aucc.2017.02.028 Exercise is delayed in critically ill patients: a five year observational study in an Australian tertiary intensive care unit Marc Nickels a,b,∗ , Leanne Aitken c,d,e , James Walsham d,f , Lisa Watson a , Steven McPhail b,g a
Intensive Care Unit and Physiotherapy Department, Princess Alexandra Hospital b School of Public Health & Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology c NHMRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Menzies Health Institute Queensland, Griffith University d Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia e School of Health Sciences, City University London, London, United Kingdom f School of Medicine, University Of Queensland g Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia Duration of bed rest among critically ill patients in ICU has been associated with development of persistent weakness that can last for more than five years. Commencing early exercise interventions in ICU is likely to reduce critically ill patients’ physical dysfunction. However, critically ill patients often experience prolonged periods of bed rest and inactivity. This study examined the timing of commencement of exercise interventions, including sitting out of bed and upright mobilisation, following physiological stability in critically ill patients and describes key clinical outcomes. Participants included consecutive patients admitted for >48 hours to a 25-bed Australian mixed medical and surgical adult ICU between July 2009 and June 2014. Time taken for patients to achieve neurological, cardiorespiratory and cardiovascular (physiological) stability was calculated and timing of initial sitting out of bed and upright mobilisation was recorded. A small number of patients (n=206, 6.0%) did not achieve physiological stability. A substantial proportion of patients (n=1377, 40.1%) did not complete any mobilisation or sitting activities. For patients (n=1851, 53.9%) who did undertake mobilisation or sitting activities, activity commenced a median (IQR) of 3.6 (2.0, 7.7) days after ICU admission. This represented a median (IQR) delay after physiological stability of 2.3 (1.3, 4.4) days for mobilisation