Faculty Bibliography

Amiodarone (Cordarone^®, Pfizer Inc) is an antiarrhythmic medication with a well-known toxicity profile, including rare cases of hyponatremia as a result of syndrome of inappropriate antidiuretic hormone (SIADH). We report on such a case in which a patient was found to be hyponatremic after evaluation. An 88-year-old male who presented to the emergency department was found to be hyponatremic secondary to amiodarone-induced SIADH following a fall, with possible seizure and traumatic brain injury. He had a history of hypertension, paroxysmal atrial fibrillation, emphysema, myocardial infarction, benign prostatic hyperplasia, chronic kidney disease, Meniere's disease, anemia, and gastroesophageal reflux. Upon admission, his urine sodium level was elevated, and his serum sodium, urine osmolality, and anion gap were below normal. In the setting of hyponatremia, the patient's amiodarone was held: he had been taking amiodarone 200 mg once daily for nine months prior to admission. He was treated with intravenous (IV) normal saline over four days. He was fluid-restricted and his sodium levels were closely monitored every two hours. Within 19 hours, his serum sodium levels had improved. Amiodarone was restarted approximately three days later. Upon follow-up after discharge, the patient remained on amiodarone for the next two months. His serum sodium level ranged from 126 mEq/L to 131 mEq/L over a two-week period. He was supplemented with sodium chloride tablets and has been otherwise stable. Amiodarone may cause acute or chronic SIADH, with a wide range of symptoms. Seizures have not been reported in the literature but our patient had a witnessed seizure, although his electroencephalogram (EEG) was negative. Syndrome of inappropriate antidiuretic hormone can occur with any formulation of amiodarone in a dose-dependent fashion. Our patient's sodium levels stabilized within two weeks after amiodarone was resumed. The mechanism of amiodarone-induced SIADH remains unclear.

Orthostatic hypotension is defined as a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg (or both), within three minutes of moving from a supine to an upright or standing position. Droxidopa is a synthetic amino acid analog that is directly metabolized to norepinephrine by dopa-decarboxylase, subsequently providing alpha and beta-agonist effects to increase blood pressure. It is indicated in the treatment of neurogenic orthostatic hypotension caused by primary autonomic failure that is associated with Parkinson disease, multi-system atrophy, pure autonomic failure, dopamine beta-hydroxylase deficiency, and/or non-diabetic autonomic neuropathy. In addition, it has been studied in other disease states, such as diabetic autonomic neuropathy-associated orthostatic hypotension and supine hypotension. We report on two cases of off-label droxidopa use. The first case was for diabetic autonomic neuropathy-associated orthostatic hypotension, and the second case was for hypotension due to autonomic dysfunction associated with rheumatoid arthritis. Although the outcomes differed in each case, this article contributes to the literature demonstrating that droxidopa may have varying effects in treating orthostatic hypotension of non-neurogenic etiology.

Hemophilia A, also known as factor VIII deficiency, is a rare disorder caused by an insufficient level of factor VIII, an essential clotting protein. Hemophilia A can be inherited or acquired. Inherited hemophilia A is caused by a mutation to the factor VIII gene on the X chromosome, which is commonly passed down from parents to children. However, in about one-third of cases, the cause is a spontaneous mutation in that gene. Acquired hemophilia A is due to an autoantibody to factor VIII, which is termed an inhibitor. This rare disorder can cause life-threatening bleeding complications. Management relies on a rapid and accurate diagnosis, control of bleeding episodes, and eradication of the inhibitor by immunosuppression therapy. Most treatment strategies are centered around anecdotal reports or small case series. This case report summarizes the successful treatment of a patient with acquired hemophilia A and major bleeding following a surgical procedure, with the use of desmopressin, recombinant factor VIIa, repeated doses of recombinant factor VIII, rituximab, and prednisone.

Objective/UNASSIGNED:The increased incidence of multidrug-resistant organisms is associated with increased morbidity, mortality, hospital length of stay, and cost. Estimates show that up to 50% of antimicrobial use is inappropriate. This initiative focuses on inappropriate use of antibiotics in respiratory syncytial virus (RSV) infections. This virus is the most common cause of bronchiolitis during childhood. Methods/UNASSIGNED:Baseline data from the 2011-2012 RSV season showed that 56.2% of our RSV-positive patients received antibiotics. To decrease inappropriate antibiotic use in RSV infections, we established an antimicrobial stewardship program (ASP). This process improvement initiative aimed to decrease exposure to antibiotics and days of antibiotic therapy per 1,000 patient days (DOT/1000PD) in hospitalized RSV-positive patients by 25%. Key drivers included building health-care knowledge, proactive interventions using prospective audit and feedback, emergency department engagement, and performance dashboards. Results/UNASSIGNED:= 0.017). This change represents a reduction of 164.6 DOT/1000PD from baseline after full ASP implementation. Conclusion/UNASSIGNED:Despite the lack of a unified hospitalist group in our institution, we were successful in reducing inappropriate antibiotic use by focusing on standardizing care among different private pediatricians in the community. A multifaceted strategy and well-designed quality improvement methodology led to a sustained reduction in antibiotic use.

PURPOSE/OBJECTIVE:To compare the effectiveness of continuous infusion of hydrocortisone versus intermittent boluses in the resolution of septic shock. METHODS:A retrospective chart review was performed to investigate the effects of low-dose hydrocortisone continuous infusion (200 mg per day) versus intermittent boluses (50 mg every six hours) in septic shock patients who did not respond to fluid resuscitation and vasopressors. The primary outcome was time to resolution of shock, defined by time from the initiation of hydrocortisone to time of vasopressor withdrawal when mean arterial pressure was greater than 65 mm Hg. Hospital length of stay, intensive care unit (ICU) length of stay, 28-day all-cause in-hospital mortality, and hyperglycemia were secondary outcomes. RESULTS:= 0.04). CONCLUSION/CONCLUSIONS:There was no significant difference in time to resolution of septic shock between continuous infusion (200 mg per day) and intermittent boluses (50 mg every six hours) of hydrocortisone. There were also no statistically significant differences in overall hospital length of stay, ICU length of stay, and 28-day all-cause in-hospital mortality. However, there was a significant difference in the incidence of hyperglycemia between the two groups, with patients in the bolus group experiencing more hyperglycemia than those in the continuous infusion group.

PURPOSE:The goal of this pharmacokinetic (PK) study was to evaluate whether a single 2-g prophylactic dose of cefazolin given (IV) bolus provides effective protective cefazolin levels for prophylaxis against methicillin-sensitive S. aureus (MSSA), the primary skin pathogen in bariatric surgery. MATERIALS AND METHODS:Thirty-seven patients having gastric bypass or sleeve gastrectomy received cefazolin 2-g preoperative prophylaxis. Serum, subcutaneous adipose tissue, and deep peri-gastric adipose tissue specimens were collected at incision and before skin closure. Cefazolin concentrations in serum and adipose tissue were determined by high-performance liquid chromatography. RESULTS:Penetration of cefazolin, a water soluble antibiotic, into adipose tissue was only 6-8 % of simultaneous serum levels. However, cefazolin tissue concentrations in all adipose tissue specimens, exceeded mean MIC for MSSA. CONCLUSIONS:not dose-dependent. Extremely high-dosed cefazolin, i.e., 3 or 4 g is excessive and unnecessary for bariatric surgery prophylaxis. A single cefazolin 2 g preoperative dose also eliminates the need for intraoperative redosing at 4 h.

OBJECTIVE:To assess the prevalence of delirium and coma in mechanically ventilated patients sedated with dexmedetomidine or propofol alone; to evaluate the hospital length of stay for both treatment groups; and to evaluate the level of sedation, adverse effects, and hospital outcomes. METHODS:Medical records were reviewed retrospectively for patients who were admitted to the medical or surgical intensive care units (ICUs) in a 591-bed teaching hospital and who received either dexmedetomidine or propofol alone for 24 hours or more for sedation. RESULTS:A total of 111 patients were included in the study, with 56 patients in the dexmedetomidine group and 55 patients in the propofol group. Results of the analysis showed that the propofol group had a higher prevalence of coma (43.6% versus 12.5%; P < 0.001). Dexmedetomidine patients had a longer median hospital length of stay of 23.5 days (interquartile range [IQR], 11.5-39.5 days) versus 15.0 days (IQR, 7.0-24.0 days; P = 0.01). The rates of delirium were similar in both groups, with 16% in dexmedetomidine-treated patients versus 20% in propofol-treated patients (P = 0.63). CONCLUSION/CONCLUSIONS:No difference in the prevalence of delirium was found when comparing the dexmedetomidine- and propofol-treated groups. Propofol was associated with more coma and oversedation; dexmedetomidine was associated with longer time to extubation, longer length of stay in the ICU, and longer hospital length of stay.