In this episode I’ll:
1. Discuss an article about predicting the need for critical care resources after receiving IV thromblysis for ischemic stroke.
2. Answer the drug information question “Should a pregnant woman who removed a tick from herself be prophylaxed for Lyme Disease?”
3. Share a resource with fantastic infographics on critical care topics.
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Article
ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients
Lead author: Roland Faigle
Published in Critical Care in January 2016
Background
Patients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications. At my institution they are required to be monitored in an ICU bed for at least 24 hours. The authors of this study created a prediction score to identify a subpopulation of post-IVT patients at high risk for needing critical care resources.
Methods
The authors retrospectively analyzed data from 301 patients undergoing IVT during a 5-year period. The 290 patients who met inclusion criteria were divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association.
Results
Nearly 25% of the patients required critical care resources. Black race, male sex, elevated systolic blood pressure, and NIH stroke scale (NIHSS) were independent predictors of the critical care resource utilization.
The scoring model created using these predictors was named the ICAT (Intensive Care After Thrombolysis) score. Each 1-point increase in the ICAT score was associated with 2.22-fold increased odds for critical care resource utilization.
A score ≥2 was associated with over 13 times higher odds of critical care resource utilization compared to a score <2, predicting critical care resource utilization with 97.2% sensitivity and 28.0% specificity.
Conclusion
The authors concluded that the ICAT score, combining information about race, sex, SBP, and NIHSS, predicts critical care needs in post-IVT patients and may be helpful when triaging post-IVT patients to the appropriate monitoring environment.
Discussion
Back in episode 11 I discussed the different types of patients admitted to the ICU – those who have a vital system that has failed and those who need monitoring in case a vital system does fail.
Patients who received IVT for ischemic stroke usually fall into the latter group. They need frequent neurological monitoring so that signs of hemorrhagic conversion are recognized and acted upon promptly.
A scoring tool such as the ICAT has the potential to free up critical care beds which are a scarce and expensive resource. The score needs to be validated in a second group of patients before routine application. That actually sounds like a good student / resident project!
I’ve created a calculator to determine the ICAT score at pharmacyjoe.com/ICAT.
Drug information question
Q: Should a pregnant woman who removed a tick from herself be prophylaxed for Lyme Disease?
A: No.
The Infectious Disease Society of America’s guidelines for the treatment of Lyme Disease were published in 2006, and are currently being updated. Those guidelines recommend prophylaxis for lyme disease with a single dose of doxycycline under very limited circumstances. Regarding pregnant patients, the guidelines state:
Doxycycline is relatively contraindicated in pregnant women and children <8 years old. The panel does not believe that amoxicillin should be substituted for doxycycline in persons for whom doxycycline prophylaxis is contraindicated because of the absence of data on an effective short-course regimen for prophylaxis, the likely need for a multiday regimen (and its associated adverse effects), the excellent efficacy of antibiotic treatment of Lyme disease if infection were to develop, and the extremely low risk that a person with a recognized bite will
develop a serious complication of Lyme disease (D-III).
Resource
The website propofology.com is operated by Dr. David Lyness, a doctor in the UK and a trainee in the specialty of anaesthesia. David has created some fantastic infographics in areas such as emergency medicine, intubation, and pharmacology. Here are two great ones on succinylcholine and rocuronium!
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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