In this episode I’ll:
1. Discuss an article about platelet transfusion and hospital-acquired infection.
2. Answer the drug information question “Can buprenorphine be used in opioid overdose?”
3. Share a resource for guidance on toxicologic emergencies.
Article
Is platelet transfusion associated with hospital-acquired infections in critically ill patients?
Lead author: Cécile Aubron
Published in Critical Care January 2017
Background
Platelet transfusions are commonly given to critically ill patients. Due to reports that suggest an association between platelet transfusion and infection, the authors of this study sought to determine whether platelet transfusion in critically ill patients is associated with hospital-acquired infection.
Methods
The authors conducted a multi-center prospective database study in two large academic intensive care units in Australia. The characteristics of patients who received platelets in ICUs between 2008 and 2014 were compared to those of patients who did not receive platelets.
Results
Nearly 12% of ICU patients received a transfusion of at least 1 platelet unit during the study period. This amounted to over 2000 patients. Patients who received platelet transfusions were more severely ill as evidenced by higher APACHE-III scores and had more co-morbidities. Patients who received platelet transfusions also had significantly higher rates of mechanical ventilation and renal replacement therapy. After adjusting for confounders, platelet transfusions were independently associated with infection, with an adjusted odds ratio of 2.56.
Conclusion
The authors concluded:
After adjustment for confounders, including patient severity and other blood components, platelet transfusion was independently associated with ICU-acquired infection. Further research aiming to better understand this association and to prevent this complication is warranted.
Discussion
This study is important for pharmacists since platelet transfusions are often considered as a treatment for several drug-induced bleeding conditions. Platelet transfusions are used in drug-induced thrombocytopenia from GP IIb/IIIa inhibitors, but the list of other indications is growing smaller due to the risk of harm.
In episode 87 I reviewed the possible harm that platelet transfusions may cause when given for treating intracranial hemorrhage due to antiplatelet medications. In episode 150 I discussed how the 2015 Guidelines for Reversal of Antithrombotics in Intracranial Hemorrhage do not recommend platelet transfusions for treating intracranial hemorrhage caused by alteplase.
Drug information question
Q: Can buprenorphine be used in opioid overdose?
A: Probably.
Because buprenorphine is a partial μ-opioid receptor agonist, it may reverse respiratory depression from opioid overdose but result in less severe signs and symptoms of opioid withdrawal. This may be most significant in opioid tolerant patients who overdose. Recently in the Annals of Emergency Medicine, a case report was discussed where a 20-year-old morphine-addicted man who presented with methadone-induced respiratory depression responded safely and effectively to intravenous administration of buprenorphine.
Resource
Goldfrank’s Toxicologic Emergencies is considered the standard-setting reference in medical toxicology. It is my go-to reference for any poisoning emergency. Goldfranks’s provides essential, patient-centered advice for every aspect of poison management. I think any pharmacist who works in a critical care or emergency medicine setting should have access to this reference.
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.
Greetings! I’ve really been enjoying your podcasts on my long drive to work. I had a thought on this one though – I am a clinical toxicologist and much of my practice is addiction medicine related including seeing opioid addiction and overdoses on a daily basis. While I don’t disagree that buprenorphine is probably capable of reversing the effects of a full mu receptor agonist in the setting of overdose, it is also more than capable of precipitating withdrawal – withdrawal that can be difficult to manage because of the very high binding affinity of buprenorphine to the mu receptor. Unlike naloxone, however, the effect of buprenorphine will be quite prolonged. At least with naloxone, if you precipitate withdrawal, it will only last an hour or two.
We’ve had at least two patients put themselves into precipitated withdrawal by using buprenorphine on the street. Both were heavily dependent on methadone, and one had significant cardiac comorbidities and landed in the ICU for several days with an acute MI. The doses these patients took were certainly higher than the 0.6 mg dose of buprenorphine used in the case report, but I don’t think it’s a good idea to start considering buprenorphine a safer or better option (e.g. less likely to precipitate withdrawal) just because it’s a partial agonist.
Our own practice is to titrate very small doses of naloxone in the ED – 0.04 mg q3-5 minutes until adequate arousal is achieved (resolved respiratory depression). This approach is unlikely to result in precipitated withdrawal, although it does involve some time spent at the bedside.
By the way – my husband Eugene Gorodetsky says hi. He tells me you were his preceptor once at St. Peter’s.
Thank you for the comment! I think you are right, if withdrawal is precipitated it will be more difficult to manage due to the long half-life of buprenorphine.
I also dose naloxone in small doses, as long as the patient’s life is not in danger. You could also argue that if their life is in danger you should just intubate rather than attempting large doses of naloxone.
Please say hello to Eugene!!! He was a tremendous student – congrats to you both on your marriage!