In this episode I’ll:
1. Discuss an article about post-extubation stridor.
2. Answer the drug information question “Why should patients with variceal bleeding receive ceftriaxone?”
3. Share a resource for antibiotic information.
The article for this episode recently appeared in a weekly literature digest for members of my Critical Care Pharmacy Academy. You can learn more at pharmacyjoe.com/academy.
Article
Lead author: Akira Kuriyama
Published in Chest May 2017
Background
Corticosteroid administration before elective extubation has been used to prevent post-extubation stridor and reintubation. The authors of this study updated a systematic review to identify which patients would benefit from prophylactic corticosteroid administration before elective extubation.
Methods
The authors performed a thorough search for eligible trials from inception through February 29, 2016. To be eligible for inclusion each randomized controlled trial had to examine the efficacy and safety of systemic corticosteroids given prior to elective extubation in mechanically ventilated adults.
Results
The authors analyzed 11 trials involving 2,472 patients. The use of prophylactic corticosteroids was associated with a reduced incidence of post-extubation airway events (risk ratio 0.43) and re-intubation (risk ratio 0.42) compared with placebo or no treatment. This association was driven by patients at high risk for the development of post-extubation airway complications, defined using the cuff-leak test, with a reduced incidence of post-extubation airway events (risk ratio 0.34) and reintubation (risk ratio 0.35). Adverse events were rare and there was no difference between groups.
Conclusion
The authors concluded:
Administration of prophylactic corticosteroids before elective extubation was associated with significant reductions in the incidence of post-extubation airway events and reintubation, with few adverse events. It is reasonable to select patients at high risk for airway obstruction who may benefit from prophylactic corticosteroids.
Discussion
A cuff leak test measures the air leak around a tracheal tube with the cuff deflated. The thought is that the amount of air leakage will be inversely related to the degree of laryngeal obstruction due to laryngeal edema.
The specificity of the cuff leak test is low, and a low cuff leak should not preclude extubation. However based on this study a low cuff leak can be used to identify a group of patients most likely to benefit from steroid administration prior to extubation.
Multiple steroid regimens have been studied to prevent post-extubation stridor and re-intubation. To my knowledge, no one regimen has been proven superior. Three example regimens are:
1. Dexamethasone 5 mg IV q6 hours x 4 doses the day prior to extubation
2. Methylprednisolone 20 mg IV q4 hours x 4 doses prior to extubation
3. Methylprednisolone 40 mg IV once 4 hours prior to extubation
Drug information question
Q: Why should patients with variceal bleeding receive ceftriaxone?
A: Because mortality risk decreases.
Multiple trials demonstrate that prophylactic antibiotics in patients with cirrhosis hospitalized for bleeding suggest an overall reduction in infectious complications and decreased mortality. These patients typically have variceal bleeding. The optimal antibiotic choice and duration of therapy is unknown. I use ceftriaxone 1 gram IV q q24 hours for 7 days in these patients due to a small study showing it was superior to a quinolone.
Resource
The 2017 pocket edition of The Sanford Guide To Antimicrobial Therapy is now available. I use the electronic version of Johns Hopkins Antibiotic Guide in my practice, but the Sanford guide is superior if you have pediatric patients to care for or prefer a hard-copy guide in your lab coat rather than an electronic version.
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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