In this episode I’ll:
1. Discuss an article about sedation choice and infection risk.
2. Answer the drug information question “Is phentolamine superior to terbutaline for treatment of extravasation?”
3. Share a resource for crowd-sourced medical lecture notes.
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Article
Lead Author: Daniel A. Caroff
Published early online in Infection Control & Hospital Epidemiology
Background
There is a good deal of research on the link to sedative regimens with complications like delirium, but not on other complications like infection. A recent topic of conversation in the Pharmacy Nation Slack group was the idea of running propofol in a peripheral line to decrease the risk of central line infection. The rationale being that the lipid emulsion base for propofol is an excellent growth medium for pathogens. Given that discussion, when I saw the title for this article my curiosity was piqued.
Purpose
The authors sought to better characterize the relationship between sedation strategy and infection.
Methods
A systematic literature review was performed where 70 articles were reviewed.
Results
The 3 most common sedatives for mechanically ventilated patients were benzodiazepines, propofol, and dexmedetomidine. Each of these agents have been shown to have immunologic effects based on either human or animal data.
Of the 70 articles reviewed, 14 reported healthcare-associated infection risk. A meta-analysis was not performed.
Some notable findings from the articles reviewed include:
A cohort study identified propofol was associated with less ventilator associated pneumonia vs lorazepam.
An observational study associated benzodiazepines and propofol (but not dexmedetomidine) with the development of ventilator associated events.
A non-randomized/blinded study found more ventilator free days in ICU patients who received no sedation during mechanical ventilation compared with those who were sedated.
A retrospective analysis associated the use of sedation with a 2-fold increased risk of pneumonia.
A case-control study found that use of benzodiazepines prior to intubation increased the risk of infection-related ventilator associated complications.
Conclusion
The authors concluded that:
Infection rates appear to be highest with benzodiazepines, intermediate with propofol, and lowest with dexmedetomidine. More data are needed but studies thus far suggest that a better understanding of sedation practices and infection risk may help hospital epidemiologists and critical care practitioners find new ways to mitigate infection risk in critically ill patients.
Discussion
A notable omission from this review was any attempt to look at the impact of opioids on healthcare-associated infection. I’d like to see either prospective controlled studies or a well done meta-analysis before making any changes to sedation practice for the purpose of reducing infection risk.
Drug information question
Q: Is phentolamine superior to terbutaline for treatment of extravasation?
A: No one knows. I’ll take the phentolamine.
I discussed terbutaline as an alternative to phentolamine for extravasation back in episode 6 when there was a phentolamine shortage. Now phentolamine is back on the market at a much higher price than it was before. Understandably, this is causing clinicians to consider terbutaline over phentolamine for cost reasons.
I cannot locate any comparative studies of these two agents. Despite phentolamine’s higher cost, I prefer to use it over terbutaline if it is available. My rationale is simply that phentolamine has been studied more and clinicians are more familiar with it than terbutaline.
Resource
Mediwikis.com is a collaborative platform where medical students share notes in a format similar to wikipedia. Registration is free but required before you can access the site. Once you are on the inside you can view, edit, or create pages on any medical subject you wish. I’m working on creating a page about QTc drug interactions there based on episode 12.
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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