Brian L Erstad

Abstract:

Objective: The objective of this study was to determine if patients who weigh ≥100 kg are more likely to receive under-dosing of etomidate compared to those who weigh 100 kg for rapid sequence intubation in the emergency department (ED). Methods: This was a retrospective cohort study conducted in an academic ED in the United States. Adult patients who received etomidate for rapid sequence intubation were evaluated and categorized into two groups based on weight: 1) 100 kg or 2) ≥100 kg. The mean dose of etomidate (mg/kg) was compared between the groups using an unpaired Student's t-test. The percentage of patients who received under-dosing (less than 0.2 mg/kg) was compared between groups using the Chi-squared test. Results: A total of 200 patients were included in the final analyses (100 patients in the 100 kg group and 100 patients in the ≥100 kg group). There were no baseline differences in age, sex, paralytic used, or trauma status between the treatment groups. The mean etomidate dose (mg/kg ± standard deviation) was significantly lower in the ≥100 kg group compared to the 100 kg group (0.18 ± 0.03 vs 0.28 ± 0.07, respectively; p0.001). There were significantly more patients in the ≥100 kg group who received under-dosing of etomidate compared to the 100 kg group (68% vs 2%, respectively; p0.001). Conclusions: Patients who weigh ≥100 kg are more likely to receive under-dosing of etomidate compared to those who weigh 100 kg for rapid sequence intubation in the ED. © 2013 Bentham Science Publishers.

We determine the rate and severity of medication errors, as well as factors associated with error occurrence in the emergency department (ED).

PMID: 19349402;Abstract:

Pain is a common and distressing symptom in ICU patients. Yet a major challenge exists in assessing and evaluating the pain. Although the patient's self-report of pain is the "gold standard" for pain assessment, other methods must be considered when patients are unable to self-report. Currently only two pain behavior instruments have been tested for their reliability, validity, and feasibility of use in ICUs: the pain behavior scale and the Critical-Care Pain Observation Tool. Other tools, albeit with less validity testing, include the pain assessment, intervention, and notation (PAIN) algorithm and a pain behaviors checklist. When established tools are insufficient to evaluate a patient's pain, alternative methods of augmenting a pain evaluation should be considered. These can include the completion of a pain risk profile, use of surrogates, or performance of an analgesic trial. Meticulous attention to the evaluation of a critically ill patient's pain provides the basis for selection of pain interventions and the subsequent assessment of the intervention's effectiveness. Copyright © 2009 American College of Chest Physicians.

PMID: 22751371;Abstract:

Background Albumin is broadly prescribed for critically ill patients although it does not have a mortality benefit over crystalloids. One common use of albumin is to promote diuresis. Objectives To compare urine output in patients treated with furosemide with and without albumin and to assess other variables possibly associated with enhanced diuresis. Methods A retrospective study was conducted on patients in a medical intensive care unit who received furosemide therapy as a continuous infusion with and without 25% albumin for more than 6 hours. Primary end points were urine output and net fluid loss. Results A total of 31 patients were included in the final analysis. Mean urine output in patients treated with furosemide alone did not differ significantly from output in patients treated with furo -semide plus albumin at 6, 24, and 48 hours: mean output, 1119 (SD, 597) mL vs 1201 (SD, 612) mL, P= .56; 4323 (SD, 1717) mL vs 4615 (SD, 1741) mL, P = .42; and 7563 mL (SD, 2766) vs 7432 (SD, 2324) mL, P = .94, respectively. Additionally, net fluid loss did not differ significantly between the 2 groups at 6, 24, and 48 hours. Higher concentrations of serum albumin did not improve urine output. The only independent variable significantly associated with enhanced urine output at 24 and 48 hours was increased fluid intake. Conclusion Addition of albumin to a furosemide infusion did not enhance diuresis obtained with furosemide alone in critically ill patients. © 2012 American Association of Critical-Care Nurses.

Abstract:

Several classes of drugs can be used in the management of acute pain: acetaminophen, salicylates, miscellaneous mild analgesics, nonsteroidal anti- inflammatory drugs (NSAIDs), and opioids. Last month, the role of acetaminophen, salicylates, and NSAIDs was explored. This month, in the conclusion of the series, the role of opioids is discussed. Opioids are used for more severe pain states, with morphine being an inexpensive standard of comparison for this class of compounds. Also presented is this article is a sample formulary of analgesic agents and regimens for consideration by clinicians involved in direct patient care or in the formulary decision- making process.