Brian L Erstad

Abstract:

Background: No surveys of stress ulcer prophylaxis prescribing in the USA have been conducted since 1995. Since that time, the most comprehensive meta-analysis and largest randomized study to date concerning stress ulcer prophylaxis have been published. Results: Three hundred sixty-eight surveys were sent to all members of the Section of Pharmacy and Pharmacology of the Society of Critical Care Medicine. One hundred fifty-three (42%) surveys were returned. Representatives from 86% of institutions stated that medications for stress ulcer prophylaxis are used in a majority (>90%) of patients admitted to the intensive care unit (ICU). Twenty-two per cent of institutions have recommendations for both ICU and non-ICU settings. Fifty- eight per cent of institutions stated that there was one preferred medication for stress ulcer prophylaxis, and in 77% of these histamine-2-antagonists were the most popular. Conclusions: There are wide variations in prescribing practices for stress ulcer prophylaxis. Institutions should consult published literature and use pre-existing guidelines as templates for developing their own guidelines.

PMID: 7503604;Abstract:

Background: Crystalloids, nonprotein colloids (NPCs), and albumin are used for many indications. The use of the least costly agent in situations where these products are clinically interchangeable can reduce health care costs. Objectives: To characterize the prescribing of albumin and NPC. To evaluate the appropriateness and cost implications of their use. Methods: An observational study conducted in 15 academic health centers from April 11 through May 6, 1994, to assess the appropriateness of albumin and NPC use, based on 'model' consensus-derived indication guidelines. Results: A total of 969 case report forms were evaluated. Albumin and NPCs were administered in 83% and 17% of the cases, respectively. Albumin and NPCs were administered mostly in the intensive care (50%) or operating room (31%) settings. The most common prescribers of these products were surgeons (45%) and anesthesiologists (20%). In 87% of cases, albumin or NPC was administered to reach a defined end point (eg, to achieve a target physiological state or to resolve a pathophysiological condition). Only one albumin recipient experienced an adverse event; no adverse events were noted with NPC administration. Approximately $203 000 was spent on albumin and NPC therapy for the 969 cases; $49 702 (24%) was spent on appropriate administrations, $124 939 (62%) on inappropriate administrations, and $28 014 (14%) on unevaluated indications. Conclusions: Evaluated against model guidelines, most of the albumin and NPC use in the study was found to be inappropriate. The need for institutions to define and implement guidelines that focus on the cost-efficient use of these agents is recommended in an increasingly cost-conscious health care environment.

Abstract:

Introduction: A inverse correlation has been found between changes in ionized calcium concentrations (physiologically active form) and the addition of albumin in vitro, which may explain adverse cardiovascular effects attributed to exogenous albumin in vivo. The purpose of this investigation was to determine the interaction (if any) between exogenous 25% albumin administration and calcium concentrations in unstable patients. Methods: Following a retrospective analysis involving critically ill patients in which no effect of 25% albumin on ionized calcium concentrations was noted, nine patients were studied prospectively. With one exception, all patients were studied in the ICU. Concentrations of albumin, total and ionized calcium were obtained within one hour prior to the start of a 25% 100 mL albumin infusion given over less than one-half hour, and then at the end and six hours after the infusion. The commercially-available albumin product was tested to ensure that it did not contain substantial amounts of calcium. No other albumin-containing products were administered during the study periods. Results: There were no significant differences in either the ionized or total calcium concentrations obtained before and after the administration of albumin. Ionized calcium in mMol/L*Total calcium in mg/dL Pre/1 h post/6 h post Pre/1 h post/6 h post Concentrations 1.09(0.23)/1.06(0.22)/1.06(0.21) 8.1(0.7)/8.2(0.8)/8.3(.9)*all values expressed as mean (SD); no significant differences by ANOVA Conclusions: In patients receiving relatively rapid infusions of 25% albumin, it appears that circulating calcium concentrations are well-regulated by homeostatic mechanisms. Albumin infusions had no effect on either ionized or total calcium concentrations, although it is possible that temporary changes of questionable clinical importance may have occurred between measurement periods.

PMID: 8836750;Abstract:

Objective: To evaluate physicians' recognition of possible ethanol-related complications in trauma patients, and to compare benzodiazepine requirements in patients with positive and negative blood-ethanol concentrations. Design: Retrospective investigation. Setting: University medical center (level I trauma center). Patients: One hundred thirty-one trauma patients more than 18 years of age who were admitted for at least 24 hours. Outcome measures: (1) Physicians' recognition of ethanol (EtOH) as a potential factor complicating patient recovery in trauma patients admitted with positive blood-EtOH concentrations. (2) The amount of benzodiazepines administered to trauma patients with positive EtOH-blood concentrations compared to trauma patients with no detectable EtOH in their blood. Results: The presence of EtOH in the blood or the potential for EtOH withdrawal was mentioned in the progress notes of approximately one fourth of the patients with positive blood-EtOH concentrations. Thiamine was administered in 8.2% of patients with EtOH-related injuries. Benzodiazepine requirements were significantly higher in patients with positive versus negative blood-EtOH concentrations. Conclusions: Prompt recognition and charting of suspected ethanol abuse is recommended, in conjunction with prompt administration of thiamine. It should be anticipated that patients with positive blood-ethanol concentrations will require higher doses of benzodiazepines compared to trauma patients without ethanol-related injuries.