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The ventricular assist device is being increasingly used as a “bridge-to-transplant” option in children with heart failure who have failed medical management. Care for this medically complex population must be optimised, including through concomitant pharmacotherapy. Pharmacokinetic/pharmacodynamic alterations affecting pharmacotherapy are increasingly discovered in children supported with extracorporeal membrane oxygenation, another form of mechanical circulatory support. Similarities between extracorporeal membrane oxygenation and ventricular assist devices support the hypothesis that similar alterations may exist in ventricular assist device-supported patients. We conducted a literature review to assess the current data available on pharmacokinetics/pharmacodynamics in children with ventricular assist devices. We found two adult and no paediatric pharmacokinetic/pharmacodynamic studies in ventricular assist device-supported patients. While mechanisms may be partially extrapolated from children supported with extracorporeal membrane oxygenation, dedicated investigation of the paediatric ventricular assist device population is crucial given the inherent differences between the two forms of mechanical circulatory support, and pathophysiology that is unique to these patients. Commonly used drugs such as anticoagulants and antibiotics have narrow therapeutic windows with devastating consequences if under-dosed or over-dosed. Clinical studies are urgently needed to improve outcomes and maximise the potential of ventricular assist devices in this vulnerable population.
To measure transmission frequencies and risk factors for household acquisition of community-associated and healthcare-associated (HA-) methicillin-resistant Staphylococcus aureus (MRSA).
Prospective cohort study from October 4, 2008, through December 3, 2012.
Seven acute care hospitals in or near Toronto, Canada.
Total of 99 MRSA-colonized or MRSA-infected case patients and 183 household contacts.
Baseline interviews were conducted, and surveillance cultures were collected monthly for 3 months from household members, pets, and 8 prespecified high-use environmental locations. Isolates underwent pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec typing.
Overall, of 183 household contacts 89 (49%) were MRSA colonized, with 56 (31%) detected at baseline. MRSA transmission from index case to contacts negative at baseline occurred in 27 (40%) of 68 followed-up households. Strains were identical within households. The transmission risk for HA-MRSA was 39% compared with 40% (P=.95) for community-associated MRSA. HA-MRSA index cases were more likely to be older and not practice infection control measures (P=.002–.03). Household acquisition risk factors included requiring assistance and sharing bath towels (P=.001–.03). Environmental contamination was identified in 78 (79%) of 99 households and was more common in HA-MRSA households.
Household transmission of community-associated and HA-MRSA strains was common and the difference in transmission risk was not statistically significant.
The administration of blood products to critically ill patients can be life-saving, but is not without risk. During helicopter transport, confined work space, communication challenges, distractions of multi-tasking, and patient clinical challenges increase the potential for error. This paper describes the in-flight red blood cell transfusion practice of a rural aeromedical transport service (AMTS) with respect to whether (1) transfusion following an established protocol can be safely and effectively performed, and (2) patients who receive transfusions demonstrate evidence of improvement in condition.
A two-year retrospective review of the in-flight transfusion experience of a single-system AMTS servicing a rural state was conducted. Data elements recorded contemporaneously for each transfusion were analyzed, and included hematocrit and hemodynamic status before and after transfusion. Compliance with an established transfusion protocol was determined through structured review by a multidisciplinary quality review committee.
During the study, 2,566 missions were flown with 45 subjects (1.7%) receiving in-flight transfusion. Seventeen (38%) of these transports were scene-to-facility and 28 (62%) were inter-facility. Mean bedside and in-flight times were 22 minutes (range 3-109 minutes) and 24 minutes (range 8-76 minutes), respectively. The most common conditions requiring transfusion were trauma (71%), cardiovascular (13%) and gastrointestinal (11%). An average of 2.4 liters (L) of crystalloid was administered pre-transfusion. The mean transfusion was 1.4 units of packed red blood cells. The percentages of subjects with pre- and post-transfusion systolic blood pressures of <90 mmHg were 71% and 29%, respectively. The pre- and post-transfusion mean arterial pressures were 62 mmHg and 82 mmHg, respectively. The pre- and post- transfusion mean hematocrit levels were 17.8% and 30.4%, respectively. At the receiving institution, 9% of subjects died in the Emergency Department, 18% received additional transfusion within 30 minutes of arrival, 36% went directly to the operating room, and 36% were directly admitted to intensive care. Thirty-one percent of subjects died prior to hospital discharge. There were no protocol violations or reported high-risk provider blood exposure incidents or transfusion complications. All transfusions were categorized as appropriate.
In this rural AMTS, transfusion was an infrequent, likely life-saving, and potentially high-risk emergent therapy. Strict compliance with an established transfusion protocol resulted in appropriate and effective decisions, and transfusion proved to be a safe in-flight procedure for both patients and providers.
Higgins GL 3rd, Baumann MR, Kendall KM, Watts MA, Strout TD. Red blood cell transfusion: experience in a rural aeromedical transport service. Prehosp Disaster Med. 2012;27(3):1-4.
The foundation of mastoid surgery for cholesteatoma has traditionally been a thorough knowledge of the anatomy and familiarity with landmarks, constant alertness to detect unsuspected complications and the experience to tailor the surgery to the pathology encountered. Whilst not indispensable, computed tomography (CT) scanning is a useful adjunct whose potential predictive value is only truly appreciated by skilled interpretation. We present a guide to analysis to maximize the value of pre-operative radiology.
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