While the benefits of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) for patients with obstructive sleep apnea are well described, reports in the literature of complications from its use are rare. A patient who received postoperative BiPAP after undergoing transsphenoidal craniopharyngioma resection developed severe pneumocephalus and unplanned intensive care unit admission. Although the pneumocephalus resolved with conservative management over two weeks, we propose caution in the use of CPAP postoperatively in patients undergoing procedures of the head and neck.

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Background: Preventing HIV transmission is a worldwide public health issue. Vertical transmission of HIV from a mother can be prevented with diagnosis and treatment, but screening incurs cost. The U.S. Virgin Islands follows the mainland policy on antenatal screening for HIV even though HIV prevalence is higher and rates of antenatal care are lower. This leads to many cases of vertically transmitted HIV. A better policy is required for the U.S. Virgin Islands.

Background: Albumin 25% has been studied and has demonstrated benefit in a limited number of patient populations. The use of albumin 25% is associated with higher costs compared with crystalloid therapy. The aim of this study was to describe the prescribing practices of albumin 25% at a tertiary-care medical center and identify opportunities for restriction criteria related to its use to help generate cost savings. Methods: This evaluation was a retrospective, noninterventional, descriptive study of albumin 25% use between June 2015 and February 2016. Inclusion criteria consisted of patients ≥18 years old and who received at least one dose of albumin 25% while admitted to a Cleveland Clinic main campus intensive care unit (ICU). Inclusion was restricted to 150 randomly selected patients. Results: A total of 539 albumin 25% orders were placed for the 150 included patients. The cardiovascular ICU more frequently prescribed albumin 25% compared with the medical, surgical, neurosciences, and coronary ICUs (51% vs 23% vs 11% vs 9% vs 6%, respectively). Although the cardiovascular surgery ICU most frequently prescribed albumin 25% compared with other ICUs, the medical ICU prescribed a larger total quantity of albumin 25% compared with the cardiovascular, surgical, neurosciences, and coronary ICUs (8705 g vs 7275 g vs 3205 g vs 2162 g vs 625 g, respectively). The majority of patients (61%) did not have an indication listed for albumin 25% use and only 9% of patients were prescribed for indications supported by primary literature. Of the patients prescribed albumin for other indications not supported by primary literature (30%), the most common reasons for albumin 25% were hypotension, acute kidney injury, and volume resuscitation. The median cost per patient of albumin 25% was $417 with a total cost of $122 164 for the cohort. Only 19% of the total cost aligned with dosing regimens evaluated in primary literature. Conclusion: Prescribing patterns of albumin 25% at a tertiary academic medical center do not align with indications supported by primary literature. These findings identified a major opportunity for prescriber education and implementation of restriction criteria to target cost savings.

Substantial variation was found in the duration and selection of antibiotic prophylaxis for patients with delayed sternal closure after cardiothoracic operation. Broad-spectrum antimicrobial agents and extended durations of antibiotic prophylaxis were not associated with benefits in the incidence of sternal wound infection and may increase the risk of adverse effects.