The available data suggest that low-dose tPA may be a safe and effective treatment option for acute PE, particularly in patients at a high risk of bleeding. More studies are needed to determine the optimal dosing regimen of tPA for PE.

Background There is limited data surrounding acute pain management in elderly ED patients. Ketorolac is a potent non-steroidal anti-inflammatory drug (NSAID) with dose/duration-dependent side effects. There is evidence that an analgesic ceiling effect exists for parenteral ketorolac doses greater than 10 milligrams (mg); however, this has not been studied in patients 65 years and older. Methods This was a retrospective chart review of ED patients 65 years and older who received at least one dose of parenteral ketorolac. Patients were separated into two cohorts based on the ketorolac dose received: 15 mg IV or 30 mg intramuscular (IM) and 30 mg IV or 60 mg IM. The primary objective was to evaluate the analgesic efficacy of parenteral ketorolac doses measured as needing rescue analgesia from 30 minutes to 2 hours after ketorolac administration. Secondary objectives included changes in pain scores and the occurrence of adverse drug events commonly associated with ketorolac. Results Two-hundred and sixty patients received ketorolac doses of 15 mg IV or 30 mg IM, and 52 received 30 mg IV or 60 mg IM. The primary outcome occurred in seven of 52 patients who received ketorolac 30 mg IV or 60 mg IM and 17 of 260 patients who received ketorolac 15 mg IV or 30 mg IM (13.5% vs. 6.5%, p=0094; OR: 2.22, 95% CI: 0.87-5.67). The average change in pain scores were 2.9 (±3.1) and 2.8 (±2.9) for patients who received doses 30 mg IV or 60 mg IM compared to doses 15 mg IV or 30 mg IM, respectively (p=0.154). The occurrence of adverse events was low in both groups. Conclusion Parenteral ketorolac doses of 15 mg IV or 30 mg IM did not demonstrate a greater need for rescue analgesia compared to doses of 30 mg IV or 60 mg IM.

BackgroundA neuromuscular blockade (NMB) is used in general anesthesia to facilitate endotracheal intubation and muscle relaxation during procedural and surgical interventions. Rapid and complete reversal of the NMB allows for patient recovery to the preoperative baseline with ventilation and motor function, along with the complete return of gastroesophageal motility, thereby expediting recovery and preventing microaspiration in the postoperative period. Sugammadex is a modified gamma cyclodextrin that complexes with steroidal neuromuscular blocking agents (specifically, rocuronium and vecuronium), leading to a molecular gradient and removal of the agents from the neuromuscular junction. Sugammadex has been shown to have a more rapid reversal of neuromuscular blockade compared to neostigmine. The purpose of this study was to evaluate if perioperative efficiency was increased when sugammadex was used for paralytic reversal compared to the traditional regimen of neostigmine and glycopyrrolate. MethodsA retrospective cohort study of patients admitted for surgical intervention in June 2019 was conducted. Two groups were compared: those who received sugammadex for reversal and those who received neostigmine, plus glycopyrrolate. The primary outcome was time to extubation from the administration of the reversal agent. ResultsTwo hundred seventy-one surgical cases were evaluated. Average doses of sugammadex for those with profound neuromuscular blockade as indicated by a train of four (TOF) of 0 -2 was 2.47 (0.9) mg/kg for sugammadex and 0.042 (0.01) mg/kg for neostigmine, plus glycopyrrolate. Seventeen patients in the sugammadex group experienced bradycardia after reversal compared to 22 in the neostigmine, plus glycopyrrolate, group (p = 0.73). Reintubation was required for three patients in the neostigmine, plus glycopyrrolate, group and no patients in the sugammadex group.The mean time to extubation from the procedure end comparing reversal with sugammadex and neostigmine, plus glycopyrrolate, was 12.5 (7.6) minutes versus 13.7 (8.8) minutes (p = 0.44), respectively. Comparison of reversal with sugammadex versus neostigmine, plus glycopyrrolate, and time spent in the post-anesthesia care unit was 83.6 (48.6) minutes versus 81.7 (46.6) (p = 0.73), respectively. ConclusionsIn this retrospective cohort study, we observed a deviation in the recommended sugammadex dosage and increased reintubation rates but no difference in time to extubation or Post-Anesthesia Care Unit (PACU) length of stay times when patients received sugammadex compared to neostigmine, plus glycopyrrolate, for neuromuscular blockade reversal. Understanding the PACU flow and culture, education of providers about dosages, along with completion of prospective studies, to correlate acceleromyograph values to reversal and postoperative ventilatory and deglutary function can help assess the true clinical value of sugammadex.

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respectively. The mean age for men and women were 62.6 and 61.5, respectively. Several patients demonstrated multiple emboli; to wit, 273 distinct PEs were noted among the 160 individual patients. 107 right sided emboli were found (39.2%), 50 left sided (18.3%), and 116 patients demonstrated bilateral PEs (42.5%). Conclusions: Incidence of right-sided PE exceeded left-sided PE and bilateral involvement exceeded both. Additionally, PE were more common in lower segments (24.9%) than upper segments (17.6%). The increased size of the right lung compared to the left may contribute to the tendency of emboli to locate to the right side. The clinical significance of the right-sided preference suggests an elevated PE-associated mortality risk in patients with unilateral left lung disease.Learning Objectives: Treatment of Acute Exacerbated Chronic Obstructive Pulmonary Disease (AECOPD) consists of multiple therapies including systemic steroids. AECOPD may require hospitalization and mechanical ventilation. Controversial literature exists regarding optimal dosing and duration for steroid therapy. The primary objective was to clarify the dosing of methylprednisolone (MP) for AECOPD by assessing re-intubation rates within 30 days of extubation. Secondary objectives include ICU length of stay, time on mechanical ventilation, duration of steroid therapy, insulin requirements and mortality. Methods: A retrospective review of medical intensive care unit (MICU) patients admitted at WVU Healthcare from January 1, 2009 through December 31, 2014. Patients receiving ≥72 hr of MP during hospitalization were screened. Selected patients were stratified by the initial daily MP dosing regimen -(low dose-LD ≤ 160mg, medium dose-MD 161 -239mg and high dose-HD ≥ 240mg). Descriptive statistics were used for baseline characteristics and to compare variables between groups. Results: Total of 157 patients screened, 116 were enrolled (LD [n=47], MD [n=7] and HD [n=62]). Included patients had a history of smoking (29%), home oxygen therapy (46%) and diabetes (35%). Only 1% of patients (n=2) were re-intubated within 30 days of initial extubation and 2 patients died. There was no difference in ICU length of stay or days on the ventilator in all groups (3-6 days). Overall, patients received 7-9 days of therapy. Interestingly, 25% of patients had changes to insulin therapy and 11 patients (LD [n=4] and HD [n=7]) received an insulin drip. Conclusions: Results failed to demonstrate a difference in re-intubation rates between groups. No differences in ICU length of stay, time on ventilation, duration of steroid therapy, insulin requirements and mortality was seen. These results warrant prospective dose finding studies to determine the appropriateness of a LD regimen in order to achieve optimal clinical outcomes in this population.