Prolonged intraarterial infusion of verapamil is a safe and effective treatment for medically refractory severe vasospasm and reduces the need for angioplasty in such cases.

Background: Vancomycin and piperacillin-tazobactam are commonly used first guns in the empiric management of critically ill patients. Current studies suggest an increased prevalence of acute kidney injury with concomitant use, however, these studies are few and limited by small sample size. The purpose of this study was to compare the prevalence of nephrotoxicity after treatment with vancomycin alone and concomitant vancomycin and piperacillin-tazobactam treatment at our institution. Hypothesis: Concomitant vancomycin and piperacillin-tazobactam-treated patients will experience greater prevalence of nephrotoxicity compared with vancomycin-only treated patients. Methods: This was a retrospective cohort of patients treated with vancomycin for gram-positive or mixed infections in our facility from 2005 to 2009 who were not receiving hemodialysis at the time of admission. Included patients were stratified by treatment with vancomycin, vancomycin/piperacillin-tazobactam, or vancomycin/an alternative gram-negative rod (GNR) antibiotic. p values for categorical variables were computed using w 2 while continuous variables were computed using Kruskal-Wallis. Variables deemed statistically significant (< 0.05) were included in the multivariable, log-binomial regression model. Relative risk (RR) and 95% confidence intervals (CI), and p values were computed using a generalized estimating equation (GEE) approach with robust standard errors (i.e., Huber White ''sandwich variance'' estimates) to accommodate a correlated data structure corresponding to multiple episodes of infection per individual. Results: A total of 530 patients with 1,007 episodes of infection, were treated with vancomycin (150 patients/ 302 episodes of infection), vancomycin/piperacillin-tazobactam (213 patients/372 episodes of infection), or vancomycin/GNR alternative (167 patients/333 episodes of infection). Patient demographics, comorbidities, sites of infection, and organisms of infection were compared among groups. After adjusting for statistically significant variables, neither vancomycin/piperacillin-tazobactam (RR = 1.1, 95% CI = 0.99-1.2; p = 0.073) nor vancomycin/GNR alternative (RR = 1.1, 95% CI = 0.98-1.2; p = 0.097) were found to be associated with an increased risk for nephrotoxicity compared with vancomycin alone. Conclusion: A difference in nephrotoxicity was not observed between vancomycin and vancomycin/ piperacillin-tazobactam-treated patients at our institution. Concomitant use as empiric therapy is appropriate, although larger sample sizes are needed to analyze closely this relation among at-risk subsets of this population.

No difference in nephrotoxicity was observed between lean and obese patients treated with vancomycin at our institution.

Background Many centers advocate aggressive lower extremity deep venous thrombosis (DVT) screening using ultrasound (LUS) for patients meeting high-risk criteria. We hypothesized that a high-risk screening protocol is impractical and costly to implement. Methods The University of Virginia's trauma database was queried to identify 6,656 patients admitted between 2009 and 2013. Patient characteristics and outcomes were recorded. Multivariate analyses were performed on patients who underwent LUS to assess the association between patient characteristics and the development of DVT. A predictive model for DVT was applied to the entire population to determine performance and resources required for implementation. Results Overall, 2,350 (35.3%) of admitted patients underwent US. 146 patients (6.2%) developed DVT. Patients who underwent US were significantly older (54.5 vs. 50.4 years, p<0.0001), had higher injury severity scores (13.5 vs. 8.6, p<0.0001), and longer admissions to the intensive care unit (ICU) (5.6 vs. 0.9 days, p<0.0001). Backwards selection multivariable logistic regression identified ICU length of stay, transfusion of blood products, spinal cord injury, and pelvic fracture to be associated with DVT (c-statistic 0.76). The model was applied to the entire population to evaluate probability of DVT (c-statistic 0.87). Predictive performance and costs were determined using a cost per LUS of $228. The most sensitive threshold for screening would detect 53% of DVTs, require screening of 26% of all trauma patients, and cost nearly $600,000 to implement over the study period. Conclusions Although a predictive model identified high-risk criteria for the development of DVT at our institution, the model demonstrated poor sensitivity and positive predictive value. These results suggest that implementing a high-risk screening protocol in trauma patients would require a costly and burdensome commitment of resources and that high-risk DVT screening protocols may not be practical or cost-effective for trauma patients. Level of evidence Diagnostic tests or criteria, level III.

Background Therapeutic hypothermia in severe septic shock is associated with prolonged survival. We hypothesized that moderate hypothermia would prolong survival and modulate the inflammatory response in rats with septic shock by exerting its therapeutic effect on splenic leukocytes. Materials and Methods Severe septic shock was created in rats by cecal ligation and incision (CLI). One hour after CLI or laparotomy, rats were randomized to sham, normothermia (NT), or 4 hours of hypothermia (HT) followed by 2 hours of rewarming. Hypothermia (3l±1°C) was induced using a cooling blanket, and monitored via a rectal temperature probe. Results Survival duration was 2.78±1.0 hours in NT rats and 8.33±0.32 hours in HT rats (n=8/group, p<0.0001). In separate groups, three hours after CLI, the spleen weight was significantly smaller in NT rats (769±100 mg) than in HT rats (947±157 mg, p=0.04). Fluorescent immunostaining of formyl peptide receptors (FPR) on leukocytes in spleen tissue showed considerably higher FPR expression in HT rats than in NT rats. Significantly elevated pro-inflammatory cytokines and myeloperoxidase (MPO) enzyme in plasma were found in NT rats compared with HT rats. Anti-inflammatory cytokine, IL-10, was significantly higher in HT rats. Both pro-inflammatory cytokines and plasma MPO were significantly reduced in splenectomized NT rats. Conclusions Moderate hypothermic therapy significantly prolongs the survival duration of rats with severe septic shock. Hypothermia dampens the inflammatory response during septic shock by modulating the spleen to an anti-inflammatory mode and preventing the spleen from releasing activated splenic leukocytes into the blood.