colonization by gram-negative bacilli, NI and the mortality related to it can be modified by SDD. Continuous bacteriological surveillance is necessary.

The objective of this study was to evaluate the gluconeogenic response of in vitro stimulated hepatocytes from control broilers and broilers with clinical manifestations of the ascites syndrome. The basal rate of glucose synthesis from lactate was found to be threefold greater in sick birds than in the control group and stimulation obtained with epinephrine was found to be quantitatively similar in both groups. Under basal conditions, the hepatocytes from the sick broilers exhibited 60% more ammonium than the control birds. In addition, the quantification of thiobarbituric acid reactive substances, as indicators of cellular lipoperoxidation, showed an increase of over 100% in heart and liver of sick broilers fowl. In conclusion, the complex integrated response of gluconeogenesis to epinephrine is maintained in broilers with ascites, although their hepatocytes present changes compatible with those observed in cases of oxidative stress. It is not known whether this stress is a cause or a consequence of the ascites syndrome.

BACKGROUND Current guidelines from the Infectious Diseases Society of America and the American Society of Health-System Pharmacists recommend vancomycin troughs of 15 mg/L to 20 mg/L for serious methicillin-resistant Staphylococcus aureus infections. The pharmacokinetics of vancomycin are altered in critically ill patients, leading to inadequate serum levels. Rates of initial therapeutic vancomycin troughs have ranged from 17.6% to 33% using intermittent infusions (i.e., 15–20 mg/L) and approximately 60% using continuous infusions (i.e., 15–25 mg/L) in critically ill trauma patients (1–4). We hypothesized that our dosing protocol would achieve higher rates of initial therapeutic troughs compared with previously published reports due to more aggressive loading doses than those seen in previously published reports. METHODS This was a retrospective study of all critically ill trauma patients admitted to a Level I trauma intensive care unit over a 39-month period who had a suspected serious infection, who were treated with empiric vancomycin per the “pharmacy to dose” protocol, and who had an appropriately drawn steady state trough level. The primary outcome was the rate of initial therapeutic troughs, which was defined as 14.5 mg/L to 20.5 mg/L. RESULTS One hundred ninety-seven patients were screened. Seventy patients met inclusion criteria. The study cohort had a median age of 47.5 years and a median Injury Severity Score of 28. Augmented renal clearances were observed, with a median creatinine clearance of 159.1 mL/min and a median Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) score of 7. The median vancomycin loading dose was 24.6 mg/kg with an initial maintenance dose of 17.71 mg/kg. An every eight hour dosing interval was initiated on 47.14% of the patients, and 45.71% of the patients were initially started on an every 12 hour dosing interval. Only 15.71% of the study patients achieved an initial therapeutic trough; 42.86% were less than 10 mg/L, and 8.57% were greater than 20.5 mg/L. Acute kidney injury occurred in 10% based on the Infectious Diseases Society of America/American Society of Health-System Pharmacists vancomycin guidelines and in 11.4% based on the Acute Kidney Injury Network criteria. CONCLUSION Our incidence of initial therapeutic troughs was slightly below previously reported studies. Based on our results, which are consistent with previous literature, it would appear that our guideline-adherent protocol of intermittent vancomycin is insufficient to achieve troughs of 15 mg/L to 20 mg/L. LEVEL OF EVIDENCE Therapeutic, level III.

Administration of intradermal hyaluronidase after amiodarone extravasation was associated with decreased expansion of erythema and warmth as well as an improvement in patient-reported pain scores without any noted adverse effects.