Background Benzodiazepine-based therapy for alcohol withdrawal is associated with agitation and respiratory depression. Treatment can be complicated by a need for adjunctive therapy to control these symptoms and in patients requiring mechanical ventilation. Strong evidence for the effectiveness of alternative treatment modalities is lacking, despite the availability of promising pharmacological agents such as phenobarbital. Objective To compare the standard of care for the treatment of alcohol withdrawal-a symptom-triggered benzodiazepine protocol used in conjunction with the revised Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scale-with a phenobarbital protocol. Methods Retrospective cohort study conducted from January 2016 through June 2017 at a 42-bed medical intensive care unit in a private teaching hospital in Nashville, Tennessee. The primary outcome was intensive care unit length of stay. Secondary outcomes included hospital length of stay, incidence of invasive mechanical ventilation, and use of adjunctive pharmacotherapy. Results Patients who received phenobarbital had significantly shorter stays in the intensive care unit than did those who received therapy based on the CIWA-Ar scale (mean [SD], 2.4 [1.5] vs 4.4 [3.9] days; P < .001). Those who received phenobarbital also had significantly shorter hospital stays (4.3 [3.4] vs 6.9 [6.6] days; P = .004). The incidence of invasive mechanical ventilation was lower in the phenobarbital group (1 [2%] vs 14 [23%] patients; P < .001), as was use of adjunctive agents for symptom control, including dexmedetomidine (4 [7%] vs 17 [28%] patients; P = .002). Conclusion A phenobarbital protocol for the treatment of alcohol withdrawal is an effective alternative to the standard-of-care protocol of symptom-triggered benzodiazepine therapy.

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Standardized Impella purge solutions have traditionally consisted of 5-40% dextrose with or without unfractionated heparin as a means of anticoagulation. Such a solution serves to create a pressure barrier preventing entry of blood into the pump's motor housing with heparin providing adequate purge pathway patency in the event of this occurring. We present a case of tissue plasminogen activator (tPA, Activase) utilization in lieu of the recommended purge solution due to concern for thrombus formation of the purge pathway in a 51-year-old male with cardiogenic shock status-post Impella 5.5 heart pump placement for hemodynamic support while awaiting heart transplantation. The purge solution was successfully administered for 48 hours without complication and a reduction in average purge pressure with increase in purge flow rate was observed.

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This case report describes the implementation of a heparin desensitisation strategy for a patient with confirmed galactose-alpha-1,3-galactose (alpha-gal) allergy, prior to cardiac surgery. We describe the pre-, intra-and postoperative management. We believe this report can enhance the limited data currently in existence on alternative strategies for heparin utilisation in cardiopulmonary bypass in a previously intolerant patient population.