Brian L Erstad

Abstract:

Introduction: A inverse correlation has been found between changes in ionized calcium concentrations (physiologically active form) and the addition of albumin in vitro, which may explain adverse cardiovascular effects attributed to exogenous albumin in vivo. The purpose of this investigation was to determine the interaction (if any) between exogenous 25% albumin administration and calcium concentrations in unstable patients. Methods: Following a retrospective analysis involving critically ill patients in which no effect of 25% albumin on ionized calcium concentrations was noted, nine patients were studied prospectively. With one exception, all patients were studied in the ICU. Concentrations of albumin, total and ionized calcium were obtained within one hour prior to the start of a 25% 100 mL albumin infusion given over less than one-half hour, and then at the end and six hours after the infusion. The commercially-available albumin product was tested to ensure that it did not contain substantial amounts of calcium. No other albumin-containing products were administered during the study periods. Results: There were no significant differences in either the ionized or total calcium concentrations obtained before and after the administration of albumin. Ionized calcium in mMol/L*Total calcium in mg/dL Pre/1 h post/6 h post Pre/1 h post/6 h post Concentrations 1.09(0.23)/1.06(0.22)/1.06(0.21) 8.1(0.7)/8.2(0.8)/8.3(.9)*all values expressed as mean (SD); no significant differences by ANOVA Conclusions: In patients receiving relatively rapid infusions of 25% albumin, it appears that circulating calcium concentrations are well-regulated by homeostatic mechanisms. Albumin infusions had no effect on either ionized or total calcium concentrations, although it is possible that temporary changes of questionable clinical importance may have occurred between measurement periods.

PMID: 8836750;Abstract:

Objective: To evaluate physicians' recognition of possible ethanol-related complications in trauma patients, and to compare benzodiazepine requirements in patients with positive and negative blood-ethanol concentrations. Design: Retrospective investigation. Setting: University medical center (level I trauma center). Patients: One hundred thirty-one trauma patients more than 18 years of age who were admitted for at least 24 hours. Outcome measures: (1) Physicians' recognition of ethanol (EtOH) as a potential factor complicating patient recovery in trauma patients admitted with positive blood-EtOH concentrations. (2) The amount of benzodiazepines administered to trauma patients with positive EtOH-blood concentrations compared to trauma patients with no detectable EtOH in their blood. Results: The presence of EtOH in the blood or the potential for EtOH withdrawal was mentioned in the progress notes of approximately one fourth of the patients with positive blood-EtOH concentrations. Thiamine was administered in 8.2% of patients with EtOH-related injuries. Benzodiazepine requirements were significantly higher in patients with positive versus negative blood-EtOH concentrations. Conclusions: Prompt recognition and charting of suspected ethanol abuse is recommended, in conjunction with prompt administration of thiamine. It should be anticipated that patients with positive blood-ethanol concentrations will require higher doses of benzodiazepines compared to trauma patients without ethanol-related injuries.

Abstract:

Background: A inverse correlation has been found between changes in ionized calcium concentrations and the addition of albumin in vitro, which may explain adverse cardiovascular effects attributed to exogenous albumin in vivo. The purpose of this investigation was to determine the interaction (if any) between exogenous 25% albumin administration (100 ml given over 30 min) and calcium concentrations in patients, all but one of whom were in an intensive care unit. Results: There were no significant differences in the ionized calcium concentrations obtained before, at the end and 6 h after the administration of albumin (1.09 ± 0.23, 1.06 ± 0.22, 1.06 ± 0.21 mmol/l, respectively). Similarly, there were no significant differences in the total calcium concentrations between these same time periods (2.03 ± 0.18, 2.05 ± 0.20, 2.08 ± 0.23 mmol/l, respectively). Conclusions: In patients receiving infusions of 25% albumin, it appears that circulating calcium concentrations are well regulated by homeostatic mechanisms. Albumin infusions had no effect on calcium concentrations, although it is possible that temporary changes of questionable clinical importance may have occurred between measurement periods.

PMID: 19349403;Abstract:

This article addresses conventional pharmacologic and nonpharmacologic treatment of pain in patients in ICUs. For the critically ill patient, opioids have been the mainstay of pain control. The optimal choice of opioid and dosing regimen for a specific patient varies depending on factors such as the pharmacokinetics and physicochemical characteristics of an opioid and the body's handling of the opioid, concomitant sedative regimen, potential or actual adverse drug events, and development of tolerance. The clinician must appreciate that favorable pharmacokinetic properties such as a short-elimination half-life do not necessarily translate into clinical advantages in the ICU setting. A variety of medications have been proposed as alternatives or adjuncts to the opioids for pain control that have unique considerations when contemplated for use in the critically ill patient. Most have been relatively unstudied in the ICU setting, and many have limitations with respect to availability of the GI route of administration in patients with questionable GI absorptive function. Nonpharmacologic, complementary therapies are low cost, easy to provide, and safe, and many clinicians can implement them with little difficulty or resources. However, the evidence base for their effectiveness is limited. At present, insufficient research evidence is available to support a broad implementation of nonpharmacologic therapies in ICUs. Copyright © 2009 American College of Chest Physicians.

PMID: 11685299;Abstract:

Objective: To quantify the incidence and specify the types of medication administration errors from a list of error-prone medications and to determine if patient harm resulted from these errors. Design: An observational evaluation. Setting: Five intensive care units (ICUs) in the United States. Patients and participants: Eight hundred fifty-one patients who were at least 18 years of age and admitted to surgical, medical or mixed ICUs during a 3 month period were included. Interventions: None. Measurements and results: A list of error-prone medications was adapted from the literature and evaluated for medication errors and patient harm. Of 5,744 observations in 851 patients, 187 (3.3%) medication administration errors were detected the therapeutic classes most commonly associated with errors were vasoactive drugs 61 (32.6%) and sedative/analgesics 48 (25.7%). The most common type of error was wrong infusion rate with 71 (40.1%) errors. Twenty-one errors did not reach the patient and 159 reached the patient but did not result in harm, increased monitoring or intervention. Five errors required increased patient monitoring and two required intervention. None of the errors resulted in patient death. Conclusions: This multicenter evaluation found fewer medication administration errors than the published literature, possibly due to the varying observational techniques and pharmacist involvement. Lorazepam and wrong infusion rates are associated with errors that occurred frequently, resulted in the greatest potential for harm and were common oversights in the system. These errors should be considered potential areas for betterment in the medication use process to improve patient safety.