In this episode I’ll:
1. Discuss an article about prolonged versus short-term intravenous infusion of antipseudomonal β-lactams for patients with sepsis.
2. Answer the drug information question “What IV medications are compatible with sodium bicarbonate?”
3. Share a free resource for checking IV compatibility.
Lead author: Konstantinos Z Vardakas
Published in Lancet Infectious Diseases October 2017
Studies related to prolonged β-lactam infusion have widely differing results. The authors of this meta-analysis aimed to identify the effectiveness of prolonged versus short-term infusion of antipseudomonal β-lactams in patients with sepsis.
Randomized controlled trials in patients with sepsis that compared mortality or other clinically meaningful endpoints with prolonged versus intermittent infusion of β-lactams were included. Prolonged infusion was considered at least 3 hours, and intermittent infusion was considered 60 minutes or less. The primary outcome of the meta-analysis was all-cause mortality at any time point.
In all, 22 randomized controlled trials involving nearly 2000 patients were included. Trials included used either carbapenems, penicillins, or cephalosporins. Prolonged infusion was associated with lower all-cause mortality than intermittent infusion (risk ratio [RR] 0.70, 95% CI 0.56–0.87). Neither heterogeneity or publication bias was observed.
The authors concluded:
Prolonged infusion of antipseudomonal β-lactams for the treatment of patients with sepsis was associated with significantly lower mortality than short-term infusion. Further studies in specific subgroups of patients according to age, sepsis severity, degree of renal dysfunction, and immunocompetence are warranted.
The robustness of the findings of this meta-analysis is bolstered by 3 things:
1. First, the quality of the evidence included was high according to GRADE standards.
2. Second, the studies included lacked heterogeneity. This suggests that the studies were similarly conducted and makes combining their results in a meta-analysis more meaningful.
3. Third, 2 separate tests for publication bias indicated there was none. This means that it is not likely that only positive studies were published while negative ones were buried.
Prolonged infusion of β-lactam antibiotics is being firmly established as a rare “win-win” scenario whereby drug costs are reduced while patient outcomes are improved.
Unfortunately, this data comes in the middle of a IV minibag shortage due to manufacturing delays created by recent hurricanes in Puerto Rico. Bookmark this meta-analysis for future use in implementing prolonged infusion protocols when the IV minibag shortage has passed.
Drug information question
Q: What is bicarb compatible with?
A: Sodium bicarbonate is notorious for creating IV compatibility problems. The biggest concern in ICU patients is that bicarb inactivates catecholamine based vasopressors such as norepinephrine, epinephrine, and dopamine. But there are plenty of critical care medications that bicarb is compatible with that can used to avoid placing extra IV lines in patients. It can be a good idea to have some of these combinations memorized, so that when bicarb is needed emergently you can guide administration to occur without running into an incompatibility problem.
- For vasopressors, bicarb is compatible at Y-site with vasopressin and phenylephrine.
- For sedatives, bicarb is compatible at Y-site with fentanyl, dexmedetomidine, and propofol.
- For antibiotics, bicarb is compatible at Y-site with piperacillin-tazobactam, cefepime, linezolid, and vancomycin.
The resource for this episode is the free, online Compatibility of Commonly Used IV Drugs chart published by Pharmacy Practice News. The chart provides data in an organized, concise format from which compatibility information can be accessed quickly and conveniently. A designation of “compatible” could indicate that the combination evaluated appears to be compatible based on physical, chemical, or both types of compatibility.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.