Browsing by Subject "Burn patients"

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    506 Review of Empiric Voriconazole Dosing in Large TBSA Burn Patients – A Case Series
    (Oxford University Press, 2023-05-15) Lautenslager, Lauren; Boyd, Allison; Hartman, Brett; Spera, Leigh; Graduate Medical Education, School of Medicine
    Introduction: Burn patients are significantly immunocompromised and susceptible to opportunistic fungal infections. Treatment includes aggressive surgical debridement with topical and systemic anti-fungal agents. Voriconazole (VCZ) is a systemic anti-fungal and an approved first line treatment of invasive Aspergillus and Fusarium species. Standard dosing is a 6 mg/kg loading dose twice followed by 200 mg enterally twice daily. Therapeutic drug monitoring is recommended to confirm a goal trough concentration of >1 mcg/mL, once steady state is reached, approximately 4-7 days after initiation. At our institution, VCZ levels are a send out lab, averaging 4-7 days for results. We reviewed a series of three patients with invasive fungal infections and their VCZ treatment dosing to assess impact of altered pharmacokinetics and time delays with drug monitoring. Methods: Three patients with significant burn injury (TBSA >40%) and invasive fungal wound infections were reviewed. Two were treated with standard dosing of VCZ (200 mg BID). The %TBSA, weight, albumin at time of VCZ initiation, initial VCZ dosing, initial trough concentration, time from initiation to trough result and final VCZ dose was reviewed. Consideration of the subtherapeutic drug level of prior patients led to initiation of VCZ treatment at an increased initial empiric dose (300 mg BID) for a third patient, followed by assessment and review of the same variables. Results: For the two patients treated with standard VCZ dosing, initial trough concentrations were subtherapeutic (0.4 mcg/mL and 0.9mcg/mL) and took 13 and 10 days from initiation to trough result, respectively. The albumin concentrations for these patients were 2.1 and 1.6 g/dL. Initial trough concentration for the third patient started on increased empiric dosing was therapeutic (4.9 mcg/mL), despite an albumin of < 1 g/dL. (Table 1). Conclusions: Fungal infections significantly increase the morbidity and mortality of burn patients. The time lapse from initial dose to steady state plus turnaround time of send out labs may result in 1-2 weeks of subtherapeutic treatment. Results from our case series demonstrate that standard VCZ dosing could be inadequate for large TBSA burn patients ( >40%) and higher empiric doses should be considered. Applicability of Research to Practice: Consider use of increased initial VCZ dosing for large burn patients to reach therapeutic serum levels more expeditiously.
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    742 Evaluation of Anti-Xa Levels and Venous Thromboembolism Prophylaxis with Enoxaparin in Burn Patients
    (Oxford University Press, 2023-05-15) Boyd, Allison; Walroth, Todd; Hartman, Brett; Bjornstad, Matthew; Garelli, Alyssa; Spera, Leigh; Grooms, Cortni; Medicine, School of Medicine
    Introduction: Previous studies have found that standard dose enoxaparin is inadequate in achieving goal prophylactic anti-Xa levels in burn patients. A new venous thromboembolism (VTE) prophylaxis protocol was implemented at our institution (Table 1). The objective of this study was to assess the efficacy and safety of the updated VTE prophylaxis protocol to determine if goal anti-Xa levels can be achieved earlier compared to the previous enoxaparin dosing protocol. Methods: This was a retrospective cohort study evaluating a historic protocol group from 3/1/21 to 5/31/21 and a new protocol group from 10/1/21 to 12/31/21. Revisions were made to the new protocol group and evaluated from 7/1/22 to 8/31/22. Adult patients admitted with cutaneous and/or inhalation burn who received enoxaparin for VTE prophylaxis and had anti-Xa monitoring were included. The primary endpoint was protocol efficacy defined as percentage of initial anti-Xa levels within goal range and time to goal anti-Xa level. Secondary endpoints included protocol adherence, rate of VTE occurrence, number of missed or held doses if VTE occurred, correlation to published enoxaparin dosing equations in burn patients, and bleeding events. Results: Results can be found in Table 2. The median (IQR) initial anti-Xa level in the historical (n=29) vs. new protocol group (n=22) was 0.09 (0.04-0.14) units/mL vs. 0.15 (0.10-0.19) units/mL (p=0.036). After adjusting the BMI cutoff in the new protocol from 40 kg/m2 to 35 kg/m2, the median initial anti-Xa was 0.16 (0.12-0.22) units/mL vs. 0.24 (0.19-0.28) units/mL (p=0.018). The mean ± SD time for patients to achieve goal anti-Xa level was 5 ± 3 days in the historical protocol and 5 ± 2 days in the new protocol group (p = 0.456). After protocol modification, the median time to goal anti-Xa level was 4 (3-6) days vs. 2 (1-3) days (p=0.002). No differences were noted in secondary outcomes. Conclusions: The new protocol resulted in a higher initial anti-Xa level with more patients within goal anti-Xa range which was reached in less time after modification of the BMI cutoff for weight-based dosing. The maximum anti-Xa level in the modified group was still within the prophylactic range with the new protocol, indicating no increase in supratherapeutic levels compared to previously utilized dosing strategies and there were no differences in major or minor bleeding events which supports its safety. Applicability of Research to Practice: This protocol can be replicated and utilized by other burn centers with the potential for a multicenter analysis and provides a framework for developing standardized VTE prophylaxis dosing recommendations with enoxaparin in burn patients.