2026 Eastern States Conference

Title: 
Effect of emergency department stay on second dose antibiotic administration delays   
 
Authors: 
Trevor Shaffer, PharmD, Temeka D. Lewis-Wolfson, PharmD, BCPS, BCCCP, Marcia Brackbill, PharmD, BCPS 
 
Learning Objective: 
Attendees will be able to explain the variables that affect antibiotic administration delays and sepsis outcomes. 
 
Background/Objective: 
Timely antibiotics are key in sepsis management. This study assesses whether emergency department length of stay contributes to delays in second dose antibiotic administration among sepsis patients admitted to the intensive care unit (ICU). 
 
Methods: 
A retrospective chart review was conducted including patients aged ≥ 18 years admitted to the ICU with a documented sepsis diagnosis between December 1, 2023, to November 30, 2025. Exclusions were death or comfort care within 24 hours of ICU admission, transfer from an inpatient unit or outside hospital, received fewer than two antibiotic doses, or first antibiotic dose administered more than 3 hours after emergency department (ED) arrival. The primary endpoint was the proportion of patients who experienced a delayed second antibiotic dose. Patients were stratified by ED length of stay (LOS) into two groups: <5 hours or ≥ 5 hours. Secondary outcomes included time intervals from ED arrival to antibiotic order entry, order entry to verification, and verification to administration. Additional secondary outcomes included ICU and hospital LOS, in-hospital mortality, incidence and duration of mechanical ventilation (MV), and initial antibiotic coverage. 
 
Results: 
A total of 69 patient encounters met inclusion criteria, with 30 patients in the < 5-hour group and 39 patients in the ≥ 5-hour group. A total of 16 (53%) of the < 5-hour group experienced a dose delay compared to 12 (31%) of the ≥ 5-hour group (p = 0.058). There were no significant findings for any of the secondary outcomes. 
 
Conclusion:  
In this study, no association was identified between ED LOS and second antibiotic dose delays. Given the limited sample size, additional studies with larger patient populations are warranted to further evaluate the impact of transitions of care on timely antibiotic administration in sepsis.  
 
Self-Assessment Question: 
True or False – Patients who experience an extended ED LOS are more likely to experience delayed antibiotic administration.

Authors: Halle Markle, PharmD; Lauren Albertina, PharmD, BCCCP; Bobbie McLeod, PharmD, BCCP; Maggie Shushe, PharmD, BCCCP
Objective: At the conclusion of this presentation, participants will be able to define the role of guanfacine in dexmedetomidine withdrawal management.  
Self-assessment question: Based on the results from this study, guanfacine should be routinely recommended for all patients in the ICU who are on prolonged dexmedetomidine infusions?
Background: Prolonged dexmedetomidine infusions may cause withdrawal. Guanfacine, an oral α2-agonist with greater central selectivity than clonidine, may aid in weaning. This study evaluated whether guanfacine reduces wean duration or withdrawal outcomes.
Methods: This was a retrospective, single-center, matched cohort study that included adult patients admitted to the intensive care unit (ICU) who received continuous dexmedetomidine infusions for more than 48 hours. Patients who received guanfacine during active dexmedetomidine infusions were compared to matched controls who received dexmedetomidine alone. 1:1 propensity score matching was performed using age, sex, and weight within broad diagnosis categories. The primary endpoint was time to dexmedetomidine discontinuation following the initiation of weaning. Secondary endpoints included successful discontinuation within 48, 72, and 120 hours, dexmedetomidine restart within 48 hours, and adjunctive sedative use. Time-to-event outcomes were analyzed using Kaplan-Meier methods with the Mann-Whitney U Test. Secondary outcomes were compared using Fisher's exact test. 
Results: A total of 94 patients were included in this study, with 47 patients in both the dexmedetomidine plus guanfacine and dexmedetomidine-only groups. Median time to dexmedetomidine discontinuation was 75.4 hours (IQR 31.8-182.8) in the guanfacine group versus 52.5 hours (IQR, 26.7-95.4) in the dexmedetomidine-only group (p=0.072). Patients receiving guanfacine had significantly longer total dexmedetomidine exposure (274.5 vs 163.5 hours; p<0.001). Discontinuation rates at 48 and 72 hours were similar between groups; however, by 120 hours, more patients in the dexmedetomidine-only group were successfully weaned (91.5% vs 59.6%; p<0.001). Rates of dexmedetomidine restart and adjunctive sedative use were similar between groups.  
Conclusion: In this matched cohort, guanfacine did not reduce dexmedetomidine weaning duration or withdrawal-related outcomes. Longer dexmedetomidine exposure in the guanfacine group suggests potential confounding by baseline sedation complexity and/or the subjective definition of the start of weaning in the control group. Further prospective studies are needed to clarify the role of guanfacine in dexmedetomidine withdrawal management.

Authors: Jordan Childress, PharmD; Joseph DiBlasi, PharmD, MBA, BCPS; Karen Frock, PharmD, BCCCP
Objective: This study evaluates adherence to guidelines for platelet transfusion in adults with spontaneous intracerebral hemorrhage (ICH) on antiplatelet therapy prior to admission and assesses associated clinical outcomes such as mortality, hematoma expansion, and thrombotic events.
Self-assessment Question: According to the American Heart Association (AHA)/American Stroke Association (ASA) guidelines, when are platelet transfusions recommended for patients on antiplatelet therapy who present with spontaneous intracerebral hemorrhage? 
Background: The PATCH trial showed increased mortality with platelet transfusion in spontaneous ICH. As a result, guidelines do not recommend routine administration. Platelet transfusion use in this population has not been evaluated at WellSpan York Hospital.
Methods: This is a retrospective cohort study of patients 18 years or older with a diagnosis of spontaneous ICH at WellSpan York Hospital from 06/1/2022 to 11/30/2025. This study was IRB exempt. Patients were excluded if they had a platelet count of less than 100,000/mcL, were using anticoagulants, or were not receiving antiplatelet therapy within 7 days of admission. The primary outcome was guideline adherence which was defined as no platelet transfusion and no emergent neurosurgical intervention or platelet transfusion within 24 hours of admission with neurosurgical intervention. Secondary outcomes included 90-day survival, survival to hospital discharge, and hematoma expansion on 24-hour head computed tomography. Safety outcomes included documentation of transfusion reactions and new thrombotic events. Comparative statistics between cohorts will be analyzed. Descriptive statistics were utilized for data collection and analysis.
Results: A total of 140 patients were evaluated for inclusion. Most exclusions were due to lack of antiplatelet use within 7 days of admission and/or outpatient anticoagulant use, resulting in 47 patients included in the study. Among included patients, the majority were receiving aspirin (83%) in comparison to other antiplatelet agents and had supratentorial ICH (74.5%) bleeding. A neurosurgical intervention within 24 hours of ICH was performed in 21.3% of patients. Guideline adherence was observed in 49% of patients with the most common reason for non-adherence being platelet administration without intervention. There were no differences in secondary outcomes. Thrombotic events occurred in 15% of patients receiving platelets.
Conclusions: Guideline adherence was present in about half of the patient population. There was no difference in secondary outcomes such as 90-day mortality, hematoma expansion, or safety outcomes. Future implications include additional research in a larger patient population as well as provider engagement with guideline recommendations.  

Title: Evaluation of propofol safety in critically ill obese adult patients

Authors: Emilia Pieta, PharmD; Rita Jamil, PharmD; Brittany Tyree, PharmD, MS, BCCCP

Objective: Audience members will be able to assess how increasing BMI influences the risk of propofol-associated hemodynamic adverse effects in ICU patients.

Self-Assessment Question: True or False. Propofol used for the maintenance of sedation in the ICU was associated with a higher incidence of the composite outcome of hypotension or bradycardia in obese patients compared to non-obese patients.

Background: Given propofol’s lipophilicity and hemodynamic adverse effects, evaluation of the safety of propofol administered via continuous infusion for sedation in obese (BMI ≥30 kg/m2) versus non-obese (BMI <30 kg/m2) critically ill patients is warranted.

Methods: This single-center, retrospective study at UVA Health University Hospital included adults admitted to the medical ICU that received propofol continuous infusion for sedation for ≥12 hours between January 1, 2022 and May 31, 2025. Exclusions were a diagnosis of COVID-19; concomitant continuous infusion of benzodiazepine, dexmedetomidine, ketamine, or neuromuscular blocking agent; changes in dosing weight strategy during infusion; propofol administration in the operating room; or RASS goal >0 or <-2. The primary composite endpoint was incidence of new hypotension or bradycardia. Secondary safety endpoints included individual components of the composite outcome, peak triglyceride level, ICU length of stay, and in-hospital mortality. Secondary efficacy endpoints included time to first goal RASS, propofol infusion rate at first goal RASS, and incidence of self-extubation. A subgroup analysis was performed comparing patients with BMI 30 to <35 versus BMI ≥35.

Results: A total of 539 patients were screened; 100 patients were included (50 patients in the obese group). Baseline characteristics were similar, except heart failure was more common in obese patients. The incidence of new hypotension or bradycardia occurred in 46 non-obese versus 41 obese patients (p=0.137). Time to first event was 2.5 versus 1 hour (p=0.849). No significant differences were seen in peak triglycerides, ICU length of stay, in-hospital mortality, RASS outcomes, or self-extubation. Subgroup analysis showed higher incidence of new hypotension or bradycardia in BMI ≥35 kg/m2 (n=35) than BMI 30 to <35 kg/m2 (n=15) (26 vs. 15; p=0.043).

Conclusion: No significant difference was observed in the incidence of new hypotension or bradycardia between obese and non-obese patients. Time to first incidence of new hypotension or bradycardia was longer in non-obese patients, despite no significant difference. These results suggest that obesity is not associated with a higher incidence of hemodynamic adverse effects of propofol compared to non-obese patients.

Authors
Sunkyu Han PharmD; Emily Gill PharmD, BCCCP; Bethany Rennie PharmD 
 
Learning Objective  
Compare all-cause 30-day readmission rates for patients hospitalized with acute decompensated heart failure (ADHF) who are discharged on optimized versus non-optimized loop diuretic doses. 
 
Self-Assessment Question
For patients who are admitted for ADHF on a loop diuretic prior to admission, what diuretic intervention may reduce the risk of 30-day readmission?
A. Maintain patients on the same loop diuretic dose
B. Switch to another class of diuretics
C. Increase the loop diuretic dose and discharge patients on the higher dose
D. Decrease the loop diuretic dose and discharge patients on the lower dose

Background/Objective
Loop diuretics are the therapy of choice for symptom management in ADHF. The objective of this study was to identify whether optimization of loop diuretic dose at hospital discharge lowers the risk of 30-day all-cause hospital readmission.  
 
Methods
This was a multicenter, retrospective cohort study. Adult patients admitted to the hospital due to ADHF between 12/1/2023 and 12/31/2024 were included if they had a left ventricular ejection fraction ≤40% and were prescribed a loop diuretic prior to admission (PTA). Patients who received renal replacement therapy, were admitted to the intensive care unit, or died during the admission were excluded. Patients were divided into 2 groups: diuretic dose optimized (discharged on a higher dose than the PTA dose) and non-optimized (discharged on the same or decreased dose than the PTA dose). The primary outcome was 30-day all-cause readmission. Secondary outcomes were 30-day heart failure readmission and 30-day mortality. Descriptive statistics were utilized to summarize the study variables, and a multivariable logistic regression model was constructed to identify the association between baseline characteristics and 30-day all-cause readmission. 
 
Results  
A total of 300 patients were included in the study; 130 in the optimized dose group and 170 in the non-optimized dose group. Diuretic optimization was associated with a significantly lower rate of 30-day all-cause hospital readmission compared to non-optimization (21.6% versus 43.7%; p=0.01). The rate of 30-day heart failure readmission was also significantly lower in the optimized group compared to the non-optimized group (8.5% versus 16.5%; p=0.04), but 30-day mortality was similar between groups (3.1% versus 1.8%; p=0.46). Diuretic dose optimization on discharge was independently associated with a lower risk of 30-day all-cause hospital readmission (OR 0.55, 95% CI 0.33-0.95, p=0.03). 
 
Conclusion
For patients hospitalized due to ADHF, diuretic dose optimization at discharge may decrease the risk of 30-day all-cause hospital readmission. However, due to the small sample size and retrospective design of this study, larger, randomized, prospective studies should be conducted to further validate these findings.

Title: Prescribing practices and safety of methadone for pain management in hospitalized burn patients 
Authors: Reagan Schlierf, PharmD, Sadora Franklin, PharmD, Olivia Berger, PharmD, BCPS, BCPMP, Jessica Crow, PharmD, MPH, BCCCP, FCCM, Traci Grucz, PharmD, BCCCP, Julie Caffrey, DO, FACOS, FABA, Haley Fribance, PharmD, BCCCP, CNSC 
Objective: Audience members will be able to describe the prescribing practices of methadone for pain management in burn patients at an academic medical center. 
Self-Assessment Question: True or False: Methadone has been used for pain management in burn patients, but more data are needed to standardize regimens and determine efficacy.
Background: The purpose of this study is to identify and describe the initiation, titration, and safety of methadone in hospitalized burn patients. Methadone for this indication has garnered interest, due to its unique profile, but has not been standardized. 
Methods: This retrospective, single cohort, observational study identified adult patients who were initiated on methadone during their admission for a burn managed by the JHBMC burn service. Patients on methadone prior to admission or initiated on methadone for opioid use disorder during their hospitalization were excluded. Systematic abstraction of data was performed through manual chart review. Descriptive statistics were used to characterize methadone initiation and titration, describe the patient population in which methadone was initiated, and identify the prevalence of adverse effects related to methadone use, such as QTc prolongation, serotonin syndrome, or naloxone administration, for the duration of the treatment period.  
Results: The initiation and titration of methadone, patient population characteristics, and documentation of adverse events will be described, and results will be presented. 
Conclusion: It is anticipated that the results of this retrospective chart review will demonstrate current prescribing practices and specific medication related adverse events of methadone for pain in burn patients at an academic medical center. 

Title: Magnesium boluses for post operative atrial fibrillation prevention 

Authors: Alyssa Mills PharmD, Bradley Troyer PharmD, BCCCP, Emma Kabalka, PharmD and Brian Burton, MS. 

Objective: Identify if the use of magnesium boluses in addition to standard of care prevents post-operative atrial fibrillation (POAF) after coronary artery bypass surgery (CABG).  

Self-assessment: In this study, why might the magnesium bolus group not have shown a significant reduction in POAF compared to standard of care?  
A. Magnesium caused more side effects 
B. Magnesium levels were not consistently maintained above 3mg/dl 
C. Standard of care also included magnesium therapy
D. Magnesium levels were not measured appropriately  

Background: POAF occurs in 20-50% of all cardiac surgeries. Magnesium may lower risk by prolonging the atrial refractory periods and reducing myocardial excitability. This study evaluates adding magnesium boluses to standard care to prevent POAF after CABG.  

Methods: Medical records of 290 postoperative CABG patients admitted to Charleston Area Medical Center Memorial Hospital between January 1st, 2021, and March 21st, 2025 were reviewed. The first cohort received standard of care atrial fibrillation prophylaxis with amiodarone and beta-blockers while the other received magnesium boluses in addition to standard of care to maintain magnesium levels above 3mg/dL. 

Results: When analyzing the difference between patients who received magnesium boluses vs standard of care, there was no significant difference in the rate of POAF occurrence between the two cohorts (47% vs 36%, P=0.0957). For secondary outcomes, there was no difference between hours of vasopressors, hospital length of stay, or stroke occurrence. When examining compliance with the magnesium replacement protocol in the bolus cohort, 90% of patients had a low magnesium day and only 31% of those patients received adequate replacement. 

Conclusions: It is unclear whether POAF rates reflect magnesium inefficacy or failure to maintain levels consistently above 3mg/dL in the bolus cohort. The number of replacements varied despite subtherapeutic levels. This could have been due to our institution's protocols not appropriately being followed. A lack of appropriate documentation in the standard of care group may have also been a significant confounder. Prospective studies are needed to evaluate optimal magnesium replacement and effectiveness.  

Title
Efficacy and safety of lower dose compared to standard dose intrapleural alteplase combined with dornase for complicated pleural effusion

Authors
Sarah Thompson, PharmD, MS Siu Yan Yeung, PharmD, BCCCP Mehrnaz Pajoumand, PharmD, BCCCP

Learning Objective
At the conclusion of this presentation, participants will be able to describe the efficacy and safety of lower dose compared to standard dose intrapleural alteplase combined with dornase for complicated pleural effusion.

Background/Objective
The optimal dose of intrapleural (IP) alteplase combined with dornase for complicated pleural effusion remains unclear. This study evaluates whether a lower dose regimen provides efficacy and safety comparable to the standard dose.

Methods
This multicenter retrospective cohort study included adult patients receiving IP alteplase plus dornase for complicated pleural effusion or empyema at eight hospitals within an academic health system. Patients were categorized by IP alteplase dose received: lower dose (<10 mg) or standard dose (10 mg), with consistent dornase dosing. The primary outcome was treatment success, defined as survival without need for surgical intervention within ninety days of IP fibrinolytic therapy. Secondary outcomes included bleeding events, hospital length of stay, mortality, and need for dose escalation.

Results
Among 364 patients, treatment success is similar between groups: 82.2% of the lower-dose group (n=90) and 79.9% of the standard-dose group (n=274), with risk ratio of 1.03 (95% CI 0.91 - 1.16, p = 0.62). The results are similar with adjusted analyses (adjusted RR 1.01, 95% CI 0.89–1.14). Rates of surgery (11.1% vs 11.3%) and in-hospital mortality (6.7% vs 9.1%) were similar. The lower-dose group had higher rates of additional chest tube placement (29.2% vs 19.3%) and a longer hospital length of stay (median 18.8 vs 11.9 days). The lower-dose group had dose escalation in 16.7% of patients. Analysis of bleeding events is ongoing.

Conclusions
Lower-dose intrapleural alteplase was non-inferior to standard dosing for treatment success, with comparable surgery and mortality outcomes.

Self-Assessment Question
Which outcome defines treatment success in this study of IP alteplase dosing?
A. Radiographic improvement only
B. Survival without surgical intervention within ninety days
C. Decrease in chest tube duration
D. Reduction in hospital length of stay

Title: Impact of bromocriptine on suspected neurogenic fever
Authors: Maeghan Biché, PharmD; Benjamin Wilkinson, PharmD, BCCCP; Haley Kavelak, PharmD, BCCCP; Julia Bold, PharmD
Objective: Audience members will be able to describe the impact of bromocriptine on fever in patients presenting with suspected neurogenic fever.
Self-Assessment Question: What patient population(s) may benefit most from bromocriptine use based on this study?
Background: Bromocriptine is hypothesized to have an antipyretic effect in patients with neurogenic fever, however the evidence is limited to small retrospective studies. This study aims to describe the impact of bromocriptine on neurogenic fever.
Methods: This retrospective chart review included adult patients admitted to the neurological intensive care unit (ICU) who received at least one dose of bromocriptine for suspected neurogenic fever between 6/1/2020 and 6/1/2025. The primary outcome was the change in maximum body temperature (Tmax) from the 24-hour period prior to bromocriptine administration (day 0) to the 48-to-72-hour period after initial administration (day 3). Secondary outcomes included change in Tmax from day 0 compared to 0 to 24 hours after administration (day 1) and 24 to 48 hours after administration (day 2), duration of fever, ICU length of stay (LOS), hospital LOS, and mortality 30 days after bromocriptine administration. Outcomes were analyzed by Mann-Whitney U test.
Results: A total of 75 patients were included in the analysis with a median age of 53 years. Administration of bromocriptine resulted in a significant decrease in temperature on day 3 (38.8 ºC vs 38.2 ºC, p < 0.001). The median dose of bromocriptine administered was 15mg on day 1, 30mg on day 2, and 40mg on day 3. Patients with a traumatic injury (n=22) had a greater reduction in fever compared to those with a non-traumatic injury at 72 hours (-0.8 ºC vs -0.5 ºC, p=0.002). The median duration of fever was 2 days. Hypotension occurred in 27 patients after administration, and 20 patients experienced nausea.
Conclusion: In patients with suspected neurogenic fever, bromocriptine may be an option for temperature reduction when added to other antipyretics. Patients with traumatic injury demonstrated a greater reduction in fever, suggesting greater efficacy in this population. Further investigation into dosing strategies is needed.

Sydney Jablonski, PharmD1, William Cahoon, PharmD, BCPS, BCCP, BCCCP1, Cassandra Baker, PharmD1
Virginia Commonwealth University (VCU) Health System Department of Pharmacy Services1
Learning Objective: Describe thiocyanate monitoring and factors associated with accumulation in patients receiving sodium nitroprusside.
Background/objective: The purpose of this project is to characterize current thiocyanate monitoring in patients receiving sodium nitroprusside. Results will be utilized to update thiocyanate monitoring practices and optimize resource utilization.
Methods: This project is a retrospective, single-center review from January 2022 to July 2025. Adult Coronary ICU patients who received intravenous sodium nitroprusside for at least 24 hours, and had at least one thiocyanate level obtained were included. Baseline characteristics, including age, sex, race, renal function, liver function, and mechanical circulatory support, were collected. Patients were categorized into two groups: those with and those without thiocyanate accumulation. Thiocyanate accumulation was defined as at least one thiocyanate level >30 mcg/mL. Nitroprusside factors, including cumulative nitroprusside dose, duration of nitroprusside therapy, peak nitroprusside infusion rate, peak thiocyanate level, and number of thiocyanate levels were obtained for all included patients. Symptoms of thiocyanate toxicity were assessed for each patient via Epic chart review.
Results: Sixty-nine patients were included in this study with only 10 patients (14.5%) demonstrating thiocyanate accumulation. Patients with thiocyanate accumulation had a higher dosing weight (103 kg vs. 83.3 kg), a higher cumulative nitroprusside dose (23.08 vs. 4.25 mg/kg), a longer duration of nitroprusside infusion (588.5 vs. 213 hours), and a higher peak nitroprusside infusion rate (0.8 vs. 0.5 mcg/kg/min) compared to those without accumulation. Six patients (8.7%) had symptoms of thiocyanate toxicity documented. A total of 625 thiocyanate levels were collected, of which 46.6% were undetectable (< 5 mcg/ml) and 10.1% were greater than 30 mcg/mL.
Conclusions: This project found an association between dosing weight, cumulative nitroprusside dose, duration of nitroprusside therapy, and peak nitroprusside infusion rate with thiocyanate accumulation. Given that a large percentage of thiocyanate levels obtained were undetectable, opportunities exist to decrease the frequency of thiocyanate monitoring to improve resource utilization and provide cost savings.
Self-Assessment Question:
What factor was associated with thiocyanate accumulation in patients receiving nitroprusside?
a) Liver function
b) Sex
c) Age
d) Duration of nitroprusside infusion

Authors: Leah Dykstra, PharmD; Emily Burns, PharmD; Abigail Mathes, PharmD; Mary Roth, PharmD, BCCP, BCPS 
Objective: Audience members will be able to quantify the frequency of changes made to serotonergic medications for depression and anxiety at UVA Health during the listing period due to the potential need for methylene blue to manage vasoplegia.
Background: Depression/anxiety are common in cardiac transplant candidates and many take serotonergic medications. These increase serotonin syndrome risk if methylene blue is used for perioperative vasoplegia, so medications may be changed before transplant.
Methods: This retrospective, observational study included adults who underwent cardiac transplant at UVA Health between January 1, 2014 and July 1, 2025. Patients taking serotonergic medications for depression/anxiety during the listing period were included in the primary analysis. Medications were classified as high or non-high risk based on serotonin syndrome potential if used with methylene blue. The high risk group included patients taking >1 high risk medications, while the non-high risk group included patients taking only non-high risk medications. The primary endpoint was the proportion of patients with medication changes during the listing period. Secondary endpoints included frequency of depression/anxiety, serotonergic medication use within 72 hours pre-transplant, vasoplegia and its management, serotonin syndrome, and post-transplant medication re-initiation. Data were collected via electronic medical record review and analyzed using descriptive statistics and chi-square tests.
Results: Among 111 cardiac transplant patients, 41 were on >1 serotonergic medications for depression/anxiety during the listing period (28 in the high risk group and 13 in the non-high risk group). Medication changes occurred in 23 (79%) patients in the high risk group versus 6 (21%) in the non-high risk group (p=0.029). Within 72 hours of transplant, 12 patients were in the high risk group and 16 in the non-high risk group. Vasoplegia occurred in 5 (42%) high risk group patients (0 received methylene blue) and 5 (31%) non-high risk group patients, of whom 2 (40%) received methylene blue. No cases of serotonin syndrome were documented.
Conclusions: Medication changes prior to cardiac transplant were more frequent in the high risk group than in the non-high risk group, likely to reduce serotonin syndrome risk with potential methylene blue use. However, no high risk group patients received methylene blue or developed serotonin syndrome. These findings suggest pre-transplant serotonergic medication changes may offer limited benefit and risk worsening depression/anxiety, especially at institutions where alternatives to methylene blue are used.
Self-assessment question: Based on UVA practice and the data presented in this project, which of the following would be a reasonable recommendation to make for a patient listed for cardiac transplant who takes sertraline and buspirone for depression/anxiety?

Authors
Victoria Yeung, PharmD; William Smith, PharmD; Kaden Shen, PharmD, BCEMP; Felicia Wang, PharmD, BCCCP; Karlie Knobloch, PharmD, BCEMP; Melanie Goodberlet, PharmD, BCPS, BCCCP

Learning Objective
Summarize the safety and treatment-escalation outcomes associated with reduced-dose lorazepam in adult patients with status epilepticus (SE) at an academic medical center.

Background
Guideline recommended dosing of intravenous (IV) lorazepam for SE is 0.1 mg/kg (max 4 mg). A reduced dose of 2 mg is sometimes used to mitigate safety concerns. The objective was to evaluate the efficacy and safety of reduced dose lorazepam for SE management. 

Methods
This single-center, retrospective analysis was conducted at a tertiary academic medical center. Adult patients were included if they were diagnosed with SE and treated with at least one dose of IV lorazepam during admission between January 2020 to March 2025. Patients were excluded for pregnancy, IV access issues, unclear seizure diagnosis, or seizing out of the hospital. The primary outcome was the percentage of patients that required more than one dose of lorazepam for SE within 20 minutes. Secondary outcomes included the percentage of patients who required second- or third-line agents, total lorazepam doses within 40 minutes of initial treatment, time between first and second dose, and rates of adverse events associated with uncontrolled SE, including incidence of intubation, aspiration events, or cardiac arrhythmias, within 24 hours of initial lorazepam dose. Descriptive statistics were used to analyze baseline characteristics and outcomes.

Results
Of 287 patients identified, 80 and 6 patients were included in the 2 mg and 4 mg groups, respectively. The primary outcome was observed in 10 (12.5%) in the 2 mg group and 3 (50%) in the 4 mg group. 32.5% in the 2 mg and 66.7% in the 4 mg group required additional agents. The median number of lorazepam doses within 40 minutes of initial dose was 1 in the 2 mg group and 1.5 in the 4 mg group. If initial dose failed, time between first and second doses of lorazepam was 7.5 minutes in the 2 mg group and 4.7 minutes in the 4 mg group. Rates of intubation, aspiration events, and cardiac arrhythmias were 13.8%, 11.3%, and 0% in the 2 mg group and 33.3%, 0%, and 0% in the 4 mg group, respectively.

Conclusions
This study characterizes the institutional prescribing patterns and assesses the efficacy and safety of reduced dose lorazepam for the initial management of SE at an academic medical center.

Self-Assessment Question
True or False – Patients in the 2 mg group required more lorazepam doses in the first 40 minutes compared to those in the 4 mg group.