2026 Eastern States Conference

Authors: Emmy Zhao, PharmD; Nehal Ahmed, PharmD, BCPS; Daryn Norwood, PharmD, BCPS; Eun Jin Park, PharmD, BCPS, BCIDP; Kelly Hu, PharmD, BCPS

Learning Objective: Describe the impact of pharmacist education on appropriate de-escalation of stress ulcer prophylaxis (SUP).

Background/Objective: Assess appropriateness of SUP discontinuation in the intensive care unit (ICU) prior to and following pharmacist education to providers.

Methods: This single-center study assessed the percentage of appropriate SUP discontinuation pre- and post-pharmacist education in the ICU. Exclusion criteria include patients ≤18 years of age, patients transferred to another hospital on SUP, patients who passed away in the ICU, or patients with an alternative indication for pantoprazole or famotidine. The primary outcome was percentage of patients inappropriately continued on SUP at 48 hours after ICU downgrade. Secondary outcomes included percentage of patients appropriately initiated on SUP per the 2024 SCCM/ASHP guidelines, patients inappropriately discharged on SUP, and patients with documented side effects to SUP.

Results: A higher proportion of patients in the post-intervention group (22/40, 55.0%) compared to the pre-intervention group (22/50, 44.0%) had SUP appropriately discontinued. However, the results were not statistically different (two-sided p = 0.40). Rates of appropriate SUP initiation were similar between pre- and post-intervention groups (76.0% vs 82.5%), as were rates of inappropriate discharge on SUP (12.0% vs 12.5%). There were no documented adverse events thought to be related to SUP medications.

Conclusion: Pharmacist education to providers was numerically associated with increased appropriateness of SUP discontinuation, however, this difference was not statistically significant. This study was limited by its retrospective nature and small sample size. Additional education to decentralized pharmacists to review SUP indications and intervene as appropriate may further elucidate the benefit of pharmacy intervention on appropriate SUP discontinuation.

Self-Assessment Question:
Which of the following is not an indication for SUP per the 2024 SCCM/ASHP guidelines?

• Coagulopathy
• Shock
• Chronic liver disease
• Mechanical ventilation

Title: Safety of high dose norepinephrine for the treatment of septic shock in the ICU 
Authors: Kenzie Alexanian, Pharm.D., Martin C. Taylor Jr., Pharm.D., BCPS, Joan Mege, Pharm.D., BCPS 
Objective: Evaluate the safety of high dose norepinephrine when used for the treatment of septic shock 
Self-Assessment Question: It is safe to titrate to doses of NE above 1mcg/kg/min. (True/False) 
Background: There is limited data on the safety of high infusion rates of NE. The objective of this study is to assess the safety of NE when doses exceed 1mcg/kg/min in patients undergoing treatment for septic shock. 
Methods: We conducted a retrospective review of patients, with septic shock, who received doses of norepinephrine exceeding 1mcg/kg/min in the ICU at Sinai Hospital of Baltimore from January 2024 to December 2025. The primary outcome is the incidence of extravasation, tachycardia, and limb necrosis in patients receiving high dose NE. 
Results: Among 38 patients, 15 adverse drug reactions (ADRs) were reported in 11 patients. The most common ADR was tachycardia with eight occurrences. There were two occurrences of digit/limb necrosis. The majority of ADR occurred in patients receiving 1 – 1.9mcg/kg/min. We did not observe a linear relationship in the incidence of ADR with higher doses of NE. Hydrocortisone was administered to 68.4% of patients. The median amount fluid administered during the first six hours of resuscitation was only 13mL/kg. The most common adjunct vasopressor utilized was vasopressin (79%). The overall mortality rate was 76.3% with the greatest mortality rate in patients with NE doses greater than or equal to 3mcg/kg/min (95.65%).
Conclusions: Doses of NE greater than or equal to 3mcg/kg/min were associated with few ADRs (digit/limb necrosis and extravasation).  Mortality was highest with doses greater than or equal to 3mcg/kg/min.  High dose norepinephrine may be safe but has limited efficacy.  Further studies are required to assess the efficacy and safety of high dosed norepinephrine.

Authors: Mary Taylor, PharmD, PGY-1 Pharmacy Resident, Asra Kidwai, PharmD, BCPS and Jessica Hagy, PharmD, BCPS
Learning Objective: Audience members will be able to explain the efficacy of ketamine for analgesia-based sedation in mechanically ventilated intensive care unit (ICU) patients.
Background: This study aims to evaluate whether ketamine is an effective and safe alternative to fentanyl for analgesia-based sedation in mechanically ventilated ICU patients, given limited evidence despite its potential opioid-sparing and sedative benefits.
Methods: This retrospective, multicenter, medication use evaluation will include adult medical ICU patients who received ketamine or fentanyl for 24 hours or more for analgesia and adjunct sedation while mechanically ventilated. Patients receiving ketamine at Northwest Hospital will be compared to those receiving fentanyl at Sinai Hospital, where ketamine use is rare, to reduce institutional confounding. Exclusions include surgical ICU patients, pregnancy, need for deep sedation (Richmond Agitation Sedation Score (RASS) of -5) or neuromuscular blockade, primary neurological injury, ketamine use for status asthmatics or refractory status epilepticus, or receipt of both agents. The primary outcome is time to extubation; secondary outcomes include Critical-Care Pain Observation Tool (CPOT) scores, RASS goal attainment, adjunct opioid use, Confusion Assessment Method for the ICU (CAM-ICU), hemodynamics and mortality. Data collected from chart reviews will be analyzed using descriptive statistics.
Results: A total of 40 patients were included in the results, 20 patients in the ketamine group and 20 patients in the fentanyl group. Results showed that time to extubation in the ketamine group was about 76 hours and 14 minutes and 81 hours and 46 minutes in the fentanyl group. Secondary outcomes showed average CPOT scores were 0.36 in the ketamine group and 0.33 in the fentanyl group, however, the ketamine group required more adjunct as-needed opioids (11 (55%) vs 5 (25%)). Additionally, CAM-ICU positivity within 12 hours after treatment initiation was also notably higher in the ketamine group compared to the fentanyl group (18 (90%) vs 6 (30%)).
Conclusion(s): Overall, while ketamine may offer a potential alternative to fentanyl for analgesia-based sedation in mechanically ventilated medical ICU adults, these finding suggest possible limitations related to sedation quality and delirium that warrant further investigation with larger prospective studies.
Self-Assessment Question: Based on this study, which of the following best describes a potential advantage of ketamine compared to fentanyl?

• Improved maintenance of RASS goals
• Lower CPOT pain scores
• Reduced time to extubation
• Decreased need for adjunct opioids

Title: Determining direct oral anticoagulant eligibility among warfarin-treated inpatients: a retrospective chart review 
Authors: Ciara Marro-Wilson, PharmD; Samantha Paone, PharmD, MBA, BCPS; Preethi Samuel, PharmD, BCACP, AAHIVP; Jennifer Premus, PharmD
Objective: At the conclusion of my presentation, the participant will be able to differentiate between eligible patients and those who are ineligible for conversion from warfarin to a direct oral anticoagulant (DOAC) based on patient-specific factors and clinical characteristics.
Self Assessment Question: Which of the following patients would be eligible for a DOAC?
A. A patient with triple antiphospholipid syndrome
B. A patient with non-valvular atrial fibrillation
C. A patient with moderate-to-severe rheumatic mitral stenosis
D. A patient with a mechanical mitral valve
Background: To evaluate whether patients admitted on warfarin were eligible for transition to a DOAC and, for those ineligible, identify and categorize by reason for ineligibility.
Methods: This retrospective chart review assessed patients 18 years and older on warfarin admitted to Staten Island University Hospital North and Princes Bay between December 31st, 2024 and December 31st, 2025 with pregnancy and/or breastfeeding as the sole exclusion criteria. For patients who met the pre-specified criteria, anticoagulation indication was documented along with pertinent clinical factors such as HAS-BLED and CHA2DS2-VASc scores for those with atrial fibrillation, Child-Pugh classification for hepatic dysfunction, eGFR, duration of warfarin use, total weekly warfarin dose, INR goal, previous DOAC use, history of bleeding and/or thrombosis while on warfarin, current DAPT, and relevant drug-drug interactions. Descriptive statistics were utilized to determine the proportion of patients who were appropriate candidates for a DOAC during admission and to identify, as well as quantify, specific factors that deemed patients ineligible.
Results: A total of 229 charts were reviewed. Overall, 44.5% of patients were deemed eligible for conversion to a DOAC during the reviewed admissions. Among ineligible patients, the most common reasons for ineligibility were presence of a mechanical heart valve (44.1%), valvular atrial fibrillation (33.1%), and antiphospholipid syndrome (29.1%). Additional reasons included a thromboembolic event while on a DOAC (15.7%), a transcatheter aortic valve replacement (5.5%), thrombophilia (6.3%), moderate-to-severe mitral stenosis (5.5%), Child-Pugh Class C (3.1%), and unclear valvular involvement or embolic stroke of undetermined source (0.8%). Patients could have more than one reason for ineligibility.
Conclusion: Several patients remained eligible for a DOAC, revealing missed opportunities for consideration of safer, less pharmacokinetic-reliant anticoagulation options. Overall, these findings may suggest that structured, real-time inpatient review may improve DOAC candidate identification and foster provider collaboration to provide patients with proven, safer alternatives.

Title: Use of antipsychotics compared to polypharmacy de-escalation in resolution of intensive care unit delirium 
Authors: Kaylee Simon, PharmD; Keri Denchfield, PharmD, BCCCP, CNSC; Lisa Pickmans, PharmD, BCCCP, BCPS; Ayah Arafat
Learning Objective: Audience members will be able to describe limitations in current guideline recommendations for treatment of ICU delirium  
Background/Objective: Evaluate whether de-escalation of sedating and/or anticholinergic medications is as effective as antipsychotic initiation for resolving ICU delirium  
Methods: This retrospective single center cohort study utilized chart review to identify patients admitted to the surgical ICU from January 1-October 31, 2025 who are over 18 years of age, have a Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) positive assessment after 24 hours of admission, and are receiving at least one anticholinergic or sedating medication based on the Drug Burden Index. Patients with alternative etiologies of altered mental status or baseline psychiatric disorders requiring antipsychotics were excluded. Patients were grouped into three treatment strategies: antipsychotic initiation, de-escalation of sedative or anticholinergic medications, or no changes. Outcomes included time to resolution of delirium, ICU length of stay, and intensity of medication changes before and after delirium onset. Continuous data was measured using means with standard deviations and medians with interquartile ranges and groups will be compared using the Kruskal-Wallis test.
Results: 170 patients were screened with 14 patients being included. Patients were most frequently excluded due to mechanical ventilation on continuous sedatives within 48 hours of CAM-ICU + score. No statistical analysis was performed on the primary or secondary outcomes and no subgroup analysis was conducted due to the small sample size. The observed median time to delirium resolution in the antipsychotic group was 5 days, 1 day for the de-escalation group, and 2 days for the no change group. The most commonly identified anticholinergic and sedative medications were fentanyl, oxycodone, hydromorphone, methocarbamol, metoclopramide, gabapentin, and buprenorphine. The most common medications de-escalated were opioids.
Conclusions: No firm conclusions can be drawn about the effectiveness of de-escalation of anticholinergic and sedative medications compared to antipsychotics for time to resolution of delirium. De-escalation was observed only in the hypoactive delirium subgroup, suggesting potential utility in this population, though further research is needed.   

Self Assessment Question: What is the current recommendation for antipsychotics for delirium treatment?

Title: Early simultaneous versus stepwise implementation of Guideline-directed medical therapy in Veterans with reduced ejection fraction heart failure at the Washington DC VA Medical Center: Impact on clinical outcomes and tolerability.

Authors: Dr. LaNisha Potts, PharmD
              Dr. Bi Kim, PharmD, BCPS, BCCCP
              Dr. Josephine Tefferi, PharmD, MPH,BCPS, BCGP
              Dr. Samuel Oh, PharmD, BCPS 

Learning Objectives:
1. Determine whether early simultaneous implementation of GDMT results in lower rates of hospitalization for HF exacerbation compared to stepwise implementation.
2. Evaluate the impact of simultaneous versus stepwise GDMT implementation on cardiovascular mortality in Veterans with reduced ejection fraction heart failure (HFrEF, EF<40%). 

Objective:
The primary objective of this study is to compare the clinical outcomes of early simultaneous (ES) implementation of all four classes of Guideline-Directed Medical Therapy (GDMT) compared to a stepwise (SW) implementation approach in Veterans with heart failure with reduced ejection fraction (HFrEF, EF<40%).

Methods:
This is a single- center, retrospective cohort study conducted at the Washington DC VA Medical Center, a 164- medicine bed tertiary care teaching hospital. GDMT exposure will be determined from the Computerized Patient Record System (CPRS), Veterans Health Information Systems and Technology Architecture (VistA), and HF Dashboard, and its including agents active at discharge and any new starts within 60 days post-discharge. The  distinct GDMT classes are defined as one of ARNI (preferred over ACEi/ARB), ACEi/ARB (counted as one class), evidence based β-blocker, MRA, and SGLT-2 inhibitor. Both continued therapies, either active on the discharge medication list, or newly initiated agents will contribute toward the total class count. Dose adjustments or agent substitutions within the same class will not add an additional class. The variables of interest will include patient demographics, comorbidities, baseline heart failure characteristics, medication timing/dosage, laboratory values, number of GDMT classes prescribed, and clinical outcomes. This data will be analyzed to evaluate the progression or improvement of HFrEF in relation to the extent of GDMT utilization. Veterans included in the study consist of those diagnosed with heart failure with reduced ejection fraction (HFrEF, EF <40%) by ICD 10 codes for left ventricular heart failure (I50.1X), systolic heart failure (I50.2X), and combined heart failure (I50.4X), and associated with the index encounter of earliest qualifying HF discharge or earliest outpatient HF visit during the study period of Jan 1, 2022 – Dec 31, 2024. Veterans with pre-index GDMT agent used is permitted. The primary outcome is the number of hospitalization for heart failure exacerbation, all–cause and cardiovascular mortality. The secondary outcome in the incidence of adverse effects and the rates of GDMT continuation. The sample size will be determined by the number of patients meeting predefined inclusion and exclusion criteria within the study cohort. To avoid selection bias, all eligible patients will be included, and no patients will be excluded based on outcomes or treatment exposure. The primary outcome data analysis includes Logistic and Multivariable Cox proportional hazards regression for hospitalization and CV mortality (OR/HRs with 95% CIs).

Results:
In the 60 day landmark analysis, overall there was not statistical difference in any event occurring or the time to an event, however when adjusting for age there was statistical difference in both. In the 30 day analysis, there was a 7 times higher odds of any event occurring in the delayed group vs. the early group. For adherence in the 60 day landmark analysis, the rates of GDMT continuation was significant for each individual agent. In the 30 day analysis, neither adherence measures were significant.

Conclusions:
• Delayed GDMT implementation was associated with higher incidence of events compared to the ES implementation group at 30 days, although those      differences did not sustain at 60 days once GDMT was optimized
• No overall significant differences in time-to-event outcomes were identified in either analysis except when adjusting for age as a predictor
• Medication adherence was similar in both landmarks, suggesting outcomes were not explained by adherence alone
• Early implementation may reduce short-term risk, but long-term outcomes may depend on eventual GDMT optimization
• Age was a consistent predictor of outcomes across analysis, suggesting a need for age-tailored treatment strategies

Self Assessment question:
M/C: Which covariant would predict the best approach in regards to the timing in optimizing GDMT in HFrEF patients?
A. Ejection fraction
B. Age
C. Blood pressure
D. Serum creatinine levels 

Objective: The objective of this study is to compare the safety and short-term outcomes of intravenous (IV) metoprolol and IV diltiazem for rate control in this population

Self-Assessment Question: Which concern limits guideline use of diltiazem in patients with heart failure with reduced ejection fraction?
A. QT prolongation
B. Negative inotropic effects
C. Increased renal clearance
D. Reduced beta receptor sensitivity

Background: Atrial fibrillation (AF) with rapid ventricular response in heart failure with reduced ejection fraction (HFrEF) is commonly managed with beta blockers, while diltiazem is generally avoided due to negative inotropic effects

Methods: This retrospective cohort study included adults presenting to the ED from January 2020 to June 2025 with AF with rapid ventricular response and ejection fraction <40% who received IV metoprolol or IV diltiazem. The primary outcome was clinical deterioration within 48 hours, defined as escalation of respiratory support, vasopressor or inotrope use, or intensive care unit (ICU) transfer. Secondary outcomes included safety events (bradycardia, hypotension, emergent cardioversion within 120 minutes) and efficacy, defined as achievement of heart rate <100 bpm at 30, 60, or 120 minutes. Disposition outcomes included ICU admission, ED readmission for heart failure, and ED discharge within 48 hours

Results: A total of 580 patients were screened, of whom 46 met inclusion criteria (metoprolol n=30; diltiazem n=16). There was no difference in the primary outcome; 1 patient (6.3%) in the diltiazem group required escalation of respiratory support, with no vasopressor use, inotropes, or ICU transfers. There were no statistically significant differences in secondary outcomes, including safety, efficacy, and disposition between the groups. Safety events were observed only in the metoprolol group, including emergent cardioversion (n=9) and adverse events (n=3; hypotension n=1, bradycardia n=2), with none in the diltiazem group. Rate control, defined as HR <100 bpm was achieved in 4 patients (13.3%) receiving metoprolol and 7 (43.8%) receiving diltiazem. Most patients were discharged (metoprolol n=29, 96.7%; diltiazem n=13, 81.3%

Conclusion: Intravenous diltiazem demonstrated similar safety and short-term outcomes compared with intravenous metoprolol in patients with HFrEF presenting with atrial fibrillation with rapid ventricular response, with no difference in clinical deterioration. This study was underpowered, and larger studies are needed to further evaluate the safety and effectiveness of diltiazem in this population.

Authors: Castin Schulz, PharmD; Natalia Smith, PharmD; Sharon Wilson, PharmD, BCPS, BCCCP; Jennifer Frawley, PharmD, BCPS, BCCCP; Wallace Johnson, MD; Megan Wanzer, DNP; Stephanie Katzer, DNP, AGACNP-BC; Nicholas Ledlich, PA; Samuel Tisherman, MD, FACS, FCCM 
Learning Objective: At the conclusion of my presentation, audience members will be able to describe the impact of optimization of intravenous to oral antihypertensives regarding time to oral antihypertensive conversion, intensive care unit length of stay, intravenous anti-hypertensive costs, and 30-day readmission rates. 
Background/Objective: Type B Aortic Dissection can be managed surgically or with anti-impulse therapy. Delays in transitioning from IV to PO antihypertensives raise complication risk and length of stay.  This hospital created an algorithm to facilitate this transition. 
Methods: This was a single-center, prospective, cohort study to determine time to oral medication transition pre and post implementation of an IV to PO protocol conducted at the University of Maryland Medical Center (UMMC). All patients with type B aortic dissections were identified through review of UMMC’s electronic medical records (EPIC).  Pre-algorithm data (July 1st, 2020 - June 20th, 2022) had previously been collected in a prior study (HP-00102749). The post-algorithm group data was collected from July 1st, 2024, through April 1st, 2026. Data was collected and stored using Research Electronic Data Capture (REDCap).  Descriptive statistics were used to summarize the study population. Categorical variables were compared between both intervention groups using chi-square or Fisher’s exact tests, as appropriate based on expected cell counts. Continuous variables were analyzed using the t-test for normally distributed data or the Wilcoxon rank-sum test for non-normally distributed data.  
Results: A total of 102 patients were included in this study with 51 patients each in the pre-algorithm and post-algorithm groups.  The time from IV to PO anti-hypertensive conversion was significantly reduced in the post-algorithm group compared to the pre-algorithm group (1.5 days vs 3.8 days; p=0.0005).  There was a slight trend toward reduction in total hospital length of stay in the post-algorithm group but not significant (7 days vs 8 days; p=0.3).  Time to arterial line removal was significantly shorter in the post-algorithm group (2.4 vs 5 days; p<0.0001).  There were no significant differences in intensive care unit length of stay, 30-day mortality, or safety outcomes.   
Conclusion: Implementation of the type B aortic dissection algorithm at UMMC reduced transition time from IV to PO antihypertensives with equivocal efficacy and safety outcomes.  Time to arterial line removal was also reduced suggesting more efficient IV therapy use.  Further exploration into potential cost savings and hospital readmission comparison is warranted. 
Self-Assessment Question: 
Which of the following is an anticipated outcome of using a standardized algorithm to transition intravenous to oral anti-hypertensives in patients with Type B Aortic Dissections (TBAD)? 
A: increased 30-day mortality 
B: reduced time to oral antihypertensive conversion 
C: increased intensive care unit length of stay 
D: delayed blood pressure control 

Title: Evaluating the Safety and Efficacy of Clonidine versus Guanfacine for Transitioning Off Dexmedetomidine 

Authorship: Juliet Nowak, PharmD; Rachel Winner, PharmD, BCCCP; Skyler Starkel, PharmD, BCCCP; Lydia R. Ware, PharmD, BCCCP, BCPS; Jeremy R. DeGrado, PharmD, BCCCP; Kenneth Lupi, PharmD, BCCCP, BCPS; Kaitlin E. Crowley, PharmD, BCCCP, BCPS; Brigham and Women’s Hospital, Boston, MA 
 
Learning Objective: At the end of this presentation, participants will be able to evaluate the use of enteral agents to facilitate dexmedetomidine (DEX) discontinuation. 

Background: Clonidine and guanfacine, alpha-2 agonists, have been used to facilitate DEX discontinuation. This analysis compared the safety and efficacy of clonidine and guanfacine for dexmedetomidine weaning in intensive care unit (ICU) patients.

Methods: This single-center, retrospective cohort analysis at a tertiary medical center included adult ICU patients who received DEX infusion >24 hours and more than one dose of enteral clonidine or guanfacine concomitantly. Patients were excluded if they died while on DEX, received one of the enteral agents prior to admission, used both guanfacine and clonidine during DEX wean attempt, or received DEX for sleep. The major outcome was discontinuation of DEX within 48 hours of clonidine or guanfacine initiation. Discontinuation was defined as cessation of DEX without reinitiation for at least 12 hours. Minor outcomes included hypotension (MAP <65 mmHg, initiation of vasopressors, or ≥25% increase in vasopressor dose), bradycardia (HR <50 bpm or >20% decrease), ICU/hospital length of stay (LOS), and in-hospital mortality. For categorical data, Chi-Square or Fisher’s exact tests were used as appropriate. Wilcoxon rank sum tests were used for non-parametric continuous data.

Results: A total of 136 patients (102 receiving clonidine and 34 receiving guanfacine) were included in a 3:1 ratio. Patients were enrolled from September 2015-November 2025. There was no statistically significant difference between the two groups in discontinuation of DEX within 48 hours of enteral agent initiation (68% in clonidine group vs 56% in guanfacine group, p=0.21). Incidence of hypotension was higher in the guanfacine group (67%) compared to clonidine (43%) (p=0.01). Additionally, vasopressor use at the time of enteral agent initiation was greater in the guanfacine group than in the clonidine group, respectively (38% vs 21%; p=0.04). There was no difference in bradycardia, hospital LOS, ICU LOS, or in-hospital mortality between the two groups.

Conclusion: This is the first study to our knowledge that compared clonidine versus guanfacine for transitioning off DEX in the ICU. Although there was no associated difference in groups between discontinuation of DEX within 48 hours of clonidine or guanfacine initiation, rates of hypotension were more prevalent in the guanfacine group, through this may be confounded by higher vasopressor use in the guanfacine group. This analysis also gives guidance on feasibility for a future prospective randomized controlled trial.
 
 
Self- Assessment Question:  
Within the first 48 hours of dexmedetomidine weaning, which oral α₂-agonist was associated with a higher incidence of hypotension? 
A. Guanfacine
B. Clonidine
C. Both medications have similar rates of hypotension
D. Hypotension is uncommon with either medication

Title
Analysis of Nursing RASS Assessment Appropriateness and Its Clinical Impact on Patient Oversedation in the Medical Intensive Care Unit
Authors
Syeda Rahman, PharmD, MPH; Ilanit Zada, PharmD, BCCCP; Amanda S. Rampersaud, PharmD, BCPS
Learning Objective
Participants will be able to identify the relationship between nursing RASS assessment appropriateness, oversedation, and key clinical outcomes in mechanically ventilated ICU patients.
Background/Objective
Deep oversedation in mechanically ventilated ICU patients is associated with prolonged mechanical ventilation, delirium, and increased mortality and may be driven in part by inappropriate bedside RASS assessments. The objective of this study is to evaluate the appropriateness of nursing RASS documentation, quantify the prevalence of oversedation, and assess the association between RASS assessment appropriateness, oversedation, and clinical outcomes at SBH Health System.
Methods
This single-center, retrospective cohort study will include adults aged 18 years and older admitted to the medical ICU who require invasive mechanical ventilation for at least 24 hours, receive continuous sedation, have a documented RASS goal, and have at least 6 documented RASS assessments during mechanical ventilation. Exclusion criteria include baseline coma or severe encephalopathy, status epilepticus requiring therapeutic coma, severe traumatic brain injury requiring deep sedation, ECMO support, DNR/comfort-measures-only status within 24 hours of ICU admission, incomplete records preventing assessment of primary outcomes, and receipt of neuromuscular blocking agents during mechanical ventilation. De-identified data collected will include patient demographics, comorbidities, admitting diagnosis, illness severity as measured by SOFA score when available, sedative and analgesic regimens, all documented RASS and CAM-ICU assessments with corresponding goals and timestamps, and ICU and hospital outcomes, including ICU and hospital length of stay, duration of mechanical ventilation, ventilator-free days at day 28, ICU-free days at day 28, delirium incidence and duration, and mortality. RASS assessments will be classified as appropriate or inappropriate using predefined criteria. Oversedation will be evaluated in relation to documented RASS scores and ordered sedation goals. Descriptive and comparative analyses will be used to evaluate the association between RASS assessment appropriateness, oversedation, and clinical outcomes.
Results
Data collection and analysis are in progress. We anticipate describing the prevalence of inappropriate RASS assessments and oversedation, as well as their association with duration of mechanical ventilation, delirium, and mortality. Results will be presented at the conference.
Conclusion
This study is expected to characterize the clinical impact of nursing RASS assessment appropriateness on oversedation and key patient outcomes and provide actionable data to support education, protocol refinement, and quality improvement in ICU sedation management.

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.  

Evaluation of hemorrhagic conversion and use of fibrinogen products after fibrinolytic therapy for acute ischemic stroke 

Authors
Norah Albanyan PharmD; Nihad Medar PharmD, BCCCP; Patricia Cyrus PharmD, BCPS; Melanie Goodberlet PharmD BCPS, BCCCP; Skyler Starkel PharmD, BCCCP

Learning Objective
Describe the differences in hemorrhagic conversion and bleeding outcomes between tenecteplase (TNK) and alteplase (tPA) in acute ischemic stroke.

Self-Assessment Question 
In this retrospective cohort study comparing tPA and TNK for acute ischemic stroke, what was observed regarding intracranial hemorrhagic (ICH) conversion within 24 hours?

A. TNK was associated with a significantly higher rate of ICH
B. tPA was associated with a significantly higher rate of ICH
C. There was no statistically significant difference in ICH between tPA and TNK
D. TNK eliminated the risk of ICH compared to tPA

Background /objective
Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality. Alteplase (tPA) or tenecteplase (TNK) are used to improve outcomes. This study compares incidence of hemorrhagic conversion and use of fibrinogen products following tPA or TNK

Method
This was a single-center retrospective cohort study at a tertiary academic medical center approved by the Mass General Brigham Institutional Review Board (2025P002247). Adult patients (≥18 years) with AIS treated with tPA or TNK between January 2020 and October 2025 were included. Our institution transitioned to TNK as the preferred fibrinolytic agent for AIS in June 2023. Patients were excluded if 24-hour post-treatment neuroimaging was unavailable or thrombolytic dosing was outside guideline recommendations

The major outcome was intracranial hemorrhagic conversion within 24 hours. Minor outcomes included extracranial bleeding, time to hemorrhagic conversion, post-lysis fibrinogen levels, fibrinogen product use, and 30-day mortality. Categorical outcomes were compared using chi-square or Fisher’s exact tests, continuous variables using t-test or Mann–Whitney U test. A multivariable logistic regression identified independent predictors of hemorrhagic conversion.

Results
A total of 114 patients met eligibility, 55 (48.2%) received TNK and 59 (51.8%) tPA. Hemorrhagic conversion within 24 hours occurred in 6 patients in the TNK group and 7 in the tPA (10.9% vs 11.8%, p=0.87). There was no difference in time to hemorrhagic conversion, extracranial bleeding within 24 hours, or mortality between groups. Replacement with fibrinogen products was only seen in the tPA group (4 patients). Median fibrinogen at hemorrhagic conversion 381 mg/dL (TNK) vs 138.5 mg/dL (tPA). When controlling for confounders, a higher National Institutes of Health Stroke Scale score was associated with hemorrhagic conversion.

Conclusion  
In this retrospective cohort of patients with AIS, TNK and tPA had similar rates of hemorrhagic transformation, extracranial bleeding, and 30-day in-hospital mortality, suggesting comparable bleeding safety profiles between the two agents in our cohort. Notably, fibrinogen product use was observed only in the tPA group, which had lower fibrinogen levels. Further research is needed to better define optimal reversal strategies for these agents.

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: Ngan Le, PharmD; Lauren Albertina, PharmD, BCCCP; Kimberly Hall, PharmD, BCCP, BCPS 

Learning Objective: Audience members will be able to explain the role of colchicine in the prevention of post-operative atrial fibrillation (POAF) following cardiothoracic surgery. 

Background/Objective: The purpose of this study is to evaluate the safety and effectiveness of the addition of colchicine to institutional standard of amiodarone and beta blocker therapy for the prevention of POAF in patients who have undergone cardiothoracic surgery. 

Methods: This single-center retrospective cohort study was conducted at Inova Fairfax Medical Campus. Adults (≥18 years) undergoing cardiothoracic surgery requiring cardiopulmonary bypass were included. Exclusion criteria were renal dysfunction, acute kidney injury, transaminitis, chronic liver disease, congenital heart disease, or colchicine use for other indications. The colchicine group consisted of patients from January-June 2025 who received colchicine 0.6 mg twice daily starting on postoperative day two. The control group consisted of patients from January-June 2024 who did not receive colchicine post-operatively. The primary outcome was the incidence of POAF. Secondary outcomes included the incidence of post-operative pericarditis, postpericardiotomy syndrome, and post-operative ileus. Safety outcomes included any events warranting colchicine dose reduction or discontinuation. Categorical variables were analyzed via two-sided Fisher’s exact or Pearson Chi-square tests where appropriate. 

Results: Over the pre-specified periods, 160 patients were included (colchicine n= 81, control n= 79). As part of the institutional POAF prophylaxis protocol, 84.4% of patients received amiodarone and 88.1% received beta blockers. POAF occurred in 19 patients (23.5%) in the colchicine group and in 23 patients (29.11%) in the control group (p=0.42). The median onset of POAF was three days after surgery. Secondary outcomes showed no difference in the incidence of post-operative pericarditis, postpericardiotomy syndrome, and post-operative ileus. Colchicine dose reduction occurred in 4.9% of patients, and discontinuation occurred in 21.0% of patients, most commonly due to diarrhea. 

Conclusions: Among patients undergoing cardiothoracic surgery, the addition of colchicine to institutional standard amiodarone and beta blocker therapy did not significantly reduce the incidence of POAF. Diarrhea was the most common adverse event leading to colchicine dose reduction or discontinuation. The study limitations included retrospective study design and limited sample size.  

Self-Assessment Question: According to our study, colchicine showed reduced incidence of post-operative atrial fibrillation in patients undergoing cardiothoracic surgery (True/False) 

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.

Authors: Rachel Rivers, PharmD; April Finnigan, PharmD, BCCCP; Stefan Leichtle, MD, FACS; Jenna Smith, PharmD, BCCCP

Presentation Objective: Audience members will be able to describe the proposed pathophysiologic mechanisms of beta-blocker and amantadine therapy for neurological recovery in traumatic brain injury (TBI) patients.   

Background: This study aims to bridge the evidence gap for dual propranolol and amantadine therapy in adult TBI patients, namely, to assess the impact of dual therapy on cognitive recovery.

Methods: This was a single-center retrospective cohort study of adult patients with moderate-severe TBI between January 1, 2020 and December 31, 2024. Study subjects were excluded if they received propranolol or amantadine for an indication outside of TBI or prior to admission. The study population was stratified to three subgroups: patients who received dual therapy, patients who received amantadine only, and a control group in which participants received neither therapy. The primary endpoint was defined as the change in total Glasgow Coma Scale (GCS) score from baseline to day seven of therapy or admission. Secondary endpoints included change in motor GCS, peak GCS at therapy discontinuation and hospital discharge, ICU and hospital length of stay, use of adjunctive agents for agitation, and days of therapy with a Richmond Agitation-Sedation scale score > +1. Continuous endpoints were analyzed using the Kruskal-Wallis test and categorical endpoints using Pearson’s chi-squared statistics.

Results: Of 200 patients screened, 120 were included in the study population. Statistical analysis revealed significant improvement in total and motor GCS scores from admission to day seven in all subgroups, and from day one of therapy to day seven among the amantadine and dual therapy subgroups. However, the median score changes were comparatively similar between arms. Subjects in the amantadine and dual therapy arms had a greater incidence of neurosurgical intervention and intracranial pressure monitor placement, longer hospital and ICU LOS, and lower baseline GCS, suggesting more critical injury. The control population was noted to have a significantly greater incidence of agitation, with more frequent adjunct agent use and RASS scores > +1.

Conclusion: While outcome analyses did not reveal significant improvement in neurological recovery in the treatment subgroups compared to the control population, the variability in baseline characteristics and illness severity as well as treatment timeline should be noted. The greater incidence of adjunctive agent use for agitation in the control arm may suggest an accessory role of propranolol and amantadine in TBI symptom management. Post-hoc analyses are needed to delineate key between-group differences.

Self-Assessment Question: Which of the following statements describe the role of beta-blocker therapy in traumatic brain injury? (select all that apply) 
A. Beta-blockers play a preventative role in paroxysmal sympathetic hyperactivity by helping to blunt sympathetic overtone.  
B. Beta-blockers regulate disrupted dopaminergic and glutaminergic pathways.  
C. Beta-blockers reduce cerebral metabolic demand.
D. Beta-blockers increase myocardial oxygen demand.

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

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.