PSHP 2026 Residency Conference

Purpose: This study aims to retrospectively analyze and evaluate the efficacy and safety of dexmedetomidine being tapered with and without clonidine in critically ill patients. A cost analysis comparing tapering methods was also conducted. 


Methods: This study includes patients aged 18 years and older who were admitted to the ICU from July 1, 2023, to June 30, 2025, and received dexmedetomidine intravenously for two or more consecutive days. Exclusion criteria include clonidine use solely for blood pressure management or for opioid withdrawal, and dexmedetomidine discontinuation within 48 hours of discharge. The primary endpoint includes the incidence of at least two signs of agitation or withdrawal from the start of infusion taper to 48 hours after dexmedetomidine discontinuation. Signs of withdrawal include a RASS score greater than +1, use of fast-acting sedatives, use of restraints, heart rate greater than 100 bpm, and systolic blood pressure greater than 140 mmHg or mean arterial pressure greater than 90 mmHg. Secondary endpoints include length of inpatient stay, length of ICU stay, duration of dexmedetomidine, and incidence of hypotension or bradycardia. 


Results: There was not a statistically significant difference in occurrence of at least three withdrawal symptoms between patients tapering dexmedetomidine with clonidine compared to tapering without clonidine (86.0% vs 83.7%; p=1.00). There was a greater incidence of RASS > +1 in the clonidine taper group (p=0.03). The clonidine taper group had a longer average inpatient length of stay (35 vs 24 days), average ICU length of stay (18 vs 16 days), and average duration of dexmedetomidine infusion (11 vs 7 days) compared to the group tapering without clonidine. The group tapering without clonidine had a higher incidence of hypotension and bradycardia. The overall cost was greater in the group tapering with clonidine ($18,410.96 vs $8,035.20). 


Conclusion: Prescribing bias led to the use of clonidine in more severe patients or with alcohol withdrawal, causing the group tapering with clonidine to have longer duration of stays and length of infusions. Overall, tapering dexmedetomidine with clonidine did not reduce the incidence of withdrawal compared to tapering dexmedetomidine without clonidine and tapering with clonidine did not provide a cost benefit. 

Purpose: The purpose of this study was to determine the differences in outcomes between patients who received nimodipine with and without vasopressors initially presenting with subarachnoid hemorrhage. 
Methods: This was a retrospective single center study which included patients between ages 18 and 65 years of age who experienced subarachnoid hemorrhage and received nimodipine for the prevention of vasospasm and delayed cerebral ischemia. Patients who received at least one vasopressor were assigned to the vasopressor group and compared to patients who received nimodipine alone. Patients were excluded from the study if they were transferred from a hospital not within the Penn State Health network within 48 hours of hemorrhage, left against medical advice within 7 days of admission or died during admission. The primary outcome was length of intensive care unit stay. Secondary outcomes included the duration of nimodipine therapy, duration of vasopressor therapy, and discharge disposition. 
Results/Conclusions: Between 2018 and 2025, a total of 153 patients were included in the study. A total of 34 patients were included in the group who received nimodipine and at least one vasopressor, and 119 patients were included in the nimodipine alone group. The average duration of ICU length of stay was 16.1 days in the vasopressor group versus 9.9 days in the group who received nimodipine alone. At the time of submission of this abstract, secondary outcomes and data analysis of all endpoints are in progress.  

Purpose: To evaluate whether an alternative hydrocortisone (HC) dosing regimen used during a national shortage, 100 mg IV every 8 hours (q8h), provides comparable clinical outcomes to the standard regimen, 50 mg IV every 6 hours (q6h), in the management of septic shock in adult patients.  


Methods: This single-center, retrospective cohort study included adults treated for septic shock in intensive care units. Patients were included if they received HC 50 mg IV q6h (5/21/2022–9/9/2022) or HC 100 mg IV q8h (5/21/2023–9/9/2023), had suspected infection, met ≥2 SIRS criteria, required vasopressors for >4 hours, and received ≥200 mg of the HC regimen of interest. Exclusion criteria included pregnancy or breastfeeding, vasopressor initiation at an outside hospital, or receipt of >200 mg daily hydrocortisone for indications other than septic shock. The primary outcome was time to shock reversal, defined as discontinuation of vasopressors for ≥24 hours. Secondary outcomes included mortality (in-hospital, 28-day, 90-day), ICU length of stay, duration of mechanical ventilation, and hyperglycemia. Descriptive statistics were used to describe baseline characteristics. Outcomes were analyzed using the Mann–Whitney U and chi-square tests. 


Results: Of 290 screened patients, 121 were included (50 mg q6h, n=35; 100 mg q8h, n=86). Baseline characteristics, illness severity, and vasopressor use were similar between groups. Shock reversal occurred in 51.4% of patients receiving 50 mg q6h and 54.7% receiving 100 mg q8h (p=0.747). Median time to shock reversal was 84.0 hours (IQR 46.3–145.0) versus 72.5 hours (IQR 46.2–136.8), respectively (p=0.769). There were no significant differences in mortality, ICU length of stay, duration of mechanical ventilation, or hyperglycemia between groups. 


Conclusion: This single-center, retrospective cohort study showed that the alternative dosing strategy of HC 100 mg q8h demonstrated similar clinical outcomes compared to the standard regimen of HC 50 mg q6h in patients with septic shock. Future prospective, randomized trials are needed to confirm findings. 
 

Purpose: 
To evaluate enteral nutrition (EN) practices and tolerance in critically ill patients receiving ≥2 vasopressors and to inform evidence-based feeding recommendations for this high risk population. 
Methods: 
This single center, retrospective chart review included adult ICU patients receiving ≥2 vasopressors between September 2024 and September 2025. The primary outcome was incidence of clinically significant EN intolerance, defined as abdominal pain, distention, nausea/vomiting, diarrhea, or interruption/discontinuation of feeds. Secondary outcomes included EN route, initial and maximum EN rates, and vasopressor requirements quantified as norepinephrine equivalents. 
Results: 
286 patients were screened, while only 29 patients were included, with only 2 (6.9%) who had documented EN intolerance, recorded as regurgitation and fecal intolerance. 
EN was most commonly delivered via nasogastric (NG) and orogastric (OG) tube (72.4%), followed by percutaneous endoscopic gastrostomy (PEG) (27.6%). Vital AF 1.2 Liter® was the most frequently used formula (58.6%), with other formulas used less commonly. Patients were managed across multiple ICUs, reflecting consistent feeding practices. 
Septic (38%) and cardiogenic (37%) shock were most prevalent. At EN initiation, the mean norepinephrine equivalent dose was 0.3 [0.34] mcg/kg/min, with most patients receiving moderate to high vasopressor support. EN was initiated conservatively 20 [35] cc/hour and advanced as tolerated to a mean maximum of 45 [30] cc/hr. 
Conclusion: 
Despite frequent mechanical ventilation and continuous renal replacement therapy (CRRT) use, EN intolerance was uncommon evidenced by continued feeding until tolerating food by mouth or discharge. Institutional practice demonstrated a tendency to discontinue tube feeds when patients escalate to three vasopressors or high vasopressor doses. EN was typically initiated at trophic rates and advanced cautiously. 
These findings suggest that EN may be tolerated in select critically ill patients receiving multiple vasopressors, particularly at low infusion rates. However, feeding practices remain conservative, highlighting the need for further research to define safe and standardized thresholds for EN initiation and continuation in this population. 

To evaluate the safety and effectiveness of a standardized phenobarbital protocol for alcohol withdrawal syndrome in a mixed ICU at a community hospital compared to benzodiazepine based management. 


This retrospective cohort study evaluated adults admitted to a mixed ICU at a community hospital with alcohol withdrawal (AWS) between May–November 2024 and May–November 2025. Adults with a diagnosis of AWS and critical care admission who received phenobarbital through a standardized weight-based protocol, or benzodiazepines through the medical AWS order set were included. Exclusion criteria consisted of mechanical ventilation before medication initiation, use of phenobarbital or benzodiazepines prior to admission based on the home medication list or dispense history, or benzodiazepine-treated patients who received phenobarbital. The primary outcome was incidence of escalation to continuous sedation or intubation within 72 hours, with secondary outcomes assessing safety, medication use, symptom control, adjunctive sedative use, and length of stay (LOS).


Of 230 patients reviewed, 170 met inclusion criteria (phenobarbital n=90; benzodiazepine n=80). The primary outcome occurred in 18 phenobarbital patients and 24 benzodiazepine patients. Phenobarbital was associated with lower odds of escalation (20% vs 32.5%); however, this was not statistically significant (OR 0.59, 95% CI 0.29–1.19; p=0.14). Median ICU LOS (2.1 vs 2.9 days; p=0.008), hospital LOS (4 vs 5 days; p=0.032), and as needed benzodiazepine use (1 vs 38.5 milligrams; p≤0.001) were significantly lower with phenobarbital. Adverse respiratory events were more frequent with phenobarbital (13.3% vs 0%; p≤0.001), while seizures (1.1% vs 10%; p=0.013) and delirium tremens (0% vs 83.8%; p≤0.001) were more frequent with benzodiazepines.


Although the primary outcome was not statistically significant, the findings suggest potential clinical benefit. A standardized phenobarbital protocol was associated with reduced ICU and hospital LOS and decreased incidence of seizure and delirium tremens when compared to benzodiazepine based management. Further studies with larger populations are needed to confirm these findings.

Purpose: To evaluate whether ketamine-based sedation is associated with a difference in duration of mechanical ventilation compared with standard sedation strategies in mechanically ventilated medical intensive care unit patients. 


Methods: A single center retrospective study of patients admitted to the medical intensive care unit at a community teaching hospital between January 2023 and July 2025 was conducted. Patients administered continuous sedation with or without ketamine for at least 6 hours while mechanically ventilated for at least 24 hours were identified. The primary outcome was duration of mechanical ventilation. Secondary outcomes included mortality, intensive care unit and hospital length of stay, CAM-ICU results, and fentanyl requirements. Patients on adjunctive ketamine were compared to those on standard sedation regimens. Baseline characteristics were collected and compared between groups. Continuous variables were analyzed using medians with interquartile ranges and compared using Mann-Whitney U. Categorical variables were compared using chi-square or Fisher’s exact tests. The study was IRB approved.


Results: Twenty-eight patients were included with 14 in each arm. Patients in the ketamine arm received adjunctive sedation with propofol, dexmedetomidine, or midazolam compared to patients sedated with at least two of the previously mentioned agents. Median duration of mechanical ventilation did not differ between the ketamine and standard sedation groups (10.6 days vs 8.4 days, p=0.603). Mortality was lower in the ketamine group (7.1% vs 50%, p=0.012). Hospital and intensive care unit length of stay were similar between groups. Patients receiving ketamine required higher median fentanyl doses (200 mcg/hr vs 100 mcg/hr, p=0.007).


Conclusion: Ketamine-based sedation was not associated with reduced duration of mechanical ventilation compared with standard sedation strategies. However, ketamine use was found to have a lower observed mortality. Larger prospective studies are needed to further evaluate the role of ketamine in intensive care unit sedation regimens.

Purpose: Bromocriptine is hypothesized to have an antipyretic effect in patients with neurogenic fever, however the evidence is limited to small retrospective studies. This study aimed to evaluate 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 during and 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


IRB Approval: This study went through IRB approval and received exempt status.

Purpose: The purpose of this research project is to determine lorazepam-equivalent usage with a gabapentin taper compared to no gabapentin taper in the inpatient management of alcohol withdrawal syndrome. 


Methods: This was a retrospective chart review that was approved by the Jefferson Health Institutional Review Board and conducted from January 1, 2024 to December 31, 2024. Patients were identified by initiation on the alcohol withdrawal scale (AWS) protocol. The study was divided into 2 groups: gabapentin and benzodiazepine or benzodiazepine-only. The primary endpoint was lorazepam-equivalent usage with a gabapentin taper compared to no gabapentin taper. Secondary outcomes included time from admission to AWS protocol initiation, time from AWS protocol initiation to gabapentin start, time to resolution of AWS symptoms, and length of stay in days from admission to discharge. A subgroup analysis of the primary endpoint was conducted among patients who received the appropriate gabapentin taper according to the AWS protocol.  


Results: A total of 400 patients were screened for study inclusion, 70 patients met criteria for evaluation, and 35 patients were included in each group. The median lorazepam-equivalent usage (mg) during the withdrawal period was statistically significantly higher in the gabapentin and benzodiazepine group than in the benzodiazepine-only group (20 vs 3.10; p = 0.020). Among the 23 patients who received the appropriate gabapentin taper, the median lorazepam-equivalent usage (mg) was statistically significantly higher in the gabapentin and benzodiazepine group than in the benzodiazepine-only group (18 vs 3.10; p = 0.032). None of the secondary endpoints in the primary or subgroup analyses were statistically significant. 


Conclusion: Benzodiazepine utilization in the management of alcohol withdrawal syndrome was not reduced by the addition of a gabapentin taper. Further research is needed to fully evaluate the benzodiazepine-sparing potential of gabapentin and to develop a standardized regimen for alcohol withdrawal management.

Evaluate the safety and efficacy of fixed dose versus titratable vasopressin infusions in critically ill patients with septic shock by comparing rebound hypotension when stopping fixed dose vs. weaning titratable vasopressin infusions. 


This retrospective cohort study reviewed patients in a medical/surgical ICU at a community hospital from October 1, 2023 to October 1, 2024 and January 1, 2025 to January 1, 2026. Adults with septic shock who received vasopressin and norepinephrine were included. Exclusion criteria included use of other catecholamines at wean, vasopressor withdrawal due to death or comfort care, mechanical circulatory support, or non-adherence to vasopressin orders. The primary endpoint was rebound hypotension defined as MAP ≤ 60 mmHg with an intervention to improve blood pressure within six hours of vasopressin discontinuation or dose reduction. Secondary endpoints included MAP changes after vasopressin discontinuation, vasopressor duration, time to vasopressor wean, time on mechanical ventilation, and ICU length of stay. Exploratory endpoints compared rebound hypotension when vasopressin or norepinephrine was discontinued first. 


A total of 78 patients were included in the analysis, with 43 in the fixed‑dose (FD) group and 35 in the titratable (TD) group. The primary outcome was met by 20 (47%) patients in the FD group and 23 (61%) patients in the TD group. There was no significant difference in rebound hypotension between groups (OR, 0.82; 95% CI, 0.45–2.01; p = 0.666). When comparing FD vs. TD vasopressin, there was no difference in rebound hypotension based on the order of vasopressor discontinuation, whether vasopressin (p = 0.524) or norepinephrine (p = 0.747) was stopped first. Patients in the TD group demonstrated significantly shorter time to vasopressor wean (p ≤ 0.001), duration of mechanical ventilation (p = 0.010), and ICU length of stay (p = 0.006). 


Overall, there was no difference in the incidence of rebound hypotension in patients who underwent abrupt discontinuation of vasopressin and those who were down-titrated off the infusion. The order of vasopressor discontinuation did not affect the likelihood of rebound hypotension. These findings suggest that titratable vasopressin strategies may support more efficient critical care management with similar hemodynamic outcomes in septic shock. 

Purpose: Evaluate the overall impact of transitioning from a weight-based to non-weight-based fentanyl infusion dosing strategy in critically ill, mechanically ventilated patients in the critical care unit.
Methods: Through a retrospective electronic medical record chart review, adult patients who were admitted to the critical care unit, were mechanically ventilated and receiving a fentanyl infusion were identified for inclusion. Exclusion criteria included patients not admitted to the critical care unit, not mechanically ventilated, did not receive a fentanyl infusion for more than 24 hours, received concomitant neuromuscular blockers and patients who underwent targeted temperature management. The patient population was characterized using descriptive statistics. Students’ T-test or Mann-Whitney U tests were used for continuous variables, and Chi-squared was used to measure the association between categorical variables. Power calculation determined that 100 patients would be included to evaluate study outcomes.
Results: One hundred patients were included in the final analysis. For daily fentanyl dose, there was no statistically significant difference between pre- and post-implementation groups (p-value: 0.391). There was a statistically significant difference between groups for the maximum fentanyl infusion dose (p-value = 0.007). The subset of patients with BMI 30 or greater showed no difference between groups for daily fentanyl dose (p-value: 0.411). The difference between subset groups for maximum fentanyl infusion dose was statistically significant (p-value: 0.006). For length of stay in the critical care unit and total time spent on mechanical ventilation, there was not a statistically significant difference between groups (p-value: 0.139).
Conclusion: Implementation of a non-weight-based fentanyl infusion dosing strategy did not significantly reduce mean daily fentanyl dose compared to weight-based dosing. However, it significantly reduced maximum infusion doses, including in patients with a BMI ≥30. No significant differences were observed in ICU length of stay or duration of mechanical ventilation. These findings suggest non-weight-based dosing may reduce peak opioid exposure without compromising clinical outcomes.

Purpose: This study compared the trends of total daily dose (TDD) of sedation and paralytic medications in intubated pediatric patients prior to and after the implementation of the State Behavioral Scale (SBS) and Cornell Assessment of Pediatric Delirium (CAPD). 


Methods: This was an IRB-exempt single center retrospective chart review taking place during three different time periods in the pediatric intensive care unit (PICU) at Penn State Health Golisano Children’s Hospital (PSHGCH). Study periods were defined as follows: Stage 1, (January 1, 2017-December 31, 2018) prior to the implementation of both SBS and CAPD; Stage 2 (March 5, 2024-January 31, 2025), following SBS but prior to CAPD implementation; and Stage 3 (February 1, 2025-August 31, 2025), after implementation of both SBS and CAPD. In each cohort, TDD was calculated for all sedative, paralytic, and delirium agents. Daily sedation burden was calculated using the Pediatric Normalized sedation Index (PNSI), which provides an objective measure of sedation burden for the patient. The primary outcome of this study is to compare sedative and paralytic use before and after the implementation of SBS and CAPD. Data analysis was done using the Kruskal-Wallis test. 


Results: 526 patients were screened with the inclusion of 134 patients in the final analysis. Baseline characteristics were well balanced across groups, with no meaningful differences observed except length of intubation (p = 0.0496).  PNSI differed overall across all time points combined and changed differently overtime with an apparent increase in sedation use during Stage 2 and subsequent decrease in sedation use during Stage 3 (Group p <0.001; Interaction p <0.0010). PNSI on each individual day was not statistically significant except for day 1 (p < 0.001). Vecuronium use differed across all time points combined but did not distinctly change over time (Group p < 0.001; Interaction p = 0.1008). 


Conclusion: Sedation use increased during Stage 2 following implementation of SBS scoring and subsequently decreased during Stage 3 with the implementation of CAPD scoring. Trends in paralytic use remained inconclusive and limited clinical interpretation. Larger future studies are needed to better evaluate these patterns and determine the clinically meaningful impact of SBS and CAPD on both sedation and paralytic use. 

PURPOSE: The purpose of this study is to evaluate the safety and efficacy of bivalirudin versus heparin as anticoagulation for patients receiving either VA or VV ECMO. 
 
METHODS: This single center, retrospective chart review evaluated patients at Temple University Hospital between June 1st, 2019 to June 30th, 2025 who were placed on either VA or VV ECMO and received anticoagulation with either heparin or bivalirudin for at least 72 hours. The primary composite endpoint for the efficacy of bivalirudin in the use of ECMO compared to heparin was the overall incidence of thrombosis occurrences including venous and arterial thromboembolism and/or circuit related thrombotic event occurring after anticoagulation initiation. Secondary outcomes included bleeding occurrences while on anticoagulation and ECMO and the average volume of blood products received. Data collection included patient demographics, baseline characteristics, and anticoagulant used while on ECMO. Demographic data was analyzed using descriptive statistics, categorical data was analyzed using Chi- square test, and continuous data was analyzed by Student T-test. 
 
RESULTS: A total of 78 patients were included: median age 59, 69% male, and 60% received VV ECMO. The incidence of thrombotic events was similar between heparin and bivalirudin (10.2% versus 12.5%, p = 0.754). More patients who received heparin experienced a major bleeding event compared to those who received bivalirudin (28.2% versus 2.6%, p < 0.001). Additional analysis is ongoing.
 
CONCLUSION: Patients receiving bivalirudin for systemic anticoagulation on extracorporeal membrane oxygenation did not have an increased incidence of thrombotic events and had a significantly lower incidence of major bleeding events compared to heparin.  

Purpose:
To evaluate the proportion of patients with spontaneous intracerebral hemorrhage (ICH) achieving institutional systolic blood pressure (SBP) targets within 60 minutes of head computed tomography (HCT).


Methods:
This retrospective cohort study included adult patients with spontaneous ICH admitted to entities within the University of Pennsylvania Health System between January 1, 2025, and November 30, 2025. Patients were stratified by presenting SBP (<220 mmHg vs >220 mmHg), corresponding to institutional protocol targets. For patients presenting with SBP greater than 220 mmHg, the initial goal is to reduce SBP to less than 180 mmHg within the first hour. For patients presenting with SBP between 180–220 mmHg, the target range is 130–150 mmHg. The  primary outcome was achievement of protocol-defined SBP target within 60 minutes of HCT confirmation. Secondary outcomes included antihypertensive medication regimen, time to target SBP, SBP variability during the first six hours after HCT , neurologic outcomes , incidence of hematoma expansion or ischemic stroke, mortality, and safety outcomes including hypotension and bradycardia. 


Results: 
A total of 39 patients met inclusion criteria (SBP <220 mmHg: n=23; SBP >220 mmHg: n=16). Achievement of target SBP within 60 minutes occurred more frequently in patients presenting with SBP > 220 mmHg (39.1% vs 93.8%, p<0.01).  Nicardipine was utilized in all patients and was initiated within 30 minutes of HCT confirmation in 69.6% and 75% of patients with SBP <220 mmHg and >220 mmHg, respectively. In-hospital mortality occurred in 8.7% of patients with SBP <220 mmHg and 6.3% with SBP >220 mmHg (p=1.00). The incidence of ischemic stroke was 8.7% versus 25.0%, respectively (p=0.21). Hypotension occurred in one patient (4.3%) in the SBP <220 mmHg group (p=1.00).  No  cases of bradycardia were observed.


Conclusion:
Patients with SBP >220 mmHg were more likely to achieve protocol-defined SBP targets within 60 minutes compared with those <220 mmHg. Despite rapid blood pressure reduction, rates of hypotension and bradycardia were low. These findings suggest that early SBP control in patients with moderately elevated SBP may reflect differences in clinical attention and management intensity, highlighting a potential need for more optimized titration strategies.

Abstract Title: Evaluation of Guideline-Recommended Weight-Based Initial Vancomycin Dosing in Septic Patients and the Effects on Therapeutic Level Achievement and Clinical Outcomes
Purpose: This study was designed to evaluate guideline-recommended weight-based initial vancomycin dosing of 25 mg/kg in septic patients and the effects on therapeutic level achievement and clinical outcomes.  
Methods: Institutional Review Board approval was obtained for this retrospective observational chart review. Patients were identified based on the order set utilized by providers for vancomycin loading dose. The order set used prior to September 2023 allowed providers to order a maximum loading dose of 1,500 mg, while the new sepsis order set guides providers to order 25 mg/kg loading doses with a maximum dose of 3,000 mg. Data was collected from March 1^st 2023, through March 31^st, 2025. The primary outcome is to determine if sufficient loading doses of vancomycin in septic patients result in faster achievement of therapeutic levels. Secondary outcomes include the rate of patients who experienced nephrotoxicity, time to administration of loading doses, length of stay, 30-day mortality, critical care admission, and the rate of MRSA bacteremia. Data analysis was completed with descriptive statistics, Wilcoxon Sum Rank test and Chi-squared test. 
Results: Initial vancomycin doses of 25 mg/kg, based on total body weight, in septic patients results in faster therapeutic achievement (p-value 0.000004) and lower rates of acute kidney injuries (p-value 0.005). The time from order to administration of initial vancomycin doses in the post-implementation group was about 25 minutes faster than the pre-implementation group and was almost one day shorter for the average length of stay compared to the pre-implementation group. In the pre-implementation group, the average loading dose was 15.5 (SD of 3.1) and the average AUC was 365.3 mg/h/L (SD of 122.6). In the post-implementation group, the average loading dose was 20.1 (SD of 4.4) and the average AUC was 419.9 (SD of 95.2).
Conclusion: Increased initial vancomycin doses resulted in faster therapeutic achievement and lower rates of acute kidney injury. There were no statistically significant differences between 30-day mortality, admission to critical care unit, MRSA bacteremia, time from order to administration and length of stay. Results support updating non-sepsis vancomycin order sets to increase the initial dose, as well as promoting batching larger vancomycin doses. 
Authorship: Paige de Fremery, PharmD; Miranda Cason, PharmD, BCPS; Troy Albrecht, PharmD, BCPS, BCIDP

Purpose:  
The purpose of this study is to evaluate the impact of prophylactic anti-Xa monitoring on rates of venous thromboembolism (VTE) events and bleeding in trauma patients at a level one trauma center.  
 
 
Methods:  
This retrospective cohort study includes patients admitted to the trauma surgery service from January 2019 – July 2025 treated with enoxaparin for VTE prophylaxis. Exclusion criteria includes patients who spent 48 hours or more at a referring facility before transfer or an anti-Xa level collected before 3.5 hours of after 6.5 hours from last enoxaparin dose. Patients were identified via an Enterprise Information Management report, data was extracted from the electronic health record using REDCap, and statistical analysis was completed using Microsoft Excel. The primary outcome is rate of thromboembolic events, and secondary outcomes include rates of bleeding, units of red blood cells transfused, ICU and hospital length of stay (LOS). Categorical data is compared using a chi-squared test, and continuous data is reported using descriptive statistics. The study is IRB exempt by the institutional review board at the study site.  
 
Results:  
A total of 196 patients are included in the study; 91 received anti-Xa monitoring and 105 patients did not. No statistically significant differences in rates of VTE events were observed between patients who received anti-Xa monitoring compared with those who did not (9.9% vs 7.6%, p-value 0.573). Rates of bleeding were higher in the anti-Xa monitoring group (44.0% vs 26.7%, p-value 0.01). Patients who received anti-Xa monitoring were more likely to have missed doses of enoxaparin (56.0% vs 41.0% p-value 0.03) and had a longer median ICU LOS (13.6 days vs 6.3 days). In patients receiving anti-Xa monitoring, 48/91 (52.7%) patients had an initial anti-Xa within the goal range, and only 3/91 (2.2%) had an anti-Xa above the goal range.  
 
 
 
Conclusion: 
Anti-Xa monitoring did not result in a difference in VTE events and was associated with higher bleeding rates. However, the anti-xa monitoring group had more missed doses of enoxaparin and longer ICU length of stay, which are risk factors for VTE events. This suggests that patients who received anti-xa monitoring likely had a greater severity of illness, leading to higher rates or bleeding, despite not having supratherapeutic anti-xa levels.  

PURPOSE: This study evaluates the incidence of bradycardia following dexmedetomidine initiation in critically ill patients and identifies clinical predictors and dosing patterns to inform monitoring and optimize sedation practices.
METHODS: This retrospective chart review included critically ill adult patients who received a dexmedetomidine infusion for greater than 2 hours admitted to a non-cardiac intensive care unit (ICU) from November 1st, 2024 to November 1st, 2025. The primary outcome was the incidence of bradycardia defined as less than 60 beats per minute (bpm) following dexmedetomidine initiation. Secondary outcomes included incidence of severe bradycardia (less than 40 bpm or requiring clinical action), incidence of hypotension, time to first bradycardic event, dose and duration of infusion, liver function on ICU admission, body mass index (BMI) at time of infusion initiation, and concomitant use of vasoactive or rate-controlling medications. Descriptive statistics were used to summarize primary and secondary outcomes, and a binary logistic regression was performed as an exploratory analysis to identify predictors of bradycardia.
RESULTS: Seventy patients were included, with bradycardia occurring in 25 patients (35.7%). Severe bradycardia occurred in 2 patients (2.9%). Median time to first bradycardic event was 6.33 hours [2.93, 10.45]. Median infusion duration was 28.1 hours [14.6, 72], and mean infusion rate was 0.99 ± 0.48 mcg/kg/hr. Hypotension occurred in 41 patients (58.6%), and vasopressor therapy was continued or initiated in a subset of patients during infusion. In a binary logistic regression, higher heart rate on hospital admission was associated with increased odds of bradycardia [p=0.013, (OR 1.046, 95% CI 1.010-1.084)], while higher heart rate at dexmedetomidine initiation was associated with decreased odds of bradycardia [p=0.004 (OR 0.936, 95% CI 0.896-0.979)].
CONCLUSION: Bradycardia occurred in over one-third of critically ill patients receiving dexmedetomidine. Baseline heart rate predicted bradycardia risk, with effects varying based on when it was measured, as higher heart rate on hospital admission increased risk while higher heart rate at dexmedetomidine initiation was associated with lower risk. These findings highlight the need for patient-specific assessment and close monitoring during therapy.
IRB Approval: iRISID-2026-0188