Week In Review: 10/3/21

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Melina Alexander
St. Vincent's Emergency Medicine Resident, PGY-1

For some spaced repetition, here’s a review of this week’s content:

Farm to City Xylazines: As a Drug of Abuse by Lauren Igneri 

  • Xylazine is an alpha2-agonist that is FDA approved as a veterinary sedative.
  • Xylazine has been increasingly implicated as an adulterant in heroin, fentanyl, and cocaine
  • Potentiates the sedative effects of opioids and balances the sympathomimetic effects of cocaine.
  • May cause significant CNS and respiratory depression, as well as hypotension and bradycardia.
  • Following xylazine exposure, supportive treatment focused on maintaining an airway, breathing, and circulation should be implemented. 
  • Since xylazine is not an opioid, naloxone may be less effective in reversing respiratory depression in a xylazine-associated opioid overdose.

Big Breaths in at the Bedside by Stephen Bhiel

  • Know your patient’s current and past medical history to appropriately assess their transfusion threshold.
  • Keep >7.0 g/dl in non-cardiac and orthopedic surgery patients.
  • Those undergoing orthopedic surgery, cardiac surgery, pre-existing cardiac disease or active cardiac disease transfuse for > 8.0 g/dL.
  • Know the adverse reactions to transfusions.
  • Consider suggesting electrolytes for patients receiving massive transfusion

The Vitals: Spontansous Awakening Trials 101 by Bassam Zahid

  • Sedation protects our patients from the pain, agitation, anxiety, and discomfort associated with being intubated. Additionally, it decreases excessive oxygen consumption, facilitates nursing care, and expedites safe completion of procedures and imaging.
  • The lipophilic nature of commonly used sedatives, especially when continuously infused over long periods of times, leads to increased accumulation of the drug in the body. This challenges our ability to perform neurological evaluations, and results in more ventilator-associated days, increasing the risk of infection and other complications.
  • Spontaneous awakening trials (SATs) arose when clinicians and researchers started to wonder if their patients were staying on the vent longer than necessary and thereby risking complications. Long continuous infusions led to prolonged sedation and longer time to assess neurologic status for extubation.
  • A number of studies have found that daily awakening trials have a number of benefits, including decreased time on the ventilator, less delirium, a lower complication rate, and an earlier discharge from the ICU and the hospital.
  • The ABC trial’s “Wake Up and Breathe” protocol is a standardized checklist that guides clinicians in assessing if their patients are eligible and if they can pass a spontaneous awakening and a spontaneous breathing trial


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