Additionally, many institutions have adopted heparin dosing protocols for each indication based on the various published nomograms for the treatment of venous thromboembolism (VTE), acute coronary syndrome (ACS), and stroke. When following the heparin nomogram for obese patients, a delay Axitinib structure in time to achieve an adequate pharmacodynamic effect has been reported [37, 38]. It has been noted that prescribers have a tendency to deviate from nomograms for obese patients [38, 39].It is important to emphasize that the American College of Chest Physicians (ACCP) recommends an initial IV bolus dose of 80 units/kg or 5,000 units with an initial continuous infusion of 18 units/kg/hr or 1,300 units/hr for the treatment of VTE.

For the treatment of ACS (NSTEMI, unstable angina, and STEMI), ACCP recommends an initial IV bolus dose of 60 units/kg (maximum 4,000 units) and an initial continuous IV infusion of 12units/kg/hr (maximum 1,000 units/hr) [40]. Both current regimens utilize ABW for dosing. Still, several alternative dosing regimens have been developed based on IBW, dosing weight, modified dosing weight (average of ABW and IBW), and ABW with a maximum initial bolus dose. A review of the studies used to develop these alternate dosing strategies suggests that ABW is the preferred means of dosing heparin for nonmorbidly obese patients. The dosing limits set by ACCP for VTE and ACS are controversial in morbidly obese patients due to the risk of underdosing. However, four of the five ADRs associated with heparin seen in our study involved overweight or obese patients, suggesting overdosing.

Regardless, data and comparative evidence for different types of weight-based strategies in overweight, as well as underweight, patients are limited [6]. Given the lack of evidence, such patients should be evaluated and dosed on an individual basis.As with the vasoactives, sedative dosing guidelines are not always applicable and may be titrated to a desired clinical endpoint based on a patient’s specific situation (mechanical ventilation, deep sedation). Much higher sedative doses are often seen in ICU patients compared to those in non-ICU patients [7]. In our study, sedatives were often dosed outside the recommendations in the package insert for all weight categories [19�C22]. The sedatives reviewed in this study (midazolam and propofol) are both short-acting, hepatically metabolized, renally eliminated medications.

Midazolam, a benzodiazepine, is converted to an active metabolite (1-hydroxymidazolam glucuronide) with central Dacomitinib nervous system (CNS) depressant effects, which may accumulate in critically ill patients. Also, midazolam is highly lipophilic leading to a greater accumulation in obese patients and prolonged sedation [41]. The two ADRs with midazolam seen in our study involved overweight patients.