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Purpose The purpose of this review is to discuss important considerations when prescribing buprenorphine for opioid use disorder (OUD) in the intensive care unit (ICU) setting, recognizing the challenges of providing detailed recommendations in the setting of limited available evidence. Summary Buprenorphine is a partial mu-opioid receptor agonist that is likely to be increasingly prescribed for OUD in the ICU setting due to the relaxation of prescribing regulations. The pharmacology and pharmacokinetics of buprenorphine are complicated by the availability of several formulations that can be given by different administration routes. There is no single optimal dosing strategy for buprenorphine induction, with regimens ranging from very low-dose to high dose regimens. Faster induction with higher doses of buprenorphine has been studied and is frequently utilized in the emergency department. In patients admitted to the ICU who were receiving opioids either medically or illicitly, analgesia will not occur until their baseline opioid requirements are covered when their preadmission opioid is either reversed or interrupted. For patients in the ICU who are not on buprenorphine at the time of admission but have possible OUD, there are no validated tools to diagnose OUD or the severity of opioid withdrawal in critically ill patients unable to provide the subjective components of instruments validated in outpatient settings. When prescribing buprenorphine in the ICU, important issues to consider include dosing, monitoring, pain management, use of adjunctive medications, and considerations to transition to outpatient therapy. Ideally, addiction and pain management specialists would be available when buprenorphine is prescribed for critically ill patients. Conclusion There are unique challenges when prescribing buprenorphine for OUD in critically ill patients, regardless of whether they were receiving buprenorphine when admitted to the ICU setting for OUD or are under consideration for buprenorphine initiation. There is a critical need for more research in this area. [ABSTRACT FROM AUTHOR]

Critical care clinicians are likely to see an increasing number of patients admitted to the ICU who are receiving US Food and Drug Administration-approved medications for opioid use disorder (MOUDs) given the well-documented benefits of these agents. Oral methadone, multiple formulations of buprenorphine, and extended-release naltrexone are the three types of MOUD most likely to be encountered by ICU clinicians; however, these drugs vary with respect to formulations, pharmacokinetics, and adverse effects. No published clinical practice guidelines or consensus statements are available to guide decision-making in patients admitted to the ICU setting who are receiving MOUDs before admission. Additionally, no randomized trials and limited observational studies have evaluated issues related to MOUD use in the ICU. Therefore, ICU clinicians caring for patients admitted who are taking MOUDs must base their decision-making on data extrapolation from pharmacokinetic, pharmacologic, and clinical studies performed in non-ICU settings. Despite the challenges in administering MOUDs in critically ill patients, extrapolation of data from other hospital settings suggests that the benefits of continuing MOUD therapy outweigh the risks in patients able to continue therapy. This article provides guidance for critical care clinicians caring for patients admitted to the ICU already receiving methadone, buprenorphine, or extended-release naltrexone. The guidance includes algorithms to aid clinicians in the clinical decision-making process, recognizing the inherent limitations of the existing evidence on which the algorithms are based and the need to account for patient-specific considerations. [ABSTRACT FROM AUTHOR]

The authors examine the intravenous administration of 23.4% hypertonic sodium solutions for the management of severe traumatic brain injury. They discuss a review article that discussed controversies and warnings related to the administration of 23.4% sodium chloride in life-threatening situations, as well as a retrospective study supporting peripheral administration that was available at the time of their review. The authors advise practicing caution when considering the treatment approach.

Purpose Creatinine-based estimates of glomerular filtration rate (GFR) have been the standard for classifying kidney function and guiding drug dosing for over 5 decades. There have been many efforts to compare and improve different methods to estimate GFR. The National Kidney Foundation recently updated the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations without race for creatinine (CKD-EPIcr_R) and creatinine and cystatin C (CKD-EPIcr-cys_R), and the 2012 CKD-EPI equation based on cystatin C (CKD-EPIcys) remains. The focus of this review is to highlight the importance of muscle atrophy as a cause for overestimation of GFR when using creatinine-based methods. Summary Patients with liver disease, protein malnutrition, inactivity, denervation, or extensive weight loss may exhibit markedly lower creatinine excretion and serum creatinine concentration, leading to overestimation of GFR or creatinine clearance when using the Cockcroft-Gault equation or CKD-EPIcr (deindexed). In some cases, estimated GFR appears to exceed the physiological normal range (eg, >150 mL/min/1.73 m2). Use of cystatin C is recommended when low muscle mass is suspected. One would expect discordance between the estimates such that CKD-EPIcys < CKD-EPIcr-cys < CKD-EPIcr ≈ Cockcroft-Gault creatinine clearance. Clinical evaluation can then occur to determine which estimate is likely accurate and should be used for drug dosing. Conclusion In the setting of significant muscle atrophy and stable serum creatinine levels, use of cystatin C is recommended, and the resulting estimate can be used to calibrate interpretation of future serum creatinine measurements. [ABSTRACT FROM AUTHOR]

Purpose To review the evidence cited in recent consensus documents providing recommendations for drug dosing for venous thromboembolism (VTE) prophylaxis in obese trauma patients Summary Recent publications from the American Association for the Surgery of Trauma and the American College of Surgeons provide recommendations for VTE prophylaxis in trauma. These documents address key aspects of pharmacologic prophylaxis, one of which is drug dosing in obesity. Both documents provide recommendations for obese patients, but they were not formulated using Grading of Recommendations Assessment, Development and Evaluation methodology, which has become the standard approach for guideline development. We reviewed and critiqued the literature cited in recently published consensus documents along with identifying additional studies retrieved from a PubMed search pertaining to drug dosing for VTE prophylaxis in obesity. The overall body of evidence was reviewed, and caveats for application in the clinical setting are provided. Dosing strategies for obese trauma patients are largely extrapolated from studies conducted in nonobese patients. Studies evaluating clinical outcomes are limited as most rely on anti–factor Xa concentrations versus VTE occurrence. Conclusion The strength of the evidence surrounding dosing recommendations for VTE prophylaxis in obese trauma patients is low. Further research efforts should be directed towards this subset of trauma patients. [ABSTRACT FROM AUTHOR]

The article examines the potential drug prescribing errors that involve the use of weight and size descriptors. Topics discussed include ways to decrease the likelihood of error occurrence, results of a study on dosing regimens selected by pharmacists when exposed to multiple weight choices for estimating kidney function, and consistency in size descriptor use.

In the article, the authors discuss topics on vancomycin dosing in adult patients with obesity. Other topics include the U.S. Centers for Disease Control and Prevention (CDC) data on the prevalence of obesity in the country, the factors affecting vancomycin dosing like individual comorbidities and care setting, and the essential vancomycin pharmacokinetic parameters like clearance (CL), and the standardization of blood creatinine measurement through isotope dilution mass spectrometry.

Background: The reversal of anticoagulant or antiplatelet medications is a priority in the management of patients with severe injury with the goal of minimizing further bleeding without thrombotic complications. There are few studies, however, evaluating the dosing of reversal agents in the setting of trauma specific to patients with extreme obesity. Nevertheless, clinicians must still make decisions, balancing concerns of ongoing bleeding with excessive thrombosis.Objectives: We describe the literature pertaining to dosing of medications used for the reversal of both drug-induced and trauma-related coagulopathy with the intent of providing a framework for clinicians to make dosing decisions in this challenging population.Discussion: Obesity is known to impact both the volume of distribution and the clearance of medications, but these changes are not usually linear with size nor are they uniform across drugs. Current strategies for dosing reversal agents in obesity include a capped dose (e.g., prothrombin complex concentrates), fixed dosages (e.g., andexanet alfa, idarucizumab, and tranexamic acid), and weight-based dosing (e.g., desmopressin). Extreme obesity, however, was not highly prevalent in the studies that have validated these dosing strategies. In fact, many of the clinical studies fail to report the average weight of the patients included.Conclusion: Future studies should make efforts to increase reporting of patients with obesity included in clinical trials along with results stratified by weight class. In the meantime, doses listed in product labels should be used. Desmopressin should be dosed using either ideal body weight or a dose-capping strategy. [ABSTRACT FROM AUTHOR]

Purpose To discuss the potential implications of obesity for drug administration and absorption from subcutaneous (SC) and intramuscular (IM) injection sites. Summary The SC and IM routes are useful for the parenteral administration of medications to optimize pharmacokinetic properties such as time to onset and duration of effect, for cost considerations, or for ease of administration, such as when intravenous access is unavailable. The choice of SC or IM injection depends on the specific medication, with SC administration preferred for products such as insulin where a slower and more sustained response is desirable, while IM administration is usually preferred for products such as vaccines where more rapid absorption leads to a more rapid antibody response. Obesity has the potential to influence the rate and extent of absorption, as well as adverse effects, of medications administered by the SC or IM route through changes in SC tissue composition and depth or by inadvertent administration of IM medications into SC tissue because of improper needle length. Potential adverse effects associated with IM or SC injections in addition to pain, bruising, and hematoma formation include sciatic nerve injury, particularly with IM injection in the upper outer quadrant of the buttock; bone contusion or rarely osteonecrosis if the IM injection is excessively deep; and granulomas, fat necrosis, and calcification with SC injection. Conclusion Issues related to medication absorption in obese patients are likely to become more prominent in the future with increasing approvals of a wide range of biotherapeutic agents administered by SC injection. Studies should be directed toward these and other agents to assist with dosing decisions in this challenging population. [ABSTRACT FROM AUTHOR]

The article recommends against the use of extremely hypo-osmolar IV solutions for the treatment of hypernatremia. Topics discussed include properties of intravenous solutions to treat hypernatremia, important factor when considering hypotonic solutions for hypernatremia, and major justification for the use of hypo-osmolar, hypotonic solutions such as sterile water for injection and 0.225 percent sodium chloride.

What is known and objective: The purpose of this paper is to discuss the limitations of the evidence supporting the SIS recommendations for antibiotic prescribing in patients with traumatic facial fractures and to provide suggestions for clinical decision‐making and further research in this area given the wide variation in prescribing practices. Comment: The Surgical Infection Society (SIS) recently published guidelines on antibiotic use in patients with traumatic facial fractures. The guidelines recommend against the use of prophylactic antibiotics for all adult patients with mandibular or non‐mandibular facial fractures undergoing non‐operative or operative procedures. Despite the available evidence, surveys conducted in the United States and the United Kingdom prior to the publication of the SIS guidelines demonstrate substantial preoperative, intraoperative and postoperative prophylactic prescribing of antibiotics for patients with facial fractures undergoing surgery. What is new and conclusion: With the exception of strong recommendations based on moderate‐quality evidence to avoid prolonged postoperative antibiotic prophylaxis, the weak recommendations in the guidelines are a function of low‐quality evidence. A logical choice for a narrow‐spectrum antibiotic is cefazolin administered within 1 h of surgery and no longer than 24 h after surgery, since it is the gold standard of comparison based on clinical practice guidelines concerning antibiotic prophylaxis. [ABSTRACT FROM AUTHOR]

The article provides an overview of key clinical trials comparing normal saline (NS) and balanced salt solutions (BSS). Topics include concerns over potential adverse effects from chloride-replacement anions commonly found in BSS, general prescribing considerations for NS and BSSs, and considerations for using NS and BSS.

What is known and objective: The purpose of this paper was to discuss the limitations of the studies serving as the evidence for recommendations in clinical practice guidelines concerning albumin use for cirrhosis‐related complications, review relevant studies published since the guidelines and suggest directions for future investigations. Comment: There are no recent comprehensive clinical practice guidelines concerning albumin. Instead, more recent albumin guidelines reflect areas of specialty practice such as those by American and European associations for the study of the liver and liver disease. Studies published since the guidelines are useful for helping to define the most appropriate indications for albumin with respect to cirrhosis‐related complications, as well as directions for future research. What is new and conclusion: Albumin has a long history of attempts to define appropriate uses by meta‐analysis, but given the high cost and episodic shortages of albumin, there is a need for adequately powered randomized controlled trials using current state‐of‐the‐art care evaluating the use of albumin to prevent or treat cirrhosis‐related complications. [ABSTRACT FROM AUTHOR]

The article recommends several publications related to critical care pharmacy practice. Topics discussed include the articles that offer a historical background of critical care pharmacists and pharmacy services, significance of the creation of the Board Certified Critical Care Pharmacist (BCCCP) program in 2013, and opportunities for awareness and discussion of articles on critical care pharmacy offered by podcasts such as the series "Pharmacy to Dose: The Critical Care Podcast."

There is no consensus on which weight clinicians should use for weight-based dosing of neuromuscular blocking agents (NMBAs), as exemplified by differing or absent recommendations in clinical practice guidelines. The purpose of this paper is to review studies that evaluated various size descriptors for weight-based dosing of succinylcholine and non-depolarising NMBAs, and to provide recommendations for the descriptors of choice for the weight-based dosing of these agents in patients with obesity. All of the studies conducted to date involving depolarising and non-depolarising NMBAs in patients with obesity have assessed single doses or short-term infusions conducted in perioperative settings. Recognising that any final dosing regimen must take into account patient-specific considerations, the available evidence suggests that actual body weight is the size descriptor of choice for weight-based dosing of succinylcholine and that ideal body weight, or an adjusted (or lean) body weight, is the size descriptor of choice for weight-based dosing of non-depolarising NMBAs. [ABSTRACT FROM AUTHOR]

The article examines the value of critical care pharmacists as members of multidisciplinary critical care teams. It examines their involvement in patient care, teaching and training, and scholarship. It suggests the growing value of pharmacists as researchers, the need for board certification to become residency program directors, and demand for more studies for their staffing needs and prioritization of activities.

Purpose: The purpose of this study was to compare the volume of fluid removal associated with and without 25% albumin administration in conjunction with hemodialysis. Methods: This retrospective, cohort study was conducted at a large academic medical center over a 6-month period to compare the net fluid amount removed (mL) during hemodialysis between patients administered 25% albumin and those without albumin. Results: A total of 238 patients consisting of 973 unique hemodialysis sessions were evaluated. The mean overall net fluid removed by hemodialysis in the 25% albumin and no albumin groups were 1242 mL and 1899 mL, P <.001, respectively. No albumin group had significantly higher mean fluid losses compared with 25% albumin for a total dose of either 25 g (P =.001) or 50 g (P =.001). There were no significant differences in mean fluid loss between the no albumin group and patients receiving 75 g or 100 g of albumin. Post hoc analysis failed to demonstrate a dose-dependent response in those patients receiving 25% albumin and no albumin. Conclusion: Hyperoncotic albumin administered during hemodialysis sessions reduced net fluid loss associated with hemodialysis. The findings of this study do not support the routine use of 25% albumin to improve fluid removal during dialysis. [ABSTRACT FROM AUTHOR]

Purpose Medication product labeling was reviewed to determine if sufficient information is available to appropriately calculate dosing regimens for special intensive care unit (ICU) populations, including patients at extremes of body habitus and patients receiving hemodialysis, continuous renal replacement therapy (CRRT), or extracorporeal membrane oxygenation (ECMO). Methods The labeling of the 100 most commonly used injectable medications in the adult ICUs of an academic medical center in Arizona were evaluated. Any information related to adult weight-based dosing, weight descriptors, dosing of patients at extremes of weight (body mass index of <18.5 or >40 kg/m2), and dosing of patients receiving hemodialysis, CRRT, or ECMO was extracted from Food and Drug Administration–approved product labeling. Information was ranked for dosing usefulness on a scale of 0 to 3; an information usefulness score of 2 or greater was considered minimally adequate for dosing special ICU populations. Results Among the 100 medications evaluated, the labeling of 47 provided information on weight-based dosing, with the labeling of 30% referring to a specific weight descriptor. The labeling of 15 medications had information on dosing for patients at extremes of body habitus: underweight (3 medications), obesity (12 medications), and extreme obesity (2 medications), with the labeling of 8 medications receiving an information usefulness score of ≥2 (2, 6, and 1 medication in the respective categories). Among the 42 medications whose labeling provided hemodialysis-related dosing information, the labeled information of 52% was assigned a usefulness score of ≥2; among the 3 medications with CRRT-related dosing information, the labeling of 1 received a score of ≥2. ECMO-related dosing information was available for 2 medications, with 1 score of ≥2 assigned. Conclusion Information in the product labeling of injectable medications commonly used in the ICU is limited and generally inadequate for calculating an appropriate dose for special ICU populations. [ABSTRACT FROM AUTHOR]

In the article, the author discusses the origin of and perspectives on the use of predicted normal weight for establishing tidal volumes in mechanically ventilated patients. Topics include the equations for computing ideal body weight (IBW) in patients with obesity, the importance of size descriptor nomenclature awareness for intensive care unit (ICU) clinicians, and the standardized criteria from the American Thoracic Society.

Objective: To provide lessons learned for colleges of pharmacy and large health systems that are contemplating or in the process of undergoing integration. Method: This report describes the merger of an academic medical center and large health system with a focus on the implications of the merger for pharmacy from the perspectives of both a college of pharmacy and a health system's pharmacy services. Results: Overarching pharmacy issues to consider include having an administrator from the college of pharmacy directly involved in the merger negotiation discussions, having at least one high-level administrator from the college of pharmacy and one high-level pharmacy administrator from the health system involved in ongoing discussions about implications of the merger and changes that are likely to affect teaching, research, and clinical service activities, having focused discussions between college and health system pharmacy administrators on the implications of the merger on experiential and research-related activities, and anticipating concerns by clinical faculty members affected by the merger. Conclusion: The integration of a college of pharmacy and a large health system during the acquisition of an academic medical center can be challenging for both organizations, but appropriate pre- and post-merger discussions between college and health system pharmacy administrators that include a strategic planning component can assuage concerns and problems that are likely to arise, increasing the likelihood of a mutually beneficial collaboration. [ABSTRACT FROM AUTHOR]

Summary: What is known and Objective: The purpose of this critical narrative review is to analyse studies evaluating the disposition of albumin in critically ill patients and to compare the findings to studies involving healthy subjects and less severely ill patients. Comment: PubMed and EMBASE were reviewed for prospective studies involving the disposition of radiolabelled albumin. Studies of normal volunteers, patients undergoing surgical procedures and critically ill patients indicate a relationship between increasing disease acuity or severity and increasing transcapillary escape of albumin. In the only study that directly compared the disposition of radiolabelled albumin in healthy subjects and patients with septic shock, the transcapillary escape rate of albumin was more than twice as rapid in the patients with shock. What is new and Conclusion: Limited studies suggest that increasing disease severity increases transcapillary escape of albumin. Only one study compared the disposition of radiolabelled albumin in healthy subjects and critically ill patients. More studies are needed in subsets of critically ill patients. [ABSTRACT FROM AUTHOR]

There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low‐quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to provide clinicians with important considerations and caveats when evaluating published literature on medication dosing in obese subjects, since much of this literature involves short-term pharmacokinetic or pharmacodynamic studies that are not designed to look at clinically important outcomes. A secondary objective is to suggest improvements in the reporting of dosing information derived from clinical studies and incorporated into product information labeling that should help clinicians design medication-specific dosing regimens for patients with obesity. Data sources included published studies, review papers, and clinical practice guidelines concerning drug dosing of subjects with obesity. Medication dosing recommendations in product labeling typically are derived from studies of normal healthy volunteers and patients with single-system disease states or patients in a specialized setting (e.g. operating room, intensive care unit). Even in studies with relatively large sample sizes there are often relatively few subjects with extremes of body composition such as patients with a body mass index (BMI) greater than 40 kg/m, so the appropriateness of labeled dosing information for these subjects is particularly ill-defined. Investigations of medication labeling information have demonstrated the inadequacy of this information for dosing patients of more extreme body size. Clinical investigations of drugs should be designed and the results reported in a manner that allows for meaningful recommendations for drug dosing in patients with varying degrees of obesity. Until and when such studies are routinely performed, there are steps that can be taken by the pharmaceutical industry, clinicians, and governmental agencies to help insure optimal drug dosing in obesity. [ABSTRACT FROM AUTHOR]

Critical care medicine has grown from a small group of physicians participating in patient care rounds in surgical and medical intensive care units (ICUs) to a highly technical, interdisciplinary team. Pharmacy's growth in the area of critical care is as exponential. Today's ICU requires a comprehensive pharmaceutical service that includes both operational and clinical services to meet patient medication needs. This article provides the elements for a business plan to justify critical care pharmacy services by describing the pertinent background and benefit of ICU pharmacy services, detailing a current assessment of ICU pharmacy services, listing the essential ICU pharmacy services, describing service metrics, and delineating an appropriate timeline for implementing an ICU pharmacy service. The structure and approach of this business plan can be applied to a variety of pharmacy services. By following the format and information listed in this article, the pharmacy director can move closer to developing patient-centered pharmacy services for ICU patients. [ABSTRACT FROM AUTHOR]

Objective: The objective of this evaluation was to compare total hospital costs and length of stay of critically ill patients who received dexmedetomidine versus propofol for sedation in the intensive care unit (ICU). Methods: This was a retrospective quality improvement evaluation at a tertiary care, academic medical center in the United States. Data were retrieved for patients discharged between April 2012 and June 2013. Patients were included if they were admitted to the ICU, were 18 years of age or older, and received dexmedetomidine or propofol for sedation. Multivariate regression models were developed to determine the association between sedative type and hospital costs, ICU length of stay, and hospital length of stay. Results: The final cohort included 3294 patients. Of these, 2685 received propofol and 609 received dexmedetomidine. The median hospital cost was US$31 041 (interquartile range [IQR] US$17 963-US$57 826) in the propofol group and US$46 716 (IQR US$31 247 to US$85 490) in the dexmedetomidine group (P < .001). The median ICU length of stay was 2 days (IQR 1-6 days) and 4 days (IQR 2-9 days) in the propofol and dexmedetomidine groups, respectively (P < .001). Overall, hospital length of stay was 8 days (IQR 4-15 days) and 9 days (IQR 5-18 days) in the 2 groups, respectively (P < .001). In the multivariate analyses, dexmedetomidine use was associated with increased costs, ICU length of stay, and hospital length of stay (P < .001 for each outcome). Conclusions: In this academic medical center, dexmedetomidine use was associated with higher costs when compared to propofol for sedation in the ICU. Also, use of dexmedetomidine was associated with increased lengths of ICU and hospital stay. Future prospective trials are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

With ever-increasing total healthcare expenditures and expenditures on new pharmaceuticals, there is a temptation to enact relatively simple silo-based, cost-control measures such as attempts to control a burgeoning health-system medication budget by limiting physician and ultimately patient access to medications without considering cost-effectiveness or overall value. Such an approach with a singular focus on dollars does not make sense. The challenge is to think beyond a pure dollars approach in a specialty of health care where the high cost of care is acknowledged but the dynamics are not always understood. This will take a thoughtful, coordinated effort by a team of dedicated health professionals that includes a clinical pharmacist with expertise in optimal and comprehensive medication management. [ABSTRACT FROM AUTHOR]

Objective To compare succinylcholine and rocuronium regarding mortality in patients with traumatic brain injury ( TBI) who are intubated in the emergency department ( ED). Methods This was a retrospective cohort study conducted in an academic ED in the United States. Adult patients with TBI who underwent rapid sequence intubation ( RSI) in the ED with rocuronium or succinylcholine between October 2010 and October 2014 were included. The main outcome of interest was in-hospital mortality. Subjects were stratified based on severity of injury using head abbreviated injury scores. The high-severity group had a severe or critical head injury (score 4 or higher); the low-severity group had a less than severe head injury (score lower than 4). Main Results The final study cohort included 233 patients who were underwent RSI with succinylcholine (149 patients) or rocuronium (84 patients). In patients who received rocuronium, mortality was 22% (12/54) and 23% (7/30) in the low-severity and high-severity categories, respectively (difference 1%, 95% confidence interval [ CI] −18% to 20%). In patients who received succinylcholine, mortality was 14% (14/103) and 44% (20/46) in the low-severity and high-severity categories, respectively (difference 30%, 95% CI 14-46). In the multivariate analysis after adjusting for important confounders, there was no significant association between succinylcholine and mortality in the low-severity category (odds ratio [ OR] 0.75, 95% CI 0.29-1.92). However, in patients in the high-severity category, succinylcholine was associated with increased mortality compared with rocuronium ( OR 4.10, 95% CI 1.18-14.12). Conclusions In severely brain-injured patients undergoing RSI in the ED, succinylcholine was associated with increased mortality compared with rocuronium. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this review is to discuss infectious disease–related adverse effects associated with long-term proton pump inhibitor (PPI) therapy in patients with cirrhosis and to provide recommendations for appropriate use and choice of PPI when such therapy is indicated. Summary Long-term PPI therapy in patients with cirrhosis increases the risk of infections, with infections in turn increasing the risk of mortality in this patient population. Expert recommendations include restricting long-term PPI use in cirrhosis to patients with appropriate gastrointestinal indications, using a PPI for the shortest possible duration and at the lowest possible dose, and avoiding PPIs with unfavorable pharmacogenetic properties. Conclusion Long-term PPI use in patients with cirrhosis has been associated with increased infections. The risk of adverse effects in observational studies, including decompensation, severe infection (especially spontaneous bacterial peritonitis), and increased mortality, appears to increase as the dose and duration of PPI increase. [ABSTRACT FROM AUTHOR]

The article provides an overview of the kinds of pharmacy student qualities or characteristics desired by experiential preceptors. The qualities include a positive attitude, a healthy skepticism, and being proactive, prepared and confident. The applicability of these qualities to students in the didactic setting is discussed, as well as their importance to their effort to get a letter of recommendation.

Purpose Nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended as opioid-sparing agents. The objective of this scoping review was to conduct a thorough search of the current literature to determine whether in adult critically ill patients there is an association between exposure to NSAIDs vs no NSAIDs and the subsequent development of serious adverse events, particularly gastrointestinal bleeding and acute kidney injury (AKI). Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews was utilized as a guideline for reporting. Searches were performed in PubMed (National Library of Medicine), Cochrane Library (Wiley), EMBASE (Elsevier), Stat!Ref (Teton), and Access Pharmacy (McGraw Hill) for articles published from January 2016 to August 2022. Results Of the 3,062 citations and titles identified in the search, 2,737 titles remained after removal of duplicates, 2,588 were excluded at title and abstract screening, and 149 articles remained for full-text review. None of the studies involved heterogeneous groups of critically ill patients in nonspecialty intensive care unit settings. Most studies evaluated were conducted in the perioperative setting and had limited adverse events reporting, particularly with respect to serious NSAID-related adverse effects of concern in critically ill patients. Conclusion In published studies primarily involving perioperative patients, there is insufficient detail concerning the definitions and reporting of NSAID-related serious adverse events such as bleeding and AKI. These events are of particular concern in heterogeneous critically ill patient populations predisposed to such complications. In most (if not all) critically ill patients, sustained dosing of NSAIDs should be avoided regardless of COX-1 selectivity due to the paucity of safety data. [ABSTRACT FROM AUTHOR]

The field of critical care medicine began to flourish only within the last 40 years, yet it provides some of the best examples of collaborative pharmacy practice models and evidence for the value of pharmacist involvement in interdisciplinary practice. This collaborative approach is fostered by critical care organizations that have elected pharmacists into leadership positions and recognized pharmacists through various honors. There is substantial literature to support the value of the critical care pharmacist as a member of an interdisciplinary intensive care unit (ICU) team, particularly in terms of patient safety. Furthermore, a number of economic investigations have demonstrated cost savings or cost avoidance with pharmacist involvement. As the published evidence supporting pharmacist involvement in patient care activities in the ICU setting has increased, surveys have demonstrated an increase in the percentage of pharmacists performing clinical activities. In addition, substantial support of pharmacists has been provided by other clinicians, safety officers, and administrative personnel who have been involved with the initiation and expansion of critical care pharmacy services in their own institutions. Although there is still room for improvement in the range of pharmacist involvement, particularly with respect to interdisciplinary activities related to education and scholarship, pharmacists have become essential members of interdisciplinary care teams in ICU settings. [ABSTRACT FROM AUTHOR]

Compilations of key articles and guidelines in a particular clinical practice area are useful not only to clinicians who practice in that area, but also to all clinicians. We compiled pertinent articles and guidelines pertaining to drug therapy in the intensive care setting from the perspective of experienced critical care pharmacists. A broad assembly of practitioners with expertise in various areas of intensive care unit pharmacology were involved in the compilation of this update. [ABSTRACT FROM AUTHOR]

Abstract: Candidemia and delay to appropriate therapy contribute to increased morbidity and mortality. Current literature addresses the delay between blood culture collection and final identification; however, it fails to delineate differences among species. The purpose of this study was to quantify the time to yeast detection and identification relative to blood culture collection and determine whether differences exist among species. In this retrospective study, all cases of Candida isolation for 2 years were reviewed. The time delays between blood culture and detection of Candida growth were quantified as well as the additional time required for final species identification. Initiation of antifungal therapy was assessed in relation to culture collection, detection of yeast, and final identification. The appropriateness of therapy at each time point was also analyzed. Most Candida infections were caused by either Candida albicans (n = 43) or Candida glabrata (n = 27). Mean time to positive yeast detection for C. albicans was 35.3 ± 18.1 h, whereas that of C. glabrata was 80.0 ± 22.4 h (P < 0.0001). Mean time to final identification for C. albicans was 85.8 ± 30.9, whereas that of C. glabrata was 154 ± 43.8 h (P < 0.0001). Mean time to appropriate therapy for C. albicans isolates was 43.3 ± 27.6 h compared with 98.1 ± 38.3 h (P < 0.0001) for C. glabrata isolates. The time delay between blood culture collection and yeast detection as well as final identification was significantly longer for C. glabrata isolates when compared with C. albicans. As a result, mean time to appropriate antifungal therapy was significantly longer in patients with C. glabrata isolates. [Copyright &y& Elsevier]

The article presents a study on the conventional pharmacologic and non-pharmacologic pain treatment in patients admitted in intensive care units (ICUs). The study examined the effectiveness of opioid analgesics which are cited to have been the mainstay to control pain. It proposed various alternative medications to the opioids for pain control and investigated their effectivity in the critically ill patient. It showed that the effectiveness of nonpharmacologic therapies in ICUs is limited.

Background: The purpose of this study was to evaluate the impact of recombinant human erythropoietin (rHuEPO) use for anemia of critical illness at a practice site where delayed initiation is common. Methods: Retrospective medical record review involving patients treated with rHuEPO for anemia of critical illness. Those patients given rHuEPO or diagnosed with end-stage renal disease (ESRD) prior to ICU admission were excluded. The primary endpoints were rHuEPO use and RBC transfusion patterns. Results: Complete data were collected for consecutive admissions of 126 patients. Average age (SD) and APACHE II score were 56.5 (18.6) years and 25 (7.8), respectively. The median ICU (IQR) and hospital length of stay (LOS) were 24 (11.25, 39) and 29 (17, 44.75) days, respectively. Treatment with rHuEPO was started an average of 12.5 ± 10.5 days after ICU admission and given for 3.8 ± 3.8 doses. Eighty percent of patients were transfused with an average total of 5.42 ± 5.08 units received. RBC exposure inversely correlated with a lower mean hemoglobin response to rHuEPO. ICU LOS (p < 0.0001), hemoglobin at 24 hours (p = 0.055), transfusion within 48 hours of admit (p < 0.0001), and postoperative status (p = 0.019) were the best predictors of transfusion requirements (r² = 0.37). Conclusion: Delayed initiation of rHuEPO for anemia of critical illness resulted in comparable hemoglobin and transfusion benefits. Future studies are needed to establish clinical benefit and role in therapy. RBC exposure may blunt the erythropoietic effects of rHuEPO, potentially frustrating benefits to those of greatest apparent need. [ABSTRACT FROM AUTHOR]

Compilations of key articles and guidelines in a particular clinical practice area are useful not only to clinicians who practice in that area, but to all clinicians. We compiled pertinent articles and guidelines pertaining to drug therapy in the intensive care setting from the perspective of actively practicing critical care pharmacists. This document differs from the original 2002 version in that a broader assembly of intensive care practitioners was involved in the compilation. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this investigation was to perform a cost-effectiveness analysis of adjunctive oral and intravenous proton pump inhibitor (PPI) therapies for patients with acute peptic ulcer-related bleeding of sufficient severity to warrant hospitalization.Design: Cost-effectiveness investigation. Four clinical scenarios were considered: scenario 1, diagnostic endoscopy with oral PPI therapy; scenario 2, diagnostic and therapeutic endoscopy with high-dose intravenous PPI therapy; scenario 3, diagnostic and therapeutic endoscopy available with oral PPI therapy; and scenario 4, diagnostic and therapeutic endoscopy (no PPI). Effectiveness was evaluated in terms of episodes of bleeding averted and quality-adjusted life years.Setting: University teaching hospital in the United States.Patients: Hospitalized patients with acute peptic ulcer bleeding.Interventions: None.Measurements and Main Results: Therapeutic endoscopy with high-dose intravenous PPI therapy (scenario 2) was the most cost-effective approach in terms of bleeding episode averted (8,490 vs. 10,201 US dollars for scenario 1, 8,756 US dollars for scenario 3, and 12,459 US dollars for scenario 4) and per quality-adjusted life year (4,810 vs. 5,533 US dollars for scenario 1, 4,946 US dollars for scenario 3, and 5,876 US dollars for scenario 4). The high-dose intravenous PPI scenario was the dominant approach as evidenced by both superior effectiveness and lower costs over the range of probability and cost variables used in the sensitivity analysis. However, the dominance would be lost if the purchase cost of the intravenous PPI was substantially higher than the baseline cost assumed in this investigation (61 US dollars per 3-day course of therapy).Conclusion: High-dose intravenous PPI therapy in conjunction with therapeutic endoscopy is the most cost-effective approach for the management of hospitalized patients with acute peptic ulcer bleeding. [ABSTRACT FROM AUTHOR]

The pharmacological methods used to achieve systemic hemostasis have generated much discussion due to concerns of serious adverse effects (e.g., thromboembolic complications) and costs of therapy in addition to efficacy considerations. There are a limited number of well-controlled trials involving pharmacological hemostasis for spine surgery. In the largest double-blinded randomized controlled trial to date involving spine surgery, there was a trend toward reduced homologous transfusion in patients receiving aprotinin, but the only statistically significant result (p<0.001) was a reduction in autologous red cell donations. The findings of this trial are important, since the investigators used a number of restrictive transfusion strategies (e.g., autologous donation, low hematocrit trigger for transfusion, blood-salvaging procedures with the exception of no cell saver) that were not always employed in earlier trials involving hemostatic agents. Smaller studies involving antifibrinolytic agents other than aprotinin have demonstrated reductions in blood loss and transfusion requirements in patients undergoing spine surgery, although the results were not always statistically significant. A very large randomized trial would be required to address comparative medication- and transfusion-related adverse events; such a trial involving patients undergoing cardiac surgery is currently being performed. Additionally, cost-effectiveness analyses are needed to help define the role of these agents based on the data that is available. [ABSTRACT FROM AUTHOR]

Objective: To derive recommendations for the dosing of commonly used medications in the morbidly obese patient in the ICU.Data Sources: Articles were obtained through computerized searches involving MEDLINE. The bibliographies of retrieved publications and textbooks were reviewed for additional references.Study Selection: All studies involving the pharmacokinetics or pharmacodynamics of medications in obese subjects or patients.Data Extraction: The emphasis was on studies involving morbidly obese patients but, in the absence of such data, investigations involving lesser forms of obesity were extracted.Data Synthesis: There is a paucity of data upon which to make recommendations for dosing commonly used medications in the morbidly obese patient in the ICU, although recommendations were provided based on the available information.Conclusions: There is clearly a need for more investigations involving dosing regimens of medications in the morbidly obese population. Until such studies are available, the clinician must try to derive the best dosing regimens for medications based on the limited pharmacokinetic data available for some agents and clinical judgement. [ABSTRACT FROM AUTHOR]

Peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), and upper gastrointestinal bleeding are conditions that can make large demands on health care resources. Acid suppression is common therapy for these conditions. The economic implications of managing Helicobacter pylori-related PUD, GERD, and upper gastrointestinal bleeds were considered by several investigators. Economic analyses of drug regimens for PUD show that eradication is more cost effective than H[sub2]-receptor antagonist (H[sub2]RA) maintenance therapy. Although various eradication regimens have been compared, the results depend on a number of assumptions that preclude general conclusions regarding cost-effectiveness. Economic analyses related to GERD are hindered by the often chronic, relapsing nature of the disease, particularly once therapy is discontinued. Therefore, as with PUD, results of the economic analyses depend largely on initial assumptions relative to the model employed. With regard to upper gastrointestinal bleeding, proton pump inhibitors (PPIs) are potent acid suppressors that may help prevent rebleeding that was managed endoscopically. Further clinical and economic investigations of PPIs for stress ulcer prophylaxis are necessary. Cost-effectiveness studies comparing PPIs and H[sub2]RAs should focus on overall costs of managing these conditions and include economic benefits of preventing complications, and not on drug-acquisition costs alone. [ABSTRACT FROM AUTHOR]

Studies the adverse effects of enteral naloxone and intravenous neostigmine when used to treat constipation. Characteristics of patients receiving naloxone or neostigmine for constipation; Vital signs before and after doses of naloxone and neostigmine.

Examines the rationale for using a weight other than total body weight for weight-based medication calculations in adult obese patients. Review of terminologies related to weight-based dosage regimens; Rationale for common dosing equations; Effects of obesity on organ function and protein binding; Selection of weight for the initiation of weight-based dosage regimens.

Discusses the implications of prion-induced diseases for the use of medications that theoretically could harbor the infectious pathogens. Transmissible spongiform encephalopathies; Variant of Creutzfeldt-Jakob disease; Infection control.

Objectives: Several chemoimmunotherapy and targeted treatment regimens are approved as front-line therapies in chronic lymphocytic leukemia. We estimated for the 10-year cost-effectiveness of these treatment regimens and the economic burden of following the estimated risk-stratified 21 040 patients with chronic lymphocytic leukemia diagnosed in 2020 for 10 years.Methods: A Markov model with 7 exclusive health states was specified over a 10-year time horizon. Treatment effectiveness inputs were obtained from a novel network meta-analysis on the progression-free survival, overall survival curves, and time to next treatment. Costs and utilities inputs were included for each health state for each treatment and discounted at 3.0%/year. Life-years (LYs) and quality-adjusted LYs (QALYs) for each treatment were determined. Using the lowest cost regimen as reference, the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) were estimated. The 10-year per-patient cost was determined by risk status and by initial treatment.Results: Venetoclax-plus-obinutuzumab was the lowest cost regimen, hence the reference. Superior in effectiveness to all chemoimmunotherapies, it was cost saving. With the highest effectiveness gains at 6.26 LYs and 5.01 QALYs and despite being the most expensive regimen ($1 298 638 per patient), acalabrutinib-plus-obinutuzumab yielded the best ICER ($409 343/LY gained) and ICUR ($501 236/QALY gained). The remaining ICERs of targeted therapies ranged from $512 101/LY gained to $793 236/LY gained and the ICURs from $579 737/QALY gained to $869 300/QALY gained. The 10-year postdiagnosis low/high (venetoclax-plus-obinutuzumab/acalabrutinib-plus-obinutuzumab) economic burden ranges were $42 690 to $98 665 for low-risk, $141 339 to $326 660 for intermediate-risk, and $273 650 to $632 453 for high-risk patients.Conclusions: Compared with venetoclax-plus-obinutuzumab, chemoimmunotherapies are associated with less health benefits at higher cost. The targeted therapies achieve greater benefits at higher cost. [ABSTRACT FROM AUTHOR]

Purpose Several studies have shown hydrocortisone to be beneficial in the treatment of vasopressor-refractory septic shock, but there are minimal data evaluating the efficacy of this fixed dosing regimen in overweight and obese patients. The purpose of this study was to compare the effects of fixed-dose hydrocortisone on vasopressor dose and mean arterial pressure in obese and nonobese patients with septic shock refractory to adequate fluid resuscitation and vasopressor administration. Methods In this multicenter, retrospective study, we included adult patients with a confirmed or suspected diagnosis of septic shock who received hydrocortisone (200 mg/day). Patients were divided into 4 study groups based on admission body mass index (BMI; defined as BMI of <25 kg/m2, 25-29.9 kg/m2, 30-34.9 kg/m2, and ≥35 kg/m2). The primary outcomes analyzed were change in norepinephrine equivalent dose requirements and mean arterial pressure (MAP) at 6, 12, and 24 hours after initiating hydrocortisone. Results Between October 1, 2017, and September 30, 2020, 431 patients were screened of whom 219 met inclusion criteria. Baseline characteristics were comparable among the groups. Mean vasopressor requirements (in μg/min) at 6, 12, and 24 hours were as follows: BMI of <25 kg/m2: 28.8, 24.8, and 20; BMI of 25-29.9 kg/m2: 34.1, 33.5, and 24.8; BMI of 30-34.9 kg/m2: 29.5, 33.5, and 24.8; and BMI of ≥35 kg/m2: 32, 25.7 and, 21.2 (P = 0.75, 0.41, and 0.61, respectively). Mean MAP (in mm Hg) at 6, 12, and 24 hours was as follows: BMI of <25 kg/m2: 73.5, 73.6, and 74; BMI of 25-29.9 kg/m2: 71.6, 73.8, and 71.9; BMI of 30-34.9 kg/m2: 72.2, 70, and 72.7; and BMI of ≥35 kg/m2: 70.7, 73.5, and 71.4 (P = 0.56, 0.15, and 0.62, respectively). Conclusion BMI does not appear to impact the effects of fixed-dose hydrocortisone on vasopressor dose or blood pressure in patients with septic shock. Fixed-dose hydrocortisone should continue to be used for vasopressor-refractory septic shock in obese patients. [ABSTRACT FROM AUTHOR]

The author reflects on the study which examines the association between obesity, processes of care and the outcomes for critically ill patients. He considers the use of fluid-adjusted body mass index (BMI) and the processes of care as the strengths of the study. He outlines the factors considered in the process of care which include sedative use and ventilatory parameters.

Purpose. Product information and pivotal studies on newly marketed injectable medications were reviewed to determine whether a weight descriptor was included and if information was provided for dosing patients with extremes of body weight. Methods. Products with new drug applications approved by the Food and Drug Administration between January 1, 2004, and January 30, 2009, were evaluated. Any information related to weight descriptors or dosing of patients with extremes of weight (body mass index of <18.5 or >40 kg/m2) relative to age and height was extracted from the product labeling or pivotal studies. Pharmaceutical companies were contacted if pivotal studies had not been published. The information was evaluated with a dosing usefulness score of 0--3; a score of 2 or greater was considered minimally adequate for dosing patients with extremes of weight. Results. Of the 84 medications evaluated, some reference to weight descriptors was found for 23 (27%). None had a calculated usefulness score of 2 or above based on information from product information or pivotal trials. Conclusion. Information from product labeling and pivotal studies involving newly marketed injectable medications is inadequate for dosing patients with extremes of weight. [ABSTRACT FROM AUTHOR]

The article investigates the accuracy and reproducibility of small-volume injections using various-sized syringes. There is a need to select the smallest syringe appropriate for the volume of medication to be delivered, as accuracy and reprodicibility decreased as syringe size increased. Errors in volume delivery would result in overdosing rather than underdosing. One cause of excess volume delivery was the investigator's perception of the plunger position relative to the syringe mark.