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Summary: Background: Opioid analgesic use before total hip or knee arthroplasty has been associated with worse postoperative outcomes. This pilot study aimed to examine the feasibility of a telehealth‐based pharmacist‐partnered opioid tapering intervention before elective primary hip or knee arthroplasty and its potential effectiveness compared with usual care. Methods: This study was conducted at seven hospitals in New South Wales, Australia. Eligible patients were those aged ≥ 18 years, scheduled to undergo primary hip or knee arthroplasty for osteoarthritis and taking opioid analgesics pre‐operatively. The intervention group participated in an opioid tapering telehealth service, a partnership between a pharmacist and general practitioner, for 3 months pre‐operatively up to the day of surgery, while the control group received usual care. The primary outcomes of the study were to investigate the feasibility of the intervention (i.e. adherence to treatment) and potential effectiveness in decreasing baseline daily opioid dose by > 50% before surgery. Results: Between December 2021 and June 2023, 70 patients were recruited and assigned randomly to the intervention group (n = 35) or control group (n = 35). Baseline characteristics were similar between groups. Thirty patients in each group completed their allocated treatment. All patients allocated to the intervention group completed at least one appointment with a pharmacist, with the median (IQR [range]) being 2 (1–4 [1–6]) appointments. The number of patients who successfully decreased their baseline daily opioid dose by ≥ 50% before surgery was 27/30 in the intervention group compared with 5/30 in the usual care group (p < 0.001). Conclusions: The findings of this pilot study support the feasibility of a telehealth‐delivered, pharmacist‐partnered opioid tapering service for patients scheduled for primary hip or knee arthroplasty. A broader multicentre study to examine the effectiveness of this intervention on clinical outcomes is warranted. [ABSTRACT FROM AUTHOR]

Background: Multimodal analgesia regimens are recommended for the postoperative period after hip and knee replacement surgeries. However, there are no data on practice patterns for analgesic use in the immediate postoperative period after hip and knee replacements in Australia. Objectives: To describe analgesic prescribing patterns in the inpatient postoperative phase for patients undergoing hip and knee replacement. Methods: Retrospective study of electronic medical record data from two major hospitals in Sydney, Australia. We identified analgesic medication prescriptions for all patients aged 18 years and older who underwent hip or knee replacement surgery in 2019. We extracted data on pain medications prescribed while in the ward up until discharge. These were grouped into distinct categories based on the Anatomical Therapeutic Chemical classification. We described the frequency (%) of pain medications used by category and computed the average oral morphine equivalent daily dose (OMEDD) during hospitalisation. Results: We identified 1282 surgeries in 1225 patients. Patients had a mean (SD) age of 69 (11.8) years; most (57.1%) were female. Over 99% of patients were prescribed opioid analgesics and paracetamol during their hospital stay. Most patients (61.4%) were managed with paracetamol and opioids only. The most common prescribed opioid was oxycodone (87.3% of patients). Only 19% of patients were prescribed nonsteroidal anti-inflammatories (NSAIDs). The median (IQR) average daily OMEDD was 50.2 mg (30.3–77.9). Conclusion: We identified high use of opioids analgesics as the main strategies for pain control after hip and knee replacement in hospital. Other analgesics were much less frequently used, such as NSAIDs, and always in combination with opioids and paracetamol. [ABSTRACT FROM AUTHOR]

Due to variability in pharmacokinetics and pharmacodynamics, clinical outcomes of antimicrobial drug therapy vary between patients. As such, personalised medication management, considering both pharmacokinetics and pharmacodynamics, is a growing concept of interest in the field of infectious diseases. Therapeutic drug monitoring is used to adjust and individualise drug regimens until predefined pharmacokinetic exposure targets are achieved. Minimum inhibitory concentration (drug susceptibility) is the best available pharmacodynamic parameter but is associated with many limitations. Identification of other pharmacodynamic parameters is necessary. Repurposing diagnostic biomarkers as pharmacodynamic parameters to evaluate treatment response is attractive. When combined with therapeutic drug monitoring, it could facilitate making more informed dosing decisions. We believe the approach has potential and justifies further research. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The objective of this study was to compare pain control and opioid consumption in critically ill patients who were treated with buprenorphine sublingual or oxycodone oral/enteral during ICU admission. DESIGN: This was a retrospective, parallel, cohort study. SETTING: General medical or surgical ICUs of a quaternary, urban hospital in Sydney, NSW, Australia. PATIENTS: Data were obtained for all patients admitted to two general medical or surgical ICU from January 2019 to January 2023. Patients were grouped as those who received buprenorphine sublingual versus oxycodone oral/enteral. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pain control was compared between a propensity score matched cohort of patients who received buprenorphine versus oxycodone. The primary outcome was the probability of significant pain. A significant pain score was defined as greater than or equal to 4 on the 0–10 Numeric Rating Scale or greater than or equal to 6 on the Behavioral Pain Scale. The study cohort included 1,070 patients (288 buprenorphine and 782 oxycodone). After propensity score matching, there were 288 patients in each group. The mean age of the matched cohort was 64±16 years, 295 (51%) were male, and 359 (62%) had a surgical admission. The median probability of significant pain was 0.16 with buprenorphine and 0.17 with oxycodone (median difference, 0.01; 95% CI, –0.02 to 0.04; p = 0.50). Median opioid consumption in oral morphine milligram equivalents (MMEs) was 65 with buprenorphine and 70 with oxycodone (median difference, –1mg; 95% CI, –10 to 10mg; p = 0.73). Median MME per ICU day was 22 with buprenorphine and 22 with oxycodone (median difference, 1mg; 95% CI, –2 to 5mg; p = 0.38). CONCLUSIONS: Buprenorphine sublingual is as effective as oxycodone oral/enteral with regard to pain control and opioid consumption in the ICU. Buprenorphine sublingual is an appropriate option for patients in the ICU who are unable to take oral/enteral medications. [ABSTRACT FROM AUTHOR]

Purpose To provide key pharmacological concepts underlying drug-drug interactions (DDIs), a decision-making framework, and a list of DDIs that should be considered in the context of contemporary acutely ill patients with COVID-19. Summary DDIs are frequently encountered in the acutely ill. The implications of DDIs include either increased risk of drug toxicity or decreased effectiveness, which may have severe consequences in the acutely ill due to lower physiological and neurocognitive reserves in these patients. In addition, an array of additional therapies and drug classes have been used for COVID-19 that were not typically used in the acute care setting. In this update on DDIs in the acutely ill, we provide key pharmacological concepts underlying DDIs, including a discussion of the gastric environment, the cytochrome P-450 (CYP) isozyme system, transporters, and pharmacodynamics in relation to DDIs. We also provide a decision-making framework that elucidates the identification of DDIs, risk assessment, selection of alternative therapies, and monitoring. Finally, important DDIs pertaining to contemporary acute care clinical practice related to COVID-19 are discussed. Conclusion Interpreting and managing DDIs should follow a pharmacologically based approach and a systematic decision-making process to optimize patient outcomes. [ABSTRACT FROM AUTHOR]

Purpose. To assess the agreement in 24-hour area under the curve (AUC24) value estimates between commonly used vancomycin population pharmacokinetic models in the critically ill. Materials and Methods. Adults admitted to intensive care who received intravenous vancomycin and had a serum vancomycin concentration available were included. AUC24 values were determined using Tucuxi (revision cd7bd7a8) for dosing intervals with a vancomycin concentration using three models (Goti 2018, Colin 2019, and Thomson 2009) previously evaluated in the critically ill. AUC24 values were categorized as subtherapeutic (<400 mg·h/L), therapeutic (400–600 mg·h/L), or toxic (>600 mg·h/L), assuming a minimum inhibitory concentration of 1 mg/L. AUC24 value categorization was compared across the three models and reported as percent agreement. Results. Overall, 466 AUC24 values were estimated in 188 patients. Overall, 52%, 42%, and 47% of the AUC24 values were therapeutic for the Goti, Colin, and Thomson models, respectively. The agreement of AUC24 values between all three models was 48% (223/466), Goti-Colin 59% (193/466), Goti-Thomson 68% (318/466), and Colin-Thomson 67% (314/466). Conclusion. In critically ill patients, vancomycin AUC24 values obtained from different pharmacokinetic models are often discordant, potentially contributing to differences in dosing decisions. This highlights the importance of selecting the optimal model. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic has required an unprecedented surge in the pharmacy workforce to support mass vaccination hubs. This review discusses the challenges faced while training and credentialing a surge pharmacy workforce and how these challenges were overcome. The process used for training and credentialing new employees has been described and recommendations and insights have been provided based on the lessons learned at two COVID‐19 mass vaccination hubs in New South Wales. Operationalising one of the largest mass vaccination hubs in Australia required efficient training and credentialing of the pharmacy workforce. This process included the use of pharmacist‐extenders such as students, assistants, and those from other healthcare and non‐healthcare backgrounds. Training was optimised by using a flipped classroom model, so that the vaccine preparation process was provided via asynchronous online videos. The videos covered each step of vaccine dose preparation with visual cues to guide appropriate technique. On‐site training involved use of simulation and checklists for credentialing. Many factors contributed to the success of this process, including the use of triaging and the re‐allocation of personnel based on skill level, collaboration with the Sydney Pharmacy School to train and support a surge workforce involving students, initial on‐site information technology support in the form of pharmacy superusers, the use of checklists and guides for troubleshooting, and assigned pharmacy educators to train new employees. The public health response to the COVID‐19 pandemic forced us to rapidly adapt to build a pharmacy workforce in record time to support mass vaccination hubs. The recommendations and insights provided from our experience can guide future surges. Some of these concepts may also be applied to pharmacy practice in hospitals when resources are constrained. [ABSTRACT FROM AUTHOR]

Purpose Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide guidance for conducting cost-avoidance studies pertaining to clinical pharmacy practice. Summary Cost-avoidance studies represent a paradigm conceptually different from traditional pharmacoeconomic analysis. A cost-avoidance study reports on cost savings from a given intervention, where the savings is estimated based on a counterfactual scenario. Investigators need to determine what specifically would have happened to the patient if the intervention did not occur. This assessment can be fundamentally flawed, depending on underlying assumptions regarding the pharmacists' action and the patient trajectory. It requires careful identification of the potential consequence of nonaction, as well as probability and cost assessment. Given the uncertainty of assumptions, sensitivity analyses should be performed. A step-by-step methodology, formula for calculations, and best practice guidance is provided. Conclusions Cost-avoidance studies focused on pharmacist interventions should be considered low-level evidence. These studies are acceptable to provide pilot data for the planning of future clinical trials. The guidance provided in this article should be followed to improve the quality and validity of such investigations. [ABSTRACT FROM AUTHOR]

Objectives: To conduct a cost analysis of adjunctive hydrocortisone therapy for severe septic shock from the perspective of a third-party payer in the United States.Design: Estimates of outcomes were aggregate data from the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and Activated Protein C and Corticosteroids for Human Septic Shock trials. In these trials, the outcomes of interests were ICU length of stay, vasopressor-free days, ventilation-free days, and the proportion of patients receiving blood transfusion. Each outcome was monetized into a set of mutually exclusive components and was aggregated to estimate the cost-per-patient based on each trial. Cost inputs for each outcome were obtained from literature and adjusted based on the medical care consumer price index. To estimate the budget impact using adjunctive hydrocortisone therapy, per-patient avoided cost was multiplied by expected septic shock annual incidence. Deterministic one-way sensitivity analysis evaluated the robustness of the findings, and Monte Carlo simulation estimated 95% CI of the findings.Setting: A total of 103 medical-surgical ICU (69 for Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and 34 for Activated Protein C and Corticosteroids for Human Septic Shock).Patients: Adults greater than or equal to 18 years old with septic shock.Interventions: Adjunctive hydrocortisone therapy (hydrocortisone at a dose of 200 mg/d for 7 d for Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and hydrocortisone at a 50 mg IV bolus every 6 hr and fludrocortisone as a 50 μg tablet once daily).Measurements and Main Results: Per Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock, adjunctive hydrocortisone therapy showed a 90-day monetized benefit of $8,111 (95% CI, $3,914-$12,307) per patient, driven by improvements in ICU-free days, vasopressor-free days, ventilation-free days, and blood transfusion proportion. The total estimated annual impact of adjunctive hydrocortisone therapy, in 2019 dollars, was $750 million. Per Activated Protein C and Corticosteroids for Human Septic Shock, adjunctive hydrocortisone therapy showed a 90-day monetized benefit of $25,539 per patient (95% CI, $22,853-$28,224), driven by improvements in ICU free-days, vasopressor-free days, and ventilation-free days. The total estimated annual impact of adjunctive hydrocortisone therapy, in 2019 dollars, was $2.3 billion. The deterministic one-way sensitivity analysis showed the cost of ICU stays to be the most influential factor in both analyses. The sensitivity analysis using the reported median showed a greater monetized benefit of $10,658 (Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock) and $30,911 (Activated Protein C and Corticosteroids for Human Septic Shock) per patient.Conclusions: Using adjunctive hydrocortisone therapy yields a significant monetized benefit based on inputs from the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and Activated Protein C and Corticosteroids for Human Septic Shock trials. [ABSTRACT FROM AUTHOR]

Previous studies have shown associations between genetic polymorphisms and pain tolerance, but psychological evaluations are seldom measured. The objective of this study was to determine the independent effects of demographic, psychological, and genetic predictors of cold noxious pain tolerance. Healthy subjects (n = 89) completed the Pain Catastrophizing Scale (PCS) and Fear of Pain Questionnaire (FPQ‐III), underwent genotyping for candidate single nucleotide polymorphisms (SNPs), and completed a cold‐pressor test in a 1–2°C water bath for a maximum of 3 minutes. The primary outcome measure was pain tolerance, defined as the maximum duration of time subjects left their nondominant hand in the cold‐water bath. Cox proportional hazards regression indicated that female sex, Asian race, and increasing PCS and FPQ‐III scores were associated with lower pain tolerance. No candidate SNP was significantly associated with pain tolerance. Future genetic studies should include demographic and psychological variables as confounders in experimental pain models. [ABSTRACT FROM AUTHOR]

Objective To compare rates of VTE occurrence in obese versus non-obese hospitalized patients who received UFH 5000 units subcutaneously q8 h. Materials and methods This was a retrospective cohort study conducted in an academic medical center in the United States. Consecutive adult patients who were hospitalized during a 1-year time frame (2015) receiving UFH 5000 units subcutaneously q8 h for VTE prophylaxis. The primary outcome was occurrence of VTE during hospitalization. This was compared between obese (body mass index ≥30 kg/m 2 ) and non-obese (body mass index <30 kg/m 2 ) patients. Secondary outcomes included the occurrence of significant bleeding (i.e. intracranial and gastrointestinal hemorrhage). Results There were 5110 patients included in the study cohort, with a mean age of 57 ± 18 years; and 54% (n = 2757) were male. A similar proportion of patients in the obese group (n = 11/1673, 0.7%) and non-obese group (n = 19/3437, 0.6%) developed a VTE (difference 0.1%, 95% CI −0.4 to 0.6%, p = 0.70). The incidence of VTE was also low (n = 1/394, 0.3%) in patients with body mass index ≥40 kg/m 2 . Intracranial bleeding occurred in 3 (0.2%) patients in the obese group and 2 (0.1%) patients in the non-obese group (difference 0.1%, 95% CI −0.1 to 0.3%, p = 0.34). Gastrointestinal bleeding occurred in 6 (0.4%) patients in the obese group and 13 (0.4%) patients in the non-obese group (difference 0%, 95% CI −0.4 to 0.3%, p > 0.99). Conclusions UFH 5000 units subcutaneously q8 h may be sufficient for prevention of VTE in obese patients. [ABSTRACT FROM AUTHOR]

Purpose. A practical guide to conducting and reporting medical record review studies, including instruction and insights on topics ranging from idea conception to manuscript submission, is provided. Summary. Research based on the retrospective collection and analysis of data from medical records is often the first type of research conducted by new investigators; such research can be particularly useful in high-acuity populations and is often more feasible and cost-effective than prospective studies. The research process begins with formulating a valid hypothesis-driven or exploratory research question and refining it into one that is testable; this can be facilitated by incorporating information from various sources (e.g., relevant literature, consultation with experts, observations of practice). Accurate sample size calculations are important in ensuring study feasibility (i.e., the estimated sample sizes required can be obtained). Appropriate data collection methods are particularly crucial in medical record review studies; key considerations include pertinent variables, systematic subject identification, standardized data collection instruments, training of data collectors to minimize interrater variability, processes to ensure the accuracy and reliability of data, and blinded collection of the outcome variable. Checklists are provided to guide investigators in retrospective data collection, manuscript preparation, and decisions regarding authorship eligibility and sequencing. Conclusion. The quality of medical record review studies and the likelihood of their acceptance for publication can be improved through adherence to recommended standards of research design, data collection and analysis, ethical authorship, and manuscript preparation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the evidence for the use of intravenous ketamine for analgosedation in the intensive care unit. Methods: MEDLINE and EMBASE were queried from inception until July 2015. Search terms used included ketamine, intensive care, and critical care. The search retrieved 584 articles to be screened for inclusion. The intent was to include randomized controlled studies using sustained intravenous infusions (>24 hours) of ketamine in the critically ill patients. Results: One trial evaluated opioid consumption as an outcome in postoperative critically ill patients who were randomized to ketamine or saline infusions. The mean cumulative morphine consumption at 48 hours was significantly lower in the ketamine group (58 ± 35 mg) compared to the morphine-only group (80 ± 37 mg; P < .05). Other trials showed the potential safety of ketamine in terms of cerebral hemodynamics in patients with traumatic brain injury, improved gastrointestinal motility, and decreased vasopressor requirements. The observational study and case reports suggest that ketamine is safe and effective and may have a role in patients who are refractory to other therapies. Conclusion: Ketamine use may decrease analgesic consumption in the intensive care unit. Additional trials are needed to further delineate the role of ketamine for analgosedation. [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]

Background: Behavioral health (BH)-related visits to the emergency department (ED) by older adults are increasing. This population has unique challenges to providing quality, timely care.Objective: To characterize older adults with BH-related ED visits and determine risk factors associated with prolonged length of stay (LOS) and adverse events (AEs).Methods: We performed a retrospective electronic health record review of all patients ≥65 years who presented to our ED from September 2011 to August 2012 for BH-related complaints. Sociodemographic, clinical, and utilization data were tested for association with LOS and AE.Results: The 213 elder BH patients represented 4% of the 5267 total elder visits during the study period. Median age was 75 (interquartile range [IQR] 70-82); largely white (84.5%), female (58.7%), and non-Hispanic (69.5%). There was a median of two comorbidities (IQR 1-3), and 46.9% were cognitively impaired. Most (71.5%) were being evaluated on an involuntary basis. Median LOS was 16.2 h (IQR 9.7-29.7). Increased LOS was associated with involuntary status (12.4 h, 95% confidence interval [95% CI] 6.4-18.4); use of restraints (11.9 h, 95% CI 5.7-18.2); and failed discharge (28.8 h, 95% CI 21.2-36.6). For every 10 additional hours in the ED, the risk for an AEs (p = .002) or potential AEs (p = .01) increased 20%.Conclusion: Elderly ED patients with BH complaints had high rates of cognitive impairment and multiple comorbidities. LOS was prolonged, and there were multiple contributing factors including involuntary status, chemical or physical restraint, and failed discharge. Patients with longer LOS were at increased risk of an AE or potentially AEs. [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]

Aims: To assess the association between insulin infusion rates, and 24-h insulin consumption on hypoglycemia in the intensive care unit (ICU).Methods: This was a retrospective case-control study, conducted at an academic institution in the United States. Adult patients admitted to the ICU receiving intravenous insulin infusions for blood glucose control were included. Hypoglycemic (blood glucose <70 mg/dL) patients were matched 1:1 with non-hypoglycemic controls based on age, gender, and body mass index. Multivariable conditional logistic regression analyses were conducted to determine the effect of: (1) weight-adjusted insulin infusion rate (units/kg/h), (2) non-weight-adjusted insulin infusion rate (units/h), or (3) 24-h insulin consumption (units/day) on hypoglycemia.Results: A total of 122 patients were included in the study (61 cases, 61 controls). Compared to those patients who received <0.05 units/kg/h, the odds of hypoglycemia was higher in those who received was ≥0.1 units/kg/h (OR 4.57, 95% CI 1.45-14.41, p=0.010). Compared to those patients who received <4 units/h, the odds of hypoglycemia was higher in those who received was ≥8 units/h (4.17, 95% CI 1.18-14.75, p=0.027). The risk of hypoglycemia did not increase with higher 24-h insulin consumption.Conclusions: Higher insulin infusion rates rather than 24-h insulin consumption may be associated with hypoglycemia in critically ill patients in the ICU. [ABSTRACT FROM AUTHOR]

Background: Medication reconciliation is an effective strategy to reduce medication errors upon hospital admission. The process involves obtaining a best possible medication history (BPMH), which can be both time-consuming and resource-intensive. During the COVID-19 pandemic, telepharmacy was used to reduce the risk of viral transmission. Telepharmacy is the remote provision of pharmacy-led clinical services, such as obtaining BPMHs, using telecommunications. However, the accuracy of telephone-obtained BPMHs has not yet been evaluated. Therefore, the primary aim of this study was to evaluate the proportion of patients who have an accurate BPMH from the telephone-obtained BPMH compared to an in-person obtained BPMH. Methods: This prospective, observational study took place in a large tertiary hospital. Recruited patients or carers had their BPMH obtained by a pharmacist over the telephone. The same patients or carers then had their BPMH conducted in-person to identify any deviations between the telephone-obtained and in-person obtained BPMH. All telephone-obtained BPMHs were timed with a stopwatch. Any deviations were categorised according to their potential consequence. An accurate BPMH was defined as having no deviations. Descriptive statistics were used to report all quantitative variables. A multivariable logistic regression was conducted to identify risk factors for patients and medications for having medication deviations. Results: In total, 116 patients were recruited to receive both a telephone-obtained and in-person obtained BPMH. Of these, 91 patients (78%) had an accurate BPMH with no deviations. Of the 1104 medications documented across all the BPMHs, 1064 (96%) had no deviation. Of the 40 (4%) medication deviations, 38 were deemed low-risk (3%) and 2 high-risk (1%). A patient was more likely to have a deviation if they are taking more medications (aOR: 1.11; 95% CI: 1.01–1.22; p < 0.05). A medication was more likely to have a deviation if it was regular non-prescription medication (aOR: 4.82; 95% CI: 2.14–10.82; p < 0.001) or 'when required' non-prescription medication (aOR: 3.12; 95% CI: 1.20–8.11; p = 0.02) or a topical medication (aOR: 12.53; 95% CI: 4.34–42.17; p < 0.001). Conclusions: Telepharmacy represents a reliable and time-efficient alternative to in-person BPMHs. [ABSTRACT FROM AUTHOR]

Objective: To review emerging pharmacological agents for the treatment of traumatic brain injury with regard to survival outcomes and provide recommendations regarding their use. Methods: An Ovid MEDLINE (up to May 2013) and the Cochrane Central Register of Controlled Trials (up to May 2013) search was conducted to identify emerging pharmacological therapies for the treatment of traumatic brain injury. The search was limited to English language and humans. Pharmacological agents that were evaluated with respect to survival as an outcome were included. Main results: Based on the search, the investigators identified the following new therapies: beta-receptor antagonists, erythropoiesis stimulating agents, hydroxymethylglutaryl-CoA reductase inhibitors (statins) and progesterone. With the exception of progesterone, which was studied in several small, randomized, controlled trials, the remaining agents were primarily studied in observational retrospective cohorts. For each of the agents identified, a potential increase in survival was noted. Conclusions: Emerging pharmacological agents represent promising treatment options for traumatic brain injury to improve survival. Most of these agents are commercially available for other indications. However, limitations in study design, sample size, duration of treatment, timing of treatment and inclusion of heterogeneous patient populations make it difficult to draw definitive conclusions from the literature. [ABSTRACT FROM AUTHOR]

Abstract: Background: Propofol dose requirements may differ in the elderly due to age-related changes in pharmacokinetic or pharmacodynamic variables. Objective: The objective of this study was to determine the effect of patient age on propofol dose required for procedural sedation in the Emergency Department (ED). Methods: This was a retrospective cohort study conducted in a tertiary hospital ED. Adult patients who underwent procedural sedation in the ED using propofol were grouped a priori by age into three categories: 18–40 years, 41–64 years, and ≥65 years. The median induction dose and total dose of propofol required for the procedure was compared between the three age group categories. Multivariate linear regression analyses were used to adjust for confounders. Results: A total of 170 patients were included in the final analyses: 18–40 years (n = 66), 41–64 years (n = 59), and ≥65 years (n = 45). The median induction dose was 1.4, 1, and 0.9 mg/kg, respectively; and the median total propofol dose was 2, 1.7, and 1.2 mg/kg, respectively. The ≥65 year-old group required significantly less propofol (mg/kg) for induction (compared to the 18–40-year-old group) and for the entire procedure (compared to all other groups) (p < 0.001). In the multivariate linear regression analyses, patient age was negatively predictive of induction dose (coefficient −0.011, 95% confidence interval [CI] −0.017 to −0.005) and total dose (coefficient −0.014, 95% CI −0.022–0.007) after adjusting for confounders. Conclusion: Elderly patients may require lower doses of propofol for procedural sedation in the ED, compared to younger adults. [Copyright &y& Elsevier]

Abstract: Background: Although debate exists about the treatment of sepsis, few disagree about the benefits of early, appropriately targeted antibiotic administration. Study Objectives: To determine the appropriateness of empiric antimicrobial therapy and the extent to which therapy would be altered if the causative organism for sepsis was known at the time of administration. Methods: This was a retrospective cohort study, conducted in an academic Emergency Department (ED), on consecutive positive blood cultures between November 1, 2008 and February 1, 2009. Blood cultures and the appropriateness of administered antimicrobial therapy were evaluated. Therapy choices were categorized based on whether or not a physician, complying with antimicrobial guidelines, would have made changes to empiric antibiotic therapy had the causative organism initially been known. Results: There were 90 positive blood cultures obtained from 84 patients. Of these, 21.1% (n=19) were considered contaminants. The final categorization of empiric antibiotics given in the ED for the remaining blood culture results were: 1) therapy would be changed to narrower-spectrum antibiotics (n=34, 55.7%); 2) therapy would be changed because the organism was not covered (n=13, 21.3%); and 3) therapy would remain the same (n=14, 23.0%). There was 90.2% inter-rater agreement for these classifications (p <0.0001), with a kappa of 0.84. Polymerase chain reaction analysis had a statistically significant advantage (p <0.0001) over Infectious Disease Society of America protocols in facilitating accurate antimicrobial therapies. Conclusion: This study confirms the need for more rapid and accurate laboratory methods for bloodstream pathogen identification. [Copyright &y& Elsevier]

BACKGROUND: The purpose of this study was to evaluate the effect of epidural analgesia use on postoperative complications in patients undergoing pancreaticoduodenectomy. METHODS: This retrospective cohort study used the 2009 Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. Patients who underwent pancreaticoduodenectomy were grouped on the basis of whether they received epidural analgesia. The effect of epidural use on the composite end point of major complications including death was investigated using a generalized linear model. RESULTS: Overall, 8,610 cases of pancreaticoduodenectomy occurred within the United States in 2009, and 11.0% of these patients received epidural analgesia. After controlling for various potential confounders, results of the multivariate regression indicated that epidural analgesia use was associated with lower odds of composite complications including death (odds ratio, .61; 95% confidence interval, .37-99; P = .044). CONCLUSIONS: In patients who underwent pancreaticoduodenectomy, epidural analgesia was as-sociated with significantly lower postoperative composite complications. [ABSTRACT FROM AUTHOR]

This study aims to summarize the effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge. A systematic search was conducted on 6 electronic databases by 2 independent reviewers. We included original research articles reporting on quantitative outcomes of organizational interventions targeting appropriate opioid prescribing on hospital discharge. Quality assessment was performed by 2 independent reviewers. The protocol for this review was prospectively registered on PROSPERO (ID: CRD42020156104). Out of 173 full texts assessed for eligibility, 43 were included in this review. The majority of studies had a moderate to serious risk of bias (33 out of 43). Most of the studies implemented a multifaceted organizational intervention (16 studies). Other interventions included guideline implementation, prescriber education and default opioid‐prescribing quantity changes in electronic medical records. Multiple studies found that the dissemination of patient‐specific and procedure‐specific guidelines reduced the quantity of opioids prescribed by 44 to 57%. Prescriber education provided with feedback was implemented in 4 studies and resulted in a 33 to 44% decrease in prescribing rates. Lowering the default quantities in the electronic medical records produced a 40% decrease in opioids prescribed in 1 study. Guideline implementation, prescriber education and default opioid‐prescribing quantity changes all appear effective in improving the appropriate prescribing of opioids on hospital discharge. However, the extent of reduction of opioid prescribing upon hospital discharge after the implementation of multifaceted intervention strategies appears similar to that of simpler interventions which require fewer resources. [ABSTRACT FROM AUTHOR]

The article offers information on the significant role played by pharmacists in different processes of procedural sedation and analgesia (PSA) given to patients in emergency department (ED). Pharmacists help in the preprocedure evaluation process by reducing risks of respiratory depression and hypotension and also play an important role in forming a pharmacologic plan by selecting the type of procedure to be performed. Their assistance in other functions like drug selection is also discussed.

Critically ill patients are at the greatest risk of experiencing preventable and non-preventable adverse drug events (ADEs) compared to other patient populations. Information on ADEs concerning these patients is derived from a wide spectrum of sources such as surveillance studies involving large databases to landmark clinical investigations. Historically there has been a lack of consistency with regard to definitions of commonly used terms such as medication error, ADE, and preventability, which is a fundamental to appropriately conduct and interpret results of epidemiological investigations in this setting. However, attempts have been made to standardize this terminology by national organizations. The increased risk of ADEs in the critically ill patient population is due to a variety of reasons, which include the routine use of the intravenous route of drug administration, medications with a low therapeutic index and high complexity, 'off-label' use and an environment that may be conducive to errors. Reporting of ADEs is largely voluntary and is generally underreported and skewed towards the most serious events. Other methods for surveillance of ADEs in the critical care setting include medical record review and direct observation. Each of these methods has their own limitations and the data obtained can vary depending on the method used. A combination of data from all of these methods is likely to produce the most comprehensive information to improve patient safety. [ABSTRACT FROM AUTHOR]

Purpose. The use of hypertonic saline injection in trauma patients is discussed. Summary. Patients with hemorrhage, burns, and traumatic brain injury (TBI) may develop hypovolemic shock and require resuscitation. Compared with conventional isotonic crystalloids, hypertonic saline has several advantages, including hemodynamic, immune-modulating, and antiinflammatory effects, for use in trauma patients for resuscitation. In addition, hypertonic saline is also used in patients with TBI to reduce intracranial pressure (ICP). Overall, studies have not shown a difference in mortality or other clinically important outcomes with the use of hypertonic saline for resuscitation in trauma patients; however, most of these studies were not adequately powered to show significant differences. A recent Cochrane review concluded that there is no evidence that hypertonic crystalloids are better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients. Two recent trials that were adequately powered to investigate a mortality endpoint were halted for futility. A few small randomized controlled studies found that hypertonic saline was more effective than mannitol as a hyperosmolar agent for ICP reduction. Recent guidelines from the American Burn Association have suggested that hypertonic saline may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia. One of the main concerns with the use of hypertonic saline is its potential to cause central pontine myelinolysis due to a rapid increase in serum sodium levels. Conclusion. There is no evidence that hypertonic saline provides any additional benefit over isotonic crystalloid solutions for trauma resuscitation. Hypertonic saline may be more effective than mannitol at reducing ICP in patients with TBI. [ABSTRACT FROM AUTHOR]

Abstract: Background: Antiemetic agents are among the most frequently prescribed medications in the emergency department (ED). Nevertheless, there are no widely accepted evidence-based guidelines to optimize the use of these medications for nausea or vomiting in this setting. Objective: The objective of this article is to briefly review the evidence supporting the use of antiemetic agents for the treatment of nausea or vomiting for adults in the ED, and to provide recommendations to help guide therapy. Discussion: The antiemetic agents studied include droperidol, promethazine, prochlorperazine, metoclopramide, and ondansetron. Droperidol was commonly used in the past, and is more effective than prochlorperazine or metoclopramide, but due to the US Food and Drug Administration black box warning regarding the potential for QT prolongation with this drug, its use is limited to refractory cases. Promethazine is more sedating than other comparative agents, and also has the potential for vascular damage upon intravenous administration. It may be a suitable option when sedation is desirable. Patients given prochlorperazine or metoclopramide must be monitored for akathisia that can develop at any time over 48 h post administration. Decreasing the infusion rate can reduce the incidence of this adverse effect, and the effect can be treated with intravenous diphenhydramine. Ondansetron is as effective as promethazine, and is not associated with sedation or akathisia. Conclusion: Based on the safety and efficacy of ondansetron, it may be used as a first-line agent for relief of nausea or vomiting for most patient populations in the ED. [ABSTRACT FROM AUTHOR]

Purpose. The case of a patient who developed aseptic meningitis, hemolytic anemia, hepatitis, and orthostatic hypotension simultaneously during treatment with trimethoprim-sulfamethoxazole is described. Background. A healthy 37-year-old African- American man was receiving treatment with trimethoprim-sulfamethoxazole double strength. This was the patient's first experience with trimethoprim- sulfamethoxazole, and he was not taking any other medications during the treatment period. He had been taking trimethoprim-sulfamethoxazole for approximately eight days when he revisited his family physician, complaining of headaches, dizziness, difficulty with speech, weakness, and itching on the trunk of his body and legs, where a maculopapular rash was noted. Orthostatic hypotension was also noted at that visit, with a standing blood pressure measurement of 95/80 mm Hg. Based on these findings and since the patient had no signs of infection, his physician instructed him to discontinue the drug. The patient was admitted to the emergency department of a local hospital within two days due to ongoing headache, elevated temperature, and nuchal rigidity, symptoms suggestive of meningitis. Because of the presence of hemolysis, the patient underwent testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency, for which he tested positive. The patient was discharged five days after admission and referred to a hematology clinic for follow-up. The patient has since returned to his routines of daily living and has reported no fatigue or other lingering adverse symptoms. Conclusion. A 37-year-old African- American man with G6PD deficiency developed hemolytic anemia, hepatitis, orthostatic hypotension, and aseptic meningitis simultaneously after using trimethoprim- sulfamethoxazole. [ABSTRACT FROM AUTHOR]

Objective: The primary objective of this study was to determine the effectiveness of a lower dose of levetiracetam (500 mg every 12 hours) to prevent early seizures after traumatic brain injury (TBI). It was hypothesized that the seizure rate would be low and comparable to previous studies using phenytoin. Methods: This was a retrospective cohort study conducted in a tertiary care, academic institution that is designated as a level 1 trauma centre in the US. Consecutive patients with TBI were evaluated. Patients who were given a levetiracetam dose of 500 mg every 12 hours were included. The primary outcome was the occurrence of a seizure within 7 days of TBI. Results: There were a total of 169 patients included in the study, who were treated with levetiracetam 500 mg every 12 hours. The median time to first dose of levetiracetam was 3.5 hours after injury (interquartile range = 1–13 hours). After initiation of levetiracetam, there were four (2.4%) patients who had a seizure within 7 days. This was not significantly different than the hypothesized population value of 3.6% (p= 0.390). Conclusions: A lower dose of levetiracetam 500 mg every 12 hours after TBI may be effective for early seizure prevention after TBI. [ABSTRACT FROM AUTHOR]

Study Objectives. To compare opioid requirements in opioid-tolerant and opioid-naive patients after total knee arthroplasty, and to compare pain scores, sedation scores, and adverse effects between the groups. Design. Prospective, observational study. Setting. Academic medical center. Patients. Twenty-nine patients aged 18 years or older who underwent elective total knee arthroplasty between October 1, 2005, and June 31, 2007. Measurements and Main Results. Patients were classified on the basis of their daily opioid consumption during the week before surgery: those who required 10 mg or less of oral morphine equivalent were considered opioid naive (20 patients), and those who required at least 30 mg of oral morphine equivalent were opioid tolerant (nine patients). Postoperative opioid consumption, pain scores, sedation scores, and adverse effects were compared between the two groups up to 48 hours after discharge from the postanesthesia care unit (PACU). Postoperative opioid consumption (in intravenous morphine equivalents) was significantly greater in the opioidtolerant group than in the opioid-naive group in the PACU (median 56 vs 8.2 mg, p=0.0013), during the first 24 hours after discharge from the PACU (108 vs 20.5 mg, p=0.0004), and 24-48 hours after discharge from the PACU (152.3 vs 25 rag, p=0.0001). Pain scores, assessed by using a verbal numeric scale from 0-10, were significantly greater in the opioid-tolerant group than in the opioid-naive group during the first 24 hours after discharge from the PACU (5.9 vs 4.1, p=0.03). We observed no significant difference in pain scores during the other time periods studied. Sedation scores and adverse effects were similar between groups. Conclusion. After total knee arthroplasty, patients tolerant to opioids required significantly more opioids in the PACU and up to 48 hours after discharge from the PACU than did opioid-naive patients. Opioid-tolerant patients also experienced greater pain during the first 24 hours after discharge from the PACU; however, sedation scores and adverse effects did not appear to be significantly different at any of the time periods studied. Clinicians need to be aggressive with pain management immediately after surgery and ensure that patients restart any opioid treatment at home as soon as possible. [ABSTRACT FROM AUTHOR]

Purpose. The use of factor VIIa (recombinant) for the treatment of acute traumatic hemorrhage is reviewed. Summary. Factor VIIa (recombinant) has received considerable attention as a hemostatic agent and is increasingly being used for the management of bleeding associated with a variety of conditions. Severely injured trauma patients with uncontrolled bleeding are at high risk for coagulopathy and may benefit from the administration of factor VIIa (recombinant). A literature review was conducted to identify original research in the form of randomized controlled trials investigating the use of factor VIIa (recombinant) for the treatment of traumatic hemorrhage. Due to the paucity of such trials, three retrospective evaluations and three large case series pertaining to this topic were also reviewed. Of the two randomized controlled trials, one found a reduction in red blood cell (RBC) transfusion requirements in patients with blunt traumatic hemorrhage after the administration of factor VIIa (recombinant). This reduction in RBC requirements was not found in the study conducted with patients with penetrating trauma. These trials were not powered to show a mortality difference, and the effect of factor VIIa (recombinant) on survival in blunt and penetrating traumatic hemorrhage is unknown. Ongoing clinical trials may answer questions regarding its effect on mortality and other clinically important outcomes. Conclusion. Factor VIIa (recombinant) reduces RBC transfusion requirements in patients with blunt traumatic hemorrhage, and its effect on mortality is currently being investigated. Adjunctive use of factor VIIa (recombinant) should be considered only after other treatment modalities have been optimized. [ABSTRACT FROM AUTHOR]

Study Objective. To compare the effectiveness of common laxatives in producing a bowel movement in patients admitted to a medical intensive care unit (M1CU). Design. Retrospective medical record review. Setting. MICU of an academic medical center. Patients. Ninety-five patients admitted to the MICU from July 1-October 31, 2004. Measurements and Main Results. Fifty patients satisfied the inclusion criteria. Patient-specific data such as age, weight, sex, length of MICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) II score, dietary intake, opioid intake, laxative intake, and bowel movements were recorded during the first 96 hours of admission. Logistic regression analysis was used to compare patients who did and did not have a bowel movement. Of the 50 patients, 25 did not have a bowel movement during the first 96 hours of M1CU admission. Patients given a stimulant laxative (senna, bisacodyl) and/or an osmotic laxative (lactulose, milk of magnesia) were more likely to have a bowel movement (odds ratio [OR] 26.6, 95% confidence interval [CI] 3.2-221, p=0.002). Opioid intake, expressed as logarithmic morphine equivalents, was negatively associated with occurrence of a bowel movement (OR 0.76, 95% C1 0.59-0.97, p=0.027). Disease severity, as determined by APACHE I1 score, was also negatively associated with a bowel movement (OR 0.84, 95% CI 0.7-0.99, p=0.04). Conclusion. Critically ill patients have a high frequency of constipation, and opioid therapy is a significant risk factor. Routine administration of stimulant or osmotic laxatives should be considered for this patient population. [ABSTRACT FROM AUTHOR]

The author conveys his concerns on the implementation of a comprehensive approach to decrease opioid prescribing in the emergency department (ED). Topics mentioned include the role of EDs to help reverse the opioid crisis in the U.S., a change in the paradigm of acute pain management, and the use of opioids or combination products with opioids for moderate to severe pain.

Background and Objective: Although paracetamol (acetaminophen) combined with other analgesics can reduce pain intensity in some pain conditions, its effectiveness in managing low back pain and osteoarthritis is unclear. This systematic review investigated whether paracetamol combination therapy is more effective and safer than monotherapy or placebo in low back pain and osteoarthritis. Methods: Online database searches were conducted for randomised trials that evaluated paracetamol combined with another analgesic compared to a placebo or the non-paracetamol ingredient in the combination (monotherapy) in low back pain and osteoarthritis. The primary outcome was a change in pain. Secondary outcomes were (serious) adverse events, changes in disability and quality of life. Follow-up was immediate (≤ 2 weeks), short (> 2 weeks but ≤ 3 months), intermediate (> 3 months but < 12 months) or long term (≥ 12 months). A random-effects meta-analysis was conducted. Risk of bias was assessed using the original Cochrane tool, and quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: Twenty-two studies were included. Pain was reduced with oral paracetamol plus a non-steroidal anti-inflammatory drug (NSAID) at immediate term in low back pain (paracetamol plus ibuprofen vs ibuprofen [mean difference (MD) − 6.2, 95% confidence interval (CI) −10.4 to −2.0, moderate evidence]) and in osteoarthritis (paracetamol plus aceclofenac vs aceclofenac [MD − 4.7, 95% CI − 8.3 to − 1.2, moderate certainty evidence] and paracetamol plus etodolac vs etodolac [MD − 15.1, 95% CI − 18.5 to − 11.8; moderate certainty evidence]). Paracetamol plus oral tramadol reduced pain compared with placebo at intermediate term for low back pain (MD − 11.7, 95% CI − 19.2 to − 4.3; very low certainty evidence) and osteoarthritis (MD − 6.8, 95% CI − 12.7 to −0.9; moderate certainty evidence). Disability scores improved in half the comparisons. Quality of life was infrequently measured. All paracetamol plus NSAID combinations did not increase the risk of adverse events compared to NSAID monotherapy. Conclusions: Low-to-moderate quality evidence supports the oral use of some paracetamol plus NSAID combinations for short-term pain relief with no increased risk of harm for low back pain and osteoarthritis compared to its non-paracetamol monotherapy comparator. [ABSTRACT FROM AUTHOR]

Background: Surgical site infection (SSI) after liver transplant (LT) is common, but no studies have been conducted in Australia. The purpose of this study was to determine the proportion of patients who developed an SSI post‐LT in Australia's largest LT unit. Methods: This was a single‐center retrospective cohort study. We included all LT recipients who were aged 18 years or more and received their transplant between March 1, 2018 and April 1, 2023. The primary outcome was to determine the proportion of LT recipients who developed an SSI within 30 days of transplantation. Results: There were 404 LTs performed during the study period, and 375 met inclusion criteria. Of these, 8% (n = 31/375) developed an SSI and were classified as superficial (3%, n = 12/375) or deep/organ space (5%, n = 19/375). The most common antibiotics used for prophylaxis were amoxicillin/clavulanate (75%, n = 281/375), followed by piperacillin/tazobactam (17%, n = 62/375). Independent risk factors associated with the development of SSI were Roux‐en‐Y hepaticojejunostomy (aOR 3.16, 95% CI 1.17–8.28, p =.02), operative time (per 60‐min increment) (aOR 1.23, 95% CI 1.02–1.48), and re‐operation (aOR 4.16, 95% CI 1.81–9.58, p <.01). Type of antibiotic received perioperatively was not significantly associated with SSI. Conclusion: SSI occurred in 8% of LT recipients and was predominantly related to operation‐related factors rather than patient‐ or antibiotic‐related factors. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 37-year-old male brought to the emergency department (ED) after a high-speed motorcycle collision. It notes the patients with altered mental status with a Glasgow Coma Scale score of seven. The article discusses role of pharmacist in evaluating the patient based on principles of advanced trauma life support and anticipating pharmacological requirements.

Purpose. The interventions of a clinical pharmacist on an emergency department (ED) trauma response team were studied. Methods. The study site was an academic, tertiary care hospital designated as a level 1 trauma center, with a clinical pharmacist present in the ED 40 hours per week. For a two-month period, interventions by the pharmacist in trauma cases were documented in an electronic quality-improvement database. Results. A total of 304 interventions were recorded; the most common were dosage recommendations (60%) and provision of drug information (27%). The top five drug classes involved were analgesics, sedatives, antimicrobials, vaccines, and fluids. In 83% of the interventions, the pharmacist documented involvement in facilitating drug administration. Conclusion. A pharmacist participating on the ED trauma response team commonly provided dosage recommendations and drug information, facilitated drug administration, and optimized sedation, analgesia, and antimicrobial therapy. [ABSTRACT FROM AUTHOR]

To evaluate the cost-effectiveness of tapentadol immediate-release (IR) versus oxycodone IR for post-operative pain after a major hip surgery. This study has been conducted using an Australian societal perspective, focusing on adult patients after a major hip surgery. A cost-effectiveness analysis was conducted using a decision-analytic model. The model incorporated drug and other resource costs, the probability of opioid-related adverse events, and quality-adjusted life months (QALM) in each treatment arm. A willingness to pay (WTP) threshold of AU$2500 was used per QALM gained. A probabilistic sensitivity analysis was conducted to examine the uncertainty of the assumptions. The primary outcome was the incremental cost-effectiveness ratio (ICER) of tapentadol IR versus oxycodone IR, expressed as Australian dollars (AU$) per QALM gained. Tapentadol IR dominated oxycodone IR, with a cost savings of AU$201 and an increase in QALM by 0.014. The ICER was −13,946 AU$/QALM (negative value attributed to numerator). In the probabilistic sensitivity analysis, 84.2% of the simulations were in favour of tapentadol IR at the WTP threshold. Tapentadol IR may be more cost-effective than oxycodone IR for the treatment of acute postoperative pain after major hip surgeries. [ABSTRACT FROM AUTHOR]

Introduction: The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). Methods: We analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014--June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE. Results: A total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference = - 10.3%, 95% confidence interval (CI), - 14.8% to - 5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference = - 10.7%, 95% CI, - 17.3% to - 4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference = - 21.4%, 95% CI, - 27.0% to - 16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21 - 0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19 - 0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11 - 0.33]. Conclusion: FPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials. [ABSTRACT FROM AUTHOR]

The article discusses how medication reconciliation fits into an emergency medicine practice and how emergency pharmacists consider medication reconciliation relative to other functions. Topics discussed include the importance of a comprehensive medication lists with dosages when the decision is made to admit a patient to the hospital or continue care for a longer period in the emergency department (ED) and the barriers to the involvement of pharmacist for detailed medication reconciliation.

Background: At this time, there are no studies evaluating the risk of delirium or coma with the use of ketamine in mechanically ventilated adult patients, compared to conventional therapies such as propofol or dexmedetomidine. Objective: The objective of this study was to evaluate the number of days alive without delirium or coma in mechanically ventilated patients in the intensive care unit receiving analgosedation infusions with ketamine versus without ketamine. Methods: This was a retrospective cohort study conducted at an academic medical center in the United States. Consecutive mechanically ventilated adult patients between November 2015 and April 2017 were evaluated. Patients were divided into 2 groups based on the sedative regimen used: ketamine based or nonketamine based. The primary outcome was the number of days alive without delirium or coma. The secondary outcomes were incidence of delirium, incidence of coma, and ventilator-free days at day 28. Results: The study cohort consisted of 79 patients, of which 39 received ketamine- and 40 received nonketamine-based sedation. The number of days alive without delirium or coma was 6 days (interquartile range [IQR]: 2-9 days) with ketamine and 4 days (IQR: 3-7 days) with nonketamine (P =.351). Delirium occurred in 29 (74%) of 39 patients with ketamine and 34 (85%) of 40 patients with nonketamine (P =.274). Coma occurred in 16 (41%) of 39 patients with ketamine and 6 (15%) of 40 patients with nonketamine (P =.013). The median ventilator-free days were 13 days (IQR: 0-23 days) with ketamine and 21 days (0-25 days) with nonketamine (P =.229). Conclusions: Sustained ketamine-based sedation in mechanically ventilated patients may be associated with a higher rate of observed coma but similar delirium- and coma-free days compared nonketamine-based regimens. [ABSTRACT FROM AUTHOR]

Background: Total hip and knee arthroplasties are common surgeries performed worldwide, but the management of pain during the subacute period (defined as hospital discharge to 3 months postoperatively) is poorly understood. This study aimed to determine patients' experiences, facilitators and barriers to subacute pain management following total hip or knee arthroplasty. Methods: Semi‐structured interviews with a purposive sample of patients following total hip or knee arthroplasty were conducted between June and August 2022. Participants were recruited from two tertiary metropolitan hospitals. Interviews were audio‐recorded and transcribed verbatim. Data were analysed using an inductive thematic approach to identify common themes. Results: In total, 30 interviews were conducted with patients following hip or knee arthroplasty. Four main themes were identified: (i) Physical constitution before surgery (joint condition, analgesic use, age, and hearing); (ii) Attitude and knowledge (motivation, outlook on life, attitude towards taking medications, individual benchmarking, and knowledge); (iii) Socio‐ethno‐cultural factors (family and community connection, language, and religion), and (iv) Health‐system support (health‐professional delivered education, medications, services, staff, and costs). Conclusions: Participants' experiences of subacute pain following hip or knee arthroplasty were shaped by multidimensional factors. Strategies to empower patients through increased education and support during postoperative opioid tapering as well as a shift to a biopsychosocial approach to pain management during the subacute period may improve patient and health‐system outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Airway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period. Methods: An airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means. Results: EM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference = -7.9%, 95% CI -13.4% to -2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%). Conclusion: The use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events. [ABSTRACT FROM AUTHOR]

RATIONALE: Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES: To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN: A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS: Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS: From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS: Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research. [ABSTRACT FROM AUTHOR]

Opioid analgesics prescribed for the management of acute pain following orthopaedic surgery may lead to unintended long-term opioid use and associated patient harms. This study aimed to examine the prevalence of opioid use at 90 days after elective orthopaedic surgery across major city, regional and rural locations in New South Wales, Australia. We conducted a prospective, observational cohort study of patients undergoing elective orthopaedic surgery at five hospitals from major city, regional, rural, public and private settings between April 2017 and February 2020. Data were collected by patient questionnaire at the pre-admission clinic 2–6 weeks before surgery and by telephone call after 90 days following surgery. Of the 361 participants recruited, 54% (195/361) were women and the mean age was 67.7 years (standard deviation 10.1 years). Opioid use at 90 or more days after orthopaedic surgery was reported by 15.8% (57/361; 95% confidence interval (CI) 12.2–20%) of all participants and ranged from 3.5% (2/57) at a major city location to 37.8% (14/37) at an inner regional location. Predictors of long-term postoperative opioid use in the multivariable analysis were surgery performed at an inner regional location (adjusted odds ratio 12.26; 95% CI 2.2–68.24) and outer regional location (adjusted odds ratio 5.46; 95% CI 1.09–27.50) after adjusting for known covariates. Long-term opioid use was reported in over 15% of patients following orthopaedic surgery and appears to be more prevalent in regional locations in Australia. [ABSTRACT FROM AUTHOR]