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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]

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.

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.

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.

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."