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Recent literature has demonstrated significant improvements in neurologic outcomes in patients who have received induced hypothermia in the setting of out-of-hospital cardiac arrest. Through multiple metabolic mechanisms, the induction of hypothermia slows the progression and devastation of transient cerebral hypoxia. Despite these benefits, the desired reduction in core temperature is often a challenging venture as the body attempts to maintain homeostasis through the induction of thermoregulatory processes aimed at elevating body temperature. Shivering is an involuntary muscular activity that enhances heat production in an attempt to restore homeostasis. For successful induction and maintenance of induced hypothermia, shivering, as well as other thermoregulatory responses, must be overcome. Several pharmacologic options are available, either used alone or in combination, that safely and effectively prevent or treat shivering after the induction of hypothermia. We conducted a PubMed search (1966-March 2009) to identify all human investigations published in English that discussed pharmacologic mechanisms for the control of shivering. Among these options, clonidine, dexmedetomidine, and meperidine have demonstrated the greatest and most clinically relevant impact on depression of the shivering threshold. More research in this area is needed, however, and the role of the clinical pharmacist in the development and implementation of this therapy needs to be defined.

Study Objective To evaluate the safety and cost-effectiveness of a clinical protocol adopted in June 2006 that included a comprehensive, objective assessment of snake bite envenomations and standardized the use of Crotalidae polyvalent immune Fab antivenom (FabAV). Design Retrospective medical record review. Setting Academic medical center that serves as the regional level I trauma center. Patients Seventy-five adults treated with FabAV for snake envenomations in the emergency department between June 1, 2003, and June 1, 2009; 30 patients received treatment according to the protocol (treatment group), and 45 patients received treatment that did not adhere to the protocol (control group). Measurements and Main Results Demographic and envenomation characteristics, as well as treatment details, were collected for all patients. In addition, information on quantity of FabAV vials required, length of hospital stay, and length of intensive care unit stay were compared between the treatment and control groups. In the treatment group, significantly fewer vials of FabAV were used (2.5 vs 4.727 vials, p=0.007). This decreased in usage correlated to a cost savings of approximately $2000/patient. Despite no significant difference in the severity of the envenomations between the two groups (p=0.379), the treatment group experienced a significantly shorter hospital length of stay (1.933 vs 2.791 days, p=0.030). No significant difference in the progression to fasciotomy or the development of allergic reactions was noted between the two groups. Conclusion Use of a clinical protocol related to snake envenomations resulted in approximately two fewer vials of FabAV required for each patient. In addition, the treatment group experienced a shorter hospital length of stay without a corresponding increase in adverse events or envenomation progression. Data show that use of the protocol was cost-effective. The development of institution-specific multidisciplinary protocols regarding snake bite envenomations is recommended. Clinical pharmacists can play a vital role in the protocol development to ensure that optimal care is provided for this distinct patient population.

Aneurysmal subarachnoid hemorrhage (SAH) accounts for a significant percentage of morbidity and mortality among patients admitted to neurosurgical centers throughout the world. Even for individuals surviving beyond the initial presentation and intervention for aneurysmal SAH, the occurrence of cerebral vasospasm has the potential to induce a second tier of complications that can be just as devastating as the inciting event. However, despite numerous studies and some initial advancements in management, therapeutic modalities are limited to help prevent or treat this complex entity. Historically, the mainstay of treatment for cerebral vasospasm has been a combination of hypervolemia, hemodilution, and hypertension. In addition, other systemic therapies such as oral nimodipine, statins, and intravenous magnesium, as well as intensive glucose control, appear to have some promise, although they are limited at times by adverse effects. To avoid these adverse consequences and perhaps gain some modicum of efficacy, attempts have been made to use endovascular techniques to physically dilate vessels or to administer drugs directly to the site of action and thus avoid many of the untoward effects of systemic pharmacotherapy. Controversy still remains over the success of intraarterial therapy, the drugs or techniques to be used, and the best timing of this therapy. Based on the currently available literature, it is impossible to assess the most effective intraarterial therapy. Randomized controlled trials that can control for baseline factors and technical expertise are needed to provide more conclusive data. Clinical pharmacists should be actively involved in assisting interventional radiologists and neurosurgeons in providing safe and appropriate pharmacotherapy in this promising but controversial arena of intraarterial drug delivery.

The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are the most commonly prescribed agents for hypercholesterolemia and have revolutionized the management of hyperlipidemia and the area of cardiovascular risk reduction. However, recent data suggest that their effects go well beyond the lipid lowering seen with long-term use and may include acute antiinflammatory activity, anticoagulation, immunomodulation, as well as promotion of changes in smooth-muscle tone. Because of these data, promising research has begun into the use of these agents in various critical care areas such as the early phases of sepsis, bacteremia, and ischemic stroke. Recent data also show a decrease in cerebral vasospasm after subarachnoid hemorrhage, an area deficient in therapeutic options. More research is necessary to ascertain the true role of statins in the treatment of these various disorders. Nevertheless, the concept of a statin's role as being only a routine preventive therapy with benefits limited to patients undergoing extended treatment is rapidly becoming inaccurate.

Antiplatelet therapy is commonly administered for primary and secondary prevention of stroke, recurrent angina, myocardial infarction, and death in patients with cardiovascular disorders. It also is associated with an increased risk of bleeding. We describe the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery. In addition, we provide basic information about the mechanisms of action by which the most common antiplatelet agents inhibit platelet function. This information is integrated with results from pharmacologic studies and clinical trials. Determining the net effect in patients undergoing coronary artery bypass graft surgery requires knowledge about the pharmacokinetics, pharmacodynamics, and clinical efficacy of each drug, and an estimation of the absolute thrombotic versus hemorrhagic risk for each patient.

Compilations of articles important to the pharmacist practicing in the emergency department have not been published. Consistent with other specialty areas of practice, a collection of important literature is valuable for both the new and experienced clinician. A diverse breadth of medical problems are represented that were felt to be the most pertinent issues facing the emergency medicine pharmacist; however, it is not intended to be a complete representation of available literature.

In 2000, the Society of Critical Care Medicine (SCCM) and the American College of Clinical Pharmacy (ACCP) published a position paper that defined critical care pharmacy services as fundamental, desirable, and optimal. A task force was developed that included individuals who are members of the ACCP Critical Care Practice and Research Network, the SCCM clinical pharmacy and pharmacology section, and the American Society of Health-System Pharmacists to develop an opinion paper with three primary objectives: to provide recommendations for the level of preparation and training of pharmacists to practice in critical care, to develop recommendations for the credentialing of pharmacists providing critical care services, and to develop mechanisms for documenting and justifying intensive care unit (ICU) pharmacy services. Each objective was addressed to accommodate the levels of services defined as fundamental, desirable, or optimal, and are targeted at all pharmacists providing or wanting to provide pharmacy services to critically ill patients. The training and preparing of the pharmacist caring for critically ill patients is discussed in the context of the knowledge and skills required to provide pharmacy services in the ICU. Credentialing of the critical care pharmacist and the documentation of services take into account the various scopes of practice, and recommendations are based on current and idealistic mechanisms. A detailed outline is provided for the process of services justification. This paper provides a foundation that is focused on delivering direct and proactive patient care services, particularly at the desirable and optimal levels, with the ultimate goal of enhancing the level of pharmacy services provided to the care of critically ill patients. This commentary should be of interest to numerous stakeholders including pharmacists, other pharmacy department staff, other ICU health care professionals, hospital and academic administrators, accrediting agencies, government officials, and payers. The task force encourages the profession of pharmacy in general to incorporate key recommendations provided in this document with respect to specialized training, credentialing, and service justification.