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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]

The article discusses the evolution of critical care pharmacy practice and the acceptance of critical care pharmacists by their colleagues. It highlights the importance of a landmark study by Leape et al. published in 1999, which demonstrated the value of pharmacists in preventing adverse drug events (ADEs) in the ICU setting. The study found that involving a pharmacist in ICU rounding significantly reduced preventable ADEs. This study, along with other publications and consensus recommendations, has helped establish the role and value of critical care pharmacists in medication optimization and patient safety. [Extracted from the article]

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 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.

Reports on data from pharmaceutical students' experiential training based on paired baseline and end-of-rotation short-answer tests of 86 students over a 10-year period. Significant improvements from baseline to end-of-rotation were found. Results suggest the value of the written examination as an interactive assessment instrument, but not as a replacement for more subjective evaluations. (DB)

Each survey allowed for the assessment of two specialty practice organizations, so there could have been up to four organizations assessed if both the chair and vice chair/chair elect provided an assessment of two organizations, but this did not happen. SCCM was cited as a major interprofessional organization by Emergency Medicine PRN leadership but had one "no" response in contrast to all "yes" responses from the Critical Care PRN, but it is unclear how much to read into this single difference. In a previous publication of JACCP, I wrote an editorial providing criteria that might prove useful by health care professionals for determining their perceptions of interprofessional involvement in their specialty interprofessional health care organizations.[1] The criteria had three levels with a series of questions allowing for yes or no responses and a column for comments. [Extracted from the article]

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.

Introduction: Despite its widespread use, there is a paucity of data to guide the optimal use of arginine vasopressin (AVP) in critically ill patients with septic shock. Methods: This multicenter retrospective cohort study conducted in critically ill adults sought to evaluate the role of catecholamine requirements and timing on responsiveness to AVP. Responsiveness was defined as both a decrease in = 50% of catecholamine requirements and no decrease in mean arterial pressure (MAP) at 4 hours post-AVP initiation. Primary outcomes of interest included the proportion of patients who started AVP within 4 hours after starting catecholamine therapy, as well as baseline norepinephrine (NE) equivalents (< 15, 15-39, or = 40 mcg/min). Multivariate analyses and logistic regression were performed to identify other factors associated with AVP responsiveness. Results: There were 300 patients included in this study, with 74 patients being responders and 226 being non-responders. There was no significant difference in the number of patients who received AVP within 4 hours from catecholamine initiation between responders and non-responders (35% vs. 42%, P=0.29). There were more patients in the non-responder group requiring = 40 mcg/min of NE equivalents at AVP initiation (30% vs. 16%, P=0.023). Stress dose steroid use was less common in responders (35% vs. 52%, P=0.011), which was consistent with logistic regression analysis (OR 0.56, 95% 0.32-0.98, P=0.044). Clinical outcomes between responders and non-responders were similar, apart from ICU (5.4% vs. 19.5%) and hospital (5.4% vs. 20.4%) mortality being lower in responders (P =0.0032 and P=0.0002, respectively). Conclusion: Shorter times to AVP initiation was not associated with responsiveness at 4 hours post-catecholamine initiation, although non-responders tended to require higher doses of NE equivalents at time of AVP initiation. Concomitant corticosteroids were associated with a lower likelihood of AVP responsiveness. [ABSTRACT FROM AUTHOR]

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]