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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]

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

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

Objectives: The purpose of this critical narrative review is to discuss the revised Starling equation for microvascular fluid exchange and the associated implications for intravenous fluid administration. Data Sources: PubMed (1946 to December 2019) and EMBASE (1947 to December 2019) were used, and bibliographies of retrieved articles were searched for additional articles. Study Selection and Data Extraction: Articles pertaining to the revised Starling equation and microvascular fluid exchange. Additionally, prospective human studies involving the disposition and oncotic action of radiolabeled albumin and large randomized trials comparing fluid requirements associated with isotonic crystalloid and albumin administration were included. Data Synthesis: In the revised Starling equation, oncotic forces act across the endothelial cell layer, more specifically between the fluid in the vessel lumen and the protein-sparse subglycocalyx space. The revised Starling equation and radiolabeled investigations of albumin necessitate a reconsideration of conventional views of the plasma-expanding properties of exogenous albumin. Large clinical trials demonstrate that the administration of iso-oncotic or hyper-oncotic albumin solutions in patients undergoing resuscitation does not have the reductions in fluid requirements anticipated from a traditional understanding of the oncotic actions of albumin. Relevance to Patient Care and Clinical Practice: When used as a resuscitation fluid, albumin does not have the degree of plasma expansion or intravascular retention commonly used to justify its use. Conclusions: The principles underlying the revised Starling equation in conjunction with data from radiolabeled studies of albumin and large clinical trials demonstrate that albumin does not have the perceived degree of plasma expansion or duration of intravascular retention beyond crystalloid solutions predicted by the classic Starling equation. [ABSTRACT FROM AUTHOR]

Background:Optimal albumin use in the intensive care unit (ICU) remains challenging with inappropriate use approaching 50%. No published reports have described clinical pharmacist impact aimed at mitigating inappropriate albumin use in the ICU. Objective: To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin in the ICU. Methods: A retrospective cohort study evaluated all adult (≥18 years) ICU patients administered albumin at an academic medical center over a 2-year period. Institutional guidelines were developed with clinical pharmacists targeting inappropriate albumin use. The primary end point was to compare inappropriate use of albumin administered before and after pharmacist intervention implementation. Secondary analyses compared the overall albumin use between study periods. In-hospital mortality, length of stay, and albumin-related costs between study periods were also compared. Results: A total of 4419 patients were identified, with 2448 (55.4%) critically ill patients included. The pharmacist-led strategy resulted in a 50.9% reduction of inappropriate albumin use (P < 0.001). The rate of inappropriate albumin use was 44.3 ± 10.5 and 5.5 ± 2.9 g per patient-day in the preimplementation and postimplementation periods, respectively (P < 0.001). Costs associated with overall and inappropriate albumin use in the ICU decreased by 34.8% and 87.1%, respectively. Total annual cost-savings was $355 393 in the ICUs. No differences in clinical outcomes were found. Conclusion and Relevance: Clinical pharmacist-led interventions reduced overall and inappropriate albumin use and costs without negatively affecting clinical outcomes. [ABSTRACT FROM AUTHOR]

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

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]

Proponents of dexmedetomidine often cite the agent’s analgesic properties as one of its main advantages over propofol and benzodiazepines. However, there are very limited studies utilizing endpoints such as analgesic requirements to provide supporting evidence for these claims. The primary purpose of this retrospective study was to compare opioid analgesic requirements in trauma patients receiving nonconcurrent dexmedetomidine and propofol for sedation while being weaned from mechanical ventilation. Total analgesic requirements were similar between dexmedetomidine and propofol within 48 hours of sedative initiation in adult trauma patients ( P > .05). [ABSTRACT FROM AUTHOR]

Propofol use may lead to hypotension in trauma patients intubated in the emergency department. In this study, predictors of hypotension were identified. We hypothesized that demographic variables could be associated with hypotension. Hypotension occurred in 33 of 200 patients. In the multivariate analysis, hypotension was associated with patient age greater than 55 years (odds ratios [OR], 3.61; 95% confidence interval [CI], 1.32-9.86; P = .012), obesity (OR, 2.66; 95% CI, 1.08-6.55; P = .034), and lower baseline blood pressure (OR, 1.59 [per 10-mm Hg decrease]; 95% CI, 1.29-1.96; P = .000). Age greater than 55 years, obesity, and lower baseline systolic blood pressure are associated with a higher risk of propofol-induced hypotension in trauma patients. [ABSTRACT FROM AUTHOR]

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

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

Background Albumin is broadly prescribed for critically ill patients although it does not have a mortality benefit over crystalloids. One common use of albumin is to promote diuresis. Objectives To compare urine output in patients treated with furosemide with and without albumin and to assess other variables possibly associated with enhanced diuresis. Methods A retrospective study was conducted on patients in a medical intensive care unit who received furosemide therapy as a continuous infusion with and without 25% albumin for more than 6 hours. Primary end points were urine output and net fluid loss. Results A total of 31 patients were included in the final analysis. Mean urine output in patients treated with furosemide alone did not differ significantly from output in patients treated with furo - semide plus albumin at 6, 24, and 48 hours: mean output, 1119 (SD, 597) mL vs 1201 (SD, 612) mL, P= .56; 4323 (SD, 1717) mL vs 4615 (SD, 1741) mL, P = .42; and 7563 mL (SD, 2766) vs 7432 (SD, 2324) mL, P = .94, respectively. Additionally, net fluid loss did not differ significantly between the 2 groups at 6, 24, and 48 hours. Higher concentrations of serum albumin did not improve urine output. The only independent variable significantly associated with enhanced urine output at 24 and 48 hours was increased fluid intake. Conclusion Addition of albumin to a furosemide infusion did not enhance diuresis obtained with furosemide alone in critically ill patients. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to determine the effect of paralytic type and dose on first-attempt rapid sequence intubation (RSI) success in the emergency department (ED). Methods: This was a retrospective evaluation of information collected prospectively in a quality improvement database between July 1, 2007, and October 31, 2008. Information regarding all intubations performed in a tertiary care ED was recorded in this database. All RSI performed using succinylcholine or rocuronium were included. Logistic regression was used to analyze the effect of paralytic type and dosing, as well as age, sex, body mass index, physician experience, device type, and presence of difficult airway predictors on first attempt RSI success. Results: A total of 327 RSI were included in the final analyses. All patients received etomidate as the induction sedative and were successfully intubated. Of these, 113 and 214 intubations were performed using succinylcholine and rocuronium, respectively. The rate of first-attempt intubation success was similar between the succinylcholine and rocuronium groups (72.6% vs. 72.9%, p = 0.95). Median doses used for succinylcholine and rocuronium were 1.65 mg/ kg (interquartile range [IQR] = 1.26-1.95 mg/ kg) and 1.19 mg/ kg (IQR = 1-1.45 mg/ kg), respectively. In the univariate logistic regression analyses, variables predictive of first-attempt intubation success were laryngeal view (more success if Grade 1 or 2 compared to Grade 3 or 4 of the Cormack-Lehane classification, odds ratio [OR] = 55.18, 95% confidence interval [CI] = 18.87 to 161.39), intubation device (less success if direct laryngoscopy, OR = 0.57, 95% CI = 0.34 to 0.96), and presence of a difficult airway predictor (OR = 0.55, 95% CI = 0.31 to 0.99). In the multivariate analysis, the only variable predictive of first-attempt intubation success was laryngeal view. Conclusions: Succinylcholine and rocuronium are equivalent with regard to first-attempt intubation success in the ED when dosed according to the ranges used in this study. [ABSTRACT FROM AUTHOR]

Objective: To compare possible differences in the proportion of medication errors associated with high-risk medications that were avoided by the use of automated infusion device (AID) technology in pediatric and adult intensive care unit (ICU) patients. A secondary purpose was to investigate the number of serious adverse drug events (ADEs) identified by root-cause analyses (RCA).Method: The study included pediatric and adult patients receiving high-risk medications by continuous infusion in an academic medical center with mixed medical-surgical ICUs. A retrospective evaluation of 1 year’s data collected prospectively in an AID database was used to compare the proportion of medication errors avoided based on reprogramming events (2.5 times limit as a low threshold) and overrides (10 times limit as high). Information obtained from RCAs was used to compare the proportion of serious ADEs that occurred during the 5-year periods before and after AID implementation.Results: The pediatric population was 1.68 times (95% confidence interval [CI], 1.18 to 2.38) more likely to require a reprogramming event than the adult acute care population for all high-risk medications combined. Significantly more reprogramming events occurred in the pediatric patients with potassium (relative risk [RR], 2.77; 95% CI, 1.15 to 6.68) and insulin (RR, 2.73; 95% CI, 1.15 to 6.45) infusions. Additionally, there were more overrides in the pediatric compared to the adult population for the high-risk medications (RR, 1.82; 95% CI, 1.32 to 2.53). The number of serious adverse or sentinel events as identified in RCAs decreased from six before (four deemed preventable by AID technology) to three (zero preventable) after AID implementation.Conclusions: This study demonstrates that AID technology when properly used leads to reductions in medication errors and possibly serious ADEs in critically ill patients receiving high-risk medications. The technology appears to be particularly beneficial in pediatric patients with weight-based dosing strategies. However, the potential for clinicians to override the alerts remains a concern. [ABSTRACT FROM AUTHOR]

Study Objectives. To determine whether use of inhaled alprostadil (PGE1) or epoprostenol (PGI2) significantly improved oxygenation in patients with acute respiratory distress syndrome (ARDS), and to determine whether differences between the two drugs exist with regard to oxygenation, duration of mechanical ventilation and hospitalization, adverse effects, and survival. Design. Retrospective chart review. Setting. A 360-bed tertiary care teaching facility with medical and surgical intensive care units. Patients. Twenty-seven patients admitted to the hospital who received either PGI2 or PGE1 for a primary or secondary diagnosis of ARDS. Measurements and Main Results. Seventeen patients received inhaled PGE1 and 10 received inhaled PGI2. There were no significant changes in the ratio of arterial partial pressure of oxygen (PaO2):fraction of inspired oxygen (FiO2) and in the PaO2, from baseline to any time point that was analyzed during treatment, for patients receiving either PGE1 (p=0.2120 and 0.3399, respectively) or PGI2 (p=0.1655 and 0.0784, respectively). Conclusion. No statistically significant improvement in oxygenation was observed in patients receiving either PGE1 or PGI2. In addition, no significant differences were found between the two prostaglandins for the variables studied. Until positive results from large, prospective studies are available, we recommend that these inhaled prostaglandins not be used to treat ARDS. [ABSTRACT FROM AUTHOR]

The article presents an update on expert recommendations on the use of neuromuscular blocking agents (NMBA) in critically ill adult patients for 2016. Topics covered include scheduled eye care for patients receiving continuous infusions with NMBA, NMBA administration in patients undergoing therapeutic hypothermia, implementation of measures to attenuate the risk of unintended extubation and the use of analgesic and sedative drugs before and during neuromuscular blockade.

Purpose To evaluate potential differences in days on mechanical ventilation for patients with coronavirus disease 2019 (COVID-19) based on route of administration of analgesic and sedative medications: intravenous (IV) alone vs IV + enteral (EN). Summary This institutional review board–approved study evaluated ventilation time and fentanyl or midazolam requirements with or without concurrent EN hydromorphone and lorazepam. Patients were included in the study if they were 18 to 89 years old and were admitted to the intensive care unit with a positive severe acute respiratory syndrome coronavirus 2 reverse transcription and polymerase chain reaction or antigen test and respiratory failure requiring invasive mechanical ventilation for more than 72 hours. In total, 100 patients were evaluated, 60 in the IV-only group and 40 in the IV + EN group. There was not a significant difference in ventilation time between the groups (mean [SD], 19.6 [12.8] days for IV + EN vs 15.6 [11.2] days for IV only; P = 0.104). However, fentanyl (2,064 [847] μg vs 2,443 [779] μg; P < 0.001) and midazolam (137 [72] mg vs 158 [70] mg; P = 0.004) requirements on day 3 were significantly higher in the IV-only group, and the increase in fentanyl requirements from day 1 to day 3 was greater in the IV-only group than in the IV + EN group (378 [625] μg vs 34 [971] μg; P = 0.033). Conclusion Addition of EN analgesic and sedative medications to those administered by the IV route did not change the duration of mechanical ventilation in patients with COVID-19, but the combination may reduce IV opioid requirements, decreasing the impact of IV medication shortages. [ABSTRACT FROM AUTHOR]