Search

Purpose Medication product labeling was reviewed to determine if sufficient information is available to appropriately calculate dosing regimens for special intensive care unit (ICU) populations, including patients at extremes of body habitus and patients receiving hemodialysis, continuous renal replacement therapy (CRRT), or extracorporeal membrane oxygenation (ECMO). Methods The labeling of the 100 most commonly used injectable medications in the adult ICUs of an academic medical center in Arizona were evaluated. Any information related to adult weight-based dosing, weight descriptors, dosing of patients at extremes of weight (body mass index of <18.5 or >40 kg/m2), and dosing of patients receiving hemodialysis, CRRT, or ECMO was extracted from Food and Drug Administration–approved product labeling. Information was ranked for dosing usefulness on a scale of 0 to 3; an information usefulness score of 2 or greater was considered minimally adequate for dosing special ICU populations. Results Among the 100 medications evaluated, the labeling of 47 provided information on weight-based dosing, with the labeling of 30% referring to a specific weight descriptor. The labeling of 15 medications had information on dosing for patients at extremes of body habitus: underweight (3 medications), obesity (12 medications), and extreme obesity (2 medications), with the labeling of 8 medications receiving an information usefulness score of ≥2 (2, 6, and 1 medication in the respective categories). Among the 42 medications whose labeling provided hemodialysis-related dosing information, the labeled information of 52% was assigned a usefulness score of ≥2; among the 3 medications with CRRT-related dosing information, the labeling of 1 received a score of ≥2. ECMO-related dosing information was available for 2 medications, with 1 score of ≥2 assigned. Conclusion Information in the product labeling of injectable medications commonly used in the ICU is limited and generally inadequate for calculating an appropriate dose for special ICU populations. [ABSTRACT FROM AUTHOR]

Background Whether or not norepinephrine infusions for support of hemodynamic status in patients with septic shock should be weight based is unknown. This situation is particularly pertinent in patients who are extremely overweight or obese. Objective To compare dosing requirements and effect of norepinephrine on blood pressure in obese and nonobese patients with septic shock. Methods In a retrospective cohort study, data on adult patients with septic shock who received norepinephrine infusion for support of hemodynamic status in a tertiary care, academic medical center were analyzed. Patients were categorized as obese (body mass index ≥ 30) or nonobese (body mass index < 30). The primary outcome was dosing requirements of norepinephrine at 60 minutes after the start of the infusion. The secondary outcome was the log-transformed ratio of mean arterial pressure to norepinephrine. Results The final cohort consisted of 100 obese and 100 nonobese patients. Mean norepinephrine infusion rate at 60 minutes was 0.09 (SD, 0.08) µg/kg per minute in the obese group and 0.13 (SD, 0.14) µg/kg per minute in the nonobese group (P = .006). The non--weight-based dose at 60 minutes was 9 µg/min in obese patients and 8 µg/ min in nonobese patients (P = .72). The log transformed mean arterial pressure to norepinephrine ratio at 60 minutes was 2.5 (SD, 0.9) in obese patients and 2.5 (SD, 0.8) in nonobese patients (P = .54) Conclusions Compared with nonobese patients, obese patients with septic shock require lower weight-based doses of norepinephrine and similar total norepinephrine doses. [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]

Purpose The need for high-quality research during disaster responses has been well described in the literature, and such research is supported by efforts at the federal level through the National Institutes of Health Disaster Research Response (DR2) Program. This article describes the fourth DR2 workshop with a specific focus on opportunities for pharmacists to get involved with disaster research efforts. Summary Pharmacists have historically played a significant role in disaster planning and response, and there are a number of opportunities for pharmacists to bring their unique perspective, positioning, and skills to disaster research response (ie, onsite and other research on the medical and public health aspects of disasters and public health emergencies). In February 2019, the fourth DR2 workshop was held in Tucson, AZ, in conjunction with the University of Arizona College of Medicine–Tucson, the university's Mel and Enid Zuckerman College of Public Health, University of Arizona College of Pharmacy, and the university's Bio5 Institute to explore clinical and population-based research in a simulated disaster setting. This article describes the workshop and discusses several opportunities for pharmacists to design, lead, and support research efforts during disaster scenarios through involvement in research areas including clinical, operational, educational, and logistic aspects of pharmacy practice. Conclusion Due to their positioning throughout health systems, unique perspective, training, and skills, pharmacists are uniquely situated to play an important role in disaster research response. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of a transition-of-care pharmacist during hospital discharge., Setting: An academic medical center in southern Arizona., Practice Description: One pharmacist coordinated patient discharges in two inpatient units from August 2012 through July 2013. The pharmacist attended interdisciplinary discharge coordination meetings, ensured appropriate discharge orders, facilitated the filling of medications, and educated patients on discharge medications., Practice Innovation: The implementation of a transition-of-care pharmacist to provide discharge medication reconciliation and education., Main Outcome Measures: Readmission rates and medication interventions made by the pharmacist at discharge., Results: The pharmacist was involved in the education of 1,011 patients and performed 452 interventions. There were more readmissions per month in the control year versus the year of pharmacist involvement (median 27.5 vs. 25, P = 0.0369). Interventions made by the pharmacist to improve discharge management included starting an omitted medication (23.5%), preventing multiple discharge problems (16.4%), avoiding duplication of therapy (15.7%), correcting insurance issues related to medication coverage (12.2%), changing an improper medication dose or quantity (11.3%), changing an inappropriate prescription for a medication (5.1%), preventing a drug interaction (3.3%), and resolving other problems (12.6%). The most common medication classes involved were antimicrobial agents (9.1%), anticoagulants (8%), antihyperglycemic agents (3.8%), other drug classes (24%), and multiple drug classes (35%)., Conclusion: A transition-of-care pharmacist is in a unique position to educate patients on hospital discharge, to intercept a substantial number of medication errors, and to resolve insurance issues that may lead to adherence problems. These improvements in care may result in reduced hospital readmission rates.

Purpose: The cost implications of and potential adverse events prevented by the interventions of a critical care pharmacist were studied., Methods: A decentralized clinical pharmacist assigned to a surgical intensive care unit (ICU) documented all interventions made from mid-October 2003 through February 2004 using a standardized written form. The data were retrospectively evaluated and the following information was extracted: amount of time spent performing various clinical activities, how drug-related problems were identified (e.g., order entry versus chart review), and a general description of the interventions. The interventions were independently reviewed by two other clinical pharmacists to determine whether an actual or potential adverse drug event (ADE) would have occurred without the intervention, the probability that an ADE would have occurred without the intervention, the type of intervention, and potential cost avoidance of the intervention. Once the evaluations were completed, the data obtained from order entry and verification activities were compared with the data obtained during other clinical functions., Results: A total of 129 interventions were documented over 4.5 months. The majority of interventions were identified during chart review (40%) and patient care rounds (39%). The potential cost avoidance of the documented interventions was $205,919-$280,421. Interventions identified during patient care rounds and chart review were most likely to achieve the greatest impact on cost avoidance., Conclusion: Among the interventions performed and documented by a clinical pharmacist in an ICU, patient care rounds and chart-review activities were associated with the greatest number of interventions and the greatest potential cost avoidance.

Objective: To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated., Design: Prospective, direct observation study., Setting: A 16-bed pediatric medical/surgical ICU at a tertiary care academic medical center., Patients: One enrolled nurse caring for at least one pediatric ICU patient age <18 yrs was randomly chosen during each observation period., Interventions: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort., Measurements and Main Results: Medication errors and potential and actual ADEs were identified throughout the entire medication use process. The 26 12-hr observation periods included 357 reviewed written orders and 263 observed doses. The study observers identified 58 incidents, which were subsequently classified by the evaluators according to clinical importance, severity, and preventability. Fifty-two of these incidents were considered medication errors; six incidents were determined to be nonpreventable ADEs. Of the 52 medication errors, 42 (81%) were considered clinically important. Potential ADEs comprised 35 (83%) of these important medication errors; the other seven (17%) were classified as actual, preventable ADEs. Overall, the actual and potential ADE rate occurred at 3.6 events and 9.8 events per 100 orders, respectively., Conclusions: Our medication error rate was similar to that of previous pediatric ICU studies that used the direct observation method for reporting but higher than the rates in previous studies using other detection techniques such as voluntary incident reporting. Periodic direct observation and other ongoing data collection methods such as voluntary incident reporting have the potential to be complementary approaches to medication error and ADE detection.

Objective: To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence., Design: Prospective, direct observation study., Setting: Tertiary care academic medical center., Patients: Patients in a medical/surgical intensive care unit., Interventions: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort., Measurements and Main Results: The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%)., Conclusions: Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions.