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Introduction: Opioid exposure has been identified as a contributing factor to the opioid epidemic. Reducing patient exposure, by altering heavy opioid prescribing patterns but appropriately addressing patient pain, may represent one approach to combat this public health issue. Our goal was to create and implement an opioid education program for emergency medicine (EM) interns as a means of establishing foundational best practices for safer and more thoughtful prescribing.Methods: This was a retrospective study at an academic, urban emergency department (ED) comparing ED and discharge opioid prescribing practices over a 12-week time period for two 14-intern EM classes (2016 and 2018) to evaluate an early opioid reduction education program. The education programincluded opioid prescribing guidelines for common ED disease states associated with moderate pain,clinician talking points, and electronic education modules, and was completed by EM interns in July/August 2018. Opioid prescription rates per shift were calculated and opioid prescribing best practices described. We used chi-squared analysis for comparisons between the 2016 and 2018 classes.Results: Overall, ED and discharge opioid orders prescribed by EM interns were fewer in the 2018 class that received education compared with the 2016 class. ED opioid orders were reduced by 64% (800 vs 291 orders, rate per shift 1.8 vs 0.7 orders) and opioid discharge prescriptions by 75% (279 vs 70 prescriptions, rate per shift 0.7 vs 0.2 prescriptions). The rate of prescribing combination opioid products compared to opioids alone was decreased for ED orders (32% vs 16%, P < 0.01) and discharge prescriptions (91% vs 74%, P < 0.01) between the groups. Also, the median tablets per discharge prescription (14.5 vs 10) and total tablets prescribed (4,305 vs 749) were reduced, P

The authors share their experience developing and implementing on-site clinical pharmacy services within a freestanding emergency departments (FSEDs). Topics include pharmacy team structure, medication safety measures unique to the FSED, and collaboration of the FSED pharmacy team with other pharmacy department members.

Purpose Vasoactive medications are used during advanced cardiac life support (ACLS) to shunt oxygenated blood to vital organs and after return of spontaneous circulation (ROSC) to maintain hemodynamic goals. However, limited evidence exists to support vasoactive medication recommendations in such scenarios, and it is unknown how practices vary among emergency departments across the US. Methods A survey questionnaire (15 questions) was electronically distributed to emergency medicine pharmacists (EMPs) in the US through various professional listservs. Demographic information, American Heart Association ACLS algorithm medication use, and use of continuous vasopressor infusions and adjunct medications following ROSC were assessed and are reported descriptively. Results The survey was distributed to 764 EMPs, with a 23% response rate from a wide geographic distribution and 48% of respondents practicing in academic medical centers. Epinephrine dosing and administration during cardiac arrest were reported by most to be in accordance with ACLS cardiac arrest algorithms. Calcium, magnesium sulfate, and sodium bicarbonate were the most common adjunct intravenous medications given during cardiac arrest. Norepinephrine was the first-choice vasopressor (81%) for post-ROSC hypotension, while epinephrine was preferred less frequently (17%). Antibiotics and sodium bicarbonate were the most frequently administered post-ROSC adjunct medications. Conclusion This survey of a geographically diverse group of EMPs demonstrated high ACLS algorithm adherence for epinephrine during cardiac arrest with frequent additional administration of nonalgorithm medications. Sodium bicarbonate and calcium were the most frequently administered adjunct medications during cardiac arrest, while sodium bicarbonate and antibiotics were the most frequently used adjunct medications following ROSC. Norepinephrine was the most commonly used vasopressor following ROSC. [ABSTRACT FROM AUTHOR]

Background: Critical care pharmacists are well‐established, valuable members of the intensive care unit interprofessional team with unique skills to perform comprehensive medication management in complex critically ill patients. However, standardized and consequential productivity metrics for critical care pharmacists have not been established. Objective: To characterize the utilization and perception of contemporary critical care pharmacy productivity metrics utilized among individual institutions. Design, Setting, and Participants: An electronic survey was distributed to critical care pharmacist members of the Society of Critical Care Medicine Clinical Pharmacy and Pharmacology Section and the American College of Clinical Pharmacy Critical Care Practice and Research Network. Main Outcomes and Measures: The survey included 23 questions to assess institution demographics, individual respondent demographics, institution practices, and individual respondent perceptions about the value of critical care pharmacist productivity metrics. Results: A total of 204 critical care pharmacists, largely from the United States, responded to the survey between July and November 2022. Institutional metrics captured by more than 50% of the respondents' institutions included order verification rate/number of orders verified (60%), number of clinical interventions (57%), and intravenous to enteral product interchanges (52%). Of these metrics, critical care pharmacists only agreed with the value of the number of clinical interventions, were indifferent to the value of intravenous to oral product interchanges, and disagreed with the value of order verification rate/number of orders verified. Conclusions: Significant discrepancies exist between institutional productivity metric practices and their perceived value and utility among critical care pharmacists. [ABSTRACT FROM AUTHOR]

Objective. Describe continuous infusion (CI) ketamine practices in pediatric intensive care units (PICUs) and evaluate its effect on pain/sedation scores, exposure to analgesics/sedatives, and adverse effects (AEs). Methods. Multicenter, retrospective, observational study in children <18 years who received CI ketamine between 2014 and 2017. Time spent in goal pain/sedation score range and daily cumulative doses of analgesics/sedatives were compared from the 24 hours (H) prior to CI ketamine to the first 24H and 25−48H of the CI. Adverse effects were collected over the first 7 days of CI ketamine. Results. Twenty‐four patients from 4 PICUs were included; median (IQR) age 7 (1‐13.25) years, 54% female (n = 13), 92% intubated (n = 22), 25% on CI vasopressors (n = 6), and 33% on CI paralytics (n = 8). Ketamine indications were analgesia/sedation (n = 21, 87.5%) and status epilepticus (n = 3, 12.5%). Median starting dose was 0.5 (0.48–0.70) mg/kg/hr and continued for a median of 2.4 (1.3–4.4) days. There was a significant difference in mean proportion of time spent within goal pain score range (24H prior: 74% ± 14%, 0–24H: 85% ± 10%, and 25−48H: 72% ± 20%; p = 0.014). A significant reduction in median morphine milligram equivalents (MME) was seen (24H prior: 58 (8–195) mg vs. 0–24H: 4 (0–69) mg and p = 0.01), but this was not sustained (25−48H: 24 (2–246) mg and p = 0.29). Common AEs were tachycardia (63%), hypotension (54%), secretions/suctioning (29%), and emergence reactions (13%). Conclusions. Ketamine CI improved time in goal pain score range and significantly reduced MME, but this was not sustained. Larger prospective studies are needed in the pediatric population. [ABSTRACT FROM AUTHOR]

The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support. We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock. The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison. The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed to characterize medication-related practices during and immediately following rapid sequence intubation (RSI) in pediatric care units across the United States and to evaluate adverse drug events. METHODS: This was a multicenter, observational study of medication practices surrounding intubation in pediatric and neonatal intensive care unit (NICU) and emergency department patients across the United States. RESULTS: A total of 172 patients from 13 geographically diverse institutions were included. Overall, 24%, 69%, and 50% received preinduction, induction, and neuromuscular blockade, respectively. Induction and neuromuscular blocking agent (NMBA) use was low in NICU patients (52% and 23%, respectively), whereas nearly all patients intubated outside of the NICU received both (98% and 95%, respectively). NICU patients who received RSI medications were older and weighed more. Despite infrequent use of atropine (21%), only 3 patients developed bradycardia after RSI. Of the 119 patients who received an induction agent, fentanyl (67%) and midazolam (34%) were administered most frequently. Hypotension and hypertension occurred in 23% and 24% of patients, respectively, but were not associated with a single induction agent. Etomidate use was low and not associated with development of adrenal insufficiency. Rocuronium was the most used NMBA (78%). Succinylcholine use was low (11%) and administered despite hyperkalemia in 2 patients. Postintubation sedation and analgesia were not used or inadequate based on timing of initiation in many patients who received a non-depolarizing NMBA. CONCLUSIONS: Medication practices surrounding pediatric RSI vary across the United States and may be influenced by patient location, age, and weight. [ABSTRACT FROM AUTHOR]