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Background: Critical care pharmacists complete comprehensive medication reviews in Post Intensive Care Syndrome (PICS) patients at Intensive Care Unit Recovery Centers (ICU-RCs) to optimize medication therapies after hospital discharge. Inpatient pharmacists often complete medication reconciliations prior to hospital discharge, which could affect interventions at an ICU-RC. However, this association remains ill-described. Objective: The purpose of this study was to, in patients with PICS, describe the effect of an inpatient, pharmacist-led medication reconciliation on the number of clinical pharmacist interventions at the first ICU-RC visit. Methods: This was a post-hoc subgroup analysis of an international, multicenter cohort study of adults who had a pharmacist-led comprehensive medication reconciliation conducted in 12 ICU-RCs. Only patients' first ICU-RC visit was eligible for inclusion. The primary outcome was the number of medication interventions made at initial ICU-RC visit in PICS patients who had an inpatient, pharmacist-led medication reconciliation compared to those who did not. Results: Of 323 patients included, 83 received inpatient medication reconciliations and 240 did not. No difference was observed in the median number of medication interventions between groups (2 vs 2, p =.06). However, a higher incidence of any intervention (86.3% vs 78.3%, p =.09) and dose adjustment (20.4% vs 9.6%; p =.03) was observed in the no medication reconciliation group. Only ICU Sequential Organ Failure Assessment score was associated with an increased odds of medication intervention at ICU-RC visit (aOR 1.15, 95% CI 1.05-1.25, p <.01). Conclusion and Relevance: No difference in the total number of medication interventions made by ICU-RC clinical pharmacists was observed in patients who received an inpatient, pharmacist-led medication reconciliation before hospital discharge compared to those who did not. Still, clinical observations within this study highlight the continued importance and study of clinical pharmacist involvement during transitions of care, including ICU-RC visits. [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 intensive care unit (ICU) liberation (A–F) bundle is recommended by the Society of Critical Care Medicine guidelines as standard supportive care. Significant deviations were made to providing bundled care during the coronavirus disease 2019 (COVID‐19) pandemic. The objective of the study is to describe how COVID‐19 affected bundle adherence at a single academic medical center. This is a retrospective cohort study of adult medical ICU patients on mechanical ventilation (MV) for at least 48 h and an ICU stay of at least 7 days. Patients were separated into three cohorts based on ICU admission date and COVID‐19 status from April 2019 to March 2021; pre‐pandemic (pre‐COV), pandemic COVID‐19 negative (COV‐neg), and pandemic COVID‐19 positive (COV‐pos). Primary outcomes were median average daily bundle adherence over 7 days and daily complete bundle adherence. Secondary outcomes were individual bundle component adherence rates and patient outcomes. A total of 67 patients were included. Median average daily bundle adherence (pre‐COV 68.6% vs. COV‐neg 51.4% vs. COV‐pos 32.6%; p < 0.001), median number of days with complete adherence (pre‐COV 1 [interquartile range (IQR) 0–1] vs. COV‐neg 0 [IQR 0–0] vs. COV‐pos 0 [IQR 0–0]; p < 0.001), and percentage of patients with any day of complete bundle adherence (pre‐COV 78.6% vs. COV‐neg 14.3% vs. COV‐pos 7.1%) were different among groups and individual bundle component adherence varied. Also, median duration of MV (pre‐COV: 6.3 days [IQR 5.6–9], COV‐neg: 8.9 days [IQR 7.6–14], COV‐pos: 11.6 days [IQR 8.4–21], p = 0.01) and median days alive and free from MV up to Day 30 (pre‐COV: 23 [IQR 21–24], COV‐neg: 20 [IQR 15–22], COV‐pos: 18 [IQR 7–21], p = 0.015) were significantly different between groups. ICU A–F bundle adherence was significantly reduced during the COVID‐19 pandemic in patients with and without COVID‐19 infection. [ABSTRACT FROM AUTHOR]

Managing pain and agitation in patients with opioid abuse is becoming more common in intensive care units. Tolerance to commonly used agents is often observed, leading to inadequate pain control and increased agitation. Ketamine’s unique mechanism of action and opioid-sparing effects make it an ideal agent for patients with suboptimal response to opioid therapy.

Introduction: Pulmonary embolism response teams (PERTs) were developed to assist with diagnosis, risk stratification, and management of intermediate and high‐risk pulmonary embolism (PE) and have been shown to reduce 90‐day mortality. The pharmacist's role on the PERT is not well defined. Objectives: Describe the pharmacist's role as a PERT member and determine if pharmacists can improve time to anticoagulation and promote use of low molecular weight heparin (LMWH) instead of unfractionated heparin (UFH). Methods: A retrospective, observational study of adult patients with massive or submassive PE between January 2014 and May 2020. Patient demographics, clinical variables, anticoagulation treatment/timing, and pharmacist activities during PERT response were evaluated. Patients were divided into three groups for comparisons (pre‐PERT vs post‐PERT with a pharmacist vs post‐PERT without a pharmacist). Wilcoxon rank‐sum or Kruskal‐Wallis test and chi‐squared analysis were used for continuous and categorical data, respectively. Results: A total of 573 patients were included (mean age 63.2 ± 15.6 years, 54% male, 78% submassive PE); 137 in the pre‐PERT and 436 in the post‐PERT groups. Within the post‐PERT group, 305 patients (70%) had a pharmacist as a member of the PERT, of which 222 (73%) had a documented pharmacotherapy‐related intervention/activity. Most (n = 178, 58%) involved a pharmacist facilitating ordering/administration of an anticoagulant/thrombolytic. Median time from diagnosis to anticoagulation was significantly reduced in the post‐PERT groups (pre‐PERT: 104 minutes [IQR 124.5], post‐PERT with a pharmacist: 63 minutes [IQR 84], post‐PERT without a pharmacist: 75.5 minutes [IQR 113], P =.0001). More patients in the post‐PERT groups received LMWH compared to UFH when a pharmacist was involved vs without a pharmacist (69.5% vs 53.3%, P =.0019) and major bleeding events were reduced (pre‐PERT: 14.6%, post‐PERT with a pharmacist: 4.6%, and post‐PERT without a pharmacist: 9.9%, P =.0013) Conclusion: Pharmacists have an active role on the PERT and their involvement was associated with a shorter diagnosis to anticoagulation time, increased LMWH use, and fewer major bleeding events. [ABSTRACT FROM AUTHOR]

Purpose: Rapid response teams (RRTs) have been developed to provide early therapy to patients with risk factors for cardiopulmonary arrest. We sought to investigate the role a pharmacist could have as a member of the RRT. Methods: Two pharmacists trained in critical care and emergency medicine proposed a pilot program to determine whether a pharmacist as a member of the RRT could help to optimize pharmacotherapy and facilitate medication administration. During response, 1 pharmacist was at the bedside with the RRT for patient evaluation, consult, chart review, and to facilitate medication administration. The responding RRT pharmacist collected patient demographics, medications administered, pharmacotherapy recommendations, and time commitment. Results: The pharmacists responded to 32 RRT alerts. A majority (65.6%) of patients required at least 1 medication, and a total of 45 medications were administered. The pharmacists performed 49 pharmacotherapy-related interventions in 21 patients. These included medication facilitation (15), dose (15) or therapy (8) recommendations, and adding (6) or discontinuing (5) a medication. The pharmacists spent a median time of 15 minutes (interquartile range [IQR] 15, range 2-70) for each RRT alert and a total of 612 minutes (10.2 hours). Conclusion: With a minimal time commitment, pharmacists can be valuable members of the RRT. [ABSTRACT FROM AUTHOR]

Purpose To summarize current literature evaluating tranexamic acid in the management of intracranial bleeding associated with traumatic and nontraumatic brain injuries and implications for clinical practice. Summary Intracranial hemorrhage, regardless of etiology, is associated with high morbidity and mortality. Tranexamic acid is an antifibrinolytic with anti-inflammatory properties shown to reduce mortality in trauma patients with extracranial injuries. In traumatic brain injury, a large randomized trial found no difference in outcomes when tranexamic acid was compared to placebo; however, subgroup analyses suggested that it may reduce head injury–related mortality in the context of mild-to-moderate injury if treatment occurs within 1 hour of symptom onset. More recent out-of-hospital data have disputed these findings and even suggested harm in severely injured patients. In spontaneous, nontraumatic intracranial hemorrhage, treatment with tranexamic acid did not result in a difference in functional status; however, rates of hematoma expansion, even though modest, were significantly reduced. In aneurysmal subarachnoid hemorrhage, tranexamic acid may prevent rebleeding, but has not led to improved outcomes or reduced mortality, and there is concern for increased incidence of delayed cerebral ischemia. Overall, tranexamic acid has not been shown to result in increased risk of thromboembolic complications across these classes of brain injury. Conclusion Despite its favorable safety profile overall, tranexamic acid does not seem to improve functional outcomes and cannot be routinely recommended. More data are needed to determine which head injury subpopulations are most likely to benefit from tranexamic acid and which patients are at increased risk for harm. [ABSTRACT FROM AUTHOR]

Background: For treatment of severe alcohol withdrawal syndrome, high dose benzodiazepines (BZDs) may cause delirium and oversedation. Phenobarbital (PBT) is a long-acting barbiturate effective for the treatment of alcohol withdrawal. Given the potential benefits of PBT, we sought to investigate the effectiveness of PBT as adjunctive treatment for alcohol withdrawal. Methods: This was a retrospective cohort study on patients with a diagnosis of alcohol withdrawal who had a CIWA-Ar score > 10 treated with either BZDs alone (BZD alone group) or BZDs with adjunctive PBT (PBT-adjunct group). The patients received at least one dose of PBT in addition to BZDs (variable doses) in the PBT-adjunct group, and three doses of 20 mg diazepam equivalents within 6 hours in the BZD alone group. The primary endpoint was the proportion of patients with a CIWA-Ar score < 10 at 24 hours after initial treatment. Duration of withdrawal and cumulative dose of BZDs were also assessed. Results: Seven subjects in the adjunctive phenobarbital and 21 in the benzodiazepine group were included in the final analysis. Two patients (28.6%) in the PBT-adjunct group and 5 patients (23.8%) in the BZD only group achieved the primary endpoint, though the difference between the two groups was not statistically significant (P = 0.588). The median (IQR) duration of withdrawal symptoms was 44 (12-62) hours in the PBT-adjunct group compared to 53 (37-87) hours in the BZD only group, with no significant difference between the groups (P = 0.249). The median (IQR) cumulative BZD dose requirement (diazepam equivalent) in the PBT-adjunct group was significantly lower than BZD alone group (25 (20-226) vs. 326 (160-550) mg, P = 0.02). Conclusion: PBT appears to be a safe and effective alternative to BZDs for the treatm ent of alcohol withdrawal in non-critically ill patients and may be BZD sparing. [ABSTRACT FROM AUTHOR]

Background: This Rapid Practice Guideline (RPG) aimed to provide evidence-based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research., Methods: The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities., Results: Data from 17 randomized clinical trials (n = 898) and nine observational studies (n = 1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied., Conclusion: The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence., (© 2024 Acta Anaesthesiologica Scandinavica Foundation.)

Disclaimer: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time., Purpose: To compare the incidence of ICU pharmacist interventions in intensive care unit recovery center (ICU-RC) in-person and virtual clinic visits., Methods: This was a post hoc analysis of interventions implemented by ICU pharmacists among adult patients who were referred to 12 ICU-RCs across the United States and the United Kingdom between September 2019 and July 2021, as reported in a previously published study "An International, Multicenter Evaluation of Comprehensive Medication Management by Pharmacists in ICU Recovery Centers." That study included patients who received a comprehensive medication review by an ICU pharmacist. Medication-related interventions performed by an ICU pharmacist during ICU-RC in-person clinic visits were compared to those performed during virtual clinic visits., Results: There were 507 patients referred to an ICU-RC, of whom 474 patients attended a clinic visit. Of those, 472 received a comprehensive medication review, with 313 patients attending in-person visits and 159 patients attending virtual visits. The incidence of medication-related interventions implemented was higher in the ICU-RC in-person clinic group compared to the virtual clinic group (86.5% vs 79.2%, P = 0.04). There was no difference in the median number of ICU pharmacist interventions per patient between the in-person and virtual clinic groups (2 vs 2, P = 0.13). An ICU admission diagnosis was an independent predictor of medication-related interventions among all patients., Conclusion: The incidence of ICU pharmacist interventions was higher at ICU-RC in-person clinic visits compared to virtual clinic visits. Pharmacists aid in meeting the complex pharmacologic challenges of post-intensive care syndrome in both settings., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: Pulmonary embolism response teams (PERTs) were developed to assist with diagnosis, risk stratification, and management of intermediate and high-risk pulmonary embolism (PE) and have been shown to reduce 90-day mortality. The pharmacist's role on the PERT is not well defined., Objectives: Describe the pharmacist's role as a PERT member and determine if pharmacists can improve time to anticoagulation and promote use of low molecular weight heparin (LMWH) instead of unfractionated heparin (UFH)., Methods: A retrospective, observational study of adult patients with massive or submassive PE between January 2014 and May 2020. Patient demographics, clinical variables, anticoagulation treatment/timing, and pharmacist activities during PERT response were evaluated. Patients were divided into three groups for comparisons (pre-PERT vs post-PERT with a pharmacist vs post-PERT without a pharmacist). Wilcoxon rank-sum or Kruskal-Wallis test and chi-squared analysis were used for continuous and categorical data, respectively., Results: A total of 573 patients were included (mean age 63.2 ± 15.6 years, 54% male, 78% submassive PE); 137 in the pre-PERT and 436 in the post-PERT groups. Within the post-PERT group, 305 patients (70%) had a pharmacist as a member of the PERT, of which 222 (73%) had a documented pharmacotherapy-related intervention/activity. Most (n = 178, 58%) involved a pharmacist facilitating ordering/administration of an anticoagulant/thrombolytic. Median time from diagnosis to anticoagulation was significantly reduced in the post-PERT groups (pre-PERT: 104 minutes [IQR 124.5], post-PERT with a pharmacist: 63 minutes [IQR 84], post-PERT without a pharmacist: 75.5 minutes [IQR 113], P = .0001). More patients in the post-PERT groups received LMWH compared to UFH when a pharmacist was involved vs without a pharmacist (69.5% vs 53.3%, P = .0019) and major bleeding events were reduced (pre-PERT: 14.6%, post-PERT with a pharmacist: 4.6%, and post-PERT without a pharmacist: 9.9%, P = .0013)., Conclusion: Pharmacists have an active role on the PERT and their involvement was associated with a shorter diagnosis to anticoagulation time, increased LMWH use, and fewer major bleeding events., Competing Interests: CONFLICT OF INTEREST The authors declare no conflicts of interest.