David M. Angaran

Clinical Pharmacy: Looking 20 Years Back… Looking 20 Years Forward

Angaran: We have two main goals in this panel discussion. First, to describe the current status of the health care delivery environment, the medication use system, and the pharmacy profession. And second, to discuss the specific challenges and opportunities for pharmacy over the next 5–10 years. Our hope is that you identify at least one specific action that you can apply that will catalyze change in your professional practice, regardless of your country of origin. Our discussion will be in three sections. The first part will concentrate on the broad topics of health care and the health care environment, admittedly from only the European and United States’ perspectives. The second part will deal with pharmacy specifically, and how pharmacy should respond to these environmental changes. And finally, we will close with specific recommendations from each panelist. Bert, you have written about future scenarios regarding medication use in health care. Probably every country in the world is faced with a demand for health care that exceeds the resources available to support that health care. In the U.S., spending on prescription pharmaceuticals constitutes 7–11% of total health care expenditures—and that percentage is rising. Further, the cost of pharmaceuticals is rising at a faster rate than any other segment of health care. Recognizing that differences exist among countries, can you provide a perspective on the current status of health care systems in Europe and comment on important trends that you envision over the next 5 years?

Oxygen Homeostasis: Theory, Measurement, and Therapeutic Implications

The ultimate goal of therapeutic intervention in a critically ill patient is to maintain oxygen homeostasis where delivery of oxygen to the cells is greater than, or at least equal to, the oxygen demand of the cells. Oxygen demand varies from organ to organ. Total body oxygen demand is the sum of all oxygen required by all tissues and organs for aerobic cellular function. Oxygen consumption (V̇O2) is the quantity of oxygen actually used by the cells. V̇O2 may be calculated if the values of cardiac output (CO), hemoglobin concentration, and arterial and venous oxygen saturations (SaO2 and SV̄O2, respectively) are known. Under normal circumstances, the quantities of oxygen demanded and oxygen consumed are equal, but in situations of inadequate oxygen delivery, oxygen demand may not be satisfied and the quantity of oxygen actually consumed will be governed by the quantity delivered. This then may result in an oxygen deficit and, ultimately, cellular death. This article discusses the principles of oxygen homeostasis, techniques for measuring V̇O2, CO, and SV̄O2, and the relevance of these principles and techniques to clinical practice.

Near misses and incidents

Take a deep breath; try again. How did the oxygen content of the room drop? I am sweating and becoming really lightheaded—that 6 G-feeling. In a minute, the world view will narrow to a dark tunnel, then complete blackness, and I will keel over. I need to sit on the floor; it is hard to fall too