J Van Bommel

Uremic encephalopathy in critical care: does it exist and does renal replacement therapy improve outcome?

Neurological disturbances and acute kidney injury (AKI) commonly co-exist in critically ill patients. However, it is unclear if AKI directly contributes to neurological disturbances (uremic encephalopathy) or if neurological disturbances and AKI are both reflections of multi-organ failure. Furthermore, it is unclear if renal replacement therapy (RRT) improves outcome, especially if other indications for RRT are absent.

Response on: C-reactive Protein as a Predictor for Complications Following Esophagectomy.

With pleasure, we respond to the comment of Straatman et al. on our study on the diagnostic value of C-reactive protein and procalcitonin levels post-esophagectomy. The first issue raised by Straatman et al. is the classification of postoperative complications. As mentioned in the BMethods^ section of the article, we have used the Accordion severity grading scale to score complication severity. The Accordion severity grading is a 5-point grading scale comparable in its definitions of complications and severity to the Clavien-Dindo classification for postoperative complications. We are unaware of any literature suggesting one being superior to the other. As only complications considered grade 2 or higher were used in the primary outcome, the resulting cutoff values in our study in fact do differentiate between minor and major complications. Regarding the classification of complications, the most frequent complications after esophagectomy are either pneumonia (infectious) or anastomotic leakage (surgical). Although both lead to a hyper-inflammatory state, they are completely different conditions, requiring different management strategies. Therefore, we separated our study population in infectious and surgical complication subgroups and hypothesized that C-reactive protein is a sensitive but non-specific marker of inflammation (increased in both groups), while procalcitonin might be a more specific marker for the presence of infection and thus not increased in the surgical complication group. Unfortunately, the number of patients included in this proof of principle study was too small to draw definite conclusions or to compare the levels of complication severity within these subgroups. However, a standardized algorithm based on Creactive protein levels alone certainly does not discriminate between infection and inflammation and might lead to unnecessary procedures. At the time of our study, the consensus classification of post-esophagectomy complications was not yet available. Nevertheless, the diagnostic methods and definitions we used are in line with those suggested by Low et al. As stated before, patient numbers in our proof of principle study were insufficient to report on different severity categories. However, unlike Straatman and colleagues, we do not expect that Creactive protein levels might be useful for the assessment of minor vs. major complications. Especially in the postoperative pro-inflammatory state, C-reactive protein levels are overall increased and although extreme levels have been associated with complications after gastro-intestinal surgery, they have to be interpreted with caution. With great interest, we await the results of the standardized C-reactive protein-based treatment after surgery by Straatman et al. Addition of procalcitonin to their analysis might improve the understanding of the meaning and relevance biomarkers in the postoperative period.

GRP-032 Beneficial Effect of Hospital Pharmacist Participation in Intensive Care Rounds: Reduction in Medicines Errors and Hospital Costs

Background Medicines errors may result in patient harm. Especially in intensive care patients, adverse drug events caused by medicines errors are common. Interventions by hospital pharmacists have been shown to reduce adverse drug events and costs in intensive care units (ICUs). Purpose To evaluate the effect of active participation of a hospital pharmacist in the ICU on medicines errors and hospital costs. Materials and Methods A three-month pilot study was performed at the adult 32-bed ICU of the academic hospital Erasmus MC. Four hospital pharmacists were trained in specific aspects and protocols of intensive care. From July to September 2011, each patient’s medicines profile was reviewed weekly using a standardised written form and a pharmacist was present on rounds. Potential medicines errors requiring intervention were documented and discussed during the round. In addition, the amount of time spent performing clinical activities at the ICU was recorded. Results 267 medicines reviews were performed for a total of 169 patients in 51 rounds. 288 interventions for a total of 120 drugs were made. About 60% of the medicines reviews resulted in at least one intervention with an acceptance rate of 56%. Non-acceptance was mainly due to a lack of information at the time the medicines review was performed. 30% of interventions were relating to unnecessary drug use, 24% to drug omission and 17% to a wrong dose. Time spent on medicines reviews and visiting rounds was 7.3 hour per week. Based on these results we developed a business case for structural participation of a hospital pharmacist at the ICU. Conclusions Participation of a hospital pharmacist in ICU rounds improves medicines safety and can be cost-effective. The pilot study and business case have resulted in the appointment of 0.5 FTE hospital pharmacist in the ICU. No conflict of interest.