Jaclyn M. LeBlanc

Role of the Bispectral Index in Sedation Monitoring in the ICU

Objective: To review and critique evidence for the use of the bispectral index (BIS) in intensive care unit (ICU) patients. Data Sources: A computer search of English-language articles in MEDLINE (1966–July 2005), International Pharmaceutical Abstracts (1971–July 2005), and Scientific Citation Index Expanded (1980–July 2005) was conducted. A manual search of abstracts was also performed using the key search terms BIS, sedation, and critical care. Study Selection and Data Extraction: Case series, letters, editorials, and clinical studies that evaluated BIS in ICU patients were considered for inclusion. Data Synthesis: Nineteen studies comparing the BIS with sedation scales were evaluated, revealing that the BIS trends lower with increasing sedation. The BIS appeared to correlate better when sedation scores were grouped rather than individual values. However, correlations between BIS and subjective scales were low in most studies (r2 0.21–0.93). Additionally, there was poor correlation between drug dosage and the BIS. Randomized, controlled trials demonstrating improved outcomes with BIS monitoring have not been reported. Conclusions: Interpreting literature on the usefulness of the BIS in the ICU is difficult for reasons that include heterogeneous populations, different methods of collecting BIS data, and use of different versions of BIS software and hardware. Outcomes data are lacking. The 2002 Society of Critical Care Medicine Sedation Guidelines recommendation that more data are needed before the BIS should be used routinely in the ICU remains unchanged. We recommend that further studies be conducted to determine the optimal method of obtaining BIS data and evaluate the impact of the BIS on relevant patient outcomes.

Electrolyte disturbances associated with commonly prescribed medications in the intensive care unit.

Electrolyte imbalances are common in critically ill patients. Although multiple disease states typically encountered in the intensive care unit may be responsible for the development of electrolyte disorders, medications may contribute to these disturbances as well. Medications can interfere with the absorption of electrolytes, alter hormonal responses affecting homeostasis, as well as directly impact organ function responsible for maintaining electrolyte balance. The focus on this review is to identify commonly prescribed medications in the intensive care unit and potential electrolyte disturbances that may occur as a result of their use. This review will also discuss the postulated mechanisms associated with these drug-induced disorders. The specific drug-induced electrolyte disorders discussed in this review involve abnormalities in sodium, potassium, calcium, phosphate, and magnesium. Clinicians encountering electrolyte disturbances should be vigilant in monitoring the patients medications as a potential etiology. Insight into these drug-induced disorders should allow the clinician to provide optimal medical management for the critically ill patient, thus improving overall healthcare outcomes.

Evaluation of lacrimal fluid as an alternative for monitoring glucose in critically ill patients

ObjectiveThis study evaluated the use of lacrimal fluid glucose concentrations as a minimally invasive, alternative sampling strategy for monitoring glucose concentrations in surgical/trauma ICU patients.Design and settingProspective, paired sample study in an adult surgical/trauma ICU.PatientsPatients receiving subcutaneous or intravenous insulin requiring routine capillary blood glucose measurements. Patients receiving ocular lubricants, artificial tears, or routinely administered ophthalmic medications and patients with facial injuries were excluded.InterventionsLacrimal fluid was collected using glass capillary tube placed near the cul-de-sac of the eye. Capillary blood glucose was determined using a bedside glucose meter as per routine ICU care.Measurements and resultsLacrimal fluid glucose concentration was analyzed using high-performance liquid chromatography with pulse amperometric detection. Forty-four paired samples from five patients were analyzed. Pearson correlation between lacrimal fluid (µM) and blood glucose (mM) concentrations and the proportional change from baseline revealed no significant associations. Due to the very poor association, enrollment was discontinued after five patients.ConclusionsLacrimal fluid and blood glucose concentrations were poorly correlated, suggesting that the former is not a reliable alternative to blood glucose monitoring in surgical/trauma ICU patients requiring insulin therapy.

Scope of International Hospital Pharmacy Practice

OBJECTIVE: To review the published English literature regarding international hospital pharmacy practice. DATA SOURCES: A computer search of all English-language articles in MEDLINE (1966–June 2004) and other Internet sources and International Pharmaceutical Abstracts (1971–June 2004). STUDY SELECTION AND DATA EXTRACTION: All studies that discussed hospital pharmacy or clinical hospital pharmacy activities outside of the US were considered for inclusion. DATA SYNTHESIS: The scope of international hospital pharmacy practice is quite varied, both inter- and intra-country, and varying degrees of specialization exist. Although clinical pharmacy is well developed in some countries, it is still in infancy stages in others. In addition, there is disparity in the actual definition of clinical pharmacy throughout the world. CONCLUSIONS: Since very few data have been published regarding hospital pharmacy practice on an international scale, we suggest a survey be conducted to objectively capture this information and increase awareness of clinical pharmacy in this setting.

A multicenter study of the point prevalence of drug-induced hypotension in the ICU.

Objective:To determine the point prevalence of drug-induced hypotension episodes in critically ill patients, to assess the episodes resulting from error, and to describe how episodes are treated. Design:Multicenter observational, 24-hour snapshot study. Setting:Forty-seven ICUs in 27 institutions located in the United States, Canada, and Singapore. Patients:A total of 688 ICU patients were evaluated. Interventions:None. Measurements and Main Results:Patients were included in the study if they had an episode of hypotension in the 24 hours prior to the clinical pharmacists’ evaluation. The definition for a hypotensive episode is either a systolic blood pressure less than 90 mm Hg or a decrease in systolic blood pressure of 30 mm Hg over a 2-hour period. Each episode of unintentional hypotension was assessed for suspected drug-related causes. When a drug-related cause was suspected, an objective assessment tool, the modified Kramer, was used to determine causality. A score of at least “possible” was considered drug induced, referred to as a “drug-related hazardous condition.” A drug-related hazardous condition is the temporal gap (intermediate stage) between the identification of an adverse drug reaction and the subsequent onset of drug-induced injury, known as an “adverse drug event.” Drug-induced episodes were evaluated for medication errors and treatment. One hundred fifty-eight patients experienced 204 hypotensive episodes that were considered unintentional and drug related. Common drugs implicated included propofol, fentanyl, metoprolol, lorazepam, hydralazine, and furosemide. A total of 54 episodes (26.5%) resulted from medication errors. Common error types were improper dose/quantity (46%) and prescribing (25%). A total of 56.9% episodes were treated. Conclusions:Many hypotensive episodes in the ICU are drug related and require treatment. A substantial portion of these episodes result from errors and are therefore preventable. This presents opportunities to improve prescribing including optimizing drug dosing to avoid possible patient harm from drug-induced hypotension.

Canadian Survey of Critical Care Pharmacists' Views and Involvement in Clinical Research

BACKGROUND: The involvement of Canadian critical care pharmacists in clinical research is not well documented. OBJECTIVE: To describe the clinical research experience of Canadian critical care pharmacists, describe their views about clinical research, and identify factors that facilitate their involvement in clinical research. METHODS: A cross-sectional electronic survey of Canadian critical care pharmacists was developed through an iterative process and conducted from July to October 2010. We invited 325 pharmacists from 129 hospitals across Canada to participate. Surveys with more than 30% of questions unanswered were discarded. RESULTS: Analyzable response rate was 66.2%. Overall, 33 pharmacists (15.7%) were highly involved in research, 54 (25.7%) were moderately involved, and 123 (58.6%) were minimally involved. Most respondents (97.2%) believed that critical care pharmacist involvement in research was desirable, and many (80.4%) expressed interest to be more involved in research. Nearly all respondents (99.5%) agreed that more support should be provided to pharmacists interested in conducting research. Pharmacists currently involved in research have obtained higher academic degrees (adjusted OR 11.23; p < 0.001), express a strong interest in research (adjusted OR 7.44; p < 0.001), report a higher level of training for involvement in research (adjusted OR 2.23; p = 0.047), and practice more often in a university hospital (adjusted OR 3.68; p = 0.004) within an intensive care unit where involvement in research is valued (adjusted OR 5.61; p < 0.001). Support from pharmacy departments is not related to involvement in research (adjusted OR 1.22; p = 0.633). CONCLUSIONS: Canadian critical care pharmacists are involved to varying degrees in clinical research and are very interested in initiating and supporting research activities. Opportunities are present but significant barriers exist. The value of pharmacist-initiated research needs recognition as a priority within hospital pharmacy administration.

Multiprofessional survey of protocol use in the intensive care unit

PURPOSE To date, there has been no large multicenter, multiprofessional evaluation of protocol and guideline use in the intensive care unit (ICU). The primary purpose of this study was to describe national availability, development, implementation, and assessment of protocols in ICUs. A secondary objective was to compare perceived utility by ease of use, patient safety, cost containment, and compliance of protocols between nurses, physicians, and pharmacists. MATERIALS AND METHODS The survey was developed and tested for validity by 15 clinicians who identified additional domains of interest. An additional 15 clinicians of the 3 different professions evaluated the survey for relevancy and appropriateness of responses. Three survey experts evaluated survey construction. The survey was uploaded to a Web survey tool and pilot tested for clarity and ease of completion. RESULTS The overall response rate for the survey was 18.1% (n = 614). Popular methods of education for protocol implementation included staff meetings (85.3%) and unit-specific in-services (77.7%). Protocols were most often updated when new information was available (40.8%) or every 12 months (17.9%). The most common limitation to development and implementation was limited personnel resources (24.5%) and physicians not wanting to use them (21.3%), respectively. Clinicians indicated that protocols made their job easier and improved cost containment some or most of the time. Sepsis protocols were identified as most useful in promoting patient outcomes by all 3 professions. CONCLUSIONS The types of protocols available appear to be those assisting with management of high-alert medications. Overcoming the perceived barriers of protocol use within ICUs requires personnel for development and physician support. A better protocol review process may be necessary to assure optimal content, desired outcomes, and consistency with Institute for Safe Medication Practices guidelines.

Impact of Disease States on the Pharmacokinetics and Pharmacodynamics of Angiotensin-Converting Enzyme Inhibitors

The pharmacokinetics and pharmacodynamics of angiotensin‐converting enzyme inhibitors (ACE) in elderly patients and patients with renal and hepatic impairment were examined, and a role for an AUC/EC50 ratio to guide dosing was evaluated. A Medline and International Pharmaceutical Abstracts search was used to identify human studies and abstracts. Relevant data were evaluated and summarized. Dosing regimens were compared using an AUC/EC50 ratio. Most studies evaluating ACE inhibitors in renal impairment report a strong linear correlation between creatine clearance and drug elimination. AUC and EC50 values for these drugs in elderly subjects appear similar to younger and hypertensive patients. There is increased AUC in some patients with hepatic impairment. Pharmacodynamic data are conflicting. Prolonged ACE inhibition is evident in renal impairment but not necessarily other disease states. ACE inhibitor dosing for hypertension is reasonable based on pharmacokinetics and EC50 values. Further individualization of therapy may improve outcomes, and using the threshold AUC/EC50 ratio may help guide appropriate dosing.

912: DETERMINING CAUSALITY FOR SUSPECTED ADVERSE DRUG REACTION-RELATED ICU ADMISSIONS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) seventeen patients received melatonin for the prevention of ICU delirium, with 8.6% of patients developing ICU delirium (time spent in delirium was 44 ± 16 hrs). Average ICU and hospital length of stay was 15 ± 30 days and 30 ± 40 days, respectively, with 85% of patients being alive at discharge. Melatonin was used for 6.3 ± 7.9 days, with a median dose of 3 mg (range 1–10 mg). Twenty two patients received 1 or more doses of antipsychotic medications (17 patients received quetiapine and 5 patients received quetiapine plus haloperidol). Of these patients, median quetiapine use was 2 doses (range 1–7 doses) with a median dose of 25 mg (range 12.5–200 mg). Median intravenous haloperidol use was 1 dose (range 1–4 doses) with a median dose of 2 mg (range 1–4 mg).Conclusions: This is one of the only studies to date that has examined the use of melatonin for the prevention of ICU delirium. ICU delirium occurred in 8.6% of patients receiving melatonin, a much lower incidence rate than previously reported at this institution (33%). Melatonin may be a promising agent for the prevention of ICU delirium; however, prospective data is needed to validate its safety and efficacy in this patient population.

Analgesics and Neuromuscular Blocking Agents

Analgesic medications are used routinely in the ICU patient. In general, adverse drug events resulting from analgesic administration are common such as decreased gastrointestinal motility and hypotension. Clinicians are developing a better understanding of other adverse drug events such as delirium and infection. In addition, critically ill patients often have impairments in renal and hepatic function that increase the risk for adverse drug events due to pharmacokinetic alterations. As well, there are specific situations, such as hypothermia, that ICU patients experience which may affect drug dosing. While not used as routine care, neuromuscular blockers are high-risk medications that contribute to adverse events in a population already at high risk of adverse effects. This chapter will review the patient safety concerns associated with analgesics and neuromuscular blocking agents.