Jeffrey T. Fish

Propylene glycol-associated renal toxicity from lorazepam infusion.

Objectives. Using data from patients who developed elevations in serum creatinine concentrations while receiving continuous‐infusion lorazepam, we sought to determine the correlations between the magnitude of serum creatinine concentration rise and each of the following variables: serum propylene glycol level, cumulative lorazepam dose, and duration of lorazepam administration. An additional objective was to identify clinical markers for propylene glycol toxicity.

Inappropriate Continuation of Stress Ulcer Prophylactic Therapy After Discharge

Background: Medications for stress ulcer prophylaxis are appropriately started in critically ill patients with risks for developing stress ulcers. It is unknown whether these drugs are discontinued once the risk factors are removed. Objective: TO assess the duration of stress ulcer prophylactic therapy in critically ill patients. Methods: A retrospective chart review was conducted at a multidisciplinary, 24 bed medical/surgical intensive care unit (ICU) of a university-affiliated tertiary referral medical center. Three hundred ninety-four patients fulfilled eligibility criteria during the study period of July 1, 2005, through September 30, 2005. Patients were considered to be appropriately discharged from the hospital on gastric acid suppressants it they met any of the following criteria: continued mechanical ventilation, gastroesophageal reflux disease, peplic ulcer disease, history of gastrointestinal ulceration or bleeding within the past year, prescribed medications used for stress ulcer prophylaxis prior to admission, gastrointestinal bleed during hospitalization, or prescriber indication of reason to continue therapy. Results: Three hundred fifty-seven patients received stress ulcer prophylaxis during their ICU stay. Of these, 80% continued on gastric acid suppressants on transfer from the ICU, with 60% of the therapy being inappropriate. The percentage of critically ill patients discharged from the hospital with inappropriate prescription of gastric acid suppressants was 24.4%. Based on the average wholesale cost, the total cost for unnecessary gastric acid suppressant therapy within the follow-up period was

Stress Ulcer Prophylaxis: Reducing Non-Indicated Prescribing after Hospital Discharge

13,973. Conclusions: Gastric acid suppressant medications initially prescribed for stress ulcer prophylaxis are frequently prescribed inappropriately on discharge for patients who were initially admitted to the medical/surgical ICU.

Daptomycin Dosing Based on Ideal Body Weight versus Actual Body Weight: Comparison of Clinical Outcomes

Background: Gastric acid suppressant medications used as stress ulcer prophylaxis (SUP) in the intensive care unit (ICU) are often prescribed inappropriately after discharge. We present tools to reduce the use and cost of non-indicated SUP. Objective: To reduce the non-indicated use of SUP after hospital discharge originally started in the ICU, using an education intervention and pharmacist-led medication reconciliation on patient care rounds and at hospital discharge. Methods: In a retrospective medical record review using a historic control, 356 consecutively admitted patients to the medical/surgical ICU at the University of Wisconsin Hospital were assessed for the appropriate use of SUP at admission to the ICU, at transfer to a general care unit, and at hospital discharge. The education intervention involved teaching both the medical and pharmacist staff about indications for SUP using a memorandum and a pocket guide. Pharmacists also conducted medication reconciliation during daily patient care rounds and at discharge to justify medication use. The outcome of this study is the percentage of patients prescribed non-indicated gastric acid suppressants at hospital discharge. This outcome is compared to a previous study conducted at our hospital. Results: Of 356 eligible patients, 308 (86.5%) received SUP while in the ICU. Thirty-nine (11%) were given continuing SUP after discharge from the hospital, of which 31 (8.7%) had no clear indication. This was a 64.3% reduction from the 24.4% found in the prior study (p < 0.0001). Conclusions: Educational materials that guide prescribing, pharmacist interaction on patient care rounds, and pharmacist-conducted medication reconciliation significantly reduced the prescribing of non-indicated gastric acid suppressant medications after hospital discharge.

Difference Between Pharmacist-Obtained and Physician-Obtained Medication Histories in the Intensive Care Unit

ABSTRACT Daptomycin use at our institution changed to ideal body weight dosing based on a published analysis of pharmacokinetic-pharmacodynamic efficacy target attainment, bacterial ecology, and a desire to reduce drug toxicity. The current study compared outcomes between actual body weight and ideal body weight dosing of daptomycin before and after this intervention. In the evaluable group, 69 patients received doses based on actual body weight and 48 patients received doses based on ideal body weight. Patients were treated for documented Enterococcus species, Staphylococcus aureus, or coagulase-negative Staphylococcus infections, including bloodstream, intraabdominal, skin and soft tissue, urinary, and bone. There was no statistically significant difference in clinical success between the groups (88.9% for actual body weight compared to 89.1% for ideal body weight, P = 0.97). After we adjusted for gender, age, body mass index, concomitant 3-hydroxy-3-methylglutaryl–coenzyme A reductase inhibitors, infection type, and organism type, clinical success rates remained similar between groups (adjusted odds ratio of 0.68 in favor of actual body weight, 95% confidence interval [CI] of 0.13 to 3.55). Microbiological outcomes, length of stay, mortality, and adverse effects were also similar between groups. Further studies are warranted to confirm that ideal body weight dosing provides similar outcomes to actual body weight dosing for all patients and types of infections and organisms.

Preceptor development: Responses to frequently asked questions from preceptors in academic hospitals.

Purpose To quantify the differences between medication histories obtained by physicians and pharmacists from critically ill patients in the intensive care unit (ICU) and to identify patient types at greatest risk of medication errors. Methods Retrospective medical record review of 200 consecutively admitted critically ill patients to the medical/surgical ICU of a university-affiliated hospital. The pharmacist-obtained medication history was compared to the physician-obtained medication history. Variations assessed included the number of drugs identified, drug name, drug formulation, dose, and frequency of administration. Inpatient medication orders were reviewed to obtain the number and accuracy of home medications prescribed in the ICU. Patients were divided into predefined groups: trauma, medical, and nontrauma surgical to assess the risk of medication error by patient type. Results Pharmacists and physicians identified a total of 981 and 665 medications, respectively. The mean (±SD) number of home medications per history was 4.2 (±4.9) for physicians and 6.2 (±5.7) for pharmacists (P < .0001). Physician-obtained medication histories contained 1,628 variances relative to the pharmacist-obtained medication histories. The variances by type included the frequency of administration, 37%; drug dose, 34.6%; missing drugs, 22.3%; extra drugs, 3.6%; and drug formulation, 2.5%. Thirty-nine patients received continuation of their home medications in the ICU totaling 97 orders (9.9% of home medications identified by pharmacists). Thirty of these orders varied from the pharmacy history and 27 were subsequently corrected. Conclusion. Pharmacists identified more home medications than physicians when obtaining a medication history in the ICU. This may improve the accuracy of home medications ordered in the ICU.

Recommendations for the use of medications with continuous enteral nutrition

Preceptor development continues to be a trending topic within our profession. ASHP’s accreditation standards include requirements for preceptor development, and residency program directors continue to seek novel and unique methods for developing preceptors’ aptitude and ability for teaching.[1][