Joel Feih

Pharmacist involvement on a rapid response team

Purpose. The effect of a pharmacist on a rapid response team (RRT) was investigated. Methods. This study evaluated 234 patients before and 157 patients after pharmacist involvement on an RRT. The primary outcome was time to medication administration, with a goal turnaround time of less than 30 minutes. Secondary outcomes included most frequently used medications, readmissions to the intensive care unit (ICU) within 48 hours, number of rapid responses that resulted in ICU admission, length of hospital stay, and survival to hospital discharge. Additionally, pharmacist interventions were tracked in the postinterventional group. Results. The preinterventional group screened 326 rapid response events, of which 234 were included for analysis; during the postinterventional phase, 256 rapid response events were evaluated, of which 157 were included. The primary outcome, median time to medication administration from central pharmacy, was lower in the postinterventional group compared with the preinterventional group (32.0 minutes versus 64.5 minutes, p = 0.004). ICU admission rates following rapid response were not significantly different between the two groups. Additionally, there were no significant differences between rates of medical emergency and survival to hospital discharge. The most common medications administered were metoprolol and naloxone. Pharmacists provided documentation for 90 of 157 (57%) patient cases. In the 90 cases with documentation, 18 (20% of patients) had documented pharmacist interventions, including dosing assistance for 8 cases (44% of interventions). Conclusion. The addition of a pharmacist to an RRT reduced time to medication administration, helped improve medication accessibility, and helped optimize medication selection and dosing.

Major publications in the critical care pharmacotherapy literature: January–December 2016

Purpose: To summarize select critical care pharmacotherapy guidelines and studies published in 2016. Summary: The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 31 journals monthly for relevant pharmacotherapy articles and selected 107 articles for review over the course of 2016. Of those included in the monthly CCPLU, three guidelines and seven primary literature studies are reviewed here. The guideline updates included are as follows: hospital‐acquired pneumonia and ventilator‐associated pneumonia management, sustained neuromuscular blocking agent use, and reversal of antithrombotics in intracranial hemorrhage (ICH). The primary literature summaries evaluate the following: dexmedetomidine for delirium prevention in post‐cardiac surgery, dexmedetomidine for delirium management in mechanically ventilated patients, high‐dose epoetin alfa after out‐of‐hospital cardiac arrest, ideal blood pressure targets in ICH, hydrocortisone in severe sepsis, procalcitonin‐guided antibiotic de‐escalation, and empiric micafungin therapy. Conclusion: The review provides a synopsis of select pharmacotherapy publications in 2016 applicable to clinical practice. Highlights:Reviews pharmacotherapy‐focused guidelines (n = 3) and studies (n = 7)Articles selected based on applicability, relevance, and strength of study designCommentary provided by critical care pharmacists on clinical impact

Hydroxocobalamin With or Without Methylene Blue May Improve Fluid Balance in Critically Ill Patients With Vasoplegic Syndrome After Cardiac Surgery: A Report of Two Cases

Fluid resuscitation is a cornerstone of the treatment of vasodilation associated with vasoplegic syndrome after cardiopulmonary bypass. Excessive nitric oxide production contributes to capillary leak and creates the need for ongoing volume resuscitation. In this report, the authors describe two patients with vasoplegic syndrome after cardiac surgery in which treatment with hydroxocobalamin in the presence or absence of methylene blue reduced volume resuscitation requirements and restored catecholamine responsiveness. The current case series describes the possible efficacy of hydroxocobalamin for reversing positive fluid balance associated with catecholamine-refractory vasoplegic syndrome in cardiac surgery patients.

Answer to April 2014 Photo Quiz

Answer: Inflammatory tinea capitis. The differential diagnosis included acute bacterial abscesses, tinea capitis (kerion), seborrheic dermatitis, atopic dermatitis, alopecia folliculitis, and psoriasis. Upon presentation, the patient was diagnosed with kerion, the most exaggerated cellular response to tinea capitis, a fungal infection of the scalp and hair shaft (1, 2). A patients history and physical examination results are often used to make a clinical diagnosis; however, clinical diagnosis is often unreliable, making laboratory confirmation necessary (3, 4). Specimens should be aspirated for a superior sample or collected via the toothbrush or cotton swab method, which involves rubbing the respective sterile object over the lesions and sending it to the laboratory for evaluation (5, 6). Microscopic evaluation using 10 to 20% potassium hydroxide, with or without a fungal stain, such as calcofluor white for enhancement of hyphal elements, should be performed (3). Additionally, cultures should be sent, due to the potential for false negatives with the use of potassium hydroxide smears in patients with early or inflammatory tinea capitis (2). Specimens should be plated on one medium containing cycloheximide, such as dermatophyte test medium, and one medium without cycloheximide. Dermatophyte test medium changes from yellow to red in the presence of dermatophytes, including Microsporum canis and Trichophyton tonsurans, the pathogens most often implicated in tinea capitis. Confirmatory cultures may require a 3- to 4-week incubation period, and treatment should be initiated immediately for all patients for whom there is a high level of suspicion. Treatment requires systemic therapy, due to inadequate absorption of topical therapeutic agents into the hair shaft (1, 4). Currently, griseofulvin at 20 to 25 mg/kg of body weight/day is considered the gold standard treatment for tinea capitis, although treatment with newer agents such as itraconazole and terbinafine may be as effective (2). Mycological cure rates for a 6- to 8-week treatment course range from 70 to 100%, depending on dose, duration, and causative organism. Adjunctive therapeutic agents, such as 2% ketoconazole or 1% selenium sulfide shampoo, are effective at reducing the risk of transmission once oral therapy has been initiated by reducing the keratin food source for the fungus. Initial stains demonstrated hyphae, and cultures subsequently grew out Trichophyton tonsurans. The patient had been empirically started on griseofulvin at 500 mg daily with dinner and 1% selenium sulfide shampoo nightly and was to return to clinic in 4 weeks for a follow-up. (See page 1027 in this issue [doi:10.1128/JCM.00020-13] for photo quiz case presentation.)

Photo Quiz: A 5-Year-Old Male with Multiple Pustules Covering the Entire Scalp

A 5-year-old Mayan male presented to a volunteer-staffed clinic in a remote location in rural southern Belize with a chief complaint of multiple open, painful, pus-filled lesions unresponsive to previous antimicrobial treatment. The child had presented 6 weeks earlier to a neighboring clinic in a