Komal Pandya

Prescriber Compliance with a New Computerized Insulin Guideline for Noncritically Ill Adults

BACKGROUND: In March 2008, the University of California, Davis Medical Center (UCDMC), implemented a guideline for the inpatient management of diabetes in noncritically ill adults. In accordance with national guidelines, all patients with type 2 diabetes are prescribed basal, nutritional, and correctional insulin. The guideline was added to the electronic medical record as a standardized physician order set in April 2008 and provider training on the insulin guideline occurred in May 2008. OBJECTIVE: To evaluate provider compliance with a new electronic standardized insulin order set in a hospital setting. METHODS: All patients with insulin orders admitted to the general internal medicine service between June 1, 2008, and November 1, 2008, were evaluated in this single-center retrospective chart review at UCDMC in Sacramento. Patients older than 18 years with a history of type 2 diabetes were included in the analysis. Insulin orders were categorized as preferred (followed the guideline) or nonpreferred regimens (did not follow all components of the guideline). RESULTS: A total of 265 patients were identified during the study period. The preferred regimen was ordered in 82 (30.9%) of the evaluated patient admissions. Of the 183 (69.1%) nonpreferred regimens, more than half (54.6%) contained correctional insulin alone; 84.2% of patient admissions prescribed nonpreferred regimens lacked nutritional insulin. Average admission blood glucose readings were higher in the preferred versus nonpreferred regimen group (224.4 vs 164.8 mg/dL, p < 0.001). CONCLUSIONS: The preferred regimen was not prescribed for the majority of patients admitted with a history of type 2 diabetes, despite computerized decision support. Nutritional insulin was the most common missing component in the nonpreferred regimens. Baseline clinical factors, educational modalities, and guideline content may have influenced prescribing patterns.

Managing the Rising Costs and High Drug Expenditures in Critical Care Pharmacy Practice.

Pharmaceutical costs for patients in the intensive care unit (ICU) constitute a large portion of hospital drug budgets. Unfortunately, prices for medications commonly used in the ICU are on the rise for a variety of reasons. In particular, the U.S. Food and Drug Administrations Unapproved Drugs Initiative, generic manufacturers cornering the marketplace, drug shortages, and regulatory device changes are major drivers of pharmaceutical price escalation affecting costs in the ICU. Furthermore, traditional high acquisition cost items still pose challenges to controlling costs. To offer strategies to mitigate the rising costs of pharmaceuticals in the ICU setting, we searched the PubMed/Medline and International Pharmaceutical Abstracts databases and other related sources to identify published cost‐saving protocols concerning specific medications that are affected by rising prices or have traditional high acquisition costs. In the absence of specific protocols, we offer possible cost‐saving initiatives based on published literature regarding specific agents or based on our own diverse set of experiences. Finally, we review suggested clinical and operational activities at an institutional level to address these rising drug costs in the ICU setting.

Pharmacotherapy Considerations for the Management of Advanced Cardiac Life Support

Health care providers should be aware of the pharmacotherapy considerations in the American Heart Associations guidelines for advanced cardiac life support (ACLS). Current evidence does not suggest a reduction in mortality with ACLS medications; however, these medications can improve return of spontaneous circulation. Proper agent selection and dosing are imperative to maximize benefit and minimize harm. The latest guideline update included major changes to the ventricular fibrillation/pulseless ventricular tachycardia and pulseless electrical activity/asystole algorithms, which providers should adopt. It is critical that providers be prepared for post-code management. Health care professionals should remain abreast of changing evidence and guidelines.

Enteral Guanfacine to Treat Severe Anxiety and Agitation Complicating Critical Care After Cardiac Surgery

This article is the first reported case describing the off-label use of enteral immediate-release guanfacine, a long-acting α-2 adrenergic agonist most commonly used in the treatment of attention-deficit hyperactivity disorder, for sedation in a patient with severe anxiety and agitation limiting mechanical ventilation weaning several days after cardiac surgery. In this case, after several days of unsuccessful attempts to control his agitation and anxiety with conventional therapies, guanfacine therapy was initiated, and the patient was rapidly weaned from all other sedatives and mechanical ventilation shortly thereafter. The patient was weaned from guanfacine therapy without evidence of bradycardia, hypotension, or rebound syndrome. Enteral guanfacine therapy should be further studied as a potentially useful and cost-effective sedative therapy for patients with severe anxiety and/or agitation in the intensive care unit following cardiac and thoracic surgical procedures.

Evaluating the impact of obesity on safety and efficacy of weight-based norepinephrine dosing in septic shock: A single-center, retrospective study

OBJECTIVE Norepinephrine is the first-line vasopressor recommended for patients in septic shock. Weight-based dosing may increase drug exposure and the risk of adverse effects in obese patients. The objective was to evaluate the safety and efficacy of weight-based norepinephrine dosing using actual body weight in the morbidly obese compared with normal weight patients. METHODS This was a single centre, retrospective study of adult patients admitted with septic shock requiring norepinephrine for at least 12hours. The primary endpoint was the incidence of tachycardia within 48hours after norepinephrine initiation. Secondary endpoints included timing and dosing of norepinephrine when adjunctive agents were added. RESULTS The incidence of tachycardia was similar between groups. Total norepinephrine exposure was significantly greater in obese patients on day 1 (p=0.02). Obese patients were more likely to be started on vasopressin (p<0.001) and steroids at a lower weight-based norepinephrine dose (p=0.016). CONCLUSIONS Weight-based norepinephrine dosing using actual body weight did not result in more tachycardia in the morbidly obese compared to normal weight patients, despite greater total exposure. These results were limited by the low doses used and a small cohort. However, use of actual body weight in morbidly obese patients appears to be safe.

621: AN EVALUATION OF NOREPINEPHRINE DOSING STRATEGIES IN MORBIDLY OBESE PATIENTS WITH SEPTIC SHOCK

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) Alternatively, levalbuterol contains one (L) enantiomer and is often preferred in cases where tachycardia may be detrimental. There is very limited human data on the change in heart rate (HR) and oxygen consumption (V’O2) with albuterol and levalbuterol. Methods: Single center prospective randomized controlled single blinded study of healthy adult volunteers. Subjects separately received A (5mg) and L (2.5mg) aerosolized over 10 min. We measure HR and V’O2 before the medications and 5,10,20,40 and 60 min thereafter. V’O2 was measured noninvasively with a laser diode absorption spectrometer. The maximum increase in measured values from baseline were compared between groups using Wilcoxon Signed Rank test. Results: We enrolled 14 patients median age 32 yr (range 27 – 48). Compared to baseline, there was a significant maximum increase in V’O2 following both A (mean 12% (1,3 IQR 7, 45%) p<0.001) and L (mean 19% (1,3 IQR 9, 34%) p<0.001). There was no difference in maximum increase in V’O2 between A and L (p=0.9). Compared to baseline there was a significant maximal increase in HR with both A (mean 28% (1,3 IQR 18, 39%) p<0.001) and L (mean 21% (1,3 IQR 17, 24%) p<0.001) and a significant difference between A and L (p=0.011). Conclusions: Oxygen consumption and heart rate significantly increased following albuterol as well as levalbuterol compared to baseline. The increase was seen in as little as 5 min and lasted up to 60 min. There was a statistically significant greater increase in heart rate change following albuterol as compared to levalbuterol. The difference in heart rate effect may not be clinically relevant and therefore in standard doses there may be no clinical benefit to use of levalbuterol over albuterol.

569: EFFECT OF SODIUM AND FLUID ON SERUM SODIUM LEVELS IN PATIENTS WITH INTRACRANIAL HYPERTENSION

was available for analysis.10 patients had a combination of traumatic subdural hematoma, intraparenchymal and subarachnoid hemorrhage.1 patient had nonconvulsive status epilepticus and 3 had malignant MCA stroke.Left sided oximetry values had a spearman correlation co-efficient of 0.201(p< 0.001),0.146(p< 0.001) and -0.369(p< 0.001) with pulse pressure,MAP and ICP respectively. Right sided oximetry values had a spearman correlation co-efficient of 0.209(p< 0.001),0.346(p< 0.001) and -0.142(p=0.004) with MAP,pulse pressure and ICP respectively. Conclusions: Brain oximetry showed a weak but positive correlation with MAP and pulse pressure indicating some preservation of cerebral autoregulation.ICP had weak but negative correlation with Cerebral oxygenation suggesting minor changes in ICP may be important in optimizing cerebral oxygenation in acute brain injuries.Further studies using longer monitoring and more patients are needed to confirm these findings.