Kyle A. Weant

Cost effectiveness of a clinical pharmacist on a neurosurgical team

OBJECTIVEIn 1999, the Society of Critical Care Medicine formally recognized that pharmacists were essential for the provision of high quality care to the critically ill population. This study is a brief quantitative analysis of the benefit provided by a clinical pharmacist in a multidisciplinary neurosurgical setting. METHODSPatients admitted to the neurosurgical service in the 2 years before and 2 years after the implementation of dedicated neurosurgical pharmacy services were retrospectively reviewed. The clinical pharmacist was responsible for monitoring and evaluating all adult patients on the service and rounding with the team 6 days a week. RESULTSA total of 2156 patients were admitted during the study period. No significant differences were noted among severity of illness scores between the 2 groups. During this time, 11 250 interventions were recorded by the pharmacist. The average pharmacy and intravenous therapy cost per patient between the pre- and postimplementation groups decreased from

ACUTE RELATIVE ADRENAL INSUFFICIENCY AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

4833 to

Pharmacologic options for reducing the shivering response to therapeutic hypothermia.

3239, resulting in a total savings of

The Role of Coenzyme Q10 in Heart Failure

1 718 260 over the duration of the study period. The average hospital stay decreased from 8.56 to 7.24 days (P = 0.003). Early hospital mortality also decreased from 3.34% to 1.95% (P = 0.06). For those patients who were discharged from the hospital, there was a significant decrease in readmission rates between the 2 groups (P < 0.05) CONCLUSIONHaving a dedicated clinical pharmacist with critical care training rounding routinely with a neurosurgical team significantly reduced hospital stay, readmission rates, and pharmacy costs. Clinical pharmacists can have a significant effect on clinical and economic measures in the intensive care unit, and their participation on a multidisciplinary critical care team should be a standard of care.

Conversion from Continuous Insulin Infusions to Subcutaneous Insulin in Critically Ill Patients

OBJECTIVEThe hypothalamic-pituitary-adrenal axis is an important part of the bodys natural response to acute illness. Adrenal insufficiency has the potential to lead to hemodynamic instability and electrolyte imbalances, limit the bodys ability to respond to stress, and worsen overall clinical outcome. In this case series, we describe 16 patients evaluated for acute adrenal insufficiency after aneurysmal subarachnoid hemorrhage. CLINICAL PRESENTATIONOver a 2-year period, the medical records of 16 patients admitted to the adult neurosurgery service for aneurysmal subarachnoid hemorrhage who were nonresponsive to vasopressor therapy and received cosyntropin for the evaluation of adrenal insufficiency within 14 days of their event were reviewed. INTERVENTIONThe median baseline cortisol in this population was 22.5 μg/dL, with a poststimulation cortisol level of 31 μg/dL. Of the population surveyed, a total of 11 patients met the preestablished criteria for adrenal insufficiency, 3 with baseline cortisol levels of less than 15 μg/dL and 11 with poststimulation concentration changes of less than 9 μg/dL. Baseline serum cortisol concentrations were significantly correlated with hospital stay (P = 0.045), intensive care unit stay (P = 0.005), and ventilator days (P = 0.006). CONCLUSIONTo date, this is the only investigation evaluating the incidence of acute relative adrenal insufficiency in this population. In our cohort, 69% of the patients met the preestablished criteria for relative adrenal insufficiency. The impact of low-dose corticosteroid therapy in this population also needs review, as it could have significant implications for the management of cerebral vasospasm.

Effect of emergency medicine pharmacists on medication-error reporting in an emergency department.

Recent literature has demonstrated significant improvements in neurologic outcomes in patients who have received induced hypothermia in the setting of out‐of‐hospital cardiac arrest. Through multiple metabolic mechanisms, the induction of hypothermia slows the progression and devastation of transient cerebral hypoxia. Despite these benefits, the desired reduction in core temperature is often a challenging venture as the body attempts to maintain homeostasis through the induction of thermoregulatory processes aimed at elevating body temperature. Shivering is an involuntary muscular activity that enhances heat production in an attempt to restore homeostasis. For successful induction and maintenance of induced hypothermia, shivering, as well as other thermoregulatory responses, must be overcome. Several pharmacologic options are available, either used alone or in combination, that safely and effectively prevent or treat shivering after the induction of hypothermia. We conducted a PubMed search (1966–March 2009) to identify all human investigations published in English that discussed pharmacologic mechanisms for the control of shivering. Among these options, clonidine, dexmedetomidine, and meperidine have demonstrated the greatest and most clinically relevant impact on depression of the shivering threshold. More research in this area is needed, however, and the role of the clinical pharmacist in the development and implementation of this therapy needs to be defined.

Procedural Sedation and Analgesia in the Emergency Department

OBJECTIVE: To review the clinical data demonstrating the safety and efficacy of coenzyme Q10 (CoQ10) in heart failure (HF). DATA SOURCES: Pertinent literature was identified through MEDLINE (1966–January 2005%) using the search terms coenzyme Q10, heart failure, antioxidants, and oxidative stress. Only articles written in the English language and evaluating human subjects were used. DATA SYNTHESIS: HF impairs the ability of the heart to maintain its normal cardiac output. Following an initial insult, cardiac remodeling ensues, resulting in left ventricular dilation and hypertrophy. Oxidative stress is also increased, while CoQ10 levels are decreased in patients with HF. This has led to the hypothesis that CoQ10, an antioxidant, may decrease oxidative stress, impair remodeling, and improve cardiac function. CONCLUSIONS: Large, well-designed studies on this topic are lacking. The limited data from well-designed trials indicate there may be some minor benefits with CoQ10 therapy in ejection fraction and end diastolic volume. CoQ10 therapy has been shown to be relatively safe with a low incidence of adverse effects.

Potential benefits of high-dose methylprednisolone in acute spinal cord injuries.

Background: Continuous insulin infusions have become a standard of care in many intensive care units (ICUs); however, methods for transitioning patients from continuous infusions to other insulin therapies have not been extensively evaluated. Objective: To determine the most effective method for transitioning ICU patients from continuous insulin infusions to subcutaneous insulin therapy. Methods: A searchable pharmacy database at the University of North Carolina Hospitals was used to retrospectively identify adults admitted to the neurosurgery ICU and prescribed a continuous insulin infusion between May 2007 and February 2008, All patients were transitioned to subcutaneous insulin upon floor transfer. Patients were stratified according to the dose of subcutaneous insulin as a percentage of their prior 24-hour continuous insulin requirement and then analyzed on the rate of achievement of goal blood glucose values (80–150 mg/dL) within the first 48 hours after transition. Results: A total of 769 blood glucose values from 79 patients were recorded during the study. Data analysis demonstrated significantly lower median blood glucose values with the use of subcutaneous insulin doses that were 60–70% of insulin infusion requirements when compared with all other groups. For patients without a history of diabetes mellitus, the use of a subcutaneous dose that was 60–70% of the insulin infusion requirement resulted in a significantly greater percentage of patients within the target range compared with other groups (78%; p < 0.05). For those with a history of diabetes, subcutaneous doses higher than 70% of the insulin infusion requirement yielded the most frequent achievement of target values, although there was substantial variability within this group. No significant difference was noted in the incidence of hypoglycemia (blood glucose <80 mg/dL) between groups, although the frequency of hypoglycemia was almost twice as high in the group with diabetes as in those without it (4.2% vs 2.2%). Conclusions: Methods currently used to transition patients off insulin infusions vary widely. Initial data suggest that utilizing 60–70% of the 24-hour insulin infusion requirement as a subcutaneous dose would result in blood glucose values of 80–150 mg/dL 70% of the time. Further study is necessary to adequately assess the optimal insulin infusion transition protocol for critically ill patients to ensure both safety and efficacy.

Toxic alcohol ingestions: focus on ethylene glycol and methanol.

PURPOSE The effect of an emergency medicine (EM) clinical pharmacist on medication-error reporting in an emergency department (ED) was studied. METHODS The medication-error reports for patients seen at a universitys ED between September 1, 2005, and February 28, 2009, were retrospectively reviewed. Errors reported before the addition of an EM pharmacist (from September 1, 2005, through February 28, 2006) were compared with those reported after the addition of two EM pharmacists (from September 1, 2008, through February 28, 2009). The severity of errors and the provider who reported the errors were characterized. RESULTS A total of 402 medication errors were reported over the two time periods. Pharmacy personnel captured significantly more errors than did other health care personnel (94.5% versus 5.7%, p < 0.001). The addition of two EM pharmacists resulted in 14.8 times as many medication-error reports as were made when no EM pharmacist was in the ED. More errors that actually occurred were captured with two pharmacists providing care (95.7% versus 4.3%, p < 0.001). A majority of the errors documented were ordering errors (79.8%). Of these, 73.7% were captured after the addition of two EM pharmacists. Performance (40.0%) and knowledge (27.9%) deficits were the most common contributing factors to medication errors. CONCLUSION During the study period after the addition of two EM pharmacists in the ED, 371 medication-error reports were completed, compared with 31 reports during the study period before the addition of the pharmacists. Pharmacy personnel reported the majority of medication errors during both study periods.

Safety and efficacy of glucagon for the relief of acute esophageal food impaction

Patients present to the emergency department (ED) for a variety of reasons and some require diagnostic and therapeutic procedures for their conditions. In order for some of these procedures to be carried out successfully, the patient must be at a suppressed level of consciousness in order to tolerate the associated pain and anxiety. Medications administered to achieve these goals include analgesics and sedatives as they decrease the patient’s discomfort and awareness while allowing the patient to maintain their airway. However, medication selection and dosing is critical and should be tailored to each patient and procedure. Pharmacists have an opportunity to reduce medication errors during procedural sedation and analgesia (PSAA) as the majority of medication errors leading to adverse events occur during the ordering and administration steps of the medication use process. Common errors include drug-dosing, potential drug interactions, and administration of the wrong pharmacologic agent. Pharmacists in the ED can provide drug information and assist with drug selection and dosing; medication preparation; and monitoring of the patient and of the time intervals since medication administration relative to the duration of the procedure. Having a pharmacist present provides an extra layer of protection and reduces the likelihood for potential medication errors.