Laura Siemianowski

Impact of Pharmacy Technician-Centered Medication Reconciliation on Optimization of Antiretroviral Therapy and Opportunistic Infection Prophylaxis in Hospitalized Patients With HIV/AIDS

Purpose: This study aimed to examine the role of a pharmacy technician-centered medication reconciliation (PTMR) program in optimization of medication therapy in hospitalized patients with HIV/AIDS. Methods: A chart review was conducted for all inpatients that had a medication reconciliation performed by the PTMR program. Adult patients with HIV and antiretroviral therapy (ART) and/or the opportunistic infection (OI) prophylaxis listed on the medication reconciliation form were included. The primary objective is to describe the (1) number and types of medication errors and (2) the percentage of patients who received appropriate ART. The secondary objective is a comparison of the number of medication errors between standard mediation reconciliation and a pharmacy-led program. Results: In the PTMR period, 55 admissions were evaluated. In all, 50% of the patients received appropriate ART. In 27of the 55 admissions, there were 49 combined ART and OI-related errors. The most common ART-related errors were drug–drug interactions. The incidence of ART-related medication errors that included drug–drug interactions and renal dosing adjustments were similar between the pre-PTMR and PTMR groups (P = .0868). Of the 49 errors in the PTMR group, 18 were intervened by a medication reconciliation pharmacist. Conclusion: A PTMR program has a positive impact on optimizing ART and OI prophylaxis in patients with HIV/AIDS.

Levetiracetam: an unusual cause of delirium.

Levetiracetam is a second-generation anticonvulsant that was approved by the Federal Drug Administration in 1999 for the treatment of epilepsy. Recently, levetiracetam has become more popular for the prevention of posttraumatic seizures. Some of the well-known adverse effects of levetiracetam are somnolence, behavioral abnormalities, and less commonly, psychosis. Delirium is not a well-known adverse effect of levetiracetam. Here, we present the case of a 77-year-old Caucasian male who developed disorientation, agitation, and lethargy after initiation of levetiracetam to prevent posttraumatic seizures. Imaging on admission demonstrated a subacute subdural hematoma in the left frontal lobe without mass effect, and the patient was started on levetiracetam 500 mg intravenously twice daily. Less than 24 hours later, the patient began to display a fluctuating level of consciousness, disorientation, an inability to follow commands, and garbled speech. His symptoms continued for 12 days unabated despite episodic treatment with sedatives and antipsychotics. At one point, the patient progressed to aggressive behavior and required restraints. Laboratory tests during this period did not demonstrate signs of infection or metabolic abnormalities. Delirium from levetiracetam was suspected and the drug was discontinued. The patients mental status improved dramatically within 24 hours after administration of the last dose of levetiracetam and he was discharged home. Based on the Naranjo scale, the episode of delirium was probably related to levetiracetam. Although the other neuropsychiatric effects of levetiracetam are well known, we highlight the first case of delirium without psychotic features associated with levetiracetam.

Nalbuphine-induced psychosis treated with naloxone

PURPOSE A case of nalbuphine-induced psychosis, which resolved after the administration of naloxone, is described. SUMMARY A 25-year-old African-American woman with a history of systemic lupus erythematosus was admitted to the hospital for management of cholecystitis. A laparoscopic cholecystectomy was performed, and the patient received multiple doses of i.v. hydromorphone for postoperative pain management. Four days later, shortly after receiving a dose of i.v. nalbuphine for opioid-induced pruritus, she experienced an acute psychotic event, with symptoms including intense headache, akathisia, altered mental status, and formication (a hallucinatory sensation of insects crawling on the skin). The neuropsychiatric symptoms abated within 5 minutes of two consecutively administered doses of i.v. naloxone. During this event, which lasted 25-30 minutes, there was no evidence of metabolic abnormalities and were no signs of infection. The patient did not have a history of mental illness or substance abuse. The patient did not receive further doses of nalbuphine and did not experience similar events during her hospital stay; she was discharged home 10 days later without further complications. According to the algorithm of Naranjo et al., the case was assigned a score of 6, indicating a probable adverse reaction to nalbuphine. CONCLUSION A patient developed an acute psychotic reaction that was probably secondary to administration of i.v. nalbuphine for opioid-induced pruritus. Evidence supporting this diagnosis included correlation between the timing of administration of nalbuphine and symptom onset and the marked improvement in mentation following the administration of naloxone.

Intravenous Vancomycin Associated With the Development of Nephrotoxicity in Patients With Class III Obesity

Background:A consensus statement recommends initial intravenous (IV) vancomycin dosing of 15-20 mg/kg every 8- 24 hours, with an optional 25- to 30-mg/kg loading dose. Although some studies have shown an association between weight and the development of vancomycin-associated nephrotoxicity, results have been inconsistent. Objective: To evaluate the correlation between incidence of nephrotoxicity associated with weight-based IV vancomycin dosing strategies in nonobese and obese patients. Methods: This retrospective cohort study evaluated hospitalized adult patients admitted who received IV vancomycin. Patients were stratified into nonobese (body mass index [BMI] <25 kg/m2), obesity class I and II (BMI 30-39.9kg/m2), and obesity class III (BMI≥40 kg/m2) groups; patients who were overweight but not obese were excluded. Incidence of nephrotoxicity and serum vancomycin trough concentrations were evaluated. Results: Of a total of 62 documented cases of nephrotoxicity (15.1%), 13 (8.7%), 23 (14.3%), and 26 (26.3%) cases were observed in nonobese, obesity class I and II, and obesity class III groups, respectively (P=0.002). Longer durations of therapy (P<0.0001), higher initial maintenance doses in both total milligrams/day (P=0.0137) and milligrams/kilogram (P=0.0307), and any trough level >20 mg/L (P<0.0001) were identified as predictors of development of nephrotoxicity. Concomitant administration of piperacillin/tazobactam, diuretics, and IV contrast were associated with development of nephrotoxicity (P<0.005, all). Patients with class III obesity were 3-times as likely to develop nephrotoxicity when compared with nonobese patients (odds ratio [OR]=2.99; CI=1.12-7.94) and obesity class I and II patients (OR=3.14; CI=1.27-7.75). Conclusions: Obesity and other factors are associated with a higher risk of vancomycin-associated nephrotoxicity.

Variables Affecting Pharmacy Students’ Patient Care Interventions during Advanced Pharmacy Practice Experiences

Objective. To identify the temporal effect and factors associated with student pharmacist self-initiation of interventions during acute patient care advanced pharmacy practice experiences (APPE). Methods. During the APPE, student pharmacists at an academic medical center recorded their therapeutic interventions and who initiated the intervention throughout clinical rotations. At the end of the APPE student pharmacists completed a demographic survey. Results. Sixty-two student pharmacists were included. Factors associated with lower rates of self-initiated interventions were infectious diseases and pediatrics APPEs and an intention to pursue a postgraduate residency. Timing of the APPE, previous specialty elective course completion, and previous hospital experience did not result in any significant difference in self-initiated recommendations. Conclusion. Preceptors should not base practice experience expectations for self-initiated interventions on previous student experience or future intentions. Additionally, factors leading to lower rates of self-initiated interventions on infectious diseases or pediatrics APPEs should be explored.

969: REBOUND ENOXAPARIN ANTIFACTOR XA ACTIVITY AFTER DIALYSIS DISCONTINUATION IN A VERY-LOW-WEIGHT ADULT

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: While low dose unfractionated heparin (UFH) is considered the gold standard for patients requiring thromboprophylaxis and renal replacement therapy (RRT), there exist challenges with dosing in low weight adults. Low molecular weight heparins (LMWH) such as enoxaparin may be considered an alternative to UFH since it can be dosed based on body weight and there exist accepted target anti factor Xa activity (AFXa) ranges to measure enoxaparin activity and to detect accumulation. We describe a case of a very low weight, critically ill adult requiring RRT who was treated with AFXa-guided enoxaparin and experienced rebound AFXa following RRT discontinuation. Methods: A 28 year old, 20 kg female with a past medical history significant for stage IV neuroblastoma status-post bone marrow transplant, CKD stage IV, and cirrhosis was admitted to our hospital for gram-negative septic shock. She was stabilized initially with IV fluid resuscitation, antimicrobials, and continuous RRT. Additional supportive care, including thromboprophylaxis with subcutaneous enoxaparin was provided. A target steady-state (SS) 4 hour peak AFXa of 0.2-0.4 IU/mL was used as a goal range for dose adjustments. The patient was initiated on an initial dose of 0.5 mg/kg q24h, which was subsequently increased twice for subtherapeutic AFXa measurements. During this time, the patient was transitioned from continuous to intermittent RRT. A SS peak AFXa, measured on a non-RRT day, was 0.18 IU/mL and the dose was again increased. Thereafter, a repeat SS peak AFXa, measured 2 hours post-HD, was 0.69 IU/mL. With thought that this surprisingly elevated AFXa could be due to rebound enoxaparin plasma concentrations following RRT discontinuation, the dose was not changed but the administration time was rescheduled to allow pre-HD peak AFXa monitoring. Thereafter, a SS peak AFXa, measured before RRT, was 0.19 IU/mL and the dose was again increased. Subsequent SS peak AFXa thereafter were therapeutic. No acute thromboembolism or bleeding complications occurred during the hospitalization. Results: Careful consideration should be made for drug selection, dosing and monitoring of thromboprophylaxis in low weight adults requiring RRT. Lack of weight-based dosing and accepted AFXa targets for subcutaneous UFH make the use of a LMWH, such as enoxaparin, a more attractive option. The implications of “rebound” AFXa following RRT should be considered when timing AFXa measurements to measure enoxaparin activity and accumulation.

923: CHALLENGES IN THE DELIVERY OF ALL-TRANS RETINOIC ACID TO PATIENTS WITH IMPAIRED SWALLOWING ABILITY

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Patients with acute promyeloid leukemia (APML) can present with intracranial or alveolar hemorrhage that renders them unconscious or with respiratory distress requiring intubation. The preferred drug to induce APML remission is all-trans-retinoic-acid (ATRA), which is available only as a gelatin capsule for oral administration. The capsule must be swallowed whole and intact. It is too large and viscous to be administered via feeding tube. Preparing a suspension with the contents is not recommended by the manufacturer due to reports of low plasma levels after administration via this method. Given that unconscious and intubated patients have an impaired ability to swallow, alternative delivery routes are needed. Methods: We present a case of acute onset APML in a 22 year old female with no significant past medical history who presented with obtundation secondary to extensive intracranial hemorrhage and large right subdural hematoma. She was intubated and transferred to our hospital where she underwent emergent right decompressive hemicraniectomy and subsequently developed disseminated intravascular coagulation (DIC). Her blood smear demonstrated prominent immature white blood cells leading to a high suspicion of APML. Conventional anthracycline-based chemotherapy was not considered due to concern of worsening DIC. ATRA was recommended for the induction of APML remission. Given that the patient was comatose, she was unable to swallow the gel capsules so alternative methods were researched. A literature search yielded one report of clinically successful sublingual administration of ATRA. Sublingual administration was immediately initiated. Despite aggressive treatment and commencement of ATRA, the patient developed multiorgan failure and cerebral edema leading to herniation. She passed away on day 3 of hospitalization. Results: The lack of a convenient dosage form for ATRA poses a challenge when caring for patients unable to swallow capsules whole. Considering that conventional anthracycline-based chemotherapy is not a good option in APML patients with DIC, more studies should be conducted to determine a standard, effective and reliable method to deliver ATRA to these patients.

1023: Impact of patient location on time to antimicrobial administration in severe sepsis and septic shock

Introduction: No study has examined the differences in time to antimicrobials between patient locations at the time of severe sepsis and septic shock onset and its impact on outcomes. This study aimed to compare the time from onset of severe sepsis or septic shock to antimicrobial administration bet