Meredith L. Howard

Strategies for the Management of Postoperative Anemia in Elective Orthopedic Surgery.

Objective: To assess the use of oral iron, intravenous (IV) iron, and erythropoiesis-stimulating agents (ESAs) for the prevention and management of perioperative anemia in elective orthopedic surgery patients, and to provide a clinical algorithm for use. Data Sources: A PubMed and MEDLINE search was conducted from 1964 through March 2016 using the following search terms alone or in combination: orthopedic, surgery, elective, anemia, blood transfusion, iron, erythropoiesis-stimulating agents, and erythropoietin. Study Selection and Data Extraction: All English-language prospective and retrospective human studies and meta-analyses evaluating oral iron, IV iron, or ESA alone or in combination in elective orthopedic surgery patients were evaluated, provided they reported blood transfusion outcomes. Data Synthesis: A total of 9 prospective and retrospective studies and 1 meta-analysis were identified and included. In the preoperative setting, administration of oral iron, IV iron, or ESA alone or in combination to correct underlying anemia led to significantly reduced transfusion rates. Transfusion requirements were generally less with combination therapy (ESA + oral or IV iron). In the short-term perioperative or postoperative period, use of oral or IV iron led to conflicting results, with some reporting a statistically significant reduction in blood transfusions, whereas others reported none. Conclusions: In elective orthopedic surgery, IV or oral iron with or without an ESA may provide benefit in prevention of postoperative anemia and results in blood transfusion reduction without significantly increasing the risk of adverse events. These agents should be considered at the lowest effective dose with emphasis on administration prior to planned surgery.

Statin Effects on Exacerbation Rates, Mortality, and Inflammatory Markers in Patients with Chronic Obstructive Pulmonary Disease: A Review of Prospective Studies

Chronic obstructive pulmonary disease (COPD) is a debilitating, irreversible disease with currently available therapies targeting symptom control and exacerbation reduction. A need for alternative disease‐modifying therapies remains, specifically those that may have antiinflammatory and immunomodulatory properties that impact the pathophysiologic components of COPD. Statin drugs, the current gold standard for the treatment of dyslipidemia and prevention of cardiovascular disease (CVD), contain properties that affect the inflammatory disease processes seen in COPD. Several retrospective studies have demonstrated that statins may have a benefit in the reduction of morbidity and mortality in patients with COPD. This has led to prospective trials evaluating the impact of statins on various COPD‐related outcomes. This article reviews the current body of prospective evidence for use of statins in patients with COPD. A search of the PubMed/Medline database of English‐language articles was conducted from 1964 through November 2015; references of relevant articles were also reviewed for qualifying studies. Prospective studies of all types relating to statin use in patients with COPD were included if they had COPD‐ or respiratory‐related outcomes; ultimately, eight studies were identified for this review. Statin effects on exacerbation rates, mortality, and inflammatory markers in patients with COPD are discussed. Strong prospective evidence does not currently exist to suggest that statins provide a clinical benefit in patients with COPD who do not have other CVD risk factors. Benefits from statins that have been illustrated are likely explained by their impact on underlying CVD risk factors rather than the COPD disease process. An opportunity exists for unanswered questions to be addressed in future studies.

Direct Oral Anticoagulants in Cardioversion: A Review of Current Evidence:

Objective: Direct oral anticoagulants (DOACs) are recommended for the prevention of stroke or systemic embolism in nonvalvular atrial fibrillation. Dabigatran, rivaroxaban, apixaban, and edoxaban represent possible alternatives to warfarin in the setting of cardioversion. A literature review was conducted to evaluate the safety and efficacy of DOAC use pericardioversion. Data Sources: A PubMed and MEDLINE search through August 2017 was conducted using the following search terms alone or in various combinations: dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban, DOAC, NOAC, TSOAC, cardioversion. Study Selection and Data Extraction: All English-language, human studies comparing the safety and efficacy of DOACs with that of other anticoagulants in the setting of cardioversion were eligible for inclusion. References from published articles were reviewed for additional relevant citations for study inclusion. Four retrospective and 2 prospective trials comparing DOACs with warfarin were identified. Data Synthesis: The majority of studies included patients undergoing electric cardioversion. Based on current evidence, the DOACs perform similarly to warfarin in the prevention of stroke and systemic embolism, and bleeding rates are comparable. Conclusions: DOACs may be an attractive alternative to warfarin because of fast onset of action, potentially reducing delay to cardioversion. More robust studies are needed in patients with renal dysfunction and patients undergoing pharmacological cardioversion.

Pharmacy residents as primary educators within a professional pharmacy elective

BACKGROUND AND PURPOSE The purpose of this study was to evaluate the impact of a course change from a faculty-led professional pharmacy elective to a primarily pharmacy resident-led course on student satisfaction and learning. EDUCATIONAL ACTIVITY AND SETTING In 2014, pharmacy residents were transitioned into primary teaching roles in a drug-induced diseases elective to increase student exposure to residents and different teaching styles. Student learning roles did not change. Course evaluations and grades were compared between the resident-led year and prior year. FINDINGS There was no significant difference between overall course grades during the resident-led year (94.2 ± 36.6 in 2014 vs. 94.1 ± 2.7 in 2013; p=0.975). Course evaluations were similar to the previous year and students provided favorable feedback. DISCUSSION AND SUMMARY This pharmacy resident-led elective allowed for resident integration in to an interactive professional elective. Student satisfaction with the course remained similar to the previous year and overall course grades did not differ.

Glycemic Management in the Bariatric Surgery Population: A Review of the Literature

Obesity is a worldwide epidemic often complicated by multiple comorbidities, including type 2 diabetes mellitus (T2DM). Bariatric surgery is an increasingly common and effective weight‐loss strategy for obese patients that may result in resolution of metabolic‐related disease states, such as T2DM. Although bariatric surgery has many positive outcomes for patients, dietary and pathophysiologic changes can create difficult‐to‐control blood glucose, especially in the immediate perioperative setting. Depending on oral antidiabetic agent and insulin needs preoperatively, many patients require cessation of oral agents and reduction or cessation of insulin. Unfortunately, despite available perioperative bariatric surgery guidelines, no specific recommendations for perioperative oral antidiabetic agent or insulin management exist. The purpose of this article is to review the current body of evidence for blood glucose management in the setting of bariatric surgery. An English‐language PubMed and MEDLINE search was conducted from 1964 through March 2018 using the following search terms alone and in various combinations: bariatric surgery, gastric banding, laparoscopic sleeve gastrectomy (LSG), Roux‐en‐Y gastric bypass (RYGB), glucose management, insulin, and oral antidiabetic agent. Five articles were identified evaluating insulin management in the perioperative bariatric surgery setting, which were separated into two categories: immediate perioperative insulin management and long‐term postoperative insulin management. Overall, various blood glucose management insulin protocols were evaluated. All studies included some type of insulin reduction in the perioperative setting. No studies identified specifically evaluated down‐titration or discontinuation of oral antidiabetic agents. Given the lack of specific guideline recommendations, limitations of standardized insulin protocols, and inconsistency of outcomes studied, perioperative insulin at reduced doses compared to previous maintenance doses coupled with frequent blood glucose monitoring is reasonable. An opportunity exists for successful protocols to be addressed in future, larger studies.

Continuous Infusion Nonsteroidal Anti-Inflammatory Drugs for Perioperative Pain Management:

Purpose: To review the use of continuous infusion (CI) nonsteroidal anti-inflammatory drugs (NSAIDs) as an alternative modality for pain control in surgical patient populations. Methods: A PubMed and MEDLINE search was conducted from 1964 through February 2016 using the following search terms alone or in combinations: continuous, infusion, nonsteroidal anti-inflammatory drug, diclofenac, ibuprofen, indomethacin, ketoprofen, ketorolac, and surgery. All English-language, prospective and retrospective, adult and pediatric studies evaluating intravenous or intramuscular CI NSAIDs for surgical pain were evaluated for inclusion in this review. Results: Twenty four prospective and retrospective publications evaluating CI NSAIDs were identified: 12 in abdominal surgery, 7 in orthopedic surgery, and 5 in pediatric surgery. Specific CI NSAIDs utilized included diclofenac, indomethacin, ketoprofen, and ketorolac. Most studies compared the CI NSAID to placebo or an alternative analgesic and evaluated pain control, supplemental opioid use, and related adverse effects. In these surgical populations, CI NSAIDs decreased opioid consumption, alongside provision of adequate pain control. While long-term adverse effects were rarely collected, a decrease in nausea and sedation was often seen with the CI NSAID groups. Conclusions: In the abdominal, orthopedic, and pediatric surgical populations, CI NSAIDs represent a feasible alternative modality for perioperative pain control.

Efficacy and Safety of Appetite-Stimulating Medications in the Inpatient Setting

Background: Hospitalized patients are subject to acute illness and stress which may impact appetite or weight. Loss of appetite may lead to increased morbidity or mortality. Medications such as dronabinol, megestrol, and mirtazapine are used for weight gain in the outpatient setting; however, there is limited information about safety or effectiveness when initiated inpatient. Objectives: To analyze the effectiveness and safety of appetite-stimulating medications in hospitalized patients. Methods: This was a retrospective cohort study of hospitalized patients initiated on dronabinol, megestrol, or mirtazapine for appetite. The primary outcome was change in meal intake between drug initiation and discontinuation. Secondary outcomes included documented improvement in appetite, change in weight and various laboratory parameters, and incidence of adverse effects. Results: A total of 38 patients met inclusion criteria, and mirtazapine was most commonly used (42%). There was no significant difference between groups of appetite-stimulating medications with regard to mean change in meal intake, weight, albumin, or documented improvement in diet. Within groups, each agent showed numerical improvement in percentage meal intake, with a mean change from initiation to discontinuation of 17.12%. Almost half (48%) of the patients experienced improvement in diet after the start of medications. No serious adverse effects were observed. Conclusion and Relevance: In inpatients, there was no difference in change in meal intake or weight between dronabinol, megestrol, or mirtazapine, but they may show numerical improvements in meal intake. To our knowledge, this is the first study to evaluate the use of dronabinol, megestrol, and mirtazapine initiated in the inpatient setting.

437: EVALUATION OF CODE BLUE SIMULATION ON INTERPROFESSIONAL COMPETENCY AMONG PHARMACY STUDENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) (43%) were women; 59 (70%) patients needed MV and 48 (57%) required VP. Of 59 (70%) patients assessed by OT, 34 (40%) received EM. PC occurred on ICU days 3-4 and 8-9 and was requested for depression/anxiety in 29 (35%) and for delirium in 23 (27%). CAM-ICU was recorded in 77, only 26 screened positive. Delirium was diagnosed by ICU physicians in 35 (42%) and by psychiatry in 61 (73%). Rate of concordance with psychiatrists was 53% for nurses and 45% for ICU physicians. ICU and overall hospital mortality rates were 19% and 25%, respectively. Among hospital survivors, 29 went home and 34 to a rehabilitation/hospice facility. Conclusions: Identification of delirium by ICU clinicians remains challenging. Psychiatric consultation is an underutilized resource.