Sandeep Devabhakthuni

Impact of a Clinical Pharmacy Admission Medication Reconciliation Program on Medication Errors in “High-Risk” Patients

Background: Medication errors are common upon hospital admission. Clinical pharmacist involvement in medication reconciliation is effective in identifying and rectifying medication errors. However, data is lacking on the economic impact, time requirements, and severity of errors resolved by clinical pharmacists. Objective: To determine the incidence of unintended admission medication discrepancies resolved by clinical pharmacists. Secondary objectives were to determine the type of discrepancies, potential severity, proximal cause, and economic impact of this clinical pharmacy program. Methods: This was a single-center, prospective, observational study conducted at a major teaching medical institution. Following institutional review board approval, data collection was conducted over a 4-week period (August 22, 2011, to September 16, 2011). Descriptive statistical methods were performed for all data analyses. Results: A total of 517 patients involving 5006 medications were included in this study. More than 25% (n = 132) of patients had at least 1 error associated with a medication ordered on hospital admission. Pharmacists resolved a total of 467 admission medication errors (3.5 ± 2.3 errors/patient). The most common type of medication error resolved was medication omission (79.6%). In regard to severity, 46% of medication errors were considered significant or serious. Overall, the mean total time was 44.4 ± 21.8 minutes per medication reconciliation. This clinical pharmacy program was estimated to carry a net present value of

Evaluation of dexmedetomidine: safety and clinical outcomes in critically ill trauma patients.

5.7 million over 5 years. Conclusion: Clinical pharmacist involvement within a multidisciplinary health care team during the admission medication reconciliation process demonstrated a significant improvement in patient safety and an economic benefit.

A multicenter study of the point prevalence of drug-induced hypotension in the ICU.

BACKGROUND To compare safety and clinical outcomes of prolonged infusions with standard-dose (≤0.7 μg/kg/h) dexmedetomidine (SDD) or high-dose (>0.7 μg/kg/h) dexmedetomidine (HDD) to propofol in critically ill trauma patients. METHODS This was a retrospective review of 127 adult mechanically ventilated trauma patients between 2008 and 2009, who received propofol, SDD, or HDD for >24 hours. Primary outcomes were significant changes in blood pressure or heart rate. Secondary outcomes included hospital and intensive care unit (ICU) length of stay (LOS), ventilator time, and any concomitant analgesic, sedative, and antipsychotic use. Pairwise comparisons were based on Wilcoxon rank-sum test for continuous data and Pearsons chi-square test for categorical data. Statistical significance was defined as p value <0.05. RESULTS Patients in HDD group had higher rate of hypotension (98% vs. 78%; p = 0.02) but no significant differences in heart rate compared with propofol group. These patients had median longer hospital LOS (25 days vs. 12 days; p < 0.001), ICU LOS (20 days vs. 12 days; p = 0.004), and longer ventilator time (14 days vs. 7 days; p = 0.008). They also had increased requirements for oxycodone (74% vs. 40%; p = 0.003), midazolam (36% vs. 8%; p = 0.004), and haloperidol (50% vs. 24%; p = 0.02). Patients in SDD group had longer hospital LOS compared with propofol group (21 days vs. 13 days; p < 0.001). CONCLUSION Higher doses of dexmedetomidine may result in higher incidence of hypotension, longer LOS, and increased concomitant analgesic, sedative, and antipsychotic use, requiring further evaluation in trauma patients.

Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients.

Objective:To determine the point prevalence of drug-induced hypotension episodes in critically ill patients, to assess the episodes resulting from error, and to describe how episodes are treated. Design:Multicenter observational, 24-hour snapshot study. Setting:Forty-seven ICUs in 27 institutions located in the United States, Canada, and Singapore. Patients:A total of 688 ICU patients were evaluated. Interventions:None. Measurements and Main Results:Patients were included in the study if they had an episode of hypotension in the 24 hours prior to the clinical pharmacists’ evaluation. The definition for a hypotensive episode is either a systolic blood pressure less than 90 mm Hg or a decrease in systolic blood pressure of 30 mm Hg over a 2-hour period. Each episode of unintentional hypotension was assessed for suspected drug-related causes. When a drug-related cause was suspected, an objective assessment tool, the modified Kramer, was used to determine causality. A score of at least “possible” was considered drug induced, referred to as a “drug-related hazardous condition.” A drug-related hazardous condition is the temporal gap (intermediate stage) between the identification of an adverse drug reaction and the subsequent onset of drug-induced injury, known as an “adverse drug event.” Drug-induced episodes were evaluated for medication errors and treatment. One hundred fifty-eight patients experienced 204 hypotensive episodes that were considered unintentional and drug related. Common drugs implicated included propofol, fentanyl, metoprolol, lorazepam, hydralazine, and furosemide. A total of 54 episodes (26.5%) resulted from medication errors. Common error types were improper dose/quantity (46%) and prescribing (25%). A total of 56.9% episodes were treated. Conclusions:Many hypotensive episodes in the ICU are drug related and require treatment. A substantial portion of these episodes result from errors and are therefore preventable. This presents opportunities to improve prescribing including optimizing drug dosing to avoid possible patient harm from drug-induced hypotension.

Evaluation of Vancomycin Dosing and Monitoring in Adult Medicine Patients

Approximately 16–31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol‐related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom‐triggered treatment of AWS with γ‐aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first‐line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD‐resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD‐resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD‐resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.

Clinical Practice Guideline: Safe Medication Use in the Icu

Purpose To assess the clinical impact of a vancomycin dosing protocol and monitoring tool on initial dose, dosing interval, and trough concentrations in adult medicine patients. Methods This was a retrospective chart review of adult medicine patients who received at least one dose of vancomycin and were admitted during the pre-implementation period, February 1 to April 2009, or during the post-implementation period, June 1 to October 31, 2009. All outcomes for patients in the pre-implementation group were compared to those in the post-implementation group. The primary outcomes were frequency of appropriate initial vancomycin dose and dosing interval. The secondary outcomes included frequency of appropriate initial vancomycin trough concentrations, mean number of levels drawn per patient, and mean duration of therapy. Results A total of 450 patients were identified, with 225 patients in each study group. Patients with an appropriate initial vancomycin dose significantly increased in the post-implementation group (56% vs 40%; P < .001). The number of patients with an appropriate original dosing interval (67% vs 63%; P = 0.32), appropriate initial trough concentration (44% vs 45%; P = 0.89), mean number of levels drawn (1.9 vs 2.1; P = 0.56), and duration of therapy (4.9 vs 5.0; P = 0.77) was similar between the 2 groups. Conclusions The implementation of a vancomycin empiric dosing protocol and monitoring tool had a significant impact on the initial dose. Further education regarding vancomycin dosing and monitoring is warranted to improve initial dosing interval, initial trough concentration, number of levels drawn, and duration of therapy.

Efficacy and Safety of Remifentanil as an Alternative Labor Analgesic

Objective: To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. Data Sources: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. Study Selection: Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. Data Extraction: Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. Data Synthesis: The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. Conclusions: This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

Safe and Effective Use of Pharmacologic and Device Therapy for Peripartum Cardiomyopathy.

The objective of this review was to evaluate the clinical efficacy and safety of remifentanil in the management of labor pain. Although neuraxial analgesia is the best option during labor, alternative analgesic options are needed for patients with contraindications. Using a systematic literature search, clinical outcomes of remifentanil for labor pain have been summarized. Also, comparisons of remifentanil to other options including meperidine, epidural analgesia, fentanyl, and nitrous oxide are provided. Based on the literature review, remifentanil is associated with high overall maternal satisfaction and favorable side-effect profile. However, due to the low reporting of adverse events, large, randomized controlled trials are needed to evaluate maternal and neonatal safety adequately and determine the optimal dosing needed to provide effective analgesia. While remifentanil is a feasible alternative for patients who cannot or do not want to receive epidural analgesia, administration should be monitored closely for potential adverse effects.

Review of the Target-Specific Oral Anticoagulants in Development for the Treatment and Prevention of Venous Thromboembolism.

Peripartum cardiomyopathy (PPCM) is an uncommon, idiopathic complication of pregnancy associated with significant (10–30%) mortality. The disease occurs late in pregnancy or in the months following delivery, resulting in reduced systolic function and heart failure (HF) symptoms. Limited direction is provided for the management of PPCM, and the safe and effective use of medications in pregnant and breastfeeding women with PPCM presents a unique challenge. Although several HF therapies in pregnant and lactating women are supported by robust evidence, evidence to support the use of other therapies is significantly lacking. Current guidelines recommend treatment as in other forms of HF with reduced left ventricular ejection fraction (LVEF) but with consideration for the important nuances in this population as well as the unique and potential teratogenic effects of these therapies. Since most patients with PPCM recover their LVEF, the duration of therapy is currently unknown and warrants further study. We review the available literature surrounding pharmacologic and device therapy for PPCM and provide insight into managing patients with the condition.

A Collaborative Cardiologist-Intensivist Management Model Improves Cardiac Intensive Care Unit Outcomes

Anticoagulation therapy is often indicated for the treatment and prevention of venous thromboembolism (VTE). Despite advances in anticoagulant management with parenteral anticoagulants and vitamin K antagonists, limitations to their use still exists, leading to investigation of alternative anticoagulants such as factor Xa inhibitors and direct thrombin inhibitors. To date, 3 target-specific oral anticoagulants (TSOACs) are Food and Drug Administration approved; several other agents are currently in development to optimize VTE management and minimize bleeding risks. The objective of this systematic review article is to provide clinicians an overview of the clinical evidence on the investigational TSOACs for the treatment and prevention of VTE. Of the agents in development, edoxaban holds the most promise due to robust data supporting its clinical benefit with a similar bleeding risk to currently approved agents. Clinicians should understand the TSOACs under investigation, since differences in pharmacokinetics and pharmacodynamics may influence clinical decision making and agent selection for management of VTE. Currently, no direct comparisons between TSOACs have been conducted. Agents under investigation have yet to overcome the major limitations of the currently existing TSOACs. Further studies are necessary to clarify which TSOAC agent is best for management of VTE in clinical practice.