In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are ...posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
Kindling the fire: The power of mentorship Newsome, Andrea Sikora; Ku, Pam M; Murray, Brian ...
American journal of health-system pharmacy,
12/2021, Letnik:
78, Številka:
24
Journal Article
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been ...peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
Prolonged duration of intravenous (IV) vasopressor dependence in critically ill adult patients with vasodilatory shock results in increased length of stay in both the intensive care unit (ICU) and hospital, translating to higher risk of infection, delirium, immobility, and cost. Acceleration of vasopressor liberation can aid in reducing these risks. Midodrine is an oral α1-adrenergic receptor agonist that offers a potential means of liberating patients from IV vasopressor therapy. This clinical review summarizes primary literature and proposes a clinical application for midodrine in the recovery phase of vasodilatory shock.
Five studies with a total of over 1,000 patients conducted between 2011 and 2021 were identified. In observational studies, midodrine administration was demonstrated to lead to faster time to liberation from IV vasopressor therapy and shorter ICU length of stay in patients recovering from vasodilatory shock. These findings were not replicated in a prospective, multicenter, randomized controlled trial. In this review, literature evaluating midodrine use for IV vasopressor liberation is summarized and study limitations are discussed.
On the basis of this review of current literature, recommendations are provided on selecting appropriate candidates for adjunctive midodrine in the recovery phase of vasodilatory shock and considerations are discussed for safely and effectively initiating, titrating, and discontinuing therapy.
Background:
Fluid overload is associated with poor outcomes, but mitigating its occurrence poses significant challenges.
Objective:
This study sought to assess the impact of hidden fluid volume on ...fluid overload.
Methods:
This study was a multi-center, retrospective evaluation of adults admitted to a medical or surgical intensive care unit for at least 72 h. Patients were divided into tertiles (low, moderate, and high) based on the hidden fluid volume received. Hidden fluids were defined as intravenous medications, line flushes, blood products, and enteral nutrition. The primary outcome was the incidence of fluid overload at intensive care unit (day 3). Secondary outcomes included mechanical-ventilation free days and association of hidden fluid volume with fluid overload, length of stay, and mortality.
Results:
A total of 219 (73 per tertile) were included, with hidden fluid volume comprising ⩽2500, 2501–4400, and >4400 mL in the low, moderate, and high tertiles, respectively. Incidence of fluid overload was significantly different across groups (low: 3%, moderate: 14%, high: 25%; p < 0.001). No difference existed in mechanical-ventilation free days or in-hospital mortality across tertiles. In binary logistic regression, hidden fluid volume received at 3 days was independently associated with fluid overload (odds ratio = 1.40, 95% confidence interval = 1.15–1.70).
Conclusion:
The volume of hidden fluid volume administered by intensive care unit day 3 independently predicted development of fluid overload.
Intravenous fluids are the most commonly prescribed medication in the intensive care unit (ICU) and can have a negative impact on patient outcomes if not utilized properly. Fluid stewardship aims to ...heighten awareness and improve practice in fluid therapy. This report describes a practical construct for implementation of fluid stewardship services and characterizes the pharmacist's role in fluid stewardship practice.
Fluid stewardship services were integrated into an adult medical ICU at a large community hospital. Data characterizing these services over a 2-year span are reported and categorized based on the 4 rights (right patient, right drug, right route, right dose) and the ROSE (rescue, optimization, stabilization, evacuation) model of fluid administration. The review encompassed 305 patients totaling 905 patient days for whom 2,597 pharmacist recommendations were made, 19% of which were related to fluid stewardship. This corresponded to an average of 1.52 fluid stewardship recommendations per patient. Within the construct of the 4 rights, 39% of recommendations were related to the right patient, 33% were related to the right route, 17% were related to the right drug, and 11% were related to the right dose. By the ROSE model, 1% of recommendations were related to the rescue phase, 3% were related to optimization, 79% were related to stabilization, and 17% were related to evacuation.
Implementation of fluid stewardship pharmacy services in a community hospital medical ICU is feasible. Integration of this practice contributed to 19% of pharmacy recommendations. The most common recommendations involved evaluation of the patient for the appropriateness of fluid therapy during the stabilization phase. The impact of fluid stewardship on patient outcomes needs to be explored.
•Poor guideline adherence increases unnecessary empirical and continued vancomycin.•Hematological malignancy was associated with appropriate empirical vancomycin prescribing.•Education and patient ...assessment is needed to improve vancomycin prescribing.
The purpose of this study was to evaluate the use of empirical vancomycin for patients with neutropenic fever (NF) with regard to adherence to treatment guidelines.
Adult patients with a diagnosis of neutropenia, who met the definition of NF as per treatment guidelines, were identified. Use of vancomycin was evaluated as part of empirical therapy and again after 72h. Outcomes were assessed using descriptive statistics, the Chi-square or Fisher’s exact test, and univariate exact logistic regression analyses.
Sixty-four patients were included. Overall, inappropriate empirical vancomycin use was observed in more than 30% of patients. Of 35 patients with indications for empirical vancomycin, only 68% received it. At 72h, appropriate vancomycin continuation, de-escalation, or discontinuation occurred in 21 of 33 patients. On univariate regression, hematological malignancy was associated with appropriate empirical vancomycin prescribing, whether initiating or withholding (odds ratio 4.0, 95% confidence interval 1.31–12.1). No variable was independently associated with inappropriate continuation at 72h.
There is poor guideline adherence to vancomycin prescribing as empirical therapy and at 72-h reassessment in patients with NF. Further efforts are needed to foster a more rational use of vancomycin in patients with NF.
Maternal mortality continues to be an issue globally despite advances in technology and pharmacotherapy. Pregnancy can lead to complications that necessitate immediate action to prevent severe ...morbidity and mortality. Patients may need escalation to the ICU setting for close monitoring and administration of advanced therapies not available elsewhere. Obstetric emergencies are rare but high-stakes events that require clinicians to have prompt identification and management. The purpose of this review is to describe complications of pregnancy and provide a focused resource of pharmacotherapy considerations that clinicians may encounter. For each disease state, the epidemiology, pathophysiology, and management are summarized. Brief descriptions of non-pharmacological (e.g., cesarean or vaginal delivery of the baby) interventions are provided. Mainstays of pharmacotherapy highlighted include oxytocin for obstetric hemorrhage, methotrexate for ectopic pregnancy, magnesium and antihypertensive agents for preeclampsia and eclampsia, eculizumab for atypical hemolytic uremic syndrome, corticosteroids, and immunosuppressive agents for thrombotic thrombocytopenic purpura, diuretics, metoprolol, and anticoagulation for peripartum cardiomyopathy, and pulmonary vasodilators for amniotic fluid embolism.
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