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Management of loop diuretic resistance in the intensive care unit.

Am J Health Syst Pharm. 2009 Sep 15;66(18):1635-40

Authors: Asare K

PURPOSE: The management of loop diuretic resistance in the intensive care unit (ICU) is reviewed. SUMMARY: Volume overload, a common complication of fluid resuscitation, is frequently encountered in the ICU and is associated with numerous adverse effects, including pulmonary and peripheral edema, acute lung injury, and pleural effusions. Loop diuretics are used to treat volume overload and acute renal failure and to ameliorate their associated complications. When administered intravenously, these drugs induce vigorous and prompt diuresis, which may result in negative fluid balance. This may also result in significant adverse effects, including electrolyte imbalance, ototoxicity, and volume contraction. Prolonged use of loop diuretics may lead to loop diuretic resistance, a frequent observation in the ICU. Three general mechanisms are used to explain loop diuretic resistance: rebound sodium retention, postdiuretic effect, and diuretic braking. While very few agents have joined the armamentarium and no new strategies have been developed to deal with this phenomenon, several options are available to clinicians for managing loop diuretic resistance, including salt restriction, administration of i.v. loop diuretics, continuous infusion of loop diuretics, and combination therapy using loop diuretics and thiazides. CONCLUSION: Loop diuretic resistance presents a challenge for clinicians in the ICU setting. Strategies to improve patients’ responsiveness to these agents include fluid and salt restriction, switching from oral to i.v. loop diuretics, increasing diuretic dose, continuous infusion, and combination therapy with thiazides. Several of these strategies may be used concurrently to combat diuretic resistance and promote symptomatic relief of edema in the critically ill patient.

PMID: 19729568 [PubMed - indexed for MEDLINE]

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Effect of clinical pharmacists on care in the emergency department: a systematic review.

Am J Health Syst Pharm. 2009 Aug 1;66(15):1353-61

Authors: Cohen V, Jellinek SP, Hatch A, Motov S

PURPOSE: A systematic literature review was conducted to ascertain the scope of involvement of clinical pharmacists in the emergency department (ED); summarize economic, humanistic, and clinical outcomes data; describe current limitations of these data; and identify areas for future research. METHODS: A search of MEDLINE, The Cochrane Library, International Pharmaceutical Abstracts, and CINAHL Plus databases was conducted. Articles were included in this review if the title and abstract indicated that the article’s content addressed the scope of involvement of pharmacists in the ED or pharmacist interventions in the ED and their associated outcomes, such as humanistic outcomes, cost avoidance, or improved quality. Qualitative analyses were conducted to characterize pharmacists’ activities and effects in the ED. RESULTS: Of the 533 returned citations, only 17 met the inclusion criteria. Each provided a description of clinical pharmacy services at 12 different institutions. Descriptions of these institutions and job responsibilities of the ED pharmacists are described. Six studies reported information about pharmacist interventions, including the number and types of interventions, time spent per intervention, and acceptance rate of interventions. Four studies reported cost-related outcomes data. CONCLUSION: A review of the literature revealed that pharmacists have been involved in the ED for decades. Services provided by pharmacists in the ED included traditional clinical pharmacy services, responding to medical emergencies, providing consultations on medication issues, identifying and reducing medication errors, and conducting medication histories at hospital admission. Some services were shown to be cost saving or cost avoiding.

PMID: 19635771 [PubMed - indexed for MEDLINE]

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Medication errors resulting from computer entry by nonprescribers.

Am J Health Syst Pharm. 2009 May 1;66(9):843-53

Authors: Santell JP, Kowiatek JG, Weber RJ, Hicks RW, Sirio CA

PURPOSE: The characteristics of medication errors associated with the use of computer order-entry systems by nonprescribers are discussed. METHODS: A retrospective analysis of records submitted to MEDMARX was conducted for the period from July 1, 2001, to December 31, 2005, to identify all computer-related medication errors made by nonprescribers. Quantitative analysis of the records included the severity of each error, the origin within the medication-use process, the type of error, principal causes, the location within the facility where the error was made, and the therapeutic drug classes frequently involved. Similar data from the University of Pittsburgh Medical Center (UPMC) were also analyzed and compared with the national data set. RESULTS: During the 4.5 years, 693 unique facilities submitted 90,001 medication error records that were the result of computer entry by nonprescribers. The national data set and the UPMC data had similar findings for error severity, error origin, and type of error but showed some differences in the rank ordering of error causes, location where the error occurred, and drug classes frequently associated with such errors. The percentage of harm associated with computer-entry errors was small for both the national data set and UPMC data (0.99% and 0.80%, respectively). Both data sets cited performance deficit as the leading cause of computer-entry errors, but large percentage differences were seen with other causes, including inaccurate or omitted transcription (30% versus 12.6%, respectively), documentation (19.5% versus 10.6%, respectively), and procedure or protocol not followed (21.7% versus 30.3%, respectively). Both data sets implicated the inpatient pharmacy department as the location where most computer-entry errors occurred (49.3% versus 69.0%, respectively). CONCLUSION: Analysis of the characteristics of medication errors associated with the use of computer-entry systems by non-prescribers from both MEDMARX and an individual health system database demonstrated that computer systems create new opportunities for errors to occur. Working closely with information technology personnel dedicated to assisting pharmacy departments and vendors, adequate training of pharmacy staff, and development of national standards for drug information displays in computer order-entry systems may help minimize such errors.

PMID: 19386948 [PubMed - indexed for MEDLINE]

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Takotsubo cardiomyopathy.

Am J Health Syst Pharm. 2009 Mar 15;66(6):562-6

Authors: Coons JC, Barnes M, Kusick K

PURPOSE: Takotsubo cardiomyopathy is discussed as an alternative diagnosis to acute coronary syndrome (ACS) for emotionally and physically stressed patients with transient apical akinesis or dyskinesis of the left ventricle (LV) in the absence of coronary artery disease (CAD). SUMMARY: The name takotsubo cardiomyopathy refers to the hallmark shape of the LV during initial presentation. The apical portion of the heart balloons out, while the base of the heart has preserved systolic function. It is estimated that 0.5-2% of all patients with ACS symptoms may have takotsubo cardiomyopathy. Symptoms mimic those of a myocardial infarction (MI), and the evaluation of cardiac biomarkers, including troponin, may show a mild increase. Clinical symptoms are generally similar to ACS symptoms. While chest pain and dyspnea are most common, other features, such as cardiogenic shock, are rarer. A case example is described in which a 52-year-old white woman presented herself with complaints of chest pain and shortness of breath. She explained that the chest pain started after an argument with her supervisor. An electrocardiogram showed ST-segment elevation, and the patient was treated for ST-segment elevation MI. A left ventriculogram showed severe apical hypokinesis as well as anterolateral akinesis with a normal anterobasal segment, which led to the diagnosis of takotsubo cardiomyopathy. For patients with complications such as congestive heart failure, standard supportive care for takotsubo cardiomyopathy may include diuretics and vasodilators. In general, vasopressors and inotropes should be avoided because of the association of this syndrome with massive catecholamine release. CONCLUSION: Takotsubo cardiomyopathy may be an alternative diagnosis to ACS for emotionally and physically stressed patients with transient-apical akinesis or dyskinesis of the LV in the absence of CAD. Because the exact pathophysiology has not been fully elucidated, the optimal management continues to evolve.

PMID: 19265184 [PubMed - indexed for MEDLINE]

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Posaconazole: a new oral antifungal agent with an expanded spectrum of activity.

Am J Health Syst Pharm. 2009 Feb 1;66(3):225-36

Authors: Morris MI

PURPOSE: The pharmacology, pharmacokinetics, pharmacodynamics, spectrum of activity and resistance, clinical utility, adverse effects, dosage and administration, and recommended monitoring of posaconazole are reviewed. SUMMARY: Posaconazole is a member of the azole class of antifungals recently approved for the prophylaxis and treatment of invasive fungal infections. Posaconazole has a large volume of distribution and distributes well into tissues. Posaconazole-induced fungal killing is optimal when peak drug concentrations achieved are 2-10 times the organism’s minimum inhibitory concentration. Posaconazole demonstrates fungistatic activity against most species of Candida, Cryptococcus, and Trichosporon. In a direct comparison, posaconazole appeared 2-4 times more active than itraconazole against most pathogenic yeast species. Posaconazole also showed activity against Candida and Aspergillus isolates resistant to the other azoles and amphotericin B. Posaconazole has superior activity to the other azoles against Zygomycetes isolates. It has demonstrated activity equal or superior to other antifungal agents against almost all varieties of yeast and mold. The most common treatment-related adverse events associated with posaconazole are nausea, vomiting, diarrhea, rash, hypokalemia, thrombocytopenia, and abnormal liver function test values. Significant drug interactions include cimetidine, rifabutin, and phenytoin, for which concomitant use should be avoided, as well as cyclosporine, tacrolimus, and midazolam, for which dosage reductions are recommended. CONCLUSION: Posaconazole is an oral anti-fungal agent with a broader spectrum of activity and better clinical efficacy than other available antifungals. It is less nephrotoxic than the polyenes and probably less likely to be involved in drug-drug interactions than the mold-active azoles.

PMID: 19179636 [PubMed - indexed for MEDLINE]

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Effectiveness of a medication discharge plan for transitions of care from hospital to outpatient settings.

Am J Health Syst Pharm. 2008 Aug 1;65(15):1451-7

Authors: Lalonde L, Lampron AM, Vanier MC, Levasseur P, Khaddag R, Chaar N

PURPOSE: The effect of a medication discharge plan (MDP) on the rate of medication discrepancies between hospital and outpatient settings was evaluated. METHODS: In a pragmatic, open, randomized, controlled trial, MDPs were completed for all patients before discharge from the hospital. Patients were then assigned to either an MDP group, for whom MDPs were sent to community pharmacies and treating physicians, or a usual care group, for whom an MDP was not sent. Discrepancies between MDPs and community pharmacy dispensing records and medication use reported by patients during a telephone interview were documented. The percentage of patients with discrepancies and the mean percentage of medications with discrepancies were compared between the two groups. The clinical severity of discrepancies was blindly evaluated. RESULTS: A total of 83 patients agreed to participate in the study. The percentage of patients with at least one discrepancy was high and similar in both groups when MDPs were compared with pharmacy dispensing records and patient self-reports. Comparison of MDPs to pharmacy dispensing records revealed discrepancies for 13-15% of medications; more than a third were clinically significant. Comparison of MDPs to patient self-reports revealed discrepancies for 10-12% of medications; 48% were clinically significant. No significant differences were observed between the two groups. CONCLUSION: The rate of medication discrepancies was not decreased in patients whose MDP was provided to their community pharmacy and physician at the time of hospital discharge compared with the rate in patients who received usual care.

PMID: 18653816 [PubMed - indexed for MEDLINE]

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Patient satisfaction and costs associated with insulin administered by pen device or syringe during hospitalization.

Am J Health Syst Pharm. 2008 Jul 15;65(14):1347-57

Authors: Davis EM, Christensen CM, Nystrom KK, Foral PA, Destache C

PURPOSE: Patient satisfaction, safety and efficacy outcomes, and cost savings with insulin pens versus conventional insulin delivery via vials and syringes in hospitalized patients with diabetes were compared. METHODS: Patients were recruited from two general medical-surgical units from July 2005 to May 2006. Patients completed a survey regarding satisfaction with the method in which insulin was administered before discharge. Patients completed a telephone survey approximately four weeks after discharge to determine home insulin use. Cost savings were determined using the average wholesale price of insulin vials and syringes, pens, and pen needles. RESULTS: A total of 94 patients were randomized to receive insulin administered via pen devices (n = 49) or using conventional vials and syringes (n = 45). Significantly more subjects in the pen group prepared or self-injected at least one dose of insulin during hospitalization, wanted to continue taking insulin at home using the method used during hospitalization, and would recommend their method of insulin administration used during hospitalization to other patients with diabetes compared with the vial and syringe group (p < 0.05). A cost saving of $36 per patient was projected if only insulin pens were dispensed during the entire hospital stay compared to insulin vials and syringes (p < 0.05). CONCLUSION: Increased patient satisfaction and continuation of the method of insulin administration used in the hospital at home were reported by patients who received insulin pens compared with patients who received conventional vials and syringes during hospitalization. A substantial cost saving was projected for patients in the insulin pen group if insulin pens had been dispensed during their entire hospital stay.

PMID: 18593681 [PubMed - indexed for MEDLINE]

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Implementation of standard order sets for patient-controlled analgesia.

Am J Health Syst Pharm. 2008 Jun 15;65(12):1184-91

Authors: Weber LM, Ghafoor VL, Phelps P

PURPOSE: The implementation of standard order sets for patient-controlled analgesia (PCA) is described. SUMMARY: A review of naloxone usage at the University of Minnesota Medical Center (UMMC) from January to June 2004 found that 8% of patients receiving PCA had severe respiratory depression. A subanalysis of each event found that 85% of these patients had never before received opioid therapy. To reduce the risk of respiratory depression with PCA, separate standard order sets were developed for patients new to or tolerant of opioid therapy. A major component of both order sets was the standardization of a 10-minute lockout interval between each PCA dose. Implementation of the new PCA order sets raised concerns among health care professionals at UMMC that medication safety may be improved at the cost of increased pain. After implementation of the order sets, prescriber compliance, pharmacist interventions, the frequency of adverse effects, and patients' pain management were evaluated. After implementation of standard order sets for patients receiving PCA, 57% of patients' pain was documented as being controlled, and the orders for 93% of patients were in compliance with the recommended dosage interval of > or =10 minutes. There were no reports of oversedation or respiratory depression requiring reversal with naloxone. CONCLUSION: The implementation of standard order sets for PCA resulted in a dramatic decrease in the number of cases of severe respiratory depression and increased use of the order set for patients new to opioid therapy. Changing the order sets to improve medication safety did not appear to negatively affect patients' satisfaction with pain management.

PMID: 18541691 [PubMed - indexed for MEDLINE]

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Once-weekly vancomycin for patients receiving high-flux hemodialysis.

Am J Health Syst Pharm. 2008 Jul 1;65(13):1248-53

Authors: Crawford BS, Largen RF, Walton T, Doran JJ

PURPOSE: The effectiveness of a once-weekly vancomycin dosing protocol for patients receiving long-term high-flux hemodialysis (HFHD) in the outpatient setting was studied. METHODS: Eligible patients were at least 18 years old, required hemodialysis for at least two months before study enrollment, and were not known to have any active infection. All patients received outpatient dialysis at a 1000-bed urban teaching hospital three times per week through a high-flux synthetic dialyzer. All patients received vancomycin 35 mg/kg, rounded to the nearest 250 mg, administered during hemodialysis at a rate of 1 g/hr via an infusion pump and scheduled to end when the hemodialysis session was over. Vancomycin was infused either predialyzer or postdialyzer, and infusion pumps were used in patients who received vancomycin through the postdialyzer access port. Serum vancomycin levels were measured before the third hemodialysis session (study day to evaluate the percentage of patients who maintained therapeutic vancomycin concentrations of >or=10 microg/mL. RESULTS: No patients achieved a vancomycin concentration of >or=10 microg/mL on study day 8 (mean serum concentration, 5.1 microg/mL). When patients were separated into two groups based on administration technique, six patients (83%) who received vancomycin predialyzer had undetectable vancomycin levels (<3.5 microg/mL) by study day 8 (n = 6). Patients who received vancomycin postdialyzer maintained a mean serum concentration of 6.4 microg/mL at day 8 (n = 3). CONCLUSION: A single dose of vancomycin 35 mg/kg administered during HFHD in oliguric patients with end-stage renal disease did not achieve the therapeutic serum concentration necessary for once-weekly dosing.

PMID: 18574015 [PubMed - indexed for MEDLINE]

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Adverse-drug-reaction reporting by pharmacy students in a teaching hospital.

Am J Health Syst Pharm. 2008 Jun 15;65(12):1177-9

Authors: Sullivan KM, Spooner LM

PURPOSE: Adverse-drug-reaction (ADR) reporting by pharmacy students in a teaching hospital is described. SUMMARY: Faculty and pharmacy staff collaborated to modify the existing data collection form for suspected ADRs. During the orientation session for each new rotation, pharmacy students received an overview of ADRs, ADR trigger medications, and the hospital’s ADR reporting program. Pharmacy students collected ADR data by prospectively and retrospectively reviewing inpatient charts for suspected ADRs that were identified through various means. The students were responsible for completely and accurately documenting all aspects of the suspected ADRs. At least once a week, patient charts were requested to aid students in their investigation of suspected ADRs. Data from patient cases involving allergy-related ADRs were confirmed and updated in the hospital’s computer system. All documented ADRs were entered into a spreadsheet for the purpose of generating quarterly reports. Report data were analyzed by faculty and students to identify hospitalwide trends in an effort to develop new ADR prevention strategies. Pharmacy student involvement with the ADR process began in January 2006. A total of 310 ADRs were documented for 2006, compared with 42 for 2005, when pharmacy students were not involved in data collection. ADR reports also led to allergy updates for 42 patients. With students collecting and analyzing ADR data, the hospital was able to recognize those medications that commonly caused ADRs and track hospitalwide trends in an effort to target new initiatives to prevent their occurrence. CONCLUSION: Pharmacy student participation in the ADR reporting program led to a significant increase in the number of ADRs documented.

PMID: 18541689 [PubMed - indexed for MEDLINE]

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Pharmacist- versus physician-obtained medication histories.

Am J Health Syst Pharm. 2008 May 1;65(9):857-60

Authors: Reeder TA, Mutnick A

PURPOSE: Physician-obtained medication histories were compared to those obtained by a pharmacist. METHODS: Patients whose medication histories were obtained were included in the evaluation if they were at least 18 years old and admitted to an internal medicine service at the University of Virginia Medical Center. Data were collected in two phases. The first 20 patients identified for inclusion were asked to provide an accurate medication history to pilot test the medication history form used by the pharmacist and received no pharmacist follow-up or interventions. In the second phase, patients were asked to provide an accurate medication history, and a pharmacist intervened when discrepancies in the pharmacist-obtained medication history were identified. RESULTS: A total of 55 patients were included in the study. The pharmacists identified 614 medications for these patients, compared with 556 identified by the physicians (p < or = 0.001). The pharmacist documented significantly more medication doses and dosage schedules than did physicians (614 versus 446 and 614 versus 404, respectively) (p < or = 0.001 for both comparisons). The pharmacist identified 353 discrepancies, including 58 medications not initially identified from the physician-obtained histories. The pharmacist intervened for 161 discrepancies, correcting 142 after contacting the respective physician; 19 medication discrepancies could not be justified by the physician. CONCLUSION: A total of 353 discrepancies were identified when medication histories obtained by physicians were compared with those obtained by a pharmacist during the study. During the intervention phase, the majority of discrepancies identified were either corrected by the pharmacist after contacting the respective physician or justified by the physician.

PMID: 18436732 [PubMed - indexed for MEDLINE]

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FDA approves levoleucovorin.

Am J Health Syst Pharm. 2008 Apr 15;65(8):686

Authors: Traynor K

PMID: 18387890 [PubMed - in process]

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