Critical care therapeutics: a frontier for clinical pharmacy. 1982.
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Critical Care↗
Biomedical subjects
Joseph F Dasta
Publications and source records attributed to Joseph F Dasta.
Critical care.
2006 marks the 40th year of publication for The Annals. Over that time, The Annals has been an important contributor to the development of clinical pharmacy. Throughout 2006, we are publishing articles reflecting on the history of clinical pharmacy through the eyes of practitioners, including those pioneering clinical pharmacy, as well as those who have more recently entered the profession and a well-established specialty.
Critical Care↗
Critical care pharmacy services in United States hospitals.
BACKGROUND: Critical care pharmacy activities have been described as fundamental, desirable, and optimal, but actual services provided have not been evaluated. OBJECTIVE: To characterize the type and level of pharmacy services provided to intensive care units (ICUs). METHODS: A 38 question survey was sent in 2 consecutive mailings to all US institutions (N = 3238) with an ICU. Questions were categorized according to clinical, educational, administrative, and scholarly activities, with levels of services stratified as fundamental, desirable, or optimal. RESULTS: Completed surveys were received from 382 (11.8%) institutions encompassing 1034 ICUs. Direct clinical pharmacy activities were provided at 62.2% of ICUs. The pharmacists in those programs attended rounds 4.4 +/- 1.5 days/wk, mean +/- SD, and had a workweek that consisted of patient care (43% of hours worked), drug distribution (26.2%), administration (12.6%), education (10.9%), and scholarly activities (7.3%). Fundamental clinical activities performed during at least 75% of patient ICU days were providing drug information, drug therapy evaluation, drug therapy intervention, and pharmacokinetic monitoring. Conducting in-services (92.8%), a fundamental service, was the only educational activity frequently provided. Most respondents were involved with at least one multidisciplinary committee, and 45.5% conducted scholarly activities. Desirable or optimal activities were not frequently provided across all service categories. CONCLUSIONS: Clinical pharmacists are directly involved as caregivers in nearly two-thirds of ICUs in the US. Although they provide a range of clinical and administrative services, involvement in educational and scholarly activities is variable. The level of services provided is consistent with the criteria deemed fundamental for improving patient care. Higher-order services are far less likely to be provided.
Clinical Pharmacy Information Systems↗
Role of the bispectral index in sedation monitoring in the ICU.
OBJECTIVE: To review and critique evidence for the use of the bispectral index (BIS) in intensive care unit (ICU) patients. DATA SOURCES: A computer search of English-language articles in MEDLINE (1966-July 2005), International Pharmaceutical Abstracts (1971-July 2005), and Scientific Citation Index Expanded (1980-July 2005) was conducted. A manual search of abstracts was also performed using the key search terms BIS, sedation, and critical care. STUDY SELECTION AND DATA EXTRACTION: Case series, letters, editorials, and clinical studies that evaluated BIS in ICU patients were considered for inclusion. DATA SYNTHESIS: Nineteen studies comparing the BIS with sedation scales were evaluated, revealing that the BIS trends lower with increasing sedation. The BIS appeared to correlate better when sedation scores were grouped rather than individual values. However, correlations between BIS and subjective scales were low in most studies (r(2) 0.21-0.93). Additionally, there was poor correlation between drug dosage and the BIS. Randomized, controlled trials demonstrating improved outcomes with BIS monitoring have not been reported. CONCLUSIONS: Interpreting literature on the usefulness of the BIS in the ICU is difficult for reasons that include heterogeneous populations, different methods of collecting BIS data, and use of different versions of BIS software and hardware. Outcomes data are lacking. The 2002 Society of Critical Care Medicine Sedation Guidelines recommendation that more data are needed before the BIS should be used routinely in the ICU remains unchanged. We recommend that further studies be conducted to determine the optimal method of obtaining BIS data and evaluate the impact of the BIS on relevant patient outcomes.
Critical Care↗
Contemporary issues in the pharmacologic management of acute heart failure.
Acute heart failure is an evolving syndrome that continues to be defined by ongoing studies and registries. It is associated with significant morbidity and mortality and places a huge economic burden on health care systems. Improved understanding of the underlying pathophysiologic processes has prompted interest into understanding the implications of current and future pharmacologic management strategies beyond hemodynamics. Diuretics, vasodilators, and inotropes remain the mainstays of therapy with several new classes of agents on the horizon. Clinicians should understand the rationale for use and limitations of each therapy to maximize benefit and cost-effectiveness, while minimizing the potential for adverse outcomes.
Aged↗
Impact of disease states on the pharmacokinetics and pharmacodynamics of angiotensin-converting enzyme inhibitors.
The pharmacokinetics and pharmacodynamics of angiotensin-converting enzyme inhibitors (ACE) in elderly patients and patients with renal and hepatic impairment were examined, and a role for an AUC/EC50 ratio to guide dosing was evaluated. A Medline and International Pharmaceutical Abstracts search was used to identify human studies and abstracts. Relevant data were evaluated and summarized. Dosing regimens were compared using an AUC/EC50 ratio. Most studies evaluating ACE inhibitors in renal impairment report a strong linear correlation between creatine clearance and drug elimination. AUC and EC50 values for these drugs in elderly subjects appear similar to younger and hypertensive patients. There is increased AUC in some patients with hepatic impairment. Pharmacodynamic data are conflicting. Prolonged ACE inhibition is evident in renal impairment but not necessarily other disease states. ACE inhibitor dosing for hypertension is reasonable based on pharmacokinetics and EC50 values. Further individualization of therapy may improve outcomes, and using the threshold AUC/EC50 ratio may help guide appropriate dosing.
Aging↗
Addition of dexmedetomidine to standard sedation regimens after cardiac surgery: an outcomes analysis.
STUDY OBJECTIVE: To characterize inpatient use of intravenous sedatives in the real-world setting, and to evaluate clinical and economic outcomes when dexmedetomidine was used with midazolam and propofol for select cardiovascular procedures. DESIGN: 12-month retrospective analysis. DATA SOURCE: An administrative claims database of operational data from a nationally representative sample of 250 medical and surgical hospitals. PATIENTS: Patients who received midazolam plus propofol (9996 patients) or dexmedetomidine, midazolam, plus propofol (356 patients) after cardiac valve or vessel surgery. MEASUREMENTS AND MAIN RESULTS: The source of patient demographics (e.g., age, sex, Charlson Comorbidity Index) and outcomes (e.g., charges, length of stay, mortality rate) was the hospital billing claim form. Patients in the dexmedetomidine-midazolam-propofol cohort tended to be younger and male and to have fewer comorbidities than those midazolam-propofol cohort. The primary outcomes for the three-drug cohort showed significant reductions in total charges/patient (approximately $18,000, p<0.05), total hospital length of stay (0.6 days, p<0.0001), days in the intensive care unit or cardiac care unit (3.87 days, p<0.0001), and mortality (2%, p=0.0142). Although pharmacy charges were higher (approximately $4000/patient), lower charges for the intensive care or cardiac care unit, operating room, room and board, and respiratory services were observed in the dexmedetomidinemidazolam-propofol cohort compared with the two-drug cohort. Also, mechanical ventilation was shorter by approximately 0.5 day in the three-drug cohort (p<0.01). CONCLUSION: These initial findings of a real-world assessment of dexmedetomidine use with other agents suggest favorable clinical and economic outcomes. Further research through randomized clinical trials of dexmedetomidine is warranted to better understand its optimum patient population, dosage, and the causality of the results, and to confirm the potential clinical and economic benefits observed in our patients.
Aged↗
Daily cost of an intensive care unit day: the contribution of mechanical ventilation.
OBJECTIVE: To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit. DESIGN: Retrospective cohort analysis using data from NDCHealth's Hospital Patient Level Database. SETTING: A total of 253 geographically diverse U.S. hospitals. PATIENTS: The study included 51,009 patients >/=18 yrs of age admitted to an intensive care unit between October 1, 2002, and December 31, 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Days of intensive care and mechanical ventilation were identified using billing data, and daily costs were calculated as the sum of daily charges multiplied by hospital-specific cost-to-charge ratios. Cost data are presented as mean (+/-sd). Incremental daily cost of mechanical ventilation was calculated using log-linear regression, adjusting for patient and hospital characteristics. Approximately 36% of identified patients were mechanically ventilated at some point during their intensive care unit stay. Mechanically ventilated patients were older (63.5 yrs vs. 61.7 yrs, p < .0001) and more likely to be male (56.1% vs. 51.8%, p < 0.0001), compared with patients who were not mechanically ventilated, and required mechanical ventilation for a mean duration of 5.6 days +/- 9.6. Mean intensive care unit cost and length of stay were 31,574 +/- 42,570 dollars and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and 12,931 +/- 20,569 dollars and 8.5 days +/- 10.5 for those not requiring mechanical ventilation. Daily costs were greatest on intensive care unit day 1 (mechanical ventilation, 10,794 dollars; no mechanical ventilation, 6,667 dollars), decreased on day 2 (mechanical ventilation:, 4,796 dollars; no mechanical ventilation, 3,496 dollars), and became stable after day 3 (mechanical ventilation, 3,968 dollars; no mechanical ventilation, 3,184 dollars). Adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was 1,522 dollars per day (p < .001). CONCLUSIONS: Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter. Mechanical ventilation is associated with significantly higher daily costs for patients receiving treatment in the intensive care unit throughout their entire intensive care unit stay. Interventions that result in reduced intensive care unit length of stay and/or duration of mechanical ventilation could lead to substantial reductions in total inpatient cost.
Adult↗
Monitoring abnormal laboratory values as antecedents to drug-induced injury.
BACKGROUND: Clinical abnormalities associated with drug therapy may lead to injury if untreated. Detection of preceding drug-related hazardous conditions (DRHCs) may provide the opportunity to prevent injury. This study evaluated the frequency of abnormal laboratory values attributed to the effect of drugs. METHODS: A total of 590 patients consecutively admitted to a surgical intensive care unit during a 3-month period were prospectively studied. Serum electrolyte, platelet, creatinine, glucose, magnesium, and liver enzyme concentrations were classified as either normal or abnormal using standard criteria. DRHCs were abnormal laboratory results determined to be caused by drugs. RESULTS: DRHCs were detected in 16.4% of patients, reflecting a rate of 47 events per 1,000 patient days. 66%, 22%, and 12% of DRHCs were categorized as either definite, probable, or possible, respectively. In 97% of suspected DRHCs, clinicians responded by ordering additional laboratory tests or changing drug regimens. CONCLUSIONS: Monitoring laboratory values and assessing the association to medications may reduce the risk of injury consequent to adverse drug events.
Adult↗
Scope of international hospital pharmacy practice.
OBJECTIVE: To review the published English literature regarding international hospital pharmacy practice. DATA SOURCES: A computer search of all English-language articles in MEDLINE (1966-June 2004) and other Internet sources and International Pharmaceutical Abstracts (1971-June 2004). STUDY SELECTION AND DATA EXTRACTION: All studies that discussed hospital pharmacy or clinical hospital pharmacy activities outside of the US were considered for inclusion. DATA SYNTHESIS: The scope of international hospital pharmacy practice is quite varied, both inter- and intra-country, and varying degrees of specialization exist. Although clinical pharmacy is well developed in some countries, it is still in infancy stages in others. In addition, there is disparity in the actual definition of clinical pharmacy throughout the world. CONCLUSIONS: Since very few data have been published regarding hospital pharmacy practice on an international scale, we suggest a survey be conducted to objectively capture this information and increase awareness of clinical pharmacy in this setting.
Formularies as Topic↗
Intensive insulin therapy for critically ill patients.
OBJECTIVE: To evaluate the clinical outcomes of glycemic control of intensive insulin therapy and recommend its place in the management of critically ill patients. DATA SOURCES: Searches of MEDLINE (1966-March 2004) and Cochrane Library, as well as an extensive manual review of abstracts were performed using the key search terms hyperglycemia, insulin, intensive care unit, critically ill, outcomes, and guidelines and algorithms. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and deemed relevant if they included and assessed clinical outcomes. DATA SYNTHESIS: Mortality among patients with prolonged critical illness exceeds 20%, and most deaths are attributable to sepsis and multisystem organ failure. Hyperglycemia is common in critically ill patients, even in those with no history of diabetes mellitus. Maintaining normoglycemia with insulin in critically ill patients has been shown to improve neurologic, cardiovascular, and infectious outcomes. Most importantly, morbidity and mortality are reduced with aggressive insulin therapy. This information can be implemented into protocols to maintain strict control of glucose. CONCLUSIONS: Use of insulin protocols in critically ill patients improves blood glucose control and reduces morbidity and mortality in critically ill populations. Glucose levels in critically ill patients should be controlled through implementation of insulin protocols with the goal to achieve normoglycemia, regardless of a history of diabetes. Frequent monitoring is imperative to avoid hypoglycemia.
Blood Glucose↗
Comparing dexmedetomidine prescribing patterns and safety in the naturalistic setting versus published data.
BACKGROUND: In clinical practice, new drugs may be used differently than the product labeling recommends. Furthermore, it often takes several years of use before adverse drug reactions (ADRs) are reported. OBJECTIVE: To compare prescribing patterns and safety of the newly released drug dexmedetomidine as observed in clinical practice with published data on the drug. METHODS: Information from a convenience sample of adults receiving dexmedetomidine as part of routine patient care at 10 institutions was retrospectively collected from June 27, 2001, to May 31, 2002. Investigators reviewed medical records daily and entered dosing information, patient demographics, and predefined categories of ADR severity and probability anonymously via the Internet on a secure server. RESULTS: Only 33% of the total sample (n = 136) of patients received a loading infusion of dexmedetomidine; however, maintenance dosing was usually within product labeling guidelines. Of note, 27.2% of patients received dexmedetomidine above the maximum dose and 33.8% received the drug beyond 24 hours. Some patients (15.4%) were never mechanically ventilated, while 59.5% received dexmedetomidine following extubation for an average of 11.3 hours. ADRs were reported in 30% of patients: 20% of the reactions required treatment or increased length of stay. Hypotension was the most common ADR, occurring in 22.7% of patients. Bradycardia was reported in 4.4% of patients. The rate and type of ADRs were similar in patients receiving dexmedetomidine >24 hours compared with the total population. CONCLUSIONS: Dexmedetomidine is prescribed within product labeling guidelines except for low use of a loading dose, some patients received the drug at doses above the maximum, and others received it for longer than 24 hours. Since ADR rates are similar to those of other published reports, dexmedetomidine maintained its expected safety profile in our patients.
Dexmedetomidine↗
Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update.
OBJECTIVE: To provide the American College of Critical Care Medicine with updated guidelines for hemodynamic support of adult patients with sepsis. DATA SOURCE: Publications relevant to hemodynamic support of septic patients were obtained from the medical literature, supplemented by the expertise and experience of members of an international task force convened from the membership of the Society of Critical Care Medicine. STUDY SELECTION: Both human studies and relevant animal studies were considered. DATA SYNTHESIS: The experts articles reviewed the literature and classified the strength of evidence of human studies according to study design and scientific value. Recommendations were drafted and graded levels based on an evidence-based rating system described in the text. The recommendations were debated, and the task force chairman modified the document until <10% of the experts disagreed with the recommendations. CONCLUSIONS: An organized approach to the hemodynamic support of sepsis was formulated. The fundamental principle is that clinicians using hemodynamic therapies should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis by monitoring a combination of variables of global and regional perfusion. Using this approach, specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult patients were promulgated.
Adult↗
Managing anemia in the critically ill patient.
Anemia of critical illness is a multifactorial condition caused by phlebotomy, ongoing blood loss, and inadequate production of red blood cells. It occurs early in the course of critical illness. Although red blood cell transfusion is the treatment of choice for immediate management of anemia in the intensive care unit, controversy surrounds the most appropriate hemoglobin concentration or hematocrit "trigger." Therapeutic options, including blood-conservation tools, minimization of phlebotomy, erythropoietic agents, and investigational oxygen-carrying agents, may be alternatives to red blood cell transfusions in critically ill patients with anemia. Patient selection for erythropoietic agents will depend on further work dealing with outcomes and the total cost of care in managing the anemia of critical illness.
Anemia↗
The impact of critical care pharmacists on enhancing patient outcomes.
The highly specialized knowledge and skills needed to care for critically ill patients requires a multidisciplinary team approach. Pharmacists are integral members of this team. They make valuable contributions to improve clinical, economic, and humanistic outcomes of patients. The purpose of this article is to review the literature pertaining to pharmacists' contributions within a multidisciplinary intensivist-led intensive care unit (ICU) team. Pharmacist interventions include correcting/clarifying orders, providing drug information, suggesting alternative therapies, identifying drug interactions, and therapeutic drug monitoring. Pharmacist involvement in improving clinical outcomes of critically ill patients is associated with optimal fluid management and substantial reductions in the rates of adverse drug events, medication administration errors, and ventilator-associated pneumonia. Furthermore, economic evaluations of clinical pharmacy services in the ICU consistently reveal the potential for considerable cost savings.
Cost-Benefit Analysis↗
Impact of intensive care unit (ICU) drug use on hospital costs: a descriptive analysis, with recommendations for optimizing ICU pharmacotherapy.
OBJECTIVE: To determine the cost impact of intensive care unit (ICU) drug use on a hospital's total drug expense and to compare ICU pharmacy resource utilization with resource utilization of other hospital departments that provided services to the ICU. Additionally, to suggest strategies, based on these methods and results, to optimize ICU drug use. METHODS: Financial transactions for all ICU patients (n = 23,107) treated during fiscal years 1999-2002 were retrieved from the hospital's data repository. ICU drug costs were calculated both as the percentage of total drug costs for each fiscal year and adjusted for hospital volume (ICU patient days). ICU department charges were calculated as a percentage of total ICU charges and analyzed by simple descriptive statistics (mean +/- sd). Drug utilization was retrieved for those patients accounting for the highest percentage of ICU pharmacy charges. MAIN RESULTS: ICU drug costs accounted for 38.4% (+/-4.1% sd) of the total drug costs and have increased at a rate greater than non-ICU drug costs (12% vs. 6%). ICU pharmacy charges accounted for an average of 11.1% (+/-9.2% sd) of the total ICU charges, ranking as the fourth most costly of ICU charges. Both costly and highly used ICU therapies were identified for focus on cost-effectiveness analyses or application of an evidence-based drug use and disease state management program model to ICU pharmacotherapy. CONCLUSIONS: ICU drug therapies have a significant impact on hospital costs, and effective clinical informatics services and multidisciplinary collaboration programs are necessary to optimize ICU pharmacotherapy.
Academic Medical Centers↗
Bispectral Index in the intensive care setting.
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Artifacts↗
Amphotericin B lipid complex for Hansenula anomala pneumonia.
OBJECTIVE: To document the first successful treatment of a patient with Hansenula anomala pneumonia. CASE SUMMARY: A healthy 32-year-old white man who underwent splenectomy and aortic repair following a motor vehicle accident developed a life-threatening infection 2 days after admission into the intensive care unit (ICU). A rare fungus, H. anomala, was isolated from his lungs, blood, and urine. Lipid complex amphotericin B (ABLC) was initiated following worsening signs of infection complicated by renal failure. The patient received ABLC for 17 days, eventually making a full recovery, allowing ICU discharge 1 month after admission. DISCUSSION: This case represents the first successful treatment of H. anomala pneumonia reported in the literature. H. anomala infections typically occur in immunocompromised, neonatal, or pediatric populations in extrapulmonary sites. All 6 cases of H. anomala pneumonia reported in the literature were fatal, and all preceded the availability of ABLC. This case of H. anomala pneumonia is unique because our adult patient survived possibly due to the availability of aggressive treatment. CONCLUSIONS: ABLC may be the agent of choice for treatment of H. anomala infections, particularly in patients with acute renal failure.
Adult↗