The Elective Rotation: A Critical Care Hospital Pharmacy Podcast

Show notes at pharmacyjoe.com/episode85. In this episode I’ll: 1. Share an article about using earplugs to reduce ICU delirium. 2. Answer the drug information question: “Should dextrose containing solutions be avoided in ischemic stroke patients?” 3. Share the resource I used to answer the drug information question.

Show notes at pharmacyjoe.com/episode85

In this episode I'll:

1. Share an article about using earplugs to reduce ICU delirium.

2. Answer the drug information question: "Should dextrose containing solutions be avoided in ischemic stroke patients?"

3. Share the resource I used to answer the drug information question.

Article

The Efficacy of Earplugs as a Sleep Hygiene Strategy for Reducing Delirium in the ICU: A Systematic Review and Meta-Analysis

Lead author: Edward Litton

Published in Critical Care Medicine May 2016

Background

In a world of fancy & expensive medications and procedures, I enjoy seeing a simple & cheap intervention performing well. Aspirin & crystalloid fluids are two examples - perhaps after this article we can add earplugs to that list.

Objective

The authors conducted a systematic review and meta-analysis to assess the efficacy of earplugs as an ICU strategy for reducing delirium.

Methods

Intervention studies (randomized or nonrandomized) assessing the efficacy of earplugs as a sleep hygiene strategy in patients admitted to a critical care environment were included.

Nine studies published between 2009 and 2015, including 1,455 participants, fulfilled the eligibility criteria and were included in the systematic review. Three studies included earplugs as an isolated intervention, two as part of a bundle with eye shades, and four studies looked at earplugs, eye shades, and additional sleep noise abatement strategies.

Results

Five studies comprising 832 participants reported incident delirium. Earplug placement was associated with

Show notes at pharmacyjoe.com/episode84. In this episode I’ll discuss chemical sedation for acute agitation.

Show notes at pharmacyjoe.com/episode84

In this episode I'll discuss chemical sedation for acute agitation.

Chemical sedation is part of the array of options to treat acute agitation. Prevention strategies, verbal de-escalation techniques, and physical restraints also play a role in the prevention and management of acute agitation.

The ideal first line medications to use for rapid tranquilization of an acutely agitated patient are benzodiazepines and antipsychotics. These medications may be given alone or in combination.

Evidence for the use of chemical sedation is limited to small trials of at most a few hundred patients. Midazolam or lorazepam are the most studied benzodiazepines and haloperidol or droperidol are the most studied antipsychotics. Generally, control of the patient’s agitation is achieved within 15-20 minutes with these medications. The main side effect to monitor and be prepared for is

Show notes at pharmacyjoe.com/episode83. 1. Discuss an article on the pharmacodynamics of a fluid challenge. 2. Answer the drug information question “Why is epinephrine added to lidocaine for injection?” 3. Share a resource for staying up to date with FDA safety information.

Show notes at pharmacyjoe.com/episode83

In this episode I'll:

1. Discuss an article on the pharmacodynamics of a fluid challenge.

2. Answer the drug information question "Why is epinephrine added to lidocaine for injection?"

3. Share a resource for staying up to date with FDA safety information.

Article

Pharmacodynamic Analysis of a Fluid Challenge

Lead author: Hollmann Aya

Published in Critical Care Medicine May 2016

Background

Earlier in my career I didn’t pay close attention to IV fluids. As I discussed in episode 42 on the treatment of sepsis and septic shock:

Despite a lack of focus on IV fluids in my training, I’ve learned to treat them as a medication that requires a specific dose to be effective.

So of course the title of this article “Pharmacodynamic Analysis of a Fluid Challenge” caught my eye.

The authors of the study perfectly summarize the fluid challenge by saying:

Show notes at pharmacyjoe.com/episode82. In this episode I’ll discuss cyanide toxicity.

Show notes at pharmacyjoe.com/episode82

In this episode I'll discuss cyanide toxicity.

Cyanide is a rapidly lethal toxin. It causes death within minutes to hours of exposure.

Cyanide inhibits oxidative phosphorylation in the mitochondria, shutting down aerobic metabolism. Oxygen supply remains adequate but cells are unable to utilize the oxygen.

Cyanide is present in low background levels in the environment and is safely metabolized to thiocyanate by the liver. The capacity to metabolize cyanide is limited, and just ~0.5mg/kg is enough to be fatal.

Cyanide toxicity is relatively rare. Domestic fires, industrial accidents, and sodium nitroprusside are more common possible causes of cyanide poisoning.

Fabrics, upholstery, and melamine (often used as a coating on shelves and cabinets) can all give off cyanide when burned.

Cyanide is used in the extraction of gold and silver, and the production of nylon.

The antihypertensive sodium nitroprusside contains cyanide. Cyanide toxicity may occur in patients who receive prolonged infusions of sodium nitroprusside, have chronic renal failure, or in pediatric patients. Significant toxicity has resulted from rates higher than

Show notes at pharmacyjoe.com/episode81. In this episode, I ll: 1. Discuss an article about using tigecycline for clostridium difficile infection. 2. Answer the drug information question Has mycophenolate ever been associated with aveolar hemorrhage?” 3. Share a resource that can be used to determine a patient s warfarin dose.

Show notes at pharmacyjoe.com/episode81

In this episode, I’ll:

1. Discuss an article about using tigecycline for clostridium difficile infection.

2. Answer the drug information question “Has mycophenolate ever been associated with avelor hemorrhage?"

3. Share a resource that can be used to determine a patient’s warfarin dose.

When tigecycyline first arrived on the market it was called a - 1st in class antibiotic - a glycycycline. The drug was accompanied by tigers walking next to doctors in the advertisements, and a black-box warning about increased mortality after a meta-analysis of phase 3&4 trials. This prompted me to look closer at tigecycline. I noticed that tigecycline is structurally identical to minocycline, with an extra 4-carbon chain dangling off one end. I immediately thought: