The Elective Rotation: A Critical Care Hospital Pharmacy Podcast

Show notes at pharmacyjoe.com/episode75. In this episode I’ll discuss the drug ciraparantag.

Show notes at pharmacyjoe.com/episode75

In this episode I'll discuss the drug ciraparantag.

Shout out to Pharmacy Lawrence on Twitter for requesting this topic!

If you are not on Twitter you should consider it. I believe it is the best social media platform to use for education and collaboration with other healthcare providers. For more information listen to episode 69 where I discuss using twitter hashtags for free open access medication education. You can find me on twitter as @PharmacyJoe.

Ciraparantag or PER977 is a broad spectrum anticoagulant reversal agent under fast track review at the FDA.

Ciraparantag is reported to antagonize the effects of all anticoagulants except warfarin and agratroban - even enoxaparin and fondaparinux!

Not much is published on the exact mechanism of action for PER977. According to a letter to the editor published in NEJM November 2014:

Show notes at pharmacyjoe.com/episode74. In this episode I’ll discuss monitoring continuous infusions of neuromuscular blocking agents.

Show notes at pharmacyjoe.com/episode74

In this episode I'll discuss monitoring continuous infusions of neuromuscular blocking agents.

The non-depolarizing neuromuscular blocking agents (NMBAs) cisatracurium, rocuronium, and vecuronium are occasionally given as a continuous infusion in critically ill patients.

These medications paralyze all skeletal muscle, including the diaphragm muscle.

Adverse effects

NMBAs, especially the steroid-based rocuronium and vecuronium are associated with reports of prolonged recovery and myopathy. For this reason it is critical to use the lowest possible NMBA dose for the shortest possible duration.

Indications

Continuous infusions of neuromuscular blocking agents are usually given to critically ill patients for 1 of 2 reasons:

1. To facilitate mechanical ventilation

2. To prevent movement

To facilitate mechanical ventilation

When given to facilitate mechanical ventilation, NMBAs prevent dysynchrony with the ventilator, stop spontaneous respiration and muscle movement, and improve gas exchange.

To prevent movement

When given to prevent movement, NMBAs are used in patients with

Show notes at pharmacyjoe.com/episode73. In this episode I’ll: 1. Discuss an article about calcium correction in the ICU 2. Answer the drug information question “What weight should be used to calculate an initial dose of IV immune globulin (IVIG)?” 3. Share a resource about open access medical journals.

Show notes at pharmacyjoe.com/episode73

In this episode I'll:

1. Discuss an article about calcium correction in the ICU

2. Answer the drug information question "What weight should be used to calculate an initial dose of IV immune globulin (IVIG)?"

3. Share a resource about open access medical journals.

Article

Ionized Calcium in the ICU: Should It Be Measured and Corrected?

Author: Scott Aberegg

Published in CHEST March 2016

Shout out to “Intensivist Anna” for bringing this review article to my attention.

Calcium is vital for many functions, including muscle contraction and coagulation (it is also called clotting factor IV!).

Abnormal calcium levels in ICU patients are a common occurrence, but these levels are not usually due to a disorder in calcium homeostasis.

Routine monitoring and correction of calcium levels is commonplace in many ICUs, including my institution. However routine efforts to correct the serum calcium level only treat the laboratory number; there is no evidence that replacement has an effect on patient morbidity and mortality.

The author of this review article makes the point that

Show notes at pharmacyjoe.com/episode72. In this episode I’ll discuss how to taper patients off a fentanyl infusion.

Show notes at pharmacyjoe.com/episode72

If a patient has been on a continuous fentanyl infusion for 7 or more days, they are likely to have physical signs of opioid withdrawal if the infusion is suddenly stopped.

This is a fairly regular problem due to opioid-first sedation strategies such as those recommended in the SCCM sedation guidelines, or those popularized by Vanderbilt University Medical Center at icudelirium.org.

High quality data for deciding how to taper fentanyl infusions is lacking.

Not every patient who has been on a fentanyl infusion for > 7 days will experience withdrawal. Many patients may tolerate a decrease in opioid dose has high as 75% and do not experience withdrawal symptoms.

Resources

Some of the resources that I use to shape my practice in this area are:

Replacement of fentanyl infusion by enteral methadone decreases the weaning time from mechanical ventilation: a randomized controlled trial

Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice

Pharmacist’s Letter Chart: Medications That Need Tapering

Fentanyl patch Prescribing Information

Chapter 5 from Demystifying opioid conversion calculations - soon to be updated in May 2016

3 Strategies

I’ve used 3 strategies to solve this problem; one that works fast and two that take a bit more time to work.

Show notes at pharmacyjoe.com/episode71. In this episode I’ll: 1. Discuss an article about predicting the need for critical care resources after receiving IV thromblysis for ischemic stroke. 2. Answer the drug information question “Should a pregnant woman who removed a tick from herself be prophylaxed for Lyme Disease?” 3. Share a resource with fantastic infographics [...]

Show notes at pharmacyjoe.com/episode71

In this episode I'll:

1. Discuss an article about predicting the need for critical care resources after receiving IV thromblysis for ischemic stroke.

2. Answer the drug information question "Should a pregnant woman who removed a tick from herself be prophylaxed for Lyme Disease?"

3. Share a resource with fantastic infographics on critical care topics.

Article

ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients

Lead author: Roland Faigle

Published in Critical Care in January 2016

Background

Patients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications. At my institution they are required to be monitored in an ICU bed for at least 24 hours. The authors of this study created a prediction score to identify a subpopulation of post-IVT patients at high risk for needing critical care resources.

Methods

The authors retrospectively analyzed data from 301 patients undergoing IVT during a 5-year period. The 290 patients who met inclusion criteria were divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association.

Results

Nearly 25% of the patients required critical care resources. Black race, male sex, elevated systolic blood pressure, and NIH stroke scale (NIHSS) were independent predictors of the critical care resource utilization.

The scoring model created using these predictors was named the