The Elective Rotation: A Critical Care Hospital Pharmacy Podcast

Show notes at pharmacyjoe.com/episode65. In this episode I’ll: 1. Discuss an article that evaluates continuous vs intermittent dosing of cefazolin during CABG surgery. 2. Answer the drug information question “Can I give heparin subcutaneously for VTE prophylaxis to a patient with an epidural catheter in place?” 3. Share an update on a resource I use [...]

Show notes at pharmacyjoe.com/episode64

IIn this episode I'll:

1. Discuss an article that evaluates continuous vs intermittent dosing of cefazolin during CABG surgery

2. Answer the drug information question "Can I give heparin subcutaneously for VTE prophylaxis to a patient with an epidural catheter in place?"

3. Share an update on a resource I use to evaluate drug interactions.

Article

Impact of Intraoperative Continuous-Infusion Versus Intermittent Dosing of Cefazolin Therapy on the Incidence of Surgical Site Infections After Coronary Artery Bypass Grafting

Lead author: Bethany Shoulders

Published in Pharmacotherapy February 2016

Background

Cefazolin is routinely used to prevent surgical site infection following coronary artery bypass grafting (CABG). Such infections have been associated with hospital readmissions and increased mortality rates.

Cardiopulmonary bypass decreases the serum concentrations of cefazolin but small pilot studies of continuous infusion of cefazolin vs standard intermittent infusion have shown higher serum and tissue levels at the site of incision.

Methods

The study was a retrospective pre and post intervention cohort study in a large academic medical center. The goal was to determine whether intraoperative continuous-infusion (CI) cefazolin reduced the incidence of surgical site infections (SSIs) compared with intermittent (INT) cefazolin dosing in patients undergoing coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB).

The study included 516 adults who underwent CABG on CPB and received cefazolin intraoperatively between June 1, 2013, and December 31, 2014. Patients in the first 9 months of the study period received INT dosing and patients in the last 9 months received CI dosing.

The CI cohort included 232 patients and the INT cohort included 284 patients.

Results

The primary end point was incidence of SSIs. The overall incidence of SSIs was

Show notes at pharmacyjoe.com/episode64. In this episode I’ll discuss how I identify drug fever.

Show notes at pharmacyjoe.com/episode64

In this episode I'll discuss how I identify drug fever.

Background

Drug fever is a common condition that coincides temporally with the administration of a drug and disappears after discontinuation of the medication. Unfortunately it is usually an unclear diagnosis, often made by exclusion.

It is just as valuable to the healthcare team for the pharmacist to identify a drug that might be causing fever as it is to identify when medications are not involved in causing a fever.

An excellent review of drug fever was published by Ruchi Patel in Pharmacotherapy 2010.

A fever often leads clinicians to suspect and treat infection. For this reason drug fever can lead to over-utilization of antibiotics, putting a patient at risk of adverse effects and the development of antimicrobial resistance.

Drug fever that occurs during the course of treating an infection may mislead clinicians into believing that the patient is not responding to treatment for the infection.

Drug fever may precede or accompany more serious adverse drug reactions.

A key feature that differentiates drug fever from fever of other causes is that it disappears once the offending drug is discontinued.

Many medications have been implicated in drug fever. I discussed in episode 27 how dexmedetomidine has been associated with drug fever. In episode 40 I discussed severe hyperthermia from serotonin syndrome, malignant hyperthermia, and neuroleptic malignant syndrome.

The most frequent drugs implicated are antimicrobials, anticonvulsants (carbamazepine and phenytoin), anti-arrhythmic agents (procainamide and quinidine), and other cardiac agents. Here is a list of other medications that may cause drug fever.

Identification of drug fever

Identifying drug fever is complicated because fever can be a characteristic of many disease processes other than infection, including malignancy, thromboembolic disease, cerebrovascular accidents, collagen vascular diseases, acute gout, surgery, and trauma.

To identify drug fever, I

Show notes at pharmacyjoe.com/episode63. In this episode I ll: 1. Discuss an article about identifying patients at risk of death from sepsis outside of the ICU. 2. Answer the drug information question: What are the new definitions and clinical criteria for sepsis and septic shock? 3. Share a resource for understanding the new definitions and clinical [...]

Show notes at pharmacyjoe.com/episode63

In this episode I’ll:

1. Discuss an article about identifying patients at risk of death from sepsis outside of the ICU.

2. Answer the drug information question: What are the new definitions and clinical criteria for sepsis and septic shock?

3. Share a resource for understanding the new definitions and clinical criteria for sepsis.

This episode focuses on sepsis definitions, clinical criteria, and identification. For information on the treatment of sepsis check out episode 42.

Article

Assessment of Clinical Criteria for Sepsis

Lead author: Christopher W. Seymour

Published in JAMA February 2016

Background

Sepsis is now defined by The Third International Consensus Definitions Task Force as: “life-threatening organ dysfunction due to a dysregulated host response to infection.”

The performance of clinical criteria to identify sepsis according to this definition is unknown.

Methods

A derivation, validation and confirmatory cohort were used to identify new clinical criteria and compare them to existing criteria to identify septic patients at risk of higher mortality.

The derivation and validation cohorts were composed of a group of 148,907 patients with suspected infection at 12 community and academic hospitals in the UPMC health care system in southwestern Pennsylvania.

The confirmatory cohort was composed of 4 different data sets totaling 706,399 patients from out-of-hospital and hospital encounters at 165 hospitals.

The existing clinical criteria evaluated were the Sequential Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, and Logistic Organ Dysfunction System (LODS) score. In addition a new model derived using multivariable logistic regression was evaluated: The Quick Sequential Organ Failure Assessment (qSOFA) score.

The qSOFA score evaluates 3 clinical criteria and assigns 1 point for each positive criteria:

1. Systolic BP < 100 mmHG

2. Respiratory rate >/= 22 per min

3. Altered mentation (defined as Glasgow Coma Scale (GCS) score of 13 or less)

Results

The Sequential Organ Failure Assessment (SOFA) score or Logistic Organ Dysfunction System (LODS) score were the best predictors of mortality in ICU patients. However the new Quick Sequential Organ Failure Assessment (qSOFA) score had a predictive validity that was statistically greater than SOFA or SIRS for patients outside of the ICU. Compared to patients with a qSOFA score less than 2, those with a score of 2 or greater had a 3 to 14 fold increase in mortality.

Conclusion

The authors concluded that

Show notes at pharmacyjoe.com/episode62. In this episode I ll share my top 6 tips to incorporate precepting advanced pharmacy practice experience (APPE) students into your workflow.

Show notes at pharmacyjoe.com/episode62

In this episode I’ll share my top 6 tips to incorporate precepting advanced pharmacy practice experience (APPE) students into your workflow.

I look at precepting as providing a student the opportunity to develop and apply the art and science of pharmacy in a practice setting.

It is the responsibility of us, as a profession, to provide these opportunities and guidance to the next generation of pharmacists.

I’ve been precepting 6 to 8 advanced pharmacy practice experience (APPE) students per year for over 10 years.

Here are my top 6 tips:

#1 Set expectations

Set expectations for how you want the rotation to go on day 1, and immediately address anything that is not up to your expectations.

It has been a long time since I had a student that wasn’t able to meet expectations for the rotation. I attribute this both to the quality of the students the college sends my way and my ability to recognize and immediately correct when things are not going according to expectations.

Despite the discomfort that comes from explaining to someone you want them to change their behavior, it is so much easier to address things the moment they happen rather than days or weeks later.

#2 The student doesn’t need (or want) to be attached to your hip for 100% of the rotation

Once I realized this concept, much of the stress of balancing precepting with my other duties vanished. Here are 2 ways that I make sure this happens:

Show notes at pharmacyjoe.com/episode61. In this episode I’ll: 1. Discuss an article about the toxicology of rivaroxaban and apixaban. 2. Answer the drug information question “Is vancomycin compatible with piperacillin-tazobactam at Y-site?” 3. Share a resource I use when taking care of a pregnant patient in the ICU.

Show notes at pharmacyjoe.com/episode61

In this episode I'll:

1. Discuss an article about the toxicology of rivaroxaban and apixaban.

2. Answer the drug information question "Is vancomycin compatible with piperacillin-tazobactam at Y-site?"

3. Share a resource I use when taking care of a pregnant patient in the ICU.

Article

An Observational Study of the Factor Xa Inhibitors Rivaroxaban and Apixaban as Reported to Eight Poison Centers

Lead author: Henry A. Spiller

Published in the Annals of Emergency Medicine in February 2016

Background

Rivaroxaban and apixaban have been approved for use by the FDA since 2011 and 2012. Little is known about the toxicology of these oral factor Xa inhibitors.

Purpose

The purpose of this study was to characterize the clinical effect in patients exposed to supratherapeutic doses of rivaroxaban and apixaban.

Methods

The study was a retrospective collection of data from 8 regional poison centers covering 9 states spanning 3 years. Inclusion criteria included single-substance exposure to rivaroxaban or apixaban. Exclusion criteria were animal exposure, polysubstance exposure, or informational calls.

Results