The Elective Rotation: A Critical Care Hospital Pharmacy Podcast

Show notes at pharmacyjoe.com/episode60. In this episode, I ll discuss the treatment of ACE inhibitor induced angioedema.

In this episode, I’ll discuss the treatment of ACE inhibitor induced angioedema.

Angioedema due to Angiotensin-converting enzyme (ACE) inhibitors is a rare event. Because of the high frequency of ACE inhibitor use, many patients will go on to develop ACE inhibitor induced angioedema.

Angioedema is the swelling of deep dermis, subcutaneous, or submucosal tissue due to vascular leakage. When this swelling involves the upper airway, angioedema can be life-threatening. ACE inhibitor angioedema is related to elevated levels of bradykinin.

Swelling usually develops over minutes to hours, peaks, and then resolves over 24 to 72 hours. There are no definitive tests to confirm ACE inhibitor angioedema. One unique characteristic (besides a medication history including an ACE inhibitor) that helps make the clinical diagnosis of ACE inhibitor induced angioedema is the absence of itching or urticaria.

Treatment

When you encounter a patient with ACE inhibitor induced angioedema that involves the upper airway, the first and only priority is to protect the patient’s airway.

If you hear stridor, see that the patient is drooling, using accessory muscles to breathe, or has edema of the tongue or floor of the mouth, assume that the physician will want to immediately intubate the patient and obtain the necessary medications to assist with this process. I discussed medications used during intubation in episode 15.

Because ACE inhibitor induced angioedema results from bradykinin and not histamine release, therapies that work for histamine induced angioedema are not considered effective.

If the diagnosis of ACE inhibitor induced angioedema is clear, don’t waste time with epinephrine, glucocorticoids, and antihistamines as they do not effect bradykinin or alter the course of ACE inhibitor induced angioedema.

Depending on the location of the angioedema, the physician may choose a nasal rather than oral approach to intubation.

Other treatments

Show notes at pharmacyjoe.com/episode59. In this episode I ll: 1. Discuss an article about vasopressors and pressure ulcers in critical care. 2. Answer the drug information question: “How long should I hold etanercept before surgery?” 3. Share a resource I use to obtain pictures of the chemical structure of medications.

Show notes at pharmacyjoe.com/episode59

In this episode I’ll:

1. Discuss an article about vasopressors and pressure ulcers in critical care.

2. Answer the drug information question: "How long should I hold etanercept before surgery?"

3. Share a resource I use to obtain pictures of the chemical structure of medications.

Article

Vasopressors and development of pressure ulcers in adult critical care patients

Lead author: Jill Cox

Published in the American Journal of Critical Care in November 2015

Background

Vasopressors provide life-saving support for many critically ill patients. Given their vasoconstrictive effects it would seem they would also play a role in the development of pressure ulcers.

Purpose

The purpose of this study was to examine associations between type, dose, and duration of vasopressors (norepinephrine, epinephrine, vasopressin, phenylephrine, dopamine) and development of pressure ulcers in critically ill medical, surgical and cardiothoracic patients. A secondary goal was to examine predictors of the development of pressure ulcers in these patients.

Methods

The study was a retrospective sample of 306 medical, surgical and cardiothoracic patients who received vasopressors in 2012 in Englewood Hospital and Medical Center in New Jersey.

Results

Norepinephrine and vasopressin were found to be

Show notes at pharmacyjoe.com/episode58. In this episode I’ll discuss using patient controlled analgesia in ICU patients.

Show notes at pharmacyjoe.com/episode58

In this episode I'll discuss using patient controlled analgesia in ICU patients.

What is PCA?

Patient controlled analgesia (PCA) is when a patient self-administers opioid medication through the use of a programmable IV pump. PCA allows self-dosing up to a predetermined limit set by the clinician.

PCA generally involves a demand dose such as 1 mg morphine every 6 minutes. Select patients may also receive a continuous or basal rate such as 1 mg/hr of morphine. A lockout period is programmed in the IV pump to prevent excess opioids from being administered.

When used correctly, PCA can allow patients to safely receive opioids while giving the patient a sense of control over their pain.

Patient selection

Proper patient selection is critical to the safe use of PCA. For patients in the ICU with postoperative or rapidly resolving pain, PCA can be an excellent choice.

Patients must be capable of using PCA correctly. The ISMP in their monograph for PCA use says:

Show notes at pharmacyjoe.com/episode57. In this episode I’ll: 1. Review the updated CHEST guidelines on Antithrombotic Therapy for VTE Disease. 2. Answer the drug information question: “Can I continue metronidazole for prevention of recurrent clostridium difficile infection (CDI) in patients requiring antimicrobial therapy?” 3. Share a resource I wear around my wrist.

Show notes at pharmacyjoe.com/episode57

Shout out to Pharmacy Nation member Noha for suggesting this article for review!

In this episode I'll:

1. Review the updated CHEST guidelines on Antithrombotic Therapy for VTE Disease

2. Answer the drug information question: "Can I continue metronidazole for prevention of recurrent clostridium difficile infection (CDI) in patients requiring antimicrobial therapy?"

3. Share a resource I wear around my wrist.

Article

The American College of Chest Physicians have recently published the 10th edition of their guidelines on Antithrombotic Therapy for VTE Disease. This edition of the guidelines continues the use of the GRADE methodology to describe the quality of the evidence and the strength of the recommendation for each guideline statement.

The 9th edition of the CHEST guidelines on Antithrombotic Therapy for VTE Disease was published in 2012. The guideline authors made at the time several innovative changes to the way their guidelines were structured. Three notable changes were

1. Prominently taking patient values and preferences into account in the guideline recommendations.

2. A series of podcasts were released with the AT9 guideline publications explaining the new approach to guideline development and highlighting the new recommendations compared to the previous version.

3. Providing a more critical bias-free look at the evidence which resulted in the weakening of many guideline recommendations.

The second change turned out to be of critical importance. In the age of guideline-based quality metrics deciding payment, giving controversial evidence a strong recommendation results in front-line providers and patients being placed in no-win situations. One need look no further than the sepsis quality measures and the ridiculous mess this has created as proof of the need to reserve strong recommendations for when the evidence is uncontroversial. For a great review of what happens when poor evidence creeps into strong guideline recommendations check out the post titled “We Are Complicit” by Scott Weingart at EMCrit.org.

The 2016 publication of the 10th edition of the CHEST guidelines on Antithrombotic Therapy for VTE Disease builds on the excellence of the 9th edition with this major change:

Show notes at pharmacyjoe.com/episode56. In this episode I ll discuss a long time pet peeve of mine – the Cockcroft Gault formula can be used to predict – not calculate – creatinine clearance.

Show notes at pharmacyjoe.com/episode56

In this episode I’ll discuss a long time pet peeve of mine - the Cockcroft Gault formula can be used to predict - not calculate - creatinine clearance.

40 years after it’s publication, the Cockcroft Gault formula remains the most appropriate method of estimating kidney function for the purpose of renal dose adjustment of medications. I use the formula dozens of times each day.

Even though in 2010 the FDA changed it's guidance for industry to allow using MDRD estimated GFR for drug dosing, I'm not aware of any medications that use the MDRD formula in place of Cockcroft-Gault for renal dose adjustment.

The Cockcroft-Gault formula is: (((140-age)*weight in kg)/(serum creatinine*72))*0.85 if female

The full text of the 1976 study by Cockcroft and Gault is required reading for my pharmacy students and residents. I haven't found it available for free online so you'll need to check with your medical librarian to get a copy.

Rapid, non-invasive bedside prediction of kidney function is essential for patient care and medication dosing. 24 hour urine creatinine clearance calculations are impractical for many reasons including being time-consuming and error-prone.

History

Donald W. Cockcroft is an asthmatologist who teaches at the University of Saskatchewan.

In 1973 he was finishing a 3 month nephrology rotation with M. Henry Gault. As part of his nephrology rotation, he completed a research project to verify the accuracy of a nomogram that predicted creatinine clearance based on age, weight, and serum creatinine. Cockcroft and Gault were reviewing the data and the negative linear correlation between age and creatinine clearance when Cockcroft realized this could be turned into a formula to predict creatinine clearance. In a 1992 interview Cockcroft stated: