The Elective Rotation: A Critical Care Hospital Pharmacy Podcast

Show notes at pharmacyjoe.com/episode55. In this episode I ll: 1. Discuss an article that found an increase in mortality when succinylcholine was used for rapid sequence intubation in patients with traumatic brain injury. 2. Answer the drug information question “Do antibiotics need to be stopped prior to fecal microbiota transplantation (FMT) to treat clostridium difficile infection?” [...]

Show notes at pharmacyjoe.com/episode55

In this episode I’ll:

1. Discuss an article that found an increase in mortality when succinylcholine was used for rapid sequence intubation in patients with traumatic brain injury.

2. Answer the drug information question "Do antibiotics need to be stopped prior to fecal microbiota transplantation (FMT) to treat clostridium difficile infection?"

3. Share a resource I use during in-hospital medical emergencies.

Article

Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department.

Lead author: Asad Patanwala

Published in the journal Pharmacotherapy January 2016

Background

The "Sux vs Roc" debate over whether to use succinylcholine or rocuronium in the setting of rapid sequence intubation (RSI) has been going on for a long time. I gave my opinion on the matter back in episode 14.

Purpose

The purpose of this article was to compare mortality in patients with traumatic brain injury (TBI) who received either succinylcholine or rocuronium for rapid sequence intubation.

Methods

The study examined a retrospective cohort in an academic emergency department (ED) in the United States. The cohort consisted of adult patients with TBI who underwent rapid sequence intubation (RSI) in the ED with rocuronium or succinylcholine between October 2010 and October 2014. The main outcome of interest was in-hospital mortality. Subjects were stratified based on severity of injury using head abbreviated injury scores. The high-severity group had a severe or critical head injury (score 4 or higher); the low-severity group had a less than severe head injury (score lower than 4).

Results

A total of 233 patients were studied; 149 received succinylcholine and 84 received rocuronium. In patients who received rocuronium, mortality was

Show notes at pharmacyjoe.com/episode54. In this episode I’ll discuss the use of daptomycin in the context of adult critically ill patients.

Show notes at pharmacyjoe.com/episode54

In this episode I'll discuss the use of daptomycin in the context of adult critically ill patients.

Mechanism of action

Daptomycin demonstrates concentration-dependent bactericidal activity against essentially all gram positive organisms. It has a unique mechanism of action. Daptomycin binds to bacterial cell membranes and causes a rapid depolarization of membrane potential. This loss of membrane potential causes inhibition of DNA, RNA, and protein synthesis, which results in bacterial cell death.

Indications

Due to daptomycin's high cost (~$1/mg) and the principle of reserving certain antibiotics for resistant or serious infections, daptomycin is frequently restricted and used second line unless allergies, resistance, or contraindications to other agents exist.

FDA approved

Daptomycin is approved for use in complicated skin and skin structure infections and in staphylococcal bacteremia including right sided endocarditis.

Off label

Daptomycin is also used for osteomyelitis, septic arthritis, hepatic or splenic abscess, and severe infections caused by methicillin resistant staphylococcus aureus or vancomycin resistant enterococci.

Pregnancy category

Daptomycin is pregnancy category B.

Dosing

In general, the more severe the infection the higher the dose of daptomycin that should be used.

Skin infection

For skin infection use daptomycin 4mg/kg IV q24 hrs.

All other infections

For all other infections use daptomycin 6 mg/kg IV q24 hrs.

Many references as well as the ID Society of America MRSA Guidelines say

Show notes at pharmacyjoe.com/episode53

In this episode I’ll:

1. Discuss an article about evaluating the presence of pain in patients with ICU delirium

2. Answer the drug information question: “Does quetiapine reduce the duration of ICU delirium?"

3. Share a resource I use to find information about the prevention and treatment of ICU delrium

Article

Validation of the Critical Care Pain Observation Tool in Critically Ill Patients With Delirium: A Prospective Cohort Study

Lead author: Salmaan Kanji

Published ahead of print in the journal Critical Care Medicine January 2016

Background

Despite the high incidence of ICU delirium, currently available tools to evaluate the presence of pain in ICU patients have not been validated in patients with delirium.

Purpose

The purpose of the study was to investigate the validity of the Critical Care Pain Observation Tool (CPOT) in patients with ICU delirium.

Methods

The study was a prospective cohort study in two ICUs within a Canadian tertiary healthcare center. The authors enrolled 40 consecutive adult patients deemed delirious on the day of enrollment using the Confusion Assessment Method for ICU (CAM-ICU).

Serial Critical Care Pain Observation Tool assessments were conducted simultaneously by study personnel and objective nurses at baseline and after nonpainful and painful stimuli. Subjective opinions about pain and objective physical variables (such as mean arterial pressure, heart rate, respiratory rate, and oxygen saturation) were collected at the same time points.

Results

Show notes at pharmacyjoe.com/episode53. In this episode I ll: 1. Discuss an article about evaluating the presence of pain in patients with ICU delirium 2. Answer the drug information question: Does quetiapine reduce the duration of ICU delirium?” 3. Share a resource I use to find information about the prevention and treatment of ICU delrium

Show notes at pharmacyjoe.com/episode52

In this episode I’ll review the inpatient treatment of hypoglycemia.

Hypoglycemia is a medical emergency

To help myself remember and apply medical concepts, I break them down into the most simple terms I can. While most rapid response calls are for problems related to oxygen delivery, hypoglycemia is a problem of ATP generation.

Hypoglycemia is a common reason for activation of in-hospital rapid response teams. It constitutes a medical emergency, however most individuals will recover completely with treatment.

Hypoglycemia may range from a mild lowering of glucose ( < 70 mg/dL) with minimal or no symptoms to severe hypoglycemia (< 40 mg/dL) and neurological symptoms.

The lack of ATP generation results in both adrenergic and CNS responses which comprise the symptoms of hypoglycemia.

Signs and symptoms of hypoglycemia

Adrenergic signs and symptoms

The adrenergic signs and symptoms of hypoglycemia include anxiety, irritability, dizziness, diaphoresis, pallor, tachycardia, headache, shakiness, and hunger.

CNS signs and symptoms

The CNS signs and symptoms of hypoglycemia include altered mental status that proceeds to headache, malaise, impaired concentration, confusion, disorientation, irritability, lethargy, slurred speech, and irrational or uncontrolled behavior.

More serious CNS effects include seizures and hemiplegia.

At a blood glucose level of 10 mg/dL hypoglycemia manifests as coma, pupillary dilation, shallow breathing, bradycardia, and hypotonicity.

When responding to any in-hospital rapid response call where an adrenergic sign of hypoglycemia or altered mental status is present, a fingerstick blood glucose value should be checked immediately.

Causes of hypoglycemia

Common causes of hypoglycemia in the inpatient setting are:

Drug effect (usually insulin or other hypoglycemics)

Antidiabetic medication use without appropriate carbohydrate intake

Critical illness such as major organ failure, sepsis, and severe trauma

Other causes include:

Endocrine disorders

Tumors

Ingestion of large amounts of alcohol or salicylates

Sudden reduction of corticosteroid dose

Emesis

Reduction of rate of intravenous dextrose

Interruption of enteral feedings or parenteral nutrition

Medication error

Treatment of hypoglycemia

Treatment of hypoglycemia should occur as quickly as possible to prevent neurologic injury.

The two decision points in treatment are:

Show notes at pharmacyjoe.com/episode52. In this episode I ll review the inpatient treatment of hypoglycemia.

Show notes at pharmacyjoe.com/episode51

In this episode I’ll:

1. Discuss an article recommending DDAVP for intracranial hemorrhage from anti-platelet agents

2. Answer the drug information question: “What should I use to treat a DVT in a patient on CRRT with a recent history of HIT?"

3. Share a resource I use to get an early clue on the identification of organisms in cultures

Article

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine

Lead author: Jennifer A. Frontera

Published in the journal Neurocritical Care in December 2015

The article provides a comprehensive review of the available reversal strategies for intracranial hemorrhage (ICH) due to antithrombotics. In this episode I’ll highlight the article's recommendations on when to give desmopressin (DDAVP) for ICH.

Desmopressin

Desmopressin is an analog of vasopressin but has little vasopressor activity. Desmopressin causes the release of von Willebrand factor and increases platelet adhesion.

In uremic patients desmopressin normalizes hemostasis and reduces bleeding time. In uremic patients exposed to aspirin desmopressin has been found to improve platelet function. DDAVP has also been shown to significantly reduce blood loss and improve thrombus formation in cardiac surgery patients exposed to aspirin pre-operatively.

DDAVP for anti-platelet reversal in intracranial hemorrhage has been reported in a handful of studies, usually at a dose of 0.4 mcg/kg IV. It appears DDAVP can stabilize platelet function, but the duration of effect is influenced by the amount and frequency of anti-platelet dosing. Repeat dosing of DDAVP may be required in some patients.

Side effects of DDAVP are considered mild and include facial flushing, edema, fluid overload, and hyponatremia. Rarely cerebrovascular or cardiac thrombosis has been reported.

Recommendations

Because of the low risk of serious side effects, the relatively low cost, and the suggestion of benefit the authors state:

Show notes at pharmacyjoe.com/episode51. In this episode I ll: 1. Discuss an article recommending DDAVP for intracranial hemorrhage from anti-platelet agents 2. Answer the drug information question: What should I use to treat a DVT in a patient on CRRT with a recent history of HIT?” 3. Share a resource I use to get an early [...]