The Elective Rotation: A Critical Care Hospital Pharmacy Podcast

Show notes at pharmacyjoe.com/episode45. In this episode I’ll: 1. Review an article about using melatonin to decrease the need for sedation in the ICU 2. Answer the drug information question “How long can I take NSAIDs before I need to take GI prophylaxis? 3. Share a resource I use when taking care of a patient [...]

Show notes at pharmacyjoe.com/episode44. In this episode I’ll discuss the management priorities for a hospital pharmacist when caring for a patient with status epilepticus.

Show notes at pharmacyjoe.com/episode44

In this episode I'll discuss the management priorities for a hospital pharmacist when caring for a patient with status epilepticus.

Seizure

Whenever I encounter a hospital inpatient with an acute seizure, I make sure that I have IV lorazepam available. Most seizures stop after about 2 minutes. In reality this means that by the time the lorazepam has been brought to the bedside, the seizure is usually over.

When the seizure is over, I assist the team in identifying and treating the underlying cause of the seizure. Common reasons for an adult inpatient to experience a seizure include:

1. Intracerebral mass or bleed

2. CNS infection

3. Cerebral hypoxia

4. Drug overdose (such as tricyclic antidepressants)

5. Drug withdrawal (such as anticonvulsants, alcohol, or benzodiazepines)

6. Metabolic disturbance (low glucose or sodium)

Status epilepticus

If the seizure lasts more than 5 minutes, the patient is now considered to be in status epilepticus.

Status epilepticus is a neurologic emergency and can result in respiratory failure, cardiovascular collapse, and neurologic damage if it is not terminated.

Rapid treatment is essential for a good patient outcome.

Guidelines for the treatment of status epilepticus published in 2012 are available from the Neurocritical Care Society.

Treatment should begin immediately with a benzodiazepine. Use lorazepam 0.1 mg/kg IV or midazolam 0.2 mg/kg IM.

Avoid giving midazolam IV because this is more likely to cause respiratory arrest and force endotracheal intubation upon a patient who might not have required it.

Immediately after an appropriate dose of benzodiazepine is given, obtain medications necessary to support the patient if they develop respiratory failure or hypotension. This involves preparing medications for endotracheal intubation (see episode 15) and vasopressor therapy (see episode 5).

Whether or not seizure activity has stopped after you have obtained intubation and vasopressor medications, an anti-epileptic drug will be needed. A 2014 update (available free here) recommends levetiracetam (30 mg/kg IV), valproic acid (30 mg/kg IV), or phenytoin (20 mg/kg IV).

Refractory status epilepticus

Refractory status epilepticus is treated with general anesthesia and mechanical ventilation.

When status epilepticus is considered refractory is up for debate:

Show notes at pharmacyjoe.com/episode43. In this episode I ll: 1. Review an article I used to answer the drug information question Can olanzapine be given IV?” 2. Share a resource for finding free open access medical education content

Show notes at pharmacyjoe.com/episode43

In this episode I’ll:

1. Review an article I used to answer the drug information question “Can olanzapine be given IV?"

2. Share a resource for finding free open access medical education content

Article

Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient

Lead author: Esther W. Chan

Published in Annals of Emergency Medicine January 2013

Background

Olanzapine is labelled in the US for intramuscular use only but intravenous adminstration is often preferred to intramuscular due to a faster onset of action and less discomfort.

Purpose

The purpose of the study was to determine the efficacy and safety of intravenous droperidol or olanzapine as an adjunct to intravenous midazolam for rapid sedation of acutely agitated patients.

Methods

The authors undertook a randomized, double-blind, placebo-controlled, double-dummy, clinical trial in 3 Emergency Departments in Australia from August 2009 to March 2011. 336 adult patients requiring intravenous drug sedation for acute agitation were randomized to receive placebo, droperidol 5 mg, or olanzapine 5 mg via IV bolus. This was immediately followed by incremental IV midazolam boluses of 2.5 to 5 mg until sedation was achieved. The primary outcome was time to sedation. Secondary outcomes were the need for rescue sedatives and adverse events.

Results

Baseline characteristics were similar across groups. The differences in medians for times to sedation between the control and droperidol and control and olanzapine groups were 4 minutes and 5 minutes, respectively. At any point, patients in the droperidol and olanzapine groups were approximately 1.6 times more likely to be sedated compared with controls. Patients in the droperidol and olanzapine groups required less rescue or alternative drug use after initial sedation. The 3 groups' adverse event profiles and lengths of stay did not differ.

The authors concluded that intravenous droperidol or olanzapine as an adjunct to midazolam is effective and decreases the time to adequate sedation compared with midazolam alone.

Show notes at pharmacyjoe.com/episode42. In this episode I ll talk about tips for the pharmacist in the initial treatment of severe sepsis / septic shock.

Show notes at pharmacyjoe.com/episode42

In this episode I’ll talk about tips for the pharmacist in the initial treatment of severe sepsis / septic shock.

Introduction

Severe sepsis is sepsis with organ dysfunction, and septic shock is sepsis induced hypotension that remains after adequate fluid resuscitation. Additional criteria for the definitions of severe sepsis / septic shock can be found in the Surviving Sepsis Guidelines, and the Center for Medicare quality measures. I’d also highly recommend that you take a look at two landmark studies that have been published since the Sepsis Guidelines came out in 2012 - the ARISE and PROCESS trials.

The treatment of severe sepsis / septic shock involves a great deal of supportive care, much of which I’ve already covered on this podcast. I’ll be referring you to previous episodes went relevant throughout this episode.

Airway and breathing

A patient with severe sepsis / septic shock may need stabilization of their airway and breathing with mechanical ventilation. Episode 15 provides a great review of the role and expectations of a pharmacist during endotracheal intubation.

IV Fluids

After the airway is secure, IV fluids are the most important intervention for a patient with severe sepsis / septic shock.

Septic shock is a distributive shock state. The intravascular volume is low, and therefore stroke volume and oxygen delivery are reduced. Giving IV fluids directly replenishes the intravascular volume, increases the stroke volume and increases oxygen delivery.

Despite a lack 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 the first thing I focus on when I encounter a patient with severe sepsis or septic shock is getting the right the dose of IV fluid.

Nearly all your severe sepsis / septic shock patients will need a 30 ml/kg bolus or 2 or more liters of crystalloid IV fluid such as normal saline or lactated ringers.

This bolus of IV fluids will need to be administered over 20-30 minutes. Most IV pumps that I’ve seen have a maximum rate of 999 mL/hr. I always consult with the patient’s nurse to determine if they think the patient’s IV access is sufficient to get the bolus administered fast enough off the pump. If the IV pump turns out to be faster due to small IV lines, I ask for 2 IV sites to each have a liter of IV fluid running at 999 mL/hr.

Be aware if you are not in a critical care area, the nurses may not be aware of or comfortable with the rate necessary to give an IV fluid bolus, and you will need to be assertive to get the IV fluids dosed correctly.

Show notes at pharmacyjoe.com/episode41. In this episode I’ll: 1. Review an article on monitoring enoxaparin with antifactor Xa levels in morbidly obese patients 2. Answer a drug information question about using morphine in a patient on dialysis 3. Share a great resource I use for researching which medications exacerbate porphyria

Show notes at pharmacyjoe.com/episode41

In this episode I'll:

1. Review an article on monitoring enoxaparin with antifactor Xa levels in morbidly obese patients

2. Answer a drug information question about using morphine in a patient on dialysis

3. Share a great resource I use for researching which medications exacerbate porphyria

Article

Monitoring Enoxaparin with Antifactor Xa Levels in Obese Patients

Lead author: Young R. Lee

Published in Pharmacotherapy November 2015

Background

The bleeding risk potential and best dosing strategy for enoxaparin in morbidly obese patients is unknown.

Methods

This study was a retrospective cohort of 99 morbidly obese patients in a community hospital. All patients either weighed more than 150 kg or had a BMI >40, and had steady-state antifactor Xa peak levels between April 2009 and January 2014.

Purpose

To characterize antifactor Xa peak levels (as therapeutic, subtherapeutic, and supratherapeutic) in morbidly obese patients receiving treatment doses of enoxaparin, using a therapeutic range of 0.5–1.1 units/ml, and to assess the occurrence of bleeding complications in these patients.

Results

Enoxaparin therapy was monitored by using antifactor Xa levels; steady-state enoxaparin antifactor Xa levels were measured 4 hours after administration of the third dose for peak level monitoring. The primary outcome was the proportion of patients whose steady-state antifactor Xa peak values were in the therapeutic, subtherapeutic, and supratherapeutic ranges. The secondary outcome was occurrence of major bleeding. Univariate regression analysis was performed to identify the correlation between baseline patient characteristics and antifactor Xa levels. Most of the patients (50.5%) had supratherapeutic levels, (35.4%) had levels within the therapeutic peak range (0.5–1.1 units/ml), and 14.1% had subtherapeutic levels. No bleeding was observed in any of the patients. Univariate analysis revealed a negative association between antifactor Xa levels and serum creatinine concentration (r = −0.262, p=0.009).

The authors concluded that monitoring antifactor Xa levels is warranted to ensure the safety and efficacy of enoxaparin in the obese patient population. Enoxaparin dose individualization and antifactor Xa level monitoring need further validation with clinical outcomes.

I really appreciate this article being published, as there is a dearth of evidence with how to treat morbidly obese patients with enoxaparin. Most often when I have a morbidly obese patient who needs full dose parenteral anticoagulation I favor the use of a heparin infusion since it can be monitored quantitatively.

Show notes at pharmacyjoe.com/episode40. In this episode, I ll discuss the recognition and treatment of serotonin syndrome (SS), malignant hyperthermia (MH), and neuroleptic malignant syndrome (NMS).