The Pharm So Hard Podcast: An Emergency Medicine and Hospital Pharmacy Podcast

• More than 3,000 species of snakes are identified worldwide, with nearly 800 species considered venomous.
• All venomous species are classified taxonomically into one of 4 general groups.
• These include the families Viperidae, Elapidae, and Colubridae, as well as the Atractaspidinae, a subfamily of the Lamprophiidae family.
• The United States is home to nearly 30 species and subspecies of venomous snakes, with many more found throughout Mexico. All belong to either the Crotalinae subfamily of Viperidae or the Elapidae family.
• Of crotalid bites for which the type of snake is reported, about half are rattlesnake species, and the remainder copperheads and cottonmouths.
•  Rattlesnakes are found throughout most of the United States, but encounters are most common in western and southern states.

• Specific venom components are expected to be present to various degrees among all North American pit vipers.
• Pit viper snake venom is a complex pool of more than 100 components that contribute to toxicity
• Some examples include snake venom metalloproteinases, snake venom serine proteases, phospholipase A2, disintegrins, bradykinin potentiating peptides, C-type lectinlike peptide, and vascular endothelial growth factors.
• The content, potency, and quantity of these components are dictated by a variety of factors that include but are not limited to the following: genus, species, age, diet, climate (season), and geography.
• Available human and animal data suggest that venom antigens are absorbed into blood within minutes of envenomation, with peak concentrations detected within 4 hours

• Diagnosis of North American snake envenomation is based on a history of a snakebite and presence of clinical signs of envenomation
• Platelet counts, fibrinogen concentrations, and PTs are useful in the diagnosis of pit viper envenomation if they are abnormal.
• However, normal results do not exclude envenomation because thrombocytopenia and coagulopathy do not develop in all patients with pit viper envenomation.

https://www-ncbi-nlm-nih-gov.pallas2.tcl.sc.edu/pubmed/?term=Review+of+North+American+pit+viper+antivenoms+craig

https://crofab.com/about-crofab/What-is-CroFab

https://empharmd.com/2019/12/07/anavip-is-the-juice-worth-the-squeeze/

https://www.saem.org/cdem/education/online-education/m4-curriculum/group-m4-environmental/snake-bites

Ruha A, Pizon AF. Native (US) Venomous Snakes and Lizards. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e New York, NY: McGraw-Hill; http://accesspharmacy.mhmedical.com.pallas2.tcl.sc.edu/content.aspx?bookid=2569§ionid=210277153. Accessed January 12, 2020.

Otten EJ. Venomous Animal Injuries. In: Marx, J. A., & Rosen, P. (2014). Rosen’s emergency medicine: Concepts and clinical practice (8th ed.). Philadelphia, PA: Elsevier/Saunders. Accessed January 12, 2020.

Cocchio C, Johnson J, Clifton S. Review of North American pit viper antivenoms. Am J Health Syst Pharm. 2020 Jan 24;77(3):175-187. 

The post Episode 18: The Management of Snake Bites with Craig Cocchio, PharmD, DABAT appeared first on The Pharm So Hard Podcast.

1. Benchmarking – Finding and implementing the best practices.  Health-system administrators are turning to benchmarking vendors for help in improving operational performance
2. Efficiency – Avoiding waste or maximizing possible outputs from a set of resource inputs
3. Productivity – defined as the efficient use of resources, labor, capital, land, materials, energy, information, in the production of various goods and services.
4. Case Mix Index – is the average relative DRG weight of a hospital’s inpatient discharges, calculated by summing the Medicare Severity-Diagnosis Related Group (MS-DRG) weight for each discharge and dividing the total by the number of discharges.
5. Diagnose Related Group – DRG- patient classification scheme which provides a means of relating the type of patients a hospital treats (specific to drugs)

1. Goal is to find and implement the best practices of peer organizations
2. Vendors without expertise in pharmacy practice often sell benchmarking metrics that ultimately result in the downsizing of pharmacy departments and services
3. Goal is to find and implement the best practices of peer organizations
4. Vendors without expertise in pharmacy practice often sell benchmarking metrics that ultimately result in the downsizing of pharmacy departments and services

1. Selecting an external benchmarking system: Select a meaningful peer comparison group, select the most meaningful key indicator metrics for comparing performance with that of peers, Understand the limitations of commercially available systems (see complete list in article)
2. Metric examples
   1. Cost-based ratios – Total Cost per adjusted discharge, Labor cost per adjusted discharge
   1. Labor Productivity ratios – Hours worked per CMI discharge, FTEs per order processed
3. Using DRG versus CMI in your weighted scores

1. Pharmacy Intensity Score (PIS) Formula
2. Σ(DRG intensity weights x DRG volumes)/ Total Admissions = Pharmacy Intensity Score
3. PIS uses pharmaceutical resource consumption data to produce DRG-specific drug-use
   1. (0.1 to 100; DRG with highest median drug cost per admission assigned value of 100)

1. Strategies for selecting a vendor à meaningful peer comparison group and accuracy of financial data
2. Vendors may use different formulas and knowing which formulas to avoid

Steve S. Rough, Michael McDaniel, James R. Rinehart, Effective use of workload and productivity monitoring tools in health-system pharmacy, part 1, American Journal of Health-System Pharmacy, Volume 67, Issue 4, 15 February 2010, Pages 300–311, https://doi.org/10.2146/ajhp090217.p1

The post Episode 17: Do You Even Lift – Looking At The Metrics Used For External Benchmarking with Oscar Santalo and Joanna Longueira appeared first on The Pharm So Hard Podcast.

1. Benchmarking – Finding and implementing the best practices.  Health-system administrators are turning to benchmark vendors for help in improving operational performance
2. Efficiency – Avoiding waste or maximizing possible outputs from a set of resource inputs
3. Productivity – defined as the efficient use of resources, labor, capital, land, materials, energy, information, in the production of various goods and services.

1. Goal is to find and implement the best practices of peer organizations
2. Vendors without expertise in pharmacy practice often sell benchmarking metrics that ultimately result in the downsizing of pharmacy departments and services
3. Goal is to find and implement the best practices of peer organizations
4. Vendors without expertise in pharmacy practice often sell benchmarking metrics that ultimately result in the downsizing of pharmacy departments and services

1. External benchmarking helps seeing where your pharmacy department stands with other departments
2. Many limitations such as:
   1. No gold standard or evidence-based literature
   2. Variability to which pharmacy departments provide distributive and clinical services
   3. Unable to incorporate outpatient services
   4. Vendors do not easily identify peer groups or reveal components of their formula

 Steve S. Rough, Michael McDaniel, James R. Rinehart, Effective use of workload and productivity monitoring tools in health-system pharmacy, part 1, American Journal of Health-System Pharmacy, Volume 67, Issue 4, 15 February 2010, Pages 300–311, https://doi.org/10.2146/ajhp090217.p1

The post Episode 16: How Much Do You Bench? An Overview on External Benchmarking with Oscar Santalo and Joanna Longueira appeared first on The Pharm So Hard Podcast.

Stroll to the bottom for resources and protocols

COVID-19 is

The disease

It is Related

It is most closely

Initial cases and spread linked to a seafood market in Wuhan. There are Bats and bat droppings in the market and the surrounding region, which is consistent with viral genetics.

The virus is

Limited data

Prior coronaviruses do remain on inanimate surfaces for up to 9 days, and it’s likely that this viral strain will be very similar

One study of

The good news is that the virus was not isolated outside of the patient’s room. Also, With proper cleaning of other rooms of COVID (+) patients, similar samples were negative in other patients

The transmission has been shown by asymptomatic carriers.

Mean incubation period of 6.4 days in humans (95% CI 2.1 – 11.1 days).

Early estimations from China propose almost 1/3 of infected individuals may be asymptomatic. This high estimation of asymptomatic carriers could explain the speed at which the virus has spread across the world

As of March 17th, the world health organization has reported over 167 thousand cases worldwide, with an overall mortality rate of 3.9% so far. They are updating their website daily with new information. The CDC has reported 4,226 cases in the US with 75 deaths, and a mortality rate of 1.8% thus far. The CDC is updating its website during weekdays, and most state departments are as well. Keep in mind that the mortality rates thus far will continue to increase, as a lot of the patients who have tested positive are still receiving care at this time. I also wanted to clear up some previous confusion thus far about the difference between CDC-reported numbers and those reported by state departments or local news stations. The CDC was previously performing confirmation tests on all (+) isolates identified by the state, which was causing a delay. They have since changed that requirement

Some of the Vulnerable Populations identified thus far are elderly patients, those with a prior immunocompromising condition, or any comorbidity such as hypertension. Some studies have shown up to 50% of patients with at least one chronic condition. This doesn’t mean that other populations are not at risk. These are the patient populations that have been diagnosed in the highest frequency thus far, but it is likely that other patients with non-severe symptoms are not presenting for testing.

Most symptoms are consistent with those of other respiratory viral illnesses. The most commonly reported symptom thus far is fever (83- 96% of patients depending on the pt cohort), followed by cough (68-82%). Other symptoms include shortness of breath, rhinorrhea, muscle aches, and confusion. Gastrointestinal symptoms are relatively uncommon, but were reported in 1-3% of patients.

Official COVID-19 tests are being provided by the CDC to state laboratories. Every hospital should have in place or be developing a process for screening patients and obtaining tests from their state labs if patients qualify for testing.

I want to stress up front that everything we have is experimental at this point. The mainstay of therapy for treating COVID-19 patients is still supportive care, but there are some agents with possible benefits based upon in vitro activity as well as very limited clinical data.

There is a lot of information that we

Corticosteroids: Prior studies have shown negative outcomes with corticosteroid use in respiratory viral infections. One study with the middle eastern coronavirus showed that corticosteroid therapy was associated with a significant delay in viral RNA clearance. We don’t have data yet for the effect of corticosteroids on this SARS-coronavirus 2 strain. Most experts are currently recommending AGAINST the use of corticosteroids in patients with COVID-19 infections. This is more tricky in patients with underlying COPD or those that develop ARDS. Use clinical judgment in those cases.

ACEi/ARBs: there are currently discussions going on surrounding ACE inhibitors and ARBs. In vitro, SARS-CoV-2 is thought to use ACE2 as a binding site. Patients on ACE inhibitors have increased the production of ACE2 on cells as a result of their ACE inhibitor therapy. The current recommendation is to discontinue ACE inhibitors or ARBs in patients diagnosed with COVID-19 infections since there is a possibility that therapy may increase the rate of infection of host cells by viral particles. This is probably easy to do, as these patients will often develop sepsis and hypotension at some point during their infection course.

NSAIDs: French authorities recently advised against the use of NSAIDs, as they may worsen the clinical course of coronavirus. Although there is no specific data yet, this is likely due to an immunosuppressive effect similar to corticosteroids, as well as an upregulation of ACE2 similarly to ACE inhibitors. At this point, it would be a good idea to avoid NSAIDs in these patients and use acetaminophen instead.

The answer to this question will differ based upon the design of each hospital and your standard workflow for code response. All healthcare personnel actively resuscitating the patient should be wearing appropriate N95 masks, especially if the patient is not intubated. Respiratory should be hopefully intubating them as quickly as possible if they weren’t intubated prior to the code. The number of personnel inside patient rooms should be limited in order to decrease exposure and also conserve our limited supply of PPE. One option is to have the medicine components of the code cart outside if the room for preparation, and then carefully pass compounded medications to personnel in the room. Be sure to discuss this process workflow at your institution.

We should

Avoid

And try to

There will be a lot of meetings in the coming months with updates on patient care: Videoconference when possible for meetings. (limit in-person meetings to those with <10-15 people if possible). Make sure any in-person meetings are held in open, well-ventilated spaces

If you or a family member is feeling sick, STAY HOME. Although our immune systems may limit the illness to mild symptoms, we may be carriers and spread the virus to our patients with weakened immune systems. In areas being hit hard thus far, there are reports of 10% of the workforce being out due to illness. We will already be stretched thin, and spreading the virus amongst each other could be catastrophic.

The level of public panic has led to some crazy behaviors. Everything from toilet paper hoarding to buying up massive amounts of medical supplies, such as masks and cleaning supplies. Patients who use alcohol swabs on a daily basis for self-injection of medications are having difficulty finding them, and hospitals are having trouble obtaining masks. We can do our best to encourage everyone to be mindful of the needs of others and only buy what you and your family would reasonably need as a 1 month supply, which is the current recommendation. Try to keep members of our community informed that masks alone will not prevent spread– Encourage hand hygiene and social distancing instead. In the hospital, use of masks should be limited to essential personnel so we can conserve what we have

• CDC
  • https://rebelem.com/wp-content/uploads/2020/03/COVID-19-Fact-Sheet.pdf
  • https://rebelem.com/wp-content/uploads/2020/03/Suspected-COVID-19-Fact-Sheet.pdf
• Johns Hopkins Tracker
  • https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
• Pulmcrit
  • https://emcrit.org/ibcc/covid19/
  • https://emcrit.org/pulmcrit/split-ventilators/
• REBELEM
  • https://rebelem.com/covid-19-the-novel-coronavirus-2019/

• UW Medicine COVID-19 Resource Site
  • https://covid-19.uwmedicine.org/Pages/default.aspx
  • https://em.uw.edu/faculty/uw-department-emergency-medicine-edicu-covid-19-preparedness

• EMPharmD.com
  • https://empharmd.com/2020/03/15/hydroxychloroquine-for-sars-cov-2/

• Global MediXchange for Combating COVID-19
  • https://covid-19.alibabacloud.com/

• WHO
  • https://www.who.int/emergencies/diseases/novel-coronavirus-2019
• King’s Critical Care
  • https://www.dropbox.com/s/6glielky1ux4w5f/King%27s%20Critical%20Care%20COVID%20Summary.pdf?dl=0
• Critical Care North Hampton
  • https://criticalcarenorthampton.com/2020/03/08/covid-19-your-one-stop-resource/

1. Zu F, Yu T, Du R, at al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020.
2. Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA 2020.
3. KCDC. Updates on COVID-19 in Korea. March 14, 2020. https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030 (Accessed on March 14, 2020).
4. Cai J, Xu J, Lin D, et al. A Case Series of children with 2019 novel coronavirus infection: clinical and epidemiological features. Clin Infect Dis 2020.
5. Liu W, Zhang Q, Chen J, et al. Detection of Covid-19 in Children in Early January 2020 in Wuhan, China. N Engl J Med 2020.
6. Liu YC, Liao CH, Chang CF, et al. A Locally Transmitted Case of SARS-CoV-2 Infection in Taiwan. N Engl J Med 2020.
7. Wei M, Yuan J, Liu Y, et al. Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China. JAMA 2020.
8. Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020; 382:727.
9. Lu R, Zhao X, Li J, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet 2020; 395:565.
10. Perlman S. Another Decade, Another Coronavirus. N Engl J Med 2020; 382:760.
11. Tang X, Wu C, Li X, et al. On the origin and continuing evolution of SARS-CoV-2. National Science Review 2020.
12. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med 2020.
13. Li Z, Yi Y, Luo X, et al. Development and Clinical Application of A Rapid IgM-IgG Combined Antibody Test for SARS-CoV-2 Infection Diagnosis. J Med Virol 2020.
14. Centers for Disease Control and Prevention. Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) Infection, Updated February 12, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html (Accessed on February 14, 2020).
15. Tang A, Tong ZD, Wang HL, et al. Detection of Novel Coronavirus by RT-PCR in Stool Specimen from Asymptomatic Child, China. Emerg Infect Dis 2020; 26.
16. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA 2020.
17. Zhou P, Yang XL, Wang XG, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020.
18. Yu P, Zhu J, Zhang Z, et al. A familial cluster of infection associated with the 2019 novel coronavirus indicating potential person-to-person transmission during the incubation period. J Infect Dis 2020.
19. Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA 2020.
20. Hu Z, Song C, Xu C, et al. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci 2020.
21. orld Health Organization. Director-General’s remarks at the media briefing on 2019-nCoV on 11 February 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-ncov-on-11-february-2020 (Accessed on March 12, 2020).
22. Centers for Disease Control and Prevention. 2019 Novel coronavirus, Wuhan, China. Information for Healthcare Professionals. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html (Accessed on March 12, 2020).
23. World Health Organization. Novel Coronavirus (2019-nCoV) technical guidance. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance (Accessed on March 12, 2020).
24. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 24 February 2020 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—24-february-2020 (Accessed on March 15, 2020).
25. National Health Commission of the People’s Republic of China. New coronavirus cases rise to 571 in Chinese mainland. March 15, 2020. http://en.nhc.gov.cn/2020-01/23/c_76004.htm (Accessed on March 15, 2020).
26. Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – an update on the status. Mil Med Res. 2020;7(1):11. Published 2020 Mar 13. doi:10.1186/s40779-020-00240-0
27. Arabi YM, Asiri AY, Assiri AM, Aziz Jokhdar HA, Alothman A, Balkhy HH, et al. Treatment of Middle East respiratory syndrome with a combination of lopinavir/ritonavir and interferon-β1b (MIRACLE trial): statistical analysis plan for a recursive two-stage group sequential randomized controlled trial. Trials. 2020;21(1):8.
28. Chu CM, Cheng VC, Hung IF, Wong MM, Chan KH, Chan KS, et al. Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings. Thorax. 2004;59(3):252–6.
29. Cvetkovic RS, Goa KL. Lopinavir/ritonavir: a review of its use in the management of HIV infection. Drugs. 2003;63(8):769–802.

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1. Acute heart failure (AHF) is a common underlying cause for dyspnea in patients presenting to EDs around the globe.1-2  SCAPE is a subset of hypertensive heart failure which develops rapidly due to an abrupt increase in catecholamine release, subsequently leading to increased pulmonary capillary permeability and flooding of alveolar space.3-5  Patients with SCAPE present with an abrupt onset of shortness of breath which progresses over minutes-to-hours into life-threatening pulmonary edema. This is unlike other subsets of AHF, which  traditionally progress over days.3-5 Patients often present with extremely severe respiratory distress, restlessness, diaphoresis, and hypoxia on arrival to the ED. Patients may also be tachycardic with marked hypertension, suggesting elevated sympathetic activity in vivo.3-7 Nitroglycerin reduces preload and, at higher doses (> 50 mcg/min), also reduces afterload. Thus, it is imperative to initiate nitroglycerin at high, effective doses in a timely manner to treat the underlying pathophysiology.4 Multiple studies have validated the use of high dose nitroglycerin with improvement in patient-centered outcomes which include reduction in patients requiring intubation, intensive care unit (ICU) admission, hospital length of stay, and decreased myocardial infarction.8-13

https://www.grepmed.com/images/3068/sympathetic-management-treatment-pulmonary-crashing-scape-edema

https://www.emnote.org/emnotes/high-dose-ntg-boluses

https://wikem.org/wiki/Sympathetic_crashing_acute_pulmonary_edema_(SCAPE)

1. Nitroglycerin. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved February 5, 2020, from http://www.micromedexsolutions.com/
2. Fromm RE, Jr, Varon J, Gibbs LR. Congestive heart failure and pulmonary edema for the emergency physician. J Emerg Med. 1995;13:71–87
3. Howlett JG. Current treatment options for early management in acute decompensated heart failure. Can J Cardiol. 2008;24(Suppl B):9B–14B.
4. Kramer K, Kirkman P, Kitzman D, Little WC. Flash pulmonary edema: Association with hypertension and reoccurrence despite coronary revascularization. Am Heart J. 2000;140:451–5.
5. Gandhi SK, Powers JC, Nomeir AM, Fowle K, Kitzman DW, Rankin KM, et al. The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med. 2001;344:17–22
6. Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Crit Care Med. 2016;20:39–43.
7. Mebazaa A, Yilmaz MB, Levy P, Ponikowski P, Peacock WF, Laribi S, et al. Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine. Eur J Heart Fail. 2015;17:544–58.
8. Viau DM, Sala-Mercado JA, Spranger MD, O’Leary DS, Levy PD. The pathophysiology of hypertensive acute heart failure. Heart. 2015;101:1861–7.
9. McMurray JJ, Adamopoulos S, Anker `, Auricchio A, Bohm M, Dickstein K, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail.2012;14:803–69.
10. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, DraznerMH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2013;62:e147–239.
11. Hsieh Y et al. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018; 18(1): 34–36.
12. Wilson SS et al. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126–31.
13. Levy P et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007;50:144–52.
14. Sharon A et al. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. J Am Coll Cardiol. 2000;36(3):832-7.
15. Cotter G et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998;351(9100):389-93.
16. Paone S, Clarkson L, Sin B, et al. Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med. 2018;36(8):1526.e5-1526.e7.
17. López-Rivera F, Cintrón Martínez HR, Castillo LaTorre C, et al. Treatment of Hypertensive Cardiogenic Edema with Intravenous High-Dose Nitroglycerin in a Patient Presenting with Signs of Respiratory Failure: A Case Report and Review of the Literature. Am J Case Rep. 2019 Jan 21;20:83-90.
18. Clemency BM, Thompson JJ, Tundo GN. Prehospital high-dose sublingual nitroglycerin rarely causes hypotension. Prehosp Disaster Med. 2013 Oct;28(5):477-81.

The post Episode 14: High-Dose Nitroglycerin for Sympathetic Crashing Pulmonary Edema (SCAPE) with Rachel Wein, PharmD, BCPS appeared first on The Pharm So Hard Podcast.

PMID:31223154  

PMID: 27698497

PMID: 27402987

PMID: 24106162

The post Episode 13: Assessing Pharmacy Candidates for Pharmacy Residency Programs with Dan Hu appeared first on The Pharm So Hard Podcast.

• Merger & Acquisition – defined as the consolidation of companies.
  • Differentiating the two terms, Mergers is the combination of two companies to form one, while Acquisitions is one company taken over by the other

• Throughout the 1990s, mergers and acquisitions were prominent in the healthcare sector. After a drastic decline in the early 2000s, there was a resurgence of mergers and acquisitions in the market in the last ten years. According to Kaufman Hall, after just 50 health-system mergers and acquisition consolidations in 2009, the number has increased to 115 consolidations in 2017.
• One major contrast between mergers and acquisitions is the propensity for acquisitions to become hostile
• Vertical mergers occur when complement products or services consolidate. As it relates to healthcare, examples of vertical mergers include an outpatient pharmacy merging with a generic medication manufacturer, or CVS Health’s plan to purchase Aetna (2). Vertical mergers do not remove a competing substitute from the market, and for that reason carry less risk of violating federal antitrust laws.
• Financial implications: Cost savings remains a driver in the pursuit of hospital consolidation

Horizontal mergers inherently lessen competition by removing an alternative source of a particular product or service from the consumer market. However, horizontal mergers may also create more efficient companies through reduced redundancies in services, lower capital expenses through shared resources, and supply chain savings obtained through large volume purchasing.

Strategic plan where vision should focus on pharmaceutical care and highlight the strengths of each department that add value to the organization

• Opportunities in budgeting a volume-based discounts on drug purchasing utilizing group purchasing organizations (GPO), formulary management and standardization, perpetual inventories, and direct manufacturer contracts, cost savings can be realized.
• Concerns: Staffing productivity, formulary mgmt.

• Pharmacy departments within expanding health-systems may undergo a drastic overhaul to the clinical services provided by their department following consolidation.
• Hospitals entering a larger health-system may be faced with required implementation of established pharmacy services including the use of therapeutic interchanges, intravenous to oral conversions, dose rounding, and therapeutic drug monitoring protocols used throughout the existing system. These services can be accomplished through the utilization of clinical decision support systems (CDS).
• Pharmacy departments and health-systems will need to create and manage their inpatient formulary

1. M&As impact pharmacies financially through labor, supply chain, and strategy
2. Opportunities in buying power and organizational support when merging with a larger system
3. Formulary mgmt., clinical services, and productivity should be the highest of concerns

• Twitter
• Linkedin

Iredell B, Farano J, Corsi MP, Santalo O, Covert A. Clinical and financial impacts on pharmacy surrounding health-system mergers and acquisitions [published online ahead of print, 2019 Dec 1]. Am J Health Syst Pharm. 2019;zxz263. doi:10.1093/ajhp/zxz263. [PMID: 31788688]

The post Episode 12. Mergers and Acquisitions with Oscar Santalo PharmD, MBA, MHA, BCPS appeared first on The Pharm So Hard Podcast.

There are many key members of the trauma team that include the trauma nurses, respiratory technicians, ED physicians, trauma surgeons, medical residents, PA/NPs, radiology techs, and anesthesiologists.

• Trauma centers are centers that are equipped to treat the most critical of patients who suffer from traumatic injury.
• This includes blunt trauma such as falls and motor vehicle crashes as well as penetrating trauma (like our gun and knife club members).
• Trauma centers are usually designated by levels (level one, level two, and so on) and are defined based on the resources available and the number of patients treated annually.

Hands-on training is your best friend for these patients.

Being able to anticipate the team’s needs for trauma patients is key.

• You have to know where your medications are stored, what medications are immediately available and which medications you need to expedite from your central pharmacy.
• You also have to know where your supplies are stored such as your needles, IV pumps, IV tubing, etc.
• Know your code cart and where it is located, so you are ready for any patients that either present in traumatic arrest or decompensate into cardiac arrest.

The primary survey is a systematic way of evaluating a trauma patient. It consists of A for airway, B for breathing, C for circulation, D for disability, and E for exposure.

I believe the trauma pharmacist is a part of every single step in the primary survey:

• Airway:
  • A pharmacist thinking about medications for RSI. Know the kinetics of your induction agent and paralytic agents including onset and duration of the medications used. Also, know what to expect from the medications used.

• Breathing:
  • if the team thinks your patient has a pneumothorax and a chest tube is imminent, be ready for local analgesia or possible IV systemic analgesia for patient comfort

• Circulation:
  • If the patient is found to be hypotensive while circulation is being assessed, think adjuncts to blood product replacement.
  • Any patient in the trauma bay who is hypotensive and tachycardic is in hemorrhagic shock until proven otherwise.
  • These patients will get blood. This includes getting ready to administer calcium to patients receiving multiple rounds of blood products as hypocalcemia may develop due to citrate toxicity.
  • For traumas that present early, plus/minus TXA, and if your patient is on anticoagulation, reversal strategies based on what your patient was taking.

• Disability:
  • Think of traumatic brain injury and if present, Ruben anticipates the need for hypertonic saline or mannitol. He generally prefers 3% hypertonic saline as it does not affect hemodynamics and it is easier to get ready versus mannitol.

• Exposure:
  • Finally, the patients are exposed, this is when Ruben thinks ahead about antibiotics for open fractures and of course, life-saving tdap.

An

• A – Allergies
• M – Medication History
• P – Past illness/pregnancy
• L – Last meal
• E – Events/Environment related to injury

Pharmacists play an integral role in obtaining allergies or past medication history such as myasthenia gravis where certain medications are contraindicated

• A medication history may also be obtained from these patients.

Pharmacists have an integral role in MTP.

• Electrolyte Disturbances
  • Being prepared for complications associated with MTP are key aspects in the management of trauma patients receiving multiple blood transfusions.
  • These patients may suffer from hypocalcemia due to citrate toxicity.
  • Citrate located in blood products may bind with calcium, causing hypocalcemia.
  • Be ready with calcium replacement. Patients may also have hyperkalemia as a complication from MTP due to the age of the PRBCs used rate of infusion, underlying renal failure, and severe tissue injury.
  • Classic EKG changes associated with hyperkalemia such as peaked T waves may be present.
  • This should be treated similarly to other conditions that cause hyperkalemia.

• Anticoagulation Reversal
  • Patients who are on oral anticoagulation present unique challenges.
  • At Rubens’s shop, They have developed an order set that helps streamline the ordering of anticoagulation reversal strategies based on the medication the patient was taking prior to presentation.
  • Kcentra is our reversal strategy for both VKA (including vitamin K) and factor Xa inhibitors (sorry Andexxa) and we use idarucizumab for dabigatran reversal +/- FEIBA.
  • Ruben’s role is ensuring the correct doses are ordered, and then expedited to the patient’s bedside.
  • Also, Ruben provides education to the receiving nurse on how the medication should be administered.

• Pharmacists are integral in choosing the appropriate antibiotic for patients that present with open fractures.
• This includes choosing the correct agent based on the type of open fracture (extremity vs. jaw. vs. skull), and environment (ex. aquatic traumas). Clarifying allergies prior to medication administration is another place that pharmacists have a role.
• This includes choosing the correct agent based on the type of open fracture (extremity vs. jaw. vs. skull), and environment (ex. aquatic traumas). Clarifying allergies prior to medication administration is another place that pharmacists have a role.
• Living in Miami, almost everyone says they have a penicillin allergy.
  • Letting the team know that you may use a third-generation cephalosporin routinely in this patients population and that it is safe as the R-side chains are different and there is little to no cross-reactivity (thank you, Bryan Hayes!).

• If suspecting TBI, Ruben generally goes for hypertonic saline.
• In these situations, I recommend a 250 mL bolus of 3%.
• I like it better cause I can give it fast, don’t have to worry about hemodynamic effects, and do not need a 0.2-micron filter like with mannitol.
• Another aspect of care for these patients is if they are intubated, ensuring they receive appropriate sedation and analgesia post-intubation.
  • This will help with ICP management.

Be open to learning new aspects of care you did not learn at your previous hospital.

Learn from your nurses and physicians leading the traumas. Do the little things (get blankets, help expose, etc.) and show up for every trauma.

Show them how much you care, and the team will appreciate and value how much you know.

• There are so many!!!
• There was an MVC where the patient needed an emergency cric, then placed on ECMO
• Another was a truck driver who was on dabigatran and we used idarucizumab and FEIBA
• Another was a boat propeller injury where I held the patient’s legs (still attached) and provided antibiotic recommendations due to the saltwater exposure.
• Also, a couple of shark bites.

• Hopkins TL, Daley MJ, Rose DT, et al. Presumptive antibiotic therapy for civilian trauma injuries. J Trauma Acute Care Surg. 2016 Oct;81(4):765-74.
• Scarponcini TR, Edwards CJ, Rudis M, et al. The role of the emergency pharmacist in trauma resuscitation. J Pharm Pract. 2011 Apr;24(2):146-59.
• Patanwala AE. Pharmacist’s activities on a trauma response team in the emergency department. Am J Health Syst Pharm. 2010 Sep 15;67(18):1536-8.
• Amini A, et al. Effect of a pharmacist on timing of postintubation sedative and analgesic use in trauma resuscitations. Am J Health Syst Pharm. 2013 Sep 1;70(17):1513-7
•  Lane JE, et al. Current Concepts of Prophylactic Antibiotics in Trauma: A Review. Open Orthop J. 2012; 6: 511–517.
• Montgomery K, et al. Pharmacist’s impact on acute pain management during trauma resuscitation. J Trauma Nurs. 2015 Mar-Apr;22(2):87-90.
• Rossaint R, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016; 20: 100.
• Morrison JJ, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012 Feb;147(2):113-9. 

The post Episode 11: The Role of an ED Pharmacist as Part of the Trauma Team with Ruben Santiago, Pharm.D., BCPS, BCCCP appeared first on The Pharm So Hard Podcast.

1. Formulary medication – A determination that the medication is “appropriate for routine use” in select patient populations
   1. Per 2008 ASHP Guidelines on the Pharmacy and Therapeutics Committee and the Formulary System
2. Pharmacy and Therapeutics (P & T) Committee – establishes policy development, communication, education, and formulary management

1. How most hospital/health systems define formulary is: product readily available or stocked in the pharmacy
2. The environment surrounding hospital pharmacies has changed dramatically. The cost of pharmaceuticals, the types of newly approved medications for specific disease states, and the stipulations related to the reimbursement or procurement of medications have all been significantly altered.
3. Medication Use Evaluations or Drug Utilizations Reviews are a formal process that aid in the evaluation of medication formulary decisions
4. When evaluating a drug for formulary addition, the following factors need to be taken into account:
   1. Procurement and regulatory restrictions, economic considerations, safety & regulatory risks

1. Factors influencing formulary management decisions
   1. Cost, reimbursement, availability, specialization of medications (niche)
2. Can have different sub-committees roll into or feed up to P&T
   1. Subcommittees include medication safety, quality, antimicrobial stewardship, adverse drug reaction, biotechnology subcommittee
3. Instead of having formulary and non-formulary designations, we can expand this to include:
   1. Formulary, stocked
   1. Formulary, not stocked (or not consistently stocked)
   1. Formulary, restricted
   1. Formulary, requirement for confirmation of benefits of coverage prior to use
   1. Formulary, outpatient (or clinic) use only
   1. Non-formulary, stocked
   1. Non-formulary, not stocked
4. Post formulary decision implementation strategy plays a significant role in deciding the success or failure of that formulary decision
   1. It is equally important as the building up towards the P&T Process

Heindel GA, McIntyre CM. Contemporary challenges and novel strategies for health-system formulary management. Am J Health Syst Pharm. 2018 Apr 15;75(8):556-560. 

Leonard MC, Thyagarajan R, Wilson AJ, et al. Strategies for success in creating an effective multihospital health-system pharmacy and therapeutics committee. Am J Health Syst Pharm. 2018 Apr 1;75(7):451-455

The post Episode 10. Formulary Management with Oscar Santalo appeared first on The Pharm So Hard Podcast.

• TF is a 58-year-old 50 kg female that presented to the ED with a chief complaint of progressively worsening weakness and fatigue over the past day since ingesting MDMA (Ecstasy) and increased fluid intake over last 24 hours. During the physical exam, TF started to have tonic-clonic seizures that lasted 2 minutes. The ED resident orders POC labs and the Na+ came back at 118 mEq/L.

 How do you treat this symptomatic hyponatremia?

• Hyponatremia is defined as any serum sodium

• Mild/moderate Hyponatremia
  • Headache
  • Nausea/vomiting
  • Muscle cramps
  • Lethargy
  • Restlessness
• Severe Hyponatemia
  • Disorientation
  • Focal neurologic deficits
  • Seizures (Status epilepticus common)
  • Coma

• Often requires prompt correction
  • Fluid restriction and intravenous hypertonic

• Reversible causes of hyponatremia corrected

• Sodium deficit can be calculated to estimate

• – Sodium deficit (mEq) = TBW x (desired Na –

• TBWMEN = 0.6 L/kg x weight in kg

• TBWWOMEN= 0.5 L/kg x weight in kg

• May use adjusted body weight in obese

• Treat neurologic emergencies with hypertonic saline
  • Hypertonic Saline 3%
    • 100-150 ml or 2ml/kg  over 10-30 minutes through a central OR peripheral line
  • Provide up to two additional 100-150 mL boluses, spaced 20 minutes apart, until a 5 mmol/L increase in sodium concentration is reached

• Rapid correction of serum sodium by 2-3 mEq/L

• If symptoms do not improve continue IV 3%

• This rate depends on each patient’s weight and

• Monitor sodium concentration every 4 hours

• 50 cc of 8.4% sodium bicarbonate (1 “ampule”

• PMID 15026402
• PMID 7511708
• PMID 30745195
• PMID 28471928
• PMID 23283268
• https://emcrit.org/squirt/peripheral-hypertonic-saline-safe/

https://www.uwhealth.org/cckm/cpg/medications/Peds-IV-Administration-CPG—January-2018.pdf

https://www.universityhealthsystem.com/~/media/files/clinical-pathways/hypertonic-saline-2018.pdf?la=en

http://vcportal.ventura.org/VCHCA/Hospitals/Medical%20Staff%20Services/CPG/hypertonic-saline-practice-guideline-4-2011.pdf

• Is there a protocol that guide the use of 3% NaCl for Symptomatic Hyponatremia?
  • Is the language clear on the recommendation on the type of line required vs recommended?
  • Is the protocol for ICP management?
  • Is the protocol for Hyponatremia?
• Verifying 3% NaCl in the ED
  • A quick look at labs
  • The nursing note may have info about symptomatic hyponatremia
  • Quick Lit search if uncertain and no one to consult with
    • Institution guidelines, Tintinalli’s, Rosen’s, Uptodate, Pubmed, Societal Guidelines
  • When reaching out to team ask questions and be ready with a therapeutic alternative
• 3% Hypertonic Saline through Peripheral Line?
  • Should be through a central line if one is available, however, 3% can and should be bolus on IV smart pump through a large Bore IV
• Is 3% NaCl in your institutional automatic dispense cabinet? If not why? If not how quickly can it be obtained?

• Ask for clarification from experience nurse, pharmacist, and provider if there is confusion as to what is being asked of you and is this treatment appropriate
• Be aware that this is a time-sensitive matter and newer healthcare professionals may be uncomfortable explaining why there’s confusion on the treatment plan
• 18 G IV in the most distal access point
• IV pump, pump tubbing, and no need for a filter, and have dedicated line for hypertonic initially
• Nursing note with communication from Provider and description of what the symptoms of symptomatic hyponatremia

• Clear communication about what you need the

• Helps pharmacy see whats it for and prompt quick

• Rapid

• ODS

• Do

• Often

EMCrit

• https://emcrit.org/emcrit/hyponatremia/

CanadianEM

• https://canadiem.org/hyponatremia-in-the-ed/

Emergencymedicinecases

• https://emergencymedicinecases.com/episode-60-emergency-management-hyponatremia/

EmDoc

• http://www.emdocs.net/core-em-severe-hyponatremia/

Pulmcrit

• https://emcrit.org/pulmcrit/emergent-treatment-of-hyponatremia-or-elevated-icp-with-bicarb-ampules/

1. Moritz ML and Ayus JC. 100 cc 3% sodium

The post Episode 9: The Treatment of Symptomatic Hyponatremia with Hypertonic Saline with Jimmy Pruitt appeared first on The Pharm So Hard Podcast.