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

To view the handout for the Pharmacy Friday Pearl visit: https://www.pharmacy-pearls.com/home

• Insulin with dextrose is an effective method to lower potassium levels quickly in acute hyperkalemia
• Literature shows ranges of potassium reduction by 0.5-1.0 mEq after administration of a single dose.

• Patients with renal insufficiency and end-stage renal disease (ESRD) have a higher incidence of hypoglycemia after treatment with insulin for hyperkalemia due to:
  • Reduced insulin clearance (prolonged insulin action)
  • Reduced hepatic glucose production
  • Reduced renal gluconeogenesis

The appropriate dose of insulin to minimize hypoglycemic events when using for the treatment of hyperkalemia in patients with renal insufficiency is still debated.

Moussavi et al conducted a Meta-analysis (n = 3437) that looked at 10 units vs <10 units IV regular insulin. They found that <10 units IV regular insulin had lower pooled odds of hypoglycemia odds ratio [OR] 0.55 and severe hypoglycemia OR 0.41

• Hypoglycemia risk seems to be elevated in those patients with renal insufficiency, especially those who are insulin-naive
• Consideration should be made to lower the initial dose of IV insulin for patients with AKI or CKD

The post Episode 47. I Plead the Fifth! 5 vs 10 units of Insulin for Hyperkalemia appeared first on The Pharm So Hard Podcast.

In this episode of the Pharm So Hard Podcast, Jimmy Pruitt PharmD, BCPS, BCCCP discuss with Brian Cox, RN the various tasks and skills that we can improve on in the ED.

Intro 0-3:17

EKG 3.21-8.24

IV Access Skills 8:29-18:14

Meds We Don’t Need 18:17-28:50

Trauma and MTP 28:43-41:36

https://www.oakroadbrewery.com/

• Instagram

The post Episode 46. Do Better! How to Become a Super Nurse in the ED with Brian Cox, RN appeared first on The Pharm So Hard Podcast.

Around 9,000 Americans are treated for snake bites and 5 die each year. Most are bitten by members of the Crotalinae subfamily (a.k.a. crotalids) of the pit viper family which includes copperheads, water moccasins, and rattlesnakes.

Crotalid envenomation’s can cause a broad range of adverse effects, including local tissue, hematologic, and/or systemic effects including shock and life-threatening bleeding.

• Use symptom progression such as swelling beyond 1 major joint or hematologic effects (decreased fibrinogen, thrombocytopenia, or increased PT) as an indicator for initial or additional doses of antivenom.
• Identification of the snake can be helpful but should not determine decision to initiate or continue therapy in place of symptom progression.
• Patients can develop delayed or recurrent hematologic symptoms up to a week after treatment cessation, especially following a severe envenomation.

Fab fragment of IgG antibody isolated from sheep serum; antibody binds to venom and removes it from tissue

• F(ab’)2 fragment of IgG antibody isolated from horse serum; antibody binds to venom and removes it from tissue

• Initial Dose
  • Progressing tissue/hematologic effects: 4 – 6 vials
  • Systemic effects including shock: 8 – 12 vials
  • May repeat every hour as needed until initial control of local, hematological, and systemic symptoms is achieved
• Maintenance
  • 2 vials q6h x 3 after control is achieve

• Initial dose:
  • 10 vials
    • May repeat every hour as needed until initial control of local, hematological, and systemic symptoms is achieved

• Maintenance
  • 4 vials as needed; may administer for any re-emerging symptoms

• Inject ≥18 mL NS (or SWFI) into each vial; more volume will speed up the dissolution
• Gently swirl or roll vials in hand or combine all vials in the bag to roll simultaneously; DO NOT SHAKE
• Add/QS solution to 250 mL bag of NS admin over 1 hour
• NOTE: Many clinicians choose a slower initial rate to allow for assessment of allergic reaction

• Reconstitute each vial with 10 mL NS
• Gently swirl or roll vials in hand or combine all vials in bag to roll simultaneously; DO NOT SHAKE
• Solution should be clear to yellow/green and opalescent; do not use if otherwise discolored
• Add/QS solution to 250 mL bag of NS
• Administer total volume over 1 hour
• NOTE: Many clinicians choose a slower initial rate to allow for assessment of allergic reaction

T½: 12 – 23 hours

T½: ~5.5 days

• Hypersensitivity reactions ranging from pruritus/urticaria to anaphylaxis
• Serum sickness (rare

• Nausea (23%), arthralgia (11%), peripheral edema (8%)
• Hypersensitivity reactions ranging from pruritus/urticaria to anaphylaxis
• Serum sickness (rare)

No known drug interactions

No known drug interactions

NS or SWFI for reconstitution; NS for infusion

NS

Approved for the treatment of any North American crotalid envenomation

Recently approved any North American crotalid envenomation

Crofab® and Anavip® seem to be comparable for initial symptom control, although due to the longer half-life, Anavip® may have a larger role in the prevention of late-onset or recurrent coagulopathy

Each health system will likely need to make a formulary decision on which agent to use. This decision should be based on which snake species are endemic to that region, preparation time, agent costs, and the prevalence of recurring coagulopathy in their patient population.

1. Lavonas et al. BMC Emerg Med. 2011;11:2.

1. Cocchio C, et alAm J Health Syst Pharm. 2020;77(3):175-187.
2. Crotalidae Polyvalent Immune FAB (Ovine). Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed April 28, 2020.
3. Crofab® [package insert]. West Conshohocken, PA: BTG International Inc; 2000.
4. Crotalidae Immune F(ab’)2 (Equine). Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed April 28, 2020.
5. Anavip® [package insert]. Franklin, TN: Instituto Bioclon, S.A. de C.V.; 2015.
6. Dart RC, et al. Ann Emerg Med. 1997;30(1):33-9.
7. Dart RC, et al. Arch Intern Med. 2001;161(16):2030-6.
8. Boyer LV, et al. Toxicon. 2013;74:101-8.
9. Bush SP, et al. Clin Toxicol (Phila). 2015;53(1):37-45.
10. Gerardo CJ, et al. Ann Emerg Med. 2017;70(2):233-244.e3.
11. Gerardo CJ, Keyler DE, Rapp-Olsson AM, Schwarz J III, Dart RC. Post Hoc Analysis of the RCT Comparing F(ab’)2 to Fab Antivenom: Control of Venom-Induced Tissue Injury in Copperhead Snakebite Patients. Annals of Emergency Medicine 76(4) Supp:S29Dec;26(4):472-87.

Jimmy

What’s good fam? It’s your host, Jimmy Pruitt aka PharmD in the ED and I’m bringing you another episode of the Pharm So Hard Podcast.Today is going to be one of our shorter episodes, we’re going to be having our Pharmacy Friday Pearl.

So happy Pharmacy Friday to all of you guys out there.

And today, we’re going to talk about snake bites. And particularly talking about the management of snake bites using two agents, Crofab and Anavip.

So what we know about snake bites is about 9000 Americans are treated for each year, and about five of them die, and most are bitten by the Pit Vipers.

And a good bit of them are gonna be local tissue, hematological, and it can be systemic, including shock and life threatening bleeding.

When figuring out if we’re going to give the initial dose or additional doses of anti venom, we’re gonna use things like swelling beyond one major joint, or hematological effects like decreased fibrinogen, thrombocytopenia, or an increase PT and INR. But the very interesting thing is that patients can develop delayed or recurrent hematological symptom up to one week after we finished treatment, especially falling less severe envenomation.

Alright, so let’s move on to these two agents, Crofab and Anavip. So when looking at Crofab, the mechanism of action is that the fab fragment of the IgG antibody is isolated from sheep serum. And these antibodies bind to the venom removed from the tissue.

While looking at the initial dose of Crofab, we’re gonna see for progressing tissue or hematological effects, you can start with four to six vials of Crofab. But if you have systemic effects, including shock, you’re going to do eight to 12 vials, and it may be repeated every hour as needed until initial control of local, hematological and systemic effects are achieved. Once you get there, then you move on to their maintenance, and that’s gonna be two vials every six hours times three, you should be good to go. All my pharmacists out there can attest to the fact that mixing Crofab is a mofo. You it takes forever, of gently rolling and swirling in your hand. And then you’re going to do that for 10 to 20 minutes depending on how many vials you’re using. And once you are able to reconstitute that with sterile water or normal saline, then you’re gonna put all that in a normal saline bag of 250 and administer that over one hour. However, you have to watch out for the fact that you can have some infusion related reactions. So, you’re going to want to slow that bag way down and drop that infusion rate so the patient can tolerate it. One thing that I talked about that scenario doesn’t matter most of the time, but actually do in this particular scenario is the half-life, it’s going to be for Crofab, 12 to 23 hours. And that’s going to make a big difference when we’re talking about the other agent, Anavip. Until very recently, it was the only FDA approved agent for the treatment of any North American pit viper envenomation.

The other agent that we have is Anavip, and it’s gonna be Crotalidae Immune F(ab’)2 or Anavip as most of us call it, and it’s going to work by that F(ab’)2 fragment of the IgG antibody, going to be isolated from horse serum.

And then that antibody itself is going to bind to the venom and remove it from the tissue. The initial dose is going to be 10 vials. You may repeat that every hour until you get the initial control of the local, hematological, or systemic symptoms. And after that there’s no scheduled dose like for Crofab, but you may get four vials as needed for any reemerging symptoms. The reconstitution can be a little easier. And you should be able to reconstitute each vial at 10 ml. So, ns it didn’t put that into a 250 bag of saline and administer that over one hour.

The half-life is going to be interesting to me 5.5 days,

and that’s going to be pretty cool when we start getting into some of the data. And the adverse effects are very mild with nausea, arthralgia and peripheral edema listed to some of the studies and hypersensitivity reactions can happen with any drug. But with these two agents, that’s something that we look at. And if you do have them, you can just dilute the drug a little bit more and slow down the infusion rate. And a very cool thing about Anavip is that until recently, and I’m talking about April 1st, it did not have an FDA indication for some of the other snakes in this family like copperheads. And now Anavip is FDA approved for any North American crotalid envenomation.

Alright, guys, let’s jump into some evidence. One of the first studies that looked at Crofab was then in  1997 by Dart and colleagues. And it was a randomized controlled trial with only 11 patients. But what they did was look at patients that had minimal or moderate crotalid envenomation. And they use 4 vials of Crofab for the initial control of those symptoms. And what they found was that 10 of the 11 patients were deemed to have a clinical response and reduce snake severity score. And some later studies again, repeated those same results showing that Crofab did a phenomenal job in reducing the symptoms of patients that had crotalid envenomation. Now, the controversy is not really there. The controversy comes when talking about using Crofab or just your fab compared to Anavip F(ab’)2. In a study done by Boyer and colleagues, it was a phase 2 randomized controlled trial looking at rattlesnake bites in Arizona, and it was Crofab vs Anavip. And this was going to be for the reduction in serum venom levels at various predefined times following crotalid envenomation. And what they found was that venom levels were insignificantly lower following initial control in the Crofab group, but significantly lower following maintenance and follow up in Anavip group. So looking at all that they also found that there is no major difference in safety outcomes between these patients. So the last study I want to talk about is this Bush and colleague study that was put out in 2015, which is an RCT at 18 sites in the US, it had 123 patients. They looked at the use of Crofab vs Anavip for prevention of late coagulopathy following crotalid envenomation. And what they found was more patients in the Crofab group, compared to Anavip group experienced late coagulopathy. It’s about 29.7% in Crofab group, compared to just 10.3% in the Anavip group, and what they found that is worth physically significant. It was a number needed to treat a five for this group of no bring the original review and approval of antibiotics. The FDA made the decision to exclude copperheads patients since late coagulopathy are more commonly observed in rattlesnake envenomations. And FDA is focused on rattlesnake data at the time also led to exclusion of copperhead envenomation as the indication for Anavip. This is cool because the original Anavip clinical trial still included Copperhead data, which was recently reviewed in a Post hoc analysis that looked at two groups of Anavip with the initial 10-vial group with maintenance therapy after that, 4 vials Q6 times three. It also looked at Anavip with the initial 10 vials by itself plus placebo. And they compare that to Crofab 5 vials up front and then two vials Q6 times three, and what they found in those 21 patients that there is no major difference between Anavip and Crofab, we’re looking at time to initial control, patients requiring PRN, or unscheduled doses. And the study concluded that Anavip was non inferior to Crofab for the treatment of Copperhead envenomations. So when looking at all of this, this post hoc analysis, and some animal studies showing that Anavip actually neutralize venom from Copperhead and cottonmouth, and mice in human case report information. This all led to the FDA giving a knock to Anavip for all crotalid envenomations.

 So get ready for all of your committee meetings, when it comes to whether you should add Anavip to your formulary, replace it or have it in combination and use it for just rattlesnake bites, that’s going to be something that really comes to what you and your site is seeing. And the other thing to consider is the cost component because at one period of time, depending on if you need to get additional vials of Anavip compared to Crofab, people were saving like $15,000. So that was going to be a huge, huge, huge cost savings. But the word from the streets is that Crofab realizes what’s going on. And it’s going to drop those prices quite a bit. So reach out to your buyers see the actual prices because I’ve heard from mine, that the price of Crofab drops tremendously. So for me guys, I can be solved inAnavip. Initially, I wasn’t when I didn’t see that post hoc data, but now I’m kind of onboard and if the pricing benefit is still there, I’m pretty good with adding it to formulary. If it’s just up to me. My doctors seem to want it on formulary as well. So I’m going to go ahead and try to get that push forward and let me guys know what you guys are doing. Many people are talking about this right now. Love to hear what you and your shopper doing. But as we close out, don’t forget to go over to our sister site, pharmacy-pearls.com where you can type in pharmacyfriday.com, it’s going to take you to the website. Go ahead and click and subscribe to that email list so you never miss the latest and greatest when it comes to acute care pharmacotherapy. If you haven’t already, go ahead and click on that subscribe button in your Spotify, your Apple podcasts, YouTube, whatever you’re listening to this podcast on. Go ahead and give us some support and subscribe to that podcast. Hit me up on Twitter @PharmD_intheEd and let me know what you think about this podcast. You guys know how it ended every single time. Just know you don’t have to be a pharmacist.

You don’t have to work in ED, but everything you do, make sure you Pharm So Hard.

The post Episode 45. Staying Fabulous with Fabs: Pharmacologic Management of Snake Bites with Crofab and Anavip appeared first on The Pharm So Hard Podcast.

Series Title: Keeping Up With COVID-19

Part 2:  Revisiting Remdesivir

1. Situation (Jimmy)
   • .We are over a year into this pandemic and we have only one FDA approved medication for the treatment of COVID-19: Remdesivir.
   • The purpose of this episode is to briefly review the role of Remdesivir in the treatment of COVID with a focus on real-world application in the post-EUA era.
2. Background
   • MOA: remdesivir is a monophosphoramidate nucleoside pro-drug of adenosine analog. It works by inhibiting viral replication by competing with endogenous nucleotides for incorporation into replicating viral RNA via RNA dependent RNA polymerase. Binding promotes premature termination of RNA transcription which halts viral replication.
   • Remdesivir history
     • Originally developed in response to the 2014-2016 Ebola outbreak in West Africa
     • First EUA approval on 5/1/2020 for use in hospitalized patients with severe COVID-19 disease. EUA was later revised on 8/28/2020 to expand use, no longer limited to patients with severe disease
     • FDA approval for treatment of hospitalized patients with ,COVID-19 was granted on 10/22/2020 for adult and pediatric patients (at least 12 years old and weighing at least 40 kg). 
3. Summary of Key Remdesivir Trials
   • ACTT
     • Shorter median time to recover 8 vs 11 days for patient with severe COVID (SpO2 < 94%); failed to show mortality benefit or improvement in time to recovery for mechanically ventilated/ ECMO
   • Wang Y et al. Lancet 2020
     • Remdesivir demonstrated trend towards faster clinical improvement (18 vs 23 days) in patients with severe COVID when initiated within 10 days of symptom onset
   • Spinner CD et al. JAMA 2020
     • Five days of remdesivir demonstrated significant improvement in clinical status on day 11 vs standard of care (SOC). 
     • No difference in clinical status with 10 days of remdesivir vs SOC
   • Goldman JD et al. NEJM 2020
     • Demonstrated similar time to clinical improvement for patients that received a 5 day course of remdesivir compared to those that received 10 days. (10 vs 11 days)
4. IDSA and NIH Guidelines both recommend the use of remdesivir in hospitalized patients
   1. IDSA Guidelines (as of 6/30/21): Suggest use when SpO2 < 94% on room air. 
   2. NIH Guidelines (as of 6/30/21): Suggest use in patients requiring increased supplemental oxygen from baseline including high-flow or non-invasive O2. 
5. Major End Points  (Oscar)
   1. Real world evaluation of Remdesivir use: UF Health Central Florida
      • Medication use evaluation of remdesivir utilization
      • Mostly evaluated patients after EUA expansion and FDA approval (hospitalized, not exclusive to severe disease)
      • Stratified groups for analysis based on SPO2 above or below 94% and supplemental O2 requirements (total of 100 patients)
      • ~80% of participants exceeded 65 years old (median age 73 years old). By definition these patients are at high risk of progressing to severe COVID-19 disease based on advanced age alone.
      • Key findings: Remdesivir didn’t make an impact on clinical improvement by day 5 regardless of SpO2. This study reinforces the IDSA’s stance on advocating against remdesivir use when SpO2 exceeds 94%. However, even when remdesivir was given along with SOC treatment (95% received steroids), 54.2% of patients with an SpO2 < 94% expired and the use of remdesivir did not demonstrate clinical improvement with 5 days of treatment.
   2. Remdesivir use in patients with eGFR < 30 mL/min
      • Per the package insert, is remdesivir is not recommended in patients with eGFR < 30 mL/min 
      • There is PK data to suggest active metabolites may accumulate in the setting of renal impairment. This may be augmented by sulfobutylether-beta-cyclodextrin sodium (SBECD) which is present in the IV formulation and can also accumulate in the setting of renal impairment.
      • There are some data that exists now that suggest a lack of clinically significant SCr elevation/ LFT rising with sort term use (5-10 days) but there are no formal studies.
      • Gilead is currently enrolling for a PK study to assess this 
6. Summary
   1. Remdesivir is the only FDA approved medication for the treatment of COVID-19 infection.
   2. Remdesivir should be considered for use in hospitalized patients, particularly those with SpO2 < 94% on room air or require an increase in supplemental oxygen from baseline 
   3. In real-world practice, 5 days of remdesivir did not appear to make a difference with regards to clinical improvement in patients with advanced age, regardless of SpO2 saturation.
   4. At this time, there is a lack of robust data to support the safe use of remdesivir in patient with an eGFR less than 30 mL/min.

The post Episode 44. Keeping Up With COVID-19: Revisiting Remdesivir with Theora Canonica, Pharm D appeared first on The Pharm So Hard Podcast.

1. Kcentra (prothrombin complex concentrate [Human]) [package insert]. Kankakee, IL: CSL Behring LLC; 2013.
2. Tomaselli, Gordon F., et al. “2017 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways.” Journal of the American College of Cardiology 70.24 (2017): 3042-3067.
3. Schwebach, Alyson A., Ryan A. Waybright, and Thomas J. Johnson. “A Review of Fixed‐Dose Four‐Factor Prothrombin Complex Concentrate for Vitamin K Antagonist Reversal: Does One Dose Fit All?.” Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy (2019).
4. Khorsand, Nakisa, et al. “An observational, prospective, two-cohort comparison of a fixed versus variable dosing strategy of prothrombin complex concentrate to counteract vitamin K antagonists in 240 bleeding emergencies.” haematologica 97.10 (2012): 1501-1506.
5. Abdoellakhan, Rahat Amadkhan, et al. “Fixed versus variable dosing of prothrombin complex concentrate in vitamin K antagonist-related intracranial hemorrhage: a retrospective analysis.” Neurocritical care 26.1 (2017): 64-69.
6. Klein L, Peters J, Miner J, Gorlin J. Evaluation of fixed dose 4-factor prothrombin complex concentrate for emergent warfarin reversal. Am J Emerg Med. 2015;33(9):1213-1218.
7. Astrup G, Sarangarm P, Burnett A. Fixed dose 4-factor prothrombin complex concentrate for the emergent reversal of warfarin: a retrospective analysis. J Thromb Thrombolysis. 2018;45(2):300-305.
8. Dietrich, Mixon, Holowatyj et al. Multi-centered evaluation of a novel fixed-dose four-factor prothrombin complex concentrate protocol for warfarin reversal. Am J Emerg Med. 2020;38(10):2096-2100.
9. Stoecker, Van Amber, Woster et al. Evaluation of fixed versus variable dosing of 4-factor prothrombin complex concentrate for emergent warfarin reversal. Am J Emerg Med. 2021;48:282-287.
10. McMahon, Halfpap, Zhao et al. Evaluation of a fixed-dose regimen of 4-factor prothrombin complex concentrate for warfarin reversal. Ann Pharmacother. 2021. [Epub ahead of print]
11. Elsamadisi P, Cepeda MAG, Yankama T, Wong A, Tran Q, Eche IM. Weight-Based Dosing Versus a Fixed-Dose Regimen of 4-Factor Prothrombin Complex Concentrate in Obese Patients Requiring Vitamin K Antagonist Reversal. Am J Cardiovasc Drugs. 2021 May;21(3):355-361. doi: 10.1007/s40256-020-00442-w. Epub 2020 Nov 5. PMID: 33150496.
12. Mohammadi, Yaribash, Mohmood, Talasaz. Efficacy and safety of the fixed-dose versus variable-dose of 4-PCC for vitakmin K antagonist reversal: a comprehensive systematic review  and meta-analysis. Cardiovasc Drug Ther. 2021. [Epub ahead of print]
13. Dietrich SK, Mixon MA, Rech MA. Fixed-dose prothrombin complex concentrate for emergent warfarin reversal among patients with intracranial hemorrhage. Am J Emerg Med. 2021 Jun 26;49:326-330. doi: 10.1016/j.ajem.2021.06.032. Epub ahead of print. PMID: 34224954.

The post Episode 43: Put It in Reverse Terry! Fixed-Dosed Kcentra for Vitamin K Antagonist Reversal appeared first on The Pharm So Hard Podcast.

• Sarah Cummings
  • PharmD: Purdue
  • PGY1: Thomas Jefferson University Hospital
  • PGY2 EM 2020-21: UC Davis
• Britany Byrkit
  • PharmD: Wingate
  • PGY1: Vidant Medical Center
  • PGY2 EM 2020-21: MUSC Health
• Tramauni E. Brock
  • PharmD: Texas Southern University
  • PGY1: MUSC Health
  • PGY2 HSPAL: MUSC Health
• Kailey Denny
  • PharmD: University of Mississippi School
  • PGY1: Froedtert
  • PGY2 EM 2021-22: MUSC Health
• Nicholas A. DeFilippo
  • PharmD: U Conn
  • PGY1 2021-22: Yale New Haven
• Ryan Watts
  • PharmD ’16: Hampton University
  • PGY1 2021-22: Homestead Hospital

• Ryan and Nicholas, tell us about your journey to obtaining PGY1?
• What advice would you give current students?
• Comments from the group

• What are your goals for this upcoming year?
• What are your biggest concerns about this upcoming year?
• Comments from the group

• What does the future looks like post PGY2?
• What’s something you wish you would have known prior to starting residency?

• How do you stay up to date with the latest guideline changes without flooding your inbox?
• How did you transition your CV from PGY1 to PGY2 in preparation for the job search?
• How did you transition your CV from PGY1 to PGY2 in preparation for the job search?

The post Episode 42. Residency Here I Come! The Pharm So Hard Residency Panel appeared first on The Pharm So Hard Podcast.

• Why this topic important?
  • Accidental injury is the most common cause of death in the United States in individuals between the ages of 1 and 45
  • Falls are the most common reasons for hospital admissions in this older age group and account for 87% of fractures.
  • Open fractures are high-energy injuries with an increased risk of infection due to potential exposure of bone and deep tissue to a variety of environmental debris.

• What is the Gustilo and Anderson classification of open fractures?
  • Definition: a grading system that offered prognostic information about the outcome of infected fractures created by Gustilo and Anderson in 1976 described their treatment of 1025 open fractures.  
  • Grade I: Wound less than 1 cm long, punctured from below.
  • Grade II: Laceration 5 cm long; no contamination or crush; no excessive soft tissue loss, flaps, or avulsion
  • Grade III: Large laceration, associated contamination or crush; frequently includes a segmental fracture.
    • IIIA: Involves extensive soft tissue stripping of bone
    • IIIB: Periosteal stripping has occurred
    • IIIC: Major vascular injury present

• Infection rates for open fractures
  • Type 1
    •  0-2% risk of developing an infection
  • Type II
    •  2-12% risk of developing an infection
  • Type III
    • 10-50%   risk of developing an infection                 

• What does the Eastern Association for the Surgery of Trauma (EAST) guidelines recommend for grade 1, 2, and 3 open fractures?
  • Systemic antibiotic coverage directed at gram-positive organisms should be initiated as soon as possible after injury.
  • Additional gram-negative coverage should be added for type III fractures.
  • High-dose penicillin should be added in the presence of fecal or potential clostridial contamination (e.g., farm-related injuries).
  • In type III fractures, antibiotics should be continued for 72 hours after injury or not 24 hours after soft tissue coverage has been achieved.
  • Once-daily aminoglycoside dosing is safe and effective for types II and III fractures.

• What pharmacologic agents can we use for Grade 1+2 open fractures
  • Preferred: Cefazolin 2 g (3 g if > 120 kg) IV q8h
  • Clindamycin 900 mg IV q8h
  • Known MRSA colonization: Add vancomycin 15 mg/kg IV q12h
  • Duration of prophylaxis: 24 hours

• What pharmacologic agents can we use for Grade 3 open fractures
  • Preferred: Ceftriaxone 2g q24 x 2 days
    • Based on a study by Rodrigeuz et al in 2014 that reported significantly decreased use of aminoglycoside and glycopeptide antibiotics with no increase in skin and soft tissue infection rates.
  • Severe beta-lactam allergy: Clindamycin 900 mg IV q8h + levofloxacin 500 mg IV q24h

• Is there additional coverage for contamination with soil or fecal material?
  • Ceftriaxone 2 g IV q24h + metronidazole 500 mg IV q8h
  • Severe Beta-lactam allergy: Levofloxacin 500 mg IV q24h + metronidazole 500 mg IV q8h

• Is there additional coverage for contamination with standing water:
  • Preferred: Zosyn 4.5 g q8
  •  Severe beta-lactam allergy: Levofloxacin + Flagyl
  • When should we give Td/Tdap for open fractures?
    • >10 years clean wound
    • >5  years dirty wound

• Do studies show that having EM PharmDs involved helped with the antibiotic selection
  • Harvey et al. Impact of an emergency medicine pharmacist on initial antibiotic prophylaxis for open fractures in trauma patients. Am J Emerg Med. 2018 Feb;36(2):290-293.
    • P: 146 Trauma patients with open fractures at Level 2 trauma center in Lakeland FL
    • I: Pharmacist participating during trauma resuscitation
    • C: Prior time without pharmacists’ involvement in trauma resuscitation
    • O: More patient’s initial antibiotic prophylaxis was in accordance with the EAST guideline recommendations with a PharmD compared to none.
      • 81% versus 47%  Pharm vs no-pharmacist present (p < 0.01)
    • Median door-to antibiotic time was 14 mins

The post Episode 41: Scratch the Gent! Antibiotics for Open Fractures with Rob O’Connell appeared first on The Pharm So Hard Podcast.

1. For continued growth and development, hospital pharmacist would benefit from leadership training
2. Pharmacy schools provide some administrative training
3. Hospital pharmacist may one day want to become a clinical or operations manager
4. With an increase in residency programs, a leadership path may be more difficult for those who did not complete a residency  
5. Just being good at one job may not translate to the other
   1. Specialist positions vs leadership positions is a different skillset
6. Little training in project management

• Additional training
  • Shadowing
  • Master’s degree
  • Lean thinking, leadership certificates
  • Materials –> Podcasts & articles
  • Conferences

• Opportunities in people management
  • Students
  • Interns
  • Residents
  • Taking the schedule

• Creating service lines/programs
• Involvement in committees
  • P&T, Controlled Substances, Med Safety, Specialty
• Implementing projects
• Networking

1. Everyone’s path is different and not every hospital can hire an Admin Resident
2. Seek opportunities in people management, leadership training, and project management

The post Episode 40: Leveling Up As a Clinical Staff Pharmacist by oscar Santalo and Jimmy Pruitt appeared first on The Pharm So Hard Podcast.

• 0:25 Introduction
• 2:30 The importance of ultrasound-guided peripheral nerve blocks
• 3:49 Overview of ultrasound-guided peripheral nerve blocks
• 4:40 What are the training and credential required to perform ultrasound-guided peripheral nerve blocks
• 7:58 What does the data say about the efficacy and safety of ultrasound-guided peripheral nerve blocks
• 12:59 What are the most common ultrasound-guided peripheral nerve blocks in adults and pediatrics
• 20:47 What equipment and supplies are needed for ultrasound-guided peripheral nerve blocks
• 28:22 Walk through an ultrasound-guided peripheral nerve blocks step by step
• 38:22 Is there a preference for particular anesthetic agents (with or without epinephrine)
• 42:16 What resources are useful to learn about ultrasound-guided peripheral nerve blocks
• 44:32 What do you want pharmacists to know about ultrasound-guided peripheral nerve blocks
• 49:21 Conclusion

https://www.nysora.com/techniques/

http://faculty.washington.edu/bramhall/lectures/regional%20anesthesia/General%20Techniques.html

https://www.nuemblog.com/blog/oral-nerve-blocks

https://www.tamingthesru.com/head-and-neck-nerve-blocks

https://www.emra.org/books/pain-management/ultrasound-guided-nerve-blocks/

The post Episode 39: Welcome to the Block Shop! Regional Anesthesia with Drs. Shah, CUmmings, Oliva, and Moake appeared first on The Pharm So Hard Podcast.

1:14 Review of previous episodes of the series
2:40 Pharmacy Friday Pearls
3:24 EMPoweRx Conference
5:28 Cardiac Arrest Patho of Acidosis
6:04 Why have we been using sodium bicarbonate
7:08 Adverse Effects of sodium bicarbonate
9:29 History of sodium bicarbonate for ACLS
10:17 Bishop et al study
11:45 Wang et al study
12:26 Ahn et al
13:18 Kwano et al
14:37 Wu et al
16:31 Alshahrani et al
17:45 Summary

1. Why this topic
   1. Something we commonly do without much evidence to support its use
2. Pathophysiology of acidosis in Cardiac Arrest
   1. One of the critical pathophysiologic components of cardiac arrest is the generation of both metabolic and respiratory acidosis. Obviously, if you are not breathing to oxygenate your blood and remove CO2, you will generate respiratory acidosis. Also, if your heart is not delivering oxygen-rich blood to the tissues and CO2 is unable to be removed, then metabolic acidosis will ensue. 
   2. The hypothesis of using alkalizing agents in cardiac arrest is to scavenge hydrogen ions, thus improving the body’s systemic acidosis to improve cardiovascular function.

1. Transient aggravation of the intracellular acidosis with further reduced contractility of the myocardium as a consequence [11,43,86,87]
   1. Am J Physiol 1982;242:F586–91
   1. Am J Physiol 1958;195:412–6
   1. Am J Physiol 1967;212:917–23.
   1. Science 1985;227:754–6
2. Administration of only 1 mequiv./kg of sodium bicarbonate has been demonstrated to increase arterial PCO2 by more than 20 mmHg during CPR.
   1. J Am Med Assoc 1976;235:506–9.
3. Thus, treatment with sodium bicarbonate may add substantial quantities of the potent negative inotrope carbon dioxide to the burdens of an arrested or recently resuscitated heart.
   1. Crit Care Med 1993;21:901–6.
4. Clowes et al suggested that both metabolic (pH < 7.25) and respiratory (Pco2 > 65 mm Hg) acidosis were associated with decreased survival in postoperative patients
   1.  
5. Hypotension
   1. It has been suggested that the observed effect may be explained by a reduction in diastolic pressure due to arterial vasodilation in combination with a modest increase in right atrial pressure due to increased preload produced by the hypertonic buffer.
   1. The hypotensive effect of hypertonic solutions has been postulated to be mediated by a vagal reflex [96], or to result from a direct action of hypertonic solutions on arterial resistance vessels [97].
      1. J Appl Physiol 1969;27:251–5
      1. Chest 1981;79:552–4.
   1. Sodium bicarbonate combined with epinephrine tended to produce lower systemic blood pressure than other combinations.
6. Cerebral Effects
   1. Sodium bicarbonate therapy has been demonstrated to reduce cerebral O2 availability, and cerebral hypoxia contributes to the brain dysfunction encountered after the initiation of such therapy in acidaemia.
      1. J Pediatr 1980;96:968–73
   1. Hyperosmolar states due to sodium excess may cause congestion of cerebral white matter and intracranial hemorrhage [104–106]
      1. Am J Med 1974;56:162–8
      1. New Engl J Med 1974;291:6–10
      1. Acta Paediatr Scand 1976;65:429– 32.

1. History of Bicarb
   1. Correction of metabolic acidosis with SB was recommended by early advanced cardiac life support (ACLS) guidelines published in 1976, and SB was the medication most frequently used during cardiac arrest until the mid-1980s.
   1. The 2010 ACLS guidelines for adults published by the American Heart Association (AHA) state that “Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest” (class III recommendation, based on level of evidence (LOE) B)

How did we get here to using bicarb in the manner that we do now?

References

1. Sodium bicarbonate. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved October 11, 2018, from http://www.micromedexsolutions.com/
2. Bishop RL, et al. Sodium bicarbonate administration during cardiac arrest. Effect on arterial pH PCO2, and osmolality. JAMA. 1976 Feb 2;235(5):506-9.
3. Vukmir RB, et al. Sodium bicarbonate in cardiac arrest: a reappraisal. Am J Emerg Med. 1996 Mar;14(2):192-206.
4. Vukmir RB, et al. Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest. Am J Emerg Med. 2006 Mar;24(2):156-61.
5. Wang CH,et al. The effects of calcium and sodium bicarbonate on severe hyperkalaemia during cardiopulmonary resuscitation: A retrospective cohort study of adult in-hospital cardiac arrest. Resuscitation. 2016 Jan;98:105-11.
6. Ahn S, et al. Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study. J Thorac Dis. 2018 Apr;10(4):2295-2302
7. Kawano T, et al. Prehospital sodium bicarbonate use could worsen long term survival with favorable neurological recovery among patients with out-of-hospital cardiac arrest. Resuscitation. 2017 Oct;119:63-69.
8. Chen YC, et al. The association of emergency department administration of sodium bicarbonate after out of hospital cardiac arrest with outcomes.  Am J Emerg Med. 2018 Mar 5. pii: S0735-6757(18)30187-6.
9. Wu KH, Chang CY, Chen YC, Chang CP, Hsiao CT, Weng HH. Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-analysis. J Emerg Med. 2020 Dec;59(6):856-864. doi: 10.1016/j.jemermed.2020.08.012. Epub 2020 Sep 22. PMID: 32978028.
10. Alshahrani MS, Aldandan HW. Use of sodium bicarbonate in out-of-hospital cardiac arrest: a systematic review and meta-analysis. Int J Emerg Med. 2021 Apr 13;14(1):21. doi: 10.1186/s12245-021-00344-x. PMID: 33849429; PMCID: PMC8042972.

The post The beef with Bicarb Part 3. The Use of Sodium Bicarbonate in Cardiac Arrest by Jimmy Pruitt appeared first on The Pharm So Hard Podcast.