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

https://www.pharmacy-pearls.com/course/proton-pump-inhibitors-ppis-for-the-management-of-upper-gi-bleed

The post Episode 37: Never use a PPI Infusion Again! PPI for Upper GI Bleed appeared first on The Pharm So Hard Podcast.

https://pharmacy-friday.webflow.io/course/ace-inhibitor-induced-angioedema

The post Episode 36. Pharmacy Friday Pearl: ACE Inhibitor-Induced Angioedema appeared first on The Pharm So Hard Podcast.

Lyrics

All you gotta do is try to maintain

Cause we taking that thang ……. (straight from where) brain to vein

All you got to is make sure you treat the pain,

Cause we taking that thang ……. (straight from where) brain to vein

All you got to do is not go insane,

Cause we taking that thang ……. (straight from where) brain to vein

All you got, all you got to, We taking it from brain to vein

Eeny meeny miny moe,

That PharmD drippin and gotta flow

And  I got that Ancef and fentanyl for trauma Four

And I’m mixing up a little Levophed,

So crank it up some more.. we not trying to leave em death

I see ortho over there scratching their head, 

But scratch that gent, let give that rocephin for that open leg

Whole ED bouncing when we jump on the scene,

room three getting crazy, gone off that Jim Bean

Now he escalating, need something to make him dream,

( But guess what) I got 500 of IM ketaMINE

The Patient  in room 2 BP’s is getting kind of soft,

But I got cefepime and vanco in our secret sauce,

And I got the fluids too, with no time loss,

The whole bundle complete, we something like a boss

The PharmD Clarifying, we order verifying, that flow so terrifying

We out here tearing it up

Just made an epi drip, before you knew you need it,

And we for the team, rarely known to be conceded

Room 1, looking like he about to crump, but guess what.. already got Levophed hanging, end already on the pump 

When it comes to this here, ain’t no need for stressing, I just mixed up another vial of vasopressin

When I walk in the nurses saying that its a blessing

When to it comes to these pharm skills, it really aint no testing,

Cause we clarifying, we order verifying, that flow so terrifying,

And when we walk in, you already know, we’re staying on our grind

And you got to catch us when we pulling on your boulevard

Everything you do and we do, we pharm so hard

The post Taking it Brain to Vein by PharmD_intheeD appeared first on The Pharm So Hard Podcast.

•Establishes alignment: allows for discussion of complex issues and for the team to get on the same page.

• Helps leaders make better decisions when gaining insight from the team •
• Builds stronger relationships: free-flowing ideas and personal interaction which can increase work success and productivity.
• Information exchange: Communicate company updates and process changes
• Promotes inclusion: avenue to freely express thoughts and ideas
• Facilitates innovation: allows team to showcase critical thinking and creativity
• Opportunity to share feedback: a great way to learn more about your team and areas you can improve
• Improve employee engagement: when team members feel that their input is considered or solicited, it helps them feel valued about the job equals more productivity

• Feeling overwhelmed by meeting
• No agenda
• No advanced communication
• No interaction
• Meeting length and frequency
• Conflicting opinions get out of control
• Not summarizing actions

• Regardless of meeting type, whether formal or informal, traditional or agile, face-to-face or electronically, they feel overwhelmed
• No agenda means no purpose for the meeting.
• No clear plan and goal of what you want to achieve.
• No advanced communication can lead to people arriving unprepared or not showing up at all
• No interaction as in talking at team members and not promoting opportunities for feedback
• Executives spend an average of nearly 23 hours per week in meetings and that excludes impromptu meetings
• Conflict can lead to a negative environment and distraction from the agenda
• Not summarizing actions – next steps are unclear, no action plan
• These issues lead to meeting failures which increase costs and decrease productivity, focus, and engagement

Only 17% reported that their meetings are generally productive uses of group and individual time

• Time is zero-sum (time spent doing more of one thing means less of another)
• Deep work meaning the ability to focus without distraction on a cognitively demanding task
• Having fewer meetings and running them poorly allows for more solo tasks and deep thinking, but weakens group productivity and collaboration
• Dysfunctional meeting behaviors (including wandering off-topic, complaining, and criticizing) decrease decreases market share, innovation, and employment stability
• Happiness: Job satisfaction correlates with the effectiveness of meetings.
• Bad meetings can undermine communication and collaboration leading to less satisfaction.

• Collect data: Survey should include questions about emotions felt about meetings, hours spent in meetings, the balance between group and individual work-time, the impact o work quality, and identifying best practices
• Interpret data: By doing this together, you are generating widespread understanding and buy-in from your team as you try to make the systemic change
• Goal: Meeting free periods allows time to feel like they have freedom and flexibility to get tasks done and free up time in the schedule.
• Handoffs are good because they require less time and people and still an adequate exchange of information to keep everyone updated.
• Use pulse checks to identify how employees feel about the way they spend their time and how they are doing working on a team •

• Establish clear agenda and stick to it
• Determine who should attend
• Set your schedule
• Determine action items and who is responsible
• Encourage feedback
• Leadership support is critical

• Pharmacists are constantly in meetings
  • The administrative role has a higher volume of meetings
• Distractions during meetings can lead to misunderstandings and mistakes
  • Improper “go-live” or medication safety issue
• Meeting failures can decrease team satisfaction thus decrease productivity in pharmacy
  • Promote high tension in an already stressful work environment
  • The team feels a disconnect between themselves and the leader
  • More push back on new initiatives

• Many factors go into making a successful meeting or a failed one

• Open communication and honesty foster stronger bonds
• Systemic change can lead to better meetings
• Better meeting means a happier team and better results

The post Episode 35: Why Meetings Fail with Oscar Santalo appeared first on The Pharm So Hard Podcast.

The unfavorable combination of insulin resistance and counter-regulatory hormones leads to the release of free fatty acids (FFA) from adipose tissue via lipolysis and decreased lipogenesis, which ultimately results in ketogenesis and the production of beta-hydryoxybutyrate and acetoacetate.

Overproduction of these strong ketoacids leads to excessive hydrogen ion production upon dissociation, overwhelming the human body’s buffering capacity, depleting bicarbonate stores, and ultimately generating an anion gap metabolic acidosis

Fluids

Insulin

Potassium

• Total potassium content is decreased, but serum potassium concentration may be normal/elevated due to extracellular shift of potassium caused by insulin deficiency, hypertonicity, and acidaemia

Phosphate

• Phosphate levels initially may be normal to elevated, but usually decline with treatment •Severe hypophosphatemia may impair oxygen delivery and cause muscle fatigue •Replacement is suggested in patients with phosphate levels less than 1.0 mg/dL, anemia, respiratory failure, or CHF.

Chua et al. Bicarbonate in Diabetic Ketoacidosis – A Systematic Review. Ann Intensive Care 2011; 1 (23). PMID: 21906367

• systematic review that included 44 articles including three RCTs

1. EKG changes and cardiac arrest due to hyperkalemia
2. Non-AG acidosis

https://ercast.libsyn.com/should-i-give-bicarbonate-in-dka

• Chua HR, Schneider A, and Bellomo R. Bicarbonate in diabetic ketoacidosis – a systematic review. Annals of Intensive Care 2011, 1:23.

• Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous Sodium Bicarbonate Therapy in Severely Acidotic Diabetic Ketoacidosis. Ann Pharmacother 2013;47:970-5.
• Gamba G, Oseguera J, Castrejon M, Gomez-Perez FJ. Bicarbonate therapy in severe diabetic ketoacidosis. A double blind, randomized, placebo controlled trial. Revista de Investigacion Clinica 1991, 43:234-238
• Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med. 1986;105(6):836.
• Okuda Y, Adrogue HJ, Field JB, Nohara H, Yamashita K. Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clin Endocrinol Metab. 1996;81(1):314.
• Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed). 1984;289(6451):1035.

The post Episode 34: The Beef with Bicarb Part 2: The Use of Sodium Bicarbonate for Diabetic Ketoacidosis appeared first on The Pharm So Hard Podcast.

Send up topics for the next Monthly Trap Up

The post Episode 33: The Monthly Trap UP aka Wrap up with Jimmy Pruitt and Oscar Santalo appeared first on The Pharm So Hard Podcast.

It is a way of managing a company or institution ensuring continuous improvement small changes in processes to deliver value to customers

Defined as: Any operations system that can reduce waste without compromising quality or productivity

Healthcare Kaizen is a lean tool that focuses on small, continuous improvements throughout the workplace. Each small change results in a minor improvement. As time passes, these minor improvements add up to significant steps forward in efficiency, quality, safety, and workplace culture.

• Streamline workflow (having our bags capped ready to be sent)
• Improving organization
• Increasing Safety  (barcodes)
• Properly using resources

Is the process of organizing and planning how to divide your time between specific activities

•Lean management is not a short term cost-reduction effort, but more a way of life or culture

•Continuously work to improve their quality measures, minimize waste, and change their set processes to improve efficiency throughout the organization

•Transition must be undertaken as a cultural shift or movement, requiring employee buy-in and encourage them to actively search for areas of improvement within their positions and wheelhouse

Holden, Richard J. “Lean thinking in emergency departments: a critical review.” Annals of emergency medicine 57.3 (2011): 265-278.

Duncan, Ewan, and Ron Ritter. “Next frontiers for lean.” McKinsey Quarterly 2 (2014): 82-89.

Mango, Paul D., and Louis A. Shapiro. “Hospitals get serious about operations.” The McKinsey Quarterly 2 (2001): 74.

The post Episode 32: Lean Thinking & Time Management in Pharmacy With Oscar Santalo appeared first on The Pharm So Hard Podcast.

1. Sodium bicarbonate was previously recommended for hyperkalemia treatment and was once considered a first-line agent for the transcellular shift.
2. Studies evaluating the beneficial effects of sodium bicarbonate used an isotonic infusion commonly  ~ 150 mEq/ 1000ml
3. Hypertonic sodium bicarbonate or “amp of bicarb” has an osmolality of 2000 mOsm, about 7x higher than plasma.
4. There’s controversy as to whether hypertonic sodium bicarbonate is beneficial for the acute treatment of hyperkalemia due to modifications in the mechanism of action.

Is hypertonic sodium bicarbonate used to treat hyperkalemia frequently in your institution ?

1/17
How does calcium "stabilize the cardiac membrane" in hyperkalemia?

I learned early in my intern year to use calcium in the setting of severe hyperkalemia.

I never really learned how it works. The answer requires some history. And uncovers a forgotten alternative treatment. pic.twitter.com/FENJMsUxUh

Aronson PS, Giebisch G. Effects of pH on potassium: new explanations for old observations. J Am Soc Nephrol. 2011;22(11):1981-1989. doi:10.1681/ASN.2011040414

Shingarev R, Allon M. A physiologic-based approach to the treatment of acute hyperkalemia. Am J Kidney Dis. 2010;56(3):578-584. doi:10.1053/j.ajkd.2010.03.014

• Sodium Bicarbonate. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved August 29, 2019, 2018, from http://www.micromedexsolutions.com/
• Gutierrez R et al. Miner Electrolyte Metab. 1991;17(5):297-302. [PMID: 1668124]
• Fraley DSet al. Kidney Int. 1977 Nov;12(5):354-60. [PMID: 24132]
• Blumberg A et al. Am J Med. 1988 Oct;85(4):507-12. [PMID: 3052050]
• Blumberg A et al. Kidney Int. 1992 Feb;41(2):369-74. [PMID: 1552710 ]
• Kim et al. Nephron. 1996;72(3):476-82. [PMID: 8852501]
• Ngugi NN et al. East Afr Med J. 1997 Aug;74(8):503-9. [PMID: 9487416]
• Long B et al. J Emerg Med. 2018 Aug;55(2):192-205. [PMID: 29731287]

The post EPISODE 31: The Beef with Bicarb! The Use of Sodium Bicarbonate in Hyperkalemia with Jimmy Pruitt appeared first on The Pharm So Hard Podcast.

http://www.tamingthesru.com/blog/2020/1/24/hypocalcemia-in-trauma

The post Episode 30: Hypocalcemia Resulting from Trauma & Blood Product Transfusion appeared first on The Pharm So Hard Podcast.

If offered the COVID Vaccine, would you receive it?

• Family
• Friends
• Co-Workers

• Skeptical of
  • The speed at which the vaccine was produced
  • Unfamiliarity with the mRNA Technology used
  • Efficacy in patient-oriented outcomes
  • Safety of the untested vaccine

Who was influencing my thoughts on the vaccine?

Why does it seem like this vaccine is rushed?

How did COVID vaccines develop so quickly?

Has any other vaccine get developed in a short turnaround time?

What steps were “skipped” to make this vaccine become developed?

What are mRNA vaccines and how do they work?

Are these vaccines really effective or are they just another press release?

What outcomes were actually studied?

Are the vaccines safe for me to take?

PFIZER-BIONTECH COVID-19 VACCINE (BNT162, PF-07302048) VACCINES AND RELATED BIOLOGICAL PRODUCTS ADVISORY COMMITTEE BRIEFING DOCUMENT

https://www.fda.gov/media/144246/download

Ghaebi M, Osali A, Valizadeh H, Roshangar L, Ahmadi M. Vaccine development and therapeutic design for 2019-nCoV/SARS-CoV-2: Challenges and chances. J Cell Physiol. 2020;235(12):9098-9109. doi:10.1002/jcp.29771

Wu SC. Progress and Concept for COVID-19 Vaccine Development. Biotechnol J. 2020;15(6):e2000147. doi:10.1002/biot.202000147

Heaton PM. The Covid-19 Vaccine-Development Multiverse. N Engl J Med. 2020;383(20):1986-1988. doi:10.1056/NEJMe2025111

Widge AT, Rouphael NG, Jackson LA, Anderson EJ, Roberts PC, Makhene M, Chappell JD, Denison MR, Stevens LJ, Pruijssers AJ, McDermott AB, Flach B, Lin BC, Doria-Rose NA, O’Dell S, Schmidt SD, Neuzil KM, Bennett H, Leav B, Makowski M, Albert J, Cross K, Edara VV, Floyd K, Suthar MS, Buchanan W, Luke CJ, Ledgerwood JE, Mascola JR, Graham BS, Beigel JH; mRNA-1273 Study Group. Durability of Responses after SARS-CoV-2 mRNA-1273 Vaccination. N Engl J Med. 2020 Dec 3. doi: 10.1056/NEJMc2032195. Epub ahead of print. PMID: 33270381.

Lurie N, Saville M, Hatchett R, Halton J. Developing Covid-19 Vaccines at Pandemic Speed. N Engl J Med. 2020 May 21;382(21):1969-1973. doi: 10.1056/NEJMp2005630. Epub 2020 Mar 30. PMID: 32227757.

Jackson LA, Anderson EJ, Rouphael NG, et al. An mRNA Vaccine against SARS-CoV-2 – Preliminary Report. N Engl J Med. 2020;383(20):1920-1931. doi:10.1056/NEJMoa2022483

Broadbent AJ, Subbarao K. Influenza virus vaccines: lessons from the 2009 H1N1 pandemic. Curr Opin Virol. 2011;1(4):254-262. doi:10.1016/j.coviro.2011.08.002

https://www.cdc.gov/flu/pandemic-resources/2009-pandemic-timeline.html

https://theconversation.com/covid-19-vaccines-were-developed-in-record-time-but-are-these-game-changers-safe-150249

https://www.nbcnews.com/science/science-news/what-mrna-how-pfizer-moderna-tapped-new-tech-make-coronavirus-n1248054

https://news.mit.edu/2020/rna-vaccines-explained-covid-19-1211

https://www.fda.gov/media/144246/download

https://www.nejm.org/doi/10.1056/NEJMoa2034577

Voysey M, Clemens SAC, Madhi SA, Weckx LY, Folegatti PM, Aley PK, Angus B, Baillie VL, Barnabas SL, Bhorat QE, Bibi S, Briner C, Cicconi P, Collins AM, Colin-Jones R, Cutland CL, Darton TC, Dheda K, Duncan CJA, Emary KRW, Ewer KJ, Fairlie L, Faust SN, Feng S, Ferreira DM, Finn A, Goodman AL, Green CM, Green CA, Heath PT, Hill C, Hill H, Hirsch I, Hodgson SHC, Izu A, Jackson S, Jenkin D, Joe CCD, Kerridge S, Koen A, Kwatra G, Lazarus R, Lawrie AM, Lelliott A, Libri V, Lillie PJ, Mallory R, Mendes AVA, Milan EP, Minassian AM, McGregor A, Morrison H, Mujadidi YF, Nana A, O’Reilly PJ, Padayachee SD, Pittella A, Plested E, Pollock KM, Ramasamy MN, Rhead S, Schwarzbold AV, Singh N, Smith A, Song R, Snape MD, Sprinz E, Sutherland RK, Tarrant R, Thomson EC, Török ME, Toshner M, Turner DPJ, Vekemans J, Villafana TL, Watson MEE, Williams CJ, Douglas AD, Hill AVS, Lambe T, Gilbert SC, Pollard AJ; Oxford COVID Vaccine Trial Group. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet. 2020 Dec 8:S0140-6736(20)32661-1. doi: 10.1016/S0140-6736(20)32661-1. Epub ahead of print. PMID: 33306989; PMCID: PMC7723445.

Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, Perez JL, Pérez Marc G, Moreira ED, Zerbini C, Bailey R, Swanson KA, Roychoudhury S, Koury K, Li P, Kalina WV, Cooper D, Frenck RW Jr, Hammitt LL, Türeci Ö, Nell H, Schaefer A, Ünal S, Tresnan DB, Mather S, Dormitzer PR, Şahin U, Jansen KU, Gruber WC; C4591001 Clinical Trial Group. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020 Dec 10. doi: 10.1056/NEJMoa2034577. Epub ahead of print. PMID: 33301246.

Funk CD, Laferrière C, Ardakani A. A Snapshot of the Global Race for Vaccines Targeting SARS-CoV-2 and the COVID-19 Pandemic. Front Pharmacol. 2020 Jun 19;11:937. doi: 10.3389/fphar.2020.00937. PMID: 32636754; PMCID: PMC7317023.

The post Episode 29: I wasn’t going to get the COVID Vaccine until I answered these questions by Jimmy Pruitt appeared first on The Pharm So Hard Podcast.