Vasopressor Discontinuation Order in Septic Shock With Reduced Left Ventricular Function

BACKGROUND

The optimal vasopressor management for septic patients with left ventricular (LV) dysfunction has not been well established, and current evidence is conflicting regarding the optimal vasopressor discontinuation order.

OBJECTIVE

The objective was to evaluate the impact of LV dysfunction on the hemodynamic management of septic shock by assessing the incidence of clinically significant hypotension after vasopressor discontinuation.

METHODS

In this single-center, retrospective cohort study, adult patients were included if they met the Sepsis-3 definition of septic shock, had LV dysfunction (defined as an ejection fraction ≤40%), and received norepinephrine and vasopressin as the last vasopressors discontinued. The primary outcome was the incidence of clinically significant hypotension following discontinuation of vasopressin or norepinephrine. Clinically significant hypotension was defined as a MAP less than 60 mmHg and the need for either: 1) the reinstitution of the previously discontinued agent at any dosage, 2) the receipt of at least 500 mL of a crystalloid at a rate of at least 500 mL/hour, 3) or the receipt of at least 25 grams of albumin 5% at a rate of at least 25 gram/hour. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and ICU and hospital mortality.

RESULTS

A total of 78 patients met inclusion criteria, with 37 patients having vasopressin discontinued first and 41 having norepinephrine discontinued first. Clinically significant hypotension occurred in 28 patients (76%) following the discontinuation of vasopressin, compared to 28 patients (81%) following the discontinuation of norepinephrine (p = 0.61). ICU length of stay was 9 days in the vasopressin discontinued first cohort, compared to 15 days in the norepinephrine discontinued first cohort (p = 0.01). There was no statistically significant difference in mortality observed.

CONCLUSION

The discontinuation order of norepinephrine and vasopressin did not impact the incidence of clinically significant hypotension in patients with septic shock and LV dysfunction, but may influence ICU length of stay, although other factors may have impacted this finding.

Fluid Stewardship of Maintenance Intravenous Fluids

Despite the frequent use of maintenance intravenous fluids (mIVF) in critically ill patients, limited guidance is available. Notably, fluid overload secondary to mIVF mismanagement is associated with significant adverse patient outcomes. The Four Rights (right drug, right dose, right duration, right patient) construct of fluid stewardship has been proposed for the safe evaluation and use of fluids. The purpose of this evidence-based review is to offer practical insights for the clinician regarding mIVF selection, dosing, and duration in line with the Four Rights of Fluid Stewardship.

Medication Regimen Complexity Score as an Indicator of Fluid Balance in Critically Ill Patients

BACKGROUND

Critically ill patients are at increased risk for fluid overload, but objective prediction tools to guide clinical decision-making are lacking. The MRC-ICU scoring tool is an objective tool for measuring medication regimen complexity.

OBJECTIVE

To evaluate the relationship between MRC-ICU score and fluid overload in critically ill patients.

METHODS

In this multi-center, retrospective, observational study, the relationship between MRC-ICU and the risk of fluid overload was examined. Patient demographics, fluid balance at day 3 of ICU admission, MRC-ICU score at 24 hours, and clinical outcomes were collected from the medical record. The primary outcome was relationship between MRC-ICU and fluid overload. To analyze this, MRC-ICU scores were divided into tertiles (low, moderate, high), and binary logistic regression was performed. Linear regression was performed to determine variables associated with positive fluid balance.

RESULTS

A total of 125 patients were included. The median MRC-ICU score at 24 hours of ICU admission for low, moderate, and high tertiles were 9, 15, and 21, respectively. For each point increase in MRC-ICU, a 13% increase in the likelihood of fluid overload was observed (OR 1.128, 95% CI 1.028-1.238, p = 0.011). The MRC-ICU score was positively associated with fluid balance at day 3 (β-coefficient 218.455, 95% CI 94.693-342.217, p = 0.001) when controlling for age, gender, and SOFA score.

CONCLUSIONS

Medication regimen complexity demonstrated a weakly positive correlation with fluid overload in critically ill patients. Future studies are necessary to establish the MRC-ICU as a predictor to identify patients at risk of fluid overload.

A descriptive report of the rapid implementation of automated MRC-ICU calculations in the EMR of an academic medical center

PURPOSE

Numerous clinical scoring tools exist for a variety of patient populations and disease states, but few tools provide information specifically designed for use by critical care pharmacists. The medication regimen complexity-intensive care unit (MRC-ICU) score was designed to provide high-level information about the complexity of critically ill patients' medication regimens for use by critical care pharmacists. To date, implementation of this score in the electronic medical record (EMR) has not been reported.

SUMMARY

Using an agile project management framework, the MRC-ICU score was rapidly implemented into an academic medical center's EMR. The score is automatically calculated for all critically ill patients and is available for critical care pharmacists to triage patient review in their individual workflow. Reporting capabilities of the score also allow for granular complexity trending over time and between units, supplementing other objective measures of pharmacist workload.

CONCLUSION

The MRC-ICU score can be quickly implemented into the EMR for pharmacist use in real time. Future investigations into how pharmacists utilize this information and how to harness reporting capabilities for pharmacist workload assessment are warranted.

Hidden Fluids in Plain Sight: Identifying Intravenous Medication Classes as Contributors to Intensive Care Unit Fluid Intake

Introduction: Fluid stewardship targets optimal fluid management to improve patient outcomes. Intravenous (IV) medications, flushes, and blood products, collectively referred to as hidden fluids, contribute to fluid intake in the intensive care unit (ICU). The impact of specific IV medications on fluid intake is unknown. Objective: Characterize IV medication classes based on contribution to ICU fluid intake by frequency of administration and total volume infused to identify targets for fluid stewardship. Methods: This multi-center, retrospective nested cohort study included patients admitted to a medical or surgical ICU between January 2017 and December 2018. The primary outcome was to identify the volume contribution of specific IV medication classes administered over the first 3 ICU days. Secondary outcomes were the administration frequency of these medications and their proportion of total daily volume intake over the first 3 ICU days. Results: The study included 210 patients. The largest mean administration volumes over the course of the first 3 ICU days were attributed to antibacterials (968 ± 846 mL), vitamins/minerals/electrolytes (416 ± 935 mL), pain/agitation/delirium agents (310 ± 512 mL), and vasoactive agents (282 ± 744 mL). The highest frequencies over the course of the first 3 ICU days were attributed to antibacterials (n = 180; 86%), pain/agitation/delirium agents (n = 143; 68%), vitamins/minerals/electrolytes (n = 123; 59%), and vasoactive agents (n = 96; 46%). IV medications contributed 2601 ± 2573 mL of fluid volume per patient over the first 3 ICU days, accounting for 42% ± 29% of overall volume. Conclusion: IV medications contribute over 40% of total fluid intake within the first 3 days of ICU admission, with antibacterials as top contributors by administration volume and frequency. Future research implementing fluid stewardship to ICU fluid sources, such as concentrating IV medications, switching IV medications to oral formulations, de-escalation of antibacterials, and reduction of maintenance fluids, should be performed to minimize hidden fluids from IV medications.

Medication regimen complexity vs patient acuity for predicting critical care pharmacist interventions

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Quantifying and predicting critical care pharmacist (CCP) workload has significant ramifications for expanding CCP services that improve patient outcomes. Medication regimen complexity has been proposed as an objective, pharmacist-oriented metric that demonstrates relationships to patient outcomes and pharmacist interventions. The purpose of this evaluation was to compare the relationship of medication regimen complexity versus a traditional patient acuity metric for evaluating pharmacist interventions.

SUMMARY

This was a post hoc analysis of a previously completed prospective, observational study. Pharmacist interventions were prospectively collected and tabulated at 24 hours, 48 hours, and intensive care unit (ICU) discharge, and the electronic medical record was reviewed to collect patient demographics, medication data, and outcomes. The primary outcome was the relationship between medication regimen complexity-intensive care unit (MRC-ICU) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and pharmacist interventions at 24 hours, 48 hours, and ICU discharge. These relationships were determined by Spearman rank-order correlation (rS) and confirmed by calculating the beta coefficient (β) via multiple linear regression adjusting for patient age, gender, and admission type. Data on 100 patients admitted to a mixed medical/surgical ICU were retrospectively evaluated. Both MRC-ICU and APACHE II scores were correlated with ICU interventions at all 3 time points (at 24 hours, rS = 0.370 [P < 0.001] for MRC-ICU score and rS = 0.283 [P = 0.004] for APACHE II score); however, this relationship was not sustained for APACHE II in the adjusted analysis (at 24 hours, β = 0.099 [P = 0.001] for MRC-ICU and β = 0.031 [P = 0.085] for APACHE II score).

CONCLUSION

A pharmacist-oriented score had a stronger relationship with pharmacist interventions as compared to patient acuity. As pharmacists have demonstrated value across the continuum of patient care, these findings support that pharmacist-oriented workload predictions require tailored metrics, beyond that of patient acuity.

Beta-Adrenergic Blockade in Critical Illness

Catecholamine upregulation is a core pathophysiological feature in critical illness. Sustained catecholamine β-adrenergic induction produces adverse effects relevant to critical illness management. β-blockers (βB) have proposed roles in various critically ill disease states, including sepsis, trauma, burns, and cardiac arrest. Mounting evidence suggests βB improve hemodynamic and metabolic parameters culminating in decreased burn healing time, reduced mortality in traumatic brain injury, and improved neurologic outcomes following cardiac arrest. In sepsis, βB appear hemodynamically benign after acute resuscitation and may augment cardiac function. The emergence of ultra-rapid βB provides new territory for βB, and early data suggest significant improvements in mitigating atrial fibrillation in persistently tachycardic septic patients. This review summarizes the evidence regarding the pharmacotherapeutic role of βB on relevant pathophysiology and clinical outcomes in various types of critical illness.

Avoiding cost avoidance

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Time to blood, respiratory and urine culture positivity in the intensive care unit: Implications for de-escalation

Objectives

Concern for late detection of bacterial pathogens is a barrier to early de-escalation efforts. The purpose of this study was to assess blood, respiratory and urine culture results at 72 h to test the hypothesis that early negative culture results have a clinically meaningful negative predictive value.

Methods

We retrospectively reviewed all patients admitted to the medical intensive care unit between March 2012 and July 2018 with blood cultures obtained. Blood, respiratory and urine culture results were assessed for time to positivity, defined as the time between culture collection and preliminary species identification. The primary outcome was the negative predictive value of negative blood culture results at 72 h. Secondary outcomes included sensitivity, specificity, positive predictive value and negative predictive value of blood, respiratory and urine culture results.

Results

The analysis included 1567 blood, 514 respiratory and 1059 urine cultures. Of the blood, respiratory and urine cultures ultimately positive, 90.3%, 76.2% and 90.4% were positive at 72 h. The negative predictive value of negative 72-h blood, respiratory and urine cultures were 0.99, 0.82 and 0.97, respectively. Antibiotic de-escalation had good specificity, positive predictive value and negative predictive value for finalized negative cultures.

Conclusion

Negative blood and urine culture results at 72 h had a high negative predictive value. These findings have important ramifications for antimicrobial stewardship efforts and support protocolized re-evaluation of empiric antibiotic therapy at 72 h. Caution should be used in patients with clinically suspected pneumonia, since negative respiratory culture results at 72 h were weakly predictive of finalized negative cultures.

Assessment of Electrolyte Replacement in Critically Ill Patients During a Drug Shortage

Purpose: The purpose of this study was to determine if national drug shortages of electrolyte replacement products negatively impact patient care. Methods: This study was a single-center, retrospective, observational cohort of adults admitted to the medical, surgical, or trauma intensive care unit (ICU) that were ordered or would have qualified for the general or continuous renal replacement therapy electrolyte replacement protocol (ERP) between April 2017 and August 2018. In October 2017, ERP use was suspended and enteral replacement was promoted due to inability to maintain consistent inventory of intravenous replacement products. The primary objective was to compare the percentage of patient days that at least 1 critically low value of potassium, magnesium, and/or phosphorus existed between protocolized and nonprotocolized electrolyte replacement. Secondary objectives included characterizing the ratio of enteral replacement to duration of critically low electrolyte values during protocolized and nonprotocolized electrolyte replacement. Results: A total of 288 patients were included. The mean percentage of ICU days with low electrolyte levels in the protocolized period was significantly higher than in the nonprotocolized period (21.4% vs 17.5%, P = .0238). There was a negative relationship between the total electrolyte replacement that was given enterally and the percentage of patient days with critically low values indicating that as enteral replacement increased, percentage of days with low values decreased. The association between percentage of enteral replacement and days with critically low electrolyte values was significantly lower in the protocolized period. Conclusion: Intravenous electrolyte replacement product shortages did not result in an increased incidence of critically low electrolyte values. Enteral replacement was associated with a decreased incidence of low electrolyte values.

Effects of Propofol on Hemodynamic Profile in Adults Receiving Targeted Temperature Management

Background: Propofol is a key component for the management of sedation and shivering during targeted temperature management (TTM) following cardiac arrest. The cardiac depressant effects of propofol have not been described during TTM and may be especially relevant given the stress to the myocardium following cardiac arrest. The purpose of this study is to describe hemodynamic changes associated with propofol administration during TTM. Methods: This single center, retrospective cohort study evaluated adult patients who received a propofol infusion for at least 30 minutes during TTM. The primary outcome was the change in cardiovascular Sequential Organ Failure Assessment (cvSOFA) score 30 minutes after propofol initiation. Secondary outcomes included change in systolic blood pressure (SBP), mean arterial pressure (MAP), heart rate (HR), and vasopressor requirements (VR) expressed as norepinephrine equivalents at 30, 60, 120, 180, and 240 minutes after propofol initiation. A multivariate regression was performed to assess the influence of propofol and body temperature on MAP, while controlling for vasopressor dose and cardiac arrest hospital prognosis (CAHP) score. Results: The cohort included 40 patients with a median CAHP score of 197. The goal temperature of 33°C was achieved for all patients. The median cvSOFA score was 1 at baseline and 0.5 at 30 minutes, with a non-significant change after propofol initiation ( P = .96). SBP and MAP reductions were the greatest at 60 minutes (17 and 8 mmHg; P < .05 for both). The median change in HR at 120 minutes was −9 beats/minute from baseline. This reduction was sustained through 240 minutes ( P < .05). No change in VR were seen at any time point. In multivariate regression, body temperature was the only characteristic independently associated with changes in MAP (coefficient 4.95, 95% CI 1.6-8.3). Conclusion: Administration of propofol during TTM did not affect cvSOFA score. The reductions in SBP, MAP, and HR did not have a corresponding change in vasopressor requirements and are likely not clinically meaningful. Propofol appears to be a safe choice for sedation in patients receiving targeted temperature management after cardiac arrest.

Productivity Tracking: A Survey of Critical Care Pharmacist Practices and Satisfaction

Introduction: The position paper on critical care pharmacy services describes two tiers of responsibilities: essential and desirable activities. Activities are categorized into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Documentation of these activities can be important for justifying pharmacist positions, comparing pharmacy practice models, conducting performance evaluations, and tracking individual workload; however, limited recommendations are provided for standardized productivity tracking, and national practices remain largely uncharacterized. Objectives: The purpose of this survey was to describe documentation practices of critical care pharmacist activities. Methods: A cross-sectional survey was distributed via email to 1694 members of the ACCP critical care practice research network. The survey asked respondents to describe the methods used to document productivity as it relates to the 5 domains. Results: Seventy-nine (4.7%) critical care pharmacists from 63 institutions completed the survey. Intervention documentation was used for position justification and annual reviews among 54.4% and 44.1% of pharmacists, respectively. Pharmacists were routinely expected to perform additional responsibilities beyond patient care that contribute to overall productivity, but the percentage of institutions that track these activities as a measure of pharmacist productivity was relatively low: quality improvement (46%), research/scholarship (29%), training/education (38%), and professional development (27%). Documentation of these additional responsibilities and activities was primarily used for annual evaluations, but the majority of respondents answered that no standardized method for tracking activities existed. In multivariate regression, dedicated ICU pharmacists was a significant predictor for increased satisfaction (Exp(ß) 4.498, 95% CI 1.054-19.187, P = .042). Conclusion: Practice variation exists in how and for what intent critical care pharmacists track productivity. Further evaluation and standardization of productivity tracking may aid in position justification and practice model evaluation for dedicated ICU pharmacists in today’s value-based era.

Cisatracurium attenuates LPS-induced modulation of MMP3 and junctional protein expression in human microvascular endothelial cells

Acute respiratory distress syndrome (ARDS) is a life-threatening form of acute lung injury (ALI) associated with hypoxemic lung damage and inflammation. Matrix metalloproteinase protein-3 (MMP3 or Stromelysin-1) is known to promote vascular injury in ALI/ARDS. Cisatracurium, a nicotinic neuromuscular blocker, is used in ARDS patients to decrease mechanical ventilator dyssynchrony, increase oxygenation, and improve mortality. However, the magnitude and the underlying mechanisms of these potential benefits of cisatracurium remains unclear. We investigated the effect of cisatracurium on lipopolysaccharide-induced MMP3 expression in human microvascular endothelial cells. In our results, cisatracurium treatment significantly decreased LPS-induced MMP3 expression and increased expression of cell junction proteins such as vascular endothelial cadherin (VE-cadherin) and claudin-5.

Medication Regimen Complexity Score as an Indicator of Fluid Balance in Critically Ill Patients

BACKGROUND

Critically ill patients are at increased risk for fluid overload, but objective prediction tools to guide clinical decision-making are lacking. The MRC-ICU scoring tool is an objective tool for measuring medication regimen complexity.

OBJECTIVE

To evaluate the relationship between MRC-ICU score and fluid overload in critically ill patients.

METHODS

In this multi-center, retrospective, observational study, the relationship between MRC-ICU and the risk of fluid overload was examined. Patient demographics, fluid balance at day 3 of ICU admission, MRC-ICU score at 24 hours, and clinical outcomes were collected from the medical record. The primary outcome was relationship between MRC-ICU and fluid overload. To analyze this, MRC-ICU scores were divided into tertiles (low, moderate, high), and binary logistic regression was performed. Linear regression was performed to determine variables associated with positive fluid balance.

RESULTS

A total of 125 patients were included. The median MRC-ICU score at 24 hours of ICU admission for low, moderate, and high tertiles were 9, 15, and 21, respectively. For each point increase in MRC-ICU, a 13% increase in the likelihood of fluid overload was observed (OR 1.128, 95% CI 1.028-1.238, p = 0.011). The MRC-ICU score was positively associated with fluid balance at day 3 (β-coefficient 218.455, 95% CI 94.693-342.217, p = 0.001) when controlling for age, gender, and SOFA score.

CONCLUSIONS

Medication regimen complexity demonstrated a weakly positive correlation with fluid overload in critically ill patients. Future studies are necessary to establish the MRC-ICU as a predictor to identify patients at risk of fluid overload.

Scholastic synergy: A team prototype for pharmacy faculty engagement in education, research, and service

INTRODUCTION

Many clinical faculty members are challenged by competing factors of scholarly productivity, education, service obligations, and patient care. A team-based approach has the potential to synergistically increase productivity and mitigate factors associated with burnout.

METHODS

The purpose of this report is to discuss a prototype for a small, team-based, practice-oriented collaborative approach to advancing critical care pharmacy practice through research and education. Productivity was evaluated in the areas of scholarship and teaching.

RESULTS

This team was formed in 2017 and includes five critical care faculty across four campuses from a single academic institution. This collaborative has published peer-reviewed articles, secured grant funding, and developed novel teaching modalities.

CONCLUSIONS

Challenges encountered include timeline adherence, development of uniform data collection processes, clarifying roles and expectations for different projects, and authorship. This team may act as a prototype for clinical faculty teams to enhance engagement and scholarship productivity in a practice-based setting.

An Argument for the Development of Ultra-Localized Antibiograms for Resistant Pathogens

The importance of intensive care unit (ICU)–specific antibiograms has not been well established but may have key patient care implications if resistance rates are significantly different between the institution and a specific ICU location. Here, we argue that institutions should investigate and develop ultra-localized antibiograms for each ICU, especially for multi-drug resistant organisms.

Pharmacological Inhibition of MMP3 as a Potential Therapeutic Option for COVID-19 Associated Acute Respiratory Distress Syndrome

The high mortality of coronavirus disease 2019 (COVID-19) patients is due to their progression to cytokine-associated organ injuries, primarily the acute respiratory distress syndrome (ARDS). The uncertainties in the molecular mechanisms leading to the switch from the early virus infection to the advanced stage ARDS is a major gridlock in therapeutic development to reduce mortality. Previous studies in our laboratory have identified matrix metalloprotease-3 (MMP3) as an important mediator of bacterial lipopolysaccharide (LPS)-induced ARDS, particularly in the exudative phase. Our studies have also reported elevated plasma MMP3 activity levels in the ARDS patients and that inhibition of MMP3 can reduce the severity of LPS-induced ARDS in mice. Given these observations, targeting MMP3 could be a potential option to treat COVID-19 patients with ARDS, and measurement of MMP3 activity in the plasma may serve as a biomarker for the early detection of ARDS in COVID-19 patients.

Association of hidden fluid administration with development of fluid overload reveals opportunities for targeted fluid minimization

Background

Fluid overload is associated with poor outcomes, but mitigating its occurrence poses significant challenges.

Objective

This study sought to assess the impact of hidden fluid volume on fluid overload.

Methods

This study was a multi-center, retrospective evaluation of adults admitted to a medical or surgical intensive care unit for at least 72 h. Patients were divided into tertiles (low, moderate, and high) based on the hidden fluid volume received. Hidden fluids were defined as intravenous medications, line flushes, blood products, and enteral nutrition. The primary outcome was the incidence of fluid overload at intensive care unit (day 3). Secondary outcomes included mechanical-ventilation free days and association of hidden fluid volume with fluid overload, length of stay, and mortality.

Results

A total of 219 (73 per tertile) were included, with hidden fluid volume comprising ⩽2500, 2501-4400, and >4400 mL in the low, moderate, and high tertiles, respectively. Incidence of fluid overload was significantly different across groups (low: 3%, moderate: 14%, high: 25%; p < 0.001). No difference existed in mechanical-ventilation free days or in-hospital mortality across tertiles. In binary logistic regression, hidden fluid volume received at 3 days was independently associated with fluid overload (odds ratio = 1.40, 95% confidence interval = 1.15-1.70).

Conclusion

The volume of hidden fluid volume administered by intensive care unit day 3 independently predicted development of fluid overload.

Twelve Tips for Synergistic Delivery of Remote Advanced Pharmacy Practice Experience Rotations

This article was migrated. The article was marked as recommended. In response to the COVID-19 pandemic, many institutions changed their staffing models to incorporate remote work which created a need for pharmacy faculty and preceptors to also shift their rotation experience to a remote format. While initially this may be a daunting task, remote experiences have the potential to equip students with unique skillsets while offering a mutually beneficial effort towards patient care and/or other responsibilities. In addition, these remote experiences can offer students a more customized rotation and a behind the scenes look at the preceptor's career. This article provides 12 tips for developing a remote learning experience.

Pharmacist perceptions of CliftonStrengths® themes important for success in advanced cardiovascular life support

WHAT IS KNOWN AND OBJECTIVE

Advanced Cardiovascular Life Support (ACLS) is an integrated, team-based approach to optimizing patient outcomes during acute cardiovascular events. Due to the fast-paced, high-stress environment, inherent strengths may impact performance and confidence with ACLS skills. The objective of this study was to assess pharmacist perceptions regarding strengths deemed important during emergency cardiovascular response.

METHODS

An electronic survey was administered to members of the American College of Clinical Pharmacists Critical Care, Cardiology, Internal Medicine, Emergency Medicine and Pediatrics Practice and Research Network listservs. The survey assessed the top 5 strengths deemed important for being part of an emergency response team, a pharmacist's role in ACLS and a team leader's role in ACLS. The primary outcome was top strengths required for pharmacist involvement in ACLS. Descriptive statistics were used to present survey results.

RESULTS

Of the 359 responses included, nearly all respondents had been certified by the American Heart Association in ACLS and/or Pediatric Advanced Life Support (PALS). The top CliftonStrengths^® themes considered important for a pharmacist's role in ACLS were communication, adaptability, analytical, focus and responsibility. The top CliftonStrengths^® themes considered important for the team leader's role in ACLS were communication, command, analytical, focus and adaptability. The top CliftonStrengths^® themes important for an emergency response team were communication, adaptability, focus, analytical and command.

WHAT IS NEW AND CONCLUSIONS

By determining the personality traits perceived to be associated with high performance in ACLS, approaches can be taken to personalize student learning in order to train "practice-ready" pharmacists that can be integral members of the ACLS team.

Development of Machine Learning Models to Validate a Medication Regimen Complexity Scoring Tool for Critically Ill Patients

INTRODUCTION

The Medication Regimen Complexity -Intensive Care Unit (MRC-ICU) is the first tool for measuring medication regimen complexity in critically ill patients. This study tested machine learning (ML) models to investigate the relationship between medication regimen complexity and patient outcomes.

METHODS

This study was a single-center, retrospective observational evaluation of 130 adults admitted to the medical ICU. The MRC-ICU score was utilized to improve the inpatient model's prediction accuracy. Three models were proposed: model I, demographic data without medication data; model II, demographic data and medication regimen complexity variables; and model III: demographic data and the MRC-ICU score. A total of 6 ML classifiers was developed: k-nearest neighbor (KNN), naïve Bayes (NB), random forest, support vector machine, neural network, and logistic classifier (LC). They were developed and tested using electronic health record data to predict inpatient mortality.

RESULTS

The results demonstrated that adding medication regimen complexity variables (model II) and the MRC-ICU score (model III) improved inpatient mortality prediction.. The LC outperformed the other classifiers (KNN and NB), with an overall accuracy of 83%, sensitivity (Se) of 87%, specificity of 67%, positive predictive value of 93%, and negative predictive value of 46%. The APACHE III score and the MRC-ICU score at the 24-hour interval were the 2 most important variables.

CONCLUSION AND RELEVANCE

Inclusion of the MRC-ICU score improved the prediction of patient outcomes on the previously established APACHE III score. This novel, proof-of-concept methodology shows promise for future application of the MRC-ICU scoring tool for patient outcome predictions.

Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features

Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.

Teaching research skills to student pharmacists: A multi-campus, multi-semester applied critical care research elective

BACKGROUND AND PURPOSE

Research electives are commonly offered in doctor of pharmacy programs but are typically limited to one faculty member mentoring individual students at a single site for a semester long self-study experience. The purpose of this paper is to describe pharmacy student experiences and perceptions of the research process after completing a multi-campus, multi-investigator critical care research elective.

EDUCATIONAL ACTIVITY AND SETTING

The Research in Critical Care Pharmacotherapy elective was launched in spring 2019 and implemented a novel approach to the pharmacy research elective that promoted collaborative research across four campuses that may be continued for up to four semesters of credit.

FINDINGS

Six second- and third-year doctor of pharmacy students enrolled in the course during the first offering. Three students were located on the main campus with one student on each of the extended campuses. Students completed a median of five unique research activities with at least one student participating in 15 of the 19 activities evaluated. Students were asked to complete a pre- and post-course survey assessing perceived research abilities using the Dreyfus model. There was a significant decrease in the number of novice responses in the post-course survey (pre- 10 vs. post- 2, p = 0.043).

SUMMARY

A multi-campus, multi-investigator critical care research elective provided broad research experiences and increased student confidence related to numerous research skills.

Characterization of changes in medication complexity using a modified scoring tool

PURPOSE

The purpose of this study was to characterize dynamic changes in medication regimen complexity over time in critically ill adults and to validate a modified version of the medication regimen complexity-intensive care unit (MRC-ICU) scoring tool.

SUMMARY

A single-center, retrospective, observational chart review was conducted with a primary aim of assessing changes in medication regimen complexity over time, as measured by both the 39-item MRC-ICU scoring tool and a modified version (the mMRC-ICU) containing just 17 items. Secondary aims included validation of the mMRC-ICU and exploration of relationships between medication regimen complexity and ICU length of stay (LOS), inpatient mortality, and patient acuity. Adults admitted to a medical ICU from November 2016 through June 2017 were included. The medication regimens of a total of 130 patients were scored in order to test, modify, and validate the MRC-ICU and mMRC-ICU tools. The modified tool was validated by evaluating correlation of mMRC-ICU scores with MRC-ICU scores and with patient outcomes including patient acuity, ICU LOS, and inpatient mortality. mMRC-ICU scores were collected at 24 and 48 hours after admission and at ICU discharge to evaluate changes over time. Significant changes in medication regimen complexity over time were observed, with the highest scores observed at 24 hours after admission.

CONCLUSION

Medication regimen complexity may provide valuable insights into pharmacist activity and resource allocation. Further validation of the MRC-ICU and mMRC-ICU scoring tools in other critically ill populations and at external sites is required.

Patients with acute respiratory distress syndrome exhibit increased stromelysin1 activity in the blood samples

Enzyme activity analyses in the blood are expected to be reliable, non-invasive diagnostic as well as prognostic markers to reflect disease progression in acute lung injury (ALI). The objective of the current study was to evaluate the enzymatic activity of stromelysin1 (matrix metalloprotease-3) in the plasma/serum samples collected from ALI patients compared to the samples collected from healthy controls. Gene expression omnibus (GEO) database analysis indicated a correlation between increased stromelysin1 gene expression and the incidence of ALI in various animal models. Our analysis of patient plasma/serum samples from healthy controls and ALI patients revealed a significant, 3-fold increase in stromelysin1 activity in ALI plasma/serum compared to healthy subjects with no difference in stromelysin1 activity between the serum and plasma samples. Interestingly, no significant difference in stromelysin1 activity between non-smoking and smoking subjects was observed. These findings provide fundamental information on the potential reliability of stromelysin1 activity analysis, combined with other biomarkers in development, in blood samples for the early detection of ALI.

Multicenter validation of a novel medication-regimen complexity scoring tool

BACKGROUND

The MRC-ICU, a novel regimen complexity scoring tool, provides an objective measure of medication regimen complexity in critically ill patients. The MRC-ICU may have the ability to evaluate the impact of critical care pharmacists on patient outcomes but requires further validation. The objective of this study was to confirm the external validity of the MRC-ICU scoring tool at multiple institutions and intensive care unit (ICU) settings.

METHODS

This was a multicenter, prospective, observational study. The electronic medical record was reviewed to collect patient demographics and patient outcomes, and the medication administration record was reviewed to collect MRC-ICU scores at 24 hours, 48 hours, and ICU discharge. Validation was performed by assessing convergent and divergent validity of the score. Spearman rank-order correlation was used to determine correlation.

RESULTS

A total of 230 patients were evaluated across both centers in both medical ICUs and surgical ICUs. Differences between the original center and the new site included that total number of orders (29 vs 126; P < 0.001) and total number of medication orders (17 vs 36; P < 0.001) were higher at the new site, whereas the original site had higher overall MRC-ICU scores (14 vs 11; P = 0.004). The MRC-ICU showed appropriate convergent validity with number of orders and medication orders (all P < 0.001) and appropriate divergent validity with no significant correlation found between age, weight, or gender (all P > 0.05).

CONCLUSIONS

External validity of the MRC-ICU has been confirmed through evaluation at an external site and in the surgical ICU population. The MRC-ICU scoring tool requires prospective evaluation to provide objective data regarding optimal pharmacist use.

Development and validation of a medication regimen complexity scoring tool for critically ill patients

PURPOSE

The purpose of this study was to develop and validate a novel medication regimen complexity-intensive care unit (MRC-ICU) scoring tool in critically ill patients and to correlate MRC with illness severity and patient outcomes.

METHODS

This study was a single-center, retrospective observational chart review of adults admitted to the medical ICU (MICU) between November 2016 and June 2017. The primary aim was the development and internal validation of the MRC-ICU scoring tool. Secondary aims included external validation of the MRC-ICU and exploration of relationships between medication regimen complexity and patient outcomes. Exclusion criteria included a length of stay of less than 24 hours in the MICU, active transfer, or hospice orders at 24 hours. A total of 130 patient medication regimens were used to test, modify, and validate the MRC-ICU tool.

RESULTS

The 39-line item medication regimen complexity scoring tool was validated both internally and externally. Convergent validity was confirmed with total medications (p < 0.0001). Score discriminant validity was confirmed by lack of association with age (p = 0.1039) or sex (p = 0.7829). The MRC-ICU score was significantly associated with ICU length of stay (p = 0.0166), ICU mortality (p = 0.0193), and patient acuity (p < 0.0001).

CONCLUSION

The MRC-ICU scoring tool was validated and found to correlate with length of stay, inpatient mortality, and patient acuity.

Therapeutic Anticoagulation With an Ultra-Low Concentration Argatroban-Based Purge Solution for Percutaneous Ventricular Assist Device in Patient With Heparin-Induced Thrombocytopenia

Purpose/Background: Percutaneous left ventricular assist devices (pVADs) require a continuous purge solution containing heparin to prevent pump thrombosis and device failure. Data regarding alternative options in patients who have suspected heparin-induced thrombocytopenia (HIT) are limited. Methods: In this report, we describe a 68-year-old white man with cardiogenic shock with an Impella CP device managed with a low concentration argatroban-based purge solution secondary to a suspected diagnosis of HIT. Results: The purge solution was initiated as argatroban in dextrose 10% at a concentration of 0.12 mg/mL and was subsequently decreased twice to 0.06 and 0.015 mg/mL based on the patient's clinical course. Conclusions: This case report describes the safe and effective use of argatroban purge solution necessary for anticoagulation although further studies are needed to confirm these findings.

Prescribing of Pressor Agents in Septic Shock: A Survey of Critical Care Pharmacists

Background: Pressor agents are recognized as high-alert medications by the Institute for Safe Medication Practices, but little evidence is available to guide their use in septic shock. Objective: Characterize the use of pressor agents for septic shock in clinical practice. Methods: A cross-sectional electronic survey assessing demographics, institutional practices, and respondent perceptions related to pressor agents was distributed to the American College of Clinical Pharmacy Critical Care Practice and Research Network. The primary outcome was the use of a weight-based dosing (WBD) strategy versus non-WBD strategy for norepinephrine. Descriptive statistics were used to summarize survey results. Binary logistic regression was performed to determine variables associated with dosing strategies. Results: The survey was completed by 223 respondents. The typical respondent worked in a medical or mixed intensive care unit at a teaching hospital and had training and/or board certification beyond the Doctor of Pharmacy degree. Nearly all respondents (n = 221, 99%) reported norepinephrine as the first-line vasopressor for septic shock; however, 38% used WBD and 60% used non-WBD. In logistic regression, respondents located in the South and practicing at institutions with larger numbers of intensive care unit beds were more likely to use WBD for norepinephrine infusions. Similar findings were observed with epinephrine and phenylephrine. Conclusion: Wide variability exists in prescribing patterns of pressor agents and in pharmacist perceptions regarding best practices. The use of WBD varied based on institutional characteristics and resulted in higher maximum allowable infusion rates of pressor agents. Future research should compare dosing strategies to identify associations with patient outcomes.

Pharmacy Student Performance in a Capstone Course Utilizing the Pharmacists' Patient Care Process

Objective. To develop, implement, and assess student performance and confidence in a pharmacy capstone course that used case-based instruction and the Pharmacist's Patient Care Process (PPCP) to develop patient work-up skills in third-year Doctor of Pharmacy (PharmD) students. Methods. A skills-based capstone course was developed by a team of faculty members and instructional designers that focused on patient evaluation skills and applying the steps of the PPCP to complex patient cases housed in a simulated electronic health record (SEHR). The acuity of the cases increased over the course of the semester. For each patient case, students were expected to identify drug-related problems and develop an assessment and plan based on the information provided in the SEHR. Results. Students (n=134) were assessed through weekly quizzes and two practical examinations. The average score for all quizzes was 81%. A significant correlation was found between average quiz scores and performance on the end-of-course practical examination. Student scores significantly improved from the first to the second practical examination (10.4 vs 12.9, respectively), and student confidence with regard to all course objectives significantly improved from the beginning to the end of the semester. Conclusion. A capstone course that applied the PPCP framework successfully taught third-year PharmD students the patient care skills they would need in advanced pharmacy practice experiences.

Fluid Stewardship During Critical Illness: A Call to Action

Intravenous fluids (IVFs) are the most common drugs administered in the intensive care unit. Despite the ubiquitous use, IVFs are not benign and carry significant risks associated with under- or overadministration. Hypovolemia is associated with decreased organ perfusion, ischemia, and multi-organ failure. Hypervolemia and volume overload are associated with organ dysfunction, delayed liberation from mechanical ventilation, and increased mortality. Despite appropriate provision of IVF, adverse drug effects such as electrolyte abnormalities and acid-base disturbances may occur. The management of volume status in critically ill patients is both dynamic and tenuous, a process that requires frequent monitoring and high clinical acumen. Because patient-specific considerations for fluid therapy evolve across the continuum of critical illness, a standard approach to the assessment of fluid needs and prescription of IVF therapy is necessary. We propose the principle of "fluid stewardship," guided by 4 rights of medication safety: right patient, right drug, right route, and right dose. The successful implementation of fluid stewardship will aid pharmacists in making decisions regarding IVF therapy to optimize hemodynamic management and improve patient outcomes. Additionally, we highlight several areas of focus for future research, guided by the 4 rights construct of fluid stewardship.

Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety

OBJECTIVE

To review the efficacy and safety of perioperative administration of intravenous (IV) antiplatelet agents as a substitute for oral P2Y₁₂ inhibitors and to provide clinicians guidance on optimal and cost-effective use of these medications.

DATA SOURCES

A MEDLINE literature search (1950 to November 2018) was performed using the key search terms abciximab, bridging, cangrelor, cardiac surgery, coronary artery bypass surgery, eptifibatide, intravenous antiplatelet agent, and tirofiban. Additional references were identified from a review of literature citations.

STUDY SELECTION AND DATA EXTRACTION

In all, 18 original research reports and case reports/series were included in the review.

DATA SYNTHESIS

Prevention of postoperative bleeding is critical to decrease morbidity and mortality after cardiac surgery. IV antiplatelet medications have short half-lives and are frequently used to substitute for oral P2Y₁₂ inhibitors to allow platelet function recovery before procedures. Functional recovery of platelets is delayed after abciximab discontinuation and increases postoperative bleeding risk. Eptifibatide and tirofiban have similar pharmacokinetic/pharmacodynamic properties and comparable efficacy and safety in the setting of perioperative bridging. Cangrelor may be considered in patients with renal insufficiency as decreased clearance of eptifibatide or tirofiban may increase the risk of postoperative bleeding. Relevance to Patient Care and Clinical Practice: Comparative studies of IV antiplatelet medications have not been published. Appropriate use of IV antiplatelet medications can prevent perioperative ischemic events and bleeding.

CONCLUSIONS

Eptifibatide, tirofiban, and cangrelor are preferred over abciximab as a perioperative bridge. The choice of agent should be tailored to clinical characteristics of the patient and institutional acquisition costs.

Anticoagulation of a Percutaneous Left Ventricular Assist Device Using a Low-Dose Heparin Purge Solution Protocol: A Case Series

Background

Impella CP® is a percutaneous left ventricular assist device that requires a heparin–dextrose purge solution. The manufacturer recommends heparin 50 units/mL, but supratherapeutic anticoagulation has been observed with this concentration.

Objective

The purpose of this evaluation was to observe the efficacy and safety of a low-dose heparin-based purge solution (25 units/mL in dextrose 20%). The primary outcome evaluated percentage of activated clotting times (ACTs) below therapeutic range. Secondary objectives included evaluating the incidence of device thrombosis and rate of heparin-induced thrombocytopenia (HIT). Platelet trends were characterized.

Methods

A single-site retrospective review was conducted for all adults with the Impella CP from January 2015 to December 2017.

Results

A total of 18 patients were included. The percentage of ACT readings within goal of 160 to 200 seconds was 49%, and 38% of readings were subtherapeutic. Per BARC bleeding criteria, 22% (n = 4) patients experienced class IIIa bleeding and 39% (n = 7) experienced class II bleeding. Though 4 (22%) patients were tested for HIT, no patients were positive. Patients showed universal reductions in platelet counts.

Conclusions

The use of a low-dose anticoagulation protocol of heparin 25 units/mL in dextrose 20% as needed warrants further evaluation.

Complications and Pharmacologic Interventions of Invasive Positive Pressure Ventilation During Critical Illness

Objective: To review the fundamentals of invasive positive pressure ventilation (IPPV) and the common complications and associated pharmacotherapeutic management in order to provide opportunities for pharmacists to improve patient outcomes. Data Sources: A MEDLINE literature search (1950-December 2017) was performed using the key search terms invasive positive pressure ventilation, mechanical ventilation, pharmacist, respiratory failure, ventilator associated organ dysfunction, ventilator associated pneumonia, ventilator bundles, and ventilator liberation. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language original research and review reports were evaluated. Data Synthesis: IPPV is a common supportive care measure for critically ill patients. While lifesaving, IPPV is associated with significant complications including ventilator-associated pneumonia, sinusitis, organ dysfunction, and hemodynamic alterations. Optimization of pain and sedation management provides an opportunity for pharmacists to directly affect IPPV exposure. A number of pharmacotherapeutic interventions are related directly to prophylaxis against IPPV-associated adverse events or aimed at reduction of duration of IPPV. Conclusions: Enhanced knowledge of the common complications, associated pharmacotherapy, and monitoring strategies facilitate the pharmacist's ability to provide increased pharmacotherapeutic insight in a multidisciplinary intensive care unit setting.