1
|
Chudow MB, Condeni MS, Dhar S, Heavner MS, Nei AM, Bissell BD. Current Practice Review in the Management of Acute Respiratory Distress Syndrome. J Pharm Pract 2023; 36:1454-1471. [PMID: 35728076 DOI: 10.1177/08971900221108713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) presents as an acute inflammatory lung injury characterized by refractory hypoxemia and non-cardiac pulmonary edema. An estimated 10% of patients in the intensive care unit and 25% of those who are mechanically ventilated are diagnosed with ARDS. Increased awareness is warranted as mortality rates remain high and delays in diagnosing ARDS are common. The COVID-19 pandemic highlights the importance of understanding ARDS management. Treatment of ARDS can be challenging due to the complexity of the disease state and conflicting existing evidence. Therefore, it is imperative that pharmacists understand both pharmacologic and non-pharmacologic treatment strategies to optimize patient care. This narrative review provides a critical evaluation of current literature describing management practices for ARDS. A review of treatment modalities and supportive care strategies will be presented.
Collapse
Affiliation(s)
- Melissa B Chudow
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
| | - Melanie S Condeni
- MUSC College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Sanjay Dhar
- Pulmonary Critical Care Ultrasound and Research, Pulmonary and Critical Care Fellowship Program, Division of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky, Lexington, KY, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Andrea M Nei
- Mayo Clinic College of Medicine & Science, Critical Care Pharmacist, Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brittany D Bissell
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
2
|
Bissell BD, Wieruszewski PM, Newsome AS, Verkerk BS, Witenko CJ, Ammar MA, Magee C, Pajoumand M, Condeni MS, Hammond DA. Fluid management and deresuscitation practices - An opportunity for collaboration. J Intensive Care Soc 2023; 24:24-26. [PMID: 37928092 PMCID: PMC10621518 DOI: 10.1177/1751143720934386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
- Brittany D Bissell
- Department of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine University of Kentucky, Lexington, KY, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY,USA
| | | | - Andrea S Newsome
- Clinical and Administrative Pharmacy, College of Pharmacy, The University of Georgia, Augusta, GA, USA
| | | | - Corey J Witenko
- New York-Presbyterian Hospital/ Weill Cornell Medical Center, New York, NY, USA
| | | | - Carolyn Magee
- Medical University of South Carolina, Charleston, SC, USA
| | - Mehrnaz Pajoumand
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Drayton A Hammond
- Rush University Medical Center, Chicago, IL, USA
- Department of Internal Medicine, Rush Medical College, Chicago, IL, USA
| |
Collapse
|
3
|
Bauer SR, Wieruszewski PM, Bissell BD, Dugar S, Sacha GL, Sato R, Siuba MT, Schleicher M, Vachharajani V, Falck-Ytter Y, Morgan RL. Adjunctive Vasopressors in Patients with Septic Shock: Protocol for a Systematic Review and Meta-Analysis. medRxiv 2023:2023.07.29.23293364. [PMID: 37546921 PMCID: PMC10402239 DOI: 10.1101/2023.07.29.23293364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background Over one-third of patients with septic shock have adjunctive vasopressors added to first-line vasopressors. However, no randomized trial has detected improved mortality with adjunctive vasopressors. Published systematic reviews and meta-analysis have sought to inform the use of adjunctive vasopressors, yet each published review has limitations that hinder its interpretation. This review aims to overcome the limitations of previous reviews by systematically synthesizing the direct evidence for adjunctive vasopressor therapy use in adult patients with septic shock. Methods We will conduct a systematic review and meta-analysis of randomized controlled trials evaluating adjunctive vasopressors (vasopressin analogues, angiotensin II, hydroxocobalamin, methylene blue, and catecholamine analogues) in adult patients with septic shock. Relevant studies will be identified through comprehensive searches of MEDLINE, Embase, CENTRAL, and reference lists of previous systematic reviews. Only randomized trials comparing adjunctive vasopressors (>75% of subjects on vasopressors at enrollment) to standard care vasopressors in adults with septic shock (>75% of subjects having septic shock) will be included. Titles and abstracts will be screened, full-text articles assessed for eligibility, and data extracted from included studies. Outcomes of interest include short-term mortality, intermediate-term mortality, kidney replacement therapy, digital/peripheral ischemia, and venous thromboembolism. Pairwise meta-analysis using a random-effects model will be utilized to estimate the risk ratio for the outcomes. Risk of bias will be adjudicated with the Cochrane Risk of Bias 2 tool, and GRADE will be used to rate the certainty of the body of evidence. Discussion Although adjunctive vasopressors are commonly used in patients with septic shock their effect on patient-important outcomes is unclear. This study is planned to use rigorous systematic review methodology, including strict adhere to established guidelines, in order to overcome limitations of previously-published reviews and inform clinical practice and treatment guidelines for the use of adjunctive vasopressors in adults with septic shock. Systematic review registration PROSPERO CRD4202327984.
Collapse
Affiliation(s)
- Seth R. Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Patrick M. Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Brittany D. Bissell
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Siddharth Dugar
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | - Ryota Sato
- Department of Critical Care Medicine, The Queen’s Health System, Honolulu, HI
| | - Matthew T. Siuba
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Mary Schleicher
- The Cleveland Clinic Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH
| | - Vidula Vachharajani
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Yngve Falck-Ytter
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
- Division of Gastroenterology and Hepatology, VA Northeast Ohio Healthcare System, Cleveland, OH
| | - Rebecca L. Morgan
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario
| |
Collapse
|
4
|
Bissell BD, Sturgill JL, Bruno MEC, Lewis ED, Starr ME. Assessment of Opioid-Induced Immunomodulation in Experimental and Clinical Sepsis. Crit Care Explor 2023; 5:e0849. [PMID: 36699245 PMCID: PMC9848529 DOI: 10.1097/cce.0000000000000849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Opioids remain a standard supportive therapy in patients admitted to the ICU with sepsis. However, as preclinical models indicate an association between opioid exposure and immunosuppression, the use of this class of drugs warrants investigation. The objective of this study was to investigate whether opioid exposure causes immunosuppression in patients with sepsis, and to use a murine sepsis model to determine the effects of opioid exposure on secondary infection. HYPOTHESIS We hypothesized opioid exposure would be associated with immunosuppression in patients with sepsis and secondary infection in a murine sepsis model. METHODS AND MODELS This was a two-phase preclinical and clinical study. The clinical phase included a subgroup of patients with sepsis from an existing randomized controlled trial while the preclinical phase used a murine model of sepsis with C57BL/6 mice. In the clinical phase, a post hoc analysis was performed in subjects receiving fentanyl versus no opioid receipt. In the preclinical phase, a murine cecal slurry-induced sepsis model followed by secondary infection was used. Mice were randomized to fentanyl versus no fentanyl concomitantly. RESULTS In clinical sepsis, a significant decrease in interleukin-23 (IL-23) level in patients with fentanyl exposure was observed and lower IL-23 was associated with mortality (p < 0.001). Other measured cytokines showed no significant differences. Concomitant fentanyl exposure during murine sepsis was associated with a significantly higher bacterial burden (p < 0.001) after secondary infection; however, immune cell counts and plasma cytokine levels were largely unaffected by fentanyl. INTERPRETATION AND CONCLUSIONS Minimal alterations in cytokines were seen with opioid exposure during clinical sepsis. In a preclinical model, opioid exposure during sepsis was associated with ineffective bacterial clearance upon secondary infection. Further studies are warranted to evaluate the immunomodulatory role of opioids and their implications, especially in the post-sepsis period.
Collapse
Affiliation(s)
- Brittany D Bissell
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Jamie L Sturgill
- Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, KY
| | - Maria E C Bruno
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY
| | - Erick D Lewis
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY
| | - Marlene E Starr
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY
| |
Collapse
|
5
|
Ammar MA, Ammar AA, Wieruszewski PM, Bissell BD, T Long M, Albert L, Khanna AK, Sacha GL. Timing of vasoactive agents and corticosteroid initiation in septic shock. Ann Intensive Care 2022; 12:47. [PMID: 35644899 PMCID: PMC9148864 DOI: 10.1186/s13613-022-01021-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/09/2022] [Indexed: 12/20/2022] Open
Abstract
Septic shock remains a health care concern associated with significant morbidity and mortality. The Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock recommend early fluid resuscitation and antimicrobials. Beyond initial management, the guidelines do not provide clear recommendations on appropriate time to initiate vasoactive therapies and corticosteroids in patients who develop shock. This review summarizes the literature regarding time of initiation of these interventions. Clinical data regarding time of initiation of these therapies in relation to shock onset, sequence of treatments with regard to each other, and clinical markers evaluated to guide initiation are summarized. Early-high vasopressor initiation within first 6 h of shock onset is associated with lower mortality. Following norepinephrine initiation, the exact dose and timing of escalation to adjunctive vasopressor agents are not well elucidated in the literature. However, recent data indicate that timing may be an important factor in initiating vasopressors and adjunctive therapies, such as corticosteroids. Norepinephrine-equivalent dose and lactate concentration can aid in determining when to initiate vasopressin and angiotensin II in patients with septic shock. Future guidelines with clear recommendations on the time of initiation of septic shock therapies are warranted.
Collapse
Affiliation(s)
- Mahmoud A Ammar
- Department of Pharmacy, Yale New Haven Health System, 20 York Street, New Haven, CT, 06510, USA.
| | - Abdalla A Ammar
- Department of Pharmacy, Yale New Haven Health System, 20 York Street, New Haven, CT, 06510, USA
| | - Patrick M Wieruszewski
- Departments of Anesthesiology and Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Brittany D Bissell
- Department of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA.,Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Micah T Long
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI, USA
| | - Lauren Albert
- Department of Pharmacy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Center for Biomedical Informatics, Perioperative Outcomes and Informatics Collaborative, Medical Center Boulevard, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue, Hb-105, Cleveland, OH, USA
| |
Collapse
|
6
|
Hillerson DB, Laine ME, Bissell BD, Mefford B. Contemporary targeted temperature management: Clinical evidence and controversies. Perfusion 2022; 38:666-680. [PMID: 35531914 DOI: 10.1177/02676591221076286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advancements in cardiac arrest and post-cardiac arrest care have led to improved survival to hospital discharge. While survival to hospital discharge is an important clinical outcome, neurologic recovery is also a priority. With the advancement of targeted temperature management (TTM), the American Heart Association guidelines for post-cardiac arrest care recommend TTM in patients who remain comatose after return of spontaneous circulation (ROSC). Recently, the TTM2 randomized controlled trial found no significant difference in neurologic function and mortality at 6-months between traditional hypothermia to 33°C versus 37.5°C. While TTM has been evaluated for decades, current literature suggests that the use of TTM to 33° when compared to a protocol of targeted normothermia does not result in improved outcomes. Instead, perhaps active avoidance of fever may be most beneficial. Extracorporeal cardiopulmonary resuscitation and membrane oxygenation can provide a means of both hemodynamic support and TTM after ROSC. This review aims to describe the pathophysiology, physiologic aspects, clinical trial evidence, changes in post-cardiac arrest care, potential risks, as well as controversies of TTM.
Collapse
Affiliation(s)
- Dustin B Hillerson
- 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | | |
Collapse
|
7
|
Raghu G, Remy-Jardin M, Richeldi L, Thomson CC, Inoue Y, Johkoh T, Kreuter M, Lynch DA, Maher TM, Martinez FJ, Molina-Molina M, Myers JL, Nicholson AG, Ryerson CJ, Strek ME, Troy LK, Wijsenbeek M, Mammen MJ, Hossain T, Bissell BD, Herman DD, Hon SM, Kheir F, Khor YH, Macrea M, Antoniou KM, Bouros D, Buendia-Roldan I, Caro F, Crestani B, Ho L, Morisset J, Olson AL, Podolanczuk A, Poletti V, Selman M, Ewing T, Jones S, Knight SL, Ghazipura M, Wilson KC. Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults: An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2022; 205:e18-e47. [PMID: 35486072 PMCID: PMC9851481 DOI: 10.1164/rccm.202202-0399st] [Citation(s) in RCA: 683] [Impact Index Per Article: 341.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: This American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Asociación Latinoamericana de Tórax guideline updates prior idiopathic pulmonary fibrosis (IPF) guidelines and addresses the progression of pulmonary fibrosis in patients with interstitial lung diseases (ILDs) other than IPF. Methods: A committee was composed of multidisciplinary experts in ILD, methodologists, and patient representatives. 1) Update of IPF: Radiological and histopathological criteria for IPF were updated by consensus. Questions about transbronchial lung cryobiopsy, genomic classifier testing, antacid medication, and antireflux surgery were informed by systematic reviews and answered with evidence-based recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. 2) Progressive pulmonary fibrosis (PPF): PPF was defined, and then radiological and physiological criteria for PPF were determined by consensus. Questions about pirfenidone and nintedanib were informed by systematic reviews and answered with evidence-based recommendations using the GRADE approach. Results:1) Update of IPF: A conditional recommendation was made to regard transbronchial lung cryobiopsy as an acceptable alternative to surgical lung biopsy in centers with appropriate expertise. No recommendation was made for or against genomic classifier testing. Conditional recommendations were made against antacid medication and antireflux surgery for the treatment of IPF. 2) PPF: PPF was defined as at least two of three criteria (worsening symptoms, radiological progression, and physiological progression) occurring within the past year with no alternative explanation in a patient with an ILD other than IPF. A conditional recommendation was made for nintedanib, and additional research into pirfenidone was recommended. Conclusions: The conditional recommendations in this guideline are intended to provide the basis for rational, informed decisions by clinicians.
Collapse
|
8
|
Bissell BD, Campbell J, Collins R, Cook C, Desai D, DeWitt J, Eche IM, Eche IJ, Elsamadisi P, Juul J, Kim S, Makowski CT, Mylvaganam RJ, Smith A, Stancati J, Stonesifer K, Tawil J, Smith Condeni M. Major Publications in the Critical Care Pharmacotherapy Literature: 2020. Crit Care Explor 2021; 3:e0590. [PMID: 34909697 PMCID: PMC8663877 DOI: 10.1097/cce.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2020. DATA SOURCES The Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update group screened 36 journals monthly for impactful publications. STUDY SELECTION The group reviewed a total of 119 articles during 2020 according to relevance for practice. DATA EXTRACTION Articles were selected with consensus and importance to clinical practice from those included in the monthly Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update. The group reviewed articles according to Grading of Recommendations, Assessment, Development, and Evaluations criteria. Articles with a 1A grade were selected. DATA SYNTHESIS Several trials were summarized, including two meta-analyses and five original research trials. Original research trials evaluating vitamin C, hydrocortisone, and thiamine versus hydrocortisone in sepsis, the use of nonsedation strategies, dexmedetomidine in cardiac surgery, remdesivir for severe acute respiratory syndrome coronavirus 2, and thrombectomy in acute ischemic stroke. Two meta-analyses determining the impact of norepinephrine initiation in patients with septic shock and the use of corticosteroids in severe acute respiratory syndrome coronavirus 2 was included. CONCLUSIONS This clinical review provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2020.
Collapse
Affiliation(s)
| | | | - Reagan Collins
- Clinical Pharmacy Specialist in Critical Care and Nutrition Support, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles Cook
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | | | | | | | - Janelle Juul
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI
| | | | | | | | - Adam Smith
- OhioHealth Riverside Methodist Hospital, Columbus, OH
| | | | | | - Justin Tawil
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI
| | | |
Collapse
|
9
|
Bissell BD, Johnston JP, Smith RR, Newsome AS, Thompson Bastin ML, Abdul-Mutakabbir J, Barlow A, Barlow B, Berger K, Crow JR, Dixit D, Jacobi J, Karaoui LR, Kiser TH, Kolesar J, Koontz SE, Mattingly TJ, Mitchell C, Nilges A, Rech MA, Heavner MS. Gender inequity and sexual harassment in the pharmacy profession: Evidence and call to action. Am J Health Syst Pharm 2021; 78:2059-2076. [PMID: 34232286 PMCID: PMC8344711 DOI: 10.1093/ajhp/zxab275] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
| | - Jackie P Johnston
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Rebecca R Smith
- Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | | | - Ashley Barlow
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Karen Berger
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Jessica R Crow
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | | | - Lamis R Karaoui
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Jill Kolesar
- College of Pharmacy, University of Kentucky, Lexington KY, USA
| | | | - T Joseph Mattingly
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | | | - Megan A Rech
- Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, and Loyola University Medical Center, Maywood, IL, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, MD, USA
| |
Collapse
|
10
|
Bissell BD, Johnston JP, Smith RR, Newsome AS, Thompson Bastin ML, Abdul-Mutakabbir J, Barlow A, Barlow B, Berger K, Crow JR, Dixit D, Jacobi J, Karaoui LR, Kiser TH, Kolesar J, Koontz SE, Mattingly TJ, Mitchell C, Nilges A, Rech MA, Heavner MS. Gender Inequity and Sexual Harassment in the Pharmacy Profession: Evidence and Call to Action Executive Summary. J Am Coll Clin Pharm 2021; 4:1375-1378. [PMID: 35187415 PMCID: PMC8849554 DOI: 10.1002/jac5.1508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/23/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Brittany D Bissell
- University of Kentucky, 1000 S. Limestone, Room H110, Lexington, KY 40536, USA
| | - Jackie P Johnston
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Rebecca R Smith
- University of Arkansas for Medical Sciences, Department of Pharmacy, 4301 West Markham Street, Slot 522, Little Rock, AR 72205
| | - Andrea Sikora Newsome
- University of Georgia College of Pharmacy, Department of Clinical and Administrative Pharmacy, 120 15th Street, HM-118, Augusta, GA 30912
| | | | - Jacinda Abdul-Mutakabbir
- Loma Linda University School of Pharmacy, Department of Pharmacy Practice, 24745 Stewart Street, Shryock Hall Room 212, Loma Linda, CA 92350, USA
| | - Ashley Barlow
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston Texas 77030
| | - Brooke Barlow
- University of Kentucky, 1000 S. Limestone, Room H110, Lexington, KY 40536, USA
| | - Karen Berger
- Neurocritical Care, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68 St, New York, NY 10065
| | - Jessica R Crow
- The Johns Hopkins Hospital, Department of Pharmacy, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD 21287
| | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | | | - Lamis R Karaoui
- Director of Experiential Education/Acting Assistant Dean for Student Affairs, Department of Pharmacy Practice School of Pharmacy, Lebanese American University, P.O.Box: 36 (S23), Byblos, Lebanon
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E Montview Blvd, C238, Aurora, CO 80045
| | - Jill Kolesar
- College of Pharmacy, University of Kentucky, 789 S. Limestone, Lexington KY 40536
| | - Susannah E Koontz
- Koontz Oncology Consulting LLC, 2617C W. Holcombe Blvd. #365, Houston, TX 77025-1601, USA
| | - T Joseph Mattingly
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Baltimore, Maryland 21201
| | | | - Alexsandra Nilges
- University of Kentucky College of Pharmacy, 789 S. Limestone, Lexington, KY 40506 USA
| | - Megan A Rech
- Adjunct Assistant Professor - Department of Emergency Medicine, Research Coordinator - Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, Loyola University Medical Center, 2160 S 1st Ave, Maywood IL 60153
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, 20 N. Pine Street, N427, Baltimore, MD 21201
| |
Collapse
|
11
|
Abstract
ABSTRACT We sought to review the pharmacology of vasoactive therapy and fluid administration in sepsis and septic shock, with specific insight into the physiologic interplay of these agents. A PubMed/MEDLINE search was conducted using the following terms (vasopressor OR vasoactive OR inotrope) AND (crystalloid OR colloid OR fluid) AND (sepsis) AND (shock OR septic shock) from 1965 to October 2020. A total of 1,022 citations were reviewed with only relevant clinical data extracted. While physiologic rationale provides a hypothetical foundation for interaction between fluid and vasopressor administration, few studies have sought to evaluate the clinical impact of this synergy. Current guidelines are not in alignment with the data available, which suggests a potential benefit from low-dose fluid administration and early vasopressor exposure. Future data must account for the impact of both of these pharmacotherapies when assessing clinical outcomes and should assess personalization of therapy based on the possible interaction.
Collapse
Affiliation(s)
- Brooke Barlow
- Department of Pharmacy, University of Kentucky, Lexington, Kentucky
- College of Pharmacy, Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
| | - Brittany D Bissell
- Department of Pharmacy, University of Kentucky, Lexington, Kentucky
- College of Pharmacy, Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
- College of Medicine, Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, Kentucky
| |
Collapse
|
12
|
Bissell BD, Mefford B, Donaldson JC. Comment: Low-Dose Tocilizumab With High-Dose Corticosteroids in Patients Hospitalized for COVID-19 Hypoxic Respiratory Failure Improves Mortality Without Increased Infection Risk. Ann Pharmacother 2021; 56:505-506. [DOI: 10.1177/10600280211036040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
|
13
|
Bissell BD, Gabbard T, Sheridan EA, Baz MA, Davis GA, Ather A. Evaluation of Bivalirudin as the Primary Anticoagulant in Patients Receiving Extracorporeal Membrane Oxygenation for SARS-CoV-2-Associated Acute Respiratory Failure. Ann Pharmacother 2021; 56:387-392. [PMID: 34323121 DOI: 10.1177/10600280211036151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a potential option for the management of severe acute respiratory failure secondary to COVID-19. Conflicting the use of this therapy is the known coagulopathy within COVID-19, leading to an incidence of venous thrombotic events of 25% to 49%. To date, limited guidance is available on optimal anticoagulation strategies in this population. OBJECTIVE The purpose of this study was to evaluate the utilization of a pharmacist-driven bivalirudin dosing protocol for anticoagulation in the setting of ECMO for COVID-19-associated respiratory failure. METHODS This was a single-center retrospective chart review over a 9-month period of patients receiving bivalirudin while on ECMO. All patients with acute respiratory failure requiring ECMO with a positive SARS-CoV-2 polymerase chain reaction were included. Bivalirudin was dosed via aPTT monitoring after a starting dose of 0.2 or 0.3 mg/kg/h. RESULTS There were 33 patients included in this study, all receiving mechanical ventilation. The most common starting dose of bivalirudin was 0.2 mg/kg/h, with an average time to therapeutic range of 20 hours. Compared to previous reports, rates of bleeding were low at 15.1%, and 6.1% of patients developed a new venous thromboembolic event while on ECMO. ECMO survival was 51.5%, with an ICU mortality rate of 48.5%. CONCLUSION AND RELEVANCE In the first published report of its use within this population, bivalirudin was found to be a viable choice for anticoagulation in those patients on ECMO for severe respiratory failure secondary to COVID-19.
Collapse
Affiliation(s)
| | - Taylor Gabbard
- The University of Kansas Health System, Kansas City, KS, USA
| | | | | | | | | |
Collapse
|
14
|
Bissell BD, Kreimer A, Burgess DS. Epidemiology of Infections With Rothia Species in an Academic Medical Center. Ann Pharmacother 2021; 56:363-365. [PMID: 34218682 DOI: 10.1177/10600280211030332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
15
|
Mefford B, Donaldson JC, Bissell BD. The immunomodulatory effects of opioids and implications for intensive care unit populations. Pharmacotherapy 2021; 41:668-675. [PMID: 34129683 DOI: 10.1002/phar.2602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/05/2022]
Abstract
Analgesia within the intensive care unit (ICU) is often achieved via the utilization of opioids in alignment with current guidelines. Recent evidence has not only demonstrated the potential impact of opioids in suppression of immune function, but also the potential harm of immunosuppression of patients within the ICU. Despite the potential immunosuppression seen with opioids in this at-risk population, their use remains frequent. In this review, we highlight the potential immunomodulatory impact of opioids within the critically ill and considerations for their use.
Collapse
|
16
|
Behal M, Barlow B, Mefford B, Thompson Bastin ML, Donaldson JC, Laine M, Bissell BD. Pharmacotherapy in Coronavirus Disease 2019 and Risk of Secondary Infections: A Single-Center Case Series and Narrative Review. Crit Care Explor 2021; 3:e0492. [PMID: 34278319 PMCID: PMC8280010 DOI: 10.1097/cce.0000000000000492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Since the onset of the coronavirus disease 2019 pandemic, immune modulators have been considered front-line candidates for the management of patients presenting with clinical symptoms secondary to severe acute respiratory syndrome coronavirus 2 infection. Although heavy emphasis has been placed on early clinical efficacy, we sought to evaluate the impact of pharmacologic approach to coronavirus disease 2019 within the ICU on secondary infections and clinical outcomes. DATA SOURCES PubMed (inception to March 2021) database search and manual selection of bibliographies from selected articles. STUDY SELECTION AND DATA EXTRACTION Articles relevant to coronavirus disease 2019, management of severe acute respiratory syndrome coronavirus 2-associated respiratory failure, and prevalence of secondary infections with pharmacotherapies were selected. The MeSH terms "COVID-19," "secondary infection," "SARS-CoV-2," "tocilizumab," and "corticosteroids" were used for article identification. Articles were narratively synthesized for this review. DATA SYNTHESIS Current data surrounding the use of tocilizumab and/or corticosteroids for coronavirus disease 2019 management are limited given the short follow-up period and conflicting results between studies. Further complicating the understanding of immune modulator role is the lack of definitive understanding of clinical impact of the immune response in coronavirus disease 2019. CONCLUSIONS Based on the current available literature, we suggest prolonged trials and follow-up intervals for those patients managed with immune modulating agents for the management of coronavirus disease 2019.
Collapse
Affiliation(s)
- Michael Behal
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | - Brooke Barlow
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | - Breanne Mefford
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | | | - J Chris Donaldson
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | - Melanie Laine
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | - Brittany D Bissell
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, College of Medicine, Lexington, KY
| |
Collapse
|
17
|
Thompson Bastin ML, Smith RR, Bissell BD, Wolf HN, Wiegand AM, Cavagnini ME, Ahmad Y, Flannery AH. Comparison of fixed dose versus train-of-four titration of cisatracurium in acute respiratory distress syndrome. J Crit Care 2021; 65:86-90. [PMID: 34118504 DOI: 10.1016/j.jcrc.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/06/2021] [Accepted: 05/15/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE To compare the ventilatory and clinical outcomes associated with a fixed-dose cisatracurium infusion versus a titrated infusion strategy in patients with Acute Respiratory Distress Syndrome (ARDS). MATERIALS AND METHODS Single-center, retrospective, cohort study in a medical ICU of a tertiary care academic medical center. Adult patients ≥18 years old with a continuous infusion of cisatracurium for ≥12 h for treatment of ARDS were included. The primary outcome was the PaO2 /FiO2 ratio assessed at 24 and 48 h following cisatracurium initiation. Secondary outcomes included amount of average dose of drug administered, 28-day ventilator-free days, LOS, and hospital mortality. RESULTS 167 patients were included; median baseline PaO2/FiO2 was 97 (76-146), median SOFA score of 9 (7-11), and ICU mortality was 71/167 (43%). In a mixed-effects model, fixed dose and titrated cisatracurium associated with similar changes in PaO2/FiO2 assessed at 24 and 48 h (p = 0.316). Fixed-dose was associated with a >3-fold increase in drug exposure (average dose 6.4 (5.4-8.0) vs. 2.0 (1.5-2.8) mcg/kg/min; p < 0.001, respectively). No differences were observed in secondary clinical endpoints. CONCLUSION Fixed-dose cisatracurium was associated with similar ventilatory and clinical outcomes compared to titrated strategy, yet it was associated with a 3-fold increase in dose administered.
Collapse
Affiliation(s)
- Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
| | - Rebecca R Smith
- University of Arkansas for Medical Sciences, Department of Pharmacy Services, United States of America.
| | - Brittany D Bissell
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America; University of Kentucky College of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, United States of America.
| | - Heather N Wolf
- St. Elizabeth Healthcare, Department of Pharmacy Services, United States of America.
| | - Alexandra M Wiegand
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America.
| | - Megan E Cavagnini
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
| | - Yahya Ahmad
- University of Kentucky College of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, United States of America.
| | - Alexander H Flannery
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
| |
Collapse
|
18
|
Bissell BD, Donaldson JC, Morris PE, Neyra JA. A narrative review of pharmacologic de-resuscitation in the critically ill. J Crit Care 2020; 59:156-162. [PMID: 32674002 DOI: 10.1016/j.jcrc.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/28/2020] [Accepted: 07/03/2020] [Indexed: 02/06/2023]
Abstract
Despite evidence highlighting harms of fluid overload, minimal guidance exists on counteraction via utilization of diuretics in the de-resuscitation phase. While diuretics have been shown to decrease net volume and improve clinical outcomes in the critically ill, a lack of standardization surrounding selection of diuretic regimen or monitoring of de-resuscitation exists. Current monitoring parameters of de-resuscitation often rely on clinical signs of fluid overload, end organ recovery and other biochemical surrogate markers which are often deemed unreliable. The majority of evidence suggests that achieving a net-negative fluid balance within 72 h after shock resolution may be of benefit; however, approaches to such goal are uncertain. Loop diuretics are a widely available type of diuretic for removal of volume in patients with sufficient kidney function, with the potential for adjunct diuretics in special circumstances. At present, administration of diuretics within the broad critically ill population fails to find uniformity and often efficacy. Given the lack of randomized controlled trials in this susceptible population, we aim to provide a thorough therapeutic understanding of diuretic pharmacotherapy which is necessary in order to achieve desired goal of fluid balance and improve overall outcomes.
Collapse
Affiliation(s)
- Brittany D Bissell
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, 740 South Limestone, Lexington, Kentucky 40536, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, 789 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - J Chris Donaldson
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, 789 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - Peter E Morris
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, 740 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - Javier A Neyra
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, 740 South Limestone, Lexington, Kentucky 40536, United States of America.
| |
Collapse
|
19
|
Gilbert BW, Bissell BD, Santiago RD, Rech MA. Tracing the Lines: A Review of Viscoelastography for Emergency Medicine Clinicians. J Emerg Med 2020; 59:201-215. [PMID: 32418869 DOI: 10.1016/j.jemermed.2020.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/25/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Viscoelastography (VE) is an established method to identify coagulopathies in various disease processes. Clinical decisions can be made with real-time tracings and quantitative values at the bedside. Thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) have been utilized in several disease states with clinical varying success. OBJECTIVES This review will summarize the literature and provide recommendations pertaining to major disease processes where VE may be beneficial, including trauma, anticoagulation reversal, liver disease, acute ischemic stroke, and acquired brain injuries. DISCUSSION VE has a role in many emergency medicine patients encountered by clinicians. Reduced mortality, decreased blood product utilization, and prognostication ability makes VE an intriguing tool that can be utilized by providers to improve patient care. CONCLUSION This review serves as a way for emergency medicine clinicians to utilize VE in their practice and provides an insightful literature overview.
Collapse
Affiliation(s)
- Brian W Gilbert
- Department of Emergency Medicine, Wesley Medical Center, Wichita, Kansas
| | - Brittany D Bissell
- Medical Intensive Care Unit, University of Kentucky Healthcare, Lexington, Kentucky
| | - Ruben D Santiago
- Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Megan A Rech
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, Illinois
| |
Collapse
|
20
|
Tompkins MG, Bissell BD, Sowders V, Kern PA. Inclusion of adrenal crisis in the differential diagnosis of distributive shock. Am J Health Syst Pharm 2020; 77:415-417. [PMID: 31950137 DOI: 10.1093/ajhp/zxz324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Madeline G Tompkins
- Department of Pharmacy Practice and Science University of Kentucky College of Pharmacy Lexington, KY
| | - Brittany D Bissell
- Department of Pharmacy Practice and Science University of Kentucky College of Pharmacy Lexington, KY.,Department of Pharmacy Services University of Kentucky Albert B. Chandler Hospital Lexington, KY
| | - Virginia Sowders
- Division of Pulmonary and Critical Care Medicine University of Kentucky Albert B. Chandler Hospital Lexington, KY
| | - Philip A Kern
- Department of Internal Medicine Division of Endocrinology University of Kentucky Albert B. Chandler Hospital Lexington, KY
| |
Collapse
|
21
|
Bissell BD, Laine ME, Thompson Bastin ML, Flannery AH, Kelly A, Riser J, Neyra JA, Potter J, Morris PE. Impact of protocolized diuresis for de-resuscitation in the intensive care unit. Crit Care 2020; 24:70. [PMID: 32111247 PMCID: PMC7048112 DOI: 10.1186/s13054-020-2795-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/17/2020] [Indexed: 12/24/2022]
Abstract
Objective Administration of diuretics has been shown to assist fluid management and improve clinical outcomes in the critically ill post-shock resolution. Current guidelines have not yet included standardization or guidance for diuretic-based de-resuscitation in critically ill patients. This study aimed to evaluate the impact of a multi-disciplinary protocol for diuresis-guided de-resuscitation in the critically ill. Methods This was a pre-post single-center pilot study within the medical intensive care unit (ICU) of a large academic medical center. Adult patients admitted to the Medical ICU receiving mechanical ventilation with either (1) clinical signs of volume overload via chest radiography or physical exam or (2) any cumulative fluid balance ≥ 0 mL since hospital admission were eligible for inclusion. Patients received diuresis per clinician discretion for a 2-year period (historical control) followed by a diuresis protocol for 1 year (intervention). Patients within the intervention group were matched in a 1:3 ratio with those from the historical cohort who met the study inclusion and exclusion criteria. Results A total of 364 patients were included, 91 in the protocol group and 273 receiving standard care. Protocolized diuresis was associated with a significant decrease in 72-h post-shock cumulative fluid balance [median, IQR − 2257 (− 5676–920) mL vs 265 (− 2283–3025) mL; p < 0.0001]. In-hospital mortality in the intervention group was lower compared to the historical group (5.5% vs 16.1%; p = 0.008) and higher ICU-free days (p = 0.03). However, no statistically significant difference was found in ventilator-free days, and increased rates of hypernatremia and hypokalemia were demonstrated. Conclusions This study showed that a protocol for diuresis for de-resuscitation can significantly improve 72-h post-shock fluid balance with potential benefit on clinical outcomes.
Collapse
Affiliation(s)
- Brittany D Bissell
- Department of Pharmacy Services, Neuro-Pulmonary Division, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA. .,College of Pharmacy, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA. .,College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, 740 S. Limestone, Lexington, KY, 40536, USA.
| | - Melanie E Laine
- Department of Pharmacy Services, Neuro-Pulmonary Division, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA.,College of Pharmacy, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Melissa L Thompson Bastin
- Department of Pharmacy Services, Neuro-Pulmonary Division, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA.,College of Pharmacy, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Alexander H Flannery
- Department of Pharmacy Services, Neuro-Pulmonary Division, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA.,College of Pharmacy, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Andrew Kelly
- Performance Analytics Center of Excellence, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Jeremy Riser
- Performance Analytics Center of Excellence, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Javier A Neyra
- College of Medicine, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, MN668, Lexington, KY, 40536, USA
| | - Jordan Potter
- Department of Pharmacy Services, Beaumont Hospital, 3601 W 13 Mile Road, Royal Oak, MI, 48073, USA
| | - Peter E Morris
- College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, 740 S. Limestone, Lexington, KY, 40536, USA
| |
Collapse
|
22
|
Mefford B, Donaldson JC, Bissell BD. To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome. Ann Pharmacother 2020; 54:899-906. [DOI: 10.1177/1060028020910132] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective: To review and evaluate neuromuscular blocking agents (NMBAs) in critically ill patients with acute respiratory distress syndrome (ARDS). Data Sources: A literature search utilizing PubMed was performed (January 1991 to January 2020) using the following search terms: ( neuromuscular blocking agents OR neuromuscular blockade OR cisatracurium OR rocuronium OR vecuronium OR pancuronium OR atracurium) AND * acute respiratory distress syndrome OR acute lung injury). Publications in English were evaluated. Study Selection and Data Extraction: Relevant clinical studies in humans were considered. Data Synthesis: Although NMBAs have been used for decades in the setting of ARDS, questions regarding mortality benefit remain. Early NMBA, within 48 hours of lung injury, have been historically used in critically ill patients with ARDS to aid in increasing alveolar recruitment, improving patient-ventilator synchrony, and promoting oxygenation by the prevention of contraction of respiratory muscles. Until recently, the literature showed an improvement in 90-day adjusted mortality. However, recent literature has demonstrated the lack of a mortality benefit. The continued receipt of NMBAs, with no clear benefit, could potentially lead to increased costs, skin breakdown, corneal abrasions, venous thromboembolisms, intensive care unit acquired weakness, and awareness with inappropriate sedation. Relevance to Patient Care and Clinical Practice: This review aims at discussing the preferred NMBA based on mechanism of action and reviews specific clinical trial data for the use of NMBAs in ARDS, clinical implications of these trial data, complications for the use of NMBAs, and needed future directions. Conclusions: The mortality benefit of NMBAs in ARDS has contradicting evidence with potentially serious adverse effects and notable controversies.
Collapse
|
23
|
Abstract
Objective: To review physiological rationale and evidence base surrounding fluid harm to prepare the clinical pharmacist for accountability regarding volume-related outcomes. Data Sources: A PubMed/MEDLINE search was conducted using the following terms: (fluid therapy) AND [(critical care) OR (sepsis)] from 1966 to August 2019 published in English. Study Selection and Data Extraction: A total of 3364 citations were reviewed with only relevant clinical data extracted. Data Synthesis: Although early fluid resuscitation may be a necessary component to decrease mortality in the majority of patients with septic shock admitted to the intensive care unit (ICU), the benefit of continued administration after the first 24 hours is uncertain. Paradoxically, a positive fluid balance secondary to intravenous fluid receipt has been associated with diverse and perpetuating detriment on a multitude of organ systems after the first 24 hours of ICU stay. Continued clinical harm has been demonstrated on patient outcomes such as rates of mortality and length of stay. Despite the growing body of evidence supporting the potential adverse aspects of positive fluid balance, fluid overload remains common during critical care admission. Conclusion: Physiological concerns to overly zealous fluid administration and subsequent volume overload are vast. Relevance to Patient Care and Clinical Practice: Optimization of fluid balance in critically ill patients with sepsis is primed for clinical pharmacy intervention. Critical care pharmacists have the potential to improve patient care by optimizing fluid pharmacotherapy while potentially reducing adverse events, days on mechanical ventilation, and length of ICU stay.
Collapse
|
24
|
McKenzie MG, Bissell BD, Disselkamp MA, Hildebrandt GC, Cox JN. Sensitizing the interdisciplinary team to desensitizations: An alemtuzumab case report. J Oncol Pharm Pract 2019; 26:742-746. [PMID: 31390960 DOI: 10.1177/1078155219865313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION We describe a case of alemtuzumab (Campath®) hypersensitivity requiring desensitization within the medical intensive care unit (MICU) in a patient with T-cell prolymphocytic leukemia. CASE REPORT We adopted a desensitization protocol from Gutierrez-Fernandez et al., which included three aliquots (0.15 mg intravenously (IV), 1.5 mg IV, and 28.5 mg IV) given approximately 1 h apart on day 1 followed by a full 30 mg dose IV on day 3. Unlike prior attempts to administer alemtuzumab to this patient, she tolerated the medication well and did not require any rescue medications. MANAGEMENT AND OUTCOME Successful plan development required a significant amount of strategic communication between hematology/oncology and MICU-related physicians, pharmacists, and nurses to ensure a safe and effective desensitization. The first step of planning required creation of a desensitization order set with directions for medication preparation and administration, premedications, and available medications in the event of an adverse reaction or anaphylaxis. Anaphylactoid-related medications were prepared at bedside and ready for administration prior to beginning the desensitization. Alemtuzumab was compounded in a chemotherapy-certified hood and verified by at least two chemotherapy-certified pharmacists. Foreword planning was also necessary to ensure multiple people were available or present at bedside for the desensitization, including a chemotherapy-certified nurse, a second chemotherapy-certified nurse for verification, a critical care-certified pharmacist, a pulmonary/critical care attending physician, and hematology attending physician. DISCUSSION This case exemplifies the importance of clear and coordinated communication between different healthcare fields to safely and effectively complete extensive protocols such as desensitization strategies.
Collapse
Affiliation(s)
- Matt G McKenzie
- Department of Pharmacy Practice, University of Kentucky Medical Center, Lexington, KY, USA
| | - Brittany D Bissell
- Department of Pharmacy Practice, University of Kentucky Medical Center, Lexington, KY, USA
| | - Margaret A Disselkamp
- Department of Pulmonary Critical Care and Sleep Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Gerhard C Hildebrandt
- Department of Hematology and Bone & Marrow Transplantation, University of Kentucky Medical Center, Lexington, KY, USA
| | - Jessica N Cox
- Department of Pharmacy Practice, University of Kentucky Medical Center, Lexington, KY, USA
| |
Collapse
|
25
|
McCleary EJ, Thompson Bastin ML, Bissell BD, Cook AM, Pierce CA, Flannery AH. Development of a Coprecepting Model for a Preceptor-in-Training Program for New Practitioners. Hosp Pharm 2019; 54:246-249. [PMID: 31320774 DOI: 10.1177/0018578718784481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Preceptor development is a focus of pharmacy residency programs across the country. Graduation from residency into the role of preceptor can be a challenge, as it is one of many transitions junior practitioners make in their early careers. Literature in recent years has brought attention to the need to establish preceptor development programs that adequately allow newer preceptors to develop their skills in experiential education, for both pharmacy residents and students. Furthermore, many preceptor development programs as implemented are often didactic in nature, and include readings, webinars, and other passive learning regarding the art of precepting. Objective: Given the need to develop a preceptor development program in our service line that met the needs of preceptors-in-training and full preceptors, we offer a description of our preceptor development program in the intensive care unit. Methods: We focused on active development of preceptor skills for multiple layers of resident and student learners. In addition, this model incorporated instructing, modeling, coaching, and facilitating, as the relationship between full preceptor and preceptor-in-training evolved. It also offered the opportunity for real-time feedback and discussion on precepting performance. Conclusions: We describe our coprecepting model as an opportunity that succeeded for us in helping to transition our preceptors-in-training to full preceptors. It met the needs of our department, staff, and patients, and we believe it has the potential to be valuable as a tool extrapolated to the preceptor development programs of other institutions.
Collapse
Affiliation(s)
- Emily J McCleary
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Brittany D Bissell
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Aaron M Cook
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Catherine A Pierce
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Alexander H Flannery
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| |
Collapse
|
26
|
Hammond DA, Sacha GL, Bissell BD, Musallam N, Altshuler D, Flannery AH, Lam SW, Bauer SR. Effects of Norepinephrine and Vasopressin Discontinuation Order in the Recovery Phase of Septic Shock: A Systematic Review and Individual Patient Data Meta‐Analysis. Pharmacotherapy 2019; 39:544-552. [DOI: 10.1002/phar.2265] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | | | | | - Simon W. Lam
- Department of Pharmacy Cleveland Clinic Cleveland Ohio
| | - Seth R. Bauer
- Department of Pharmacy Cleveland Clinic Cleveland Ohio
| |
Collapse
|
27
|
Buzzard SL, Bissell BD, Thompson Bastin ML. Ehrlichiosis presenting as severe sepsis and meningoencephalitis in an immunocompetent adult. JMM Case Rep 2018; 5:e005162. [PMID: 30425837 PMCID: PMC6230758 DOI: 10.1099/jmmcr.0.005162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/12/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Ehrlichia are obligate intracellular pathogens transmitted to vertebrates by ticks. Case presentation We report the case of a 59-year-old man who presented to the University of Kentucky Albert B. Chandler Medical Center (Lexington, KY, USA) after being found fallen down in the woods. A lumbar puncture revealed what appeared to be bacterial meningitis, yet cerebrospinal fluid cultures, Gram stains and a meningitis/encephalitis panel were inconclusive. However, an Ehrlichia DNA PCR of the blood resulted as being positive for Ehrlichia chaffeensis antibodies. The patient received a 14 day course of doxycycline, and recovered from his multiple organ failure. The aetiology of the ehrlichial meningoencephalitis was likely transmission through a tick-bite, due to the patient's outdoor exposure. Conclusion While it is rare to see Ehrlichia as a cause of meningitis, this illness can progress to severe multisystem disease with septic shock, meningoencephalitis or acute respiratory distress syndrome (ARDS). Those with compromised immunity are at a higher risk of developing the more severe form of the disease and have higher case fatality rates.
Collapse
Affiliation(s)
- Stephanie L Buzzard
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Brittany D Bissell
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA.,Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Melissa L Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA.,Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| |
Collapse
|
28
|
Abstract
Vancomycin is a first-line antibiotic for empiric treatment of gram-positive infections in the trauma intensive care unit. When dosed intermittently, difficulties arise from trough collection and drug monitoring. The objective of this study was to evaluate time to goal vancomycin levels comparing a continuous infusion protocol when compared to standard intermittent infusion dosing. This was a retrospective cohort of patients admitted to the trauma intensive care unit between July 2011 and July 2015 receiving vancomycin for at least 48 hours. In this cohort of 150 patients, continuous infusion vancomycin had a decreased time to goal vancomycin level (2.5 vs 3.8 days, P ≤ .05) with a higher incidence of target attainment (60% vs 40%, P ≤ .05). This reflected in a decrease in average number of blood samples per patient (1 vs 3, P ≤ .05) and shorter duration of therapy (3.8 vs 6.8 days, P ≤ .05). Patients receiving continuous infusion vancomycin also experienced less nephrotoxicity (21% vs 43%, P ≤ .05). Patients in the intermittent infusion group had more missed levels and doses, with only 1 in every 3 patients receiving all intended doses on time. Vancomycin continuous infusion resulted in a decrease in time to goal therapeutic vancomycin levels, number of blood samples required, and therapy duration. Larger trials are needed to validate these outcomes in broad patient groups and to validate the clinical implication and potential cost savings of these results.
Collapse
Affiliation(s)
| | - Gina Riggi
- Department of Pharmacy, Jackson Memorial Hospital, Miami, FL, USA
| | | |
Collapse
|
29
|
Abstract
OBJECTIVE To review and summarize data on angiotensin II (AT-II), approved by the Food and Drug Administration (FDA) in December 2017 to increase blood pressure in adults with septic or other distributive shock. DATA SOURCES A PubMed/MEDLINE search was conducted using the following terms: (angiotensin ii OR angiotensin 2) AND (shock) from 1966 to February 2018. STUDY SELECTION AND DATA EXTRACTION A total of 691 citations were reviewed with only relevant clinical data extracted. DATA SYNTHESIS AT-II is a peptide hormone with a multitude of physiological effects-namely, vasoconstriction of venous and arterial smooth muscle. The priority approval granted by the FDA was secondary to a phase 3 study of patients receiving at least 0.2 µg/kg/min of norepinephrine or equivalent for vasodilatory shock. Compared with placebo, AT-II had a significantly higher rate of response, defined as a mean arterial pressure of 75 mm Hg or an increase of 10 mm Hg. No significant difference was found in death by day 28. CONCLUSIONS AT-II is a newly available vasoactive agent with a novel mechanism for the treatment of distributive shock. Further research is needed to define its exact role in therapy of shock states, identify patients most likely to benefit, and further study its safety profile in critical illness.
Collapse
Affiliation(s)
- Brittany D Bissell
- 1 University of Kentucky Medical Center, Lexington, KY, USA.,2 University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Kelsey Browder
- 1 University of Kentucky Medical Center, Lexington, KY, USA
| | - Matt McKenzie
- 1 University of Kentucky Medical Center, Lexington, KY, USA
| | - Alexander H Flannery
- 1 University of Kentucky Medical Center, Lexington, KY, USA.,2 University of Kentucky College of Pharmacy, Lexington, KY, USA
| |
Collapse
|
30
|
Bissell BD, Davis JE, Flannery AH, Adkins DA, Thompson Bastin ML. Aggressive Treatment of Life-Threatening Hypophosphatemia During Recovery From Fulminant Hepatic Failure: A Case Report. J Intensive Care Med 2017; 33:375-379. [PMID: 29088996 DOI: 10.1177/0885066617738715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Acute liver failure secondary to acetaminophen overdose can be a life-threatening condition, characterized by severe electrolyte derangements. Hepatocyte regeneration is associated with phosphorous utilization and is a known complication of liver recovery following injury. We report the case of profound, life-threatening hypophosphatemia following recovery from acute fulminant liver failure. As the liver enzymes normalized, serum phosphorous levels plummeted. Our patient required an aggressive, individualized phosphorus replacement regimen, which resulted in a continuous infusion of intravenous (IV) sodium phosphate, titrated to a maximum rate of 30 mmol/h or 0.5 mmol/kg/h. The patient required over 400 mmol of total IV and oral phosphorous over the course of 48 hours. An aggressive approach to phosphorous replacement was done safely and effectively. Traditional replacement protocols are not adequate to sustain patients with this degree of hypophosphatemia. This is the first report to utilize a continuous infusion of phosphate with a maximum reported rate (0.5 mmol/kg/h). Our report summarizes a novel and safe approach for clinicians to maximally support these patients through high-dose, continuous infusion phosphorous administration.
Collapse
Affiliation(s)
- Brittany D Bissell
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Jason E Davis
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Alexander H Flannery
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA.,2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - David A Adkins
- 3 Division of Critical Care and Pulmonology, West Virginia University College of Medicine, Morgantown, WV, USA
| | - Melissa L Thompson Bastin
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA.,2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| |
Collapse
|
31
|
Abstract
RATIONALE Vasopressors such as norepinephrine are first line for support of mean arterial pressure (MAP) in the management of septic shock. Their use, however, is commonly associated with many adverse events. These detriments frequently trigger the use of alternative, noncatecholamine therapies, including vasopressin. Vasopressin deficiency is a known physiologic consequence of septic shock, and while guidelines recommend vasopressin in addition to norepinephrine, no consensus exists on the duration of deficiency or ideal time of cessation. Studies have suggested that vasopressin discontinuation prior to other vasopressors may lead to hypotension; however, data are limited. This study evaluates the optimal sequence for the discontinuation of vasopressin therapy in septic shock. METHODS This was a 1-year retrospective study of 152 patients admitted to the medical intensive care unit (ICU) with septic shock who received concurrent norepinephrine and vasopressin for vasoactive support. Patients were excluded if death occurred on vasopressors, within 24 hours after discontinuation of vasopressors, or within 48 hours of ICU admission. The primary outcome of hemodynamic instability included incidence of hypotension after vasopressor discontinuation (2 consecutive MAPs < 60 mm Hg), fluid bolus administration, greater than 0.05 μg/kg/min increase in norepinephrine requirements, or addition of an alternative vasopressor. Secondary outcomes included time to hypotension, total vasopressor duration, arrhythmias, mortality, and length of stay. RESULTS Ninety-one patients met exclusion criteria, resulting in 61 patients for evaluation. Vasopressin was the first vasoactive therapy to be discontinued in 19 patients and last in 42 patients. Baseline characteristics and the use of potentially confounding treatments known to effect MAP were similar between groups. Discontinuation of vasopressin first was associated with a significant increase in hemodynamic instability (74% vs 16.7%, P < .01), with a shorter time to hemodynamic instability (5 vs 15 hours, P < .01). Secondary outcomes were similar. CONCLUSION Vasopressin discontinuation prior to cessation of norepinephrine infusion was associated with an increased risk of hemodynamic instability.
Collapse
Affiliation(s)
- Brittany D Bissell
- 1 Department of Pharmacy, University of Kentucky Medical Center, Lexington, KY, USA
- 2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Carolyn Magee
- 1 Department of Pharmacy, University of Kentucky Medical Center, Lexington, KY, USA
| | - Peter Moran
- 2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Melissa L Thompson Bastin
- 1 Department of Pharmacy, University of Kentucky Medical Center, Lexington, KY, USA
- 2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Alexander H Flannery
- 1 Department of Pharmacy, University of Kentucky Medical Center, Lexington, KY, USA
- 2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| |
Collapse
|
32
|
Abstract
The spectrum of sepsis and septic shock remains a highly prevalent disease state, carrying a high risk of morbidity and mortality. The sympathetic nervous system (SNS) plays an important role in this initial cascade, enabling the host to respond to invading pathogens; however, prolonged activation can become pathological. The potential for unregulated sympathetic tone to become of detriment in patients with sepsis has fueled interest in the role and impact of sympatholysis, the selective inhibition of sympathetic tone. The cornerstone of septic shock therapy for decades has been the supplementation of catecholamines and thus potential further perpetuation of this sympathetic dysregulation. Although the theory of sympatholysis circulates around cardiovascular effects and stroke volume optimization, the impact of augmenting the SNS may extend well beyond this, including the impacts on the immune system, inflammatory cascade, and even gene transcription. Presently, the most robust clinical evidence involves the use of the cardioselective β-blocker esmolol in patients with septic shock with persistent tachycardia secondary to catecholamine use. Evidence is isolated only to animal models with α-agonists. Future evidence stands to elucidate the balance of sympathetic and autonomic tone as well as the potential role of redirecting and maximizing sympathetic activity.
Collapse
Affiliation(s)
- Jason A. Ferreira
- Department of Pharmacy Services, University of Florida Health Jacksonville, Jacksonville, FL, USA
| | - Brittany D. Bissell
- Department of Pharmacy Services, University of Kentucky Healthcare, Lexington, KY, USA
| |
Collapse
|
33
|
Bissell BD, Erdman MJ, Smotherman C, Kraemer DF, Ferreira JA. The impact of endocrine supplementation on adverse events in septic shock. J Crit Care 2015; 30:1169-73. [PMID: 26404956 DOI: 10.1016/j.jcrc.2015.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/18/2015] [Accepted: 08/25/2015] [Indexed: 01/07/2023]
Abstract
PURPOSE The objective of this study was to compare the incidence of severe adverse events of vasopressin vs hydrocortisone for endocrine support therapy in patients with septic shock. MATERIALS AND METHODS This was a retrospective, propensity-matched cohort of patients admitted to the medical intensive care unit with septic shock between February 2012 and February 2015. Patients were included if vasopressin or hydrocortisone was administered for hemodynamic support secondary to norepinephrine. RESULTS In the unmatched cohort of 124 patients, vasopressin was associated with a significant decrease in the number of severe adverse events (P=.03). In the matched cohort, severe adverse events occurred 3 times as often in patients receiving hydrocortisone; however, this difference was not statistically significant. (odds ratio, 3.33; 95% confidence interval, 0.92-12.11; P=.06). In the matched cohort, vasopressin was associated with a faster time to hemodynamic stability (P<.05) and discontinuation of hemodynamic support (P<.01) with an increased requirement for third-line therapy (P<.01). No statistical differences were seen in length of stay (intensive care unit and hospital), length of mechanical ventilation, and in-hospital mortality. CONCLUSION Given the lower incidence of adverse events and faster time to hemodynamic stability, vasopressin appears to be the most advantageous endocrine agent for hemodynamic support in septic shock.
Collapse
Affiliation(s)
- Brittany D Bissell
- Department of Pharmacy, UF Health Jacksonville, 655 West 8th St, Jacksonville, FL, 32209 USA.
| | - Michael J Erdman
- Department of Pharmacy, UF Health Jacksonville, 655 West 8th St, Jacksonville, FL, 32209 USA.
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, UF College of Medicine- Jacksonville, 580 West 8th St, Jacksonville, FL, 32209 USA.
| | - Dale F Kraemer
- Center for Health Equity and Quality Research, UF College of Medicine- Jacksonville, 580 West 8th St, Jacksonville, FL, 32209 USA.
| | - Jason A Ferreira
- Department of Pharmacy, UF Health Jacksonville, 655 West 8th St, Jacksonville, FL, 32209 USA.
| |
Collapse
|