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Bourne RS, Herridge MS, Burry LD. Less inappropriate medication: first steps in medication optimization to improve post-intensive care patient recovery. Intensive Care Med 2024:10.1007/s00134-024-07405-8. [PMID: 38635046 DOI: 10.1007/s00134-024-07405-8] [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] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Richard S Bourne
- Departments of Pharmacy and Critical Care, Northern General Hospital, Herries Road, Sheffield, UK
- Faculty of Biology, Medicine and Health, Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Oxford Road, Manchester, UK
| | - Margaret S Herridge
- Respiratory and Critical Care Medicine, Temerty Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Lisa D Burry
- Department of Pharmacy and Medicine, Leslie Dan Faculty of Pharmacy and Interdepartmental Division of Critical Care Medicine, Sinai Health, University of Toronto, Toronto, ON, Canada.
- Department of Pharmacy, Mount Sinai Hospital, Room 18-300E, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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2
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Carini FC, Angriman F, Scales DC, Munshi L, Burry LD, Sibai H, Mehta S, Ferreyro BL. Venous thromboembolism in critically ill adult patients with hematologic malignancy: a population-based cohort study. Intensive Care Med 2024; 50:222-233. [PMID: 38170226 DOI: 10.1007/s00134-023-07287-2] [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] [Received: 09/05/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE The aim of this study was to describe the incidence of venous thromboembolism (VTE) and major bleeding among hospitalized patients with hematologic malignancy, assessing its association with critical illness and other baseline characteristics. METHODS We conducted a population-based cohort study of hospitalized adults with a new diagnosis of hematologic malignancy in Ontario, Canada, between 2006 and 2017. The primary outcome was VTE (pulmonary embolism or deep venous thrombosis). Secondary outcomes were major bleeding and in-hospital mortality. We compared the incidence of VTE between intensive care unit (ICU) and non-ICU patients and described the association of other baseline characteristics and VTE. RESULTS Among 76,803 eligible patients (mean age 67 years [standard deviation, SD, 15]), 20,524 had at least one ICU admission. The incidence of VTE was 3.7% in ICU patients compared to 1.2% in non-ICU patients (odds ratio [OR] 3.08; 95% confidence interval [CI] 2.77-3.42). The incidence of major bleeding was 7.6% and 2.4% (OR 3.33; 95% CI 3.09-3.58), respectively. The association of critical illness and VTE remained significant after adjusting for potential confounders (OR 2.92; 95% CI 2.62-3.25). We observed a higher incidence of VTE among specific subtypes of hematologic malignancy and patients with prior VTE (OR 6.64; 95% CI 5.42-8.14). Admission more than 1 year after diagnosis of hematologic malignancy (OR 0.64; 95% CI 0.56-0.74) and platelet count ≤ 50 × 109/L at the time of hospitalization (OR 0.63; 95% CI 0.48-0.84) were associated with a lower incidence of VTE. CONCLUSION Among patients with hematologic malignancy, critical illness and certain baseline characteristics were associated with a higher incidence of VTE.
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Affiliation(s)
- Federico C Carini
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University Health Network, Toronto, ON, Canada.
- Department of Medicine, Sinai Health System, Toronto, ON, Canada.
- Mount Sinai Hospital, 600 University Avenue, Suite 5-292, Toronto, ON, M5G 1X5, Canada.
| | - Federico Angriman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES (Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Lisa D Burry
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- Department of Pharmacy, Sinai Health System, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Hassan Sibai
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
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3
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Jaworska N, Krewulak KD, Schalm E, Niven DJ, Ismail Z, Burry LD, Leigh JP, Fiest KM. Facilitators and Barriers Influencing Antipsychotic Medication Prescribing and Deprescribing Practices in Critically Ill Adult Patients: a Qualitative Study. J Gen Intern Med 2023; 38:2262-2271. [PMID: 37072535 PMCID: PMC10112822 DOI: 10.1007/s11606-023-08042-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/13/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Antipsychotic medications do not alter the incidence or duration of delirium, but these medications are frequently prescribed and continued at transitions of care in critically ill patients when they may no longer be necessary or appropriate. OBJECTIVE The purpose of this study was to identify and describe relevant domains and constructs that influence antipsychotic medication prescribing and deprescribing practices among physicians, nurses, and pharmacists that care for critically ill adult patients during and following critical illness. DESIGN We conducted qualitative semi-structured interviews with critical care and ward healthcare professionals including physicians, nurses, and pharmacists to understand antipsychotic prescribing and deprescribing practices for critically ill adult patients during and following critical illness. PARTICIPANTS Twenty-one interviews were conducted with 11 physicians, five nurses, and five pharmacists from predominantly academic centres in Alberta, Canada, between July 6 and October 29, 2021. MAIN MEASURES We used deductive thematic analysis using the Theoretical Domains Framework (TDF) to identify and describe constructs within relevant domains. KEY RESULTS Seven TDF domains were identified as relevant from the analysis: Social/Professional role and identity; Beliefs about capabilities; Reinforcement; Motivations and goals; Memory, attention, and decision processes; Environmental context and resources; and Beliefs about consequences. Participants reported antipsychotic prescribing for multiple indications beyond delirium and agitation including patient and staff safety, sleep management, and environmental factors such as staff availability and workload. Participants identified potential antipsychotic deprescribing strategies to reduce ongoing antipsychotic medication prescriptions for critically ill patients including direct communication tools between prescribers at transitions of care. CONCLUSIONS Critical care and ward healthcare professionals report several factors influencing established antipsychotic medication prescribing practices. These factors aim to maintain patient and staff safety to facilitate the provision of care to patients with delirium and agitation limiting adherence to current guideline recommendations.
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Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.
- Alberta Health Services, Calgary, AB, Canada.
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Emma Schalm
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa D Burry
- Departments of Pharmacy and Medicine, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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4
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Jaworska N, Soo A, Stelfox HT, Burry LD, Fiest KM. Impacts of antipsychotic medication prescribing practices in critically ill adult patients on health resource utilization and new psychoactive medication prescriptions. PLoS One 2023; 18:e0287929. [PMID: 37384760 PMCID: PMC10310007 DOI: 10.1371/journal.pone.0287929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Antipsychotic medications are commonly prescribed to critically ill adult patients and initiation of new antipsychotic prescriptions in the intensive care unit (ICU) increases the proportion of patients discharged home on antipsychotics. Critically ill adult patients are also frequently exposed to multiple psychoactive medications during ICU admission and hospitalization including benzodiazepines and opioid medications which may increase the risk of psychoactive polypharmacy following hospital discharge. The associated impact on health resource utilization and risk of new benzodiazepine and opioid prescriptions is unknown. RESEARCH QUESTION What is the burden of health resource utilization and odds of new prescriptions of benzodiazepines and opioids up to 1-year post-hospital discharge in critically ill patients with new antipsychotic prescriptions at hospital discharge? STUDY DESIGN & METHODS We completed a multi-center, propensity-score matched retrospective cohort study of critically ill adult patients. The primary exposure was administration of ≥1 dose of an antipsychotic while the patient was admitted in the ICU and ward with continuation at hospital discharge and a filled outpatient prescription within 1-year following hospital discharge. The control group was defined as no doses of antipsychotics administered in the ICU and hospital ward and no filled outpatient prescriptions for antipsychotics within 1-year following hospital discharge. The primary outcome was health resource utilization (72-hour ICU readmission, 30-day hospital readmission, 30-day emergency room visitation, 30-day mortality). Secondary outcomes were administration of benzodiazepines and/or opioids in-hospital and following hospital discharge in patients receiving antipsychotics. RESULTS 1,388 propensity-score matched patients were included who did and did not receive antipsychotics in ICU and survived to hospital discharge. New antipsychotic prescriptions were not associated with increased health resource utilization or 30-day mortality following hospital discharge. There was increased odds of new prescriptions of benzodiazepines (adjusted odds ratio [aOR] 1.61 [95%CI 1.19-2.19]) and opioids (aOR 1.82 [95%CI 1.38-2.40]) up to 1-year following hospital discharge in patients continuing antipsychotics at hospital discharge. INTERPRETATION New antipsychotic prescriptions at hospital discharge are significantly associated with additional prescriptions of benzodiazepines and opioids in-hospital and up to 1-year following hospital discharge.
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Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Leslie Dan Faculty of Pharmacy, O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lisa D. Burry
- Departments of Pharmacy and Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Kirsten M. Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Leslie Dan Faculty of Pharmacy, O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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5
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Burry LD, Bell CM, Hill A, Pinto R, Scales DC, Bronskill SE, Williamson D, Rose L, Fu L, Fowler R, Martin CM, Dolovich L, Wunsch H. New and Persistent Sedative Prescriptions Among Older Adults Following a Critical Illness: A Population-Based Cohort Study. Chest 2023; 163:1425-1436. [PMID: 36610663 DOI: 10.1016/j.chest.2022.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 12/01/2022] [Accepted: 12/08/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use posthospitalization. RESEARCH QUESTION For sedative-naive, older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt? STUDY DESIGN AND METHODS This population-based cohort study included ICU survivors aged ≥ 66 years who had not filled sedative prescriptions within ≤ 6 months before hospitalization (sedative-naive) in Ontario, Canada (2003-2019). Using multilevel logistic regression, demographic, clinical, and hospital characteristics and their association with new sedative prescription within ≤ 7 days of discharge are described. Variation between hospitals was quantified by using the adjusted median OR. Factors associated with persistent prescriptions (≤ 6 months) were examined with a multivariable proportional hazards model. RESULTS A total of 250,428 patients were included (mean age, 76 years; 61% male). A total of 15,277 (6.1%) filled a new sedative prescription, with variation noted across hospitals (2% [95% CI, 1-3] to 44% [95% CI, 3-57]); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (adjusted OR [aOR], 4.00; 95% CI, 3.72-4.31), receipt of inpatient geriatric (aOR, 1.95; 95% CI, 1.80-2.10) or psychiatry (aOR, 2.76; 95% CI, 2.62-2.91) consultation, invasive ventilation (aOR, 1.59; 95% CI, 1.53-1.66), and ICU length of stay ≥ 7 days (aOR, 1.50; 95% CI, 1.42-1.58). The residual heterogeneity between hospitals (adjusted median OR, 1.43; 95% CI, 1.35-1.49) had a stronger association with new sedative prescriptions than the Charlson Comorbidity Index score or sepsis. Factors associated with persistent sedative use were similar with the addition of female subjects (subdistribution hazard ratio, 1.07; 95% CI, 1.02-1.13) and pre-existing polypharmacy (subdistribution hazard ratio, 0.88; 95% CI, 0.80-0.93). INTERPRETATION One in 15 sedative-naive, older adult ICU survivors filled a new sedative within ≤ 7 days of discharge; more than one-half of these survivors filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.
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Affiliation(s)
- Lisa D Burry
- Department of Pharmacy, Sinai Health System, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
| | - Chaim M Bell
- Department of Medicine, Sinai Health System, Toronto, ON, Canada; Departments of Medicine and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andrea Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Susan E Bronskill
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health. University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada; Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Montréal, QC, Canada; Research Center, CIUSSS du Nord-de-l'Île-de-Montréal, QC, Canada
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England
| | | | - Robert Fowler
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Toronto, ON, Canada; Lawson Health Research Institute, London, ON, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada; ICES, Toronto, ON, Canada
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6
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Sprung CL, Devereaux AV, Ghazipura M, Burry LD, Hossain T, Hamele MT, Gist RE, Dempsey TM, Dichter JR, Henry KN, Niven AS, Alptunaer T, Huffines M, Bowden KR, Martland AMO, Felzer JR, Mitchell SH, Tosh PK, Persoff J, Mukherjee V, Downar J, Báez AA, Maves RC. Critical Care Staffing in Pandemics and Disasters: A Consensus Report from a Sub-committee of the Task Force for Mass Critical Care- Systems Strategies to Sustain the Healthcare Workforce. Chest 2023:S0012-3692(23)00331-8. [PMID: 36907373 PMCID: PMC10007715 DOI: 10.1016/j.chest.2023.03.008] [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: 11/18/2022] [Revised: 02/21/2023] [Accepted: 03/02/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND The 2019 coronavirus disease (COVID-19) pandemic has led to unprecedented mental health disturbances, burnout, and moral distress among healthcare workers, impacting their ability to care for themselves and their patients. METHODS The Workforce Sustainment subcommittee of the Task Force for Mass Critical Care (TFMCC) utilized a consensus development process, incorporating evidence from literature review with expert opinion through a modified Delphi approach to determine factors impacting mental health, burnout, and moral distress in healthcare workers, in order to propose necessary actions to help prevent these issues and enhance workforce resilience, sustainment, and retention. RESULTS Consolidation of evidence gathered from literature review and expert opinion resulted in 197 total statements that were synthesized into 14 major suggestions. These suggestions were organized into three categories: (1) mental health and wellbeing for staff in medical settings, (2) system-level support and leadership, and (3) research priorities and gaps. Suggestions include both general and specific occupational interventions to support healthcare worker basic physical needs, psychological distress, reduce moral distress and burnout, and foster mental health and resilience. CONCLUSIONS The Workforce Sustainment subcommittee of the TFMCC offers evidence-informed operational strategies to assist healthcare workers and hospitals plan, prevent, and treat the factors impacting healthcare worker mental health, burnout, and moral distress to improve resilience and retention following the COVID-19 pandemic.
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Affiliation(s)
- Charles L Sprung
- Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | | | - Tanzib Hossain
- New York University, Grossman School of Medicine, New York, New York, USA
| | - Mitchell T Hamele
- Tripler Army Medical Center, Honolulu, Hawaii, USA; Uniformed Services University, Bethesda, Maryland, USA
| | - Ramon E Gist
- SUNY Downstate Health Science University, Brooklyn, New York, USA
| | - Timothy M Dempsey
- David Grant Medical Center, US Air Force, Travis AFB, California, USA
| | | | | | | | - Timur Alptunaer
- Uniformed Services University, Bethesda, Maryland, USA; Leonard J. Chabert Medical Center Houma, Louisiana, USA
| | | | - Kasey R Bowden
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | | | | | - Jason Persoff
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Amado A Báez
- Medical College of Georgia, Augusta, Georgia, USA
| | - Ryan C Maves
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Jaworska N, Moss SJ, Krewulak KD, Stelfox Z, Niven DJ, Ismail Z, Burry LD, Fiest KM. A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings. BMC Health Serv Res 2022; 22:1272. [PMID: 36271347 PMCID: PMC9587627 DOI: 10.1186/s12913-022-08650-7] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 10/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background Antipsychotic medications are frequently prescribed in acute care for clinical indications other than primary psychiatric disorders such as delirium. Unfortunately, they are commonly continued at hospital discharge and at follow-ups thereafter. The objective of this scoping review was to characterize antipsychotic medication prescribing practices, to describe healthcare professional perceptions on antipsychotic prescribing and deprescribing practices, and to report on antipsychotic deprescribing strategies within acute care. Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases from inception date to July 3, 2021 for published primary research studies reporting on antipsychotic medication prescribing and deprescribing practices, and perceptions on those practices within acute care. We included all study designs excluding protocols, editorials, opinion pieces, and systematic or scoping reviews. Two reviewers screened and abstracted data independently and in duplicate. The protocol was registered on Open Science Framework prior to data abstraction (10.17605/OSF.IO/W635Z). Results Of 4528 studies screened, we included 80 studies. Healthcare professionals across all acute care settings (intensive care, inpatient, emergency department) perceived prescribing haloperidol (n = 36/36, 100%) most frequently, while measured prescribing practices reported common quetiapine prescribing (n = 26/36, 76%). Indications for antipsychotic prescribing were delirium (n = 48/69, 70%) and agitation (n = 20/69, 29%). Quetiapine (n = 18/18, 100%) was most frequently prescribed at hospital discharge. Three studies reported in-hospital antipsychotic deprescribing strategies focused on pharmacist-driven deprescribing authority, handoff tools, and educational sessions. Conclusions Perceived antipsychotic prescribing practices differed from measured prescribing practices in acute care settings. Few in-hospital deprescribing strategies were described. Ongoing evaluation of antipsychotic deprescribing strategies are needed to evaluate their efficacy and risk. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08650-7.
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Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada. .,Alberta Health Services, Calgary, AB, Canada.
| | - Stephana J Moss
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Zara Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa D Burry
- Departments of Pharmacy and Medicine, Leslie Dan Faculty of Pharmacy, Sinai Health System, University of Toronto, Toronto, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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8
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Chan K, Burry LD, Tse C, Wunsch H, De Castro C, Williamson DR. Impact of Ketamine on Analgosedative Consumption in Critically Ill Patients: A Systematic Review and Meta-Analysis. Ann Pharmacother 2022; 56:1139-1158. [PMID: 35081769 PMCID: PMC9393656 DOI: 10.1177/10600280211069617] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: The aim of this study was to synthesize evidence available on continuous
infusion ketamine versus nonketamine regimens for analgosedation in
critically ill patients. Data sources A search of MEDLINE, EMBASE, CINAHL, CDSR, and ClinicalTrials.gov was
performed from database establishment to November 2021 using the following
search terms: critical care, ICU, ketamine, sedation, and
anesthesia. All studies included the primary outcome of
interest: daily opioid and/or sedative consumption. Study selection and data extraction Relevant human studies were considered. Randomized controlled trials (RCT),
quasi-experimental studies, and observational cohort studies were eligible.
Two reviewers independently screened articles, extracted data, and appraised
studies using the Cochrane RoB and ROBINS-I tools. Data synthesis A total of 13 RCTs, 5 retrospective, and 1 prospective cohort study were
included (2255 participants). The primary analysis of six RCTs demonstrated
reduced opioid consumption with ketamine regimens (n = 494 participants,
−13.19 µg kg−1 h−1 morphine equivalents, 95% CI −22.10
to −4.28, P = 0.004). No significant difference was
observed in sedative consumption, duration of mechanical ventilation (MV),
ICU or hospital length of stay (LOS), intracranial pressure, and mortality.
Small sample size of studies may have limited ability to detect true
differences between groups. Relevance to patient care and clinical practice This meta-analysis examining ketamine use in critically ill patients is the
first restricting analysis to RCTs and includes up-to-date publication of
trials. Findings may guide clinicians in consideration and dosing of
ketamine for multimodal analgosedation. Conclusion Results suggest ketamine as an adjunct analgosedative has the potential to
reduce opioid exposure in postoperative and MV patients in the ICU. More
RCTs are required before recommending routine use of ketamine in select
populations.
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Affiliation(s)
- Katalina Chan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Novo Nordisk Canada Inc, Mississauga, ON, Canada
| | - Lisa D Burry
- Department of Pharmacy and Medicine, Sinai Health System, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Christopher Tse
- Department of Pharmacy, Princess Margaret Hospital, Toronto, ON, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Charmaine De Castro
- Sidney Liswood Health Sciences Library, Sinai Health System, Toronto, ON, Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada.,Pharmacy Department and Research Center, CIUSSS du nord-de-l'Île-de-Montréal, Sacré-Cœur Hospital, Montréal, QC, Canada
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9
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Dichter JR, Devereaux AV, Sprung CL, Mukherjee V, Persoff J, Baum KD, Ornoff D, Uppal A, Hossain T, Henry KN, Ghazipura M, Bowden KR, Feldman HJ, Hamele MT, Burry LD, Martland AMO, Huffines M, Tosh PK, Downar J, Hick JL, Christian MD, Maves RC. Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care. Chest 2021; 161:429-447. [PMID: 34499878 PMCID: PMC8420082 DOI: 10.1016/j.chest.2021.08.072] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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: 06/10/2021] [Revised: 08/05/2021] [Accepted: 08/19/2021] [Indexed: 01/25/2023] Open
Abstract
Background After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world. Research Question A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality. Study Design and Methods TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, “gray” evidence from lay media sources, and anecdotal experiential evidence. Results Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. Interpretation A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.
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Affiliation(s)
| | | | | | | | | | | | | | - Amit Uppal
- Grossman School of Medicine, New York University, New York, NY
| | - Tanzib Hossain
- Grossman School of Medicine, New York University, New York, NY
| | | | - Marya Ghazipura
- Grossman School of Medicine, New York University, New York, NY
| | | | - Henry J Feldman
- Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Cambridge, MA
| | - Mitchell T Hamele
- Uniformed Services University, Bethesda, MD; Tripler Army Medical Center, Honolulu, HI
| | | | | | | | | | | | - John L Hick
- University of Minnesota, Minneapolis, MN; Hennepin Health Care, Minneapolis, MN
| | - Michael D Christian
- Research & Clinical Effectiveness Lead/HEMS Doctor, London's Air Ambulance, Bart's NHS Health Trust, London, England
| | - Ryan C Maves
- Uniformed Services University, Bethesda, MD; Wake Forest School of Medicine, Winston-Salem, NC
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10
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Sneyers B, Duceppe MA, Frenette AJ, Burry LD, Rico P, Lavoie A, Gélinas C, Mehta S, Dagenais M, Williamson DR, Perreault MM. Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies. Drugs 2021; 80:1211-1233. [PMID: 32592134 PMCID: PMC7317263 DOI: 10.1007/s40265-020-01338-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Critically ill patients are at high risk of iatrogenic withdrawal syndrome (IWS), due to exposure to high doses or prolonged periods of opioids and benzodiazepines. PURPOSE To examine pharmacological management strategies designed to prevent and/or treat IWS from opioids and/or benzodiazepines in critically ill neonates, children and adults. METHODS We included non-randomised studies of interventions (NRSI) and randomised controlled trials (RCTs), reporting on interventions to prevent or manage IWS in critically ill neonatal, paediatric and adult patients. Database searching included: PubMed, CINAHL, Embase, Cochrane databases, TRIP, CMA Infobase and NICE evidence. Additional grey literature was examined. Study selection and data extraction were performed in duplicate. Data collected included: population, definition of opioid, benzodiazepine or mixed IWS, its assessment and management (drug or strategy, route of administration, dosage and titration), previous drug exposures and outcomes measures. Methodological quality assessment was performed by two independent reviewers using the Cochrane risk of bias tool for RCTs and the ROBINS-I tool for NRSI. A qualitative synthesis of the results is provided. For the subset of studies evaluating multifaceted protocolised care, we meta-analysed results for 4 outcomes and examined the quality of evidence using GRADE post hoc. RESULTS Thirteen studies were eligible, including 10 NRSI and 3 RCTs; 11 of these included neonatal and paediatric patients exclusively. Eight studies evaluated multifaceted protocolised interventions, while 5 evaluated individual components of IWS management (e.g. clonidine or methadone at varying dosages, routes of administration and duration of tapering). IWS was measured using an appropriate tool in 6 studies. Ten studies reported upon occurrence of IWS, showing significant reductions (n = 4) or no differences (n = 6). Interventions failed to impact duration of mechanical ventilation, ICU length of stay, and adverse effects. Impact on opioid and/or benzodiazepine total doses and duration showed no differences in 4 studies, while 3 showed opioid and benzodiazepine cumulative doses were significantly reduced by 20-35% and 32-66%, and treatment durations by 1.5-11 and 19 days, respectively. Variable effects on intervention drug exposures were found. Weaning durations were reduced by 6-12 days (n = 4) for opioids and/or methadone and by 13 days (n = 1) for benzodiazepines. In contrast, two studies using interventions centred on transition to enteral routes or longer tapering durations found significant increases in intervention drug exposures. Interventions had overall non-significant effects on additional drug requirements (except for one study). Included studies were at high risk of bias, relating to selection, detection and reporting bias. CONCLUSION Interventions for IWS management fail to impact duration of mechanical ventilation or ICU length of stay, while effect on occurrence of IWS and drug exposures is inconsistent. Heterogeneity in the interventions used and methodological issues, including inappropriate and/or subjective identification of IWS and bias due to study design, limited the conclusions.
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Affiliation(s)
- Barbara Sneyers
- Pharmacy Department, Centre Hospitalier Universitaire UCL Namur, Yvoir, Belgium.
| | | | - Anne Julie Frenette
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Lisa D Burry
- Pharmacy Department, Mount Sinai Hospital, Sinai Health System, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Philippe Rico
- Faculté de Médicine, Université de Montréal, Montreal, Canada.,Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Annie Lavoie
- Pharmacy Department, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, Canada.,Centre for Nursing Research/Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Maryse Dagenais
- Paediatric Intensive Care Unit, McGill University Health Centre, Montreal, Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Marc M Perreault
- Pharmacy Department, McGill University Health Centre, Montreal, Canada.,Faculté de Pharmacie, Université de Montréal, Montreal, Canada
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11
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Burry LD, Cheng W, Williamson DR, Adhikari NK, Egerod I, Kanji S, Martin CM, Hutton B, Rose L. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis. Intensive Care Med 2021; 47:943-960. [PMID: 34379152 PMCID: PMC8356549 DOI: 10.1007/s00134-021-06490-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [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: 03/19/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the effects of prevention interventions on delirium occurrence in critically ill adults. METHODS MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects. RESULTS Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials, N = 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha2 agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21-0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08-0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06-0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10-0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09-0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64-0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61-0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care. CONCLUSION Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.
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Affiliation(s)
- Lisa D. Burry
- grid.416166.20000 0004 0473 9881Department of Pharmacy, Mount Sinai Hospital, Room 18-377, 600 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.416166.20000 0004 0473 9881Department Medicine, Mount Sinai Hospital, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Wei Cheng
- grid.47100.320000000419368710Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
| | - David R. Williamson
- grid.14848.310000 0001 2292 3357Pharmacy Department, Université de Montréal, Montréal, Canada ,grid.414056.20000 0001 2160 7387Pharmacy Department and Research Centre, CIUSSS-NIM Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
| | - Neill K. Adhikari
- grid.413104.30000 0000 9743 1587Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Ingrid Egerod
- grid.475435.4Intensive Care Unit 4131, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Salmaan Kanji
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - Claudio M. Martin
- grid.412745.10000 0000 9132 1600Division of Critical Care, London Health Sciences Centre, London, Canada ,grid.39381.300000 0004 1936 8884Department of Medicine, The University of Western Ontario, London, Canada
| | - Brian Hutton
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Louise Rose
- grid.13097.3c0000 0001 2322 6764Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
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12
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Burry LD, Barletta JF, Williamson D, Kanji S, Maves RC, Dichter J, Christian MD, Geiling J, Erstad BL. It Takes a Village…: Contending With Drug Shortages During Disasters. Chest 2020; 158:2414-2424. [PMID: 32805237 PMCID: PMC7426714 DOI: 10.1016/j.chest.2020.08.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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: 06/12/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 12/27/2022] Open
Abstract
Critical drug shortages have been widely documented during the coronavirus disease 2019 (COVID-19) pandemic, particularly for IV sedatives used to facilitate mechanical ventilation. Surges in volume of patients requiring mechanical ventilation coupled with prolonged ventilator days and the high sedative dosing requirements observed quickly led to the depletion of “just-in-time” inventories typically maintained by institutions. This manuscript describes drug shortages in the context of global, manufacturing, regional and institutional perspectives in times of a worldwide crisis such as a pandemic. We describe etiologic factors that lead to drug shortages including issues related to supply (eg, manufacturing difficulties, supply chain breakdowns) and variables that influence demand (eg, volatile prescribing practices, anecdotal or low-level data, hoarding). In addition, we describe methods to mitigate drug shortages as well as conservation strategies for sedatives, analgesics and neuromuscular blockers that could readily be applied at the bedside. The COVID-19 pandemic has accentuated the need for a coordinated, multi-pronged approach to optimize medication availability as individual or unilateral efforts are unlikely to be successful.
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Affiliation(s)
- Lisa D Burry
- Department of Pharmacy and Medicine, Sinai Health System, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
| | | | - David Williamson
- Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal-Hôpital du Sacré-Cœur de Montréal, Faculté de pharmacie, Université de Montréal, Montréal, QC, Canada
| | - Salmaan Kanji
- The Ottawa Hospital and The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ryan C Maves
- Department of Medicine, Naval Medical Center, San Diego, CA; Department of Medicine, Uniformed Services University, Bethesda, MD
| | - Jeffrey Dichter
- Pulmonary, Allergy, Critical Care, and Sleep Medicine Division, University of Minnesota, Minneapolis, MN
| | - Michael D Christian
- London's Air Ambulance, Royal London Hospital, Barts NHS Health Trust, London, England
| | | | - Brian L Erstad
- The University of Arizona College of Pharmacy, Tucson, AZ
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13
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Mehta N, Martinez Guasch F, Kamen C, Shah S, Burry LD, Soong C, Mehta S. Proton Pump Inhibitors in the Elderly Hospitalized Patient: Evaluating Appropriate Use and Deprescribing. J Pharm Technol 2020; 36:54-60. [PMID: 34752519 DOI: 10.1177/8755122519894953] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Proton pump inhibitors (PPIs) are often prescribed for elderly patients without appropriate indication, or for longer durations than recommended. Objective: To review appropriateness of PPI use prior to and in hospital, and deprescribing rates across different hospital units. Methods: Retrospective analysis of patients ≥65 years admitted to 5 acute care units: intensive care unit, acute care for elderly, orthopedics, surgery, and medicine. Patients who were "non-naive" (prehospital PPI use) or "naive" (new PPI initiated in hospital) users were included. For both groups, demographics, reason for admission, length of stay, comorbidities, name and number of home medications, PPI name, dose and indication, and PPI discharge instructions were collected. For naive patients, duration of in-hospital use and prescriber specialty was recorded. Results: Among non-naive patients (n = 377), for 37 patients (10%), the indication for a PPI was not appropriate, and for 92 patients (24%), the indication was unclear. Most patients had their home PPI continued while in hospital (87%) and at discharge (90%). Among naive (n = 93) patients, for 8 patients (9%), the indication for a PPI was not appropriate, and for 25 (27%) patients, the indication was unclear. PPI was prescribed to only 16 (18%) by the gastrointestinal consult service. Most patients had their new PPI continued at discharge (74%); only 7 (9%) were discharged with a plan to reassess PPI indication. Conclusion: PPIs are infrequently deprescribed during hospital admission, despite inappropriate or unclear indications for use. Thorough medication reconciliation, documentation of PPI indication and duration, and institutional focus on deprescribing are encouraged.
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Affiliation(s)
- Nishila Mehta
- Faculty of Medicine, University of Toronto, Toronto ON, Canada
| | | | - Corey Kamen
- Faculty of Medicine, University of Toronto, Toronto ON, Canada
| | - Sumesh Shah
- Sinai Health System, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa D Burry
- Sinai Health System, Toronto, ON, Canada.,Department of Pharmacy, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | | | - Sangeeta Mehta
- Sinai Health System, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
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14
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van den Boogaard M, Wassenaar A, van Haren FMP, Slooter AJC, Jorens PG, van der Jagt M, Simons KS, Egerod I, Burry LD, Beishuizen A, Pickkers P, Devlin JW. Influence of sedation on delirium recognition in critically ill patients: A multinational cohort study. Aust Crit Care 2020; 33:420-425. [PMID: 32035691 DOI: 10.1016/j.aucc.2019.12.002] [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: 05/18/2019] [Revised: 12/05/2019] [Accepted: 12/12/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Guidelines advocate intensive care unit (ICU) patients be regularly assessed for delirium using either the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC). Single-centre studies, primarily with the CAM-ICU, suggest level of sedation may influence delirium screening results. OBJECTIVE The objective of this study was to determine the association between level of sedation and delirium occurrence in critically ill patients assessed with either the CAM-ICU or the ICDSC. METHODS This was a secondary analysis of a multinational, prospective cohort study performed in nine ICUs from seven countries. Consecutive ICU patients with a Richmond Agitation-Sedation Scale (RASS) of -3 to 0 at the time of delirium assessment where a RASS ≤ 0 was secondary to a sedating medication. Patients were assessed with either the CAM-ICU or the ICDSC. Logistic regression analysis was used to account for factors with the potential to influence level of sedation or delirium occurrence. RESULTS Among 1660 patients, 1203 patients underwent 5741 CAM-ICU assessments [9.6% were delirium positive; at RASS = 0 (3.3% were delirium positive), RASS = -1 (19.3%), RASS = -2 (35.1%); RASS = -3 (39.0%)]. The other 457 patients underwent 3210 ICDSC assessments [11.6% delirium positive; at RASS = 0 (4.9% were delirium positive), RASS = -1 (15.8%), RASS = -2 (26.6%); RASS = -3 (20.6%)]. A RASS of -3 was associated with more positive delirium evaluations (odds ratio: 2.31; 95% confidence interval: 1.34-3.98) in the CAM-ICU-assessed patients (vs. the ICDSC-assessed patients). At a RASS of 0, assessment with the CAM-ICU (vs. the ICDSC) was associated with fewer positive delirium evaluations (odds ratio: 0.58; 95% confidence interval: 0.43-0.78). At a RASS of -1 or -2, no association was found between the delirium assessment method used (i.e., CAM-ICU or ICDSC) and a positive delirium evaluation. CONCLUSIONS The influence of level of sedation on a delirium assessment result depends on whether the CAM-ICU or ICDSC is used. Bedside ICU nurses should consider these results when evaluating their sedated patients for delirium. Future research is necessary to compare the CAM-ICU and the ICDSC simultaneously in sedated and nonsedated ICU patients. TRIAL REGISTRATION ClinicalTrials.gov; NCT02518646.
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Affiliation(s)
- Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, the Netherlands.
| | - Annelies Wassenaar
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, the Netherlands.
| | - Frank M P van Haren
- Intensive Care Unit, The Canberra Hospital, Woden, Canberra, Australia; Australian National University Medical School, Canberra, Australia; University of Canberra, Faculty of Health, Canberra, Australia.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Antwerp, Belgium.
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Koen S Simons
- Department of Intensive Care Medicine, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, the Netherlands.
| | - Ingrid Egerod
- Intensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Lisa D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; Mount Sinai Hospital, Sinai Health System, Toronto, Canada.
| | - Albertus Beishuizen
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, the Netherlands.
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, USA.
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15
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Williamson D, Frenette AJ, Burry LD, Perreault M, Charbonney E, Lamontagne F, Potvin MJ, Giguère JF, Mehta S, Bernard F. Pharmacological interventions for agitated behaviours in patients with traumatic brain injury: a systematic review. BMJ Open 2019; 9:e029604. [PMID: 31289093 PMCID: PMC6615826 DOI: 10.1136/bmjopen-2019-029604] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The aim of this systematic review was to assess the efficacy and safety of pharmacological agents in the management of agitated behaviours following traumatic brain injury (TBI). METHODS We performed a search strategy in PubMed, OvidMEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science and Prospero (up to 10 December 2018) for published and unpublished evidence on the risks and benefits of 9 prespecified medications classes used to control agitated behaviours following TBI. We included all randomised controlled trials, quasi-experimental and observational studies examining the effects of medications administered to control agitated behaviours in TBI patients. Included studies were classified into three mutually exclusive categories: (1) agitated behaviour was the presenting symptom; (2) agitated behaviour was not the presenting symptom, but was measured as an outcome variable; and (3) safety of pharmacological interventions administered to control agitated behaviours was measured. RESULTS Among the 181 articles assessed for eligibility, 21 studies were included. Of the studies suggesting possible benefits, propranolol reduced maximum intensities of agitation per week and physical restraint use, methylphenidate improved anger measures following 6 weeks of treatment, valproic acid reduced weekly agitated behaviour scale ratings and olanzapine reduced irritability, aggressiveness and insomnia between weeks 1 and 3 of treatment. Amantadine showed variable effects and may increase the risk of agitation in the critically ill. In three studies evaluating safety outcomes, antipsychotics were associated with an increased duration of post-traumatic amnesia (PTA) in unadjusted analyses. Small sample sizes, heterogeneity and an unclear risk of bias were limits. CONCLUSIONS Propranolol, methylphenidate, valproic acid and olanzapine may offer some benefit; however, they need to be further studied. Antipsychotics may increase the length of PTA. More studies on tailored interventions and continuous evaluation of safety and efficacy throughout acute, rehabilitation and outpatient settings are needed. PROSPERO REGISTRATION NUMBER CRD42016033140.
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Affiliation(s)
- David Williamson
- Pharmacy, Université de Montréal, Montreal, Quebec, Canada
- Pharmacy, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | | | - Lisa D Burry
- Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada
- Faculty of Pharmacy, University of Toronto Leslie Dan, Toronto, Ontario, Canada
| | - Marc Perreault
- Pharmacy, Université de Montréal, Montreal, Quebec, Canada
- Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Marie-Julie Potvin
- Psychology, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Jean-Francois Giguère
- Neurosurgery, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
- Médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Francis Bernard
- Médecine, Université de Montréal, Montreal, Quebec, Canada
- Critical Care, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
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16
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Duceppe MA, Perreault MM, Frenette AJ, Burry LD, Rico P, Lavoie A, Gélinas C, Mehta S, Dagenais M, Williamson DR. Frequency, risk factors and symptomatology of iatrogenic withdrawal from opioids and benzodiazepines in critically Ill neonates, children and adults: A systematic review of clinical studies. J Clin Pharm Ther 2018; 44:148-156. [DOI: 10.1111/jcpt.12787] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/19/2018] [Indexed: 12/01/2022]
Affiliation(s)
| | - Marc M. Perreault
- Pharmacy Department; McGill University Health Centre; Montreal Quebec Canada
- Faculté de Pharmacie; Université de Montréal; Montreal Quebec Canada
| | - Anne Julie Frenette
- Faculté de Pharmacie; Université de Montréal; Montreal Quebec Canada
- Pharmacy Department; Hôpital du Sacré-Coeur de Montréal; Montreal Quebec Canada
| | - Lisa D. Burry
- Pharmacy Department, Mount Sinai Hospital; Sinai Health System; Toronto Ontario Canada
- Leslie Dan Faculty of Pharmacy; University of Toronto; Toronto Ontario Canada
| | - Philippe Rico
- Faculté de Médicine; Université de Montréal; Montreal Quebec Canada
- Department of Critical Care; Hôpital du Sacré-Coeur de Montréal; Montreal Quebec Canada
| | - Annie Lavoie
- Faculté de Pharmacie; Université de Montréal; Montreal Quebec Canada
- Pharmacy Department; Centre Hospitalier Universitaire Sainte-Justine; Montreal Quebec Canada
| | - Céline Gélinas
- Ingram School of Nursing; McGill University; Montreal Quebec Canada
- Centre for Nursing Research/Lady Davis Institute; Jewish General Hospital; Montreal Quebec Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine; University of Toronto; Toronto Ontario Canada
| | - Maryse Dagenais
- Pediatric Intensive Care Unit; McGill University Health Centre; Montreal Quebec Canada
| | - David R. Williamson
- Faculté de Pharmacie; Université de Montréal; Montreal Quebec Canada
- Pharmacy Department; Hôpital du Sacré-Coeur de Montréal; Montreal Quebec Canada
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17
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Wassenaar A, Schoonhoven L, Devlin JW, van Haren FMP, Slooter AJC, Jorens PG, van der Jagt M, Simons KS, Egerod I, Burry LD, Beishuizen A, Matos J, Donders ART, Pickkers P, van den Boogaard M. Delirium prediction in the intensive care unit: comparison of two delirium prediction models. Crit Care 2018; 22:114. [PMID: 29728150 PMCID: PMC5935943 DOI: 10.1186/s13054-018-2037-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [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: 11/27/2017] [Accepted: 04/13/2018] [Indexed: 12/12/2022]
Abstract
Background Accurate prediction of delirium in the intensive care unit (ICU) may facilitate efficient use of early preventive strategies and stratification of ICU patients by delirium risk in clinical research, but the optimal delirium prediction model to use is unclear. We compared the predictive performance and user convenience of the prediction model for delirium (PRE-DELIRIC) and early prediction model for delirium (E-PRE-DELIRIC) in ICU patients and determined the value of a two-stage calculation. Methods This 7-country, 11-hospital, prospective cohort study evaluated consecutive adults admitted to the ICU who could be reliably assessed for delirium using the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist. The predictive performance of the models was measured using the area under the receiver operating characteristic curve. Calibration was assessed graphically. A physician questionnaire evaluated user convenience. For the two-stage calculation we used E-PRE-DELIRIC immediately after ICU admission and updated the prediction using PRE-DELIRIC after 24 h. Results In total 2178 patients were included. The area under the receiver operating characteristic curve was significantly greater for PRE-DELIRIC (0.74 (95% confidence interval 0.71–0.76)) compared to E-PRE-DELIRIC (0.68 (95% confidence interval 0.66–0.71)) (z score of − 2.73 (p < 0.01)). Both models were well-calibrated. The sensitivity improved when using the two-stage calculation in low-risk patients. Compared to PRE-DELIRIC, ICU physicians (n = 68) rated the E-PRE-DELIRIC model more feasible. Conclusions While both ICU delirium prediction models have moderate-to-good performance, the PRE-DELIRIC model predicts delirium better. However, ICU physicians rated the user convenience of E-PRE-DELIRIC superior to PRE-DELIRIC. In low-risk patients the delirium prediction further improves after an update with the PRE-DELIRIC model after 24 h. Trial registration ClinicalTrials.gov, NCT02518646. Registered on 21 July 2015. Electronic supplementary material The online version of this article (10.1186/s13054-018-2037-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annelies Wassenaar
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Lisette Schoonhoven
- Faculty of Health Sciences and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (Wessex), University of Southampton, Southampton, UK.,Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, the Netherlands
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, USA
| | - Frank M P van Haren
- Intensive Care Unit, The Canberra Hospital, Canberra, Australia.,Faculty of Health, University of Canberra, Canberra, Australia.,College of Health and Medicine, Australian National University, Canberra, Australia
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Antwerp, Belgium
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Koen S Simons
- Department of Intensive Care Medicine, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, the Netherlands
| | - Ingrid Egerod
- Intensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lisa D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Mount Sinai Hospital, Sinai Health System, Toronto, Canada
| | - Albertus Beishuizen
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Joaquim Matos
- Department of Intensive Care Medicine, Hospital Espírito Santo, Evora, Portugal
| | - A Rogier T Donders
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, the Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands.,Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, the Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands.
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18
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Rose L, Agar M, Burry LD, Campbell N, Clarke M, Lee J, Siddiqi N, Page VJ. Development of core outcome sets for effectiveness trials of interventions to prevent and/or treat delirium (Del-COrS): study protocol. BMJ Open 2017; 7:e016371. [PMID: 28928181 PMCID: PMC5623471 DOI: 10.1136/bmjopen-2017-016371] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Delirium is a common, serious and potentially preventable condition with devastating impact on the quality of life prompting a proliferation of interventional trials. Core outcome sets aim to standardise outcome reporting by identifying outcomes perceived fundamental for measurement in trials of a specific interest area. Our aim is to develop international consensus on two core outcome sets for trials of interventions to prevent and/or treat delirium, irrespective of study population. We aim to identify additional core outcomes specific to the critically ill, acutely hospitalised patients, palliative care and older adults. METHODS AND ANALYSIS We will conduct a systematic review of published and ongoing delirium trials (1980 onwards) and one-on-one interviews of patients who have experienced delirium and family members. These data will inform Delphi round 1 of a two-stage consensus process. In round 2, we will provide participants their own response, summarised group responses and those of patient/family participants for rescoring. We will randomise participants to receive feedback as proportion scoring the outcome as critical or as group mean responses. We will hold a consensus meeting using nominal group technique to finalise outcomes for inclusion. We will repeat the Delphi process and consensus meeting to select measures for each core outcome. We will recruit 240 Delphi participants giving us 80% power to detect a 1.0-1.5 point (9-point scale) difference by feedback method between rounds. We will analyse differences for subsequent scores, magnitude of opinion change, items retained and level of agreement. ETHICS AND DISSEMINATION We are obtaining research ethics approvals according to local governance. Participation will be voluntary and data deidentified. Support from three international delirium organisations will be instrumental in dissemination and core outcome set uptake. We will disseminate through peer-reviewed open access publications and present at conferences selected to reach a wide range of knowledge users.
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Affiliation(s)
- Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meera Agar
- Faculty of Health Sciences, University of Technology, Sydney, New South Wales, Australia
| | - Lisa D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Noll Campbell
- College of Pharmacy, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Mike Clarke
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Jacques Lee
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Valerie J Page
- Department of Anaesthetics, Watford General Hospital, Watford, UK
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Chiu AW, Contreras S, Mehta S, Korman J, Perreault MM, Williamson DR, Burry LD. Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management. Ann Pharmacother 2017; 51:1099-1111. [PMID: 28793780 DOI: 10.1177/1060028017724538] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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] Open
Abstract
OBJECTIVE To (1) provide an overview of the epidemiology, clinical presentation, and risk factors of iatrogenic opioid withdrawal in critically ill patients and (2) conduct a literature review of assessment and management of iatrogenic opioid withdrawal in critically ill patients. DATA SOURCES We searched MEDLINE (1946-June 2017), EMBASE (1974-June 2017), and CINAHL (1982-June 2017) with the terms opioid withdrawal, opioid, opiate, critical care, critically ill, assessment tool, scale, taper, weaning, and management. Reference list of identified literature was searched for additional references as well as www.clinicaltrials.gov . STUDY SELECTION AND DATA EXTRACTION We restricted articles to those in English and dealing with humans. DATA SYNTHESIS We identified 2 validated pediatric critically ill opioid withdrawal assessment tools: (1) Withdrawal Assessment Tool-Version 1 (WAT-1) and (2) Sophia Observation Withdrawal Symptoms Scale (SOS). Neither tool differentiated between opioid and benzodiazepine withdrawal. WAT-1 was evaluated in critically ill adults but not found to be valid. No other adult tool was identified. For management, we identified 5 randomized controlled trials, 2 prospective studies, and 2 systematic reviews. Most studies were small and only 2 studies utilized a validated assessment tool. Enteral methadone, α-2 agonists, and protocolized weaning were studied. CONCLUSION We identified 2 validated assessment tools for pediatric intensive care unit patients; no valid tool for adults. Management strategies tested in small trials included methadone, α-2 agonists, and protocolized sedation/weaning. We challenge researchers to create validated tools assessing specifically for opioid withdrawal in critically ill children and adults to direct management.
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Affiliation(s)
- Ada W Chiu
- 1 Peace Arch Hospital, Fraser Health Authority, White Rock, British Columbia, Canada
| | - Sofia Contreras
- 2 Hospital Universitari de Bellvitge, L'Hospitalet de Llobretat, Barcelona, Spain
| | - Sangeeta Mehta
- 3 Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Jennifer Korman
- 3 Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Marc M Perreault
- 4 The Montreal General Hospital-McGill University Health Center, Montreal, Quebec, Canada
| | - David R Williamson
- 5 Université de Montréal, Montreal, Quebec, Canada.,6 Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Lisa D Burry
- 3 Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada.,7 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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20
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Burry LD, Williamson DR, Mehta S, Perreault MM, Mantas I, Mallick R, Fergusson DA, Smith O, Fan E, Dupuis S, Herridge M, Rose L. Delirium and exposure to psychoactive medications in critically ill adults: A multi-centre observational study. J Crit Care 2017; 42:268-274. [PMID: 28806561 DOI: 10.1016/j.jcrc.2017.08.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [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: 02/27/2017] [Revised: 06/16/2017] [Accepted: 08/02/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE Investigate the relationship between psychoactive drugs and delirium. MATERIALS AND METHODS Prospective observational study of 520 critically ill adult patients admitted ≥24h to 6 intensive care units (ICUs). Data were collected on psychoactive drug exposure, use of sedation administration strategies, and incident delirium (Intensive Care Delirium Screening Checklist score≥4). RESULTS Delirium was detected in 260 (50%) patients, median (IQR) duration 2 (1-5) days, and time to onset 3 (2-5) days. Delirious patients received more low-potency anticholinergic (P<0.0001), antipsychotic (P<0.0001), benzodiazepine (P<0.0001) and non-benzodiazepine sedative (P<0.0001), and opioid (P=0.0008) drugs. Primary regression (24-hours preceding drug exposure) revealed no association between any psychoactive drug and delirium. Post-hoc analysis (extended 48-hour exposure) revealed an association between delirium and high-potency anticholinergic (HR 2.45, 95% CI 1.08-5.54) and benzodiazepine (HR 1.08 per 5mg midazolam-equivalent increment, 95% CI 1.04-1.12) drugs. Delirious patients had longer ICU (P<0.0001) and hospital (P<0.0001) length of stay, and higher ICU and hospital mortality (P=0.003 and P=0.007, respectively). CONCLUSIONS The identification of psychoactive drugs as modifiable delirium risk factors plays an important role in the management of critically ill patients. This is particularly important given the burden of exposure and combinations of drugs used in this vulnerable patient population.
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Affiliation(s)
- Lisa D Burry
- Department of Pharmacy, Sinai Health System, 600 University Avenue, Toronto, Ontario M5G 1X5, Canada.
| | - David R Williamson
- Department of Pharmacy, Hôpital du Sacré-Coeur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, Quebec H4J 1C5, Canada.
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, 600 University Ave, Toronto, Ontario M5G 1X5, Canada.
| | - Marc M Perreault
- Department of Pharmacy, The Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.
| | - Ioanna Mantas
- Department of Pharmacy, Sinai Health System, 600 University Avenue, Toronto, Ontario M5G 1X5, Canada.
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Centre for Practice-Changing Research, 501 Smyth Road, Box 201B, Ottawa, Ontario K1H 8L6, Canada.
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Centre for Practice-Changing Research, 501 Smyth Road, Box 201B, Ottawa, Ontario K1H 8L6, Canada.
| | - Orla Smith
- Critical Care Department, St. Michael's Hospital Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada.
| | - Sebastien Dupuis
- Department of Pharmacy, Hôpital du Sacré-Coeur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, Quebec H4J 1C5, Canada.
| | - Margaret Herridge
- Interdepartmental Division of Critical Care Medicine and Institute of Medical Science, University of Toronto, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada.
| | - Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
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21
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Hutton B, Burry LD, Kanji S, Mehta S, Guenette M, Martin CM, Fergusson DA, Adhikari NK, Egerod I, Williamson D, Straus S, Moher D, Ely EW, Rose L. Comparison of sedation strategies for critically ill patients: a protocol for a systematic review incorporating network meta-analyses. Syst Rev 2016; 5:157. [PMID: 27646881 PMCID: PMC5029074 DOI: 10.1186/s13643-016-0338-x] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/13/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Sedatives and analgesics are administered to provide sedation and manage agitation and pain in most critically ill mechanically ventilated patients. Various sedation administration strategies including protocolized sedation and daily sedation interruption are used to mitigate drug pharmacokinetic limitations and minimize oversedation, thereby shortening the duration of mechanical ventilation. At present, it is unclear which strategy is most effective, as few have been directly compared. Our review will use network meta-analysis (NMA) to compare and rank sedation strategies to determine their efficacy and safety for mechanically ventilated patients. METHODS We will search the following from 1980 to March 2016: Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science. We will also search the Cochrane Library, gray literature, and the International Clinical Trials Registry Platform. We will use a validated randomized control trial search filter to identify studies evaluating any strategy to optimize sedation in mechanically ventilated adult patients. Authors will independently extract data from eligible studies in duplicate and complete the Cochrane Risk of Bias tool. Our outcomes of interest include duration of mechanical ventilation, time to first extubation, ICU and hospital length of stay, re-intubation, tracheostomy, mortality, total sedative and opioid exposure, health-related quality of life, and adverse events. To inform our NMA, we will first conduct conventional pair-wise meta-analyses using random-effects models. Where appropriate, we will perform Bayesian NMA using WinBUGS software. DISCUSSION There are multiple strategies to optimize sedation for mechanically ventilated patients. Current ICU guidelines recommend protocolized sedation or daily sedation interruption. Our systematic review incorporating NMA will provide a unified analysis of all sedation strategies to determine the relative efficacy and safety of interventions that may not have been compared directly. We will provide knowledge users, decision makers, and professional societies with ranking of multiple sedation strategies to inform future sedation guidelines. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016037480.
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Affiliation(s)
- Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H8L6, Canada. .,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Lisa D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Department of Pharmacy, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G1X5, Canada
| | - Salmaan Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H8L6, Canada.,Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Critical Care, Mount Sinai Hospital, Toronto, ON, Canada
| | - Melanie Guenette
- Department of Pharmacy, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G1X5, Canada
| | - Claudio M Martin
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H8L6, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Neill K Adhikari
- Department of Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ingrid Egerod
- University of Copenhagen, Rigshospitalet, Neurointensive Intensive Care, Copenhagen O, Denmark
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, QC, Canada.,Département de Pharmacie, Hôpital du Sacré-Coeur, Montreal, QC, Canada
| | - Sharon Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, Saint Michael's Hospital, Toronto, ON, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa, ON, K1H8L6, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - E Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Health Services Research Center, Nashville, TN, USA
| | - Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Provincial Centre of Weaning Excellence, Toronto East General Hospital, Toronto, ON, Canada
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22
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Burry LD, Hutton B, Guenette M, Williamson D, Mehta S, Egerod I, Kanji S, Adhikari NK, Moher D, Martin CM, Rose L. Comparison of pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a protocol for a systematic review incorporating network meta-analyses. Syst Rev 2016; 5:153. [PMID: 27609018 PMCID: PMC5016934 DOI: 10.1186/s13643-016-0327-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/24/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Delirium is characterized by acute changes in mental status including inattention, disorganized thinking, and altered level of consciousness, and is highly prevalent in critically ill adults. Delirium has adverse consequences for both patients and the healthcare system; however, at this time, no effective treatment exists. The identification of effective prevention strategies is therefore a clinical and research imperative. An important limitation of previous reviews of delirium prevention is that interventions were considered in isolation and only direct evidence was used. Our systematic review will synthesize all existing data using network meta-analysis, a powerful statistical approach that enables synthesis of both direct and indirect evidence. METHODS We will search Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science from 1980 to March 2016. We will search the PROSPERO registry for protocols and the Cochrane Library for published systematic reviews. We will examine reference lists of pertinent reviews and search grey literature and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We will include randomized and quasi-randomized trials of critically ill adults evaluating any pharmacological, non-pharmacological, or multi-component intervention for delirium prevention, administered in or prior to (i.e., peri-operatively) transfer to the ICU. Two authors will independently screen search results and extract data from eligible studies. Risk of bias assessments will be completed on all included studies. To inform our network meta-analysis, we will first conduct conventional pair-wise meta-analyses for primary and secondary outcomes using random-effects models. We will generate our network meta-analysis using a Bayesian framework, assuming a common heterogeneity parameter across all comparisons, and accounting for correlations in multi-arm studies. We will perform analyses using WinBUGS software. DISCUSSION This systematic review will address the existing knowledge gap regarding best practices for delirium prevention in critically ill adults by synthesizing evidence from trials of pharmacological, non-pharmacological, and multi-component interventions administered in or prior to transfer to the ICU. Use of network meta-analysis will clarify which delirium prevention strategies are most effective in improving clinical outcomes while causing least harm. The network meta-analysis is a novel approach and will provide knowledge users and decision makers with comparisons of multiple interventions of delirium prevention strategies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016036313.
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Affiliation(s)
- L D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Department of Pharmacy, Mount Sinai Hospital, 600 University Ave, Rm 18-377, Toronto, ON, M5G1X5, Canada
| | - B Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Rd, Room L1288, Ottawa, ON, K1H8L6, Canada. .,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - M Guenette
- Department of Pharmacy, Mount Sinai Hospital, 600 University Ave, Rm 18-377, Toronto, ON, M5G1X5, Canada
| | - D Williamson
- Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada.,Département de pharmacie, hôpital du Sacré-Coeur, Montreal, QC, Canada
| | - S Mehta
- Department of Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Critical Care, Mount Sinai Hospital, Toronto, ON, Canada
| | - I Egerod
- University of Copenhagen, Rigshospitalet, Neurointensive Intensive Care, Blegdamsvej 9, DK-2100, Copenhagen O, Denmark
| | - S Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Rd, Room L1288, Ottawa, ON, K1H8L6, Canada.,Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada
| | - N K Adhikari
- Department of Medicine, Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Evaluative Clinical Sciences, Trauma, Emergency & Critical Care Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - D Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Rd, Room L1288, Ottawa, ON, K1H8L6, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - C M Martin
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - L Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Evaluative Clinical Sciences, Trauma, Emergency & Critical Care Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Provincial Centre of Weaning Excellence, Toronto East General Hospital, Toronto, ON, Canada
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Abstract
All-trans-retinoic acid (ATRA) is typically used as a first line agent in the treatment of acute promyelocytic leukaemia (APL), achieving complete remission (CR) rates (incombination with chemotherapy) of about 90%. One of the drawbacks of the use of ATRA is that up to 30% of patients can present with retinoic acid syndrome (RAS), which can be fatal in some patients. We describe a case of RAS after only one dose of ATRA, which to our knowledge has not previously been identified in the literature. The pathophysiology and treatment of APL is presented. A clinical description of RAS is outlined, and an evaluation of risk factors for developing RAS is reviewed.
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Affiliation(s)
- Marisa Battistella
- Pharmacy Department, University Health Network, Toronto, Ontario, Canada
| | - Lisa D Burry
- Pharmacy Department, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jack T Seki
- Pharmacy Department, University Health Network, Toronto, Ontario, Canada
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24
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Delaney JW, Pinto R, Long J, Lamontagne F, Adhikari NK, Kumar A, Marshall JC, Cook DJ, Jouvet P, Ferguson ND, Griesdale D, Burry LD, Burns KEA, Hutchison J, Mehta S, Menon K, Fowler RA. The influence of corticosteroid treatment on the outcome of influenza A(H1N1pdm09)-related critical illness. Crit Care 2016; 20:75. [PMID: 27036638 PMCID: PMC4818504 DOI: 10.1186/s13054-016-1230-8] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/10/2016] [Indexed: 12/14/2022]
Abstract
Background Patients with 2009 pandemic influenza A(H1N1pdm09)-related critical illness were frequently treated with systemic corticosteroids. While observational studies have reported significant corticosteroid-associated mortality after adjusting for baseline differences in patients treated with corticosteroids or not, corticosteroids have remained a common treatment in subsequent influenza outbreaks, including avian influenza A(H7N9). Our objective was to describe the use of corticosteroids in these patients and investigate predictors of steroid prescription and clinical outcomes, adjusting for both baseline and time-dependent factors. Methods In an observational cohort study of adults with H1N1pdm09-related critical illness from 51 Canadian ICUs, we investigated predictors of steroid administration and outcomes of patients who received and those who did not receive corticosteroids. We adjusted for potential baseline confounding using multivariate logistic regression and propensity score analysis and adjusted for potential time-dependent confounding using marginal structural models. Results Among 607 patients, corticosteroids were administered to 280 patients (46.1 %) at a median daily dose of 227 (interquartile range, 154–443) mg of hydrocortisone equivalents for a median of 7.0 (4.0–13.0) days. Compared with patients who did not receive corticosteroids, patients who received corticosteroids had higher hospital crude mortality (25.5 % vs 16.4 %, p = 0.007) and fewer ventilator-free days at 28 days (12.5 ± 10.7 vs 15.7 ± 10.1, p < 0.001). The odds ratio association between corticosteroid use and hospital mortality decreased from 1.85 (95 % confidence interval 1.12–3.04, p = 0.02) with multivariate logistic regression, to 1.71 (1.05–2.78, p = 0.03) after adjustment for propensity score to receive corticosteroids, to 1.52 (0.90–2.58, p = 0.12) after case-matching on propensity score, and to 0.96 (0.28–3.28, p = 0.95) using marginal structural modeling to adjust for time-dependent between-group differences. Conclusions Corticosteroids were commonly prescribed for H1N1pdm09-related critical illness. Adjusting for only baseline between-group differences suggested a significant increased risk of death associated with corticosteroids. However, after adjusting for time-dependent differences, we found no significant association between corticosteroids and mortality. These findings highlight the challenges and importance in adjusting for baseline and time-dependent confounders when estimating clinical effects of treatments using observational studies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1230-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jesse W Delaney
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Rouge Valley Health System, Scarborough, ON, Canada
| | | | | | - François Lamontagne
- Centre de recherche clinique Étienne-Le Bel, Université de Sherbrooke, Sherbrooke, PQ, Canada
| | - Neill K Adhikari
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Hospital, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada
| | - Anand Kumar
- Section of Critical Care Medicine, Department of Internal Medicine, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Section of Infectious Diseases, Department of Internal Medicine, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of Medical Microbiology, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, MB, Canada.,Department of, Faculty of Health Sciences, College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - John C Marshall
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Deborah J Cook
- St. Joseph's Hospital, McMaster University, Hamilton, ON, Canada
| | - Philippe Jouvet
- CHU Sainte Justine, Université de Montréal, Montréal, PQ, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada.,Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.,Critical Care Program, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Donald Griesdale
- Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Lisa D Burry
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Critical Care, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jamie Hutchison
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Kusum Menon
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Department of Critical Care Medicine, Sunnybrook Hospital, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
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Perrott J, Burry LD. Has the Drug of Choice for Treating Critical Illness Delirium Been Established? Can J Hosp Pharm 2015; 68:430-3. [DOI: 10.4212/cjhp.v68i5.1494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Mehta S, Cook DJ, Skrobik Y, Muscedere J, Martin CM, Stewart TE, Burry LD, Zhou Q, Meade M. A ventilator strategy combining low tidal volume ventilation, recruitment maneuvers, and high positive end-expiratory pressure does not increase sedative, opioid, or neuromuscular blocker use in adults with acute respiratory distress syndrome and may improve patient comfort. Ann Intensive Care 2014; 4:33. [PMID: 25593749 PMCID: PMC4273695 DOI: 10.1186/s13613-014-0033-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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: 05/02/2014] [Accepted: 10/20/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The Lung Open Ventilation Study (LOV Study) compared a low tidal volume strategy with an experimental strategy combining low tidal volume, lung recruitment maneuvers, and higher plateau and positive end-expiratory pressures (PEEP) in adults with acute respiratory distress syndrome (ARDS). Herein, we compared sedative, opioid, and neuromuscular blocker (NMB) use among patients managed with the intervention and control strategies and clinicians' assessment of comfort in both groups. METHODS This was an observational substudy of the LOV Study, a randomized trial conducted in 30 intensive care units in Canada, Australia, and Saudi Arabia. In 16 centers, we recorded daily doses of sedatives, opioids, and NMBs and surveyed bedside clinicians about their own comfort with the assigned ventilator strategy and their perceptions of patient comfort. We compared characteristics and outcomes of patients who did and did not receive NMBs. RESULTS Study groups received similar sedative, opioid, and NMB dosing on days 1, 3, and 7. Patient comfort as assessed by clinicians was not different in the two groups: 93% perceived patients had no/minimal discomfort. In addition, 92% of clinicians were comfortable with the assigned ventilation strategy without significant differences between the two groups. When clinicians expressed discomfort, more expressed discomfort about PEEP levels in the intervention vs control group (2.9% vs 0.7%, P <0.0001), and more perceived patient discomfort among controls (6.0% vs 4.3%, P = 0.049). On multivariable analysis, the strongest associations with NMB use were higher plateau pressure (hazard ratio (HR) 1.15; 95% confidence interval (CI) 1.07 to 1.23; P = 0.0002) and higher daily sedative dose (HR 1.03; 95% CI 1.02 to 1.05; P <0.0001). Patients receiving NMBs had more barotrauma, longer durations of mechanical ventilation and hospital stay, and higher mortality. CONCLUSIONS In the LOV Study, high PEEP, low tidal volume ventilation did not increase sedative, opioid, or NMB doses in adults with ARDS, compared with a lower PEEP strategy, and appeared at least as comfortable for patients. NMB use may reflect worse lung injury, as these patients had more barotrauma, longer durations of ventilation, and higher mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT00182195.
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Affiliation(s)
- Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Suite 18-216, Toronto M5G 1X5, Ontario, Canada
| | - Deborah J Cook
- Interdepartmental Division of Critical Care, Hamilton Health Sciences and Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton L8S 4K1, Ontario, Canada
| | - Yoanna Skrobik
- Département de Medicine, Soins Intensifs, Hôpital Maisonneuve Rosemont, Universite de Montreal, Montreal H1T 2M4, Quebec, Canada
| | - John Muscedere
- Department of Medicine, Kingston General Hospital, Queen's University, Kingston K7L 2V7, Ontario, Canada
| | - Claudio M Martin
- Department of Medicine, London Health Sciences Centre, Western University, London N6A 5A5, Ontario, Canada
| | | | - Lisa D Burry
- Department of Pharmacy and Medicine, Mount Sinai Hospital, Toronto M5G 1X5, Ontario, Canada
| | - Qi Zhou
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton L8S 4K1, Ontario, Canada
| | - Maureen Meade
- Interdepartmental Division of Critical Care, Hamilton Health Sciences and Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton L8S 4K1, Ontario, Canada
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Burry LD, Seto K, Rose L, Lapinsky SC, Mehta S. Use of sedation and neuromuscular blockers in critically ill adults receiving high-frequency oscillatory ventilation. Ann Pharmacother 2014; 47:1122-9. [PMID: 24259726 DOI: 10.1177/1060028013503121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [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] Open
Abstract
BACKGROUND Nearly all patients receive sedation and neuromuscular blockers (NMBs) during high-frequency oscillatory ventilation (HFOV). OBJECTIVE To describe analgo-sedation and NMB use prior to and during HFOV in adults with acute respiratory distress syndrome. METHODS Retrospective single-center study of 131 consecutive adults whose care was managed with HFOV from 2002 to 2011. RESULTS During the first 4 days of HFOV, 89% and 95% of patients received sedation and opioids, respectively. Upon HFOV initiation, 119 (90.8%) patients received fentanyl doses higher than 200 µg/h; of these, 48 also received more than 20 mg/h of midazolam. Analgo-sedation doses increased significantly over time such that doses were double by day 3. Factors independently associated with fentanyl doses higher than 200 µg/h were NMB ever used (OR 4.43; 95% CI 1.26-15.65, p = 0.02), pH less than 7.15 (OR 2.08; 95% CI 1.22-3.5, p = 0.007), worsening partial pressure of oxygen/fraction of inspired oxygen (OR 1.05; 95% CI 1.00-1.10, p = 0.04), and Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR 0.87; 95% CI 0.79-0.97, p = 0.009). Deep sedation was commonly administered when NMBs were not being used, with 99.2% of sedation-agitation scores of 1 or 2. Eighty-six patients (65.6%) received NMBs and use was greatest on day 1 (59.5%). Train-of-Four was measured every hour for 53.4% of patients; 29.2% of the measurements were 0 of 4. NMB use declined over the 10-year study period. CONCLUSIONS High analgo-sedation doses were associated with APACHE II scores, worsening gas exchange, and NMB use. Two thirds of patients received NMBs; use was highest on day 1 and subsequently declined. The percentage of patients who received NMB during HFOV in our study was lower than that previously reported. Future research should evaluate patient outcomes with and without use of NMBs, as well as the potential to manage patients with less sedation.
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Affiliation(s)
- Lisa D Burry
- Department of Pharmacy, Mount Sinai Hospital, New York, NY
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Perreault MM, Thiboutot Z, Burry LD, Rose L, Kanji S, LeBlanc JM, Carr RR, Williamson DR. Canadian survey of critical care pharmacists' views and involvement in clinical research. Ann Pharmacother 2012; 46:1167-73. [PMID: 22932309 DOI: 10.1345/aph.1r180] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The involvement of Canadian critical care pharmacists in clinical research is not well documented. OBJECTIVE To describe the clinical research experience of Canadian critical care pharmacists, describe their views about clinical research, and identify factors that facilitate their involvement in clinical research. METHODS A cross-sectional electronic survey of Canadian critical care pharmacists was developed through an iterative process and conducted from July to October 2010. We invited 325 pharmacists from 129 hospitals across Canada to participate. Surveys with more than 30% of questions unanswered were discarded. RESULTS Analyzable response rate was 66.2%. Overall, 33 pharmacists (15.7%) were highly involved in research, 54 (25.7%) were moderately involved, and 123 (58.6%) were minimally involved. Most respondents (97.2%) believed that critical care pharmacist involvement in research was desirable, and many (80.4%) expressed interest to be more involved in research. Nearly all respondents (99.5%) agreed that more support should be provided to pharmacists interested in conducting research. Pharmacists currently involved in research have obtained higher academic degrees (adjusted OR 11.23; p < 0.001), express a strong interest in research (adjusted OR 7.44; p < 0.001), report a higher level of training for involvement in research (adjusted OR 2.23; p = 0.047), and practice more often in a university hospital (adjusted OR 3.68; p = 0.004) within an intensive care unit where involvement in research is valued (adjusted OR 5.61; p < 0.001). Support from pharmacy departments is not related to involvement in research (adjusted OR 1.22; p = 0.633). CONCLUSIONS Canadian critical care pharmacists are involved to varying degrees in clinical research and are very interested in initiating and supporting research activities. Opportunities are present but significant barriers exist. The value of pharmacist-initiated research needs recognition as a priority within hospital pharmacy administration.
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Warr J, Thiboutot Z, Rose L, Mehta S, Burry LD. Current therapeutic uses, pharmacology, and clinical considerations of neuromuscular blocking agents for critically ill adults. Ann Pharmacother 2011; 45:1116-26. [PMID: 21828347 DOI: 10.1345/aph.1q004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To summarize literature describing use of neuromuscular blocking agents (NMBAs) for common critical care indications and provide a review of NMBA pharmacology, pharmacokinetics, dosing, drug interactions, monitoring, complications, and reversal. DATA SOURCES Searches of MEDLINE (1975-May 2011), EMBASE (1980-May 2011), and Cumulative Index to Nursing and Allied Health Literature (1981-May 2011) were conducted to identify observational and interventional studies evaluating the efficacy or safety of NMBAs for management of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), status asthmaticus, elevated intracranial pressure (ICP), and therapeutic hypothermia. STUDY SELECTION AND DATA EXTRACTION We excluded case reports, animal- or laboratory-based studies, trials describing NMBA use during rapid sequence intubation or in the operating room, and studies published in languages other than English or French. DATA SYNTHESIS Clinical applications of NMBAs in intensive care include, but are not limited to, immobilizing patients for procedural interventions, decreasing oxygen consumption, facilitating mechanical ventilation, reducing intracranial pressure, preventing shivering, and management of tetanus. Recent data on ARDS demonstrated that early application of NMBAs improved adjusted 90-day survival for patients with severe lung injury. These results may lead to increased use of these drugs. While emerging data support the use of cisatracurium in select patients with ALI/ARDS, current literature does not support the use of one NMBA over another for other critical care indications. Cisatracurium may be kinetically preferred for patients with organ dysfunction. Close monitoring with peripheral nerve stimulation is recommended with sustained use of NMBAs to avoid drug accumulation and minimize the risk for adverse drug events. Reversal of paralysis is achieved by discontinuing therapy or, rarely, the use of anticholinesterases. CONCLUSIONS NMBAs are high-alert medications used to manage critically ill patients. New data are available regarding the use of these agents for treatment of ALI/ARDS and status asthmaticus, management of elevated ICP, and provision of therapeutic hypothermia after cardiac arrest. To improve outcomes and promote patient safety, intensive care unit team members should have a thorough knowledge of this class of medications.
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Affiliation(s)
- Julia Warr
- University of Waterloo, Waterloo, Ontario, Canada
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Burry LD, Tung DD, Hallett D, Bailie T, Carvalhana V, Lee D, Ramganesh S, Richardson R, Mehta S, Lapinsky SE. Regional citrate anticoagulation for PrismaFlex continuous renal replacement therapy. Ann Pharmacother 2009; 43:1419-25. [PMID: 19690224 DOI: 10.1345/aph.1m182] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Since Mehta et al. reported the first successful use of regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) in 1990, RCA is increasingly used for CRRT because it provides filter patency with minimal risk of bleeding. However, RCA has been associated with significant metabolic complications including hypocalcemia, hypernatremia, metabolic alkalosis, and citrate toxicity. OBJECTIVE To describe our experience with a newly implemented RCA protocol with acid citrate dextrose formula A (ACD-A) and intravenous calcium gluconate, for use with PrismaFlex CRRT in critically ill patients with acute kidney injury. METHODS A retrospective chart review was conducted from May 1, 2006, until May 1, 2007, in a 16-bed medical-surgical university-affiliated intensive care unit. Data collected included dialysis filter life, patient and circuit metabolic parameters, and units of packed red blood cells transfused. RESULTS Forty-eight patients received dialysis with citrate (n = 178 filters). Circuit clotting occurred in 24% of all filters. Mean +/- SD filter life was 38.4 +/- 25.9 hours, and filter survival at 48 hours was 38.2%. Persistent metabolic alkalosis while on CRRT was identified in 6 of 45 (13.3%) patients. Mild hypocalcemia (ionized calcium <3.6 mg/dL) occurred in 11 (23%) patients, but no patient had an ionized calcium level less than 2.8 mg/dL. Six patients, 3 with acute leukemia, required transfusion of 2 or more units of packed red blood cells in 24 hours. CONCLUSIONS We found that anticoagulation of PrismaFlex CRRT with ACD-A and intravenous calcium gluconate provided reasonable filter patency, but with minor metabolic complications. Close monitoring of electrolyte and acid-base balance is required to minimize metabolic derangements.
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Affiliation(s)
- Lisa D Burry
- Department of Pharmacy, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
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Affiliation(s)
| | | | | | - James E. Teresi
- Department of Anesthesia and Pain Management
Mount Sinai Hospital
Toronto, Ontario M5G1X5
Canada
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Abstract
Tumor lysis syndrome (TLS) is a complication of malignancies with high tumor cell proliferation, tumor burden, and chemosensitivity. It manifests with the release of intracellular components and results in hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia. These biochemical abnormalities may lead to serious complications such as renal failure, cardiac dysrhythmias, and death. Rasburicase, a recombinant urate oxidase enzyme, is a new agent indicated in the treatment or prophylaxis of hyperuricemia in pediatric patients with cancer who are at high risk for TLS. We reviewed the evidence for treatment with this agent compared with standard therapy with allopurinol. Rasburicase may be considered for use in patients with hyperuricemia at presentation and in patients at high risk for TLS that would otherwise result in a delay in chemotherapy. However, randomized controlled trials are required to establish the comparative efficacy of rasburicase in the adult population. Preliminary evidence suggests that single-dose or reduced-dose rasburicase may be effective in the prophylaxis and the treatment of hyperuricemia and TLS. However, to our knowledge, there is no evidence comparing clinically relevant outcomes such as acute renal failure or dialysis.
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Affiliation(s)
- Amy R Sood
- Division of Pharmacy Practice, Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Abstract
OBJECTIVE: To evaluate the utility of cosyntropin 1 μg in assessing adrenal function in critically ill patients. DATA SOURCES: A computerized literature search using MEDLINE, EMBASE, International Pharmaceutical Abstracts, and the Cochrane Database (1966–August 2004) was undertaken for trials evaluating cosyntropin 1 μg using the following search terms: adrenocorticotropin-releasing hormone (ACTH), cosyntropin, adrenal insufficiency, cortisol, corticosteroids, glucocorticoids, sepsis, septic shock, diagnosis, critically ill, intensive care, and critical care. STUDY SELECTION AND DATA SYNTHESIS: Identifying patients with sepsis with relative adrenal insufficiency (AI) using cosyntropin testing may identify those likely to benefit from corticosteroids. The results of 5 heterogeneous studies in non—intensive care unit (ICU) patients suggest that both 1 μg and 250 μg of cosyntropin stimulate similar cortisol responses and that testing using both doses correlates well with results from insulin tolerance testing. Some data from non-ICU patients suggest that the 1-μg test may be more sensitive to detect AI; 3 heterogeneous studies in ICU patients confirmed the improved sensitivity of the 1-μg test. CONCLUSIONS: Use of cosyntropin 1 μg should detect AI in all patients who would have been diagnosed using 250 μg. Unfortunately, all of the clinical trials evaluating the role of corticosteroids in septic shock that used the cosyntropin stimulation test administered 250 μg. Extrapolation of the existing guidelines to treat patients with septic shock testing positive for relative AI using the 1-μg test may provide effective therapy to appropriate patients not diagnosed by the 250-μg testing or may introduce additional adverse effects in patients who should not receive corticosteroids. Large-scale, head-to-head comparison data of steroid effectiveness after 1- and 250-μg ACTH stimulation tests are needed to expand upon these promising results.
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Burry LD, Lapinsky SE. Book Reviews: Physician's Guide to Terrorist Attack. Ann Pharmacother 2004. [DOI: 10.1345/aph.1d602] [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: 11/27/2022] Open
Affiliation(s)
- Lisa D Burry
- Critical Care Specialist, Surgical Team Leader Education Coordinator Department of Pharmacy Mount Sinai Hospital Toronto, Ontario, Canada
| | - Stephen E Lapinsky
- Critical Care Physician Site Director, Intensive Care Unit Department of Medicine Mount Sinai Hospital Faculty of Medicine, University of Toronto
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Abstract
OBJECTIVE To highlight the role of relative adrenal insufficiency in the outcome of critically ill patients with sepsis and systematically review the literature regarding the use of corticosteroids for management of severe sepsis/septic shock. DATA SOURCES A computerized search of MEDLINE, EMBASE, and the Cochrane Database was undertaken from 1966 to March 2003 using the search terms intensive care unit, critical care, corticosteroids, glucocorticoids, adrenal insufficiency, sepsis, and septic shock. Bibliographies of all articles retrieved were searched for relevant articles not identified by the computerized search. DATA EXTRACTION/SYNTHESIS Six trials were identified after publication of the meta-analyses (1995), with a total of 505 patients. The results of these trials in septic shock suggest that low-dose corticosteroids can reduce vasopressor requirements and hasten reversal of shock. Some of these trials suggested a possible mortality benefit from therapy, and no trial demonstrated an increase in mortality or significant adverse effects. The benefit of this therapy may depend on the presence of relative adrenal insufficiency, as identified by the adrenocorticotropic hormone stimulation test. CONCLUSIONS Low-dose corticosteroids should be administered to patients with septic shock empirically, but should be discontinued if relative adrenal insufficiency is not confirmed.
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Affiliation(s)
- Lisa D Burry
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada.
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Abstract
OBJECTIVE To review the role of all-trans retinoic acid (ATRA) and arsenic trioxide in central nervous system (CNS) relapses of acute promyelocytic leukemia (APL). CASE SUMMARY A 69-year-old white man diagnosed with APL presented with bleeding diathesis. His molecular and cytogenetic studies were positive for promyelocytic leukemia-retinoic acid receptoralpha (PML-RARalpha) and t(15;17) transformation. Complete molecular and cytogenetic remission was achieved with ATRA, daunorubicin, and cytarabine. Within 6 months, the patient was readmitted for investigation of severe global headaches and an ataxic gait. His peripheral blood and cerebral spinal fluid were positive for PML-RARalpha fusion protein. Intrathecal chemotherapy and radiation, as well as ATRA, were the main treatment modalities provided. Molecular and cytogenetic remission was again obtained. Three months later, a second relapse occurred in the CNS and the peripheral blood. DISCUSSION APL is typically treated with anthacycline-based chemotherapy and ATRA. Approximately 85-95% of patients achieve complete remission (CR); however, the relapse rate has been reported to be about 30-40%. A thorough literature search (MEDLINE, EMBASE, CANCERLIT, 1966-January 2002) revealed only 54 cases of extramedullary disease, of which 35 involved the CNS. CONCLUSIONS The introduction of ATRA has improved patient survival dramatically. APL relapse, in general, has been in part attributable to repetitive or prolonged exposure to ATRA and the possibility of additional chromosomal changes, making the disease more refractory to treat. Given the evidence, one could argue that, with repeated ATRA treatment, CR duration may be shortened. However, limited data are available to guide the appropriate management of APL relapsed to the CNS with either ATRA, chemotherapy, or arsenic trioxide. In our opinion, treatment using arsenic trioxide is an unconventional option worthy of exploring.
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Affiliation(s)
- Lisa D Burry
- Mt. Sinai Hospital, University of Toronto, Ontario, Canada
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