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White G, Adessky N, Chen FW, Regazzoni A, Tourian L, Chagnon M, Gursahaney A, Alharbi M, Williamson D, Perreault MM. Valproic acid for agitation in the intensive care unit: an observational study of psychiatric consults. Int J Clin Pharm 2024; 46:177-185. [PMID: 38071694 DOI: 10.1007/s11096-023-01661-2] [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: 06/23/2023] [Accepted: 10/09/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Agitation is a common clinical problem encountered in the intensive care unit (ICU). Treatment options are based on clinical experience and sparse quality literature. AIM The aim of this study was to describe the effect of valproic acid (VPA) as adjuvant treatment for agitation in the ICU, identify predictors of response to VPA and evaluate the independent effect of VPA on agitation compared to standard of care (SOC). METHOD This retrospective single center observational study evaluated adult patients admitted to the ICU for whom a psychiatric consultation was requested for agitation management, with agitation defined as a Richmond Agitation Sedation Score of 2 or greater. A descriptive analysis of the proportion of agitation-free patients per day of follow-up, the incidence of agitation-related-events, as well as the evolution of co-medications use over time are presented. A logistic regression model was used to assess predictors of VPA response, defined as being agitation-free on Day 7 and generalized estimating equations were used to evaluate the independent effect of VPA as adjuvant therapy for agitation in the critically ill. RESULTS One hundred seventy-five patients were included in the study with 78 receiving VPA. The percentage of agitation-free patients on VPA was 6.5% (5/77) on Day 1, 14.1% (11/78) on Day 3 and 39.5% (30/76) on Day 7. Multivariate regression model for clinical and demographic variables identified female gender as predictor of response on Day 7 (OR 6.10 [1.18-31.64], p = 0.03). The independent effect of VPA was non-significant when compared to SOC. CONCLUSION Although VPA used as adjuvant treatment was associated with a decrease in agitation, its effect when compared to SOC did not yield significant results.
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Affiliation(s)
- Geneviève White
- Department of Pharmacy, Réseau local de Gaspé, CISSS de la Gaspésie, 215 Boul York W, Gaspé, QC, G4X 2W2, Canada.
| | - Noah Adessky
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Fei-Wen Chen
- Department of Pharmacy, CIUSSS Centre-Sud-de-l'île-de-Montréal, Hôpital Notre-Dame, 1560 Sherbrooke St E, Montreal, QC, H2L 4M1, Canada
| | - Anne Regazzoni
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Leon Tourian
- Department of Psychiatry, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistic, University of Montreal, 2920 Chemin de la Tour, Montreal, QC, H3C 3J7, Canada
| | - Ashvini Gursahaney
- McGill University Health Centre, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Department of Medicine and Critical Care, McGill University, Montreal, Canada
| | - Majed Alharbi
- Department of Psychiatry, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Department of Adult Mental Health, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - David Williamson
- Department of Pharmacy and Research Center, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, QC, H4J 1C5, Canada
- Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Marc M Perreault
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
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Bolesta S, Burry L, Perreault MM, Gélinas C, Smith KE, Eadie R, Carini FC, Saltarelli K, Mitchell J, Harpel J, Stewart R, Riker RR, Fraser GL, Erstad BL. International Analgesia and Sedation Weaning and Withdrawal Practices in Critically Ill Adults: The Adult Iatrogenic Withdrawal Study in the ICU. Crit Care Med 2023; 51:1502-1514. [PMID: 37283558 DOI: 10.1097/ccm.0000000000005951] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Iatrogenic withdrawal syndrome (IWS) associated with opioid and sedative use for medical purposes has a reported high prevalence and associated morbidity. This study aimed to determine the prevalence, utilization, and characteristics of opioid and sedative weaning and IWS policies/protocols in the adult ICU population. DESIGN International, multicenter, observational, point prevalence study. SETTING Adult ICUs. PATIENTS All patients aged 18 years and older in the ICU on the date of data collection who received parenteral opioids or sedatives in the previous 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS ICUs selected 1 day for data collection between June 1 and September 30, 2021. Patient demographic data, opioid and sedative medication use, and weaning and IWS assessment data were collected for the previous 24 hours. The primary outcome was the proportion of patients weaned from opioids and sedatives using an institutional policy/protocol on the data collection day. There were 2,402 patients in 229 ICUs from 11 countries screened for opioid and sedative use; 1,506 (63%) patients received parenteral opioids, and/or sedatives in the previous 24 hours. There were 90 (39%) ICUs with a weaning policy/protocol which was used in 176 (12%) patients, and 23 (10%) ICUs with an IWS policy/protocol which was used in 9 (0.6%) patients. The weaning policy/protocol for 47 (52%) ICUs did not define when to initiate weaning, and the policy/protocol for 24 (27%) ICUs did not specify the degree of weaning. A weaning policy/protocol was used in 34% (176/521) and IWS policy/protocol in 9% (9/97) of patients admitted to an ICU with such a policy/protocol. Among 485 patients eligible for weaning policy/protocol utilization based on duration of opioid/sedative use initiation criterion within individual ICU policies/protocols 176 (36%) had it used, and among 54 patients on opioids and/or sedatives ≥ 72 hours, 9 (17%) had an IWS policy/protocol used by the data collection day. CONCLUSIONS This international observational study found that a small proportion of ICUs use policies/protocols for opioid and sedative weaning or IWS, and even when these policies/protocols are in place, they are implemented in a small percentage of patients.
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Affiliation(s)
- Scott Bolesta
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Marc M Perreault
- Department of Pharmacy, McGill University Health Center and Faculty of Pharmacy, University of Montréal, Montréal, QC, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, and Centre for Nursing Research/Lady Davis Institute, Jewish General Hospital-CIUSSS West-Central-Montréal, Montréal, QC, Canada
| | | | - Rebekah Eadie
- Critical Care/Pharmacy, Ulster Hospital, Dundonald, United Kingdom
| | - Federico C Carini
- MS-ICU, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Jamie Harpel
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Ryan Stewart
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Richard R Riker
- Department of Critical Care/Pulmonary Medicine, Maine Medical Center, Portland, ME
| | | | - Brian L Erstad
- Department of Pharmacy Practice and Science, The University of Arizona, Tucson, AZ
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Mahmoud SH, Hefny FR, Panos NG, Delucilla L, Ngan Z, Perreault MM, Hamilton LA, Rowe AS, Buschur PL, Owusu-Guha J, Almohaish S, Sandler M, Armahizer MJ, Barra ME, Cook AM, Barthol CA, Hintze TD, Cantin A, Traeger J, Blunck JR, Shewmaker J, Burgess SV, Kaupp K, Brown CS, Clark SL, Wieruszewski ED, Tesoro EP, Ammar AA, Ammar MA, Binning MJ, Naydin S, Fox N, Peters DM, Mahmoud LN, Keegan SP, Brophy GM. Comparison of nimodipine formulations and administration techniques via enteral feeding tubes in patients with aneurysmal subarachnoid hemorrhage: A multicenter retrospective cohort study. Pharmacotherapy 2023; 43:279-290. [PMID: 36880540 DOI: 10.1002/phar.2791] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/07/2023] [Accepted: 02/12/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Nimodipine improves outcomes following aneurysmal subarachnoid hemorrhage (aSAH) and current guidelines suggest that patients with aSAH receive nimodipine for 21 days. Patients with no difficulty swallowing will swallow the whole capsules or tablets; otherwise, nimodipine liquid must be drawn from capsules, tablets need to be crushed, or the commercially available liquid product be used to facilitate administration through an enteral feeding tube (FT). It is not clear whether these techniques are equivalent. The goal of the study was to determine if different nimodipine formulations and administration techniques were associated with the safety and effectiveness of nimodipine in aSAH. METHODS This was a retrospective multicenter observational cohort study conducted in 21 hospitals across North America. Patients admitted with aSAH and received nimodipine by FT for ≥3 days were included. Patient demographics, disease severity, nimodipine administration, and study outcomes were collected. Safety end points included the prevalence of diarrhea and nimodipine dose reduction or discontinuation secondary to blood pressure reduction. Predictors of the study outcomes were analyzed using regression modeling. RESULTS A total of 727 patients were included. Administration of nimodipine liquid product was independently associated with higher prevalence of diarrhea compared to other administration techniques/formulations (Odds ratio [OR] 2.28, 95% confidence interval [CI] 1.41-3.67, p-value = 0.001, OR 2.76, 95% CI 1.37-5.55, p-value = 0.005, for old and new commercially available formulations, respectively). Bedside withdrawal of liquid from nimodipine capsules prior to administration was significantly associated with higher prevalence of nimodipine dose reduction or discontinuation secondary to hypotension (OR 2.82, 95% CI 1.57-5.06, p-value = 0.001). Tablet crushing and bedside withdrawal of liquid from capsules prior to administration were associated with increased odds of delayed cerebral ischemia (OR 6.66, 95% CI 3.48-12.74, p-value <0.0001 and OR 3.92, 95% CI 2.05-7.52, p-value <0.0001, respectively). CONCLUSIONS Our findings suggest that enteral nimodipine formulations and administration techniques might not be equivalent. This could be attributed to excipient differences, inconsistency and inaccuracy in medication administration, and altered nimodipine bioavailability. Further studies are needed.
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Affiliation(s)
- Sherif Hanafy Mahmoud
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Fatma R Hefny
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Nicholas G Panos
- Department of Pharmacy, Rush University Medical Center, Chicago, Illinois, USA
| | - Laura Delucilla
- Department of Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada
| | - Zinquon Ngan
- Department of Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc M Perreault
- Department of Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Leslie A Hamilton
- University of Tennessee Health Science Center, College of Pharmacy, Knoxville, Tennessee, USA
| | - A Shaun Rowe
- University of Tennessee Health Science Center, College of Pharmacy, Knoxville, Tennessee, USA
| | | | | | - Sulaiman Almohaish
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, School of Pharmacy, Richmond, Virginia, USA.,College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Melissa Sandler
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, School of Pharmacy, Richmond, Virginia, USA.,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | - Michael J Armahizer
- Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aaron M Cook
- UKHealthCare, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Colleen A Barthol
- Department of Pharmacotherapy & Pharmacy Services, University Health, San Antonio, Texas, USA
| | - Trager D Hintze
- Department of Pharmacy Practice, Texas A&M College of Pharmacy, College Station, Texas, USA
| | - Anna Cantin
- Hartford Hospital, Hartford, Connecticut, USA
| | - Jessica Traeger
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Joseph R Blunck
- Department of Pharmacy, Saint Luke's Hospital, Kansas City, Missouri, USA
| | - Justin Shewmaker
- Department of Pharmacy, Saint Luke's Hospital, Kansas City, Missouri, USA
| | - Sarah V Burgess
- Queen Elizabeth II Health Sciences Centre, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Kristin Kaupp
- Queen Elizabeth II Health Sciences Centre, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | | | | | | | - Eljim P Tesoro
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Abdalla A Ammar
- Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Mahmoud A Ammar
- Department of Pharmacy, Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | | | - Neal Fox
- Premier Health Miami Valley Hospital, Dayton, Ohio, USA
| | - David M Peters
- Cedarville University School of Pharmacy, Cedarville, Ohio, USA
| | - Leana N Mahmoud
- Department of Pharmacy, Rhode Island Hospital/Lifespan, Providence, Rhode Island, USA
| | - Shaun P Keegan
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, School of Pharmacy, Richmond, Virginia, USA
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4
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Bing E, Archambault K, Sananikone A, Nguyen KD, Fang YT, Jabamikos C, Gras C, Marsot A, Duceppe MA, Perreault MM. Risk factors associated with augmented renal clearance in a mixed intensive care unit population: a retrospective study. Int J Clin Pharm 2022; 44:1277-1286. [PMID: 35834093 DOI: 10.1007/s11096-022-01458-9] [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: 01/16/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Augmented renal clearance is increasingly recognized in critically ill patients. This condition may lead to suboptimal dosing of renally excreted medications. AIM Our primary objective was to identify demographic and clinical factors associated with augmented renal clearance in a mixed critically ill population. METHOD This retrospective single center observational cohort study evaluated patients admitted in a mixed adult intensive care unit for augmented renal clearance, defined as a creatinine clearance of ≥ 130 ml/min/1.73m2, through weekly 24-h urine collection. Variables associated with augmented renal clearance were identified using univariate analysis, then served as covariates in a backward stepwise logistic regression. Goodness-of-fit of the model was assessed and receiver operating characteristic curve was generated. RESULTS Augmented renal clearance was observed in 25.3% of the study cohort (n = 324). Age below 50 years (adjusted odds ratio 7.32; 95% CI 4.03-13.29, p < 0.001), lower serum creatinine at intensive care admission (adjusted odds ratio 0.97; 95% CI 0.96-0.99, p < 0.001) and trauma admission (adjusted odds ratio 2.26; 95% CI 1.12-4.54, p = 0.022) were identified as independent risk factors. Our model showed acceptable discrimination in predicting augmented renal clearance (Area under receiver operating characteristic curve (0.810; 95% CI 0.756-0.864, p < 0.001)). CONCLUSION We identified age below 50 years, lower serum creatinine upon intensive care admission and trauma as independent risk factors for augmented renal clearance, consistent with the literature suggesting that patients with low serum creatinine upon admission could have a higher risk of developing augmented renal clearance.
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Affiliation(s)
- Emily Bing
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Kym Archambault
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Alice Sananikone
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Kim-Dan Nguyen
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Yi Tong Fang
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Caren Jabamikos
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Cécile Gras
- Département de Pharmacie, Centre Hospitalier de Montpellier, 91 av. du Doyen Giraud, 34295, Montpellier cedex 5, France
| | - Amélie Marsot
- Faculté de Pharmacie de L'Université de Montréal, Pavillon Jean-Coutu 2940, Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Marc-Alexandre Duceppe
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Marc M Perreault
- Faculté de Pharmacie de L'Université de Montréal, Pavillon Jean-Coutu 2940, Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Department of Pharmacy, McGill University Health Center, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
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5
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Jabamikos C, Fang YT, Nguyen KD, Sananikone A, Archambault K, Bing E, Chagnon M, Husainalamoodi O, Marsot A, Duceppe MA, Perreault MM. Validation of the Augmented Renal Clearance in Trauma Intensive Care scoring system for augmented renal clearance prediction in a trauma subgroup of a mixed ICU population. J Clin Pharm Ther 2022; 47:1517-1524. [PMID: 35633117 DOI: 10.1111/jcpt.13695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/24/2022] [Accepted: 05/04/2022] [Indexed: 01/25/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Augmented renal clearance is prevalent in trauma patients and leads to subtherapeutic levels of renally eliminated medications with potentially unfavourable clinical outcomes. The Augmented Renal Clearance of Trauma in Intensive Care (ARCTIC) score has been developed to predict augmented renal clearance in critically ill trauma patients. Our primary objective was to validate this score among the trauma subgroup of a mixed intensive care patient cohort. METHODS This single-centre, retrospective, observational cohort study assessed augmented renal clearance using a timed 24-h urine collection performed weekly. ARC was defined as a measured creatinine clearance of ≥130 ml/min/1.73 m2 . ARCTIC score performance was evaluated through a receiver operator characteristic curves and analysis of sensitivities and specificities for the trauma subgroup, the medical/surgical subgroup and the pooled cohort. RESULTS AND DISCUSSION Augmented renal clearance was observed in 33.9% (n = 58) of trauma patients (n = 171) and 15.7% (n = 24) of medical/surgical patients (n = 153). Examination of different cutoffs for the ARCTIC score in our trauma population confirmed that the optimal cutoff score was ≥6. Comparison between ROC curves for ARCTIC score and for regression model based upon our data in trauma patients indicated validation of the score in this subgroup. Comparison of sensitivities and specificities for ARCTIC score between trauma (93.1% and 41.6%, respectively) and medical/surgical subjects (87.5% and 49.6%, respectively) showed no clinical nor statistical difference, suggesting validation for the medical/surgical subgroup as well. WHAT IS NEW AND CONCLUSION In our mixed ICU population, the ARCTIC score was validated in the trauma subgroup. We also found that the score performed well in the medical/surgical population. Future studies should assess the performance of the ARCTIC score prospectively.
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Affiliation(s)
- Caren Jabamikos
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Yi Tong Fang
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Kim-Dan Nguyen
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Alice Sananikone
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Kym Archambault
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Emily Bing
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, University of Montreal, Montreal, Quebec, Canada
| | - Omar Husainalamoodi
- Department of Critical Care, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
| | - Amélie Marsot
- Faculté de pharmacie de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marc-Alexandre Duceppe
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Marc M Perreault
- Faculté de pharmacie de l'Université de Montréal, Montreal, Quebec, Canada.,Department of Pharmacy, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
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Perreault MM. Sommes nous en train de « boucler la boucle » pour répondre aux besoins thérapeutiques des patients des soins intensifs? Can J Hosp Pharm 2021; 74:201-202. [PMID: 34248159 DOI: 10.4212/cjhp.v74i3.3146] [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: 11/10/2022]
Affiliation(s)
- Marc M Perreault
- B. Pharm., M. Sc., Pharm. D., FCSHP, FOPQ, est pharmacien en soins intensifs à l'Hôpital général de Montréal [Québec]. Il est aussi rédacteur adjoint pour le Journal canadien de la pharmacie hospitalière
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7
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Perreault MM. Are We "Closing the Loop" on Meeting the Therapeutic Needs of Critically Ill Patients? Can J Hosp Pharm 2021; 74:199-200. [PMID: 34248158 DOI: 10.4212/cjhp.v74i3.3136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Marc M Perreault
- BPharm, MSc, PharmD, FCSHP, FOPQ, is a Critical Care Pharmacist at the Montreal General Hospital, Montréal, Quebec. He is also an Associate Editor with the Canadian Journal of Hospital Pharmacy
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8
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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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Perreault MM, Williamson D, Capilnean A. Response. Am J Crit Care 2020; 29:168-169. [PMID: 32355979 DOI: 10.4037/ajcc2020769] [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: 11/01/2022]
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Capilnean A, Martone A, Rosu VA, Sandu PR, Murgoi P, Frenette AJ, Williamson D, Lecavalier A, Jayaraman D, Rico P, Bellemare P, Gélinas C, Perreault MM. Validation of the Withdrawal Assessment Tool-1 in Adult Intensive Care Patients. Am J Crit Care 2019; 28:361-369. [PMID: 31474606 DOI: 10.4037/ajcc2019559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Withdrawal Assessment Tool-1 (WAT-1) has been validated for assessing iatrogenic withdrawal syndrome in critically ill children receiving mechanical ventilation, but little is known about this syndrome in critically ill adults. OBJECTIVE To evaluate the validity and reliability of the WAT-1 in critically ill adults. METHODS A prospective, observational, open-cohort pilot study of critically ill adults receiving mechanical ventilation and regular administration of opioids for at least 72 hours. Patients were assessed for withdrawal twice daily on weekdays and once daily on weekends using the WAT-1 after an opioid weaning episode. The presence of iatrogenic withdrawal syndrome was evaluated once daily using modified Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria. All evaluations were blinded and performed independently. The criterion validity of the WAT-1 and the interrater reliability for WAT-1 and DSM-5 evaluations were determined. RESULTS During 8 months, 52 adults (median age, 51.5 years) were enrolled. Eight patients (15%) had at least 1 positive assessment during their intensive care unit stay using the DSM-5, compared with 19 patients (37%) using the WAT-1. The overall sensitivity of the WAT-1 was 50%, and its specificity was 65.9%. Agreement between WAT-1 and DSM-5 assessments was poor (κ = 0.102). The interrater reliability for the WAT-1 was 89.1% and for the DSM-5 was 90.1%. CONCLUSION Despite showing reliability, the WAT-1 is not a valid tool for assessing the presence of iatrogenic withdrawal syndrome in adults.
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Affiliation(s)
- Anissa Capilnean
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Amanda Martone
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Vlad A Rosu
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Patricia R Sandu
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Paul Murgoi
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Anne Julie Frenette
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - David Williamson
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Annie Lecavalier
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Dev Jayaraman
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Philippe Rico
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Patrick Bellemare
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Céline Gélinas
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal
| | - Marc M Perreault
- Anissa Capilnean, Vlad A. Rosu, and Paul Murgoi are clinical pharmacists, Pharmacy Department, McGill University Health Center, Montreal, Canada. Amanda Martone is a clinical pharmacist, Pharmacy Department, Lakeshore Hospital, Montreal, Canada. Patricia R. Sandu is a clinical pharmacist, Pharmacy Department, Jewish General Hospital, Montreal, Canada. Anne Julie Frenette is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, and an associate clinical professor, Faculty of Pharmacy, University of Montreal, Montreal, Canada. David Williamson is a clinical pharmacist, Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and a clinical professor, Faculty of Pharmacy, University of Montreal. Annie Lecavalier is a resident physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an adjunct professor, Faculty of Medicine, McGill University, Montreal, Canada. Dev Jayaraman is an attending physician, Critical Care Department, Montreal General Hospital, McGill University Health Center, and an associate professor, Faculty of Medicine, McGill University. Philippe Rico is a clinical adjunct professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Patrick Bellemare is an associate clinical professor, Faculty of Medicine, University of Montreal, and an intensivist, Critical Care Department, Hôpital du Sacré-Coeur de Montréal. Céline Gélinas is an associate professor, Ingram School of Nursing, McGill University, and a senior researcher, Center for Nursing Research and Lady Davis Institute, Jewish General Hospital. Marc M. Perreault is a clinical pharmacist, Pharmacy Department, McGill University Health Center, and a clinical professor, Faculty of Pharmacy, University of Montreal.
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Perreault MM. La dose fait le poison*. Can J Hosp Pharm 2019. [DOI: 10.4212/cjhp.v72i2.2879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Perreault MM. The Dose Makes the Poison*. Can J Hosp Pharm 2019. [DOI: 10.4212/cjhp.v72i2.2878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Perreault MM. [Not Available]. Can J Hosp Pharm 2019; 72:109-110. [PMID: 31036970 PMCID: PMC6476579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Marc M Perreault
- , B. Pharm., M. Sc., Pharm. D., FCSHP, FOPQ, est pharmacien en soins critiques à l'Hôpital général de Montréal, Montréal, Québec. Il est également rédacteur adjoint au Journal canadien de la pharmacie hospitalière
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Perreault MM. The Dose Makes the Poison. Can J Hosp Pharm 2019; 72:107-108. [PMID: 31036969 PMCID: PMC6476583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Marc M Perreault
- , BPharm, MSc, PharmD, FCSHP, FOPQ, is a Critical Care Pharmacist at the Montreal General Hospital, Montréal, Quebec. He is also an Associate Editor with the Canadian Journal of Hospital Pharmacy
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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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Burry L, Mehta S, Perreault MM, Luxenberg JS, Siddiqi N, Hutton B, Fergusson DA, Bell C, Rose L. Antipsychotics for treatment of delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2018; 6:CD005594. [PMID: 29920656 PMCID: PMC6513380 DOI: 10.1002/14651858.cd005594.pub3] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Guidelines suggest limited and cautious use of antipsychotics for treatment of delirium where nonpharmacological interventions have failed and symptoms remain distressing or dangerous, or both. It is unclear how well these recommendations are supported by current evidence. OBJECTIVES Our primary objective was to assess the efficacy of antipsychotics versus nonantipsychotics or placebo on the duration of delirium in hospitalised adults. Our secondary objectives were to compare the efficacy of: 1) antipsychotics versus nonantipsychotics or placebo on delirium severity and resolution, mortality, hospital length of stay, discharge disposition, health-related quality of life, and adverse effects; and 2) atypical vs. typical antipsychotics for reducing delirium duration, severity, and resolution, hospital mortality and length of stay, discharge disposition, health-related quality of life, and adverse effects. SEARCH METHODS We searched MEDLINE, Embase, Cochrane EBM Reviews, CINAHL, Thomson Reuters Web of Science and the Latin American and Caribbean Health Sciences Literature (LILACS) from their respective inception dates until July 2017. We also searched the Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database, Web of Science ISI Proceedings, and other grey literature. SELECTION CRITERIA We included randomised and quasi-randomised trials comparing 1) antipsychotics to nonantipsychotics or placebo and 2) typical to atypical antipsychotics for the treatment of delirium in adult hospitalised (but not critically ill) patients. DATA COLLECTION AND ANALYSIS We examined titles and abstracts of identified studies to determine eligibility. We extracted data independently in duplicate. Disagreements were settled by further discussion and consensus. We used risk ratios (RR) with 95% confidence intervals (CI) as a measure of treatment effect for dichotomous outcomes, and between-group standardised mean differences (SMD) with 95% CI for continuous outcomes. MAIN RESULTS We included nine trials that recruited 727 participants. Four of the nine trials included a comparison of an antipsychotic to a nonantipsychotic drug or placebo and seven included a comparison of a typical to an atypical antipsychotic. The study populations included hospitalised medical, surgical, and palliative patients.No trial reported on duration of delirium. Antipsychotic treatment did not reduce delirium severity compared to nonantipsychotic drugs (standard mean difference (SMD) -1.08, 95% CI -2.55 to 0.39; four studies; 494 participants; very low-quality evidence); nor was there a difference between typical and atypical antipsychotics (SMD -0.17, 95% CI -0.37 to 0.02; seven studies; 542 participants; low-quality evidence). There was no evidence antipsychotics resolved delirium symptoms compared to nonantipsychotic drug regimens (RR 0.95, 95% CI 0.30 to 2.98; three studies; 247 participants; very low-quality evidence); nor was there a difference between typical and atypical antipsychotics (RR 1.10, 95% CI 0.79 to 1.52; five studies; 349 participants; low-quality evidence). The pooled results indicated that antipsychotics did not alter mortality compared to nonantipsychotic regimens (RR 1.29, 95% CI 0.73 to 2.27; three studies; 319 participants; low-quality evidence) nor was there a difference between typical and atypical antipsychotics (RR 1.71, 95% CI 0.82 to 3.35; four studies; 342 participants; low-quality evidence).No trial reported on hospital length of stay, hospital discharge disposition, or health-related quality of life. Adverse event reporting was limited and measured with inconsistent methods; in those reporting events, the number of events were low. No trial reported on physical restraint use, long-term cognitive outcomes, cerebrovascular events, or QTc prolongation (i.e. increased time in the heart's electrical cycle). Only one trial reported on arrhythmias and seizures, with no difference between typical or atypical antipsychotics. We found antipsychotics did not have a higher risk of extrapyramidal symptoms (EPS) compared to nonantipsychotic drugs (RR 1.70, 95% CI 0.04 to 65.57; three studies; 247 participants; very-low quality evidence); pooled results showed no increased risk of EPS with typical antipsychotics compared to atypical antipsychotics (RR 12.16, 95% CI 0.55 to 269.52; two studies; 198 participants; very low-quality evidence). AUTHORS' CONCLUSIONS There were no reported data to determine whether antipsychotics altered the duration of delirium, length of hospital stay, discharge disposition, or health-related quality of life as studies did not report on these outcomes. From the poor quality data available, we found antipsychotics did not reduce delirium severity, resolve symptoms, or alter mortality. Adverse effects were poorly or rarely reported in the trials. Extrapyramidal symptoms were not more frequent with antipsychotics compared to nonantipsychotic drug regimens, and no different for typical compared to atypical antipsychotics.
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Affiliation(s)
- Lisa Burry
- Mount Sinai Hospital, Leslie Dan Faculty of Pharmacy, University of TorontoDepartment of Pharmacy600 University Avenue, Room 18‐377TorontoONCanadaM5G 1X5
| | - Sangeeta Mehta
- Mount Sinai Hospital, University of TorontoInterdepartmental Division of Critical Care Medicine600 University Ave, Rm 1504TorontoONCanadaM5G 1X5
| | - Marc M Perreault
- Université de MontréalFaculty of PharmacyC.P. 6128, succ Centre‐VilleMontrealQCCanadaH3C 3J7
| | | | - Najma Siddiqi
- Hull York Medical School, University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Brian Hutton
- Ottawa Hospital Research InstituteKnowledge Synthesis Group501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Dean A Fergusson
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Chaim Bell
- Mount Sinai HospitalMedicine600 University Street Room 433TorontoONCanadaM5G 1X5
| | - Louise Rose
- Sunnybrook Health Sciences Centre and Sunnybrook Research InstituteDepartment of Critical Care MedicineTorontoCanada
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Wang PP, Huang E, Feng X, Bray CA, Perreault MM, Rico P, Bellemare P, Murgoi P, Gélinas C, Lecavalier A, Jayaraman D, Frenette AJ, Williamson D. Opioid-associated iatrogenic withdrawal in critically ill adult patients: a multicenter prospective observational study. Ann Intensive Care 2017; 7:88. [PMID: 28866754 PMCID: PMC5581799 DOI: 10.1186/s13613-017-0310-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [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: 11/22/2016] [Accepted: 08/18/2017] [Indexed: 11/10/2022] Open
Abstract
Background Opioids and benzodiazepines are frequently used in the intensive care unit (ICU). Regular use and prolonged exposure to opioids in ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in pediatrics, but no prospective study has evaluated this syndrome in adult ICU patients. The objective of this study was to determine the incidence of IWS caused by opioids in a critically ill adult population. This multicenter prospective cohort study was conducted at two level-1 trauma ICUs between February 2015 and September 2015 and included 54 critically ill patients. Participants were eligible if they were 18 years and older, mechanically ventilated and had received more than 72 h of regular intermittent or continuous intravenous infusion of opioids. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders criteria for opioid withdrawal. Results The population consisted mostly of males (74.1%) with a median age of 50 years (25th–75th percentile 38.2–64.5). The median ICU admission APACHE II score was 22 (25th–75th percentile 12.0–28.2). The overall incidence of IWS was 16.7% (95% CI 6–27). The median cumulative opioid dose prior to weaning was higher in patients with IWS (245.7 vs. 169.4 mcg/kg, fentanyl equivalent). Patients with IWS were also exposed to opioids for a longer period of time as compared to patients without IWS (median 151 vs. 125 h). However, these results were not statistically significant. Conclusions IWS was occasionally observed in this very specific population of mechanically ventilated, critically ill ICU patients. Further studies are needed to confirm these preliminary results and identify risk factors.
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Affiliation(s)
- Pan Pan Wang
- Pharmacy Department, Lakeshore General Hospital, Montreal, Canada
| | - Elaine Huang
- Pharmacy Department, Hôpital de Verdun, Montreal, Canada
| | - Xue Feng
- Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, QC, H4J 1C5, Canada
| | | | - Marc M Perreault
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Pharmacy Department, McGill University Health Center, Montreal, Canada
| | - Philippe Rico
- Critical Care Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada.,Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Patrick Bellemare
- Critical Care Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada.,Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Paul Murgoi
- Pharmacy Department, McGill University Health Center, Montreal, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, QC, Canada.,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Annie Lecavalier
- Department of Adult Critical Care, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Dev Jayaraman
- Department of Critical Care, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Anne Julie Frenette
- Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, QC, H4J 1C5, Canada.,Faculté de Pharmacie, Université de Montréal, Montreal, Canada
| | - David Williamson
- Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, QC, H4J 1C5, Canada. .,Faculté de Pharmacie, Université de Montréal, Montreal, Canada.
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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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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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Perreault MM. Today’s Research Is Tomorrow’s Practice: Promoting a Culture of Research. Can J Hosp Pharm 2017. [DOI: 10.4212/cjhp.v70i3.1654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Perreault MM. Les recherches d’aujourd’hui sont les pratiques de demain : promouvoir une culture de la recherche. Can J Hosp Pharm 2017. [DOI: 10.4212/cjhp.v70i3.1655] [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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Perreault MM. Today's Research Is Tomorrow's Practice: Promoting a Culture of Research. Can J Hosp Pharm 2017; 70:167-168. [PMID: 28680168 PMCID: PMC5491190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Marc M Perreault
- Address correspondence to: Dr Marc Perreault, Pharmacy Department, Montreal General Hospital, 1650 Cedar Avenue, Suite C1-200, Montreal QC H3G 1A4, e-mail:
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Perreault MM. [Not Available]. Can J Hosp Pharm 2017; 70:169-170. [PMID: 28680169 PMCID: PMC5491191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Marc M. Perreault
- Address correspondence to: D Marc Perreault, Service de pharmacie, Hôpital général de Montréal, 1650, avenue Cedar, bureau C1-200, Montréal (Québec) H3G 1A4, Courriel:
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Williamson DR, Frenette AJ, Burry L, Perreault MM, Charbonney E, Lamontagne F, Potvin MJ, Giguère JF, Mehta S, Bernard F. Pharmacological interventions for agitation in patients with traumatic brain injury: protocol for a systematic review and meta-analysis. Syst Rev 2016; 5:193. [PMID: 27855720 PMCID: PMC5114826 DOI: 10.1186/s13643-016-0374-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a worldwide leading cause of mortality and disability. Among TBI complications, agitation is a frequent behavioural problem. Agitation causes potential harm to patients and caregivers, interferes with treatments, leads to unnecessary chemical and physical restraints, increases hospital length of stay, delays rehabilitation, and impedes functional independence. Pharmacological treatments are often considered for agitation management following TBI. Several types of agents have been proposed for the treatment of agitation. However, the benefit and safety of these agents in TBI patients as well as their differential effects and interactions are uncertain. In addition, animal studies and observational studies have suggested impaired cognitive function with the use of certain antipsychotics and benzodiazepines. Hence, a safe and effective treatment for agitation, which does not interfere with neurological recovery, remains to be identified. METHODS/DESIGN With the help of Health Sciences librarian, we will design a search strategy in the following databases: PubMed, Ovid MEDLINE®, EMBASE, CINAHL, PsycINFO, Cochrane Library, Google Scholar, Directory of Open Access Journals, LILACS, Web of Science, and Prospero. A grey literature search will be performed using the resources suggested in CADTH's Grey Matters. We will include all randomized controlled, quasi-experimental, and observational studies with control groups. The population of interest is all patients, including children and adults, who have suffered a TBI. We will include studies in which agitation, not further defined, was the presenting symptom or one of the presenting symptoms. We will also include studies where agitation was not the presenting symptom but was measured as an outcome variable and studies assessing the safety of these pharmacological interventions in TBI patients. We will include studies evaluating all pharmacological interventions including beta-adrenergic blockers, typical and atypical antipsychotics, anticonvulsants, dopamine agonists, psychostimulants, antidepressants, alpha-2-adrenergic agonists, hypnotics, and anxiolytics. DISCUSSION Although agitation is frequent following TBI and pharmacological agents that are often used, there is no consensus on the most efficacious and safest strategy to treat these complications. There is a need for an updated systematic review to summarize the evidence in order to inform practice and future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016033140.
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Affiliation(s)
- David R Williamson
- Pharmacy Department and Research Center, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, Quebec, H4J 1C5, Canada. .,Faculté de pharmacie, Université de Montréal, Montréal, Canada.
| | - Anne Julie Frenette
- Pharmacy Department and Research Center, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, Quebec, H4J 1C5, Canada.,Faculté de pharmacie, Université de Montréal, Montréal, Canada
| | - Lisa Burry
- Department of Pharmacy and Medicine, Mount Sinai Hospital, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Marc M Perreault
- Faculté de pharmacie, Université de Montréal, Montréal, Canada.,Department of Pharmacy, McGill University Health Center, Montréal, Canada
| | - Emmanuel Charbonney
- Department of Critical Care and Research Center, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada
| | - François Lamontagne
- Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada.,Faculté de Médecine, Université de Sherbrooke, Sherbrooke, Canada
| | - Marie-Julie Potvin
- Department of Psychology, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada.,Department of Psychology, Université du Québec à Montréal, Montréal, Canada
| | - Jean-François Giguère
- Faculté de Médecine, Université de Montréal, Montréal, Canada.,Department of Neurosurgery, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Francis Bernard
- Department of Critical Care and Research Center, Hôpital du Sacré-Coeur de Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada
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Dupuis S, Martel A, Arfa T, Valma J, Williamson DR, Perreault MM. Factors Influencing Fourth-Year Pharmacy Students' Decisions to Pursue a Hospital Pharmacy Residency. Can J Hosp Pharm 2016; 69:209-15. [PMID: 27403000 DOI: 10.4212/cjhp.v69i3.1557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/10/2022]
Abstract
BACKGROUND The Canadian Society of Hospital Pharmacists promotes the recruitment of residency-trained pharmacists for work in hospitals and related health care settings. However, Quebec hospitals are still hiring non-residency trained pharmacists, in part because of a severe shortage of hospital pharmacists. To date, no studies have examined the factors influencing the career choices of fourth-year pharmacy students in Canada. OBJECTIVES To identify motivating factors and barriers influencing students' decision to pursue a hospital pharmacy residency. METHODS All 186 fourth-year students in the Faculty of Pharmacy, Université de Montréal, were invited by e-mail to participate in a validated and institutionally approved survey that was available online between March and May 2014. RESULTS Of the 138 respondents who returned a completed survey (74% response rate), 36 (26%) planned to apply for a hospital pharmacy residency. Those planning to apply for a residency were older (p = 0.037) and had more hospital work experience (36% versus 3%, p < 0.001) than those not planning to apply. The most important motivators for pursuing a residency were potential gains in knowledge (reported by 88% of respondents, whether or not they were planning to pursue a residency), experience (80%), and self-confidence (62%). The most frequently reported barriers were recognition that a hospital pharmacy residency is a highly demanding program (65%), having work available upon graduation from the undergraduate program (43%), and financial obligations (34%). Hospital experiential rotations influenced, either positively or negatively, 23 (72%) of the 32 students who changed their decision to pursue or not pursue residency training over the course of their studies. CONCLUSIONS The potential gain in knowledge and experience acquired through residency, the fact that it is considered a highly demanding program, and having work available upon graduation from undergraduate studies were the most influential factors in fourth-year pharmacy students' decision of whether to pursue a hospital pharmacy residency.
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Affiliation(s)
- Sébastien Dupuis
- PharmD, MSc, is with the Faculté de pharmacie, Université de Montréal, and the Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montréal, Quebec
| | - Alexis Martel
- PharmD, is with the Pharmacy Vandergoten and Zaccara, Saint-Eustache, Quebec
| | - Taha Arfa
- BPharm, MBA, is with the Faculté de pharmacie, Université de Montréal, Montréal, Quebec
| | - Joannah Valma
- MSc, is with the Faculté de pharmacie, Université de Montréal, Montréal, Quebec
| | - David R Williamson
- BPharm, MSc, PhD, BCPS, is with the Faculté de pharmacie, Université de Montréal, and the Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montréal, Quebec
| | - Marc M Perreault
- MSc, PharmD, BCPS, is with the Faculté de pharmacie, Université de Montréal, and the Pharmacy Department, McGill University Health Centre, Montréal, Quebec. He is also an Associate Editor with the Canadian Journal of Hospital Pharmacy
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Thiboutot Z, Perreault MM, Williamson DR, Rose L, Mehta S, Guenette MD, Cook D, Burry L. Antipsychotic Drug Use and Screening for Delirium in Mechanically Ventilated Patients in Canadian Intensive Care Units: An Observational Study. Can J Hosp Pharm 2016; 69:107-13. [PMID: 27168631 DOI: 10.4212/cjhp.v69i2.1537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 11/10/2022]
Abstract
BACKGROUND Critically ill patients frequently experience delirium, and antipsychotic drugs are often used to manage symptoms. OBJECTIVES To describe the use of antipsychotic drugs and delirium screening tools in mechanically ventilated, critically ill adult patients in Canadian intensive care units (ICUs) and to identify factors associated with the use of antipsychotic drugs. METHODS Pharmacists from 51 Canadian ICUs prospectively collected data on antipsychotic use and delirium screening in all patients for whom invasive mechanical ventilation was initiated during a chosen 2-week period occurring sometime in 2008 or 2009. RESULTS Data were collected for a total of 712 patients, of whom 115 (16.2%) received at least one dose of an antipsychotic. The antipsychotic prescribed, the total daily dose, and the administration schedule varied across sites. Delirium screening tools, validated for use in mechanically ventilated patients and endorsed by professional society guidelines, were part of routine care in a minority of ICUs (7/51 [13.7%]), and delirium screening was documented for few patients overall (41/712 patients [5.8%]). In a multivariable analysis, administration of antipsychotics was independently associated with longer duration of mechanical ventilation (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.07-1.17), daily interruption of sedation (OR 1.71, 95% CI 1.01-2.90), and use of physical restraints (OR 2.15, 95% CI 1.27-3.65). CONCLUSION A minority of mechanically ventilated patients in Canadian ICUs received antipsychotic drugs, and screening for delirium with validated tools was rare. Antipsychotic drug use was independently associated with longer duration of mechanical ventilation, daily interruption of sedation, and use of physical restraints.
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Affiliation(s)
- Zoé Thiboutot
- BPharm, MSc, is a Pharmacist with the Centre hospitalier de l'Université de Montréal, Montréal, Quebec
| | - Marc M Perreault
- BPharm, MSc, PharmD, is a Pharmacist with the McGill University Health Centre and a Full Clinical Professor with the Université de Montréal, Montréal, Quebec. He is also an Associate Editor with the CJHP
| | - David R Williamson
- BPharm, MSc, PhD, is a Pharmacist with the Hôpital du Sacré-Coeur de Montréal and a Full Clinical Professor with the Université de Montréal, Montréal, Quebec
| | - Louise Rose
- BN, MN, PhD, RN, is TD Nursing Professor of Critical Care Research with Sunnybrook Health Sciences Centre and an Associate Professor with the Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario
| | - Sangeeta Mehta
- MD, FRCPC, is an Intensivist with the Department of Medicine, Mount Sinai Hospital, and a Professor with the Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Melanie D Guenette
- HBSc, MSc, is a Research Coordinator with the Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario
| | - Deborah Cook
- MD, MSc, is an Intensivist with St Joseph's Healthcare and a Professor with the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario
| | - Lisa Burry
- BScPharm, PharmD, is a Clinical Pharmacy Specialist with Mount Sinai Hospital and a Clinician Scientist with the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
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Wheeler KE, Cook DJ, Mehta S, Calce A, Guenette M, Perreault MM, Thiboutot Z, Duffett M, Burry L. Use of probiotics to prevent ventilator-associated pneumonia: A survey of pharmacists' attitudes. J Crit Care 2015; 31:221-6. [PMID: 26643860 DOI: 10.1016/j.jcrc.2015.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/10/2015] [Accepted: 10/17/2015] [Indexed: 12/31/2022]
Abstract
PURPOSE The primary objective of this survey was to describe pharmacists' attitudes regarding probiotic use in the intensive care unit (ICU); secondary objectives were to evaluate pharmacists' knowledge and use of probiotics for critically ill patients. METHODS The survey instrument was rigorously designed and pretested, then distributed in both English and French to Canadian ICU pharmacists. The online survey was open for 5 weeks, and 3 follow-up emails were sent to maximize response rates. RESULTS Of 303 eligible surveys, 191 were returned (63.0%). Probiotics were available in the hospitals of 69.8% (113/162) of respondents, and 62.0% (101/163) indicated that they had used probiotics for at least 1 ICU patient in the previous year. Most pharmacists (137/171, 80.1%) said that they would "never" consider recommending probiotics for prevention of ventilator-associated pneumonia in ICU patients, and this response was more common (P = .0074) among pharmacists who were "unsure" about the safety of probiotics in this population when compared to those who felt that they knew how safe probiotics are. CONCLUSIONS Most Canadian ICU pharmacists have used probiotics at least once in the ICU in the last year. However, based on uncertain efficacy and safety, most ICU pharmacists would not currently recommend probiotics for the prevention of ventilator-associated pneumonia.
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Affiliation(s)
| | - Deborah J Cook
- Departments of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Sangeeta Mehta
- Department of Medicine, Mount Sinai Hospital, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Adriana Calce
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Canada
| | | | - Marc M Perreault
- Department of Pharmacy, McGill University Health Center, Montreal, Canada
| | - Zoé Thiboutot
- Department of Pharmacy, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Mark Duffett
- Departments of Pediatrics and Clinical Epidemiology and Biostatistics, Hamilton Health Sciences, Hamilton, Canada
| | - Lisa Burry
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Canada; Department of Medicine, Mount Sinai Hospital, Toronto, Canada.
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Duceppe MA, Elliott A, Para M, Poirier MC, Delisle M, Frenette AJ, Deckelbaum D, Razek T, Desjardins M, Bertrand JC, Bernard F, Rico P, Burry L, Williamson D, Perreault MM. Modifiable risk factors for delirium in critically ill trauma patients: a multicenter prospective study. Crit Care 2015. [PMCID: PMC4470827 DOI: 10.1186/cc14558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Luk E, Sneyers B, Rose L, Perreault MM, Williamson DR, Mehta S, Cook DJ, Lapinsky SC, Burry L. Predictors of physical restraint use in Canadian intensive care units. Crit Care 2014; 18:R46. [PMID: 24661688 PMCID: PMC4075126 DOI: 10.1186/cc13789] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/07/2014] [Indexed: 12/14/2022]
Abstract
Introduction Physical restraint (PR) use in the intensive care unit (ICU) has been associated with higher rates of self-extubation and prolonged ICU length of stay. Our objectives were to describe patterns and predictors of PR use. Methods We conducted a secondary analysis of a prospective observational study of analgosedation, antipsychotic, neuromuscular blocker, and PR practices in 51 Canadian ICUs. Data were collected prospectively for all mechanically ventilated adults admitted during a two-week period. We tested for patient, treatment, and hospital characteristics that were associated with PR use and number of days of use, using logistic and Poisson regression respectively. Results PR was used on 374 out of 711 (53%) patients, for a mean number of 4.1 (standard deviation (SD) 4.0) days. Treatment characteristics associated with PR were higher daily benzodiazepine dose (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.00 to 1.11), higher daily opioid dose (OR 1.04, 95% CI 1.01 to 1.06), antipsychotic drugs (OR 3.09, 95% CI 1.74 to 5.48), agitation (Sedation-Agitation Scale (SAS) >4) (OR 3.73, 95% CI 1.50 to 9.29), and sedation administration method (continuous and bolus versus bolus only) (OR 3.09, 95% CI 1.74 to 5.48). Hospital characteristics associated with PR indicated patients were less likely to be restrained in ICUs from university-affiliated hospitals (OR 0.32, 95% CI 0.17 to 0.61). Mainly treatment characteristics were associated with more days of PR, including: higher daily benzodiazepine dose (incidence rate ratio (IRR) 1.07, 95% CI 1.01 to 1.13), daily sedation interruption (IRR 3.44, 95% CI 1.48 to 8.10), antipsychotic drugs (IRR 15.67, 95% CI 6.62 to 37.12), SAS <3 (IRR 2.62, 95% CI 1.08 to 6.35), and any adverse event including accidental device removal (IRR 8.27, 95% CI 2.07 to 33.08). Patient characteristics (age, gender, Acute Physiology and Chronic Health Evaluation II score, admission category, prior substance abuse, prior psychotropic medication, pre-existing psychiatric condition or dementia) were not associated with PR use or number of days used. Conclusions PR was used in half of the patients in these 51 ICUs. Treatment characteristics predominantly predicted PR use, as opposed to patient or hospital/ICU characteristics. Use of sedative, analgesic, and antipsychotic drugs, agitation, heavy sedation, and occurrence of an adverse event predicted PR use or number of days used.
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Vlavonou R, Perreault MM, Barrière O, Shink E, Tremblay PO, Larouche R, Pichette V, Tanguay M. Pharmacokinetic characterization of baclofen in patients with chronic kidney disease: dose adjustment recommendations. J Clin Pharmacol 2014; 54:584-92. [DOI: 10.1002/jcph.247] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 12/04/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Raphaël Vlavonou
- Division of Clinical Pharmacology; inVentiv Health Clinical; Montreal Quebec Canada
| | - Marc M. Perreault
- Faculty of Pharmacy; Université de Montréal; Montreal Quebec Canada
- Department of Pharmacy; McGill University Health Center; Montreal Quebec Canada
| | - Olivier Barrière
- Division of Clinical Pharmacology; inVentiv Health Clinical; Montreal Quebec Canada
| | - Eric Shink
- Division of Clinical Pharmacology; inVentiv Health Clinical; Quebec Quebec Canada
| | | | - Richard Larouche
- Clinical division; inVentiv Health Clinical; Montreal Quebec Canada
| | - Vincent Pichette
- Centre de recherche Hôpital Maisonneuve-Rosemont; Montréal Canada
- Département de Médecine et de Pharmacologie; Université de Montréal; Montréal Canada
| | - Mario Tanguay
- Division of Clinical Pharmacology; inVentiv Health Clinical; Montreal Quebec Canada
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Sneyers B, Laterre PF, Bricq E, Perreault MM, Wouters D, Spinewine A. What stops us from following sedation recommendations in intensive care units? A multicentric qualitative study. J Crit Care 2013; 29:291-7. [PMID: 24412211 DOI: 10.1016/j.jcrc.2013.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [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: 08/01/2013] [Revised: 10/14/2013] [Accepted: 11/04/2013] [Indexed: 01/09/2023]
Abstract
PURPOSE The purpose of the study is to explore health care professionals' (HCPs) perceptions regarding sedation recommendations. MATERIALS AND METHODS This is a qualitative study, using face-to-face semistructured interviews. Health care professionals from 4 Belgian hospitals were purposively sampled. We focused on recommendations involving strategies such as protocolized sedation, sedation scales, daily sedation interruption (DSI), and providing analgesia before sedation. Knowledge, perceived barriers, expected outcomes, and responsibilities were discussed for each recommendation. Two researchers independently performed content analysis, classifying quotes according to an interdisciplinary framework and creating new categories for emerging themes. RESULTS Data saturation was reached after 21 HCPs (physicians, nurses, and physiotherapists) were interviewed. Quotes were related to HCPs, guidelines or the system. Barriers were diverse according to the type of HCP or level of experience. Task characteristics impairing implementation of protocolized sedation included lack of means communicating goals or tasks to all HCPs providing care, ambiguous responsibilities, and unclear methodology on how to execute the recommendation. Fear of adverse events and lack of clarity regarding contraindications impair implementation of DSI. CONCLUSION Barriers impairing implementation of sedation recommendations vary according to the type of HCP and the choice of strategy targeting light sedation (protocolized sedation vs DSI). Improvement strategies must target HCPs separately and tailored to specific recommendation choices.
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Affiliation(s)
- Barbara Sneyers
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium; Department of Pharmacy, Cliniques universitaires saint Luc, Brussels, Belgium.
| | - Pierre-François Laterre
- Department of Intensive Care and Emergency Medicine, Cliniques universitaires saint Luc, Brussels, Belgium
| | | | | | - Dominique Wouters
- Department of Pharmacy, Cliniques universitaires saint Luc, Brussels, Belgium
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium; Department of Pharmacy, Centre hospitalier universitaire Mont-Godinne/Dinant, Université catholique de Louvain, Yvoir, Belgium
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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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Sneyers B, Laterre PF, Perreault MM, Spinewine A. Sedation in the ICU: nurses' perceptions of practices and influencing factors. Crit Care 2012. [PMCID: PMC3363742 DOI: 10.1186/cc10931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Frenette AJ, Kanji S, Rees L, Williamson DR, Perreault MM, Turgeon AF, Bernard F, Fergusson DA. Efficacy and safety of dopamine agonists in traumatic brain injury: a systematic review of randomized controlled trials. J Neurotrauma 2011; 29:1-18. [PMID: 21846248 DOI: 10.1089/neu.2011.1812] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
In the intensive care unit, dopamine agonists (DA) have been used in traumatic brain injury (TBI) patients to augment or accelerate cognitive recovery and rehabilitation. However, the efficacy and safety of DA in this population is not well established. We conducted a systematic review of randomized controlled trials (RCTs) examining the clinical efficacy and safety of DA in patients with TBI. We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials, comparing DA to either placebo, standard treatment, or another active comparator. There was no restriction for age, date, or language of publication. Sensitivity analyses were planned to evaluate the potential effect of timing of TBI, age, drugs, and year of publication on efficacy. Among the 790 citations identified, 20 RCTs evaluating methylphenidate, amantadine, and bromocriptine were eligible. Significant clinical heterogeneity was observed between and within studies, which precluded any pooling of data. Efficacy outcomes included mainly neuropsychological measures of cognitive functioning. A total of 76 different neuropsychological tests were used, but most of them (59%) only once. Only 5 studies systematically assessed safety. No trend could be drawn from the analysis of efficacy and safety. Important sources of bias in the studies were of major concern. Considering the absence of consensus regarding clinical outcome, the lack of safety assessment, and the high risk of bias in the included trials, more research is warranted before DA can be recommended in critically ill TBI patients.
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Affiliation(s)
- Anne Julie Frenette
- Department of Pharmacy, Hôpital du Sacré-Coeur de Montréal, Faculty of Pharmacy, University of Montréal, Montréal, Quebec, Canada.
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Frenette AJ, Kanji S, Rees L, Williamson DR, Perreault MM, Turgeon AF, Bernard F, Fergusson DA. Efficacy and safety of dopamine agonists in traumatic brain injury: a systematic review of randomized controlled trials. Crit Care 2011. [PMCID: PMC3066985 DOI: 10.1186/cc9731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Ghannoum M, Lavergne V, Yue CS, Ayoub P, Perreault MM, Roy L. Successful treatment of lithium toxicity with sodium polystyrene sulfonate: a retrospective cohort study. Clin Toxicol (Phila) 2010; 48:34-41. [PMID: 19842945 DOI: 10.3109/15563650903344785] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Lithium (Li) is a first-line treatment for bipolar disorder but has a narrow therapeutic index. Treatment of Li toxicity includes supportive measures and hemodialysis in severe cases, but this modality is not always immediately available. Sodium polystyrene sulfonate (SPS, Kayexalate), a cation exchanger, has been promising in animal models and human reports to reduce absorption and enhance elimination of Li. MATERIAL AND METHODS A retrospective cohort study was conducted. All cases of chronic Li intoxication were reviewed in two adult-care hospitals from 2000 to 2009. A group comparison and a within-patient comparison were performed to compare the effect of SPS on the median Li half-life (T(1/2)). For this study, at least three serum Li levels were required for T(1/2) calculations. RESULTS Forty-eight patients met inclusion requirements, 12 of whom had taken SPS. Median Li T(1/2) in the treated and control groups was 20.5 and 43.2 hours, respectively (p = 0.0006). In the 12 treated patients, Li T(1/2) during SPS was on average 48.9% shorter than without SPS. Furthermore, in one subject in whom urinary Li data were available, Li clearance with SPS was superior to Li renal clearance. Prolonged constipation was noted in one patient whereas mild hypokalemia was noted in six patients treated with SPS. CONCLUSION This study shows that SPS reduced Li T(1/2) and suggests that SPS is capable of promoting Li elimination in chronic intoxications. These results warrant a prospective trial looking at the use of SPS in the treatment of Li overdose as an adjunct to supportive measures and hemodialysis.
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Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, Verdun, QC, Canada.
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Perreault MM, Yan J, Karamaoun A, Villeneuve E, Razek T. Trauma patients with prophylactic IVC filter and chemical prophylaxis: a descriptive study. Crit Care 2010. [PMCID: PMC2934096 DOI: 10.1186/cc8592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Delisle MS, Williamson DR, Perreault MM, Albert M, Jiang X, Heyland DK. Comparison between mortality and airway colonization vs noncolonization with Candida species in critically ill adults. J Crit Care 2009. [DOI: 10.1016/j.jcrc.2008.06.004] [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: 11/29/2022]
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Delisle MS, Williamson DR, Perreault MM, Albert M, Jiang X, Heyland DK. The clinical significance of Candida colonization of respiratory tract secretions in critically ill patients. J Crit Care 2008; 23:11-7. [DOI: 10.1016/j.jcrc.2008.01.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 01/10/2008] [Accepted: 01/15/2008] [Indexed: 10/22/2022]
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Omrane R, Eid J, Perreault MM, Yazbeck H, Berbiche D, Gursahaney A, Moride Y. Impact of a protocol for prevention of ventilator-associated pneumonia. Ann Pharmacother 2007; 41:1390-6. [PMID: 17698898 DOI: 10.1345/aph.1h678] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Several interventions have been shown to be effective in reducing the incidence of ventilator-associated pneumonia (VAP), but their implementation in clinical practice has not gained widespread acceptance. OBJECTIVE To determine the impact of a protocol that incorporates evidence-based interventions shown to reduce the frequency of VAP on the overall rate of VAP, early-onset VAP, and late-onset VAP in the intensive care unit (ICU) of a tertiary care adult teaching hospital. METHODS This pre- and postintervention observational study included mechanically ventilated patients admitted to the Montreal General Hospital ICU between November 2003 and May 2004 (preintervention) and between November 2004 and May 2005 (postintervention). A multidisciplinary prevention protocol was developed, implemented, and reinforced. Rates of VAP per 1000 ventilator-days were calculated pre- and postprotocol implementation for all patients, for patients with early-onset VAP, and for those with late-onset VAP. RESULTS In the pre- and postintervention groups, 349 and 360 patients, respectively, were mechanically ventilated. Twenty-three VAP episodes occurred in 925 ventilator-days (crude incidence rate 25 per 1000) in the preintervention period. Following implementation, the VAP rate decreased to 22 episodes in 988 ventilator-days (crude incidence rate 22.3 per 1000), corresponding to a relative reduction in rate of 10.8% (p < 0.001). The incidence of early-onset VAP decreased from 31.0 to 18.5 VAP per 1000 ventilator-days (p < 0.001), while the incidence of late-onset VAP increased from 21.9 to 24.1 VAP per 1000 ventilator-days (p < 0.001). However, when all covariates were adjusted, the impact of the prevention protocol was not statistically significant. CONCLUSIONS Implementation of a VAP prevention protocol incorporating evidence-based interventions reduced the crude incidence of VAP, early-onset VAP, and late-onset VAP. However, when covariates were adjusted, the beneficial effect was no longer observed. Further research is needed to assess the impact of such measures on VAP, early-onset VAP, and late-onset VAP.
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Affiliation(s)
- Rajae Omrane
- McGill University Health Center, Montreal, Québec, Canada.
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Abstract
Thiopental has been used for decades in the treatment of refractory intracranial hypertension in patients with traumatic and nontraumatic head injuries. Commonly reported adverse effects include hypotension, hypokalemia, respiratory complications, and hepatic dysfunction. Neutropenia has rarely been reported as an adverse effect of thiopental. We witnessed probable thiopental-induced neutropenia in two patients with traumatic brain injuries who developed increased intracranial hypertension that was refractory to standard therapy. Based on a MEDLINE search of published case reports and literature, we propose two mechanisms by which thiopental-related neutropenia might be explained. The first is inhibition of inflammatory mediator nuclear factor-kappa B (NF-kappa B), leading to granulocyte apoptosis. The second mechanism involves inhibition of calcineurin. Although the precise link between these two mechanisms has not been elucidated, calcineurin is known to regulate NF-kappa B activity. Development of neutropenia does not appear to be correlated with time but may correlate with plasma concentrations of thiopental. The optimum management of drug-induced neutropenia is unclear. The decision to discontinue thiopental in patients who develop neutropenia should be made by weighing the risks versus benefits. Broad-spectrum antibiotics may be required in the presence of fever. The role of hematopoietic growth factors such as granulocyte colony-stimulating factor is not yet defined. Given the adverse infectious consequences of neutropenia, it is essential to closely monitor neutrophil counts in patients receiving thiopental.
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Affiliation(s)
- Anne Julie Frenette
- Department of Pharmacy Services, Hôpital du Sacré-Coeur de Montréal, Quebec, Canada.
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Kanji S, Perreault MM, Chant C, Williamson D, Burry L. Evaluating the use of Drotrecogin alfa (activated) in adult severe sepsis: a Canadian multicenter observational study. Intensive Care Med 2007; 33:517-23. [PMID: 17325837 DOI: 10.1007/s00134-007-0555-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [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: 03/15/2006] [Accepted: 01/24/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The purpose of this study was to characterize the usage patterns and clinical outcomes of DAA in Ontario and Quebec over a 1-year period. METHODS All hospitals with DAA on formulary in Ontario and Quebec were invited to participate. Consecutive patients who received DAA from 1 March 2003 to 29 February 2004 were identified retrospectively. Demographic, treatment, and outcome variables were collected via chart review. Descriptive statistics on relevant variables were performed, along with logistic regression to determine relevant risk factors for survival and bleeding. RESULTS Thirty-seven sites participated with a total of 261 courses of DAA administered. The overall mortality rate was 45%; age (> 65 years), multiple organ system failure (> 3), and nosocomial source of sepsis were predictors of mortality, whereas early DAA administration (< 12 h) was associated with lower mortality. Serious bleeding events occurred in 10% of the patients. Only 1 case (0.4%) of fatal intracranial bleed was observed. Multiple organ system failure (>/= 4)and relative contraindications to DAA were predictors of bleeding events. INTERPRETATION Mortality and bleeding complications associated with the use of DAA were higher than that reported in randomized trials but similar to other usage database. This may be due to the higher severity of illness seen in this cohort of patients. Modifiable risks associated with mortality and bleeding, such as time to treatment, and knowledge of relative contraindications should be targets of further research and future educational efforts in order to optimize the risk-to-benefit ratio of DAA.
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Affiliation(s)
- Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa Health Research Institute, 501 Smyth Road, Room 1818, H1H 8L6, Ottawa, ON, Canada.
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Lacasse H, Perreault MM, Williamson DR. Systematic review of antipsychotics for the treatment of hospital-associated delirium in medically or surgically ill patients. Ann Pharmacother 2006; 40:1966-73. [PMID: 17047137 DOI: 10.1345/aph.1h241] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine which antipsychotic is associated with the greatest efficacy and safety when used for the pharmacotherapeutic management of delirium in medically or surgically ill patients. DATA SOURCES MEDLINE, Current Contents, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Biological Abstracts, Cochrane Central Register of Controlled Trials, and EMBASE databases (all to July 2006) were searched for trials evaluating the pharmacologic treatment of delirium in medically or surgically ill patients. The key terms used included delirium, agitation, or acute confusion, and antipsychotics, phenothiazine, butyrophenone, perphenazine, fluphenazine, clozapine, trifluorophenazine, loxapine, thioridazine, pimozide, molindone, haloperidol, methotrimeprazine, chlorpromazine, prochlorperazine, droperidol, risperidone, quetiapine, ziprasidone, amisulpride, or olanzapine. STUDY SELECTION AND DATA EXTRACTION Prospective, randomized, controlled trials comparing the clinical effects of antipsychotic therapy with placebo or comparing 2 antipsychotic treatments in an acute care setting were selected. Studies involving dementia-associated delirium, Alzheimer's disease-associated delirium, emergency department-associated acute agitation, acute brain trauma-associated agitation, or agitation secondary to underlying psychiatric afflictions such as depression or schizophrenia were excluded. All studies were evaluated independently by the 3 authors using a validated evaluation tool. Outcomes related to both efficacy and safety were collected. Four prospective trials were included in this systematic review. DATA SYNTHESIS Antipsychotic agents, either atypical or typical, were effective compared with baseline for the treatment of delirium in medically or surgically ill patients without underlying cognitive disorders. Oral haloperidol was associated with more frequent extrapyramidal side effects, but overall, all agents were well tolerated. Interpretation of the published evidence is limited by the small sample sizes, varied patient populations, and comparative agents of the studies reviewed. CONCLUSIONS The comparative studies evaluated here suggest that antipsychotic drugs are efficacious, when compared with baseline, and safe for the treatment of delirium. Haloperidol remains the most studied agent. Recommendation of one antipsychotic over another as a first-line pharmacologic intervention in the treatment of hospital-associated delirium is limited by the quality and quantity of data available. Better designed and larger studies evaluating the addition of antipsychotic agents to nonpharmacologic treatments are needed to measure the true effect of pharmacologic treatment.
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Affiliation(s)
- Hélène Lacasse
- Pharmaprix Jean-François Guévin, Montréal, Québec, Canada
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45
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Abstract
OBJECTIVE To report a case of acute necrotizing pancreatitis associated with simvastatin and fenofibrate use. CASE SUMMARY A 70-year-old white man presenting with rapid onset of abdominal pain, nausea, and vomiting was diagnosed with acute pancreatitis. On bowel rest, his condition deteriorated secondary to systemic inflammatory response syndrome, and he was transferred to a tertiary hospital's intensive care unit (ICU). He had been taking fenofibrate for 1 year; 6 months prior to this admission, he had been taking simvastatin 3 days of the week and fenofibrate the other 4 days of the week. The pancreatic tissue became necrotic, requiring surgical debridement. After a hospital stay of 121 days, including multiple ICU admissions, the patient died secondary to a bowel perforation. DISCUSSION Although idiopathic pancreatitis cannot be ruled out in this patient, no causes of pancreatitis were identified other than drug induced. Five cases of acute pancreatitis caused by simvastatin have been reported; no case reports were found for fenofibrate. The onset of pancreatitis relative to the duration of therapy with simvastatin supports this medication as a possible cause of the pancreatitis. CONCLUSIONS Drug-induced pancreatitis is well established as an adverse effect of some medications, although most are substantiated only with case reports. Given the absence of other apparent causes, simvastatin and fenofibrate should be considered as possible causes of pancreatitis in this patient.
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Affiliation(s)
- Kevin B McDonald
- Pharmacy Department, Ottawa Hospital-General Campus, 501 Smyth, Ottawa, Ontario, K1H 8L6, Canada.
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46
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47
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Abstract
OBJECTIVE To evaluate the efficacy and safety of intravenous potassium phosphate administered in a fixed-dose regimen in critically ill patients. DESIGN Prospective, unblind study. SETTING Surgical-medical intensive care unit (ICU). PARTICIPANTS Patients who developed hypophosphatemia during their ICU admission. INTERVENTIONS Patients with a serum phosphate concentration between 1.27 and 2.48 mg/dL (group 1) and those with a concentration of 1.24 mg/dL or less (group 2) received 15 and 30 mmol, respectively, of phosphate as a potassium salt via a central line over 3 hours. MAIN OUTCOME MEASURES Normalization of serum phosphate within 6 hours of infusion, the development of arrhythmias during the infusion, and the development of hypocalcemia and hyperkalemia after the infusion were evaluated. Redevelopment of hypophosphatemia and the need for further therapy were also assessed. RESULTS Thirty-seven episodes of hypophosphatemia were entered in this study: 27 in group 1 (17 patients) and 10 in group 2 (10 patients). The mean serum phosphate concentration increased significantly from 2.02 to 2.82 mg/dL in group 1 and from 0.83 to 2.17 mg/dL in group 2, with no change in calcium or potassium. Normalization of serum phosphate with this initial dose occurred in 81.5% of the episodes in group 1 and 30% in group 2. However, over the following 2 days, 45% of the patients in group 1 and 60% in group 2 required further phosphate supplementation. No arrhythmias occurred during the 3-hour infusion that were related to the potassium phosphate. A significant drop in total serum calcium concentrations occurred in 2 patients who were slightly hypercalcemic prior to the infusion. Serum calcium concentrations remained above normal, but this was not associated with any adverse effects. CONCLUSIONS The administration of potassium phosphate 15 mmol to critically ill patients with mild-to-moderate hypophosphatemia over 3 hours is both effective and safe. The administration of potassium phosphate 30 mmol to severely hypophosphatemic patients was safe but achieved normalization of serum phosphate in a minority of patients. Either a higher dose or the subsequent administration of more potassium phosphate may be required to normalize serum phosphate concentrations. Once normalization has occurred, there is a high likelihood of redevelopment of hypophosphatemia over the following 2 days and supplementation should be given accordingly.
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Affiliation(s)
- M M Perreault
- Department of Pharmacy, Ottawa General Hospital, Ontario, Canada
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48
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Abstract
A 51-year-old woman was brought to the emergency department unresponsive, hyponatremic, and diaphoretic, with muscle rigidity. Her condition improved dramatically after supportive treatment and dantrolene. The patient had received nefazodone for 6 months, but the drug had been discontinued 2 days before admission after a tapering period. One day before admission, paroxetine 20 mg/day was started. A repeat challenge with paroxetine 7 days after discontinuation of nefazodone did not result in recurrence of the patient's symptoms. We believe this to be the first report of serotonin syndrome associated with nefazodone and paroxetine.
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Affiliation(s)
- L John
- Department of Pharmacy, Ottawa General Hospital, Ontario, Canada
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49
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Perreault MM. [Antihypertensive and anti-inflammatory, non-steroidal drugs: significant interactions?]. Union Med Can 1994; 123:343-6. [PMID: 8085297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M M Perreault
- Département de pharmacie, Hôpital général de Montréal
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50
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Perreault MM, Kazierad DJ, Wilton JH, Izzo JL. The effect of isradipine on theophylline pharmacokinetics in healthy volunteers. Pharmacotherapy 1993; 13:149-53. [PMID: 8469622] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The effects of isradipine 2.5 mg and 5 mg on the disposition of theophylline were investigated in a placebo-controlled, randomized, three-way, crossover trial. Eleven healthy, nonsmoking men each received a treatment of placebo, and isradipine 2.5 mg and 5 mg every 12 hours for 6 consecutive days. On the morning of day 6, 2 hours after the isradipine dose, theophylline (solution) 5.0 mg/kg was administered orally, and blood samples were collected over 24 hours. A 2-week washout period separated treatment sequences. Plasma samples were analyzed for theophylline using high-performance liquid chromatography. Using a two-way analysis of variance, no significant changes in apparent theophylline clearance were observed between placebo, and isradipine 2.5 and 5 mg (0.815 +/- 0.164, 0.870 +/- 0.212, and 0.827 +/- 0.164 ml/min/kg, respectively; p = 0.136). Similarly, no significant change in volume of distribution was noted. These findings suggest that isradipine at recommended dosages does not impair theophylline metabolism.
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Affiliation(s)
- M M Perreault
- Groupe de Pharmacologie et Pharmacie Clinique, Hôtel-Dieu de Montréal, Canada
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