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Mefford B, Wallace KL, Donaldson JC, Bissell Turpin BD, Sen P, Schadler AD, Liu LJ, Thompson Bastin ML. Effect modification of dosing strategy (AUC or trough) on AKI associated with vancomycin in combination with piperacillin/tazobactam or cefepime and meropenem. Antimicrob Agents Chemother 2024; 68:e0108523. [PMID: 38606975 PMCID: PMC11064542 DOI: 10.1128/aac.01085-23] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/06/2024] [Indexed: 04/13/2024] Open
Abstract
Piperacillin-tazobactam (TZP), cefepime (FEP), or meropenem (MEM) and vancomycin (VAN) are commonly used in combination for sepsis. Studies have shown an increased risk of acute kidney injury (AKI) with TZP and VAN compared to FEP or MEM. VAN guidelines recommend area under the curve (AUC) monitoring over trough (Tr) to minimize the risk of AKI. We investigated the association of AKI and MAKE-30 with the two VAN monitoring strategies when used in combination with TZP or FEP/MEM. Adult patients between 2015 and 2019 with VAN > 72 hours were included. Patients with AKI prior to or within 48 hours of VAN or baseline CrCl of ≤30 mL/min were excluded. Four cohorts were defined: FEP/MEM/Tr, FEP/MEM/AUC, TZP/Tr, and TZP/AUC. A Cox Proportional Hazard Model was used to model AKI as a function of the incidence rate of at-risk days, testing monitoring strategy as a treatment effect modification. Multivariable logistic regression was used to model MAKE-30. Overall incidence of AKI was 18.6%; FEP/MEM/Tr = 115 (14.6%), FEP/MEM/AUC = 52 (14.9%), TZP/Tr = 189 (26%), and TZP/AUC = 96 (17.1%) (P < 0.001). Both drug group [(TZP; P = 0.0085)] and monitoring strategy [(Tr; P = 0.0007)] were highly associated with the development of AKI; however, the effect was not modified with interaction term [(TZP*Tr); 0.085)]. The odds of developing MAKE-30 were not different between any group and FEP/MEM/AUC. The effect of VAN/TZP on the development of AKI was not modified by the VAN monitoring strategy (AUC vs trough). MAKE-30 outcomes were not different among the four cohorts.
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Affiliation(s)
- Breanne Mefford
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Katie L. Wallace
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - J. Chris Donaldson
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Brittany D. Bissell Turpin
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Parijat Sen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Aric D. Schadler
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- University of Kentucky Children’s Hospital, Lexington, Kentucky, USA
| | - Lucas J. Liu
- Department of Computer Science, University of Kentucky, Lexington, Kentucky, USA
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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Atkins PE, Bastin MLT, Morgan RJ, Laine ME, Flannery AH. Pharmacist Involvement in Sepsis Response and Time to Antibiotics: A Systematic Review. J Am Coll Clin Pharm 2023; 6:942-953. [PMID: 37608990 PMCID: PMC10441617 DOI: 10.1002/jac5.1723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/28/2022] [Indexed: 08/24/2023]
Abstract
Introduction Sepsis is a life-threatening medical emergency and a leading cause of morbidity and mortality worldwide. Reductions in time to antibiotics in patients presenting with sepsis or septic shock are associated with reduced mortality, and Surviving Sepsis Campaign guidelines recommend antibiotics within one hour of recognition. Pharmacists are well-equipped to help navigate the therapeutic and operational challenges associated with achieving this goal. Objectives To assess the association of pharmacist involvement in sepsis response with time to antibiotics in hospitalized patients with sepsis and septic shock. Methods A systematic review of the following databases was conducted: PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science. Studies must have included a designated role of an individual pharmacist in the management of sepsis or septic shock and not be considered an operational change. The primary outcome of interest was time to antibiotic administration, with secondary outcomes including intensive care unit (ICU) and hospital length of stay as well as in-hospital mortality. Results We identified 10 studies including 1772 patients with sepsis or septic shock that evaluated a sepsis response in which a pharmacist was included. Studies included patients in the ICU, emergency department, and hospital ward setting. Seven studies demonstrated a significant reduction in time to antibiotics, with two other studies supporting this conclusion in extrapolation or sensitivity analysis. There was not a consistent reduction in ICU or hospital length of stay nor in-hospital mortality between those interventions involving a pharmacist compared with their defined control groups. Conclusion Pharmacist involvement in sepsis response, often as part of a multi-professional team-based approach to sepsis care, is associated with a reduced time to antibiotic administration for hospitalized patients with sepsis or septic shock.
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Affiliation(s)
- Payton E. Atkins
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Rebecca J. Morgan
- University of Kentucky Medical Center Library, Lexington, Kentucky, USA
| | - Melanie E. Laine
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
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Heavner MS, Cucci MD, Barlow B, Bell CM, Eng CC, Erdman G, Li M, Smith SE, Aldhaeefi M, Thompson Bastin ML, Hawkins WA, Rose C, Lankford A. Caring for two in the ICU: pharmacologic management of pregnancy-related complications. Pharmacotherapy 2023. [PMID: 37323102 DOI: 10.1002/phar.2837] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 06/17/2023]
Abstract
Maternal mortality continues to be an issue globally despite advances in technology and pharmacotherapy. Pregnancy can lead to complications that necessitate immediate action to prevent severe morbidity and mortality. Patients may need escalation to the ICU setting for close monitoring and administration of advanced therapies not available elsewhere. Obstetric emergencies are rare but high-stakes events that require clinicians to have prompt identification and management. The purpose of this review is to describe complications of pregnancy and provide a focused resource of pharmacotherapy considerations that clinicians may encounter. For each disease state, the epidemiology, pathophysiology, and management are summarized. Brief descriptions of non-pharmacological (e.g., cesarean or vaginal delivery of the baby) interventions are provided. Mainstays of pharmacotherapy highlighted include oxytocin for obstetric hemorrhage, methotrexate for ectopic pregnancy, magnesium and antihypertensive agents for preeclampsia and eclampsia, eculizumab for atypical hemolytic uremic syndrome, corticosteroids and immunosuppressive agents for thrombotic thrombocytopenic purpura, diuretics, metoprolol and anticoagulation for peripartum cardiomyopathy, and pulmonary vasodilators for amniotic fluid embolism.
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Affiliation(s)
- Mojdeh S Heavner
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | | | - Brooke Barlow
- Memorial Hermann Woodlands Medical Center, The Woodlands, Texas, USA
| | | | - Claire C Eng
- Memorial Hermann Sugar Land Hospital, Sugar Land, Texas, USA
| | - Grace Erdman
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Matthew Li
- Westchester Medical Center, Valhalla, New York, USA
| | - Susan E Smith
- University of Georgia College of Pharmacy, Athens, Georgia, USA
| | - Mohammed Aldhaeefi
- Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare
- University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - W Anthony Hawkins
- University of Georgia College of Pharmacy, Athens, Georgia, USA
- Medical College of Georgia at Augusta University, Albany, Georgia, USA
| | - Christina Rose
- Temple University School of Pharmacy, Philadelphia, Pennsylvania, USA
| | - Allison Lankford
- University of Maryland School of Medicine, Baltimore, Maryland, USA
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Heavner MS, Erdman G, Barlow B, Aldhaeefi M, Cucci M, Eng CC, Hawkins WA, Rose C, Smith SE, Magee Bell C, Lankford A, Li M, Thompson Bastin ML. Caring for Two in the ICU: Pharmacotherapy in the Critically Ill Pregnant Patient. Pharmacotherapy 2023; 43:403-418. [PMID: 36938691 DOI: 10.1002/phar.2795] [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: 12/23/2022] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
Safe and thoughtful medication management of pregnant patients requiring intensive care unit (ICU) level of care is key to optimizing outcomes for both mother and fetus. Pregnancy induces physiologic alterations that closely mirror the changes expected in a critically ill patient. These changes can be predictable depending on the gestational age and trimester and will directly impact the pharmacokinetic profile of medications commonly used in the ICU; examples include decreased gastric emptying, increased blood and plasma volume, increased glomerular filtration, and increased cardiac output. When pregnant patients require ICU care, the resulting impact on drug absorption, distribution, metabolism, and elimination can be difficult to predict. In addition, there are many nuances of medication metabolism and interface with the placental barrier that should be considered when selecting pharmacotherapy for the pregnant patient. Critical care clinicians need to be aware of medication interactions with the placenta and weigh the risk versus benefit profile of medication use in this patient population. Obstetric critical care admissions have increased over the years, especially during the coronavirus waves. Therefore, understanding the interplay between pregnancy and critical illness to optimize pharmacotherapy selection is crucial to improving health outcomes of mother and fetus. This review highlights pharmacotherapy considerations in the pregnant ICU patient for the following topics: physiologic alterations, categorizing medication risk, supportive care, sepsis, cardiogenic shock, acute respiratory distress syndrome, and venous thromboembolism.
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Affiliation(s)
- Mojdeh S Heavner
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Grace Erdman
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Brooke Barlow
- Memorial Hermann Woodlands Medical Center, The Woodlands, Texas, USA
| | - Mohammed Aldhaeefi
- Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, District of Columbia, USA
| | | | - Claire C Eng
- Memorial Hermann Sugar Land Hospital, Sugar Land, Texas, USA
| | - W Anthony Hawkins
- University of Georgia College of Pharmacy, Albany, Georgia, USA.,Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Christina Rose
- Temple University School of Pharmacy, Philadelphia, Pennsylvania, USA
| | - Susan E Smith
- University of Georgia College of Pharmacy, Albany, Georgia, USA
| | | | - Allison Lankford
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Matthew Li
- Westchester Medical Center, Valhalla, New York, USA
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare.,University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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Barlow B, Thompson Bastin ML, Shadler A, Cook AM. Association of chloride-rich fluids and medication diluents on the incidence of hyperchloremia and clinical consequences in aneurysmal subarachnoid hemorrhage. J Neurocrit Care 2022. [DOI: 10.18700/jnc.220068] [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: 12/24/2022] Open
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6
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Cook AM, Li D, Nestor MA, Bastin MLT. Prevalence and prediction of augmented renal clearance in the neurocritical care population. J Neurocrit Care 2022. [DOI: 10.18700/jnc.220061] [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: 11/06/2022] Open
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Whitenack K, Behal ML, Thompson Bastin ML, Aycinena JC, Adams PM, Flannery AH. Progression of Kidney Injury with the Combination of Vancomycin and Piperacillin-Tazobactam or Cefepime in Sepsis-Associated Acute Kidney Injury. Front Nephrol 2022; 2:995358. [PMID: 36507064 PMCID: PMC9730318 DOI: 10.3389/fneph.2022.995358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
INTRODUCTION The combination of vancomycin/piperacillin-tazobactam is associated with increases in serum creatinine compared to other antibiotic combinations in the treatment of infections for hospitalized patients. However, the available literature is limited to the study of incident acute kidney injury (AKI). The combination has not been evaluated in patients with AKI already present and the degree to which the trajectory of AKI is influenced by this combination is unknown. METHODS This was a single center, retrospective cohort study of adult patients with sepsis and AKI present on admission prescribed a combination of vancomycin with either piperacillin-tazobactam or cefepime within the first 3 days of admission. The primary outcome was maximum serum creatinine observed within days 2-7 of the hospital stay. Subsequent kidney outcomes were evaluated at one week and hospital discharge. RESULTS Of 480 patients with sepsis and AKI who met inclusion criteria, 288 (60%) received vancomycin/piperacillin-tazobactam, and 192 (40%) received vancomycin/cefepime. Patients were well-matched on clinical factors, including severity of illness, stage of AKI, exposure to other nephrotoxins, and durations of antimicrobial therapy. There were no differences in AKI trajectory during the first week as assessed by maximum serum creatinine (2.1 (1.4-3.5) mg/dl vs. 2.1 (1.4-3.0) mg/dl; p=0.459) and AKI progression (24.0% vs. 23.4%; p=0.895). No differences were observed with other kidney related outcomes, including the need for dialysis (14.6% vs. 13.0%; p=0.628) or major adverse kidney events at hospital discharge (48.3% vs. 47.9%; p=0.941). CONCLUSIONS In patients with sepsis and AKI, the combination of vancomycin/piperacillin-tazobactam compared to vancomycin/cefepime was not associated with higher serum creatinine values or AKI progression in the week following ICU admission.
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Affiliation(s)
- Kaylee Whitenack
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY USA
| | - Michael L. Behal
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY USA
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY USA
| | - Juan C. Aycinena
- Division of Nephrology, Bone & Mineral Metabolism, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY USA
| | - Paul M. Adams
- Division of Nephrology, Bone & Mineral Metabolism, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY USA
| | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY USA
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8
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Owusu KA, Effendi MK, Thompson Bastin ML, Tirmizi S, Lat I, Ammar MA. Narrative Review: Addressing Covid-19 Vaccine Concerns in Special and Vulnerable Populations. Hosp Pharm 2022; 57:575-587. [PMID: 35898240 PMCID: PMC9310301 DOI: 10.1177/00185787211066463] [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] [Indexed: 08/03/2023]
Abstract
Public health advocates and healthcare professionals (HCPs) have been challenged with vaccine hesitancy and addressing misinformation. In order for HCPs and pharmacists, in particular, to serve as effective stewards of COVID-19 vaccine science in the interest of the public good, it is imperative for HCPs to appreciate the various factors contributing to vaccine hesitancy and vaccine distrust. A PubMed search was performed and relevant articles on COVID-19 vaccine in populations of interest were included. Information from health agencies, such as the Centers for Disease Control and Prevention (CDC) as well as established professional health societies was incorporated for guidance. This review focuses on COVID-19 vaccine concerns in the populations of children, pregnancy and lactation, immunocompromised, and religious and ethnic disparities. We also discuss post emergency use authorization experience with respect to vaccine safety including annotations on Guillain-Barré Syndrome, myocarditis and pericarditis, and thrombosis with thrombocytopenia syndrome.
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Affiliation(s)
- Kent A. Owusu
- Yale New Haven Health, New Haven, CT, USA
- Yale New Haven Hospital, New Haven, CT, USA
| | | | | | | | - Ishaq Lat
- Shirley Ryan AbilityLab, Chicago, IL, USA
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9
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Behal ML, Thomas JK, Thompson Bastin ML, Mefford BM. Cefepime Induced Neurotoxicity Following A Regimen Dose-Adjusted for Renal Function: Case Report and Review of the Literature. Hosp Pharm 2022; 57:385-391. [PMID: 35615483 PMCID: PMC9125125 DOI: 10.1177/00185787211046856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Introduction: Cefepime induced neurotoxicity (CIN) is commonly associated with renal dysfunction, however CIN can occur in patients with normal renal function or renally dose-adjusted regimens. Few reports of this kind have obtained cefepime concentrations to assist in diagnosis. Patient Case: A 42-year old female with a complex past medical history was transferred to our facility with chief complaint of worsening shock and respiratory failure, and the patient was also noted to be hypernatremic, experiencing diabetic ketoacidosis (DKA), and acute kidney injury (AKI). Her DKA resolved and hypernatremia and AKI began to improve. As a result, cefepime was dose-adjusted for renal function estimated by the Cockcroft-Gault (CG) equation. Her hospital course was complicated by persistent altered mental status (AMS), preventing extubation. Cefepime was discontinued due to concern for CIN, and a concentration was obtained 13-hours after the last dose which was elevated at 49 µg/mL. Two days following cefepime discontinuation, the patient's mental status improved allowing for successful extubation. The patient remained stable and was discharged to an acute care floor and then ultimately back to home. Conclusion: CIN should be part of a wider differential diagnosis for patients experiencing encephalopathy, and inaccurate renal function estimation may be a risk factor for developing CIN. Furthermore, therapeutic drug monitoring (TDM) may serve as an important clinical tool in diagnosing and managing CIN.
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10
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Thompson Bastin ML, Stromberg AJ, Nerusu SN, Liu LJ, Mayer KP, Liu KD, Bagshaw SM, Wald R, Morris PE, Neyra JA. Association of Phosphate-Containing versus Phosphate-Free Solutions on Ventilator Days in Patients Requiring Continuous Kidney Replacement Therapy. Clin J Am Soc Nephrol 2022; 17:634-642. [PMID: 35477673 PMCID: PMC9269583 DOI: 10.2215/cjn.12410921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 09/16/2021] [Accepted: 03/22/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Hypophosphatemia is commonly observed in patients receiving continuous KRT. Patients who develop hypophosphatemia may be at risk of respiratory and neuromuscular dysfunction and therefore subject to prolongation of ventilator support. We evaluated the association of phosphate-containing versus phosphate-free continuous KRT solutions with ventilator dependence in critically ill patients receiving continuous KRT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our study was a single-center, retrospective, pre-post cohort study of adult patients receiving continuous KRT and mechanical ventilation during their intensive care unit stay. Zero-inflated negative binomial regression with and without propensity score matching was used to model our primary outcome: ventilator-free days at 28 days. Intensive care unit and hospital lengths of stay as well as hospital mortality were analyzed with a t test or a chi-squared test, as appropriate. RESULTS We identified 992 eligible patients, of whom 649 (65%) received phosphate-containing solutions and 343 (35%) received phosphate-free solutions. In multivariable models, patients receiving phosphate-containing continuous KRT solutions had 12% (95% confidence interval, 0.17 to 0.47) more ventilator-free days at 28 days. Patients exposed to phosphate-containing versus phosphate-free solutions had 17% (95% confidence interval, -0.08 to -0.30) fewer days in the intensive care unit and 20% (95% confidence interval, - 0.12 to -0.32) fewer days in the hospital. Concordant results were observed for ventilator-free days at 28 days in the propensity score matched analysis. There was no difference in hospital mortality between the groups. CONCLUSIONS The use of phosphate-containing versus phosphate-free continuous KRT solutions was independently associated with fewer ventilator days and shorter stay in the intensive care unit.
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Affiliation(s)
- Melissa L. Thompson Bastin
- Department of Pharmacy Services, University of Kentucky Medical Center, Lexington, Kentucky,Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
| | | | | | - Lucas J. Liu
- Department of Computer Science, University of Kentucky, Lexington, Kentucky
| | - Kirby P. Mayer
- Department of Physical Therapy, University of Kentucky, Lexington, Kentucky
| | - Kathleen D. Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California,Division of Nephrology, Department of Anesthesia, University of California, San Francisco, California
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Peter E. Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, Kentucky
| | - Javier A. Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
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Bissell BD, Johnston JP, Smith RR, Newsome AS, Thompson Bastin ML, Abdul-Mutakabbir J, Barlow A, Barlow B, Berger K, Crow JR, Dixit D, Jacobi J, Karaoui LR, Kiser TH, Kolesar J, Koontz SE, Mattingly TJ, Mitchell C, Nilges A, Rech MA, Heavner MS. Gender inequity and sexual harassment in the pharmacy profession: Evidence and call to action. Am J Health Syst Pharm 2021; 78:2059-2076. [PMID: 34232286 PMCID: PMC8344711 DOI: 10.1093/ajhp/zxab275] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
| | - Jackie P Johnston
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Rebecca R Smith
- Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | | | - Ashley Barlow
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Karen Berger
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Jessica R Crow
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | | | - Lamis R Karaoui
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Jill Kolesar
- College of Pharmacy, University of Kentucky, Lexington KY, USA
| | | | - T Joseph Mattingly
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | | | - Megan A Rech
- Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, and Loyola University Medical Center, Maywood, IL, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, MD, USA
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12
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Bissell BD, Johnston JP, Smith RR, Newsome AS, Thompson Bastin ML, Abdul-Mutakabbir J, Barlow A, Barlow B, Berger K, Crow JR, Dixit D, Jacobi J, Karaoui LR, Kiser TH, Kolesar J, Koontz SE, Mattingly TJ, Mitchell C, Nilges A, Rech MA, Heavner MS. Gender Inequity and Sexual Harassment in the Pharmacy Profession: Evidence and Call to Action Executive Summary. J Am Coll Clin Pharm 2021; 4:1375-1378. [PMID: 35187415 PMCID: PMC8849554 DOI: 10.1002/jac5.1508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/23/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Brittany D Bissell
- University of Kentucky, 1000 S. Limestone, Room H110, Lexington, KY 40536, USA
| | - Jackie P Johnston
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Rebecca R Smith
- University of Arkansas for Medical Sciences, Department of Pharmacy, 4301 West Markham Street, Slot 522, Little Rock, AR 72205
| | - Andrea Sikora Newsome
- University of Georgia College of Pharmacy, Department of Clinical and Administrative Pharmacy, 120 15th Street, HM-118, Augusta, GA 30912
| | | | - Jacinda Abdul-Mutakabbir
- Loma Linda University School of Pharmacy, Department of Pharmacy Practice, 24745 Stewart Street, Shryock Hall Room 212, Loma Linda, CA 92350, USA
| | - Ashley Barlow
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston Texas 77030
| | - Brooke Barlow
- University of Kentucky, 1000 S. Limestone, Room H110, Lexington, KY 40536, USA
| | - Karen Berger
- Neurocritical Care, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68 St, New York, NY 10065
| | - Jessica R Crow
- The Johns Hopkins Hospital, Department of Pharmacy, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD 21287
| | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | | | - Lamis R Karaoui
- Director of Experiential Education/Acting Assistant Dean for Student Affairs, Department of Pharmacy Practice School of Pharmacy, Lebanese American University, P.O.Box: 36 (S23), Byblos, Lebanon
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E Montview Blvd, C238, Aurora, CO 80045
| | - Jill Kolesar
- College of Pharmacy, University of Kentucky, 789 S. Limestone, Lexington KY 40536
| | - Susannah E Koontz
- Koontz Oncology Consulting LLC, 2617C W. Holcombe Blvd. #365, Houston, TX 77025-1601, USA
| | - T Joseph Mattingly
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Baltimore, Maryland 21201
| | | | - Alexsandra Nilges
- University of Kentucky College of Pharmacy, 789 S. Limestone, Lexington, KY 40506 USA
| | - Megan A Rech
- Adjunct Assistant Professor - Department of Emergency Medicine, Research Coordinator - Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, Loyola University Medical Center, 2160 S 1st Ave, Maywood IL 60153
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, 20 N. Pine Street, N427, Baltimore, MD 21201
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13
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Landolf KM, Lemieux SM, Rose C, Johnston JP, Adams CD, Altshuler J, Berger K, Dixit D, Effendi MK, Heavner MS, Lemieux D, Littlefield AJ, Nei AM, Owusu KA, Rinehart M, Robbins B, Rouse GE, Thompson Bastin ML. Corticosteroid use in ARDS and its application to evolving therapeutics for coronavirus disease 2019 (COVID-19): A systematic review. Pharmacotherapy 2021; 42:71-90. [PMID: 34662448 PMCID: PMC8662062 DOI: 10.1002/phar.2637] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 01/08/2023]
Abstract
Data regarding the use of corticosteroids for treatment of acute respiratory distress syndrome (ARDS) are conflicting. As the coronavirus disease 2019 (COVID‐19) pandemic progresses, more literature supporting the use of corticosteroids for COVID‐19 and non‐COVID‐19 ARDS have emerged. Glucocorticoids are proposed to attenuate the inflammatory response and prevent progression to the fibroproliferative phase of ARDS through their multiple mechanisms and anti‐inflammatory properties. The purpose of this systematic review was to comprehensively evaluate the literature surrounding corticosteroid use in ARDS (non‐COVID‐19 and COVID‐19) in addition to a narrative review of clinical considerations of corticosteroid use in these patient populations. OVID Medline and EMBASE were searched. Randomized controlled trials evaluating the use of corticosteroids for COVID‐19 and non‐COVID‐19 ARDS in adult patients on mortality outcomes were included. Risk of bias was assessed with the Risk of Bias 2.0 tool. There were 388 studies identified, 15 of which met the inclusion criteria that included a total of 8877 patients. The studies included in our review reported a mortality benefit in 6/15 (40%) studies with benefit being seen at varying time points of mortality follow‐up (ICU survival, hospital, and 28 and 60 days) in the COVID‐19 and non‐COVID‐19 ARDS studies. The two non‐COVID19 trials assessing lung injury score improvements found that corticosteroids led to significant improvements with corticosteroid use. The number of mechanical ventilation‐free days significantly were found to be increased with the use of corticosteroids in all four studies that assessed this outcome. Corticosteroids are associated with improvements in mortality and ventilator‐free days in critically ill patients with both COVID‐19 and non‐COVID‐19 ARDS, and evidence suggests their use should be encouraged in these settings. However, due to substantial differences in the corticosteroid regimens utilized in these trials, questions still remain regarding the optimal corticosteroid agent, dose, and duration in patients with ARDS.
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Affiliation(s)
- Kaitlin M Landolf
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Steven M Lemieux
- Department of Pharmacy, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Christina Rose
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, Pennsylvania, USA
| | - Jackie P Johnston
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Piscataway, New Jersey, USA
| | - Christopher D Adams
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Piscataway, New Jersey, USA
| | - Jerry Altshuler
- Department of Pharmacy, Hackensack Meridian Health JFK University Medical Center, Edison, New Jersey, USA
| | - Karen Berger
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Deepali Dixit
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Piscataway, New Jersey, USA
| | - Muhammad K Effendi
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Piscataway, New Jersey, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Diana Lemieux
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Audrey J Littlefield
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital - Rochester, Rochester, Minnesota, USA
| | - Kent A Owusu
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, Connecticut, USA.,Care Signature, Yale New Haven Health, New Haven, Connecticut, USA
| | - Marisa Rinehart
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Blake Robbins
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Ginger E Rouse
- Department of Pharmacy Services, Yale New Haven Hospital, New Haven, Connecticut, USA
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14
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Behal M, Barlow B, Mefford B, Thompson Bastin ML, Donaldson JC, Laine M, Bissell BD. Pharmacotherapy in Coronavirus Disease 2019 and Risk of Secondary Infections: A Single-Center Case Series and Narrative Review. Crit Care Explor 2021; 3:e0492. [PMID: 34278319 PMCID: PMC8280010 DOI: 10.1097/cce.0000000000000492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Since the onset of the coronavirus disease 2019 pandemic, immune modulators have been considered front-line candidates for the management of patients presenting with clinical symptoms secondary to severe acute respiratory syndrome coronavirus 2 infection. Although heavy emphasis has been placed on early clinical efficacy, we sought to evaluate the impact of pharmacologic approach to coronavirus disease 2019 within the ICU on secondary infections and clinical outcomes. DATA SOURCES PubMed (inception to March 2021) database search and manual selection of bibliographies from selected articles. STUDY SELECTION AND DATA EXTRACTION Articles relevant to coronavirus disease 2019, management of severe acute respiratory syndrome coronavirus 2-associated respiratory failure, and prevalence of secondary infections with pharmacotherapies were selected. The MeSH terms "COVID-19," "secondary infection," "SARS-CoV-2," "tocilizumab," and "corticosteroids" were used for article identification. Articles were narratively synthesized for this review. DATA SYNTHESIS Current data surrounding the use of tocilizumab and/or corticosteroids for coronavirus disease 2019 management are limited given the short follow-up period and conflicting results between studies. Further complicating the understanding of immune modulator role is the lack of definitive understanding of clinical impact of the immune response in coronavirus disease 2019. CONCLUSIONS Based on the current available literature, we suggest prolonged trials and follow-up intervals for those patients managed with immune modulating agents for the management of coronavirus disease 2019.
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Affiliation(s)
- Michael Behal
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | - Brooke Barlow
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | - Breanne Mefford
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | | | - J Chris Donaldson
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | - Melanie Laine
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
| | - Brittany D Bissell
- Department of Pharmacy Practice, University of Kentucky, College of Pharmacy, Lexington, KY
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, College of Medicine, Lexington, KY
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15
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Thompson Bastin ML, Smith RR, Bissell BD, Wolf HN, Wiegand AM, Cavagnini ME, Ahmad Y, Flannery AH. Comparison of fixed dose versus train-of-four titration of cisatracurium in acute respiratory distress syndrome. J Crit Care 2021; 65:86-90. [PMID: 34118504 DOI: 10.1016/j.jcrc.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/06/2021] [Accepted: 05/15/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE To compare the ventilatory and clinical outcomes associated with a fixed-dose cisatracurium infusion versus a titrated infusion strategy in patients with Acute Respiratory Distress Syndrome (ARDS). MATERIALS AND METHODS Single-center, retrospective, cohort study in a medical ICU of a tertiary care academic medical center. Adult patients ≥18 years old with a continuous infusion of cisatracurium for ≥12 h for treatment of ARDS were included. The primary outcome was the PaO2 /FiO2 ratio assessed at 24 and 48 h following cisatracurium initiation. Secondary outcomes included amount of average dose of drug administered, 28-day ventilator-free days, LOS, and hospital mortality. RESULTS 167 patients were included; median baseline PaO2/FiO2 was 97 (76-146), median SOFA score of 9 (7-11), and ICU mortality was 71/167 (43%). In a mixed-effects model, fixed dose and titrated cisatracurium associated with similar changes in PaO2/FiO2 assessed at 24 and 48 h (p = 0.316). Fixed-dose was associated with a >3-fold increase in drug exposure (average dose 6.4 (5.4-8.0) vs. 2.0 (1.5-2.8) mcg/kg/min; p < 0.001, respectively). No differences were observed in secondary clinical endpoints. CONCLUSION Fixed-dose cisatracurium was associated with similar ventilatory and clinical outcomes compared to titrated strategy, yet it was associated with a 3-fold increase in dose administered.
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Affiliation(s)
- Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
| | - Rebecca R Smith
- University of Arkansas for Medical Sciences, Department of Pharmacy Services, United States of America.
| | - Brittany D Bissell
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America; University of Kentucky College of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, United States of America.
| | - Heather N Wolf
- St. Elizabeth Healthcare, Department of Pharmacy Services, United States of America.
| | - Alexandra M Wiegand
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America.
| | - Megan E Cavagnini
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
| | - Yahya Ahmad
- University of Kentucky College of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, United States of America.
| | - Alexander H Flannery
- University of Kentucky HealthCare, Department of Pharmacy Services, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States of America.
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16
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Thompson Bastin ML, Adams PM, Nerusu S, Morris PE, Mayer KP, Neyra JA. Association of Phosphate Containing Solutions with Incident Hypophosphatemia in Critically Ill Patients Requiring Continuous Renal Replacement Therapy. Blood Purif 2021; 51:122-129. [PMID: 33915554 DOI: 10.1159/000514418] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/08/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hypophosphatemia in critically ill patients is a common electrolyte disturbance associated with a myriad of adverse effects. Critically ill patients requiring continuous renal replacement therapy (CRRT) are at high risk of hypophosphatemia and often require phosphate supplementation during therapy. The aim of this study was to evaluate the association of phosphate versus non-phosphate containing CRRT solutions with incident hypophosphatemia in critically ill patients requiring CRRT. MATERIALS AND METHODS This is a single-center, retrospective, cohort study at a tertiary academic medical center of 1,396 adult patients requiring CRRT during their intensive care unit stay comprising 7,529 (phosphate containing) and 4,821 (non-phosphate containing) cumulative days of CRRT. Multivariable logistic regression was used to model the primary outcome of hypophosphatemia during CRRT according to exposure to phosphate versus non-phosphate containing CRRT solutions. RESULTS Incident hypophosphatemia during CRRT, serum phosphate <2.5 mg/dL or 0.81 mmol/L, was significantly higher in the non-phosphate versus phosphate containing solution group: 304/489 (62%) versus 175/853 (21%) (p < 0.001). Cumulative phosphate supplementation was also significantly higher in the non-phosphate versus phosphate containing solution group: 79 (IQR: 0-320) versus 0 (0-16) mmol (p < 0.001). Non-phosphate solutions were associated with an 8-fold increase in the incidence of hypophosphatemia (adjusted OR 8.05; 95% CI 5.77, 11.26; p < 0.001). DISCUSSION/CONCLUSIONS The use of phosphate containing CRRT solutions was independently associated with reduced risk of incident hypophosphatemia and decreased phosphate supplementation during CRRT. Interventional studies to confirm these findings are needed.
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Affiliation(s)
- Melissa L Thompson Bastin
- Department of Pharmacy Services, University of Kentucky Medical Center, Lexington, Kentucky, USA.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Paul M Adams
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Sethabhisha Nerusu
- Center for Health Services Research, University of Kentucky, Lexington, Kentucky, USA
| | - Peter E Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Kirby P Mayer
- Department of Physical Therapy, University of Kentucky, Lexington, Kentucky, USA
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
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17
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Thompson Bastin ML, Berger K, Adams CD, Altshuler J, Dixit D, Effendi MK, Johnston JP, Lemieux DG, Lemieux SM, Littlefield AJ, Owusu KA, Rose C, Rouse GE, Heavner MS. Adapting clinical pharmacy staffing models during the
COVID
‐19 pandemic: Lessons learned and considerations for future disaster planning. J Am Coll Clin Pharm 2020. [DOI: 10.1002/jac5.1374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Melissa L. Thompson Bastin
- Department of Pharmacy Services University of Kentucky HealthCare Lexington Kentucky USA
- Department of Pharmacy Practice and Administration University of Kentucky College of Pharmacy Lexington Kentucky USA
| | - Karen Berger
- Department of Pharmacy NewYork‐Presbyterian Hospital/Weill Cornell Medical Center New York New York USA
| | - Christopher D. Adams
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New Jersey USA
| | - Jerry Altshuler
- Department of Pharmacy Hackensack Meridian JFK Medical Center Edison New Jersey USA
| | - Deepali Dixit
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New Jersey USA
| | - Muhammad K. Effendi
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New Jersey USA
| | - Jackie P. Johnston
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New Jersey USA
| | - Diana G. Lemieux
- Department of Pharmacy Services Yale New Haven Hospital New Haven Connecticut USA
| | - Steven M. Lemieux
- Department of Pharmacy Practice and Administration University of Saint Joseph West Hartford Connecticut USA
| | - Audrey J. Littlefield
- Department of Pharmacy NewYork‐Presbyterian Hospital/Weill Cornell Medical Center New York New York USA
| | - Kent A. Owusu
- Department of Pharmacy Services Yale New Haven Hospital New Haven Connecticut USA
- Clinical Redesign Yale New Haven Health New Haven Connecticut USA
| | - Christina Rose
- Department of Pharmacy Practice Temple University School of Pharmacy Philadelphia Pennsylvania USA
| | - Ginger E. Rouse
- Department of Pharmacy Services Yale New Haven Hospital New Haven Connecticut USA
| | - Mojdeh S. Heavner
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
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18
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Neyra JA, Yessayan L, Thompson Bastin ML, Wille KM, Tolwani AJ. How To Prescribe And Troubleshoot Continuous Renal Replacement Therapy: A Case-Based Review. Kidney360 2020; 2:371-384. [PMID: 35373031 PMCID: PMC8741005 DOI: 10.34067/kid.0004912020] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023]
Abstract
Continuous RRT (CRRT) is the preferred dialysis modality for solute management, acid-base stability, and volume control in patients who are critically ill with AKI in the intensive care unit (ICU). CRRT offers multiple advantages over conventional hemodialysis in the critically ill population, such as greater hemodynamic stability, better fluid management, greater solute control, lower bleeding risk, and a more continuous (physiologic) approach of kidney support. Despite its frequent use, several aspects of CRRT delivery are still not fully standardized, or do not have solid evidence-based foundations. In this study, we provide a case-based review and recommendations of common scenarios and interventions encountered during the provision of CRRT to patients who are critically ill. Specific focus is on initial prescription, CRRT dosing, and adjustments related to severe hyponatremia management, concomitant extracorporeal membrane oxygenation support, dialysis catheter placement, use of regional citrate anticoagulation, and antibiotic dosing. This case-driven simulation is made as the clinical status of the patient evolves, and is on the basis of step-wise decisions made during the care of this patient, according to the specific patient's needs and the logistics available at the corresponding institution.
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Affiliation(s)
- Javier A. Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Keith M Wille
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita J Tolwani
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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19
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Adams CD, Altshuler J, Barlow BL, Dixit D, Droege CA, Effendi MK, Heavner MS, Johnston JP, Kiskaddon AL, Lemieux DG, Lemieux SM, Littlefield AJ, Owusu KA, Rouse GE, Thompson Bastin ML, Berger K. Analgesia and Sedation Strategies in Mechanically Ventilated Adults with COVID‐19. Pharmacotherapy 2020; 40:1180-1191. [DOI: 10.1002/phar.2471] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Christopher D. Adams
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Jerry Altshuler
- Department of Pharmacy Hackensack Meridian JFK Medical Center Edison New JerseyUSA
| | - Brooke L. Barlow
- Department of Pharmacy Services University of Kentucky HealthCare Lexington KentuckyUSA
| | - Deepali Dixit
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Christopher A. Droege
- Department of Pharmacy UC Health – University of Cincinnati Medical Center Cincinnati OhioUSA
| | - Muhammad K. Effendi
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Mojdeh S. Heavner
- Department of Pharmacy Practice University of Maryland School of Pharmacy Baltimore MarylandUSA
| | - Jackie P. Johnston
- Department of Pharmacy Practice and Administration Ernest Mario School of Pharmacy Piscataway New JerseyUSA
| | - Amy L. Kiskaddon
- Department of Pharmacy Johns Hopkins All Children's Hospital St. Petersburg FloridaUSA
| | - Diana G. Lemieux
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | - Steven M. Lemieux
- Department of Pharmacy Practice and Administration University of Saint Joseph Hartford ConnecticutUSA
| | - Audrey J. Littlefield
- Department of Pharmacy New York‐Presbyterian Hospital/Weill Cornell Medical Center New York New YorkUSA
| | - Kent A Owusu
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | - Ginger E. Rouse
- Department of Pharmacy Services Yale New Haven Hospital New Haven ConnecticutUSA
| | | | - Karen Berger
- Department of Pharmacy New York‐Presbyterian Hospital/Weill Cornell Medical Center New York New YorkUSA
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20
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Mayer KP, Thompson Bastin ML, Montgomery-Yates AA, Pastva AM, Dupont-Versteegden EE, Parry SM, Morris PE. Acute skeletal muscle wasting and dysfunction predict physical disability at hospital discharge in patients with critical illness. Crit Care 2020; 24:637. [PMID: 33148301 PMCID: PMC7640401 DOI: 10.1186/s13054-020-03355-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients surviving critical illness develop muscle weakness and impairments in physical function; however, the relationship between early skeletal muscle alterations and physical function at hospital discharge remains unclear. The primary purpose of this study was to determine whether changes in muscle size, strength and power assessed in the intensive care unit (ICU) predict physical function at hospital discharge. METHODS Study design is a single-center, prospective, observational study in patients admitted to the medicine or cardiothoracic ICU with diagnosis of sepsis or acute respiratory failure. Rectus femoris (RF) and tibialis anterior (TA) muscle ultrasound images were obtained day one of ICU admission, repeated serially and assessed for muscle cross-sectional area (CSA), layer thickness (mT) and echointensity (EI). Muscle strength, as measured by Medical Research Council-sum score, and muscle power (lower-extremity leg press) were assessed prior to ICU discharge. Physical function was assessed with performance on 5-times sit-to-stand (5STS) at hospital discharge. RESULTS Forty-one patients with median age of 61 years (IQR 55-68), 56% male and sequential organ failure assessment score of 8.1 ± 4.8 were enrolled. RF muscle CSA decreased significantly a median percent change of 18.5% from day 1 to 7 (F = 26.6, p = 0.0253). RF EI increased at a mean percent change of 10.5 ± 21% in the first 7 days (F = 3.28, p = 0.081). At hospital discharge 25.7% of patients (9/35) met criteria for ICU-acquired weakness. Change in RF EI in first 7 days of ICU admission and muscle power measured prior to ICU were strong predictors of ICU-AW at hospital discharge (AUC = 0.912). Muscle power at ICU discharge, age and ICU length of stay were predictive of performance on 5STS at hospital discharge. CONCLUSION ICU-assessed muscle alterations, specifically RF EI and muscle power, are predictors of diagnosis of ICU-AW and physical function assessed by 5x-STS at hospital discharge in patients surviving critical illness.
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Affiliation(s)
- Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, 900 Rose St, Wethington 204D, Lexington, KY, 40536, USA.
- Center for Muscle Biology, University of Kentucky, Lexington, USA.
| | | | - Ashley A Montgomery-Yates
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Kentucky, Lexington, USA
| | - Amy M Pastva
- Departments of Orthopedic Surgery, Medicine, Cell Biology, and Population Health Sciences, Duke University School of Medicine, Durham, USA
| | - Esther E Dupont-Versteegden
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, 900 Rose St, Wethington 204D, Lexington, KY, 40536, USA
- Center for Muscle Biology, University of Kentucky, Lexington, USA
| | - Selina M Parry
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Peter E Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Kentucky, Lexington, USA
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21
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Flannery AH, Owen GD, Coz A, Thompson Bastin ML, Patel K. Impact of Hyperoncotic Albumin on Duration of Vasopressor Support in Septic Shock: A Propensity Score-Matched Analysis. Ann Pharmacother 2020; 55:584-591. [PMID: 33016080 DOI: 10.1177/1060028020963645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/17/2022] Open
Abstract
BACKGROUND While albumin has not been shown to reduce mortality in sepsis and septic shock, a tertiary analysis of a large trial suggested that it may reduce the duration of vasopressor use in septic shock. OBJECTIVE We sought to test if 25% albumin administration was associated with reduced cumulative vasopressor use in septic shock in a real-world setting. METHODS This was a retrospective, propensity score-matched cohort study of septic shock in which patients receiving albumin were compared with a matched cohort of those not receiving albumin. The primary outcome was days alive and free of vasopressors. RESULTS The matched cohort included 335 patients who received albumin and 335 who did not. The days alive and free of vasopressors were similar between the albumin and no albumin groups: 17.4 (0-24.8) versus 19.4 (0-25.3); P = 0.160. Similarly, in-hospital mortality was no different between groups (46.9% vs 44.8%; P = 0.587). Receipt of albumin was associated with fewer ventilator-free and intensive care unit (ICU)-free days: 0 (0-19) versus 11 (0-23), P = 0.007, and 0 (0-18) versus 10.6 (0-22.1), P = 0.002, respectively. CONCLUSION AND RELEVANCE Albumin use in septic shock was not associated with additional days alive and free of vasopressors or in-hospital mortality. The finding of fewer ventilator- and ICU-free days may reflect selection of patients who were critically ill for longer periods of time before or after albumin administration. Additional study is needed to clarify the impact that timing may have on the effectiveness of albumin in septic shock.
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Affiliation(s)
- Alexander H Flannery
- University of Kentucky College of Pharmacy, Lexington, KY, USA.,University of Kentucky HealthCare, Lexington, KY, USA
| | - Gary D Owen
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angel Coz
- University of Kentucky College of Medicine, Lexington, KY, USA.,Department of Lexington Veterans Affairs Medical Center, Lexington, KY, USA
| | - Melissa L Thompson Bastin
- University of Kentucky College of Pharmacy, Lexington, KY, USA.,University of Kentucky HealthCare, Lexington, KY, USA
| | - Kripa Patel
- University of Kentucky College of Pharmacy, Lexington, KY, USA.,University of Kentucky HealthCare, Lexington, KY, USA
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22
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Barlow B, Barlow A, Thompson Bastin ML, Berger K, Dixit D, Heavner MS. Minimizing pharmacotherapy-related healthcare worker exposure to SARS-CoV-2. Am J Health Syst Pharm 2020; 77:1529-1531. [PMID: 32469056 PMCID: PMC7314224 DOI: 10.1093/ajhp/zxaa190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brooke Barlow
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
| | - Ashley Barlow
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | | | - Karen Berger
- Department of Pharmacy, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Deepali Dixit
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ, and Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, NJ
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
- Address correspondence to Dr. Heavner (), Twitter: @HeavnerPharmD
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Bissell BD, Laine ME, Thompson Bastin ML, Flannery AH, Kelly A, Riser J, Neyra JA, Potter J, Morris PE. Impact of protocolized diuresis for de-resuscitation in the intensive care unit. Crit Care 2020; 24:70. [PMID: 32111247 PMCID: PMC7048112 DOI: 10.1186/s13054-020-2795-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/17/2020] [Indexed: 12/24/2022]
Abstract
Objective Administration of diuretics has been shown to assist fluid management and improve clinical outcomes in the critically ill post-shock resolution. Current guidelines have not yet included standardization or guidance for diuretic-based de-resuscitation in critically ill patients. This study aimed to evaluate the impact of a multi-disciplinary protocol for diuresis-guided de-resuscitation in the critically ill. Methods This was a pre-post single-center pilot study within the medical intensive care unit (ICU) of a large academic medical center. Adult patients admitted to the Medical ICU receiving mechanical ventilation with either (1) clinical signs of volume overload via chest radiography or physical exam or (2) any cumulative fluid balance ≥ 0 mL since hospital admission were eligible for inclusion. Patients received diuresis per clinician discretion for a 2-year period (historical control) followed by a diuresis protocol for 1 year (intervention). Patients within the intervention group were matched in a 1:3 ratio with those from the historical cohort who met the study inclusion and exclusion criteria. Results A total of 364 patients were included, 91 in the protocol group and 273 receiving standard care. Protocolized diuresis was associated with a significant decrease in 72-h post-shock cumulative fluid balance [median, IQR − 2257 (− 5676–920) mL vs 265 (− 2283–3025) mL; p < 0.0001]. In-hospital mortality in the intervention group was lower compared to the historical group (5.5% vs 16.1%; p = 0.008) and higher ICU-free days (p = 0.03). However, no statistically significant difference was found in ventilator-free days, and increased rates of hypernatremia and hypokalemia were demonstrated. Conclusions This study showed that a protocol for diuresis for de-resuscitation can significantly improve 72-h post-shock fluid balance with potential benefit on clinical outcomes.
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Affiliation(s)
- Brittany D Bissell
- Department of Pharmacy Services, Neuro-Pulmonary Division, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA. .,College of Pharmacy, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA. .,College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, 740 S. Limestone, Lexington, KY, 40536, USA.
| | - Melanie E Laine
- Department of Pharmacy Services, Neuro-Pulmonary Division, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA.,College of Pharmacy, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Melissa L Thompson Bastin
- Department of Pharmacy Services, Neuro-Pulmonary Division, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA.,College of Pharmacy, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Alexander H Flannery
- Department of Pharmacy Services, Neuro-Pulmonary Division, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA.,College of Pharmacy, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Andrew Kelly
- Performance Analytics Center of Excellence, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Jeremy Riser
- Performance Analytics Center of Excellence, University of Kentucky, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Javier A Neyra
- College of Medicine, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, MN668, Lexington, KY, 40536, USA
| | - Jordan Potter
- Department of Pharmacy Services, Beaumont Hospital, 3601 W 13 Mile Road, Royal Oak, MI, 48073, USA
| | - Peter E Morris
- College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, 740 S. Limestone, Lexington, KY, 40536, USA
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Nelson NR, Tompkins MG, Thompson Bastin ML. Plasma exchange as treatment for osmotic demyelination syndrome: Case report and review of current literature. Transfus Apher Sci 2019; 58:102663. [PMID: 31759898 DOI: 10.1016/j.transci.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/12/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Osmotic demyelination syndrome (ODS) is characterized by widespread degeneration of myelin within the central nervous system and has no established treatment. A limited number of cases have reported positive outcomes with plasma exchange in the treatment of ODS associated with chronic alcohol abuse or liver transplantation. We report the case of a 23-year-old female presenting with ODS following rapid correction of hyponatremia, which was attributed to hypoalbuminemia, volume overload, and malnutrition secondary to ulcerative colitis. Our patient received four plasma exchange sessions over the course of five days for a total plasma exchange of 15,500 mL. Unfortunately, the patient did not achieve significant neurologic recovery following completion of the plasma exchange regimen. This is the first report of the failure of this novel approach in the management of a patient with ODS, suggesting benefit in a limited patient population. We describe the proposed mechanism of plasma exchange in the treatment of ODS and provide a review of existing literature.
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Affiliation(s)
- Nicholas R Nelson
- University of Kentucky HealthCare, Department of Pharmacy Services, United States.
| | - Madeline G Tompkins
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy Services, United States; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, United States.
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25
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Magee CA, Thompson Bastin ML, Graves K, Burgess D, Nestor M, Lamm JR, Cook AM. Fever Burden in Patients With Subarachnoid Hemorrhage and the Increased Use of Antibiotics. J Stroke Cerebrovasc Dis 2019; 28:104313. [PMID: 31405792 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/10/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Fever occurs in the majority of subarachnoid hemorrhage (SAH) patients. Nearly 50% of SAH patients have noninfectious fevers. Data are lacking describing the effects of fever burden in the SAH patient population. METHODS This was a single-center, retrospective observational cohort study in patients more or equal to 18 years of age with a diagnosis of nontraumatic SAH admitted to an ICU between January 1, 2010 and September 1, 2015. Exclusion criteria were SAH secondary to trauma or admission for more than 48 hours. Temperature measurements, demographic data, and other pertinent information were collected from Day 0 to Day 13. Daily fever burden was calculated for each patient by calculating an area under the curve. RESULTS A total of 194 subjects were included. The mean study period maximum temperature (Tmax) for all 194 patients was 40.8 ± 0.83°C. The mean overall fever burden for all 194 patients was 89.2 ± 99.59°C h more than 37°C. The overall fever burden peaked on day 5 and declined thereafter. Fever burden, Tmax, and length of stay in the hospital were all significantly associated with receipt of antibiotics. Only Tmax was associated with poor outcome. The 31 patients who had fever but no identified cause of infection received 1000 doses of antibiotics or 32.25 doses per patient. CONCLUSION Fever is common in SAH patients and is associated with antibiotic use, infection, vasospasm, and poor outcome. Some SAH patients may receive antibiotics unnecessarily for noninfectious fever. Clinicians should consider using site-specific parameters related to infection rather than systemic symptoms such as fever to evaluate infection in SAH patients.
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Affiliation(s)
- Carolyn A Magee
- Medical University of South Carolina Hospital Authority, Department of Pharmacy Services, Charleston, South Carolina.
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy Services, Lexington, Kentucky; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, Lexington, Kentucky
| | - Katelyn Graves
- Norton Audubon Hospital, Department of Pharmacy, Louisville, Kentucky
| | - Donna Burgess
- University of Kentucky HealthCare, Department of Pharmacy Services, Lexington, Kentucky; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, Lexington, Kentucky
| | - Melissa Nestor
- University of Kentucky HealthCare, Department of Pharmacy Services, Lexington, Kentucky; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, Lexington, Kentucky
| | - John R Lamm
- Norton Audubon Hospital, Department of Pharmacy, Louisville, Kentucky; University of Kentucky HealthCare, Department of Graduate Medical Education, Lexington, Kentucky
| | - Aaron M Cook
- University of Kentucky HealthCare, Department of Pharmacy Services, Lexington, Kentucky; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, Lexington, Kentucky
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26
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McCleary EJ, Thompson Bastin ML, Bissell BD, Cook AM, Pierce CA, Flannery AH. Development of a Coprecepting Model for a Preceptor-in-Training Program for New Practitioners. Hosp Pharm 2019; 54:246-249. [PMID: 31320774 DOI: 10.1177/0018578718784481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Preceptor development is a focus of pharmacy residency programs across the country. Graduation from residency into the role of preceptor can be a challenge, as it is one of many transitions junior practitioners make in their early careers. Literature in recent years has brought attention to the need to establish preceptor development programs that adequately allow newer preceptors to develop their skills in experiential education, for both pharmacy residents and students. Furthermore, many preceptor development programs as implemented are often didactic in nature, and include readings, webinars, and other passive learning regarding the art of precepting. Objective: Given the need to develop a preceptor development program in our service line that met the needs of preceptors-in-training and full preceptors, we offer a description of our preceptor development program in the intensive care unit. Methods: We focused on active development of preceptor skills for multiple layers of resident and student learners. In addition, this model incorporated instructing, modeling, coaching, and facilitating, as the relationship between full preceptor and preceptor-in-training evolved. It also offered the opportunity for real-time feedback and discussion on precepting performance. Conclusions: We describe our coprecepting model as an opportunity that succeeded for us in helping to transition our preceptors-in-training to full preceptors. It met the needs of our department, staff, and patients, and we believe it has the potential to be valuable as a tool extrapolated to the preceptor development programs of other institutions.
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Affiliation(s)
- Emily J McCleary
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Brittany D Bissell
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Aaron M Cook
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Catherine A Pierce
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
| | - Alexander H Flannery
- University of Kentucky HealthCare, Lexington, USA.,University of Kentucky College of Pharmacy, Lexington, USA
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Laine ME, Flannery AH, Moody B, Thompson Bastin ML. Need for expanded Candida Score for empiric antifungal use in medically critically ill patients? Crit Care 2019; 23:242. [PMID: 31272491 PMCID: PMC6609394 DOI: 10.1186/s13054-019-2525-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/24/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Melanie E Laine
- Medical Intensive Care Unit/Pulmonary, University of Kentucky HealthCare, Lexington, USA. .,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 800 Rose Street, H110, Lexington, KY, 40536, USA.
| | - Alexander H Flannery
- Medical Intensive Care Unit/Pulmonary, University of Kentucky HealthCare, Lexington, USA.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Breanna Moody
- Department of Pharmacy, Lexington VA Health Care System, 1101 Veterans Drive, Lexington, KY, 40502, USA
| | - Melissa L Thompson Bastin
- Medical Intensive Care Unit/Pulmonary, University of Kentucky HealthCare, Lexington, USA.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 800 Rose Street, H110, Lexington, KY, 40536, USA
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28
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Thompson Bastin ML, Short GT, Cook AM, Rust K, Flannery AH. Patients' and Care Providers' Perceptions of Television-Based Education in the Intensive Care Unit. Am J Crit Care 2019; 28:307-315. [PMID: 31263014 DOI: 10.4037/ajcc2019156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delivery of patient education materials to promote health literacy is a vital component of patient-centered care, which improves patients' decision-making, reduces patients' anxiety, and improves clinical outcomes. OBJECTIVES To evaluate perceptions of television-based patient education among patients, caregivers, nurses, and other care providers (attending physicians, advanced practice nurses, physician assistants, and resident fellows) in the intensive care unit. METHODS A Likert-scale survey of the perceptions of patients, caregivers, nurses, and other care providers in the medical and cardiovascular intensive care units of a large academic medical center. Perceptions of the effects of television-based education on anxiety, knowledge, and health-related decision-making were assessed. RESULTS A total of 188 participants completed the survey. Among them, 75% of nurses and 76% of other providers agreed or strongly agreed that television-based education improved patients' and caregivers' knowledge (P = .95). More nurses (47%) than other providers (29%) agreed that television-based education would lead to more informed health decisions by patients (P = .04). Patients and caregivers are 23 times more likely than providers to strongly agree that television-based education reduces anxiety, and they are more optimistic regarding the benefits of television-based education (relative risk ratio 23.47; 95% CI 9.75-56.45; P < .001). CONCLUSION Patients and caregivers strongly suggested that television is a useful tool for providing health literacy education in an intensive care unit.
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Affiliation(s)
- Melissa L Thompson Bastin
- Melissa L. Thompson Bastin and Alexander H. Flannery are critical care pharmacists in the pulmonary and medical intensive care unit, Department of Pharmacy Services, University of Kentucky HealthCare, and assistant professors of pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Grant Tyler Short is a pharmacy resident (postgraduate year 2), Department of Pharmacy Services, University of Kentucky Health-Care. Aaron M. Cook is the clinical coordinator for neuroscience and pulmonary/critical care, Department of Pharmacy Services, University of Kentucky HealthCare, and an associate professor of Pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy. Katie Rust is an intensive care nurse in the pulmonary and medical intensive care unit, University of Kentucky HealthCare, and a doctoral student, University of Kentucky College of Nursing, Lexington, Kentucky.
| | - Grant Tyler Short
- Melissa L. Thompson Bastin and Alexander H. Flannery are critical care pharmacists in the pulmonary and medical intensive care unit, Department of Pharmacy Services, University of Kentucky HealthCare, and assistant professors of pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Grant Tyler Short is a pharmacy resident (postgraduate year 2), Department of Pharmacy Services, University of Kentucky Health-Care. Aaron M. Cook is the clinical coordinator for neuroscience and pulmonary/critical care, Department of Pharmacy Services, University of Kentucky HealthCare, and an associate professor of Pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy. Katie Rust is an intensive care nurse in the pulmonary and medical intensive care unit, University of Kentucky HealthCare, and a doctoral student, University of Kentucky College of Nursing, Lexington, Kentucky
| | - Aaron M Cook
- Melissa L. Thompson Bastin and Alexander H. Flannery are critical care pharmacists in the pulmonary and medical intensive care unit, Department of Pharmacy Services, University of Kentucky HealthCare, and assistant professors of pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Grant Tyler Short is a pharmacy resident (postgraduate year 2), Department of Pharmacy Services, University of Kentucky Health-Care. Aaron M. Cook is the clinical coordinator for neuroscience and pulmonary/critical care, Department of Pharmacy Services, University of Kentucky HealthCare, and an associate professor of Pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy. Katie Rust is an intensive care nurse in the pulmonary and medical intensive care unit, University of Kentucky HealthCare, and a doctoral student, University of Kentucky College of Nursing, Lexington, Kentucky
| | - Katie Rust
- Melissa L. Thompson Bastin and Alexander H. Flannery are critical care pharmacists in the pulmonary and medical intensive care unit, Department of Pharmacy Services, University of Kentucky HealthCare, and assistant professors of pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Grant Tyler Short is a pharmacy resident (postgraduate year 2), Department of Pharmacy Services, University of Kentucky Health-Care. Aaron M. Cook is the clinical coordinator for neuroscience and pulmonary/critical care, Department of Pharmacy Services, University of Kentucky HealthCare, and an associate professor of Pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy. Katie Rust is an intensive care nurse in the pulmonary and medical intensive care unit, University of Kentucky HealthCare, and a doctoral student, University of Kentucky College of Nursing, Lexington, Kentucky
| | - Alexander H Flannery
- Melissa L. Thompson Bastin and Alexander H. Flannery are critical care pharmacists in the pulmonary and medical intensive care unit, Department of Pharmacy Services, University of Kentucky HealthCare, and assistant professors of pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Grant Tyler Short is a pharmacy resident (postgraduate year 2), Department of Pharmacy Services, University of Kentucky Health-Care. Aaron M. Cook is the clinical coordinator for neuroscience and pulmonary/critical care, Department of Pharmacy Services, University of Kentucky HealthCare, and an associate professor of Pharmacy, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy. Katie Rust is an intensive care nurse in the pulmonary and medical intensive care unit, University of Kentucky HealthCare, and a doctoral student, University of Kentucky College of Nursing, Lexington, Kentucky
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Fu SH, Flannery AH, Thompson Bastin ML. Acute Hepatotoxicity After High-Dose Cytarabine for the Treatment of Relapsed Acute Myeloid Leukemia: A Case Report. Hosp Pharm 2019; 54:160-164. [PMID: 31205325 DOI: 10.1177/0018578718779763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Cytarabine is considered the standard of care for induction therapy in patients with acute myeloid leukemia (AML) who are preparing for bone marrow transplant. Summary: We report a case of a 72-year-old female presenting to the intensive care unit with hepatic failure after high-dose cytarabine (HiDAC) for the treatment of relapsed AML. The patient's liver function tests (LFTs) were elevated acutely, with a mildly elevated bilirubin and a normal alkaline phosphatase. HiDAC was discontinued but her LFTs remained high for 9 days post discontinuation, and the patient eventually expired due to sepsis and multiple organ failure. We estimated the probability of the hepatotoxicity observed with HiDAC as probable based on a score of 5 on the Naranjo scale. Conclusion: Clinicians should be aware of the potential hepatotoxicity associated with HiDAC for patients with AML, specifically in the elderly population.
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Affiliation(s)
- Samuel H Fu
- University of Kentucky College of Pharmacy, Lexington, USA
| | - Alexander H Flannery
- University of Kentucky College of Pharmacy, Lexington, USA.,University of Kentucky HealthCare, Lexington, USA
| | - Melissa L Thompson Bastin
- University of Kentucky College of Pharmacy, Lexington, USA.,University of Kentucky HealthCare, Lexington, USA
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30
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Flannery AH, Bastin MLT, Magee CA, Bensadoun ES. Vitamin C in Sepsis: When It Seems Too Sweet, It Might (Literally) Be. Chest 2019; 152:450-451. [PMID: 28797393 DOI: 10.1016/j.chest.2017.05.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 05/04/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Alexander H Flannery
- Department of Pharmacy Services, University of Kentucky HealthCare, University of Kentucky College of Pharmacy, Lexington, KY.
| | - Melissa L Thompson Bastin
- Department of Pharmacy Services, University of Kentucky HealthCare, University of Kentucky College of Pharmacy, Lexington, KY
| | - Carolyn A Magee
- Department of Pharmacy Services, University of Kentucky HealthCare, University of Kentucky College of Pharmacy, Lexington, KY
| | - Eric S Bensadoun
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY
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Thompson Bastin ML, Cook AM, Flannery AH. Use of simulation training to prepare pharmacy residents for medical emergencies. Am J Health Syst Pharm 2019; 74:424-429. [PMID: 28274986 DOI: 10.2146/ajhp160129] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The use of high-fidelity simulation training for preparing pharmacy residents for various high-stress and high-impact medical emergencies and the impact of this training on pharmacy residents' perception of preparedness are described. SUMMARY During the 2015-16 residency year at the University of Kentucky Medical Center, simulation training, in addition to lecture-based orientation training, was chosen as a method to reinforce skills and knowledge learned throughout the orientation, before residents began working on-call shifts. Three different simulation exercises were developed to cover five selected topics over the course of 3 different days: sepsis as its own session, a surgical-themed session combining bleeding reversal and malignant hyperthermia, and a neurologic-themed session combining stroke and status epilepticus. Postgraduate year 2 (PGY2) specialty residents in critical care and emergency medicine helped facilitate the cases. The specialty residents played the role of the physician or nurse for the case and were allowed to answer questions asked of the pharmacy residents, appropriate to their respective roles. Following completion of the simulation exercise, a survey tool was sent to pharmacy residents to rate their perception of preparedness before and after the training for each scenario and again at 6 months after the simulation training to assess sustainability of the training. Participants generally responded that the simulations met their expectations and that the PGY2 residents facilitated the simulations fairly well (scores of 68.5-80 on a scale of 0-100). The resident-reported that beneficial effects of simulation training persisted at 6 months following the simulation exercises. CONCLUSION Simulation training increased pharmacy residents' self-reported preparedness for high-stress, high-impact clinical scenarios and medical emergencies.
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Affiliation(s)
- Melissa L Thompson Bastin
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY .,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Aaron M Cook
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Alexander H Flannery
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
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Buzzard SL, Bissell BD, Thompson Bastin ML. Ehrlichiosis presenting as severe sepsis and meningoencephalitis in an immunocompetent adult. JMM Case Rep 2018; 5:e005162. [PMID: 30425837 PMCID: PMC6230758 DOI: 10.1099/jmmcr.0.005162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/12/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Ehrlichia are obligate intracellular pathogens transmitted to vertebrates by ticks. Case presentation We report the case of a 59-year-old man who presented to the University of Kentucky Albert B. Chandler Medical Center (Lexington, KY, USA) after being found fallen down in the woods. A lumbar puncture revealed what appeared to be bacterial meningitis, yet cerebrospinal fluid cultures, Gram stains and a meningitis/encephalitis panel were inconclusive. However, an Ehrlichia DNA PCR of the blood resulted as being positive for Ehrlichia chaffeensis antibodies. The patient received a 14 day course of doxycycline, and recovered from his multiple organ failure. The aetiology of the ehrlichial meningoencephalitis was likely transmission through a tick-bite, due to the patient's outdoor exposure. Conclusion While it is rare to see Ehrlichia as a cause of meningitis, this illness can progress to severe multisystem disease with septic shock, meningoencephalitis or acute respiratory distress syndrome (ARDS). Those with compromised immunity are at a higher risk of developing the more severe form of the disease and have higher case fatality rates.
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Affiliation(s)
- Stephanie L Buzzard
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Brittany D Bissell
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA.,Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Melissa L Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA.,Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
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Borchert JS, Phillips J, Thompson Bastin ML, Livingood A, Andersen R, Brasher C, Bright D, Fahmi-Armanious B, Leary MH, Lee JC. Best practices: Incorporating pharmacy technicians and other support personnel into the clinical pharmacist's process of care. J Am Coll Clin Pharm 2018. [DOI: 10.1002/jac5.1029] [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] [Indexed: 11/10/2022]
Affiliation(s)
| | | | | | | | | | | | - David Bright
- American College of Clinical Pharmacy; Lenexa Kansas
| | | | | | - James C. Lee
- American College of Clinical Pharmacy; Lenexa Kansas
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Flannery AH, Thompson Bastin ML, Montgomery-Yates A, Hook C, Cassity E, Eaton PM, Morris PE. Multidisciplinary Prerounding Meeting as a Continuous Quality Improvement Tool: Leveraging to Reduce Continuous Benzodiazepine Use at an Academic Medical Center. J Intensive Care Med 2018; 34:707-713. [PMID: 29683053 DOI: 10.1177/0885066618769015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Evidence-based medicine often has many barriers to overcome prior to implementation in practice, hence the importance of continuous quality improvement. We report on a brief (≤10 minutes) multidisciplinary meeting prior to rounds to establish a dashboard for continuous quality improvement and studied the success of this meeting on a particular area of focus: continuous infusion benzodiazepine minimization. METHODS This was a prospective observational study of patients admitted to the medical intensive care unit (MICU) of a large academic medical center over a 4-month period. A morning multidisciplinary prerounding meeting was implemented to report on metrics required to establish a dashboard for MICU care for the previous 24 hours. Fellows and nurse practitioners on respective teams reported on key quality metrics and other important data related to patient census. Continuous benzodiazepines were tracked daily as the number of patients per team who had orders for a continuous benzodiazepine infusion. The aim of this report is to describe the development of the morning multidisciplinary prerounding meeting and its impact on continuous benzodiazepine use, along with associated clinical outcomes. RESULTS The median number of patients prescribed a continuous benzodiazepine daily decreased over this time period and demonstrated a sustained reduction at 1 year. Furthermore, sedation scores improved, corresponding to a reduction in median duration of mechanical ventilation. The effectiveness of this intervention was mapped post hoc to conceptual models used in implementation science. CONCLUSIONS A brief multidisciplinary meeting to review select data points prior to morning rounds establishes mechanisms for continuous quality improvement and may serve as a mediating factor for successful implementation when initiating and monitoring practice change in the ICU.
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Affiliation(s)
- Alexander H Flannery
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA.,2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Melissa L Thompson Bastin
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA.,2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | | | - Corrine Hook
- 3 University of Kentucky College of Medicine, Lexington, KY, USA
| | - Evan Cassity
- 3 University of Kentucky College of Medicine, Lexington, KY, USA
| | - Phillip M Eaton
- 4 Internal Medicine, University of Kentucky HealthCare, Lexington, KY, USA
| | - Peter E Morris
- 3 University of Kentucky College of Medicine, Lexington, KY, USA
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Bissell BD, Davis JE, Flannery AH, Adkins DA, Thompson Bastin ML. Aggressive Treatment of Life-Threatening Hypophosphatemia During Recovery From Fulminant Hepatic Failure: A Case Report. J Intensive Care Med 2017; 33:375-379. [PMID: 29088996 DOI: 10.1177/0885066617738715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Acute liver failure secondary to acetaminophen overdose can be a life-threatening condition, characterized by severe electrolyte derangements. Hepatocyte regeneration is associated with phosphorous utilization and is a known complication of liver recovery following injury. We report the case of profound, life-threatening hypophosphatemia following recovery from acute fulminant liver failure. As the liver enzymes normalized, serum phosphorous levels plummeted. Our patient required an aggressive, individualized phosphorus replacement regimen, which resulted in a continuous infusion of intravenous (IV) sodium phosphate, titrated to a maximum rate of 30 mmol/h or 0.5 mmol/kg/h. The patient required over 400 mmol of total IV and oral phosphorous over the course of 48 hours. An aggressive approach to phosphorous replacement was done safely and effectively. Traditional replacement protocols are not adequate to sustain patients with this degree of hypophosphatemia. This is the first report to utilize a continuous infusion of phosphate with a maximum reported rate (0.5 mmol/kg/h). Our report summarizes a novel and safe approach for clinicians to maximally support these patients through high-dose, continuous infusion phosphorous administration.
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Affiliation(s)
- Brittany D Bissell
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Jason E Davis
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Alexander H Flannery
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA.,2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - David A Adkins
- 3 Division of Critical Care and Pulmonology, West Virginia University College of Medicine, Morgantown, WV, USA
| | - Melissa L Thompson Bastin
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA.,2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
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La MK, Thompson Bastin ML, Gisewhite JT, Johnson CA, Flannery AH. Impact of restarting home neuropsychiatric medications on sedation outcomes in medical intensive care unit patients. J Crit Care 2017; 43:102-107. [PMID: 28865338 DOI: 10.1016/j.jcrc.2017.07.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 07/21/2017] [Accepted: 07/25/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This single-center, retrospective cohort study investigated the effects of timing of initiating home neuropsychiatric medications (NPMs) on sedation-related outcomes. MATERIALS AND METHODS Subjects included adult medical intensive care unit (MICU) patients who had an NPM on their admission medication list; intubated before or on arrival to the intensive care unit (ICU); and were on benzodiazepine-based sedation. The intervention assessed was the timing of the initiation of home NPMs: early (≤5days) vs. late (>5days) into the ICU stay. RESULTS There were 56 and 53 patients in the early and late restart groups, respectively. Early cohort patients maintained a median daily RASS of -1.5, while late cohort patients had a median daily RASS of -2.0 (p=0.02). The effect was driven by the subgroup of patients on home anti-depressant therapy who were restarted early on these agents. The early restart group had a higher percentage of days with RASS scores within goal (p=0.01) and less delirium (p=0.02). Early restarting of home NPMs was associated with a non-significant decrease in ventilator days compared with late restarting (p=0.11). CONCLUSIONS Restarting home NPMs was associated with lighter sedation levels and less delirium.
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Affiliation(s)
- Mary K La
- University of North Carolina Eshelman School of Pharmacy, Division of Practice Advancement and Clinical Education, Chapel Hill, NC, United States.
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy Services, 800 Rose Street, Room H110, Lexington, KY 40536, United States; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, Lexington, KY, United States.
| | - Jenee T Gisewhite
- Beaumont Hospital - Royal Oak, Department of Pharmacy Services, Royal Oak, MI, United States.
| | | | - Alexander H Flannery
- University of Kentucky HealthCare, Department of Pharmacy Services, 800 Rose Street, Room H110, Lexington, KY 40536, United States; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, Lexington, KY, United States.
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Abstract
RATIONALE Vasopressors such as norepinephrine are first line for support of mean arterial pressure (MAP) in the management of septic shock. Their use, however, is commonly associated with many adverse events. These detriments frequently trigger the use of alternative, noncatecholamine therapies, including vasopressin. Vasopressin deficiency is a known physiologic consequence of septic shock, and while guidelines recommend vasopressin in addition to norepinephrine, no consensus exists on the duration of deficiency or ideal time of cessation. Studies have suggested that vasopressin discontinuation prior to other vasopressors may lead to hypotension; however, data are limited. This study evaluates the optimal sequence for the discontinuation of vasopressin therapy in septic shock. METHODS This was a 1-year retrospective study of 152 patients admitted to the medical intensive care unit (ICU) with septic shock who received concurrent norepinephrine and vasopressin for vasoactive support. Patients were excluded if death occurred on vasopressors, within 24 hours after discontinuation of vasopressors, or within 48 hours of ICU admission. The primary outcome of hemodynamic instability included incidence of hypotension after vasopressor discontinuation (2 consecutive MAPs < 60 mm Hg), fluid bolus administration, greater than 0.05 μg/kg/min increase in norepinephrine requirements, or addition of an alternative vasopressor. Secondary outcomes included time to hypotension, total vasopressor duration, arrhythmias, mortality, and length of stay. RESULTS Ninety-one patients met exclusion criteria, resulting in 61 patients for evaluation. Vasopressin was the first vasoactive therapy to be discontinued in 19 patients and last in 42 patients. Baseline characteristics and the use of potentially confounding treatments known to effect MAP were similar between groups. Discontinuation of vasopressin first was associated with a significant increase in hemodynamic instability (74% vs 16.7%, P < .01), with a shorter time to hemodynamic instability (5 vs 15 hours, P < .01). Secondary outcomes were similar. CONCLUSION Vasopressin discontinuation prior to cessation of norepinephrine infusion was associated with an increased risk of hemodynamic instability.
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Affiliation(s)
- Brittany D Bissell
- 1 Department of Pharmacy, University of Kentucky Medical Center, Lexington, KY, USA
- 2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Carolyn Magee
- 1 Department of Pharmacy, University of Kentucky Medical Center, Lexington, KY, USA
| | - Peter Moran
- 2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Melissa L Thompson Bastin
- 1 Department of Pharmacy, University of Kentucky Medical Center, Lexington, KY, USA
- 2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Alexander H Flannery
- 1 Department of Pharmacy, University of Kentucky Medical Center, Lexington, KY, USA
- 2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
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Smetana KS, Cook AM, Bastin MLT, Oyler DR. Antiepileptic dosing for critically ill adult patients receiving renal replacement therapy. J Crit Care 2016; 36:116-124. [PMID: 27546759 DOI: 10.1016/j.jcrc.2016.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 02/11/2016] [Revised: 06/06/2016] [Accepted: 06/28/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this review was to evaluate current literature for dosing recommendations for the use of antiepileptic medications in patients receiving renal replacement therapy (RRT). DATA SOURCES With the assistance of an experienced medical librarian specialized in pharmacy and toxicology, we searched MEDLINE, EMBASE, CINAHL, Web of Science, WorldCat, and Scopus through May 2016. STUDY SELECTION AND DATA EXTRACTION Four hundred three articles were screened for inclusion, of which 130 were identified as potentially relevant. Micromedex® DRUGDEX as well as package inserts were used to obtain known pharmacokinetic properties and dosage adjustment recommendations in RRT if known. DATA SYNTHESIS Data regarding antiepileptic drug use in RRT are limited and mostly consist of case reports limiting our proposed dosing recommendations. Known pharmacokinetic parameters should guide dosing, and recommendations are provided where possible. CONCLUSION Additional studies are necessary before specific dosing recommendations can be made for most antiepileptic drugs in critically ill patients receiving RRT, specifically with newer agents.
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Affiliation(s)
- Keaton S Smetana
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY.
| | - Aaron M Cook
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Douglas R Oyler
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
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Phillips HJ, Dangler A, Klem PM, Chu F, Pon T, Liewer S, Thompson Bastin ML, Halfpap JJ, Fish J, Stun L, Varughese CA. Preceptor development: Responses to frequently asked questions from preceptors in academic hospitals. Am J Health Syst Pharm 2016; 73:e261-6. [DOI: 10.2146/ajhp150344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | | | - Frank Chu
- UC San Diego Health System, San Diego, CA
| | - Tiffany Pon
- University of California, San Francisco School of Pharmacy, Sacramento, CA
| | | | | | | | - Jeffrey Fish
- University of Wisconsin Hospital and Clinics, Madison, WI
| | - Lucy Stun
- University of Kansas Hospital, Kansas City, KS
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Abstract
Levetiracetam is considered by many clinicians to be one of the most benign antiepileptic medications available. We report the case of a 24-year-old man presenting with seizures for which he was started on levetiracetam. Despite an extensive work-up and treatment of possible infectious and noninfectious issues, the patient remained intermittently febrile. When a marked peripheral eosinophilia was noted, the patient's levetiracetam was discontinued and phenytoin prescribed. The fever resolved within 24 hours, and the patient's eosinophilia count returned to normal limits following discharge back to his long-term care facility. We estimate the probability of this reaction related to levetiracetam as probable based on a score of 7 on the Naranjo scale. Clinicians should be aware of the possibility that levetiracetam may be an offending agent in a patient with unexplained fever and eosinophilia. These may be early signs of the progression to a more serious drug hypersensitivity reaction, such as drug rash, eosinophilia, and systemic symptoms (DRESS) syndrome.
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Affiliation(s)
- Alexander H Flannery
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Maria D Willey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Melissa L Thompson Bastin
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky.,Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Ketan P Buch
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Eric S Bensadoun
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
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Abstract
OBJECTIVE To evaluate the literature for published reports regarding the efficacy of standard versus higher dosing of oseltamivir in critically ill patients with severe influenza. DATA SOURCES An English-language literature search was conducted using MEDLINE (1966-February 2014) using the terms oseltamivir and influenza limited to humans and adults older than 19 years. Additional articles were identified through a manual search of the references obtained from the MEDLINE search. STUDY SELECTION AND DATA EXTRACTION Articles were manually screened for inclusion related to pharmacokinetic or clinical studies comparing varying doses of oseltamivir, particularly in the critically ill patient population. Studies investigating the pharmacokinetics of oseltamivir in continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) were also included. DATA SYNTHESIS During the 2009 H1N1 influenza pandemic, the World Health Organization suggested 150 mg twice daily as a consideration in critically ill patients with severe influenza. The basis for the recommendation can be traced back to animal studies investigating the H5N1 virus. Three different studies in humans investigating higher doses in severe influenza have found no differences in clinical outcomes between standard and higher dosing. Pharmacokinetic studies suggest adequate absorption in critically ill patients. Although no dosage adjustment appears to be needed for ECMO patients, reduction may berequired for CRRT.. CONCLUSIONS . Although additional data are needed for a definitive conclusion, the small body of literature available in humans does not support routine use of high-dose oseltamivir in critically ill patients.
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Affiliation(s)
- Alexander H Flannery
- University of Kentucky HealthCare, Lexington, KY, USA University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Lexington, KY, USA University of Kentucky College of Pharmacy, Lexington, KY, USA
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Abstract
BACKGROUND Etomidate is a commonly used sedative during rapid sequence intubation (RSI). Septic patients are at an increased risk of independently developing adrenal suppression, which has been associated with increased mortality in some studies. Since etomidate affects cortisol production, its use in septic patients is controversial. However, data are still lacking to prove that etomidate should be avoided in this patient population. OBJECTIVES The objective was to review patients diagnosed with sepsis who received etomidate during RSI. Our hypothesis is that patients who receive etomidate will experience clinically significant hypotension within the first 24 hours of intubation. METHODS A retrospective cohort study was conducted on patients intubated in the emergency department (ED) and medical/surgical floors at our institution from 2004 to 2010. Once patients with a diagnosis of sepsis were identified, it was determined whether the patients received etomidate or a different sedative during intubation. The primary endpoint was clinically significant hypotension: systolic blood pressure <90 mm Hg or mean arterial pressure <60 mm Hg. RESULTS One hundred fifty-seven patients, 110 etomidate and 47 non-etomidate, were included in the final analysis. Hypotension was seen in 79 (71.8%) patients who received etomidate and in 14 (29.8%) patients who received another sedative (P ≤ .001). There were no statistically significant differences in secondary objectives. CONCLUSION Etomidate use for induction of anesthesia during RSI was associated with clinically significant hypotension when compared to other sedatives. The hypotension was transient and did not translate into statistically significant differences in the secondary clinical endpoints.
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Affiliation(s)
| | - Stephanie N Baker
- Department of Pharmacy, University of Kentucky HealthCare , Lexington, Kentucky . ; Department of Emergency Services, University of Kentucky HealthCare , Lexington, Kentucky
| | - Kyle A Weant
- Department of Pharmacy, University of Kentucky HealthCare , Lexington, Kentucky . ; Department of Emergency Services, University of Kentucky HealthCare , Lexington, Kentucky
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