Pharmacist Adscription To Intensive Care: Generating Synergies. / Adscripción del farmacéutico a cuidados intensivos: generando sinergias.

OBJECTIVE: To evaluate incorporation of the hospital pharmacist to the routine activity of an Intensive Care Unit (ICU). DESIGN: A prospective observational study was carried out to evaluate the impact of pharmacist interventions, made by a pharmacist temporarily assigned to the ICU, upon medical prescriptions. SETTING: A medical and surgical ICU with 21 beds. PATIENTS: Patients with at least one ICU stay were included, while patients with admission and discharge in periods when the pharmacist was not present were excluded. INTERVENTIONS: The interventions were made after daily review of the prescriptions, and were communicated verbally or in writing to the supervising physician. MAIN VARIABLES: Number of interventions, therapeutic group of the drugs involved, type of intervention and degree of acceptance. RESULTS: A total of 194 interventions were made in 62 patients. The majority were related to safety aspects (33%) and the optimization of therapy (32%). The most frequent interventions were the administration of drugs via the nasogastric tube (19%) and pharmacokinetic monitoring (14.4%). The most frequently involved groups of drugs were anti-infectious agents (33%) and digestive system medications (27%). A total of 56.2% of the interventions were made verbally, and 80% were accepted. CONCLUSIONS: Pharmacist adscription to an ICU and the implementation of interventions on prescriptions have allowed improvement of safety and the optimization of pharmacotherapy in more than 50% of the patients. The high rate of acceptance of these interventions would support the implementation of such programs in critical care units.

[Overdose of metformin secondary to acute renal insufficiency: a report of six cases]. / Sobredosis de metformina secundaria a insuficiencia renal aguda. A propósito de 6 observaciones.

Metformin is a biguanide used in the treatment of obese adults with type 2 diabetes mellitus; metformin decreases mortality by 36% in comparison to conventional treatment. Metformin administration has certain contraindications that, when ignored, especially in the case of acute renal insufficiency, leads to the accumulation of the drug and consequent lactic acidosis that can be fatal. We present 6 patients with acute renal insufficiency that experienced extreme acute metabolic acidosis (pH <6.90 and bicarbonate <5 mEq/l) and increased anion gap while receiving metformin for the treatment of diabetes. Serum lactic acid, only evaluated in the 4 patients that survived, was high. Two patients died after cardiac arrest that could have been avoided. In conclusion, lactic acidosis appearing during metformin treatment for diabetes requires rapid diagnosis and treatment to enable the drug to be withdrawn and prolonged continuous hemofiltration or hemodialysis with bicarbonate to be initiated.

Propofol versus midazolam: safety and efficacy for sedating the severe trauma patient.

UNLABELLED: Previous studies have compared sedation profiles with midazolam (Mz) and propofol (Pf), particularly in heterogeneous populations of patients. Decreases in blood pressure and heart rate have been reported after the administration of propofol. These side effects are potentially deleterious in severe trauma patients, particularly in patients with head trauma. To assess the safety and efficacy of Mz and Pf, alone or in combination, in the prolonged sedation of severe trauma patients, we designed a prospective, controlled, randomized, study. One hundred consecutively admitted trauma patients requiring mechanical ventilation and sedation for more than 48 h were studied. Patients were sedated according to three different protocols based on the continuous i.v. administration of Mz alone, Pf alone, and Mz in combination with Pf. All patients received morphine chloride. Safety and efficacy were assessed during the sedation and wake-up periods according to clinical and laboratory variables. Cerebral hemodynamics were also studied in patients with head trauma. Patients were sedated for 6.3 +/- 4.0 days (mean +/- SD). All three sedation regimens were equally efficacious in achieving the desired sedation goal. The incidence of adverse events during the sedation period was also similar. In head trauma patients with intracranial pressure (ICP) monitoring, we did not find differences in ICP, cerebral perfusion pressure, or jugular venous oxygen saturation among the three groups. The serum triglyceride concentration was significantly higher in the Pf group. Wake-up time was significantly shorter in the Pf group. We conclude that both Mz and Pf are safe and efficacious in the sedation of severe trauma patients. The use of Pf in these patients is associated with a high incidence of hypertriglyceridemia and a shorter wake-up time. IMPLICATIONS: In a prospective, controlled, randomized study, we confirmed the safety and efficacy of midazolam and propofol, alone or in combination, in the prolonged sedation of a homogeneous group of severe trauma patients, particularly in patients with head trauma. The propofol group had shorter wake-up times and higher triglyceride levels.

Cytokines clearance during venovenous hemofiltration in the trauma patient.

The objective of the study was to investigate whether continuous venovenous hemofiltration (CVVH) would facilitate removal of substantial amounts of tumor necrosis factor (TNF) and interleukin-6 (IL-6) from the circulation in traumatized critically ill patients with multiple organ dysfunction syndrome. The study design was a prospective, nonblind, randomized controlled trial that was set in the trauma intensive care unit of a tertiary university referral hospital. Thirty consecutive critically ill, mechanically ventilated trauma patients with multiple organ dysfunction syndrome (without renal failure) were included in the study. Patients were randomized to either CVVH or conventional treatment. Blood and ultrafiltrate samples were collected from each patient before the initiation of CVVH and after 24, 72, and 168 hours of therapy. In the control group, blood samples were collected during the same periods. In the 30 patients studied, 15 had hemofiltration and 15 did not. Both groups were similar with regard to age (36+/-18 years v 36+/-14 years) and severity scores (injury severity score, 32+/-16 v 30+/-11; APACHE II score, 22+/-7 v 21+/-6; Goris score, 5.2+/-1.7 v 5.2+/-1.8). Before CVVH, TNF and IL-6 could be detected in the serum of all patients. The mean concentration of TNF was 17+/-22 pg/mL in patients and 22+/-20 pg/mL in control subjects (P = NS). The mean concentration of IL-6 was 2,153+/-2,824 pg/mL in patients and 1,774+/-1,637 pg/mL in control subjects (P = NS). We found a TNF and IL-6 substantial elimination with CVVH (excretion of TNF [microg/d] at 24, 48, and 168 hours: 112.6+/-161.2, 105.2+/-149.4, and 143.1+/-170.0; excretion of IL-6 [microg/d]: 1,655+/-719, 3,091+/-489, and 2,420+/-366). However, no significant difference was found in serum cytokines concentration between groups during the study: mean serum TNF concentration decreased from the pretreatment level to a mean level of 12+/-9.6 pg/mL in patients and 21+/-27 pg/mL in control subjects. Similar results were found with IL-6 concentration that decreased from the pretreatment level to a mean of 554+/-731 pg/mL in patients and 382 +/-568 pg/mL in control subjects. In conclusion, CVVH is associated with removal of substantial amounts of TNF and IL-6 from the circulation in traumatized critically ill patients, but the profile of these mediators is similar to that of controls, suggesting a nonclinically relevant elimination. Further prospective, randomized, clinical trials are needed to support our results.

Neuroleptic malignant syndrome in a patient with head injury.

Neuroleptic malignant syndrome is an idiosyncratic reaction associated with the use of neuroleptic drugs. We report a case of this rare syndrome in a head injury patient associated with some unusual features: rhabdomyolysis with a high level of creatine kinase, the development of acute renal failure, the early use of continuous venovenous haemofiltration in treatment and rigidity that was refractory to conventional treatment with dantrolene and bromocriptine. The diagnosis in patients with multiple injuries must be based on a high index of suspicion.