Emergency preparation and mitigation for COVID-19 response in an integrated pharmacy practice model.

PURPOSE: The purpose of this descriptive report is to share experiences in crisis response planning and risk mitigation at a university health system department of pharmacy with an integrated clinical practice model in the early months of the coronarvirus disease 2019 (COVID-19) pandemic. SUMMARY: The department of pharmacy's COVID-19 pandemic response included successful planning and implementation of measures to maintain pharmacy operations and minimize COVID-19 exposure of patients and staff. These measures included ensuring adequate personnel staffing using flexible staffing solutions, ongoing assessment of supply chain integrity, and continuation of integrated clinical pharmacy services 24/7 throughout the initial phase of the COVID-19 pandemic. Information technology (IT) and educational program modifications are also discussed. CONCLUSION: This report describes successful crisis planning and risk mitigation in the setting of COVID-19, which was facilitated by the department of pharmacy's integrated clinical practice model. This model enabled uninterrupted personnel scheduling, supply chain integrity, continued provision of 24/7 integrated clinical services, adaptive use of IT tools, and continuation of educational programs. The experiences described may be instructive to other pharmacy departments in evaluating their response to the COVID-19 pandemic and in planning for similar pandemic or other emergency scenarios.

Preoperative cesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized double-blinded placebo control trial.

BACKGROUND: The United States currently has an opioid use disorder epidemic and research evaluating ways to minimize the use of opioids postsurgery are needed. One of these options is intravenous acetaminophen. If the use of preoperative intravenous acetaminophen was found to be effective for cesarean delivery, this would be beneficial for both the mother and breast-feeding neonate. OBJECTIVE: The primary study objective was to see if maternal opioid use was significantly less in the postoperative period for the study group that received 1 g of intravenous acetaminophen preoperatively compared with a control group that received placebo. The secondary objectives were to evaluate maternal length of stay and pain scores postoperatively, and assess the acetaminophen level in cord blood at delivery. STUDY DESIGN: This study was a prospective double-blinded randomized placebo-controlled trial. All pregnant patients who entered labor and delivery for a scheduled cesarean from November 2015 through April 2017 were eligible. Once consented, the medication was supplied by the pharmacy department, which performed the blinded randomization. Both the study drug of 1000 mg (1 g) of acetaminophen and placebo of normal saline were distributed as unmarked 100-mL bags administered over 15 minutes just prior to incision. No study personnel from the obstetric or anesthesia departments had any access to the randomization. Based on a power analysis using the published surgical data results, the goal was to obtain a minimum of 100 patients (50 patients in each arm). Primary data collection included demographics, number of opioid doses and morphine milligram equivalents administered to the patient postoperatively, length of stay postdelivery, pain scores, and newborn cord blood acetaminophen levels. Exclusions were maternal acetaminophen allergy, receipt of acetaminophen in the prior 24 hours, opioid use disorder, and hepatitis/liver impairment. Statistics involved χ2, Fisher exact, and the Student t test where appropriate and a P value <.05 was considered significant with all tests considered against a 2-sided alternative hypothesis. RESULTS: A total of 105 patients were evaluated with 51 who received intravenous acetaminophen and 54 who received placebo. The number of postoperative opioid medication doses administered to the study group was 11.1 (±8.9) compared with the number received by the control group of 10.5 (±8.5), P = .72. The morphine milligram equivalents in the study group was 94.2 (±40.4) compared with the control group of 90.7 (±42.1), P = .67. The length of stay and pain scores were not different between the groups. All of the umbilical cord blood values for acetaminophen were subtherapeutic. CONCLUSION: These data demonstrate that for cesarean delivery, the use of a preoperative 1-g intravenous dose of acetaminophen does not decrease the number of opioid medication doses or the morphine milligram equivalents administered postoperatively, nor does it decrease length of stay postcesarean. The administration of 1-g intravenous acetaminophen preoperatively does not result in elevated newborn cord blood levels (ClinicalTrials.govNCT02694653).

Use of inhaled epoprostenol in patients with H1N1 influenza-associated acute respiratory distress syndrome: a case series.

OBJECTIVE: To report a series of patients with confirmed novel influenza A (H1N1) and refractory hypoxemia secondary to acute respiratory distress syndrome (ARDS) treated with inhaled epoprostenol. CASE SUMMARY: Four patients admitted to our institution with confirmed H1N1 and refractory hypoxemia were treated with inhaled epoprostenol as potential salvage therapy. All patients were treated initially with antimicrobial agents, followed by oral oseltamivir at the time of suspicion or confirmation of H1N1. None of the patients received intravenous peramivir or extracorporeal membrane oxygenation. Clinically significant improvement in oxygenation was seen in only 1 of the patients receiving inhaled epoprostenol. Mortality was significant, with only 1 patient discharged from the hospital. DISCUSSION: Use of inhaled epoprostenol for the treatment of hypoxemia secondary to ARDS has been reported, with conflicting results. Deliveries via the inhalational route compared to the intravenous route theoretically preferentially vasodilate well-ventilated areas of the pulmonary vasculature, improving arterial oxygenation and pulmonary gas exchange. Increase in the ratio of arterial oxygen tension to fraction of inhaled oxygen is greatest upon initiation of inhaled epoprostenol, but this benefit has not been conclusively demonstrated to persist throughout therapy. Serious H1N1 presents a unique challenge for clinicians, often requiring the use of salvage therapies to treat critically ill patients. CONCLUSIONS: Given the variable response to treatment, it remains unclear whether inhaled epoprostenol is beneficial in H1N1-associated ARDS. Identification of patients for whom this therapy is most appropriate remains a clinical challenge.