An International, Multicenter Evaluation of Comprehensive Medication Management by Pharmacists in ICU Recovery Centers.

BACKGROUND: Post-intensive care syndrome (PICS) is defined as a new or worsening impairment in physical, cognitive, or mental health following critical illness. Intensive care unit recovery centers (ICU-RC) are one means to treat patients who have PICS. The purpose of this study is to describe the role of pharmacists in ICU-RCs. RESEARCH QUESTION: What is the number and type of medication interventions made by a pharmacist at an ICU-RC at 12 different centers? STUDY DESIGN AND METHODS: This prospective, observational study was conducted in 12 intensive care units (ICUs)/ICU-RCs between September 2019 and July 2021. A full medication review was conducted by a pharmacist on patients seen at the ICU-RC. RESULTS: 507 patients were referred to the ICU-RC. Of these patients, 474 attended the ICU-RC and 472 had a full medication review performed by a pharmacist. Baseline demographic and hospital course data were obtained from the electronic health record and at the ICU-RC appointment. Pharmacy interventions were made in 397 (84%) patients. The median number of pharmacy interventions per patient was 2 (interquartile range [IQR] = 1,3). Medications were stopped and started in 124 (26%) and 91 (19%) patients, respectively. The number of patients that had a dose decreased and a dose increased was 51 (11%) and 43 (9%), respectively. There was no difference in the median total number of medications that the patient was prescribed at the start and end of the patient visit (10, IQR = 5, 15). Adverse drug event (ADE) preventive measures were implemented in 115 (24%) patients. ADE events were identified in 69 (15%) patients. Medication interactions were identified in 30 (6%) patients. INTERPRETATION: A pharmacist plays an integral role in an ICU-RC resulting in the identification, prevention, and treatment of medication-related problems. This paper should serve as a call to action on the importance of the inclusion of a pharmacist in ICU-RC clinics.

An international, multicenter post hoc analysis comparing in-person and virtual medication management strategies in post-ICU recovery clinics.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: To compare the incidence of ICU pharmacist interventions in intensive care unit recovery center (ICU-RC) in-person and virtual clinic visits. METHODS: This was a post hoc analysis of interventions implemented by ICU pharmacists among adult patients who were referred to 12 ICU-RCs across the United States and the United Kingdom between September 2019 and July 2021, as reported in a previously published study "An International, Multicenter Evaluation of Comprehensive Medication Management by Pharmacists in ICU Recovery Centers." That study included patients who received a comprehensive medication review by an ICU pharmacist. Medication-related interventions performed by an ICU pharmacist during ICU-RC in-person clinic visits were compared to those performed during virtual clinic visits. RESULTS: There were 507 patients referred to an ICU-RC, of whom 474 patients attended a clinic visit. Of those, 472 received a comprehensive medication review, with 313 patients attending in-person visits and 159 patients attending virtual visits. The incidence of medication-related interventions implemented was higher in the ICU-RC in-person clinic group compared to the virtual clinic group (86.5% vs 79.2%, P = 0.04). There was no difference in the median number of ICU pharmacist interventions per patient between the in-person and virtual clinic groups (2 vs 2, P = 0.13). An ICU admission diagnosis was an independent predictor of medication-related interventions among all patients. CONCLUSION: The incidence of ICU pharmacist interventions was higher at ICU-RC in-person clinic visits compared to virtual clinic visits. Pharmacists aid in meeting the complex pharmacologic challenges of post-intensive care syndrome in both settings.

Interaction between levodopa and enteral nutrition.

OBJECTIVE: To report and discuss a drug-nutrient interaction involving levodopa and protein in enteral nutrition. CASE SUMMARY: A 77-year-old male with Parkinson's disease was admitted to an intensive care unit for an intracerebral hemorrhage. To provide nutritional support, an oral gastric tube was placed and continuous enteral nutrition was initiated, with 1.4 g/kg of protein administered daily. The following medications were continued during hospitalization: immediate-release carbidopa/levodopa 25 mg/100 mg, with 1.5 tablets administered 4 times daily; pramipexole 1.5 mg 3 times daily; and entacapone 200 mg 4 times daily. Despite this drug therapy, the patient developed severe rigidity. A review of the literature revealed a potential interaction between levodopa and protein intake. To resolve this interaction, the amount of protein in the enteral nutrition was decreased to 0.9 g/kg/day and the nutritional administration was changed from continuous enteral feeding to bolus feeding, with levodopa given between boluses. After these adjustments, the patient showed marked improvement of parkinsonian symptoms. DISCUSSION: The drug-nutrient interaction between protein and levodopa in outpatient settings has been reported widely in the literature; however, this interaction has not been previously reported with continuous enteral nutrition. Decreased parkinsonian symptom control, despite adherence to an established medication regimen, together with dramatic improvement observed after manipulation of enteral nutrition delivery and content, strongly suggest interference with levodopa absorption. Use of the Naranjo probability scale supports a probable interaction between the protein content in tube feeds and levodopa, resulting in decreased levodopa efficacy. CONCLUSIONS: Clinicians should be cognizant of the potential drug-nutrient interaction between levodopa and enteral nutrition.

Clinical and economic impact of substituting dexmedetomidine for propofol due to a US drug shortage: examination of coronary artery bypass graft patients at an urban medical centre.

BACKGROUND: Propofol has reduced healthcare costs in coronary artery bypass graft (CABG) surgery patients by decreasing post-operative duration of mechanical ventilation. However, the US shortage of propofol necessitated the use of alternative agents. OBJECTIVE: This study sought to evaluate clinical and economic implications of substituting dexmedetomidine for propofol in patients undergoing CABG surgery. METHODS: This was a retrospective cohort study. Patients undergoing isolated, elective CABG surgery and sedated with either propofol or dexmedetomidine during the study period were included. The cohorts were matched 1:1 based on important characteristics. The primary outcome was the number of patients achieving a post-operative duration of mechanical ventilation ≤6 h. Secondary outcomes were post-operative intensive care unit (ICU) length of stay (LOS) ≤48 h, total post-operative LOS ≤5 days, the need for adjunctive opioid therapy and associated cost savings. Variables recorded included patient demographics, co-morbid medical conditions, health risks, sedation drug doses, post-operative medical complications and sedation-related adverse events. Univariate and multivariate analyses were completed to examine the relationship between these covariates and post-operative LOS. The cost analysis consisted of examination of the net financial benefit (or cost) of choosing dexmedetomidine versus propofol in the study population, with utilisation observed in the study converted to costs using institutional data from the Premier database. RESULTS: Eighty-four patients were included, with 42 patients per cohort. Mechanical ventilation duration ≤6 h was achieved in 24 (57.1 %) versus 7 (16.7 %) in the dexmedetomidine and propofol cohorts, respectively (p < 0.001). More patients treated with dexmedetomidine achieved ICU LOS ≤48 h (p < 0.05) and total hospital LOS ≤5 days (p < 0.05), as compared with the propofol group. Multivariate analysis revealed that having one or more post-operative medical complication was the most significant predictor of increased post-operative LOS, whereas choosing dexmedetomidine was also significant in terms of reduced post-operative LOS. The estimated net financial benefit of choosing dexmedetomidine versus propofol was US$2,613 per patient (year 2012 value). CONCLUSIONS: Findings suggest that use of dexmedetomidine as an alternative to propofol for sedation of CABG patients post-operatively contributes to reduced mechanical ventilation time, ICU LOS and post-operative LOS. Higher drug costs resulting from the propofol shortage were offset by savings in post-operative room and board costs. Additional savings may be possible by preventing medical complications to the extent possible.