Clinical Practice Guideline: Safe Medication Use in the ICU.

OBJECTIVE: To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION: Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION: Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS: The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS: This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

Comparison of clinical outcomes in nonintubated patients with severe alcohol withdrawal syndrome treated with continuous-infusion sedatives: dexmedetomidine versus benzodiazepines.

STUDY OBJECTIVE: To compare efficacy and safety outcomes in nonintubated patients with severe alcohol withdrawal syndrome (AWS) who required a continuous infusion of a benzodiazepine or dexmedetomidine in addition to standard medical therapy for AWS. DESIGN: Retrospective cohort study. SETTING: Two hospitals within the same network that used different treatment strategies for AWS. PATIENTS: A total of 61 nonintubated adults who received a continuous infusion of either a benzodiazepine (BZD) (lorazepam or midazolam; 33 patients) or dexmedetomidine (DEX) (28 patients) for severe AWS between April 1, 2011, and October 31, 2012, as well as standard medical therapy for AWS. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite end point including rates of respiratory distress requiring endotracheal intubation or occurrence of alcohol withdrawal seizures. No significant differences in the composite end point were noted between the BZD and DEX groups (9.1% and 7.1%, respectively, p>0.99) or its individual components of respiratory distress (9.1% and 7.1%, respectively, p>0.99) or alcohol withdrawal seizures (0% and 3.6%, respectively, p=0.46). The DEX group received a lower median total dose of lorazepam equivalents after initiation of the study drug (median [interquartile range] 105 [60-199.5] mg in the BZD group vs 3.5 [0-12] mg in the DEX group), but this did not translate into a reduced requirement for endotracheal intubation or decreased length of stay. DEX was associated with more adverse drug events including hypotension and bradycardia. Of concern, DEX may impair the ability to assess symptoms appropriately and administer BZDs in a symptom-triggered fashion. Although the total cost of hospitalization was similar between groups, DEX was associated with a higher study drug cost per patient. CONCLUSION: DEX demonstrated a BZD-sparing effect in the treatment of AWS; however, this surrogate end point should be interpreted with caution. Although this study cannot disprove the possibility of a protective effect of DEX in preventing the requirement for endotracheal intubation in patients with AWS, an increased rate of adverse drug events and increased study drug costs were observed. If DEX is used in clinical practice, it should only be used as adjunctive therapy with BZDs that have a proven benefit in AWS.