Efficacy of Continuous Infusion Ketamine for Analgosedation in the Medical Intensive Care Unit: A Propensity-Weighted Analysis.

BACKGROUND: Few randomized controlled trials have evaluated the use of ketamine vs opiate-based analgosedation. METHODS: A retrospective cohort analysis of 169 mechanically ventilated patients admitted to the medical intensive care unit (MICU) at an academic medical center was conducted to evaluate efficacy of ketamine vs opiate-based analgosedation by comparing the percentage of time within target sedation range. The primary outcome was percentage of time within target sedation range (RASS -1 to +1) within first 72 hours of primary sedation initiation. Secondary outcomes including percentage of time under-sedated, over-sedated, and in coma; use of concomitant analgesic, sedative, and antipsychotic agents; presence of delirium; percentage of CPOT scores at goal; and hemodynamic effects were also evaluated. RESULTS: After weighting, the mean percentage of time at RASS goal for ketamine patients was 43.0% compared to 41.4% for opiate-based sedation patients. Ketamine was not significantly non-inferior to opiate-based sedation for the mean percentage of time at RASS goal (P = .11). The median percentage of CPOT scores at goal was 13.3% higher in the ketamine group (P = .042). Patients in the ketamine group received significantly less additional sedative agents than the patients in the opiate-based sedation group. CONCLUSION: A similar percent of time at RASS goal was found for the ketamine analgosedation group compared to the opiate-based sedation group, although this did not reach statistical signicance for non-inferiority due to lack of statistical power. This study found a higher percentage of CPOT scores within goal with less additional sedative agents required compared to an opiate-based sedation regimen.

Characterization of Medication Discrepancies and Interventions Resulting From Pharmacy-Led Medication Reconciliation in the Critical Care Setting.

BACKGROUND: Medication reconciliation has been shown to reduce medication-related errors in hospitalized patients, but the impact of pharmacy-led medication reconciliation in the intensive care unit (ICU) has not been extensively studied. METHODS: This was a retrospective chart review of patients with a pharmacy-led medication reconciliation on admission to an ICU between January 1st and March 31st, 2018. Pharmacy-led medication reconciliations were completed by pharmacists, pharmacy residents, and pharmacy students. The objective of this study was to describe medication discrepancies identified by pharmacy-led medication reconciliation and to evaluate the interventions following. RESULTS: A total of 288 patients were screened and 247 met inclusion criteria. There were 1148 medication discrepancies identified resulting in an average of 4.65 discrepancies per patient. Medication addition (54.25%) and medication deletion (45.75%) were most common. Within 24 hours of medication reconciliation, 214 interventions were made to active orders. No differences were observed between discrepancies identified and type of pharmacy staff completing the medication reconciliation. CONCLUSIONS: This study identified a high rate of medication discrepancies on admission to the ICU. Furthermore, it describes the types of pharmacist interventions following pharmacy-led medication reconciliation. This process may be impactful to incorporate as a standard practice in ICUs and warrants further investigation into value, cost, and pharmacist workflow.

Comparing Opioid Usage in Non-Intensive Care Unit Trauma Patients After Implementing Multimodal Analgesia Order Sets.

INTRODUCTION: Opioid addiction frequently occurs after exposure to prescribed pain medications. Trauma patients are likely to receive opioids due to injuries and surgeries resulting in high levels of pain. Multimodal analgesia has been shown to decrease opioid consumption postoperatively. A multimodal analgesia order set was implemented with the goal of increasing prescription of multimodal analgesia contributing to decreased overall opioid use. We hypothesized that the multimodal order set would be associated with significantly less opioid utilization without affecting pain scores. METHODS: This single-center retrospective cohort analysis included non-intensive care unit trauma patients. Patients were propensity-matched by the year of treatment. Oral morphine equivalents and pain scores were compared before and after implementation of the order set. The primary objective was to evaluate differences in oral morphine equivalents 24 h prior to discharge before and after implementation of the multimodal analgesia order sets. RESULTS: One hundred and fourteen patients in the preimplementation group and 121 patients in the postimplementation group met inclusion criteria. Oral morphine equivalents did not differ significantly between the cohorts, 21.3 [0-53.5] OME in 2018 versus 18.8 [0-56.3] in 2020 (P = 0.85). Pain scores 24 h prior to discharge, 6 [4-8] versus 5.7 [3.5-7] (P = 0.4), did not differ significantly between groups despite more operations in the 2020 cohort. CONCLUSIONS: Implementation of a multimodal order set was not associated with significant reduction in the amount of opioids used in non-intensive care unit trauma patients. However, pain scores were unchanged despite an increased number of procedures performed suggesting that multimodal analgesia sets may be a useful tool to aid in decreasing opioid utilization after traumatic injuries.

Antimicrobial Stewardship in the ICU.

Increasing rates of infection and multidrug-resistant pathogens, along with a high use of antimicrobial therapy, make the intensive care unit (ICU) an ideal setting for implementing and supporting antimicrobial stewardship efforts. Overuse of antimicrobial agents is common in the ICU, as practitioners are challenged daily with achieving early, appropriate empiric antimicrobial therapy to improve patient outcomes. While early antimicrobial stewardship programs focused on the financial implications of antimicrobial overuse, current goals of stewardship programs align closely with those of critical care providers-to optimize patient outcomes, reduce development of resistance, and minimize adverse outcomes associated with antibiotic overuse and misuse such as acute kidney injury and Clostridioides difficile-associated disease. Significant opportunities exist in the ICU for critical care clinicians to support stewardship practices at the bedside, including thoughtful and restrained initiation of antimicrobial therapy, use of biomarkers in addition to rapid diagnostics, Staphylococcus aureus screening, and traditional microbiologic culture and susceptibilities to guide antibiotic de-escalation, and use of the shortest duration of therapy that is clinically appropriate. Integration of critical care practitioners into the initiatives of antimicrobial stewardship programs is key to their success. This review summarizes key components of antimicrobial stewardship programs and mechanisms for critical care practitioners to share the responsibility for antimicrobial stewardship.

Combating the Opioid Epidemic in Acute General Surgery: Reframing Inpatient Acute Pain Management.

BACKGROUND: The devastating effects of the opioid epidemic are well documented. We implemented a surgeon/pharmacist opioid reduction initiative at an academic medical center that incorporated multimodal pain therapy in an attempt to reduce total inpatient opioids prescribed. We hypothesized that less opioids would be used postoperatively without affecting pain scores or length of stay. METHODS: This single-center observational cohort analysis included patients admitted to the acute general surgical service and had one of 10 emergent general surgical (nontrauma) procedures. Patients who underwent surgery before the opioid reduction initiative were compared with patients who underwent surgery postinitiative. The primary objective was to evaluate differences in daily oral morphine equivalents and average pain scores in patients before and after implementation of the surgeon/pharmacist initiative. RESULTS: Eighty-three patients in the preopioid reduction initiative group and 92 patients in the postopioid reduction initiative group met inclusion criteria. Oral morphine equivalents were significantly different at 24 h before discharge when comparing across both year (P = 0.032) and number of procedures (P = 0.013). Our results showed decreased opioid utilization in the postopioid reduction initiative group on all observed postoperative days with unaffected pain scores. CONCLUSIONS: An opioid reduction initiative showed promise in lowering the number of opioids used during inpatient admission without affecting pain scores in emergent general surgical procedures. This initiative can be easily reproduced at other institutions to help combat the opioid epidemic.

Aspirin rechallenge in an adult patient previously diagnosed with Reye syndrome.

PURPOSE: Aspirin has been the cornerstone of antiplatelet therapy in patients with acute coronary syndromes and is well accepted and recommended by several major healthcare organizations. A combination of aspirin and a P2Y12 inhibitor, commonly known as dual antiplatelet therapy, is recommended in patients with coronary stent implantation to reduce the risk of stent thrombosis and ischemic events. SUMMARY: We recently cared for an adult male who presented with an acute coronary syndrome who had a history of Reye syndrome during childhood. During this admission, he was rechallenged with low-dose aspirin for the first time since his diagnosis of Reye syndrome as a child after aspirin therapy. There have been various case reports in children and adults who have been rechallenged with aspirin within days to weeks after the initial diagnosis of Reye syndrome. These reports show mixed results in children and adults regarding the return of Reye syndrome upon aspirin rechallenge shortly after initial aspirin exposure. CONCLUSION: This, to our knowledge, appears to be the first report of a low-dose aspirin rechallenge 30 years later in life in an adult patient with a history of Reye syndrome while receiving aspirin therapy during childhood.

Restructuring a Pharmacy Department: Leadership Strategies for Managing Organizational Change.

Background: The Director's Forum series is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health-systems. This article focuses on leadership strategies for managing organizational change within a pharmacy department. Objective: The goals of this article are to describe the foundations of pharmacy organizational structure changes and strategies to efficiently and effectively manage the associated change. Methods: This article will aim to (1) describe the organizational structure change process, (2) list known rules to follow when redesigning an organizational structure, (3) briefly describe the organizational change at the Ohio State Wexner Medical Center, and (4) describe leadership strategies to overcome potential challenges of organizational changes. Conclusion: The strategies discussed in this article and proposed sample template for organizational change process may be used by a pharmacy department in an effort to restructure their department.