Characterization of Psychotropic PRN Medications in a Canadian Psychiatric Intensive Care Unit.

BACKGROUND: Pro re nata (PRN) antipsychotics and benzodiazepines are routinely used for the rapid stabilization of acutely agitated patients. Despite the popular use of PRN medications in mental health units, primary literature supporting efficacy and safety is poor, and there is no single universally accepted practice guideline. PRN psychotropic medications have the potential to cause adverse effects when used inappropriately. AIMS: Our objective was to characterize the prescribing, administration, and documentation practices of PRN psychotropic medications in a psychiatric intensive care unit. METHODS: We conducted a retrospective chart review of patients admitted to a 12-bed psychiatric intensive care unit between June and September 2018. All PRN antipsychotic and benzodiazepine orders, administrations, documentation practices, and attempted nonpharmacological strategies were assessed for each order and patient. Descriptive statistics were used to analyze data. RESULTS: Thirty-two patients with a total of 123 physicians' orders and 1,179 PRN administrations of antipsychotics and benzodiazepines were reviewed. Of the total administrations, 720 (61%) were combinations with at least two psychotropic agents. Forty-one (33%) physicians' orders had a prescribed indication, and 559 (47%) administrations had an attempted nonpharmacological method prior to PRN administration. Eight patients (25%) had antipsychotic PRN orders, which exceeded the total daily maximum dose. Three adverse drug effects were attributed to PRN administration. CONCLUSIONS: Areas of improvement that we identified included documentation practices of effectiveness of administered PRNs, prescriptions to include clear indications and dosage within the 24-hour maximum limits, and documentation of nonpharmacological methods utilized.

Canadian Hospital Pharmacists' Perceptions of Workplace Preparedness and Personal Well-Being during the COVID-19 Pandemic.

Background: Little is known about hospital pharmacists' experiences during the COVID-19 pandemic, as studies to date have focused on community pharmacy practices. Objectives: To determine hospital pharmacists' perceptions of their workplace preparedness for the COVID-19 pandemic and to measure their mental well-being with the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Methods: Pharmacists working in Canadian hospital inpatient settings during the COVID-19 pandemic were invited to participate in a 2-part online survey. Part A was a 46-item survey containing statements related to directions and support from leadership, personal protective equipment practices, work environment, and emotions. Part B assessed respondents' mental well-being using the validated 14-item WEMWBS. Responses to both parts of the survey were based on Likert scales. The survey was open from July to September 2020. Descriptive analyses were applied. Results: A total of 432 hospital pharmacists consented to participate in the study. Most respondents were women (337/432, 78%), and most were 25 to 44 years old (293/432, 68%). Most respondents were confident that their workplace and pharmacy department were effectively managing patient demand (314/389, 81%) and the pandemic more generally (263/394, 67%). They also felt that their workplace teams were working well together (314/386, 81%). Interestingly, 22% (86/391) of the respondents did not agree that they had received training for COVID-19 infection prevention and control practices. The mean WEMWBS score was 48.9 (standard deviation 8.6), which indicated average mental well-being. Conclusions: After the initial wave of the COVID-19 pandemic, respondents perceived their hospitals and departments as being able to manage the pandemic and reported average mental well-being. Ensuring that all hospital pharmacists receive training for effective COVID-19 infection prevention and control practices is crucial. How their perceptions and well-being have changed since the time of the survey is unknown.

Contexte: On sait peu de choses sur les expériences des pharmaciens d'hôpitaux pendant la pandémie de COVID-19, car les études à ce jour se sont concentrées sur les pratiques de la pharmacie communautaire. Objectifs: Cerner les perceptions des pharmaciens d'hôpitaux quant à la préparation de leur lieu de travail à la pandémie de COVID-19 et mesurer leur bien-être mental à l'aide de l'échelle de bien-être mental Warwick-Edinburgh (WEMWBS). Méthodes: Les pharmaciens qui travaillaient en milieu hospitalier canadien pendant la pandémie de COVID-19 ont été invités à participer à un sondage en ligne en deux volets. Le volet A consistait en une enquête portant sur 46 éléments contenant des déclarations liées aux orientations et au soutien de la direction, aux pratiques en matière d'équipement de protection individuelle, à l'environnement de travail et aux émotions. Le volet B a quant à lui permis d'évaluer le bien-être mental des répondants à l'aide de l'échelle WEMWBS validée à 14 points. Les réponses aux deux volets de l'enquête se basaient sur des échelles de Likert. Le sondage était ouvert de juillet à septembre 2020. Des analyses descriptives ont été appliquées. Résultats: Au total, 432 pharmaciens d'hôpitaux ont accepté de participer à l'étude. La plupart des répondants étaient des femmes (337/432, 78 %), et la plupart avaient entre 25 et 44 ans (293/432, 68 %). La plupart des répondants étaient convaincus que leur lieu de travail et leur service de pharmacie géraient efficacement la demande des patients (314/389, 81 %) et la pandémie en général (263/394, 67 %). Ils ont aussi estimé que leurs équipes de travail travaillaient bien ensemble (314/386, 81 %). Fait intéressant : 22 % des répondants (86/391) convenaient ne pas avoir reçu de formation sur les pratiques de prévention et de contrôle des infections à la COVID-19. Le score moyen sur l'échelle WEMWBS était de 48,9 (écart type 8,6), ce qui indique un bien-être mental moyen. Conclusions: Après la première vague de la pandémie de COVID-19, les répondants ont perçu leurs hôpitaux et leurs services comme étant capables de gérer la pandémie et ont déclaré un bien-être mental moyen. Veiller à ce que tous les pharmaciens d'hôpitaux reçoivent une formation sur les pratiques efficaces de prévention et de contrôle des infections à la COVID-19 est crucial. On ne sait pas comment leurs perceptions et leur bien-être ont changé depuis le moment de l'enquête.

Management of delirium in a medical and surgical intensive care unit.

WHAT IS KNOWN AND OBJECTIVE: Delirium has been associated with increased mortality and prolonged hospital length of stay among critical care patients. Furthermore, treatment of delirium remains variable amongst clinicians due to limited evidence. The objective of this study was to determine the local incidence of delirium and to characterize the effectiveness and safety of pharmacological therapy used to treat delirium. METHODS: A retrospective chart review evaluated patients diagnosed with delirium (Intensive Care Delirium Screening Checklist score ≥4) and requiring mechanical ventilation for ≥48 hours from January 2016 to June 2017. The primary outcomes included comparison of resolution, the time to first resolution and recurrence of delirium in patients prescribed pharmacological and/or pre-emptive therapy versus those who did not. Secondary outcomes included incidence of adverse effects of drug therapy and delirium attributable adverse events. RESULTS AND DISCUSSION: The incidence of delirium during our defined study period was 49%. Of the 178 patients included in the study, 136 (76%) received drug therapy for delirium. Agents used for treatment of delirium included dexmedetomidine (n = 90 [66%]), haloperidol (n = 77 [57%]), and quetiapine (n = 74 [54%]). Resolution of delirium occurred in 94 (52%) of patients and the difference was statistically significant favoring patients who did not receive pharmacological therapy. There was no difference in the median time to resolution of delirium (3 days) for patients who received pharmacological and/or pre-emptive therapy versus those who did not. Bradycardia and hypotension were the most frequently documented medication-related adverse events. Self-removal of an invasive line/catheter, was reported in 36 (26%) patients despite receiving pharmacological treatment. WHAT IS NEW AND CONCLUSION: Despite unclear evidence that pharmacological interventions help with delirium management, the majority of our patients received such interventions. To improve patient outcomes, we should shift focus towards non-pharmacological interventions for delirium.

Vasopressin for Septic Shock in a Medical-Surgical Intensive Care Unit.

BACKGROUND: Critically ill patients often need vasopressors to treat hypotension related to septic shock and to maintain adequate systemic perfusion. Although the 2017 guidelines of the Surviving Sepsis Campaign recommend norepinephrine as first-line therapy, they also state that vasopressin may be considered as an adjunctive agent for patients with refractory shock. Limited evidence is available for directing optimal administration of vasopressin. As such, prescribing practices are not standardized and may vary according to the particular clinician, the clinical scenario, and various patient-specific factors. OBJECTIVES: To review the current practice of administering concomitant norepinephrine and vasopressin therapy to patients with septic shock, to describe variability in vasopressin administration, and to evaluate effects on patient safety in a medical-surgical intensive care unit (ICU). METHODS: This single-centre retrospective chart review involved 100 adult patients admitted to the ICU who received vasopressin and norepinephrine for septic shock between April and December 2017. The data were analyzed with descriptive statistics. RESULTS: The mean time to initiation of vasopressin was 12.0 (standard deviation [SD] 21.6) h after initiation of norepinephrine. The mean dose of norepinephrine at the time of vasopressin initiation was 29.5 (SD 19.7) µg/min. The mean vasopressin dose prescribed was 0.04 (SD 0.03) units/min, with a range of tapering and discontinuation regimens. The mean duration of vasopressin therapy was 49.1 (SD 65.2) h, and vasopressin was discontinued before norepinephrine in 49 of the patients. A total of 60 hypotensive events occurred after vasopressor discontinuation and were more common when vasopressin was discontinued before norepinephrine. CONCLUSIONS: Vasopressin dosing was comparable to that reported elsewhere; however, discontinuation practices were inconsistent. These results show that variability in the literature supporting vasopressin use has led to variability in vasopressin administration and discontinuation practices; however, correlation with improvement in clinical outcomes, such as mortality or ICU length of stay, is unclear, and further research is required to determine the ideal approach to vasopressin use.

CONTEXTE: Les patients gravement malades nécessitent souvent un vasopresseur pour traiter l'hypotension liée au choc septique et pour préserver une perfusion systémique adéquate. Bien que les directives de 2017 de la campagne Surviving Sepsis recommandent la norépinephrine en guise de thérapie de première ligne, elles précisent également que la vasopressine pourrait être envisagée comme agent d'appoint pour les patients présentant des chocs réfractaires. Seules des données probantes limitées soutiennent l'administration optimale de la vasopressine. Les pratiques de prescription proprement dites ne sont pas standardisées et peuvent varier selon le clinicien, le scénario clinique et les divers facteurs particuliers au patient. OBJECTIFS: Examiner la pratique actuelle d'administration de la norépinephrine concomitante à la thérapie de vasopressine aux patients ayant subi un choc septique, décrire la variabilité d'administration de la vasopressine et évaluer les effets sur la sécurité du patient dans une unité de soins intensifs (USI) médicale-chirurgicale. MÉTHODES: Cet examen rétrospectif unicentrique des dossiers portait sur 100 patients adultes admis dans une USI, ayant reçu de la vasopressine et de la norépinephrine en réponse à des chocs septiques entre avril et décembre 2017. Les données ont été analysées à l'aide de statistiques descriptives. RÉSULTATS: Le temps moyen du début de l'administration de la vasopressine était de 12 h (écart type [É.T.] 21,6) après le début de l'administration de la norépinephrine. La dose moyenne de norépinephrine au moment du début de l'administration de la vasopressine était de 29,5 (É.T. 19,7) µg/min. La dose moyenne de vasopressine prescrite était de 0,04 (É.T. 0,03) unités/min, avec une gamme de posologies dégressives et d'abandons. La durée moyenne de la thérapie à la vasopressine était de 49,1 h (É.T. 65,2), et 49 patients ont abandonné la vasopressine avant l'abandon de la norépinephrine. Un total de 60 événements hypotenseurs se sont produits après l'abandon du vasopresseur et ils étaient plus fréquents lors de l'abandon de la vasopressine précédant celui de la norépinephrine. CONCLUSIONS: Le dosage de vasopressine était comparable à celui indiqué dans d'autres études; cependant, les pratiques d'abandon étaient incohérentes. Ces résultats démontrent que l'indétermination de l'information publiée dans la littérature soutenant l'utilisation de la vasopressine a entraîné une fluctuation dans l'administration de la vasopressine et des pratiques d'abandon; cependant, la corrélation entre l'usage de la vasopressine et l'amélioration des résultats cliniques, comme la mortalité ou la durée du séjour en USI, n'est pas claire, et davantage de recherches sont nécessaires pour déterminer l'approche idéale à adopter à l'égard de l'utilisation de la vasopressine.

Predictive Validity of a QTc Interval Prolongation Risk Score in the Intensive Care Unit.

BACKGROUND: Torsade de pointes is a form of polymorphic ventricular tachycardia associated with heart rate-corrected QT (QTc ) interval prolongation. With approximately 24-61% of critically ill patients experiencing QTc interval prolongation, a predictive tool to identify high-risk patients could assist in the monitoring and management in the intensive care unit (ICU). The Tisdale et al. Risk Score (TRS) is a predictive tool that was developed and validated in a cardiac critical care unit. OBJECTIVES: The objective of this study was to evaluate the predictive validity (sensitivity and specificity) and likelihood ratios of the TRS in a medical ICU. METHODS: This was a longitudinal, retrospective, cohort study of consecutive patients who met the inclusion criteria from October 2017 to June 2018 with a sample size of 264 patients. The sample size was derived based on the number of TRS covariates and an exploratory variable. Baseline characteristics and risk factors were documented from electronic health records. The first occurrence of QTc interval prolongation, defined as a QTc interval > 500 ms or an increase ≥ 60 ms above baseline, was the primary endpoint. MAIN RESULTS: The sensitivity and specificity of the TRS for low-risk patients against the moderate-risk and high-risk patients were 97% (95% CI 91-99%) and 16% (95% CI 11-23%), respectively. These results corresponded to a positive likelihood ratio of 1.15 (95% CI 1.07-1.24) and a negative likelihood ratio of 0.20 (95% CI 0.06-0.65). CONCLUSIONS: In conclusion, the TRS showed a high sensitivity, making it useful in identifying patients at risk of developing QTc interval prolongation. Furthermore, patients categorized as low risk by the tool can be considered as having minimal risk of developing QTc interval prolongation. Given the tool's low specificity, it does not reliably identify all patients at low risk of QTc interval prolongation.

Stress Ulcer Prophylaxis in Critically Ill Children: A Multicenter Observational Study.

OBJECTIVE: To describe current stress ulcer prophylaxis practice in Canadian PICUs. DESIGN: Multicenter cohort study. We defined stress ulcer prophylaxis as the use of a proton-pump inhibitor, histamine-2 receptor antagonist, or sucralfate within the first 2 PICU days among children who had not been on these medications at home and had no evidence of gastrointestinal bleeding. SETTING: Seven PICUs in Canada. PATIENTS: Three hundred seventy-eight children requiring mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Children were ventilated for a median (interquartile range) of 2 days (1-6 d) and stayed in the PICU for a median (interquartile range) of 4 days (2-10 d). The median (interquartile range) age was 1.3 years (0.3-6.7 yr). Seventy percent of all children received acid suppression during their PICU stay. One hundred sixty-seven (54%) of the 309 children eligible for stress ulcer prophylaxis received it. Histamine-2 receptor antagonists were the most frequently used class (66%), followed by proton-pump inhibitors (47%) and sucralfate (4%), and 20% received more than one class. Stress ulcer prophylaxis was continued on the PICU transfer orders for 34% of these children. Children who received prophylaxis were older and had a higher Pediatric Risk of Mortality III score, more often received nonsteroidal anti-inflammatory drugs and systemic corticosteroids and received less enteral nutrition. In multivariate analysis, age and invasive mechanical ventilation were independently associated with an increased likelihood of receiving stress ulcer prophylaxis and receiving feeds was independently associated with a decreased likelihood of receiving stress ulcer prophylaxis. Gastrointestinal bleeding was reported in 21 (6%) of 378 children; three (0.8%) were clinically important. Eighteen percent were treated for a new respiratory tract infection, and 1% developed Clostridium difficile-associated diarrhea. CONCLUSIONS: Stress ulcer prophylaxis is common in Canadian PICUs. Clinically important gastrointestinal bleeding and C. difficile-associated diarrhea are rare, and the utility of routine prophylaxis should be examined.

Use of methadone for prevention of opioid withdrawal in critically ill children.

BACKGROUND: Opioids are commonly administered to critically ill children for analgesia and sedation, but many patients experience opioid withdrawal upon discontinuation. The authors' institution developed a protocol for using methadone to prevent opioid withdrawal in children who have received morphine by continuous IV infusion for 5 days or longer in the pediatric intensive care unit (PICU). OBJECTIVES: The primary objectives were to determine if opioids were tapered according to the protocol and to determine the conversion ratio for IV morphine to oral methadone that was used. Secondary objectives were to describe the methadone dosage used and the clinical outcomes, to evaluate adjustments to methadone dosing, and to report the incidence of adverse effects. METHODS: A retrospective analysis of charts was conducted for pediatric patients who had received morphine by continuous IV infusion for 5 days or longer followed by methadone in the PICU between May 2008 and August 2009. Validated scoring systems (the Withdrawal Assessment Tool and the State Behavioral Scale) were used to assess symptoms of withdrawal and degree of sedation, respectively. RESULTS: Forty-three patients were included in the study, with median age of 8 months (range 0.25-201 months). For 31 patients (72%), the protocol was not used, and there were no patients for whom the protocol was followed to completion. The median duration of weaning was 10 days (range 0-91 days). The conversion ratio for IV morphine to oral methadone was 1:0.78 for anticipated 5-day weaning and 1:0.98 for anticipated 10-day weaning. During the first 10 days of weaning, 18 patients (42%) experienced withdrawal symptoms. The methadone dose was increased for 11 (26%) of the 43 patients. Patients were sedated for a median of 1 day (range 0-9 days), were comfortable for a median of 6.5 days (range 1-64 days), and were agitated for a median of 2.5 days (range 0-23 days). Naloxone was required for 2 patients. CONCLUSIONS: The institution's methadone protocol was not followed consistently during the study period, and practices for transitioning from morphine by continuous IV infusion to methadone with tapering were also inconsistent. Further studies are needed to determine the optimal conversion ratio for morphine to methadone and the optimal tapering regimen to minimize withdrawal symptoms and adverse events.

Drug-resistant tuberculosis: pediatric guidelines.

Drug-resistant Mycobacterium tuberculosis (TB) infection represents a serious and growing problem. For patients infected or suspected of being infected with multidrug or extensively drug-resistant TB, several medications have to be given simultaneously for prolonged periods. Here, we review the literature on treatment and monitoring of adverse effects of pediatric drug-resistant TB therapy in a high resource, low TB burden setting.

Describing Intravenous Extravasation in Children (DIVE Study).

BACKGROUND: Extravasation, the inadvertent leakage of intravenous (IV) medication from the vein into the surrounding tissue, is a iatrogenic cause of patient injury. Extravasation has been reported to occur in 0.1% to 6.5% of hospital inpatients. The incidence may be higher among children because they have multiple risk factors, including small and fragile veins, decreased peripheral circulation, capillary leakage, and flexible subcutaneous tissue. OBJECTIVES: To describe the incidence of extravasation at a pediatric tertiary care hospital, to identify the agents causing extravasation, and to describe the use of antidotes to manage identified cases. A secondary objective was to describe adverse drug effects associated with the antidotes administered. METHODS: The medical records of pediatric patients with documented extravasation of an IV medication between January 1, 2006, and August 31, 2008, were analyzed retrospectively. The appropriateness of antidote use was determined in terms of adherence to the institution's protocol for treatment of extravasation. RESULTS: A total of 42 patients had documented extravasation, for an overall incidence of 0.04% per patient-day. Of the 40 cases in which location was documented, 12 (30%) occurred on the general pediatric wards, 10 (25%) on the surgical ward, 9 (22%) in the neonatal intensive care unit, 5 (12%) in the pediatric intensive care unit, 3 (8%) in day care, and 1 (2%) in the emergency department. The most common medications involved were fluids for IV administration (18 [43%]), potassium chloride (11 [26%]), antibiotics (8 [19%]), total parenteral nutrition (8 [19%]), calcium chloride (2 [5%]), and epinephrine (2 [5%]). Multiple drugs were involved in some cases of extravasation. The decision to administer an antidote and the choice of antidote (if required) were appropriate in 50% of the cases. No adverse drug effects were reported with use of antidotes. CONCLUSIONS: The incidence of extravasation was low. The medications most commonly involved were similar to those reported in the literature. Antidotes were well tolerated but were appropriately used in only half of the events. Prospective trials are needed to determine the clinical severity of injury and to assess the effectiveness and safety of antidotes.

Survey of graduates of the british columbia pharmacy practice residency programs, 1973-2009.

BACKGROUND: The Canadian Hospital Pharmacy Residency Board (CHPRB) first introduced accreditation standards to guide the development and maintenance of pharmacy residency programs in the 1970s. These standards have evolved over the years, including a comprehensive revision in 1998. Ongoing quality assessment of residency training is necessary to identify areas for improvement and to ensure that residency training keeps pace with continual changes in pharmacists' roles. OBJECTIVE: To characterize the practices of graduates of the British Columbia Pharmacy Practice Residency Programs (BCPPRPs), to review the effect of residency training on their careers, and to assess whether the BCPPRPs achieved their educational goals with respect to the 2010 CHPRB accreditation standards. METHODS: An 18-question electronic survey was sent by e-mail to all graduates of the BCPPRPs from inception in 1973 to 2009. Both quantitative and qualitative data were collected, so descriptive, narrative, and formal mixed-methods approaches were used for the analysis. RESULTS: Of the estimated 490 graduates, 144 (29%) completed the survey. About 95% of respondents (125 of 131) agreed that the BCPPRPs had adequately prepared them for a career in hospital pharmacy practice. A majority strongly or somewhat agreed that their respective programs had allowed them to aquire all core competencies. There was less agreement about the achievement of project management and leadership skills. Analysis of these results by eras (specifically, before and after the 1998 revision of the CHPRB accreditation standards) showed statistically significant improvements in achievement for 2 of the educational outcomes, "providing evidence-based direct patient care as a member of an inter-professional team" (p = 0.001) and "adequate training in literature appraisal" (p = 0.005). CONCLUSIONS: A majority of respondents recognized that their residency program had a substantial impact on their hospital pharmacy careers, especially in terms of developing direct patient care skills. The 2010 standards have introduced a specific outcome related to leadership skills. These results indicate that both the CHPRB and specific residency programs would benefit from discussions clarifying outcomes related to project management skills.