A pharmacist's guide to mitigating sleep dysfunction and promoting good sleep in the intensive care unit.

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 review causes, risk factors, and consequences of sleep disruption in critically ill patients; evaluate the role of nonpharmacological and pharmacological therapies for management of sleep in the intensive care unit (ICU); and discuss the role of pharmacists in implementation of sleep bundles. SUMMARY: Critically ill patients often have disrupted sleep and circadian rhythm alterations that cause anxiety, stress, and traumatic memories. This can be caused by factors such as critical illness, environmental factors, mechanical ventilation, and medications. Methods to evaluate sleep, including polysomnography and questionnaires, have limitations that should be considered. Multicomponent sleep bundles with a focus on nonpharmacological therapy aiming to reduce nocturnal noise, light, and unnecessary patient care may improve sleep disorders in critically ill patients. While pharmacological agents are often used to facilitate sleep in critically ill patients, evidence supporting their use is often of low quality, which limits use to patients who have sleep disruption refractory to nonpharmacological therapy. Dedicated interprofessional teams are needed for implementation of sleep bundles in the ICU. Extensive pharmacotherapeutic training and participation in daily patient care rounds make pharmacists vital members of the team who can help with all components of the bundle. This narrative review discusses evidence for elements of the multicomponent sleep bundle and provides guidance on how pharmacists can help with implementation of nonpharmacological therapies and management of neuroactive medications to facilitate sleep. CONCLUSION: Sleep bundles are necessary for patients in the ICU, and dedicated interprofessional teams that include pharmacists are vital for their successful creation and implementation.

Development and implementation of an in-hospital pharmacist emergency response simulation training curriculum.

BACKGROUND: Medical simulation is an effective educational tool used to increase confidence, improve knowledge, and refine skills when responding to high-acuity situations. Despite established roles of the pharmacist on the hospital code team, most institutions lack formalized pharmacist training for code team responses. OBJECTIVE: This pre-post analysis aimed to evaluate the impact of a didactic and simulation-based code response training for pharmacists on self-perceived improvement and preparedness when responding to in-hospital medical emergencies. METHODS: An emergency response curriculum (ERC) was developed for pharmacists and pharmacy residents at our institution. The curriculum, led by 4 lead clinical pharmacy specialists, included a 60-minute didactic code competency lecture followed by 2 medical emergency simulations and a debrief after each scenario. After completion of the simulation portion of the ERC, participants were given a survey to complete that assessed their confidence using a 5-point Likert scale (1 = very unconfident to 5 = very confident) in completing the course objectives before and after the ERC. RESULTS: Seventy-two pharmacists completed the ERC and 60 completed the postcourse survey. Of those who completed the postcourse survey, 70% were pharmacy residents. Using a 5-point Likert scale (1 = very unconfident to 5 = very confident), median participant confidence rose from 3 (interquartile range [IQR] 2-4) before the session to 4 (IQR 3-5) after the session (P < 0.001). Of the participants, 95% believed the ERC training should be required annually or multiple times a year and 100% of respondents felt the ERC training was beneficial. CONCLUSION: Development of a pharmacist ERC including didactic and simulation-based learning improved the confidence and preparedness of pharmacists when participating as members of the hospital code team. Future studies should continue to evaluate pharmacist training and curriculum development in code team responses.

A Narrative Review on the Administration of Inhaled Prostaglandins in Critically Ill Adult Patients With Acute Respiratory Distress Syndrome.

OBJECTIVE: To describe the effect of inhaled prostaglandins on both oxygenation and mortality in critically ill patients with acute respiratory distress syndrome (ARDS), with a focus on safety and efficacy in coronavirus disease 2019 (COVID-19)-associated ARDS and non-COVID-19 ARDS. DATA SOURCES: A literature search of MEDLINE was performed using the following search terms: inhaled prostaglandins, inhaled epoprostenol, inhaled nitric oxide, ARDS, critically ill. All abstracts were reviewed. STUDY SELECTION AND DATA EXTRACTION: Relevant English-language reports and studies conducted in humans between 1980 and June 2023 were considered. DATA SYNTHESIS: Data regarding inhaled prostaglandins and their effect on oxygenation are limited but show a benefit in patients who respond to therapy, and data pertaining to their effect on mortality is scarce. Concerns exist regarding the formulation of inhaled epoprostenol (iEPO) utilized in addition to modes of medication delivery; however, the limited data surrounding their use have shown a reasonable safety profile. Other avenues and beneficial effects may exist with inhaled prostaglandins, such as use in COVID-19-associated ARDS or non-COVID-19 ARDS patients undergoing noninvasive mechanical ventilation or during patient transport. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: The use of inhaled prostaglandins can be considered in critically ill patients with COVID-19-associated ARDS or non-COVID-19 ARDS who are experiencing difficulties with oxygenation refractory to nonpharmacologic strategies. CONCLUSIONS: The use of iEPO and other inhaled prostaglandins requires further investigation to fully elucidate their effects on clinical outcomes, but it appears these medications may have a potential benefit in COVID-19-associated ARDS and non-COVID-19 ARDS patients with refractory hypoxemia but with little effect on mortality.

Evaluation of Dexmedetomidine as an Adjunct to Phenobarbital for Alcohol Withdrawal in Critically Ill Patients.

INTRODUCTION: Dexmedetomidine (DEX) is commonly used with benzodiazepines for the management of alcohol withdrawal syndrome (AWS), but limited data exist regarding its use with phenobarbital (PHB). This analysis evaluated the utility of DEX in addition to PHB for AWS in adult patients admitted to the intensive care unit (ICU). METHODS: This was a single-center, retrospective cohort analysis of critically ill adult patients who received PHB plus either DEX or different adjunctive therapies (NO-DEX) for AWS between 2018 and 2021. Patients were excluded if they had underlying altered mental status or seizure disorder unrelated to AWS or received PHB at outside hospitals. Coarsened exact matching (CEM) was performed to match patients on baseline characteristics in a 1:1 ratio. The primary outcome was ICU length of stay (LOS). A multivariate linear regression analysis was performed to assess the effects of DEX on ICU LOS when accounting for confounders. Secondary outcomes included days with delirium and incidence of mechanical ventilation after PHB administration. RESULTS: Of the 606 encounters evaluated, 197 met criteria for inclusion. After CEM, 56 encounters remained in each group for analysis. The median ICU LOS was 97.2 [50.1:139.5] hours for the DEX group and 47.5 [28.8:88.1] hours for the NO-DEX group (P = .002). The multivariate linear regression analysis showed the use of DEX (P = .008) was independently associated with an increased ICU LOS by 49.8 h. The DEX group had higher rates of total delirium days (208 vs 143 days, P < .001) and a higher incidence of mechanical ventilation after PHB administration (32% vs 9%, P < .001). CONCLUSION: This analysis suggests the use of adjunctive DEX with PHB for AWS was associated with a prolonged ICU LOS. Additional studies are needed to further understand the role of adjunctive DEX in the treatment of AWS in critically ill patients.

Practical approach to clinical controversies in glycemic control for hospitalized surgical patients.

The importance of glycemic management in surgical patient populations stems from an association between hyperglycemia and increased rates of surgical site infections, sepsis, and mortality. Various guidelines provide recommendations regarding target glucose concentrations, but all stress the importance of avoiding hypoglycemia as well. Within the surgical patient population, glycemic targets may vary further depending on the surgical service, such as cardiac surgery, neurosurgery, or reconstructive burn surgery. Glycemic management in critically ill surgical patients is achieved primarily through the use of intravenous insulin infusion protocols. These protocols can include fixed protocols, multiplication factor protocols, and computerized algorithms. In contrast, noncritically ill surgical patients are generally managed through the utilization of subcutaneous insulin with a combination of basal, bolus, and sliding scale insulin. Insulin protocols should be effective at maintaining glucose concentrations within the specified target range with minimal hypoglycemic events. Monitoring glucose concentrations while on either an intravenous or subcutaneous insulin protocol is essential. Point-of-care testing is the primary method for monitoring glucose concentrations in both critically ill and noncritically ill surgical patients and allows for adjustment of the insulin regimen. As patients move between units and to the outpatient setting, ensuring adequate follow-up is essential to maintaining control of hyperglycemia.