Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update.

PURPOSE: The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP). SUMMARY: RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care. CONCLUSION: While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.

Practical implementation of remote continuous glucose monitoring in hospitalized patients with diabetes.

PURPOSE: Inpatient diabetes management involves frequent assessment of glucose levels for treatment decisions. Here we describe a program for inpatient real-time continuous glucose monitoring (rtCGM) at a community hospital and the accuracy of rtCGM-based glucose estimates. METHODS: Adult inpatients with preexisting diabetes managed with intensive insulin therapy and a diagnosis of coronavirus disease 2019 (COVID-19) were monitored via rtCGM for safety. An rtCGM system transmitted glucose concentration and trending information at 5-minute intervals to nearby smartphones, which relayed the data to a centralized monitoring station. Hypoglycemia alerts were triggered by rtCGM values of ≤85 mg/dL, but rtCGM data were otherwise not used in management decisions; insulin dosing adjustments were based on blood glucose values measured via fingerstick blood sampling. Accuracy was evaluated retrospectively by comparing rtCGM values to contemporaneous point-of-care (POC) blood glucose values. RESULTS: A total of 238 pairs of rtCGM and POC data points from 10 patients showed an overall mean absolute relative difference (MARD) of 10.3%. Clarke error grid analysis showed 99.2% of points in the clinically acceptable range, and surveillance error grid analysis showed 89.1% of points in the lowest risk category. It was determined that for 25% of the rtCGM values, discordances in rtCGM and POC values would likely have resulted in different insulin doses. Insulin dose recommendations based on rtCGM values differed by 1 to 3 units from POC-based recommendations. CONCLUSION: rtCGM for inpatient diabetes monitoring is feasible. Evaluation of individual rtCGM-POC paired values suggested that using rtCGM data for management decisions poses minimal risks to patients. Further studies to establish the safety and cost implications of using rtCGM data for inpatient diabetes management decisions are warranted.

White Paper on Natural Products.

The American College of Clinical Pharmacy (ACCP) published an initial white paper on herbal products in 2000. Since then, the global market for natural products has continued to expand, with tens of millions of consumers using such products on an annual basis in the United States alone. However, despite this expansion, natural products remain largely unregulated compared with prescription medications, have moderate- to low-level clinical evidence for efficacy, and continue to have safety concerns, including adulteration and misbranding. As comprehensive medication management experts, clinical pharmacists are uniquely qualified to navigate these concerns and advise patients appropriately. To develop and recommend a suitable care plan involving natural products, clinical pharmacists must establish a strong pharmacist-patient relationship, assess the appropriateness of therapy, educate the patient regarding key issues, and continuously monitor and follow up on the effectiveness of the care plan. This process should not only occur in an individual community or hospital setting, but also whenever a patient transitions from one care setting to another in cooperation with other clinicians.

Recommendations for Aligning PGY2 Pharmacy Residency Training and Pharmacy Specialist Board Certification.

With the increased focus and anticipated growth in specialty training and certification within the profession of pharmacy, it is important for the profession to step back and evaluate the manner in which its adopted education and certification systems interface. As a result of specialty practice development, significant growth is occurring in both postgraduate year two (PGY2) pharmacy residency programs and individuals seeking certification by the Board of Pharmacy Specialties. As the profession continues to evolve its specialty training and credentialing systems, it is important to consider the inherent relationship between these systems. This paper considers the current landscape of specialty training and certification, including issues related to the quality of PGY2 training, consistent application of standards across and within PGY2 programs, credentialing of preceptors and program directors, and alignment of training with specialty certification examination content domains. We outline recommendations across three areas: (1) creating consistency between specialty training and certification, (2) aligning qualifications of PGY2 residency program directors and preceptors with the designated specialty area, and (3) assessing program quality in the context of the expectations of specialists established by the profession. The goal of this paper is to stimulate professional dialogue on these issues. Establishing both formal and informal connections between specialty training and certification can serve as the foundation for a rational approach to professional development and the credentialing that will be recognized by stakeholders outside the pharmacy profession. Establishing these connections will also support and advance the profession's mission of meeting the medication needs of patients.

Antiinfective therapy for pregnant or lactating patients in the emergency department.

PURPOSE: Special considerations in pharmacotherapy for infectious diseases in pregnant and lactating women in the emergency department (ED) setting are reviewed. SUMMARY: With many women turning to the ED as a source of primary care, it is essential for pharmacists involved in providing ED services to guide the selection of appropriate antiinfective agents during pregnancy and lactation; this area of practice is complicated by the very limited body of published data on the safety and efficacy of maternal antimicrobial use and potential fetal or neonatal adverse effects. Infectious diseases commonly encountered in the ED include sexually transmitted diseases, bacterial vaginosis and other vaginal infections, respiratory and urinary tract infections, and pneumonia. Recommended first-line therapies for pregnant or lactating women may differ from those recommended for other patient populations. Although some widely used antiinfective classes and agents are generally considered safe for use in pregnant women, others (e.g., clarithromycin, fluoroquinolones) have been linked to birth defects and neonatal adverse effects. In addition to guiding ED practitioners in the appropriate use of antiinfective agents in pregnant women and nursing mothers, pharmacists can reinforce the importance of appropriate follow-up care (including specialist referral or culture testing in some cases) and ongoing preventive health measures such as vaccine administration. CONCLUSION: The use of antiinfective agents in pregnant or lactating women requires consideration not only of the drugs' effectiveness but also their possible effects on the fetus or newborn and the nature of follow-up care. References are available to help clinicians make treatment decisions.

Droperidol for the treatment of acute migraine headaches.

OBJECTIVE: To evaluate the safety and efficacy of droperidol for the relief of acute migraine headaches. DATA SOURCES: A MEDLINE search (1946 to August 2014) was performed using the following keywords and associated medical subject headings: droperidol, inapsine, headache, migraine, and migraine disorder. STUDY SELECTION AND DATA EXTRACTION: The search was conducted to identify randomized controlled trials comparing droperidol with placebo or an active control in adult patients with acute migraine headaches that were published in English. Primary end points included acute headache improvement after the intervention. Safety end points included the frequency of extrapyramidal symptoms, somnolence, and cardiac adverse effects. DATA SYNTHESIS: In all, 5 manuscripts are included in this review. Patients presenting to the emergency department with acute headache desire rapid pain relief, which was the primary objective in each of the evaluated studies. Droperidol was better than placebo and at least as effective as comparator drugs such as prochlorperazine, meperidine, or olanzapine using droperidol doses of 2.5 to 5 mg, given either intramuscularly (IM) or intravenously (IV). The most commonly reported adverse effects were extrapyramidal symptoms and sedation. Cardiac adverse effects were not reported in any of the studies; however, only 2 articles described using cardiac monitoring. CONCLUSIONS: Parenteral droperidol is an effective option for the treatment of acute migraine. The minimum effective dose is 2.5 mg given IM or IV. Clinicians must be aware of the risk for adverse events, select appropriate patients, perform EKG monitoring for patients at risk of QTc prolongation, and institute treatment if necessary.

"Not for human consumption": a review of emerging designer drugs.

Synthetic, or "designer" drugs, are created by manipulating the chemical structures of other psychoactive drugs so that the resulting product is structurally similar but not identical to illegal psychoactive drugs. Originally developed in the 1960s as a way to evade existing drug laws, the use of designer drugs has increased dramatically over the past few years. These drugs are deceptively packaged as "research chemicals," "incense," "bath salts," or "plant food," among other names, with labels that may contain warnings such as "not for human consumption" or "not for sale to minors." The clinical effects of most new designer drugs can be described as either hallucinogenic, stimulant, or opioid-like. They may also have a combination of these effects due to designer side-chain substitutions. The easy accessibility and rapid emergence of new designer drugs have created challenges for health care providers when treating patients presenting with acute toxicity from these substances, many of which can produce significant and/or life-threatening adverse effects. Moreover, the health care provider has no way to verify the contents and/or potency of the agent ingested because it can vary between packages and distributors. Therefore, a thorough knowledge of the available designer drugs, common signs and symptoms of toxicity associated with these agents, and potential effective treatment modalities are essential to appropriately manage these patients.

Diagnosis and treatment of drug-induced hyperthermia.

PURPOSE: The etiology, pathophysiology, clinical presentation, and management of drug-induced hyperthermia (DIH) syndromes are reviewed. SUMMARY: DIH syndromes are a rare and often overlooked cause of body temperature elevation and can be fatal if not recognized promptly and managed appropriately. There are five major DIH syndromes: (1) neuroleptic malignant syndrome, (2) serotonin syndrome, (3) anticholinergic poisoning, (4) sympathomimetic poisoning, and (5) malignant hyperthermia. The differential diagnosis of DIH syndromes can be challenging because symptoms are generally nonspecific, ranging from blood pressure changes and excessive sweating to altered mental status, muscle rigidity, convulsions, and metabolic acidosis. Evidence from the professional literature (per a MEDLINE search for articles published through November 2011) indicates that few currently available treatment options can reduce the duration of hyperthermia; therefore, prompt identification of the provoking agent based on the patient's medication history, the clinical presentation, and the timing of symptom onset is essential to determine the appropriate treatment and mitigate potentially life-threatening sequelae. For all DIH syndromes, appropriate management includes the immediate discontinuation of the suspected offending agent(s) and supportive care (external cooling, volume resuscitation as needed); in some cases, pharmacologic therapy (e.g., a benzodiazepine, bromocriptine, dantrolene) may be appropriate, with the selection of a specific agent primarily determined by the medication history and suspected DIH syndrome. CONCLUSION: DIH is a hypermetabolic state caused by medications and other agents that alter neurotransmitter levels. The treatment of DIH syndromes includes supportive care and pharmacotherapy as appropriate.

Neuroleptic malignant syndrome associated with the use of prochlorperazine in a patient with a recent history of antipsychotic-induced neuroleptic malignant syndrome.

OBJECTIVE: To describe a case of neuroleptic malignant syndrome (NMS) associated with the use of prochlorperazine in a patient recently hospitalized for NMS secondary to olanzapine. CASE SUMMARY: A 28-year-old African American male with a history of schizophrenia was hospitalized 22 days prior to the current admission for an episode of olanzapine-induced NMS. The patient was discharged from our hospital to an outside psychiatric facility. At this facility, the patient developed nausea and was given 2 doses (unknown amount and route) of prochlorperazine. Over the next 24 hours, the patient exhibited signs and symptoms of NMS including fever, agitation, and muscle rigidity. He was transported to the emergency department and became increasingly agitated. Upon admission, the patient was hyperthermic (rectal temperature 39 °C) and tachycardic (heart rate 138 beats/min), with an elevated white blood cell count of 13.5 × 10(3)/µL, creatine kinase 431 units/L, serum sodium 150 mEq/L, blood urea nitrogen 25 mg/dL, and creatinine 1.1 mg/dL. A diagnosis of NMS was speculated and infectious causes were excluded. The patient was treated with aggressive fluid resuscitation and rapid cooling measures, as well as bromocriptine and lorazepam. Cooling measures were used for 48 hours, during which time the creatine kinase, white blood cell count, sodium, blood urea nitrogen, and creatinine gradually normalized. The patient was discharged to a psychiatry facility with a treatment regimen of oxcarbazepine 600 mg twice daily, lorazepam 2 mg 3 times daily, and clozapine 25 mg at bedtime, which was titrated over 2 months to 200 mg twice daily. There have been no further occurrences of NMS. DISCUSSION: The patient had all of the major characteristics of NMS with no other likely causative factors that may have contributed to his illness. Use of the Naranjo probability scale suggested that NMS was probably related to prochlorperazine. This case highlights the potential increased risk with the use of prochlorperazine in a patient with a history of olanzapine-induced NMS. CONCLUSIONS: NMS should be considered as a rare complication of therapy with antipsychotics and agents that alter dopamine activity, especially in patients with a history of the syndrome. Careful consideration should be given regarding the risks and benefits of using non-antipsychotic dopamine antagonists in patients with a history of antipsychotic-induced NMS.