Clinical Relevance and Predictive Value of Damage Biomarkers of Drug-Induced Kidney Injury

Nephrotoxin exposure accounts for up to one-fourth of acute kidney injury episodes in hospitalized patients, and the associated consequences are as severe as acute kidney injury due to other etiologies. As the use of nephrotoxic agents represents one of the few modifiable risk factors for acute kidney injury, clinicians must be able to identify patients at high risk for drug-induced kidney injury rapidly. Recently, significant advancements have been made in the field of biomarker utilization for the prediction and detection of acute kidney injury. Such biomarkers may have a role both for detection of drug-induced kidney disease and implementation of preventative and therapeutic strategies designed to mitigate injury. In this article, basic principles of renal biomarker use in practice are summarized, and the existing evidence for six markers specifically used to detect drug-induced kidney injury are outlined, including liver-type fatty acid binding protein, neutrophil gelatinase-associated lipocalin, tissue inhibitor of metalloproteinase-2 times insulin-like growth factor-binding protein 7 ([TIMP-2]·[IGFBP7]), kidney injury molecule-1 and N-acetyl-β-D-glucosaminidase. The results of the literature search for these six kidney damage biomarkers identified 29 unique articles with none detected for liver-type fatty acid binding protein and [TIMP-2]·[IGFBP7]. For three biomarkers, kidney injury molecule-1, neutrophil gelatinase-associated lipocalin and N-acetyl-β-D-glucosaminidase, the majority of the studies suggest utility in clinical practice. While many questions need to be answered to clearly articulate the use of biomarkers to predict drug-induced kidney disease, current data are promising.

A cost-minimization analysis of dalbavancin compared to conventional therapy for the outpatient treatment of acute bacterial skin and skin-structure infections

INTRODUCTION

Acute bacterial skin and skin-structure infections (ABSSSI) are common infectious diseases (ID) that often require intravenous (IV) antibiotics. Dalbavancin is a novel lipoglycopeptide antibiotic administered once that is FDA-approved for the treatment of ABSSSI. No literature is available for real-world cost-comparability relative to conventional therapy.

METHODS

This retrospective chart review examined adults diagnosed with ABSSSI and treated with IV antibiotics at an outpatient ID clinic after hospital discharge from January 2015 to August 2016. Patients received either dalbavancin or conventional therapy. In-hospital baseline demographics as well as outpatient clinical variables and outcomes were assessed. The primary outcome was the total ID-related cost of care per patient. A Monte Carlo probalistic sensitivity analysis was conducted.

RESULTS

One hundred and fifty-eight patients were included: 64 received dalbavancin and 94 received conventional therapy. The total ID-related cost of care per patient was greater with dalbavancin (mean $4,561) vs conventional (mean $1,668), p < 0.01. In the subset of patients treated with daptomycin, the total ID-related cost (mean $5,218) was comparable to dalbavancin (mean $4,561).

CONCLUSIONS

Dalbavancin was more costly than conventional therapy for the outpatient treatment of ABSSSI. This greater overall cost was likely driven by the higher acquisition cost of dalbavancin. Dalbavancin may be comparable to the daily use of daptomycin for ABSSSI.

Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward

Background

Medication safety strategies involving trigger alerts have demonstrated potential in identifying drug-related hazardous conditions (DRHCs) and preventing adverse drug events in hospitalized patients. However, trigger alert effectiveness between intensive care unit (ICU) and general ward patients remains unknown. The objective was to investigate trigger alert performance in accurately identifying DRHCs associated with laboratory abnormalities in ICU and non-ICU settings.

Methods

This retrospective, observational study was conducted at a university hospital over a 1-year period involving 20 unique trigger alerts aimed at identifying possible drug-induced laboratory abnormalities. The primary outcome was to determine the positive predictive value (PPV) in distinguishing drug-induced abnormal laboratory values using trigger alerts in critically ill and general ward patients. Aberrant lab values attributed to medications without resulting in an actual adverse event ensuing were categorized as a DRHC.

Results

A total of 634 patients involving 870 trigger alerts were included. The distribution of trigger alerts generated occurred more commonly in general ward patients (59.8%) than those in the ICU (40.2%). The overall PPV in detecting a DRHC in all hospitalized patients was 0.29, while the PPV in non-ICU patients (0.31) was significantly higher than the critically ill (0.25) (p = 0.03). However, the rate of DRHCs was significantly higher in the ICU than the general ward (7.49 versus 0.87 events per 1000 patient days, respectively, p < 0.0001). Although most DRHCs were considered mild or moderate in severity, more serious and life-threatening DRHCs occurred in the ICU compared with the general ward (39.8% versus 12.4%, respectively, p < 0.001).

Conclusions

Overall, most trigger alerts performed poorly in detecting DRHCs irrespective of patient care setting. Continuous process improvement practices should be applied to trigger alert performance to improve clinician time efficiency and minimize alert fatigue.

Automated Screening of Emergency Department Notes for Drug-Associated Bleeding Adverse Events Occurring in Older Adults

Objective To conduct research to show the value of text mining for automatically identifying suspected bleeding adverse drug events (ADEs) in the emergency department (ED). Methods A corpus of ED admission notes was manually annotated for bleeding ADEs. The notes were taken for patients ≥ 65 years of age who had an ICD-9 code for bleeding, the presence of hemoglobin value ≤ 8 g/dL, or were transfused > 2 units of packed red blood cells. This training corpus was used to develop bleeding ADE algorithms using Random Forest and Classification and Regression Tree (CART). A completely separate set of notes was annotated and used to test the classification performance of the final models using the area under the ROC curve (AUROC). Results The best performing CART resulted in an AUROC on the training set of 0.882. The model's AUROC on the test set was 0.827. At a sensitivity of 0.679, the model had a specificity of 0.908 and a positive predictive value (PPV) of 0.814. It had a relatively simple and intuitive structure consisting of 13 decision nodes and 14 leaf nodes. Decision path probabilities ranged from 0.041 to 1.0. The AUROC for the best performing Random Forest method on the training set was 0.917. On the test set, the model's AUROC was 0.859. At a sensitivity of 0.274, the model had a specificity of 0.986 and a PPV of 0.92. Conclusion Both models accurately identify bleeding ADEs using the presence or absence of certain clinical concepts in ED admission notes for older adult patients. The CART model is particularly noteworthy because it does not require significant technical overhead to implement. Future work should seek to replicate the results on a larger test set pulled from another institution.

Perceptions of Families of Intensive Care Unit Patients Regarding Involvement in Delirium-Prevention Activities: A Qualitative Study

BACKGROUND

Nonpharmacologic delirium-prevention strategies are commonly used in the intensive care unit by bedside nurses. With up to 80% of intensive care unit patients becoming delirious, and lacking treatment options, prevention is key. However, with increasing nurse workloads, innovative delirium-prevention strategies such as involving the patient’s family are needed.

OBJECTIVE

To gain insight into opinions of patients’ families regarding active participation in delirium-prevention activities to inform specific recommendations for involving patients’ families in such activities.

METHODS

Purposeful sampling was used. Patients’ families were contacted to be interviewed about their opinions and attitudes on participation in nonpharmacologic delirium prevention activities while visiting the intensive care unit. An interview guide was created and used to facilitate discussion. Interviews were conducted, transcribed verbatim, and coded by 2 independent coders. Themes were identified, defined, and compared between independent coders; disagreements were resolved by the study team.

RESULTS

After 10 interviews were conducted, thematic saturation occurred. Three major themes emerged: (1) consistent family presence and participation in care, (2) improving ease of interactions between family and patient, and (3) delirium education for families.

CONCLUSION

Family members want to be involved with care and delirium prevention; however, many times they do not know what to do without the direction of a health care provider. Family members would benefit from open dialogue with the bedside nurse to increase family comfort and involvement in care.

Drug management in acute kidney disease - Report of the Acute Disease Quality Initiative XVI meeting

AIMS

To summarize and extend the main conclusions and recommendations relevant to drug management during acute kidney disease (AKD) as agreed at the 16^th Acute Disease Quality Initiative (ADQI) consensus conference.

METHODS

Using a modified Delphi method to achieve consensus, experts attending the 16^th ADQI consensus conference reviewed and appraised the existing literature on drug management during AKD and identified recommendations for clinical practice and future research. The group focussed on drugs with one of the following characteristics: (i) predominant renal excretion; (ii) nephrotoxicity; (iii) potential to alter glomerular function; and (iv) presence of metabolites that are modified in AKD and may affect other organs.

RESULTS

We recommend that medication reconciliation should occur at admission and discharge, at AKD diagnosis and change in AKD phase, and when the patient's condition changes. Strategies to avoid adverse drug reactions in AKD should seek to minimize adverse events from overdosing and nephrotoxicity and therapeutic failure from under-dosing or incorrect drug selection. Medication regimen assessment or introduction of medications during the AKD period should consider the nephrotoxic potential, altered renal and nonrenal elimination, the effects of toxic metabolites and drug interactions and altered pharmacodynamics in AKD. A dynamic monitoring plan including repeated serial assessment of clinical features, utilization of renal diagnostic tests and therapeutic drug monitoring should be used to guide medication regimen assessment.

CONCLUSIONS

Drug management during different phases of AKD requires an individualized approach and frequent re-assessment. More research is needed to avoid drug associated harm and therapeutic failure.

Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review

BACKGROUND

Utilization of telemedicine allows pharmacists to extend the reach of clinical interventions, connecting them with patients and providers, but the overall impact of these services is under-studied.

OBJECTIVE

Identify the impact of clinical pharmacist telemedicine interventions on clinical outcomes, subsequently defined as clinical disease management, patient self-management, and adherence, in outpatient or ambulatory settings.

METHODS

A literature search was conducted from database inception through May 2016 in Medline, SCOPUS, and EMBASE. Broad terms "telemedicine", "telehealth", and "telephone" were used in combination with "pharmacist" or "pharmacy" and "telepharmacy". The search and extraction process followed PRISMA guidelines. Results were screened for pharmacist interventions and reviewed to identify studies in outpatient our ambulatory settings. Studies of non-clinical outcomes (i.e. dispensing or product preparation) and with no comparator were excluded. The final studies were categorized by types of outcomes reported: clinical disease management, patient self-management, and adherence.

RESULTS

Only 34 studies measured clinical outcomes against a comparator, consistent with the research question. The majority utilized scheduled models of care (n = 29). Telephone was the most common communication method (n = 25). The most utilized interventions were pharmacist-led telephonic clinics (n = 10). Most studies focused on chronic disease management in adults including hypertension, diabetes, anticoagulation, depression, hyperlipidemia, asthma, heart failure, HIV, PTSD, CKD, stroke, COPD and smoking cessation. Twenty-three studies had a positive impact with one reporting negative results. Higher positive impact rate was observed for scheduled (72.4%, 21/29) and continuous (100%, 2/2) models compared to responsive/reactive (25%, 1/4).

CONCLUSIONS

Clinical pharmacy telemedicine interventions in the outpatient or ambulatory setting, primarily via phone, have an overall positive impact on outcomes related to clinical disease management, patient self-management, and adherence in the management of chronic diseases. Commonalities among studies with positive impact included utilization of continuous or scheduled models via telephone, with frequent monitoring and interventions. Studies identified did not evaluate benefits of video capability over telephone or cost-effectiveness, both of which are useful directions for future study.

Intensive care unit drug costs in the context of total hospital drug expenditures with suggestions for targeted cost containment efforts

PURPOSE

To assess costs of intensive care unit (ICU) related pharmacotherapy relative to hospital drug expenditures, and to identify potential targets for cost-effectiveness investigations. We offer the unique advantage of comparing ICU drug costs with previously published data a decade earlier to describe changes over time.

MATERIALS AND METHODS

Financial transactions for all ICU patients during fiscal years (FY) 2009-2012 were retrieved from the hospital's data repository. ICU drug costs were evaluated for each FY. ICU departments' charges were also retrieved and calculated as percentages of total ICU charges.

RESULTS

Albumin, prismasate (dialysate), voriconazole, factor VII and alteplase denoted the highest percentages of ICU drug costs. ICU drug costs contributed to an average of 31% (SD 1.0%) of the hospital's total drug costs. ICU drug costs per patient day increased by 5.8% yearly versus 7.8% yearly for non-ICU drugs. This rate was higher for ICU drugs costs at 12% a decade previous. Pharmacy charges contributed to 17.7% of the total ICU charges.

CONCLUSIONS

Growth rates of costs per year have declined but still drug expenditures in the ICU are consistently a significant driver in this resource intensive environment with a high impact on hospital drug expenditures.

Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review

Purpose: Benzodiazepines are the drug of choice for alcohol withdrawal syndrome (AWS); however, phenobarbital is an alternative agent used with or without concomitant benzodiazepine therapy. In this systematic review, we evaluate patient outcomes with phenobarbital for AWS. Methods: Medline, Cochrane Library, and Scopus were searched from 1950 through February 2017 for controlled trials and observational studies using ["phenobarbital" or "barbiturate"] and ["alcohol withdrawal" or "delirium tremens."] Risk of bias was assessed using tools recommended by National Heart, Lung, and Blood Institute. Results: From 294 nonduplicative articles, 4 controlled trials and 5 observational studies (n = 720) for AWS of any severity were included. Studies were of good quality (n = 2), fair (n = 4), and poor (n = 3). In 6 studies describing phenobarbital without concomitant benzodiazepine therapy, phenobarbital decreased AWS symptoms (P < .00001) and displayed similar rates of treatment failure versus comparator therapies (38% vs 29%). A study with 2 cohorts showed similar rates of intensive care unit (ICU) admission (phenobarbital: 16% and 9% vs benzodiazepine: 14%) and hospital length of stay (phenobarbital: 5.85 and 5.30 days vs benzodiazepine: 6.64 days). In 4 studies describing phenobarbital with concomitant benzodiazepine therapy, phenobarbital groups had similar ICU admission rates (8% vs 25%), decreased mechanical ventilation (21.9% vs 47.3%), decreased benzodiazepine requirements by 50% to 90%, and similar ICU and hospital lengths of stay and AWS symptom resolution versus comparator groups. Adverse effects with phenobarbital, including dizziness and drowsiness, rarely occurred. Conclusion: Phenobarbital, with or without concomitant benzodiazepines, may provide similar or improved outcomes when compared with alternative therapies, including benzodiazepines alone.

Perceived Motivating Factors and Barriers for the Completion of Postgraduate Training Among American Pharmacy Students Prior to Beginning Advanced Pharmacy Practice Experiences

Objective. To examine perceived motivating factors and barriers (MFB) to postgraduate training (PGT) pursuit among pharmacy students. Methods. Third-year pharmacy students at 13 schools of pharmacy provided demographics and their plan and perceived MFBs for pursuing PGT. Responses were characterized using descriptive statistics. Kruskal-Wallis equality-of-proportions rank tests determined if differences in perceived MFBs existed between students based on plan to pursue PGT. Results. Among 1218 (69.5%) respondents, 37.1% planned to pursue PGT (32.9% did not, 30% were undecided). Students introduced to PGT prior to beginning pharmacy school more frequently planned to pursue PGT. More students who planned to pursue PGT had hospital work experience. The primary PGT rationale was, "I desire to gain more knowledge and experience." Student debt was the most commonly cited barrier. Conclusion. Introducing pharmacy students early to PGT options and establishing work experiences in the hospital setting may increase students' desire to pursue PGT.

Characterization of Guideline Evidence for Off-label Medication Use in the Intensive Care Unit

BACKGROUND

Non-Food and Drug Administration (FDA) or off-label medication prescribing occurs commonly in the intensive care unit (ICU). Off-label medication use creates a concern for untoward adverse effects; however, this worry may be alleviated by supportive literature.

OBJECTIVE

To evaluate the evidence behind off-label medication use by determining the presence of guideline support and compare graded recommendations to an online tertiary resource, DRUGDEX.

METHODS

Off-label medication use was identified prospectively over 3 months in medical ICUs in 3 academic medical centers. Literature searches were conducted in PubMed and the national guideline clearinghouse website to determine the presence of guideline support. DRUGDEX was also searched for strength-of-evidence ratings to serve as a comparator.

RESULTS

A total of 287 off-label medication indication searches resulted in 44% (126/287) without identified evidence; 253 guidelines were identified for 56% (161/287) of indications. Of the published guidelines, 89% (226/253) supported the off-label indication. In the DRUGDEX comparison, 67% (97/144) of guideline gradings disagree with DRUGDEX, whereas 33% (47/144) of the gradings matched the online database.

CONCLUSION

Because more than half of off-label medication use has the benefit of supportive guidelines recommendations and a majority of gradings are inconsistent with DRUGDEX, clinicians should consider utilizing guidelines to inform off-label medication use in the ICU. Still, there is a considerable amount of off-label medication use in the ICU that lacks supporting evidence, and use remains concerning because it may lead to inappropriate treatment and adverse events.

Triple Antithrombotic Therapy With Aspirin, P2Y12 Inhibitor, and Warfarin After Percutaneous Coronary Intervention

Background:

Triple antithrombotic therapy is used in patients who require systemic anticoagulation and undergo percutaneous coronary intervention (PCI) requiring dual antiplatelet therapy. Bleeding with this combination is significant; however, few studies have described outcomes with the use of newer oral P2Y12 inhibitors in this setting.

Objectives:

We aimed to compare outcomes among patients prescribed triple therapy with prasugrel or ticagrelor compared to triple therapy with clopidogrel in patients who underwent PCI and required warfarin.

Methods:

We retrospectively evaluated 168 patients who received either prasugrel (n = 32) or ticagrelor (n = 10) and were matched (1:3) to those who received clopidogrel (n = 126) at the time of discharge from the index PCI visit. Matching was performed based on age ±10 years, sex, and indication for PCI. The primary outcome was the incidence of any bleeding during the 12-month follow-up. We also evaluated major adverse cardiovascular and cerebrovascular events (MACCEs).

Results:

Patient baseline characteristics were similar between groups. There was a significant excess of bleeding in patients who received prasugrel or ticagrelor compared to clopidogrel as part of triple therapy (28.6% vs 12.7%; odds ratio, 3.3; 95% confidence interval, 1.38-8.34). No differences were seen between groups in MACCEs.

Conclusions:

The use of prasugrel or ticagrelor as part of triple antithrombotic therapy among patients who underwent PCI and received warfarin was associated with significantly more bleeding compared to patients who received clopidogrel. Therefore, higher potency P2Y12 inhibitors should be used cautiously in these patients.

The effectiveness of intravenous vitamin K in correcting cirrhosis-associated coagulopathy

OBJECTIVES

The goal of this study was to evaluate the effectiveness of intravenous (IV) vitamin K in cirrhosis.

METHODS

This was a retrospective study of cirrhotic patients, not on anticoagulation, with administration of IV vitamin K and a baseline INR > 1.5. The primary outcome was the effectiveness of therapy defined by a 30% decrease in INR or a reduction in INR to an absolute value of ≤1.5.

KEY FINDINGS

A total of 96 patients were included in the cohort. There was an average decrease in INR of 0.31; however, 60 patients (62.3%) failed to achieve at least a 10% decrease. Sixteen patients (16.7%) met the primary effectiveness endpoint.

CONCLUSIONS

The use of IV vitamin K to correct coagulopathy of cirrhosis may not be beneficial.

Use of Telemedicine to Enhance Pharmacist Services in the Nursing Facility

OBJECTIVE

To conduct a systematic literature review to determine what telemedicine services are provided by pharmacists and the impact of these services in the nursing facility setting.

DATA SOURCES

MEDLINE®, Scopus®, and Embase® databases.

STUDY SELECTION

The terms "telemedicine" or "telehealth" were combined by "and" with the terms "pharmacist" or "pharmacy" to identify pharmacists' use of telemedicine. Also, "telepharmacy" was added as a search term. The initial search yielded 322 results. These abstracts were reviewed by two individuals independently, for selection of articles that discussed telemedicine and involvement of a pharmacist, either as the primary user of the service or as part of an interprofessional health care team. Those abstracts discussing the pharmacist service for purpose of dispensing or product preparation were excluded.

DATA EXTRACTION

A description of pharmacists' services provided and the impact on resident care.

DATA SYNTHESIS

Only three manuscripts met inclusion criteria. One was a narrative proposition of the benefits of using telemedicine by senior care pharmacists. Two published original research studies indirectly assessed the pharmacists' use of telemedicine in the nursing facility through an anticoagulation program and an osteoporosis management service. Both services demonstrated improvement in patient care.

CONCLUSION

There is a general paucity of practice-related research to demonstrate potential benefits of pharmacists' services incorporating telemedicine. Telemedicine may be a resource-efficient approach to enhance pharmacist services in the nursing facility and improve resident care.

Nonpharmacological interventions to prevent delirium: an evidence-based systematic review

Development of delirium in critical care patients is associated with increased length of stay, hospital costs, and mortality. Delirium occurs across all inpatient settings, although critically ill patients who require mechanical ventilation are at the highest risk. Overall, evidence to support the use of antipsychotics to either prevent or treat delirium is lacking, and these medications can have adverse effects. The pain, agitation, and delirium guidelines of the American College of Critical Care Medicine provide the strongest level of recommendation for the use of nonpharmacological approaches to prevent delirium, but questions remain about which nonpharmacological interventions are beneficial.

Role of the Bispectral Index in Sedation Monitoring in the ICU

Objective:

To review and critique evidence for the use of the bispectral index (BIS) in intensive care unit (ICU) patients.

Data Sources:

A computer search of English-language articles in MEDLINE (1966–July 2005), International Pharmaceutical Abstracts (1971–July 2005), and Scientific Citation Index Expanded (1980–July 2005) was conducted. A manual search of abstracts was also performed using the key search terms BIS, sedation, and critical care.

Study Selection and Data Extraction:

Case series, letters, editorials, and clinical studies that evaluated BIS in ICU patients were considered for inclusion.

Data Synthesis:

Nineteen studies comparing the BIS with sedation scales were evaluated, revealing that the BIS trends lower with increasing sedation. The BIS appeared to correlate better when sedation scores were grouped rather than individual values. However, correlations between BIS and subjective scales were low in most studies (r2 0.21–0.93). Additionally, there was poor correlation between drug dosage and the BIS. Randomized, controlled trials demonstrating improved outcomes with BIS monitoring have not been reported.

Conclusions:

Interpreting literature on the usefulness of the BIS in the ICU is difficult for reasons that include heterogeneous populations, different methods of collecting BIS data, and use of different versions of BIS software and hardware. Outcomes data are lacking. The 2002 Society of Critical Care Medicine Sedation Guidelines recommendation that more data are needed before the BIS should be used routinely in the ICU remains unchanged. We recommend that further studies be conducted to determine the optimal method of obtaining BIS data and evaluate the impact of the BIS on relevant patient outcomes.

Physician Perceptions of Consultant Pharmacist Services Associated with an Intervention for Adverse Drug Events in the Nursing Facility

OBJECTIVE

To assess the importance and performance of consultant pharmacist services delivered before and after an intervention to detect and manage adverse drug events among nursing facility residents.

DESIGN

Before and after intervention survey of physicians participating in a randomized, controlled trial.

SETTING

Four nonprofit, academically affiliated nursing facilities.

PARTICIPANTS

Attending physicians providing nursing facility care who were randomized to intervention or control groups.

INTERVENTIONS

Within the intervention arm, consultant pharmacists provided academic detailing in which trained health care professionals visit practicing physicians in their offices and present the most up-to-date clinical information. Physicians responded to alerts from a medication monitoring system, adjudicated system alerts for adverse drug events (ADEs), and provided structured recommendations about ADE management.

MAIN OUTCOME MEASURES

We compared physicians' assessments of the importance and performance of consultant pharmacist services before and after the trial intervention in the intervention and control groups.

RESULTS

In the intervention group, ratings of importance increased for all 24 survey questions, and 5 of the changes were statistically significant (P < 0.05). In the control group, ratings of importance increased for 16 questions, and none of the changes were statistically significant. In the intervention group, ratings of performance increased for all 24 questions, and 20 of the changes were statistically significant. In the control group, ratings of performance increased for 16 questions, and none of the changes was statistically significant.

CONCLUSION

A multifaceted, consultant pharmacist-led intervention comprising academic detailing, computerized decision support, and structured communication framework can improve physicians' assessment of importance and performance of consultant pharmacist services.

ABBREVIATIONS

ADE = Adverse drug event, M = Statistically significant mean, RCT = Randomized controlled trial, SBAR = Situation, Background, Discussion, Recommendation, SD = Standard deviation.

Adverse drug reactions in therapeutic hypothermia after cardiac arrest

BACKGROUND

Therapeutic hypothermia (TH) improves survival and neurologic function in comatose survivors of cardiac arrest. Many medications used to support TH have altered pharmacokinetics and pharmacodynamics during this treatment. It is unknown if or at what frequency the medications used during TH cause adverse drug reactions (ADRs).

METHODS

A retrospective chart review was conducted for patients admitted to an intensive care unit (ICU) after cardiac arrest and treated with TH from January 2009 to June 2012 at two urban, university-affiliated, tertiary-care medical centres. Medications commonly used during TH were screened for association with significant ADRs (grade 3 or greater per Common Terminology Criteria for Adverse Events) using three published ADR detection instruments.

RESULTS

A total of 229 patients were included, the majority being males with median age of 62 presenting with an out-of-hospital cardiac arrest in pulseless electrical activity or asystole. The most common comorbidities were hypertension, coronary artery disease, and diabetes mellitus. There were 670 possible ADRs and 69 probable ADRs identified. Of the 670 possible ADRs, propofol, fentanyl, and acetaminophen were the most common drugs associated with ADRs. Whereas fentanyl, insulin, and propofol were the most common drugs associated with a probable ADR. Patients were managed with TH for a median of 22 hours, with 38% of patients surviving to hospital discharge.

CONCLUSIONS

Patients undergoing TH after cardiac arrest frequently experience possible adverse reactions associated with medications and the corresponding laboratory abnormalities are significant. There is a need for judicious use and close monitoring of drugs in the setting of TH until recommendations for dose adjustments are available to help prevent ADRs.

The Importance of Research and Scholarly Activity in Pharmacy Training

Regardless of practice setting, it is imperative that pharmacists be able to either participate in generating new knowledge or use the ever-expanding body of literature to guide patient care. However, competing priorities in Pharm.D. curricula and residency training programs have resulted in limited emphasis on acquiring research and scholarly skills. Factors likely contributing to this reduced focus include the lack of curricular and postgraduate training standards emphasizing the development of research skills, time to commit to scholarly activity, and accessibility to experienced mentors. Strategies for increasing scholarly activity for pharmacy students and residents should therefore continue to be a focus of professional degree and residency training programs. Several resources are available for academic planners, program directors, and institutions to augment scholarly experience for pharmacy trainees and clinicians. This commentary highlights the importance of providing research opportunities for students and residents, describes the potential barriers to these activities, and provides recommendations on how to increase the instruction and mentoring of trainees to generate and use research.

Clinical decision support for drug related events: Moving towards better prevention

Clinical decision support (CDS) systems with automated alerts integrated into electronic medical records demonstrate efficacy for detecting medication errors (ME) and adverse drug events (ADEs). Critically ill patients are at increased risk for ME, ADEs and serious negative outcomes related to these events. Capitalizing on CDS to detect ME and prevent adverse drug related events has the potential to improve patient outcomes. The key to an effective medication safety surveillance system incorporating CDS is advancing the signals for alerts by using trajectory analyses to predict clinical events, instead of waiting for these events to occur. Additionally, incorporating cutting-edge biomarkers into alert knowledge in an effort to identify the need to adjust medication therapy portending harm will advance the current state of CDS. CDS can be taken a step further to identify drug related physiological events, which are less commonly included in surveillance systems. Predictive models for adverse events that combine patient factors with laboratory values and biomarkers are being established and these models can be the foundation for individualized CDS alerts to prevent impending ADEs.

Association Between Train-of-Four Values and Gas Exchange Indices in Moderate to Severe Acute Respiratory Distress Syndrome

BACKGROUND

Acute respiratory distress syndrome (ARDS) is associated with a mortality rate of approximately 40%. Neuromuscular blockade is associated with an improvement in oxygenation and a reduction in mortality in ARDS.

OBJECTIVE

The goal of this evaluation was to determine if the depth of paralysis, determined by train-of-four (TOF) monitoring, correlates with gas exchange in moderate to severe ARDS.

METHODS

This was a retrospective review of moderate to severe ARDS patients who were prescribed >12 hours of continuous infusion cisatracurium between January 1, 2013, and December 31, 2014, with a PaO₂:FiO₂ ratio <150 and documented TOF and arterial blood gases. Patients were evaluated for inclusion at 12, 24, and 48 hours after initiation of neuromuscular blockade.

RESULTS

A total of 378 patients were screened for inclusion, with 107 evaluable patients meeting criteria at baseline. Poor correlation existed between TOF and oxygenation index (OI) at 12 (τ = 0.03), 24 (τ = 0.15) and 48 hours (τ = 0.08). When controlling for proning and baseline OI, the depth of paralysis did not have a significant effect on OI at 12, 24, or 48 hours.

CONCLUSIONS

This evaluation demonstrates that the use of TOF monitoring for neuromuscular blockade does not correlate with gas exchange markers in moderate to severe ARDS.

Use of Text Searching for Trigger Words in Medical Records to Identify Adverse Drug Reactions within an Intensive Care Unit Discharge Summary

PURPOSE

To evaluate the performance of using trigger words (e.g. clues to an adverse drug reaction) in unstructured, narrative text to detect adverse drug reactions (ADRs) and compare the use of these trigger words to a targeted chart review for ADR detection within the intensive care unit (ICU) discharge summary note.

MATERIALS

A retrospective medical record review was conducted. Evaluation of ADRs occurred in two phases - targeted chart review of the ICU discharge summary notes in Phase 1 and targeted chart review using specific words and phrases as triggers for ADRs in Phase 2.

RESULTS

Four hundred ADRs were documented in 223 patients for Phase 1. For Phase 2, there were 219 ADRs identified in 120 patients. 138 real or accurate ADRs were identified from Phase 1 and 47 duplicate events. 34 ADRs from Phase 2 were not identified in Phase 1. Fifteen of the ADRs were inaccurately presumed in Phase 2. Fifty-eight of 127 text triggers identified at least one ADR. Low and moderate frequency trigger words were more likely to have PPVs > 5%.

CONCLUSIONS

Targeted chart review using specific words and phrases as triggers for ADRs is a reasonable approach to identify ADRs and may save time compared to other methods after further refinement leads to a more accurately performing trigger word list.

An Evaluation of Adverse Drug Reactions Associated With Antipsychotic Use for the Treatment of Delirium in the Intensive Care Unit

Purpose:

This investigation evaluated the incidence, severity, and harm of adverse drug reactions (ADRs) associated with antipsychotic use for intensive care unit (ICU) delirium.

Methods:

In this prospective, observational study patients were screened for development of delirium with the Intensive Care Delirium Screening Checklist (ICDSC). An ICDSC score of ≥4 was considered delirious. Patients with delirium were screened daily for ADRs. Suspected ADRs were evaluated for drug causality using 3 published, objective assessment tools. Suspected ADRs were considered positive when 2 of 3 instruments had an agreement rating of “possible” or greater. ADR severity was defined as “mild/moderate” or “severe” using the National Cancer Institute’s Common Terminology Criteria for Adverse Events scale. A modified National Coordinating Council Medication Error Reporting Index for Categorizing Errors categorized ADRs into “no harm” or “harmful.”

Results:

Of 90 patients with delirium, 56 received antipsychotics. Ten suspected ADRs occurred attributed to antipsychotic use. QTc prolongation was the most observed ADR (50%). Patients with ADRs had higher mean Acute Physiology and Chronic Health Evaluation II (APACHE II) scores ( P = .038). Patients who received haloperidol experienced more severe ( P = .048) ADRs.

Conclusions:

ADRs were observed in 18% of patients having delirium treated with antipsychotics with about half considered severe or harmful. A risk versus benefit assessment is needed before initiating antipsychotic therapy in ICU patients.