Albumin/hetastarch drug utilization review in an operating room pharmacy

Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis

OBJECTIVE

To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications.

DESIGN

Retrospective cohort study of population based data between 2006 and 2013.

SETTING

Data from 510 different hospitals across the United States participating in the Premier Perspective database.

PARTICIPANTS

1,051,441 patients undergoing elective total hip and knee arthroplasties.

EXPOSURES

Perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5%, or neither.

MAIN OUTCOME MEASURES

Acute renal failure and thromboembolic, cardiac, and pulmonary complications.

RESULTS

Compared with patients who received neither colloid, perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5% was associated with an increased risk of acute renal failure (odds ratios 1.23 (95% confidence interval 1.13 to 1.34) and 1.56 (1.36 to 1.78), respectively) and most other complications. A recent decrease in hydroxyethyl starch 6% use was noted, whereas that of albumin 5% increased.

CONCLUSIONS

Similar to studies in critically ill patients, we showed that use of hydroxyethyl starch 6% was associated with an increased risk of acute renal failure and other complications in the elective perioperative orthopedic setting. This increased risk also applied to albumin 5%. These findings raise questions regarding the widespread use of these colloids in elective joint arthroplasty procedures.

Clinical Pharmacy Practice in the Operating Room

An operating room pharmacy has traditionally been focused on the provision of controlled substance accounting and drug distribution services. Clinical pharmacy can be practiced in this setting as well, to the benefit of patients and operating room staff. The operating room pharmacist can provide such services as drug information, drug use evaluation, participation in patient care rounds, adverse drug reaction reporting, assistance in emergency drug therapy, formulary management, research collaboration, pharmacokinetic and pain management consultation, and education regarding drug therapy. The clinical expertise of the operating room pharmacist can be gained through literature review, surgical case observation, attendance and participation in anesthesia conferences, and direct patient care. By providing clinical services appropriate to a given institution's needs in the operating room setting, and delegating direct distributive functions to pharmacy technicians whenever possible, the pharmacist can move into a rewarding role as a clinician member of the operating room health care team.

Impact of college of pharmacy-based educational services within the hospital

Using a pharmacy intervention form, we measured the influence that university-based pharmacy educational personnel had on the pharmacy department's drug costs and on patient charges over a three-month period. A total of 278 interventions were made; 88.8 percent were implemented. Implemented interventions decreased drug costs by $1661.99 and decreased patient charges by $5938.37. The average implemented intervention decreased drug cost by $6.73 and patient cost by $24.04. Regardless of economic benefits, 218 of the 247 implemented interventions were considered to have positive clinical effects on patient care. Educational personnel were responsible for generating $6028.27 of fee revenues to the pharmacy department through generation of pharmacokinetic drug dosing consults. We conclude that the educational programs provided by the pharmacy department through affiliation with a college of pharmacy directly contributed $7690.26 to the pharmacy department in the form of cost-avoided dollars and revenue generation over a three-month period. The provision of educational services by a hospital pharmacy department results in financial rewards as well as other benefits that have been previously described.