Adverse-drug-event rates for high-cost and high-use drugs in the intensive care unit

Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: A multicentre retrospective observational study

AIMS

Knowledge about adverse drug events caused by drug-drug interactions (DDI-ADEs) is limited. We aimed to provide detailed insights about DDI-ADEs related to three frequent, high-risk potential DDIs (pDDIs) in the critical care setting: pDDIs with international normalized ratio increase (INR+ ) potential, pDDIs with acute kidney injury (AKI) potential, and pDDIs with QTc prolongation potential.

METHODS

We extracted routinely collected retrospective data from electronic health records of intensive care units (ICUs) patients (≥18 years), admitted to ten hospitals in the Netherlands between January 2010 and September 2019. We used computerized triggers (e-triggers) to preselect patients with potential DDI-ADEs. Between September 2020 and October 2021, clinical experts conducted a retrospective manual patient chart review on a subset of preselected patients, and assessed causality, severity, preventability, and contribution to ICU length of stay of DDI-ADEs using internationally prevailing standards.

RESULTS

In total 85 422 patients with ≥1 pDDI were included. Of these patients, 32 820 (38.4%) have been exposed to one of the three pDDIs. In the exposed group, 1141 (3.5%) patients were preselected using e-triggers. Of 237 patients (21%) assessed, 155 (65.4%) experienced an actual DDI-ADE; 52.9% had severity level of serious or higher, 75.5% were preventable, and 19.3% contributed to a longer ICU length of stay. The positive predictive value was the highest for DDI-INR+ e-trigger (0.76), followed by DDI-AKI e-trigger (0.57).

CONCLUSION

The highly preventable nature and severity of DDI-ADEs, calls for action to optimize ICU patient safety. Use of e-triggers proved to be a promising preselection strategy.

Nephrotoxin Stewardship

Drugs are the third leading cause of acute kidney injury (AKI) in critically ill patients. Nephrotoxin stewardship ensures a structured and consistent approach to safe medication use and prevention of patient harm. Comprehensive nephrotoxin stewardship requires coordinated patient care management strategies for safe medication use, ensuring kidney health, and avoiding unnecessary costs to improve the use of nephrotoxins, renally eliminated drugs, and kidney disease treatments. Implementing nephrotoxin stewardship reduces medication errors and adverse drug events, prevents or reduces severity of drug-associated AKI, prevents progression to or worsening of chronic kidney disease, and alleviates financial burden on the health care system.

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit

PURPOSE

Medication-related clinical decision support (CDS) has been identified as a method to improve patient outcomes but is historically frequently overridden and may be inappropriately so. Patients in the intensive care unit (ICU) are at a higher risk of harm from adverse drug events (ADEs) and these overrides may increase patient harm. The objective of this study is to determine appropriateness of overridden medication-related CDS overrides in the ICU.

MATERIALS AND METHODS

We evaluated overridden medication-related alerts of four alert categories from January 2009 to December 2011. The primary outcome was the appropriateness of a random sample of overrides based on predetermined criteria. Secondary outcomes included the incidence of adverse drug events (ADEs) that resulted from the overridden alert.

RESULTS

A total of 47,449 overridden alerts were included for evaluation. The appropriateness rate for overridden alerts varied by alert category (allergy: 94%, drug-drug interaction: 84%, geriatric: 57%, renal: 27%). A total of seven actual ADEs were identified in the random sample and where the medication(s) was administered (n=366), with an increased risk of ADEs associated with inappropriately overridden alerts (p=0.0078).

CONCLUSIONS

The appropriateness of medication-related clinical decision support overrides in the ICU varied substantially by the type of alert. Inappropriately overridden alerts were associated with an increased risk of ADEs compared to appropriately overridden alerts.

An integrative review of drug errors in critical care

Medication error is the commonest cause of medical error and the consequences can be grave. This integrative review was undertaken to critically appraise recent literature to further define prevalence, most frequently-implicated drugs and effects on patient morbidity and mortality in the critical care environment. Forty studies were compared revealing a markedly heterogeneous data set with significant variability in reported incidence. There is an important differentiation to be made between medication error (incidence 5.1-967 per 1000 patient days) and adverse drug event (incidence 1-96.5 per 1000 patient days) with significant ramifications for patient outcome and cost. The most commonly implicated drugs were cardiovascular, gastrointestinal, antimicrobial and hypoglycaemic agents. Beneficial interventions to reduce such errors include computerised prescribing, education and pharmacist input. The studies described provide insight into suboptimal management in the critical care environment and have implications for the development of specific improvement strategies and future training.

Risk factors for acute kidney injury in older adults with critical illness: a retrospective cohort study

BACKGROUND

Risk for acute kidney injury (AKI) in older adults has not been evaluated systematically. We sought to delineate the determinants of risk for AKI in older compared with younger adults.

STUDY DESIGN

Retrospective analysis of patients hospitalized in July 2000 to September 2008.

SETTING & PARTICIPANTS

We identified all adult patients admitted to an intensive care unit (n=45,655) in a large tertiary-care university hospital system. We excluded patients receiving dialysis or a kidney transplant prior to hospital admission and patients with baseline creatinine levels ≥ 4mg/dL, liver transplantation, indeterminate AKI status, or unknown age, leaving 39,938 patients.

PREDICTOR

We collected data for multiple susceptibilities and exposures, including age, sex, race, body mass, comorbid conditions, severity of illness, baseline kidney function, sepsis, and shock.

OUTCOMES

We defined AKI according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria. We examined susceptibilities and exposures across age strata for impact on the development of AKI.

MEASUREMENTS

We calculated area under the receiver operating characteristic curve (AUC) for prediction of AKI across age groups.

RESULTS

25,230 (63.2%) patients were 55 years or older. Overall, 25,120 (62.9%) patients developed AKI (69.2% aged ≥55 years). Examples of risk factors for AKI in the oldest age category (≥75 years) were drugs (vancomycin, aminoglycosides, and nonsteroidal anti-inflammatories), history of hypertension (OR, 1.13; 95% CI, 1.02-1.25), and sepsis (OR, 2.12; 95% CI, 1.68-2.67). Fewer variables remained predictive of AKI as age increased and the model for older patients was less predictive (P<0.001). For the age categories 18 to 54, 55 to 64, 65 to 74, and 75 years or older, AUCs were 0.744 (95% CI, 0.735-0.752), 0.714 (95% CI, 0.702-0.726), 0.706 (95% CI, 0.693-0.718), and 0.673 (95% CI, 0.661-0.685), respectively.

LIMITATIONS

Analysis may not apply to non-intensive care unit patients.

CONCLUSIONS

The likelihood of developing AKI increases with age; however, the same variables are less predictive for AKI as age increases. Efforts to quantify risk for AKI may be more difficult in older adults.

Multicenter evaluation of pharmacologic management and outcomes associated with severe resistant alcohol withdrawal

INTRODUCTION

A subset of patients with alcohol withdrawal syndrome does not respond to benzodiazepine treatment despite escalating doses. Resistant alcohol withdrawal (RAW) is associated with higher incidences of mechanical ventilation and nosocomial pneumonia and longer intensive care unit (ICU) stay. The objective of this study is to characterize pharmacologic management of RAW and outcomes.

METHODS

Adult patients were identified retrospectively via International Classification of Diseases, Ninth Revision codes for severe alcohol withdrawal from 2009 to 2012 at 3 hospitals. Data collected included pharmacologic management and clinical outcomes.

RESULTS

A total of 184 patients met inclusion criteria. Sixteen medications and 74 combinations of medications were used for management. Propofol was the most common adjunct agent, with dexmedetomidine and antipsychotics also used. One hundred seventy-five patients (96.2%) were admitted to the ICU, with 149 patients (81.9%) requiring ventilator support. Median time to resolution of alcohol withdrawal syndrome from RAW designation was 6.0 days. Median ICU and hospital length of stay were 9.0 and 12.7 days, respectively.

CONCLUSION

Diverse patterns exist in the management of patients meeting RAW criteria, indicating lack of refined approach to treatment. High doses of sedatives used for these patients may result in a high level of care, illustrating a need for evidence-based clinical guidelines to optimize outcomes.

Adverse drug events in patients admitted to an emergency department: an analysis of direct costs

PURPOSE

Several economic evaluations of adverse drug events (ADEs) exist, but the underlying methodology has not been standardized so far. The aim of the study was to combine prospective, intensive pharmacovigilance methods, and standardized accounting data to calculate direct costs of community-acquired ADEs (caADEs) contributing to emergency department (ED) admission and subsequent hospitalization.

METHODS

A prospective observational study with three phases extending over 2 years was implemented in a 749 bed tertiary care hospital with an annual ED census of approximately 45 000 patients. The patient records of all adult non-trauma ED admissions were systematically analyzed by a team of emergency physicians, clinical pharmacologists, and pharmacists for potential ADE. Associated diagnosis related group costs were extracted from standardized accounting data.

RESULTS

Of 2262 patients attending the ED during the study periods, the hospitalization of 366 patients (16.2%) was related to one or more caADEs of which 97.5% were considered predictable and 62.0% were classified as preventable. The mean caADE-related diagnosis related group costs were €2743 (95% bias-corrected and accelerated CI: €2498 to €3018). Extrapolated to a national scale, this corresponds to caADE-related costs of €2.245bn for the German health insurance funds, annually. Costs of €1.310bn could be attributed to events classified as predictable and preventable.

CONCLUSIONS

In an ED, caADEs are frequent, and a significant proportion of these events and their related costs appear to be predictable and preventable. The ED as a first-line provider for ADE cases appears to be an appropriate environment to implement strategic and operative improvements for enhanced patient safety.

Adverse Drug Events in Critically Ill Patients With Cancer

Objective:

To determine the incidence, characteristics, and outcomes of adverse drug events (ADEs) in critically ill patients with cancer.

Methods:

This was a 5-month prospective observational study. Patients who were admitted to the adult medical/surgical oncology intensive care unit (ICU) were evaluated for any drug-related adverse events during their ICU stay. An ADE was defined as injury or patient harm resulting from medical intervention related to a drug.

Results:

The incidence rate of ADEs was 96.5 per 1000 patient days and 35.3 per 100 ICU admissions. Of the reported ADEs, 57 (64.8%) were serious/life threatening, 30 (34.1%) were significant, 1 (1.1%) was fatal, and 14 (15.9%) of all ADEs were considered preventable. The most common drug classes associated with ADEs were antidiabetics, antibiotics, and analgesics/sedatives. The length of stay and presence of renal or respiratory failure were significantly associated with an increased number of ADEs. The length of stay and female sex were significantly associated with the likelihood of developing an ADE.

Conclusion:

Critically ill patients with cancer are at high risk of developing ADEs. Strategies that reduce the incidence and severity of ADEs are essential to improve the outcomes of this patient population.

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units

OBJECTIVE

To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process.

METHODS

Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process.

RESULTS

An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16-24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process.

CONCLUSIONS

Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.

Impact of clinical pharmacist interventions on the cost of drug therapy in intensive care units of a tertiary care teaching hospital

Objective:

To analyze clinical pharmacist interventions in the intensive care units (ICUs) setting of a tertiary care Indian hospital and to assess the pharmacoeconomic impact on drug-related problems (DRPs).

Materials and Methods:

A postgraduate clinical pharmacist reviewed drug prescriptions over a period of 7 months. Whenever a DRP is identified, it was discussed with a physician and appropriate suggestions were provided, later it was documented on a preprepared form. Clinical significance of each intervention was graded based on the predicted clinical outcome. Acceptance of the interventions is entirely at the discretion of the medical staff. Each intervention was analyzed with respect to potential cost saving and/or additional cost incurred to existing drug therapy. An independent clinical panel was convened, and all the interventions made by the intervening pharmacist were critically reviewed for potential cost savings.

Results:

The intervening pharmacist made 117 recommendations, of which 94% was accepted by the medical professionals. The most frequent DRP identified was overdose (24%). The total net cost savings made was Rs. 77260.13 (USD 1796.73). This corresponds with Rs. 965.75 per patient and an annualized savings of Rs. 135205.22.

Conclusion:

Clinical pharmacist interventions had a significant impact on the cost of drug therapy and the patient outcome in intensive care settings of our hospital.

Analysis of risk factors for adverse drug events in critically ill patients*

OBJECTIVES

An evaluation of risk factors for adverse drug events in critically ill patients has not been previously studied. The purpose of this original study was to determine risk factors for adverse drug events in critically ill adult patients.

DESIGN

This retrospective case-control study includes patients who were admitted to the intensive care unit during a 7.5-yr period.

SETTING

Academic medical center with 647 beds that contains approximately 120 intensive care unit beds.

PATIENTS

Patients in the case group experienced an adverse drug event as documented in the hospital's database. The control group comprised the next two patients admitted to the same intensive care unit by the same admitting service.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-nine suspected risk factors identified from the literature were evaluated, including patient characteristics, drug characteristics, and laboratory values using a multiple logistic regression. A sample of 1101 cases and controls (54% male), with a mean age of 59.4 ± 17.5 yrs, were identified. In 367 cases, there was a total of 499 documented adverse drug events. Patients with kidney injury, thrombocytopenia, and those admitted emergently were 16-times, 3-times, and 2-times more likely to have an adverse drug event, respectively. Patients who were administered intravenous medications had a 3% higher risk of having an adverse drug event for each drug dispensed. Overall, the case group received more drugs per intensive care unit day and more drugs per intensive care unit stay.

CONCLUSIONS

Several patient and drug-related characteristics contribute to the risk of adverse drug events in critically ill patients. Diligent monitoring of factors that can influence the pharmacokinetic properties for existing drug therapies is necessary. Drug regimens should be evaluated daily for minimization. Based on previous studies, pharmacists as part of the interdisciplinary team could help to manage these risks.

[From iatrogenesis to medical errors: review of the literature and analytical approach]

Iatrogenesis and medical errors have been increasingly studied over the past years. Because of the lack of consensus concerning the definitions, it remains difficult to draw general conclusions from the published. Moreover, it is still likely to be underestimated because of underreporting. This review aims at evaluating the overall incidence of iatrogenesis and medical errors in anaesthesia and intensive care and at discussing the strategies to prevent these incidents, at the individual or systemic level.

Systematic review of the adverse effects of cutaneous leishmaniasis treatment in the New World

Pentavalent antimonials are first-line drugs for the treatment of the cutaneous form of American tegumentary leishmaniasis. Second-line drugs include amphotericin B and pentamidine. Although these drugs have been used for decades, there are no systematic reviews about their safety. The objective of this review was to identify and classify the main adverse effects associated with these drugs and to estimate the frequency of these effects, whenever possible. Intervention studies, case series and case reports containing information regarding clinical, laboratory or electrocardiographic adverse effects of drugs used for the treatment of cutaneous leishmaniasis were systematically retrieved from 10 databases searched between August 13, 2008 and March 31, 2009. The 65 studies included in this review had treated a total of 4359 patients from 12 countries infected with eight different Leishmania species. Despite the small number of drugs used in these studies, a wide variability in the therapeutic regimens was observed. As a consequence, the adverse effects of pentavalent antimonials and pentamidine needed to be classified jointly according to system, irrespective of formulation, daily dose, duration of treatment, and route of administration. The frequencies of adverse effects were calculated based on the data of 32 articles involving 1866 patients. The most frequently reported clinical adverse effects of pentavalent antimonials and pentamidine were musculoskeletal pain, gastrointestinal disturbances, and mild to moderate headache. Electrocardiographic QTc interval prolongation and a mild to moderate increase in liver and pancreatic enzymes were additional adverse effects of pentavalent antimonials. Patients treated with liposomal amphotericin B had mild dyspnea and erythema. The adverse effects associated with miltefosine were vomiting, nausea, kinetosis, headache, diarrhea, and a mild to moderate increase in aminotransferases and creatinine. Although closer surveillance is needed for the treatment of cutaneous leishmaniasis, antileishmanial drugs are basically safe and severe side effects requiring the discontinuation of treatment are relatively uncommon.

On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study

Introduction

Patients admitted to an intensive care unit (ICU) are at high risk for prescribing errors and related adverse drug events (ADEs). An effective intervention to decrease this risk, based on studies conducted mainly in North America, is on-ward participation of a clinical pharmacist in an ICU team. As the Dutch Healthcare System is organized differently and the on-ward role of hospital pharmacists in Dutch ICU teams is not well established, we conducted an intervention study to investigate whether participation of a hospital pharmacist can also be an effective approach in reducing prescribing errors and related patient harm (preventable ADEs) in this specific setting.

Methods

A prospective study compared a baseline period with an intervention period. During the intervention period, an ICU hospital pharmacist reviewed medication orders for patients admitted to the ICU, noted issues related to prescribing, formulated recommendations and discussed those during patient review meetings with the attending ICU physicians. Prescribing issues were scored as prescribing errors when consensus was reached between the ICU hospital pharmacist and ICU physicians.

Results

During the 8.5-month study period, medication orders for 1,173 patients were reviewed. The ICU hospital pharmacist made a total of 659 recommendations. During the intervention period, the rate of consensus between the ICU hospital pharmacist and ICU physicians was 74%. The incidence of prescribing errors during the intervention period was significantly lower than during the baseline period: 62.5 per 1,000 monitored patient-days versus 190.5 per 1,000 monitored patient-days, respectively (P < 0.001). Preventable ADEs (patient harm, National Coordinating Council for Medication Error Reporting and Prevention severity categories E and F) were reduced from 4.0 per 1,000 monitored patient-days during the baseline period to 1.0 per 1,000 monitored patient-days during the intervention period (P = 0.25). Per monitored patient-day, the intervention itself cost €3, but might have saved €26 to €40 by preventing ADEs.

Conclusions

On-ward participation of a hospital pharmacist in a Dutch ICU was associated with significant reductions in prescribing errors and related patient harm (preventable ADEs) at acceptable costs per monitored patient-day.

Trial registration number

ISRCTN92487665

Non-therapeutic omission of medications in acutely ill patients

AIMS AND OBJECTIVES

To examine documentation of medication administration in medical and surgical patients.

STUDY OBJECTIVES

(1) Determine the point prevalence of non-therapeutic medication omissions; (2) identify documented reasons for non-therapeutic medication omissions; (3) examine the relationship between length of stay and medication omissions; and (4) explore the impact of outlier status (e.g. medical patients managed on surgical wards) on medication administration.

BACKGROUND

Acutely ill patients are particularly sensitive to health care errors. We previously identified a 26% rate of non-therapeutic medication omissions in patients admitted unexpectedly to intensive care unit (ICU) from medical and surgical wards.

DESIGN

A point prevalence survey of 162 medical and surgical patients across four sites in the South West of England.

METHOD

Data collected included: all instances of, and reasons for, non-therapeutic medication omission. We also recorded whether the patient was an 'outlier' and examined nursing documentation where no reason for medication omission was given on the drug chart.

RESULTS

The number of patients who missed at least one medication was high across all sites (n = 129/162; 79.6%, range 60-88%), with a total of 1077 doses omitted. Patients who were outliers (e.g. surgical patients on a medical ward) were more likely to miss medications (100% versus 74%, p < 0.001). The most common missed medications were analgesia and anti-inflammatory drugs (28%, 299/1077); 203 of these were due to patient refusal.

CONCLUSIONS

The extent of medications omitted for non-therapeutic reasons in medical and surgical patients is of concern. None were recorded as an adverse drug event; however, the extent of omitted or refused medications suggests the need for a review of prescribing and drug administration processes. These findings have important implications for the role of ICU outreach and liaison services, for example, including medication management in the monitoring of patients pre/post-ICU admission and support/education provided for ward staff.

RELEVANCE TO CLINICAL PRACTICE

Detailed analysis of medication records suggests a number of areas of medication administration that would benefit from review.

Genetic predisposition to adverse drug reactions in the intensive care unit

Adverse drug reactions are a significant public health problem that leads to mortality, hospital admissions, an increased length of stay, increasing healthcare costs, and withdrawal of drugs from market. Intensive care unit patients are particularly vulnerable and are at an elevated risk. Critical care practitioners, regulatory agencies, and the pharmaceutical industry aggressively seek biomarkers to mitigate patient risk. The rapidly expanding field of pharmacogenomics focuses on the genetic contributions to the variability in drug response. Polymorphisms may explain why some groups of patients have the expected response to pharmacotherapy whereas others experience adverse drug reactions. Historically, genetic association studies have focused on characterizing the effects of variation in drug metabolizing enzymes on pharmacokinetics. Recent work has investigated drug transporters and the variants of genes encoding drug targets, both intended and unintended, that comprise pharmacodynamics. This has led to an appreciation of the role that genetics plays in adverse drug reactions that are either predictable extensions of a drug's known therapeutic effect or idiosyncratic.This review presents the evidence for a genetic predisposition to adverse drug reactions, focusing on gene variants producing alterations in drug pharmacokinetics and pharmacodynamics in intensive care unit patients. Genetic biomarkers with the strongest associations to adverse drug reaction risk in the intensive care unit are presented along with the medications involved. Variant genotypes and phenotypes, allelic frequencies in different populations, and clinical studies are discussed. The article also presents the current recommendations for pharmacogenetic testing in clinical practice and explores the drug, patient, research study design, regulatory, and practical issues that presently limit more widespread implementation.

Adverse drug reactions in medical intensive care unit of a tertiary care hospital

PURPOSE

Patients in the intensive care unit (ICU) have multiorgan dysfunction as well as altered pharmacokinetic parameters. Hence they are susceptible to adverse drug reactions (ADRs). The objective of the study is to assess the characteristics of ADRs among inpatients in the medical ICU and to compare the same with patients who have not experienced ADRs.

METHODS

Prospective, observational study for a period of 1 year in medical ICU of a tertiary care hospital. Relevant data of patients with ADRS were analysed. Characteristics of patients with and without ADRs were compared.

RESULTS

Of 728 patients admitted in medical ICU, 222 (28.4%) had ADRs. Multiple ADRs (38.7%) implicated by the same drug and serious ADRs (37%) were noticed. Renal/electrolyte system (21%) was most commonly involved. Clinical spectrum included acute renal failure (ARF, 11.4%), hepatic injuries (5.4%), haematological dysfunction (4.2%), seizures (3.3%), upper gastrointestinal bleed (3.3%) and cutaneous ADRs (3.3%). Antimicrobials (27%) were the commonly implicated drug class. The most commonly implicated drug was furosemide (6.8%). Infrequently reported ADRs included azithromycin-induced erythema multiforme, leflunamide-induced erythema multiforme and vasculitis, ceftazidime-induced seizures and ceftriaxone-induced hepatitis. Co-morbidity, polypharmacy and duration of stay were significantly higher in patients with ADRs compared to those who have not experienced ADRs. Three patients died.

CONCLUSION

High incidence of serious and multiple ADRs noticed. A wide clinical spectrum of ADRs and infrequently reported ADRs to newer drugs were also observed.

Propofol infusion syndrome

Propofol (Diprivan) is an intravenous sedative hypnotic that is used in the induction and maintenance of anesthesia and sedation. High-dose infusions have been associated with several serious adverse effects and, when combined, they are known as propofol infusion syndrome (PRIS). Although PRIS is rare, it is frequently fatal if not identified early. The purpose of this article is to raise practitioner awareness to this syndrome, with recommendations for early identification, prevention, and treatment of PRIS.

A primer on critical care pharmacy services

The intensive care unit (ICU) continues to be a major focus of decentralized pharmacy activities in health systems that care for critically ill patients. This is not surprising, given the need for rapid decision-making involving unstable patients, the large number of powerful medications typically used per patient, the high cost of many drugs used in the ICU and, most importantly, the evidence demonstrating the benefits of having a pharmacist as part of an interdisciplinary team. The purpose of this paper is to highlight important issues to consider when introducing or developing critical care pharmacy services beginning with the establishment of basic services and continuing through practitioner development, guideline/protocol development and implementation, patient safety, residency training, and research.