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Magrum B, Smetana KS, Thompson M, Elefritz JL, Phelps M, Trolli E, Murphy CV. Characterization of Medication Discrepancies and Interventions Resulting From Pharmacy-Led Medication Reconciliation in the Critical Care Setting. J Pharm Pract 2024; 37:587-592. [PMID: 36592435 DOI: 10.1177/08971900221149788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Medication reconciliation has been shown to reduce medication-related errors in hospitalized patients, but the impact of pharmacy-led medication reconciliation in the intensive care unit (ICU) has not been extensively studied. Methods: This was a retrospective chart review of patients with a pharmacy-led medication reconciliation on admission to an ICU between January 1st and March 31st, 2018. Pharmacy-led medication reconciliations were completed by pharmacists, pharmacy residents, and pharmacy students. The objective of this study was to describe medication discrepancies identified by pharmacy-led medication reconciliation and to evaluate the interventions following. Results: A total of 288 patients were screened and 247 met inclusion criteria. There were 1148 medication discrepancies identified resulting in an average of 4.65 discrepancies per patient. Medication addition (54.25%) and medication deletion (45.75%) were most common. Within 24 hours of medication reconciliation, 214 interventions were made to active orders. No differences were observed between discrepancies identified and type of pharmacy staff completing the medication reconciliation. Conclusions: This study identified a high rate of medication discrepancies on admission to the ICU. Furthermore, it describes the types of pharmacist interventions following pharmacy-led medication reconciliation. This process may be impactful to incorporate as a standard practice in ICUs and warrants further investigation into value, cost, and pharmacist workflow.
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Affiliation(s)
- BrookeAnne Magrum
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Molly Thompson
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jessica L Elefritz
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Megan Phelps
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Elizabeth Trolli
- The Ohio State University College of Pharmacy, Columbus, OH, USA
| | - Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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May CC, Holden D, Robbins BT, Cook AM, Jung S, Smetana KS, Roels C, Harlan SS, Keegan S, Brophy G, Al Mohaish S, Sandler M, Spetz S, Wohlfarth K, Owusu-Guha J, Buschur P, Hetrick E, Dombrowski K, Glover J, Levesque M, Dingman S, Hussain M. Multicenter Comparison of the Safety and Efficacy of Clopidogrel Versus Ticagrelor for Neuroendovascular Stents. Neurocrit Care 2024; 40:262-271. [PMID: 37322326 DOI: 10.1007/s12028-023-01749-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is commonly employed for neuroendovascular stenting due to the significant risk of thromboembolism. Clopidogrel and aspirin are most often selected as initial DAPTs; however, there is limited literature available to support guidance of DAPT in this setting. The objective of this study was to evaluate safety and efficacy in patients whose final regimen included either DAPT with aspirin and clopidogrel (DAPT-C) or DAPT with aspirin and ticagrelor (DAPT-T). METHODS This was a multicenter, retrospective cohort of patients who underwent neuroendovascular stenting and received DAPT between July 1, 2017, and October 31, 2020. Study participants were allocated into groups based on discharge DAPT regimen. The primary outcome was incidence of stent thrombosis at 3-6 months on DAPT-C versus DAPT-T, as defined by the presence of thrombus on imaging or new onset stroke. Secondary outcomes included major and minor bleeding and death within 3-6 months after the procedure. RESULTS Five hundred and seventy patients were screened across 12 sites. Of those, 486 were included (DAPT-C n = 360, DAPT-T n = 126). There was no difference in the primary outcome of stent thrombosis between the DAPT-C and DAPT-T groups (8% vs. 8%, p = 0.97) and no difference in any of the secondary safety outcomes. CONCLUSIONS Using DAPT-C or DAPT-T regimens in a broad population of neuroendovascular stenting procedures appears to have similar safety and efficacy profiles. Further prospective evaluation is warranted to streamline the practice of DAPT selection and monitoring to determine the impact on clinical outcomes.
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Affiliation(s)
- Casey C May
- Department of Pharmacy Practice and Science, The Ohio State University College of Pharmacy, 214A Parks Hall, 500 12th Ave, Columbus, OH, 4321, USA.
| | - Devin Holden
- Department of Pharmacy, Albany Medical Center, Albany, NY, USA
| | - Blake T Robbins
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
| | - Aaron M Cook
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
| | - Sara Jung
- Wellstar Kennestone Hospital, Marietta, GA, USA
| | | | - Christina Roels
- Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | | | - Shaun Keegan
- University of Cincinnati Medical Center, Cincinnati, OH, USA
| | | | | | | | | | | | | | - Pamela Buschur
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | | | - Keith Dombrowski
- University of South Florida/Tampa General Hospital, Tampa, FL, USA
| | - Jennifer Glover
- University of South Florida/Tampa General Hospital, Tampa, FL, USA
| | - Melissa Levesque
- University of South Florida/Tampa General Hospital, Tampa, FL, USA
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Atyia SA, Gerlach AT, Smetana KS, Thompson MJ, May CC. Evaluation of Dexmedetomidine's Effect on Temperature in Obese Critically Ill Patients. J Pharm Pract 2024; 37:47-53. [PMID: 36056532 DOI: 10.1177/08971900221125015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Previous literature showed an association between hyperthermia and dexmedetomidine (DEX) use for ongoing sedation in non-obese patients. The purpose of this study is to evaluate DEX's effect on temperature in obese critically ill patients. Methods: This single center, retrospective, cohort study included patients ≥18 years, admitted to a surgical or medical ICU, received DEX for ≥8 hours as a single continuous infusion sedative, and weighed ≥120% of ideal body weight. Patients were excluded if they had a fever (≥38°C) and positive cultures within 48 hours of DEX initiation. The primary endpoint was a fever (Tmax of ≥38°C) within 48 hours of DEX initiation. Results: A total of 186 patients were included for evaluation. Forty-two patients (22.5%) had a fever during the first 48 hours of DEX initiation. Median weight was not different between the febrile and afebrile groups (99.4 [90.6-122.4] vs 97.6 [81.6-114.2] kg, P = .6). Median change from baseline temperature for all patients within 48 hours was an increase of .5 (.1-.8) °C, P < .001. In multiple regression analysis, duration of DEX and baseline temperature were the only significant predictors of fever development with an adjusted odds ratio of 1.041 (95% CI 1.009-1.074, P = .012) and 7.058 (95% CI 3.307-15.064, P < .001), respectively. Conclusions: This study suggests that there is a significant increase in body temperature from baseline for obese patients on DEX. Duration of DEX and baseline temperature were found to be risk factors for fever development in this population. Further studies are warranted.
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Affiliation(s)
- Sara A Atyia
- Department of Pharmacy,The Ohio State University Wexner Medical Center East Hospital, Columbus, OH, USA
| | - Anthony T Gerlach
- Department of Pharmacy,The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Keaton S Smetana
- Department of Pharmacy,The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Molly J Thompson
- Department of Pharmacy,The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Casey C May
- Department of Pharmacy,The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Smetana KS, Wilcox KJ, Cook AM. Implementing In-House Compounding of Nimodipine Oral Syringes for Aneurysmal Subarachnoid Hemorrhage Patients. Hosp Pharm 2023; 58:525-526. [PMID: 38560535 PMCID: PMC10977069 DOI: 10.1177/00185787231184150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
| | | | - Aaron M. Cook
- University of Kentucky HealthCare, College of Pharmacy, Lexington, KY, USA
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Holden D, May CC, Robbins BT, Cook AM, Jung S, Smetana KS, Roels C, Harlan SS, Keegan S, Brophy G, Al Mohaish S, Sandler M, Spetz S, Wohlfarth K, Owusu-Guha J, Buschur P, Hetrick E, Dombrowski K, Glover J, Levesque M, Dingman S, Hussain M. Multicenter comparison of antiplatelet treatment strategies for urgent/emergent neuroendovascular stenting. Interv Neuroradiol 2023:15910199231180003. [PMID: 37402388 DOI: 10.1177/15910199231180003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Emergent neuroendovascular stenting presents challenges for the utilization of antiplatelet agents. METHODS This was a multicenter, retrospective cohort of patients who underwent emergent neuroendovascular stenting. The primary endpoints were thrombotic and bleeding events in relation to the timing of antiplatelet administration, route of administration, and choice of intravenous (IV) agent and the study investigated practice variability in antiplatelet utilization. RESULTS Five-hundred and seventy patients were screened across 12 sites. Of those, 167 were included for data analysis. For patients who presented with ischemic stroke, artery dissection and emergent internal carotid artery (ICA) stenting who received an antiplatelet agent prior to or during the procedure, 57% were given an IV antiplatelet agent; for patients who were given an antiplatelet agent after the procedure, 96% were given an oral agent. For patients who presented for aneurysm repair and received an antiplatelet agent prior to or during the procedure, 74% were given an IV agent; patients who were given an antiplatelet agent after the completion of the procedure were given an oral antiplatelet agent 90% of the time. In patients who presented with ischemic stroke, artery dissection and emergent ICA stenting who received oral antiplatelet agents post-procedure were more likely to have thrombotic events compared to those who received oral antiplatelet agents prior to or during the procedure (29% vs 9%; p = 0.04). There were no differences in the primary outcomes observed when comparing other antiplatelet treatment strategies. CONCLUSION The optimal timing of antiplatelet administration in relation to stent placement and route of administration of antiplatelet agents is unclear. Timing and route of administration of antiplatelet agents may have an effect on thrombosis in emergent neuroendovascular stenting. Significant practice variation exists in antiplatelet agent utilization in emergent neuroendovascular stenting.
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Affiliation(s)
- Devin Holden
- Department of Pharmacy, Albany Medical Center, Albany, NY, USA
| | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Blake T Robbins
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
| | - Aaron M Cook
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
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He H, Atyia SA, Smetana KS, May CC. Retrospective evaluation of dexmedetomidine dosing in a cohort of neurologically injured obese critically ill patients. Int J Crit Illn Inj Sci 2023; 13:48-53. [PMID: 37547192 PMCID: PMC10401559 DOI: 10.4103/ijciis.ijciis_74_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/13/2022] [Accepted: 01/09/2023] [Indexed: 08/08/2023] Open
Abstract
Background Dexmedetomidine is used in neurocritical care units (NCCUs) due to the light, dose-dependent sedation, and anxiolysis provided. It is unknown how to dose dexmedetomidine in obese patients. The primary objective is to assess the ability to achieve the goal Richmond Agitation Sedation Scale (RASS) measurements in obese patients with a neurological injury who are solely on dexmedetomidine before and after an institutional dosing change from actual body weight (ABW) to adjusted body weight (AdjBW). Methods This study included patients admitted to the NCCU with a neurological condition, required dexmedetomidine for at least 8 h as a sole sedative, and weighed ≥120% of ideal body weight. Percentage of RASS measurements within the goal range (-1 to +1) during the first 48 h while on dexmedetomidine were compared between patients dosed on ABW and on AdjBW. Results Sixty-eight patients in the ABW cohort and 72 patients in the AdjBW cohort were included. There were no statistical differences between the two groups (ABW vs. AdjBW) in the percent of RASS measurements in the goal range (53.2% ± 34.8% vs. 55% ± 37%; P = 0.78), mean weight (99.2 ± 26 vs. 96.8 ± 20.9 kg; P = 0.55), or the average dose of dexmedetomidine required to achieve first goal RASS score (0.4 ± 0.3 vs. 0.4 ± 0.3 mcg/kg/h; P = 0.98). Conclusions Dosing dexmedetomidine using AdjBW in obese critically ill neurologically injured patients for ongoing sedation resulted in no statistical difference in the percent of RASS measurements within the goal when compared to ABW dosing. Further studies are warranted.
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Affiliation(s)
- Harrison He
- Department of Pharmacy, The Ohio State University Wexner Medical Center, OH, USA
- Pharmacy Practice and Science, The Ohio State University College of Pharmacy, OH, USA
| | - Sara A. Atyia
- Department of Pharmacy, The Ohio State University Wexner Medical Center, OH, USA
| | - Keaton S. Smetana
- Department of Pharmacy, Ohio Health Riverside Methodist Hospital, Columbus, OH, USA
| | - Casey C. May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, OH, USA
- Pharmacy Practice and Science, The Ohio State University College of Pharmacy, OH, USA
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7
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Abstract
BACKGROUND Dexmedetomidine is a highly selective α2-adrenoreceptor agonist that produces dose-dependent sedation, anxiolysis, and analgesia without respiratory depression. Due to these ideal sedative properties, there has been increased interest in utilizing dexmedetomidine as a first-line sedative for critically ill patients requiring light sedation. OBJECTIVE To evaluate the ability to achieve goal intensive care unit (ICU) sedation before and after an institutional change of dosing from actual (ABW) to adjusted (AdjBW) body weight in obese patients on dexmedetomidine. METHODS This study included patients ≥ 18 years old, admitted to a surgical or medical ICU, required dexmedetomidine for at least 8 hours as a single continuous infusion sedative, and weighed ≥ 120% of ideal body weight. Percentage of RASS measurements within goal range (-1 to +1) during the first 48 hours after initiation of dexmedetomidine as the sole sedative agent or until discontinuation dosed on ABW compared to AdjBW was evaluated. RESULTS 100 patients were included in the ABW cohort and 100 in the AdjBW cohort. The median dosing weight was significantly higher in the ABW group (95.9 [78.9-119.5] vs 82.2 [72.1-89.8] kg; p = 0.001). There was no statistical difference in percent of RASS measurements in goal range (61.5% vs 69.6%, p = 0.267) in patients that received dexmedetomidine dosed based on ABW versus AdjBW. CONCLUSION Dosing dexmedetomidine using AdjBW in obese critically ill patients for ongoing ICU sedation resulted in no statistical difference in the percent of RASS measurements within goal when compared to ABW dosing. Further studies are warranted.
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Affiliation(s)
- Sara A Atyia
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Minh C Tong
- The Ohio State University College of Pharmacy, Columbus, OH, USA
| | - Molly J Thompson
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kari M Cape
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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8
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Vlashyn OO, Murphy CV, Cape K, Phelps MK, Nunez SM, Hafford A, Jordan TA, Smetana KS. Evaluation of an Electronic Health Record Documentation Tool Use to Improve Pharmacist Intervention Tracking in the Intensive Care Unit. J Am Coll Clin Pharm 2023. [DOI: 10.1002/jac5.1752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Olga O. Vlashyn
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Claire V. Murphy
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Kari Cape
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Megan K. Phelps
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Samara M. Nunez
- The Ohio State University College of Pharmacy Columbus Ohio USA
| | - Amanda Hafford
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Trisha A. Jordan
- The Ohio State University Wexner Medical Center, Pharmacy, 410 W 10th Ave, Room 368 Doan Hall Columbus Ohio United States
| | - Keaton S. Smetana
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
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Abstract
Background and Objective: Urea is an alternative for treatment of hyponatremia however, its use has not been widely studied. The purpose of this study was to evaluate the safety and efficacy of urea for the treatment of hyponatremia. Methods: A retrospective cohort of patients with hyponatremia (serum sodium <135 mEq/L) of any cause who received at least 1 dose of urea during hospitalization and no prior use of urea. Serum sodium levels were collected at baseline and for 4 days or until urea was discontinued, whichever occurred first. The primary outcome was the serum sodium change between baseline and discharge or urea discontinuation. Results: Median serum sodium increased 2 [IQR, 0-4] mEq/L per day after urea administration at a median dose of 30 g/day. A significant difference in serum sodium was observed between baseline and discharge or discontinuation (124.2 ± 4 vs 130.1 ± 5.1; P < .001) and serum blood urea nitrogen (BUN) levels (18.4 ± 13.1 vs 41.1 ± 26.6; P ≤ .001). Serum sodium overcorrection (increase >8 mEq/L in 24 hours) occurred in 6 patients (8%). Urea was discontinued in 39 patients (53%); 20 discontinuations were due to patient intolerance. Conclusion: Urea appears to be an effective treatment for hyponatremia; however, patient tolerance, the rate of serum sodium overcorrection, and outpatient affordability may limit its use.
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Affiliation(s)
| | - Ellen A. Keating
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Megan E. Smetana
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Megan M. Bond
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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May CC, Atyia SA, Hafford AJ, Smetana KS. Clinical Advanced Pharmacy Practice Experience Rotations During COVID-19: Evaluation of a Transition to Virtual Learning. J Pharm Pract 2022:8971900221087116. [PMID: 35387511 PMCID: PMC9001055 DOI: 10.1177/08971900221087116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background All Advanced Pharmacy Practice Experience (APPE) pharmacy rotations at a large academic medical center were converted to virtual experiences during the beginning of the coronavirus disease 2019 (COVID-19) pandemic. Objective This study aimed to describe information obtained through pre- and post-rotation surveys, implemented to improve experiences for future students who may be required to complete virtual APPE pharmacy rotations. Methods A single-center, descriptive study was conducted at a 1382-bed academic medical center. A pre- and post-rotation survey was sent to 32 students, and a post-rotation survey was sent to 38 preceptors via email to assess newly implemented virtual rotations. Results Students’ response rate for pre- and post-rotation surveys was 59% and 41%, respectively, and the preceptors’ response rate for the post-rotation survey was 37%. A statistically significant improvement in videoconferencing abilities after the rotation was found for students but no differences in other skills were noted. In the post-rotation survey, students rated all of the following areas as being “effective”: rotation as a whole, virtual topic and patient discussions; but were “neutral” regarding the utility of the introductory training guide. In the post-rotation survey, preceptors rated all of the following areas as being “effective”: rotation as a whole, virtual topic and patient discussions. Conclusion Abrupt shifts to virtual pharmacy clinical rotations due to COVID-19 have led to many challenges. Both students and preceptors felt that virtual rotations were an effective alternative to in-person experiences; however, further studies are warranted to evaluate actual performance compared to perceived effectiveness.
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Affiliation(s)
- Casey C May
- 12306The Ohio State University Wexner Medical Center, Department of Pharmacy, Columbus, OH, USA
| | - Sara A Atyia
- 12306The Ohio State University Wexner Medical Center, Department of Pharmacy, Columbus, OH, USA
| | - Amanda J Hafford
- 12306The Ohio State University Wexner Medical Center, Department of Pharmacy, Columbus, OH, USA
| | - Keaton S Smetana
- 12306The Ohio State University Wexner Medical Center, Department of Pharmacy, Columbus, OH, USA
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Smetana KS, Counts J, Sodhi A, May CC. Review of Target-Specific Anticoagulation Reversal Agents. Crit Care Nurs Q 2022; 45:180-188. [PMID: 35212657 DOI: 10.1097/cnq.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bleeding related to direct oral anticoagulants accounts for nearly half of emergency department visits annually and until recently there were no reversal antidotes available. As there continues to be a shift in prescribing practices away from warfarin, it is essential to have these reversal agents readily available for the treatment of life-threatening bleeds associated with these anticoagulants. In addition, for agents that continue to lack a targeted reversal agent (eg, low-molecular-weight heparin, antiplatelets, and new antithrombotics), it is imperative that research continues to evaluate improved reversal strategies. This review focuses on target-specific anticoagulation reversal agents currently available in the United States (protamine, idarucizumab, and andexanet alfa) and summarizes agents that are in the pipeline for these anticoagulants and antiplatelets.
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Affiliation(s)
- Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus
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12
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McManus J, Ferreira J, Jones GM, Smetana KS, Condeni MS, Berger K, Witenko C, Smotherman C, Gautam S, Pizzi MA, Erdman MJ. Effect of desmopressin acetate on acute spontaneous intracranial hemorrhage in patients on antiplatelet therapy. J Neurol Sci 2022; 434:120142. [DOI: 10.1016/j.jns.2022.120142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/09/2021] [Accepted: 01/01/2022] [Indexed: 10/19/2022]
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Abstract
The application of machine learning has rapidly evolved in medicine over the past decade. In stroke, commercially available machine learning algorithms have already been incorporated into clinical application for rapid diagnosis. The creation and advancement of deep learning techniques have greatly improved clinical utilization of machine learning tools and new algorithms continue to emerge with improved accuracy in stroke diagnosis and outcome prediction. Although imaging-based feature recognition and segmentation have significantly facilitated rapid stroke diagnosis and triaging, stroke prognostication is dependent on a multitude of patient specific as well as clinical factors and hence accurate outcome prediction remains challenging. Despite its vital role in stroke diagnosis and prognostication, it is important to recognize that machine learning output is only as good as the input data and the appropriateness of algorithm applied to any specific data set. Additionally, many studies on machine learning tend to be limited by small sample size and hence concerted efforts to collate data could improve evaluation of future machine learning tools in stroke. In the present state, machine learning technology serves as a helpful and efficient tool for rapid clinical decision making while oversight from clinical experts is still required to address specific aspects not accounted for in an automated algorithm. This article provides an overview of machine learning technology and a tabulated review of pertinent machine learning studies related to stroke diagnosis and outcome prediction.
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Affiliation(s)
- Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - Marin E Darsie
- Department of Emergency Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI, United States.,Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, United States
| | - Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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May CC, Harris EA, Hannawi Y, Smetana KS. Evaluation of energy intake compared with indirect calorimetry requirements in critically ill patients with acute brain injury. JPEN J Parenter Enteral Nutr 2021; 46:1176-1182. [PMID: 34665471 DOI: 10.1002/jpen.2282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nutrition support in critically ill patients with acute brain injury is vitally important because of known hypermetabolism. We aimed to describe energy and protein intake within the first 72 h in a broad neurocritical care population and compare energy intake with the indirect calorimetry (IC) resting energy expenditure (REE) target. METHODS IC data, daily energy, and protein intake were collected through chart review over the first 7 days of hospital admission. We evaluated the type and amount of tube-feed product received, volume of propofol (1.1 kcal/ml) and clevidipine (2 kcal/ml), and amount of supplemental protein received. RESULTS Ninety-one patients were included, with the majority presenting with either intracerebral hemorrhage (35.2%) or acute ischemic stroke (26.4%). The median day of admission on which IC was completed and enteral nutrition was initiated was day 3 (2-5) and day 1 (1-2), respectively. The difference in kilocalories received compared with IC REE target within the first 72 h was significantly different (2831 kcal [1663-4072] vs 4275 kcal [3450-5811]; Z = -6.469; P < .001). The median kilocalories received as tube feeds during the first 72 h was 88% (55%-99%), and the mean protein received in the first 72 h was 0.7 ± 0.5 g/kg/day. CONCLUSION In this population, patients had lower energy intake compared with their energy needs determined by IC during the first 72 h of admission but attained 7-day goals. Future studies should investigate barriers to improve energy delivery in this patient population.
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Affiliation(s)
- Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emily A Harris
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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May CC, Cua S, Smetana KS, Powers CJ. Supraprophylactic Anti-Factor Xa Levels Are Associated with Major Bleeding in Neurosurgery Patients Receiving Prophylactic Enoxaparin. World Neurosurg 2021; 157:e357-e363. [PMID: 34655821 DOI: 10.1016/j.wneu.2021.10.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Prior studies demonstrated reduced risk for venous thromboembolism (VTE) in neurosurgical patients secondary to prophylaxis with both heparin and low-molecular-weight heparin. The ability to monitor low-molecular-weight heparin by obtaining anti-factor Xa (anti-Xa) serum levels provides an opportunity to evaluate safety and efficacy. The aim of this study was to describe characteristics of patients who have anti-Xa levels outside of the goal range (0.2-0.4/0.5 IU/mL) and investigate incidence of major bleeding and VTE. METHODS A single-center, retrospective, observational study was conducted on neurosurgical patients receiving enoxaparin for VTE prophylaxis between August 2019 and December 2020. Significance testing was conducted via Fisher exact test and independent samples t test. RESULTS The study included 85 patients. Patients were less likely to have an anti-Xa level in the goal range if they were male, had a higher weight, or were morbidly obese. Three neuroendovascular patients (3.5%) experienced a major bleed. Serum anti-Xa levels were significantly higher in patients who experienced major bleeds compared with patients who did not (0.45 ± 0.16 IU/mL vs. 0.28 ± 0.09 IU/mL, P = 0.003). Patients with a supraprophylactic anti-Xa level (>0.5 IU/mL) were more likely to experience a major bleed (P = 0.005). One VTE event occurred: the patient experienced a pulmonary embolism with anti-Xa level at goal. CONCLUSIONS Anti-Xa-guided enoxaparin dosing for VTE prophylaxis in neurosurgical patients may help prevent major bleeding. These data suggest that a higher anti-Xa level may predispose patients to major bleeding. Further evaluation is needed to identify the goal anti-Xa level for VTE prophylaxis in this population.
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Affiliation(s)
- Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| | - Santino Cua
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ciarán J Powers
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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May CC, Mahle J, Harper D, Smetana KS. Pharmacy-Based Nursing Education Utilizing a Social Media Platform. Crit Care Nurs Q 2021; 44:360-367. [PMID: 34437314 DOI: 10.1097/cnq.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Social media has changed the way individuals communicate and recently multiple articles have been published highlighting the utilization of social media for education. To our knowledge, cross-discipline education utilizing these platforms has not been evaluated. The purpose of this study was to implement a pharmacist-led, social media-based nursing education program and evaluate the perceived value. A curriculum of pharmacy-related issues was developed and topics were posted to the neurocritical care unit (NCCU) Facebook group or emailed to non-Facebook users weekly. A pre- and posteducation survey was sent out evaluating the program's effectiveness. Thirty-seven nurses were members of the NCCU Facebook group and 33 received the education via email. A total of 29% and 19% of nurses completed the pre- and posteducation survey, respectively. Of those who completed the survey, 36% received education via Facebook. As compared with the preeducation survey, there were no statistically significant differences in nursing performance on fact-based questions (P value > .05 on all assessment questions); however, 100% of respondents wanted to continue this education delivery. Utilizing social media as a means of cross-discipline education was well-received; however, the solitary utilization should be used cautiously, as performance did not improve on assessment questions.
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Affiliation(s)
- Casey C May
- Department of Pharmacy (Drs May and Smetana), Neurologic Institute (Ms Mahle), and Central Quality & Education (Ms Harper), The Ohio State University Wexner Medical Center, Columbus
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Faulds ER, Boutsicaris A, Sumner L, Jones L, McNett M, Smetana KS, May CC, Buschur E, Exline MC, Ringel MD, Dungan K. Use of Continuous Glucose Monitor in Critically Ill COVID-19 Patients Requiring Insulin Infusion: An Observational Study. J Clin Endocrinol Metab 2021; 106:e4007-e4016. [PMID: 34100545 DOI: 10.1210/clinem/dgab409] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Indexed: 12/11/2022]
Abstract
CONTEXT The coronavirus disease 2019 (COVID-19) pandemic has created a need for remote blood glucose (BG) monitoring in the intensive care unit (ICU). OBJECTIVE To evaluate feasibility and patient safety of a hybrid monitoring strategy of point-of-care (POC) BG plus continuous glucose monitor (CGM) in the ICU. DESIGN Retrospective analysis. SETTING ICU of an academic medical center. PATIENTS Patients with COVID-19 on IV insulin. INTERVENTION After meeting initial validation criteria, CGM was used for IV insulin titration and POC BG was performed every 6 hours or as needed. MAIN OUTCOME MEASURES Outcomes included frequency of POC BG, workflow, safety, and accuracy measures. RESULTS The study included 19 patients, 18 with CGM data, mean age 58 years, 89% on mechanical ventilation, 37% on vasopressors, and 42% on dialysis. The median time to CGM validation was 137 minutes (interquartile range [IQR] 114-206). During IV insulin, the median number of POC values was 7 (IQR 6-16) on day 1, and declined slightly thereafter (71% reduction compared with standard of 24/day). The median number of CGM values used nonadjunctively to titrate IV insulin was 11.5 (IQR 0, 15) on day 1 and increased thereafter. Time in range 70 to 180 mg/dL was 64 ± 23% on day 1 and 72 ± 16% on days 2 through 7, whereas time <70 mg/dL was 1.5 ± 4.1% on day 1 and <1% on days 2 through 7. CONCLUSIONS This study provides data to support that CGM using a hybrid protocol is feasible, accurate, safe, and has potential to reduce nursing and staff workload.
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Affiliation(s)
- Eileen R Faulds
- The Ohio State University College of Nursing, The Ohio State University Medical Center, Columbus, OH, USA
| | | | - Lyndsey Sumner
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Laureen Jones
- The Ohio State University Medical Center, Columbus, OH, USA
| | - Molly McNett
- Implementation/Translation Science Core, Helene Fuld Health Trust National Institute for EBP, Columbus, OH, USA
| | | | - Casey C May
- The Ohio State University Medical Center, Columbus, OH, USA
| | - Elizabeth Buschur
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, OH, USA
| | - Matthew C Exline
- Division of Critical Care Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Matthew D Ringel
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, OH, USA
| | - Kathleen Dungan
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, OH, USA
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Smetana KS, Zakeri A, Dolia J, Huttinger A, May CC, Youssef P, Gross BA, Nimjee SM. Management of tandem occlusions in patients who receive rtPA. J Thromb Thrombolysis 2021; 52:1182-1186. [PMID: 34160743 DOI: 10.1007/s11239-021-02510-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tandem occlusions exist in 17-32% of large vessel occlusion (LVO) strokes. A significant concern is bleeding when carotid stenting is performed in tandem with thrombectomy due the administration of antiplatelet agents such as glycoprotein IIb/IIIa inhibitors (GP2b3aI) after receiving rtPA, but data are limited in this setting. METHODS A mutlicenter, retrospective chart review was conducted at two comprehensive stroke centers to assess the safety and efficacy of using GP2b3aI to facilitate carotid stent placement simultaneously with endovascular thrombectomy in patients who have received rtPA. RESULTS Overall, 32 patients were included in this study, with average age of 66.3 ± 10.4 years and predominantly male (87.5%). The cause of stroke was mostly large artery atherosclerosis (59.4%) and the thrombectomy target vessels were typically first- or second segment middle cerebral artery (37.5% and 31.3%). Time from symptom onset to rtPA bolus was 1.8 h [interquartile range (IQR) 1.5-2.7], rtPA bolus to first pass was 2 h [IQR 1.5-3.1], rtPA bolus to GP2b3aI bolus was 2 h [IQR 1.6-3.5], and rtPA bolus to aspirin and clopidogrel administration was 4.3 h [IQR 2.6-8.9] and 6.6 h [IQR 4.5-11.6] respectively. No patients had acute in-stent thrombosis or post-op bleeding from the access site. Two patients (6.3%) had significant hemorrhagic conversion. CONCLUSION The use of GP2b3aI in the setting of tandem occlusions that required emergent stent placement post-rtPA appears safe and effective. Given the small sample size, these findings should be interpreted cautiously, and need to be confirmed in a larger patient population.
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Affiliation(s)
- Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amanda Zakeri
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Jaydevsinh Dolia
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Patrick Youssef
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH, 43210, USA.
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Rech MA, Adams W, Smetana KS, Gurnani PK, Van Berkel Patel MA, Peppard WJ, Hammond DA, Flannery AH. PHarmacist Avoidance or Reductions in Medical Costs in Patients Presenting the EMergency Department: PHARM-EM Study. Crit Care Explor 2021; 3:e0406. [PMID: 33912836 PMCID: PMC8078282 DOI: 10.1097/cce.0000000000000406] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To comprehensively classify interventions performed by emergency medicine clinical pharmacists and quantify cost avoidance generated through their accepted interventions. DESIGN A multicenter, prospective, observational study was performed between August 2018 and January 2019. SETTING Community and academic hospitals in the United States. PARTICIPANTS Emergency medicine clinical pharmacists. INTERVENTIONS Recommendations classified into one of 38 intervention categories associated with cost avoidance. MEASUREMENTS AND MAIN RESULTS Eighty-eight emergency medicine pharmacists at 49 centers performed 13,984 interventions during 917 shifts that were accepted on 8,602 patients and generated $7,531,862 of cost avoidance. The quantity of accepted interventions and cost avoidance generated in six established categories were as follows: adverse drug event prevention (1,631 interventions; $2,225,049 cost avoidance), resource utilization (628; $310,582), individualization of patient care (6,122; $1,787,170), prophylaxis (24; $22,804), hands-on care (3,533; $2,836,811), and administrative/supportive tasks (2,046; $342,881). Mean cost avoidance was $538.61 per intervention, $875.60 per patient, and $8,213.59 per emergency medicine pharmacist shift. The annualized cost avoidance from an emergency medicine pharmacist was $1,971,262. The monetary cost avoidance to pharmacist salary ratio was between $1.4:1 and $10.6:1. CONCLUSIONS Pharmacist involvement in the care of patients presenting to the emergency department results in significant avoidance of healthcare costs, particularly in the areas of hands-on care and adverse drug event prevention. The potential monetary benefit-to-cost ratio for emergency medicine pharmacists is between $1.4:1 and $10.6:1.
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Affiliation(s)
- Megan A Rech
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL
| | - William Adams
- Department of Biostatistics, Loyola University, Maywood, IL
| | - Keaton S Smetana
- Department of Pharmacy, Ohio State University Medical Center, Columbus, OH
| | - Payal K Gurnani
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
- Department of Internal Medicine, Rush Medical College, Chicago, IL
| | | | - William J Peppard
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Drayton A Hammond
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL
- Department of Biostatistics, Loyola University, Maywood, IL
- Department of Pharmacy, Ohio State University Medical Center, Columbus, OH
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
- Department of Internal Medicine, Rush Medical College, Chicago, IL
- Department of Pharmacy, Erlanger Medical Center, Chattanooga, TN
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Alexander H Flannery
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
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20
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Faulds ER, Jones L, McNett M, Smetana KS, May CC, Sumner L, Buschur E, Exline M, Ringel MD, Dungan K. Facilitators and Barriers to Nursing Implementation of Continuous Glucose Monitoring (CGM) in Critically Ill Patients With COVID-19. Endocr Pract 2021; 27:354-361. [PMID: 33515756 PMCID: PMC7839794 DOI: 10.1016/j.eprac.2021.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/02/2021] [Accepted: 01/08/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE We describe our implementation of a continuous glucose monitoring (CGM) guideline to support intravenous insulin administration and reduce point of care (POC) glucose monitoring frequency in the coronavirus disease 2019 medical intensive care unit (MICU) and evaluate nurses' experience with implementation of CGM and hybrid POC + CGM protocol using the Promoting Action on Research in Health Services framework. METHODS A multidisciplinary team created a guideline providing criteria for establishing initial sensor-meter agreement within each individual patient followed by hybrid use of CGM and POC. POC measures were obtained hourly during initial validation, then every 6 hours. We conducted a focus group among MICU nurses to evaluate initial implementation efforts with content areas focused on initial assessment of evidence, context, and facilitation to identify barriers and facilitators. The focus group was analyzed using a qualitative descriptive approach. RESULTS The protocol was integrated through a rapid cycle review process and ultimately disseminated nationally. The Diabetes Consult Service performed device set-up and nurses received just-in-time training. The majority of barriers centered on contextual factors, including limitations of the physical environment, complex device set-up, hospital firewalls, need for training, and CGM documentation. Nurses' perceived device accuracy and utility were exceptionally high. Solutions were devised to maximize facilitation and sustainability for nurses while maintaining patient safety. CONCLUSION Outpatient CGM systems can be implemented in the MICU using a hybrid protocol implementation science approach. These efforts hold tremendous potential to reduce healthcare worker exposure while maintaining glucose control during the COVID-19 pandemic.
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Affiliation(s)
- Eileen R Faulds
- The Ohio State University College of Nursing, The Ohio State University Medical Center, Columbus, Ohio.
| | - Laureen Jones
- The Ohio State University Medical Center, Columbus, Ohio
| | - Molly McNett
- Helene Fuld Health Trust National Institute for EBP, Columbus, Ohio
| | | | - Casey C May
- The Ohio State University Medical Center, Columbus, Ohio
| | - Lyndsey Sumner
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Elizabeth Buschur
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, Ohio
| | - Matthew Exline
- Division of Critical Care Medicine, The Ohio State University Medical Center, The Ohio State University Medical Center, Columbus, Ohio
| | - Matthew D Ringel
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, Ohio
| | - Kathleen Dungan
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Medical Center, Columbus, Ohio
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21
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Smetana KS, Hannawi Y, May CC. Indirect Calorimetry Measurements Compared With Guideline Weight-Based Energy Calculations in Critically Ill Stroke Patients. JPEN J Parenter Enteral Nutr 2020; 45:1484-1490. [PMID: 33085101 DOI: 10.1002/jpen.2035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Perturbations in resting energy expenditure (REE) among critically ill stroke patients are ill defined, and guidelines recommend weight-based dosing when indirect calorimetry (IC) is not feasible to estimate daily energy requirements. We aimed to determine whether guideline-recommended weight-based dosing provides adequate energy requirements compared with guidelines recommended IC target. METHODS IC data was collected on stroke patients admitted to a neurocritical care unit. We compared low-weight-based dosing (25 kcal/kg) and high (30 kcal/kg) with the IC REE target. Subsequently, we analyzed the effect of stroke subtype on the differences among these measurements. RESULTS Seventy-two metabolic studies were performed (45.1% intracerebral hemorrhage [ICH], 18.3% aneurysmal subarachnoid hemorrhage [aSAH], and 36.6% acute ischemic stroke [AIS]). Energy needs, estimated using low-weight-based group, were significantly lower than IC REE target (1496 kcal/day [IQR, 1224-1850] vs 1770 kcal/day [IQR, 1400-2150]; P = .003). High weight-based group energy measurements were similar to IC REE target (1806 kcal/day [IQR, 1530-2236] vs 1770 kcal/day; P = .343). Subgroup analysis showed that low-weight-based calculations were significantly lower than those of IC in ICH and aSAH, but they were similar in AIS (P ≤ .001, .016, and .078, respectively). Linear regression analysis showed that weight, height, and hemorrhagic stroke subtype were associated with IC (P ≤ .001, .024, and .051, respectively). CONCLUSION Important differences between weight-based estimation of energy needs and guideline-recommended IC estimation exist for critically ill stroke patients. Low-weight-based calculations of REE underestimate energy needs in ICH and aSAH patients.
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Affiliation(s)
- Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, Ohio, USA
| | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Kamdar HA, Hamed M, Smetana KS, Shanmugam K, Peters E, Yasin R, Thakur G, Gopal M, Sawalha K, Greene-Chandos D, Hussein O. Lorazepam timing for acute convulsive seizure control (LoTASC). Seizure 2020; 83:41-47. [PMID: 33080484 DOI: 10.1016/j.seizure.2020.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/06/2020] [Accepted: 09/23/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Guidelines specify early administration of benzodiazepines (BZD) for the management of convulsive status epilepticus. The distinction between acute convulsive seizure and status epilepticus can be misconstrued resulting in BZD administration prior to a patient meeting criteria of status epilepticus. Early BZD administration may theoretically lead to systemic vital instability. Our study aims to assess if administering lorazepam, for convulsive seizures <5 min, causes vital instability. METHODS This is a retrospective study analyzing patients who presented with a seizure lasting <5 min between 2011 and 2016. Continuous variables of lorazepam receivers versus non- receivers were analyzed using t-test for parametric and Mann-Whitney U test for nonparametric data. Categorical variables were analyzed using Chi-Square Test. Subsequently, subjects were analyzed through univariate and multivariate regression models to determine predictors of vital instability. RESULTS Out of 1052 subjects initially screened, 165 were included. Of these, 91 (55 %) received lorazepam, and 74 (45 %) did not. Through univariate and multivariate analyses, there was a significantly higher incidence of vital instability (defined as receipt of a vasopressor or intubation) in patients who received lorazepam (OR = 6.76, 95 % CI = 1.48, 30.95) (p = 0.014). This was dose-dependent (p < 0.0001). It was responsible for 22.5 % of the vital instability. Lorazepam administration significantly prolonged the intensive care unit (ICU) length of stay (0 days [IQR 0 - 0] vs [IQR 0-2.3]; p = 0.038). CONCLUSION Our study suggests that lorazepam administration for acute convulsive seizures not meeting convulsive status epilepticus criteria may lead to iatrogenic vital instability and need for ICU admission.
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Affiliation(s)
- Hera A Kamdar
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Mohammad Hamed
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Keaton S Smetana
- The Ohio State University, Wexner Medical Center, Department of Pharmacy, United States.
| | - Kruthika Shanmugam
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Elizabeth Peters
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Rabia Yasin
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Gaurav Thakur
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Mangala Gopal
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Khalid Sawalha
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Diana Greene-Chandos
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
| | - Omar Hussein
- The Ohio State University, Wexner Medical Center, Department of Neurology, United States.
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Panos NG, Cook AM, John S, Jones GM, Kelly H, Choi RK, Kalaria N, Rosini JM, Jones M, Rehman M, Ross PM, Motley B, Delibert S, George BP, Andrews CM, Neyens RR, Martin R, Schomer KJ, Armahizer MJ, Pajoumand M, May CC, Smetana KS, Strohm T, Hamm C, Jakubowski L, Keegan SP, Srinivasan V, Burdick CJ, Martinez OJ, Bahrassa F, May ST, Sowers KA, Lin EI, Rohaley DJ, Mackey J, Wetmore LL, Frick C, Thatikunta M, Urben L, Ammar AA, Owusu KA, Nguyen K, Erdman MJ, Gilbert BW, DeMott JM, Peksa GD, Tobias PE, Da Silva I, Mahmoud LN, Sheahan B, Gennaro AG, Pizzi MA, Brophy GM, Rivet DJ, Strein M, Arandela K, Hellerslia V, Caylor MM. Factor Xa Inhibitor-Related Intracranial Hemorrhage. Circulation 2020; 141:1681-1689. [DOI: 10.1161/circulationaha.120.045769] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background:
Since the approval of the oral factor Xa inhibitors, there have been concerns regarding the ability to neutralize their anticoagulant effects after intracranial hemorrhage (ICH). Multiple guidelines suggest using prothrombin complex concentrates (PCCs) in these patients on the basis of research that includes a limited number of patients with ICH. Given this, we aimed to evaluate the safety and efficacy of PCCs for factor Xa inhibitor–related ICH in a large, multicenter cohort of patients.
Methods:
This was a multicenter, retrospective, observational cohort study of patients with apixaban- or rivaroxaban-related ICH who received PCCs between January 1, 2015, and March 1, 2019. The study had 2 primary analysis groups: safety and hemostatic efficacy. The safety analysis evaluated all patients meeting inclusion criteria for the occurrence of a thrombotic event, which were censored at hospital discharge or 30 days after PCC administration. Patients with intracerebral, subarachnoid, or subdural hemorrhages who had at least 1 follow-up image within 24 hours of PCC administration were assessed for hemostatic efficacy. The primary efficacy outcome was the percentage of patients with excellent or good hemostasis on the basis of the modified Sarode criteria. Secondary outcomes included an evaluation of in-hospital mortality, length of stay, infusion-related reactions, and thrombotic event occurrence during multiple predefined periods.
Results:
A total of 663 patients were included and assessed for safety outcomes. Of these, 433 patients met criteria for hemostatic efficacy evaluation. We observed excellent or good hemostasis in 354 patients (81.8% [95% CI, 77.9–85.2]). Twenty-five (3.8%) patients had a total of 26 thrombotic events, of which 22 occurred in the first 14 days after PCC administration. One patient had documentation of an infusion-related reaction. For the full cohort of patients, in-hospital mortality was 19.0%, and the median intensive care unit and hospital lengths of stay were 2.0 and 6.0 days, respectively.
Conclusions:
Administration of PCCs after apixaban- and rivaroxaban-related ICH provided a high rate of excellent or good hemostasis (81.8%) coupled with a 3.8% thrombosis rate. Randomized, controlled trials evaluating the clinical efficacy of PCCs in patients with factor Xa inhibitor–related ICH are needed.
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Affiliation(s)
- Nicholas G. Panos
- Department of Pharmacy (N.G.P.), Rush University Medical Center, Chicago, IL
| | - Aaron M. Cook
- Department of Pharmacy, University of Kentucky Healthcare, Lexington (A.M.C.)
| | - Sayona John
- Department of Neurological Sciences (S.J.), Rush University Medical Center, Chicago, IL
| | - G. Morgan Jones
- Department of Pharmacy, Methodist University Hospital, Memphis, TN (G.M.J.)
- Departments of Clinical Pharmacy, Neurology, and Neurosurgery, University of Tennessee Health Sciences Center, Memphis (G.M.J.)
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Smetana KS. An Alternative Approach to Compare Measured Energy Expenditure With Best-Practice Recommendations. JPEN J Parenter Enteral Nutr 2020; 44:1378. [PMID: 32338771 DOI: 10.1002/jpen.1839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/24/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Keaton S Smetana
- Department of Clinical Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Hammond DA, Gurnani PK, Flannery AH, Smetana KS, Westrick JC, Lat I, Rech MA. Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department. Pharmacotherapy 2019; 39:215-231. [PMID: 30664269 DOI: 10.1002/phar.2224] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A framework for evaluating pharmacists' impact on cost avoidance in the intensive care unit (ICU) and emergency department (ED) has not been established. This scoping review was registered (CRD42018091217) and conducted to identify, aggregate, and qualitatively describe the highest quality evidence for cost avoidance generated by clinical pharmacists on interventions performed in an ICU or ED. Searches were conducted in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until April 2018. The level of evidence (LOE) for each specific category of intervention was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation evidence-to-decision framework. The risks of bias for articles were evaluated using Newcastle Ottawa and Cochrane Collaboration tools. The values from all interventions were inflated to 2018 U.S. dollars using the consumer price index for medical care. Of the 464 articles initially identified, 371 were excluded and 93 were included. After reviewing references from the articles included, an additional 71 articles were also reviewed. The 38 cost intervention categories were supported by varying LOEs: IA (0 categories), IB (1 category), IIA (4 categories), IIB (0 categories), III (27 categories), and IV (6 categories), and articles mostly displayed low to moderate risks of bias. Pharmacists generate cost avoidance through a variety of interventions in critically and emergently ill patients. The quality of evidence supporting specific cost avoidance values is generally low. Quantification of and factors associated with the cost avoidance generated from pharmacists caring for these patients are of paramount importance.
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Affiliation(s)
- Drayton A Hammond
- Medical Intensive Care Unit, Rush University Medical Center, Chicago, Illinois
| | - Payal K Gurnani
- Cardiovascular Intensive Care Unit, Rush University Medical Center, Chicago, Illinois
| | - Alexander H Flannery
- Medical Intensive Care Unit, University of Kentucky HealthCare, Lexington, Kentucky
| | - Keaton S Smetana
- Neurosciences Intensive Care Unit, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Ishaq Lat
- Department of Pharmacy, Shirley Ryan AbilityLab, Chicago, Illinois
| | - Megan A Rech
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, Illinois
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Affiliation(s)
- Keaton S Smetana
- Department of Clinical Pharmacy, The Ohio State University Wexner Medical Center, Columbus
| | - Aaron M Cook
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington
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Smetana KS, Dunne J, Parrott K, Davis GA, Collier ACS, Covell M, Smyth S. Oral factor Xa inhibitors for the treatment of left ventricular thrombus: a case series. J Thromb Thrombolysis 2017; 44:519-524. [DOI: 10.1007/s11239-017-1560-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Jones GM, Erdman MJ, Smetana KS, Mohrien KM, Vandigo JE, Elijovich L. 3-Factor Versus 4-Factor Prothrombin Complex Concentrate for Warfarin Reversal in Severe Bleeding: A Multicenter, Retrospective, Propensity-Matched Pilot Study. J Thromb Thrombolysis 2017; 42:19-26. [PMID: 26721625 DOI: 10.1007/s11239-015-1330-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Current guidelines recommend 4-factor prothrombin complex concentrate (4PCC) for emergent reversal of bleeding secondary to warfarin. While current research has demonstrated superiority of 4PCC over plasma, direct comparisons with 3-factor PCC (3PCC) are lacking. The purpose of this study is to compare the efficacy and safety of 3PCC and 4PCC. We conducted a retrospective analysis of patients who received PCC at one of four medical centers. All patients in the 3PCC group were treated at one center that utilizes a fixed, weight-based dosing protocol. After evaluation of all patients meeting inclusion criteria, propensity-score matching was used to adjust for differences in treatment characteristics. There was no difference in the primary outcome of INR ≤ 1.4 between 3PCC and 4PCC in both the unmatched (85.7 vs. 90.6 %; p = 0.37) and matched (84.2 vs. 92.1 %; p = 0.48) analyses. There was a significant difference in goal INR achieved favoring 4PCC (56.3 vs 90.0 %; p < 0.02) when baseline INR > 4.0. A total of three thrombotic events were documented, all in the 4PCC group. We found no difference in the rate of INR reversal in those treated with 3PCC and 4PCC. However, those with a baseline INR > 4.0 may experience more successful INR reversal with 4PCC.
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Affiliation(s)
- G Morgan Jones
- Department of Pharmacy, Methodist University Hospital, 1265 Union Avenue, Memphis, TN, 38104, USA. .,Department of Clinical Pharmacy, University of Tennessee Health Sciences Center (UTHSC), 920 Court Ave, Memphis, TN, 38163, USA. .,Department of Neurology and Neurosurgery, UTHSC, 920 Court Ave, Memphis, TN, 38163, USA.
| | - Michael J Erdman
- Department of Pharmacy, University of Florida Health, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Keaton S Smetana
- Department of Pharmacy, University of Kentucky HealthCare, 800 Rose St, Lexington, KY, 40536, USA
| | - Kerry M Mohrien
- Department of Pharmacy, Temple University Hospital, 3509 N Broad St, Philadelphia, PA, 19140, USA
| | - Joseph E Vandigo
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 620 W Lexington St, Baltimore, MD, 21201, USA
| | - Lucas Elijovich
- Department of Neurology and Neurosurgery, UTHSC, 920 Court Ave, Memphis, TN, 38163, USA.,Semmes-Murphey Neurologic and Spine Institute, 6325 Humphreys Blvd, Memphis, TN, 38120, USA
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Smetana KS, Cook AM, Bastin MLT, Oyler DR. Antiepileptic dosing for critically ill adult patients receiving renal replacement therapy. J Crit Care 2016; 36:116-124. [PMID: 27546759 DOI: 10.1016/j.jcrc.2016.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/06/2016] [Accepted: 06/28/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this review was to evaluate current literature for dosing recommendations for the use of antiepileptic medications in patients receiving renal replacement therapy (RRT). DATA SOURCES With the assistance of an experienced medical librarian specialized in pharmacy and toxicology, we searched MEDLINE, EMBASE, CINAHL, Web of Science, WorldCat, and Scopus through May 2016. STUDY SELECTION AND DATA EXTRACTION Four hundred three articles were screened for inclusion, of which 130 were identified as potentially relevant. Micromedex® DRUGDEX as well as package inserts were used to obtain known pharmacokinetic properties and dosage adjustment recommendations in RRT if known. DATA SYNTHESIS Data regarding antiepileptic drug use in RRT are limited and mostly consist of case reports limiting our proposed dosing recommendations. Known pharmacokinetic parameters should guide dosing, and recommendations are provided where possible. CONCLUSION Additional studies are necessary before specific dosing recommendations can be made for most antiepileptic drugs in critically ill patients receiving RRT, specifically with newer agents.
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Affiliation(s)
- Keaton S Smetana
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY.
| | - Aaron M Cook
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Douglas R Oyler
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
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Abstract
There have been a number of agents that have been tried for treatment of gastroparesis over the past 3 decades, with varying levels of success. Guidelines exist for the management of gastroparesis in adults; however, even though the cause of gastroparesis in children is similar to that in adults, no guidelines exist for treating pediatric gastroparesis as studies on the topic are limited. With what little information we have on pediatric gastroparesis, medications used in children's studies do not seem to demonstrate the same results as in adult patients with gastroparesis; thus, future studies of whether certain medications are effective for treating pediatric gastroparesis and at what dose still need to be conducted. Pharmacological treatment options for pediatric gastroparesis do not show a clear correlation of resolving or even maintaining gastroparesis-associated symptoms or disease state. This article reviews the available studies of drugs that have shown some efficacy, with an emphasis on pediatric studies.
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Affiliation(s)
- Emma M Tillman
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Keaton S Smetana
- Department of Pharmacy, University of Kentucky Heathcare, Lexington, Kentucky
| | - Likeselam Bantu
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Merrion G Buckley
- Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
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Smetana KS, Suda KJ, Hamilton LA. Fixed Drug Eruption in an Epileptic Patient Previously Receiving Treatment With Phenytoin for Seven Years. J Investig Med High Impact Case Rep 2013; 1:2324709613512622. [PMID: 26425589 PMCID: PMC4528843 DOI: 10.1177/2324709613512622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A 52-year-old African American female presented with severe left thigh pain of unknown etiology. She had a past medical history of generalized seizure disorder treated with phenytoin for 7 years without incident. During admission a nurse witnessed a seizure, and consequently loading and maintenance doses of phenytoin were administered to obtain a therapeutic serum concentration. The patient had a history of noncompliance with multiple subtherapeutic phenytoin levels. Subsequently, unifocal blue discolored spots appeared, progressing to a bullous component that was positive for skin sloughing. Drug-induced fixed drug eruption was diagnosed and attributed to phenytoin. Clinicians should be cognizant of drug-induced fixed drug eruption in patients just initiated and those receiving long-term treatment with phenytoin. The administration rate of phenytoin may be associated with the development of fixed drug eruption.
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Affiliation(s)
- Keaton S Smetana
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | - Katie J Suda
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | - Leslie A Hamilton
- University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
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