Angiotensin II Infusion for Shock: A Multicenter Study of Postmarketing Use.

BACKGROUND: Vasodilatory shock refractory to catecholamine vasopressors and arginine vasopressin is highly morbid and responsible for significant mortality. Synthetic angiotensin II is a potent vasoconstrictor that may be suitable for use in these patients. RESEARCH QUESTION: What is the safety and effectiveness of angiotensin II and what variables are associated with a favorable hemodynamic response? STUDY DESIGN AND METHODS: We performed a multicenter, retrospective study at five tertiary medical centers in the United States. The primary end point of hemodynamic responsiveness to angiotensin II was defined as attainment of mean arterial pressure (MAP) of ≥ 65 mm Hg with a stable or reduced total vasopressor dosage 3 h after drug initiation. RESULTS: Of 270 included patients, 181 (67%) demonstrated hemodynamic responsiveness to angiotensin II. Responders showed a greater increase in MAP (+10.3 mm Hg vs +1.6 mm Hg, P < .001) and reduction in vasopressor dosage (-0.20 µg/kg/min vs +0.04 µg/kg/min; P < .001) compared with nonresponders at 3 h. Variables associated with favorable hemodynamic response included lower lactate concentration (OR 1.11; 95% CI, 1.05-1.17, P < .001) and receipt of vasopressin (OR, 6.05; 95% CI, 1.98-18.6; P = .002). In severity-adjusted multivariate analysis, hemodynamic responsiveness to angiotensin II was associated with reduced likelihood of 30-day mortality (hazard ratio, 0.50; 95% CI, 0.35-0.71; P < .001). Arrhythmias occurred in 28 patients (10%) and VTE was identified in 4 patients. INTERPRETATION: In postmarketing use for vasopressor-refractory shock, 67% of angiotensin II recipients demonstrated a favorable hemodynamic response. Patients with lower lactate concentrations and those receiving vasopressin were more likely to respond to angiotensin II. Patients who responded to angiotensin II experienced reduced mortality.

Impact of drug shortages on U.S. health systems.

PURPOSE: A study was performed to quantify the personnel resources required to manage drug shortages, define the impact of drug shortages on health systems nationwide, and assess the adequacy of information resources available to manage drug shortages. METHODS: An online survey was sent to the 1322 members of the American Society of Health-System Pharmacists who were identified as directors of pharmacy. Survey recipients were asked to identify which of the 30 most recent drug shortages listed affected their health system, to identify actions taken to manage the shortage, and to rate the impact of each shortage. Employees responsible for completing predefined tasks were identified, and the average time spent by each type of employee completing these tasks was estimated. Labor costs associated with managing shortages were calculated. RESULTS: A total of 353 respondents completed the survey, yielding a response rate of 27%. Pharmacists and pharmacy technicians spent more time managing drug shortages than did physicians and nurses. There was a significant association between the time spent managing shortages and the size of the institution, the number of shortages managed, and the institution's level of automation. Overall, 70% of the respondents felt that the information resources available to manage drug shortages were not good. The labor costs associated with managing shortages in the United States is an estimated $216 million annually. CONCLUSION: A survey of directors of pharmacy revealed that labor costs and the time required to manage drug shortages are significant and that current information available to manage drug shortages is considered suboptimal.

Technique for the administration of nitrous oxide/oxygen sedation to ensure psychotropic analgesic nitrous oxide (PAN) effects.

This past year the 160th anniversary of the discovery of nitrous oxide as an analgesic/psychotropic anesthetic by an American dentist, Horace Wells, was celebrated in Hartford, Connecticut, USA. This useful gas has been in continuous use longer than any other anesthetic agent and has withstood the test of time. Applications in clinical practice over a variety of health disciplines are presented. This article provides technique guidelines for the administration of nitrous oxide/oxygen sedation to maximize and to customize individual gas dosages for optimal psychotropic and analgesic efficacy. Titration will be discussed with the intent for this manuscript to enable the proper concepts for nitrous oxide/oxygen administration and to customize individual gas dosages to achieve optimal doses of nitrous oxide consistent with psychotropic analgesic nitrous oxide (PAN).

National survey of the impact of drug shortages in acute care hospitals.

PURPOSE: The impact of drug shortages on patient care, the resources used to manage drug shortages, and the cost associated with drug shortages were studied. METHODS: A national online survey was conducted to quantify the effects of drug shortages on patient care and pharmacy expenses. Directors of pharmacy in acute care institutions in the ASHP member database were asked to estimate the impact of drug shortages on acquisition costs, pharmacist and nonpharmacist staff time dedicated to specific functions related to drug shortages, and drug-compounding expenses. RESULTS: Usable responses were received from 370 (24.7%) of 1496 pharmacy directors. Nearly all pharmacy directors surveyed believed that shortages had changed practice, and a majority felt that drug shortages had compromised patient care. Hospital pharmacy personnel devoted a significant amount of time to managing drug shortages. The results suggest that shortages increase the acquisition cost of pharmaceuticals in the United States by over dollar 99 million annually. CONCLUSION: A national survey indicated that drug shortages are having a significant impact on patient care activities and finances in hospitals.