Rapid administration of Kcentra® during cardiopulmonary arrest.

We present a case of cardiopulmonary arrest secondary to rivaroxaban related oropharyngeal hemorrhage, which required rapid intravenous (IV) push administration of 4-factor prothrombin complex concentrate (4F-PCC). Manufacturers recommend administering 4F-PCC IV at a rate of 0.12 mL/kg/min (approximately 3 units/kg/min) up to a maximum rate of 8.4 mL/min (approximately 210 units/min) [1]. The concern with rapid administration is increased potential for thromboembolic complications. There have been small studies assessing infusion rates greater than the manufacturer's recommendation with few reported thromboembolic events [2-5]. Our patient was an 81-year-old female presenting to the emergency department (ED) with sudden onset oropharyngeal hemorrhage. The patient had a pertinent history of oral and esophageal cancer and was prescribed rivaroxaban 20 mg once daily for treatment of deep vein thrombosis. Within moments of the patient arriving, she produced a large volume of blood from her nose and mouth. The source of the bleeding could not be determined, and as suctioning was attempted to clear her airway, the patient became unresponsive and pulseless. Advanced Cardiac Life Support (ACLS) procedures were initiated and 1000 mg of tranexamic acid were administered. Once the patient's active medication list was discovered, 2000 units of 4F-PCC was given as an IV push over roughly 20 s. Bleeding was controlled enough to secure the patient's airway within 5 min after 4F-PCC administration and subsequently return of spontaneous circulation was achieved. Unfortunately, the patient suffered a poor neurologic outcome and the family withdrew care after discussion with the treatment team and the patient's oncologist. This case report demonstrates rapid administration of 4F-PCC may be an effective intervention to treat immediately life threatening rivaroxaban related bleeding.

Comparison of 3 Different Prothrombin Complex Concentrate Regimens for Emergent Warfarin Reversal: PCCWaR Study.

BACKGROUND: The ideal dose and specific prothrombin complex concentrate (PCC) for warfarin reversal is unknown. OBJECTIVE: To evaluate the reduction in international normalized ratio (INR) of 3 different PCC dosing regimens: fixed-dose activated 4-factor PCC (aPCC), fixed-dose 4-factor PCC (4PCC), and standard-dose 4PCC. METHODS: This was a multicenter retrospective cohort review. Patients >18 years of age who received PCC for warfarin reversal between January 1, 2017, and December 31, 2017, were screened for inclusion. Patients were excluded if they did not receive the correct PCC dosing regimen, received PCC for nonwarfarin bleeding, had a baseline INR less than 2, or received a massive transfusion protocol. Two institutions utilized aPCC dosed at 500 IU for INR <5 and 1000 IU for INR ≥5. Two institutions utilized fixed-dose 4PCC at 1500 to 2000 units depending on patient factors. Two institutions utilized 4PCC package insert dosing. The primary outcome was achievement of post-PCC target INR ≤1.4. Secondary outcomes included percentage change in INR, lowest 24-hour INR, and mortality. RESULTS: A total of 154 patients were included (fixed-dose aPCC: n = 29; fixed-dose 4PCC: n = 53; standard-dose 4PCC: n = 72). There was no statistical difference between groups in achieving the primary outcome (58.6% vs 69.8% vs 79.2%, respectively; P = 0.103) or any secondary outcomes. CONCLUSION AND RELEVANCE: There was no difference in the ability to achieve a post-PCC INR of ≤1.4 between 3 different PCC regimens for warfarin reversal. Additional research is warranted to determine the ideal dose and PCC agent for warfarin reversal.

Review of North American pit viper antivenoms.

PURPOSE: For the first time in nearly 20 years, 2 antigen-binding fragment (Fab) antivenoms are available to treat patients who incur North American pit viper snakebites: Crotalidae polyvalent immune Fab (ovine), or simply FabAV; and Crotalidae immune F(ab')2 (equine), or simply F(ab')2. Pharmacists are in a key position for the selection, dosing, reconstitution, administration, and monitoring of antivenom therapy; however, they encounter inconsistent exposure and experience with these drugs. Thus, an updated review of the literature is necessary. METHODS: The search strategy and selection incorporated both controlled vocabulary terms and keywords to describe concepts relevant to the search. Retrieval was limited to literature published from 1997 to the present in English, Portuguese, or Spanish. RESULTS: Given the paucity of available prospective literature, the authors elected to include all prospective evidence to best describe the role of antivenom. For the primary literature review, manuscripts were excluded if they were observational studies, conference abstracts, narrative or opinion articles, letters to the editor, or in-progress studies. CONCLUSION: While there is limited evidence-based guidance on the superiority of F(ab')2 to FabAV, or vice versa, individual and regional considerations should contribute to formulary decisions. Pharmacists must play a role in the development of clinical pathways to ensure appropriate evaluation, supportive care, and antivenom procurement, administration, and monitoring.

Effect of phenylephrine and terbutaline on ischemic priapism: a retrospective review.

BACKGROUND: Ischemic priapism is the most common cause of priapism due to low blood flow. Current guidelines recommend penile aspiration and the use of intracavernous injection of vasoactive agents. The data to support these recommendations are limited and rely on expert consensus. OBJECTIVE: The objective was to determine the effectiveness of terbutaline and phenylephrine on detumescence of ischemic priapism. METHODS: This was a retrospective review of patients presenting to the emergency department with a chief concern of priapism who received oral or subcutaneous terbutaline or intracavernous phenylephrine. The primary outcome is successful detumescence. The secondary outcome is drug-related adverse drug events. RESULTS: A total of 31 cases of ischemic priapism were included, with 8 patients receiving terbutaline and 23 receiving phenylephrine. Of the cases treated with terbutaline, 25% had successful detumescence compared with phenylephrine with a 74% success rate. No drug-related adverse events were reported or identified. CONCLUSIONS: Patients receiving intracavernous irrigation with phenylephrine were more likely to achieve successful detumescence than those treated with oral or subcutaneous terbutaline.

Assessment of hospital pharmacy preparedness for mass casualty events.

OBJECTIVES: To assess the preparedness of hospital pharmacies in New Jersey to provide pharmaceutical services in mass casualty scenarios. METHODS: An electronic cross-sectional survey was developed to assess the general knowledge of available resources and attitudes toward the preparedness of the pharmacy department. RESULTS: Out of 60 invitations to participate, 18 surveys (30%) were completed. Respondents practiced at community hospitals (12, 66.6%) with no trauma center designation (11, 67.4%) that served more than 500 licensed beds (five, 29.4%). Six respondents (35.3%) indicated that 75,000 to 100,000 patients visited their emergency departments annually. Seventeen sites (94.4%) reported the existence of an institutional disaster preparedness protocol; 10 (55.5%) indicated that there is a specific plan for the pharmacy department. Most respondents (10, 55.5%) were unsure whether their hospitals had an adequate supply of analgesics, rapid sequence intubation agents, vasopressors, antiemetics, respiratory medications, ophthalmics, oral antimicrobials, and chemical-weapon-specific antidotes. Five (27.7%) agreed that the pharmacy disaster plan included processes to ensure care for patients already hospitalized, and four (22.2%) agreed that the quantity of medication was adequate to treat patients and hospital employees if necessary. Medication stock and quantities were determined based on national or international guidelines at three (16.6%) institutions surveyed. CONCLUSION: This survey demonstrates a lack of general consensus regarding hospital pharmacy preparedness for mass casualty scenarios despite individualized institutional protocols for disaster preparedness. Standardized recommendations from government and/or professional pharmacy organizations should be developed to guide the preparation of hospital pharmacy departments for mass casualty scenarios.

Analysis of Pharmacy Student Perceptions and Attitudes Toward Web 2.0 Tools for Educational Purposes.

Background: The use of Wikis, blogs, and podcasts can engage students in collaborative learning, allow peer feedback, and enhance reflective learning. However, no survey to date has been performed across all professional years of pharmacy students in order to obtain a comprehensive overview of student perceptions. Objectives: To identify the familiarity of pharmacy students with Web 2.0 resources available for medical education, and what barriers exist. Methods: This study surveyed students enrolled in the professional program of a US-accredited pharmacy school to assess their knowledge and current use of available online resources and attitudes toward the use of Web 2.0 technologies for educational purposes. Results: Of the 836 surveys distributed, 293 were collected and analyzed (35.0% response rate). Students reported using the following Web 2.0 technologies in the didactic and experiential settings, respectively: Wikipedia (88%, 70%), YouTube (87%, 41%), Khan Academy (40%, 5%), and medical or scientific blogs (25%, 38%). Although these technologies were more commonly used in the classroom, students agreed or strongly agreed such resources should be used more often in both the didactic (n = 187, 64%) and experiential settings (n = 172, 59%). The barriers associated with the use of Web 2.0 in both the didactic and experiential settings that were ranked highest among students included accuracy and quality of information and lack of familiarity among faculty members and preceptors. Conclusion: Pharmacy students across all professional years actively use Web 2.0 tools for educational purposes and believe that opportunities exist to expand use of such technologies within the didactic and experiential settings.

Gluten content of medications.

PURPOSE: The establishment of a database for the identification of the presence of gluten in excipients of prescription medications is described. SUMMARY: While resources are available to ascertain the gluten content of a given medication, these resources are incomplete and often do not contain a source and date of contact. The drug information service (DIS) at Robert Wood Johnson University Hospital (RWJUH) determined that directly contacting the manufacturer of a product is the best method to determine the gluten content of medications. The DIS sought to establish a resource for use within the institution and create directions for obtaining this information from manufacturers to ensure uniformity of the data collected. To determine the gluten content of a medication, the DIS analyzed the manufacturer's package insert to identify any statement indicating that the product contained gluten or inactive ingredients from known sources of gluten. If there was any question about the source of an inactive ingredient or if no information about gluten content appeared in the package insert, the manufacturer of the particular formulation of the queried medication was contacted to provide clarification. Manufacturers' responses were collected, and medications were categorized as "gluten free," "contains gluten," or "possibly contains gluten." To date, the DIS at RWJUH has received queries about 84 medications and has cataloged their gluten content. CONCLUSION: The DIS at RWJUH developed a database that categorizes the gluten status of medications, allowing clinicians to easily identify drugs that are safe for patients with celiac disease.

Use of Twitter at a major national pharmacy conference.

PURPOSE: The results of a study of Twitter use by attendees of the 2013 ASHP Midyear Clinical Meeting (MCM) and other interested parties are presented. METHODS: All messages posted on the social media platform Twitter under the official MCM "hashtag" (#ashpmidyear) during the five-day conference were archived and evaluated. Demographic data on authors of MCM-related tweets were collected by evaluating information provided by Twitter users in their public profiles. The archived messages were classified by content type. RESULTS: A total of 1539 messages originating from 400 unique U.S.- and foreign-based Twitter accounts were posted under the MCM hashtag, an average of 3.84 tweets per account. The estimated rate of conference-related Twitter use by MCM attendees was 1.7%. One third of Twitter users posting conference-related tweets were identified as pharmacists; 86 (21.5%) and 65 (16.25%) tweets originated from accounts held by pharmacy students and pharmaceutical industry representatives, respectively. The authors of MCM-related tweets represented a broad cross-section of pharmacy practice settings and specialties. About 39% of the evaluated Twitter postings were classified as social, with about 31% of postings pertaining to specific MCM educational sessions and nearly 25% classified as advertising. CONCLUSION: The majority of MCM-related tweets by onsite and remote Twitter users were social in nature or pertained to educational sessions held over the course of the conference.

The Scholarly Merit of Social Media Use Among Clinical Faculty.

Background: Social media (SoMe) platforms such as blogs, Twitter, and Facebook are increasingly becoming incorporated into education and scientific communities. In fields such as emergency medicine, clinicians have established communication channels through SoMe to engage in academic and clinical discussions for the purposes of professional growth. While the use of SoMe as an educational tool within the classroom has been previously described, its use as a professional tool has not been adequately investigated. Objective: To assess the perception of SoMe as an academic tool among deans of accredited health care professional schools in the United States. Methods: An electronic cross-sectional survey was distributed to deans of accredited medical, nursing, and pharmacy schools across the United States to assess the knowledge of SoMe, attitudes toward academic merit, and challenges to incorporating SoMe into scholarly activity. Responses were analyzed using descriptive statistics. Results: Of 188 responses (response rate = 22%), 162 (86%) agreed publication in a peer-reviewed journal ranked highest in academic merit, followed by publishing in medical Web sites (157, 84%), publication in a university-based newsletter (147, 78%), and personal medical education blog (150, 80%). Fifty-one (31%) of respondents stated that volume of viewership would improve academic merit, while 85 (52%) believed a peer-review process would improve academic merit. Conclusion: Although professional SoMe activities should not replace traditional publications, the result of this study suggest establishing a peer-review process to improve validity of such activities.

Activated prothrombin complex concentrates for the reversal of anticoagulant-associated coagulopathy.

OBJECTIVE: Prothrombin complex concentrate (PCC) products are emerging as alternative strategies for reversing anticoagulant pharmacotherapy. Factor eight inhibitor bypassing activity (FEIBA, or anti-inhibitor coagulant complex) is an activated PCC (aPCC). Although FEIBA is approved by the FDA to control spontaneous bleeding episodes and to prevent bleeding with surgical interventions in hemophilia A and hemophilia B patients with inhibitors to factor VIII, recent data have suggested that the product may be used off-label as an anticoagulant-reversal agent. To evaluate the safety and efficacy of aPCC products in reversing anticoagulant pharmacotherapy, we searched online databases for English-language publications that discussed this topic. DATA SOURCES: The EMBASE, MEDLINE, and International Pharmaceutical Abstracts databases were used. We evaluated all articles published in the English language identified from the data sources. We included studies conducted in human subjects and in in vitro and in vivo models in our review. RESULTS: Current published evidence suggests that the use of an aPCC, compared with fresh-frozen plasma, is associated with a significantly faster correction of supratherapeutic International Normalized Ratios (INRs) secondary to warfarin therapy. Conflicting evidence exists regarding the ability of aPCCs to reverse the prolonged bleeding times caused by the anticoagulant agents dabigatran etexilate (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and fondaparinux (Arixtra). CONCLUSION: The theoretical risks of thrombosis associated with PCC products must be carefully considered before they are administered to patients who require coagulation therapy. The use of aPCCs to reverse the anticoagulant effects of warfarin, dabigatran, or rivaroxaban should be limited because of the lack of efficacy and safety data in humans. Moreover, the safety of aPCCs in off-label indications has not been adequately assessed.

Frequency of and reasons for pharmacy residents breaching the National Matching Services applicant agreement.

PURPOSE: The frequency of and reasons for pharmacy residents breaching the National Matching Services (NMS) applicant agreement were evaluated. METHODS: An electronic survey was sent via e-mail to residency program directors of ASHP-accredited postgraduate year 1 pharmacy residencies in the United States. The survey instrument was developed based on an initial pilot survey used to test the clarity and reliability of the questions. The primary objective of the survey was to determine the frequency with which pharmacy residents breach the NMS applicant agreement and fail to report to their assigned site. Characteristics of ASHP- accredited residency programs with residents who breached the NMS agreement and any punitive action taken on these individuals were also analyzed. RESULTS: Of the 636 surveys sent to residency program directors, 302 complete surveys were returned, yielding a response rate of 47.5%. Twenty-six respondents (8.6%) indicated that within the past five years, they had matched candidates who failed to report to their assigned site. Of these respondents, 13 (50%) reported the candidate to ASHP; 11 (44%) took no action. Respondents indicated that they would be comfortable reporting all candidates who breach the NMS agreement to ASHP and placing the candidates' information on a list accessible electronically only to residency program directors. CONCLUSION: Less than 10% of residency program directors reported having residency candidates who breached the NMS applicant agreement. The majority of these respondents indicated that these residents were not their first choices. The most common reason for candidate withdrawal was family obligation.