A pain in the neck: Salmonella spp. as an unusual cause of a thyroid abscess. A case report and review of the literature.

BACKGROUND: Thyroid gland infections are rare. Their incidence is estimated to be less than 1% in immunocompromised hosts. Most common pathogens isolated are Gram positive aerobic cocci. Infections with Gram negative facultative aerobes such as Salmonella are rare. CASE PRESENTATION: A 55-year-old female with type II diabetes mellitus and a history of a colloid right thyroid lobe nodule presented with neck pain and fever. She was found to have a thyroid abscess 2 weeks following a non-specific diarrheal illness. A needle aspiration for symptomatic and diagnostic purposes was performed. Cultures grew Salmonella enterica serotype Heidelberg. She was treated with a 12-week course of oral antibiotics and serial aspiration. CONCLUSION: A thyroid abscess is a rare occurrence; however, a high index of suspicion is required to make the diagnosis. The management is directed at minimizing morbidity. The mainstay treatment is medical, but surgery is sometimes necessary to achieve adequate source control, particularly when complications arise.

Implementation and Assessment of a Pharmacy Educational Program Concerning Laboratory Monitoring for Medications.

BACKGROUND: The pharmacist's role in monitoring medication therapy, including the ability to order laboratory tests as a delegated medical function, has increased dramatically over the past 20 years. OBJECTIVES: To implement and assess the impact of an intervention designed to educate pharmacists about appropriate medication-related laboratory monitoring and clinical interpretation of results. METHODS: This pilot project had a pretest-posttest study design. The intervention was an educational program comprising 8 self-directed learning modules, each with a corresponding seminar. Evaluation of the program included scoring of the appropriateness and significance of clinical interventions related to laboratory monitoring, pre- and post-program test scores, and participants' subjective assessments of their abilities to order and assess the results of medication-related laboratory investigations. Descriptive statistics, the Wilcoxon signed rank test, the Student t-test, and the paired Student t-test were used where appropriate. Associations were assessed with the Pearson or Spearman rho correlation coefficient. All statistical tests were 2-tailed, and the p value for significance was established a priori at 0.05. RESULTS: There was no statistically significant difference with regard to the appropriateness (p = 0.70) or significance (p = 0.94) of clinical interventions undertaken before and after the educational program. Among the 21 pharmacists who completed the program, the average test score (± standard deviation) was 27.2 ± 8.1 before the program, increasing to 39.2 ± 8.7 after the program (p < 0.001). There was a statistically significant improvement in the perceived level of knowledge for each individual module (p < 0.05 for all). CONCLUSIONS: The establishment of an educational program led to improvements in both subjective and objective measures of knowledge and perceived abilities to order and assess the results of medication-related laboratory tests.

CONTEXTE: Le rôle du pharmacien dans la surveillance de la pharma-cothérapie, notamment la capacité de prescrire des examens de laboratoire en tant qu'acte médical délégué, a grandement gagné en importance au cours des vingt dernières années. OBJECTIFS: Mettre en place une intervention conçue pour enseigner aux pharmaciens comment surveiller adéquatement la pharmacothérapie au moyen d'examens de laboratoire pertinents et comment réaliser l'interpré-tation clinique des résultats, puis évaluer les effets de cet enseignement. MÉTHODES: Le présent projet pilote emploie un plan d'étude prétest post-test. L'intervention prenait la forme d'un programme d'enseignement comptant huit modules d'apprentissage autodirigé, chacun assorti d'un séminaire correspondant. L'évaluation du programme comprenait : l'attribution d'un score pour la pertinence et la portée des interventions cliniques liées à la surveillance par des examens de laboratoire, la comparaison des notes obtenues au test administré avant et après le programme d'enseignement et des évaluations subjectives par les participants de leurs capacités à prescrire des examens de laboratoire adaptés à la pharmacothérapie et à en évaluer les résultats. Le cas échéant, des éléments de statistique descriptive, le test de Wilcoxon, le test de Student et le test t pour échantillons appariés ont été employés. Les associations ont été évaluées à l'aide du coefficient de corrélation de Spearman ou de Pearson. Tous les tests statistiques étaient bilatéraux et le seuil de signification a été établi a priori à 0,05. RÉSULTATS: On n'a observé aucune différence statistiquement significative en ce qui touche à la pertinence (p = 0,70) ou à la portée (p = 0,94) des interventions cliniques effectuées avant et après le programme d'enseignement. Parmi les 21 pharmaciens ayant complété le programme, la note moyenne (± l'écart-type) obtenue au test était de 27,2 ± 8,1 avant le programme d'enseignement pour ensuite atteindre 39,2 ± 8,7 après le programme (p < 0,001). On a relevé une amélioration statistiquement significative quant au niveau subjectif de connaissance pour chaque module (p < 0,05 pour chacun). CONCLUSIONS: La mise en place d'un programme d'enseignement a mené à des améliorations, tant sur le plan des mesures subjectives et objectives des connaissances que des capacités subjectives à prescrire des examens de laboratoire adaptés à la pharmacothérapie et à en évaluer les résultats.

A multicenter study of the point prevalence of drug-induced hypotension in the ICU.

OBJECTIVE: To determine the point prevalence of drug-induced hypotension episodes in critically ill patients, to assess the episodes resulting from error, and to describe how episodes are treated. DESIGN: Multicenter observational, 24-hour snapshot study. SETTING: Forty-seven ICUs in 27 institutions located in the United States, Canada, and Singapore. PATIENTS: A total of 688 ICU patients were evaluated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were included in the study if they had an episode of hypotension in the 24 hours prior to the clinical pharmacists' evaluation. The definition for a hypotensive episode is either a systolic blood pressure less than 90 mm Hg or a decrease in systolic blood pressure of 30 mm Hg over a 2-hour period. Each episode of unintentional hypotension was assessed for suspected drug-related causes. When a drug-related cause was suspected, an objective assessment tool, the modified Kramer, was used to determine causality. A score of at least "possible" was considered drug induced, referred to as a "drug-related hazardous condition." A drug-related hazardous condition is the temporal gap (intermediate stage) between the identification of an adverse drug reaction and the subsequent onset of drug-induced injury, known as an "adverse drug event." Drug-induced episodes were evaluated for medication errors and treatment. One hundred fifty-eight patients experienced 204 hypotensive episodes that were considered unintentional and drug related. Common drugs implicated included propofol, fentanyl, metoprolol, lorazepam, hydralazine, and furosemide. A total of 54 episodes (26.5%) resulted from medication errors. Common error types were improper dose/quantity (46%) and prescribing (25%). A total of 56.9% episodes were treated. CONCLUSIONS: Many hypotensive episodes in the ICU are drug related and require treatment. A substantial portion of these episodes result from errors and are therefore preventable. This presents opportunities to improve prescribing including optimizing drug dosing to avoid possible patient harm from drug-induced hypotension.

Multiprofessional survey of protocol use in the intensive care unit.

PURPOSE: To date, there has been no large multicenter, multiprofessional evaluation of protocol and guideline use in the intensive care unit (ICU). The primary purpose of this study was to describe national availability, development, implementation, and assessment of protocols in ICUs. A secondary objective was to compare perceived utility by ease of use, patient safety, cost containment, and compliance of protocols between nurses, physicians, and pharmacists. MATERIALS AND METHODS: The survey was developed and tested for validity by 15 clinicians who identified additional domains of interest. An additional 15 clinicians of the 3 different professions evaluated the survey for relevancy and appropriateness of responses. Three survey experts evaluated survey construction. The survey was uploaded to a Web survey tool and pilot tested for clarity and ease of completion. RESULTS: The overall response rate for the survey was 18.1% (n = 614). Popular methods of education for protocol implementation included staff meetings (85.3%) and unit-specific in-services (77.7%). Protocols were most often updated when new information was available (40.8%) or every 12 months (17.9%). The most common limitation to development and implementation was limited personnel resources (24.5%) and physicians not wanting to use them (21.3%), respectively. Clinicians indicated that protocols made their job easier and improved cost containment some or most of the time. Sepsis protocols were identified as most useful in promoting patient outcomes by all 3 professions. CONCLUSIONS: The types of protocols available appear to be those assisting with management of high-alert medications. Overcoming the perceived barriers of protocol use within ICUs requires personnel for development and physician support. A better protocol review process may be necessary to assure optimal content, desired outcomes, and consistency with Institute for Safe Medication Practices guidelines.

Canadian survey of critical care pharmacists' views and involvement in clinical research.

BACKGROUND: The involvement of Canadian critical care pharmacists in clinical research is not well documented. OBJECTIVE: To describe the clinical research experience of Canadian critical care pharmacists, describe their views about clinical research, and identify factors that facilitate their involvement in clinical research. METHODS: A cross-sectional electronic survey of Canadian critical care pharmacists was developed through an iterative process and conducted from July to October 2010. We invited 325 pharmacists from 129 hospitals across Canada to participate. Surveys with more than 30% of questions unanswered were discarded. RESULTS: Analyzable response rate was 66.2%. Overall, 33 pharmacists (15.7%) were highly involved in research, 54 (25.7%) were moderately involved, and 123 (58.6%) were minimally involved. Most respondents (97.2%) believed that critical care pharmacist involvement in research was desirable, and many (80.4%) expressed interest to be more involved in research. Nearly all respondents (99.5%) agreed that more support should be provided to pharmacists interested in conducting research. Pharmacists currently involved in research have obtained higher academic degrees (adjusted OR 11.23; p < 0.001), express a strong interest in research (adjusted OR 7.44; p < 0.001), report a higher level of training for involvement in research (adjusted OR 2.23; p = 0.047), and practice more often in a university hospital (adjusted OR 3.68; p = 0.004) within an intensive care unit where involvement in research is valued (adjusted OR 5.61; p < 0.001). Support from pharmacy departments is not related to involvement in research (adjusted OR 1.22; p = 0.633). CONCLUSIONS: Canadian critical care pharmacists are involved to varying degrees in clinical research and are very interested in initiating and supporting research activities. Opportunities are present but significant barriers exist. The value of pharmacist-initiated research needs recognition as a priority within hospital pharmacy administration.

Bispectral index values, sedation-agitation scores, and plasma Lorazepam concentrations in critically ill surgical patients.

BACKGROUND: Publications on the use of the bispectral index for sedation monitoring in the intensive care unit are increasing. However, few studies have involved correlation of bispectral index with serum drug concentrations. OBJECTIVES: To assess the degree of correlation between bispectral index values, scores on the Sedation-Agitation Scale, and steady-state serum concentrations of lorazepam. METHODS: A prospective open-label study of patients in a surgical intensive care unit who were receiving mechanical ventilation and continuous infusions of lorazepam for more than 24 hours. Bispectral index was measured (BIS-XP, Aspect Medical, Norwood, Massachusetts) to assess patients' sedation. Sensors were applied and values recorded before and after stimulation (endotracheal suctioning). Concomitant plasma samples were obtained to measure lorazepam concentration and scores on the Sedation-Agitation Scale were recorded. RESULTS: Sixteen patients were studied. Correlations between plasma concentrations of lorazepam and measurements of bispectral index for 1, 2, and 3 minutes before endotracheal stimulation were poor (0.21, 0.29, and 0.25, respectively). Correlation of peak values for bispectral index (after stimulation) with plasma concentrations of lorazepam was 0.29. Correlations of scores on the Sedation-Agitation Scale with the aforementioned values for bispectral index were similarly poor. Area under the curve for bispectral index values also correlated poorly with plasma concentration of lorazepam (0.19) and score on the Sedation-Agitation Scale (0.10). CONCLUSIONS: The correlation between bispectral index and score on the Sedation-Agitation Scale was poor. Correlation between bispectral index and plasma concentration of lorazepam was modestly better, but insufficient for clinical utility.

Electrolyte disturbances associated with commonly prescribed medications in the intensive care unit.

Electrolyte imbalances are common in critically ill patients. Although multiple disease states typically encountered in the intensive care unit may be responsible for the development of electrolyte disorders, medications may contribute to these disturbances as well. Medications can interfere with the absorption of electrolytes, alter hormonal responses affecting homeostasis, as well as directly impact organ function responsible for maintaining electrolyte balance. The focus on this review is to identify commonly prescribed medications in the intensive care unit and potential electrolyte disturbances that may occur as a result of their use. This review will also discuss the postulated mechanisms associated with these drug-induced disorders. The specific drug-induced electrolyte disorders discussed in this review involve abnormalities in sodium, potassium, calcium, phosphate, and magnesium. Clinicians encountering electrolyte disturbances should be vigilant in monitoring the patient's medications as a potential etiology. Insight into these drug-induced disorders should allow the clinician to provide optimal medical management for the critically ill patient, thus improving overall healthcare outcomes.

International critical care hospital pharmacist activities.

OBJECTIVE: The role of critical care pharmacists in the United States has recently been documented; however, little information exists about the role of international critical care pharmacists. The objective of this study was to describe the duties and activities of international pharmacists who practice in critical care. DESIGN: Web-based survey. SETTING: Hospitals outside of the United States. PARTICIPANTS: International pharmacists with >50% of their time dedicated to critical care. INTERVENTIONS: An invitation to answer the survey was sent to pharmacists via mail, e-mail or newsletter. Pharmacists were requested to answer based on their current practice. The survey was open from November 2004 to November 2005. MEASUREMENTS AND RESULTS: Data were collected on demographics and clinical and non-clinical activities. The final analysis included 168 pharmacists with dedicated critical care responsibilities. Respondents indicated 74.4% attended medical rounds and 54.8% were involved in research. Therapeutic drug monitoring was completed by 72.6% of pharmacists, with the most commonly monitored medications being aminoglycosides and vancomycin. While 41.7% of pharmacists personally dispensed medications, 13% and 8.4% were involved in directly preparing intravenous medications or total parenteral nutrition, respectively. CONCLUSIONS: International critical care pharmacists participate in a wide range of activities from attending ward rounds to dispensing of medications. We hope the broad range of pharmacist activities described herein will increase the involvement of the pharmacist in the critical care team worldwide.

An instructional seminar for online case-based discussions.

OBJECTIVE: To assess a training seminar developed to prepare pharmacy instructors to facilitate online discussions. DESIGN: A 2-part seminar was developed to train faculty members and teaching assistants to facilitate online case-based discussions. A preseminar survey instrument was distributed to potential attendees and a postseminar survey instrument was given to those who attended the seminar. ASSESSMENT: Twenty (91%) instructors completed the preseminar survey instrument. Eleven of these instructors attended at least 1 session of the seminar and indicated that the didactic and/or application portions were either "helpful" or "very helpful." These faculty members and teaching assistants also completed the postseminar survey instrument and conveyed a significant increase in level of comfort in their ability to facilitate online case-based discussions (p=0.004). The 3 most frequently perceived barriers to online teaching remained consistent despite training or teaching experience. CONCLUSIONS: After attending a training seminar and/or facilitating an online case discussion, participants' comfort level in their ability to teach online increased. Further study of the impact of faculty development programs on teaching effectiveness and student satisfaction with online pharmacy education is warranted.

Impact of disease states on the pharmacokinetics and pharmacodynamics of angiotensin-converting enzyme inhibitors.

The pharmacokinetics and pharmacodynamics of angiotensin-converting enzyme inhibitors (ACE) in elderly patients and patients with renal and hepatic impairment were examined, and a role for an AUC/EC50 ratio to guide dosing was evaluated. A Medline and International Pharmaceutical Abstracts search was used to identify human studies and abstracts. Relevant data were evaluated and summarized. Dosing regimens were compared using an AUC/EC50 ratio. Most studies evaluating ACE inhibitors in renal impairment report a strong linear correlation between creatine clearance and drug elimination. AUC and EC50 values for these drugs in elderly subjects appear similar to younger and hypertensive patients. There is increased AUC in some patients with hepatic impairment. Pharmacodynamic data are conflicting. Prolonged ACE inhibition is evident in renal impairment but not necessarily other disease states. ACE inhibitor dosing for hypertension is reasonable based on pharmacokinetics and EC50 values. Further individualization of therapy may improve outcomes, and using the threshold AUC/EC50 ratio may help guide appropriate dosing.

Role of the bispectral index in sedation monitoring in the ICU.

OBJECTIVE: To review and critique evidence for the use of the bispectral index (BIS) in intensive care unit (ICU) patients. DATA SOURCES: A computer search of English-language articles in MEDLINE (1966-July 2005), International Pharmaceutical Abstracts (1971-July 2005), and Scientific Citation Index Expanded (1980-July 2005) was conducted. A manual search of abstracts was also performed using the key search terms BIS, sedation, and critical care. STUDY SELECTION AND DATA EXTRACTION: Case series, letters, editorials, and clinical studies that evaluated BIS in ICU patients were considered for inclusion. DATA SYNTHESIS: Nineteen studies comparing the BIS with sedation scales were evaluated, revealing that the BIS trends lower with increasing sedation. The BIS appeared to correlate better when sedation scores were grouped rather than individual values. However, correlations between BIS and subjective scales were low in most studies (r(2) 0.21-0.93). Additionally, there was poor correlation between drug dosage and the BIS. Randomized, controlled trials demonstrating improved outcomes with BIS monitoring have not been reported. CONCLUSIONS: Interpreting literature on the usefulness of the BIS in the ICU is difficult for reasons that include heterogeneous populations, different methods of collecting BIS data, and use of different versions of BIS software and hardware. Outcomes data are lacking. The 2002 Society of Critical Care Medicine Sedation Guidelines recommendation that more data are needed before the BIS should be used routinely in the ICU remains unchanged. We recommend that further studies be conducted to determine the optimal method of obtaining BIS data and evaluate the impact of the BIS on relevant patient outcomes.

Evaluation of lacrimal fluid as an alternative for monitoring glucose in critically ill patients.

OBJECTIVE: This study evaluated the use of lacrimal fluid glucose concentrations as a minimally invasive, alternative sampling strategy for monitoring glucose concentrations in surgical/trauma ICU patients. DESIGN AND SETTING: Prospective, paired sample study in an adult surgical/trauma ICU. PATIENTS: Patients receiving subcutaneous or intravenous insulin requiring routine capillary blood glucose measurements. Patients receiving ocular lubricants, artificial tears, or routinely administered ophthalmic medications and patients with facial injuries were excluded. INTERVENTIONS: Lacrimal fluid was collected using glass capillary tube placed near the cul-de-sac of the eye. Capillary blood glucose was determined using a bedside glucose meter as per routine ICU care. MEASUREMENTS AND RESULTS: Lacrimal fluid glucose concentration was analyzed using high-performance liquid chromatography with pulse amperometric detection. Forty-four paired samples from five patients were analyzed. Pearson correlation between lacrimal fluid (microM) and blood glucose (mM) concentrations and the proportional change from baseline revealed no significant associations. Due to the very poor association, enrollment was discontinued after five patients. CONCLUSIONS: Lacrimal fluid and blood glucose concentrations were poorly correlated, suggesting that the former is not a reliable alternative to blood glucose monitoring in surgical/trauma ICU patients requiring insulin therapy.

Scope of international hospital pharmacy practice.

OBJECTIVE: To review the published English literature regarding international hospital pharmacy practice. DATA SOURCES: A computer search of all English-language articles in MEDLINE (1966-June 2004) and other Internet sources and International Pharmaceutical Abstracts (1971-June 2004). STUDY SELECTION AND DATA EXTRACTION: All studies that discussed hospital pharmacy or clinical hospital pharmacy activities outside of the US were considered for inclusion. DATA SYNTHESIS: The scope of international hospital pharmacy practice is quite varied, both inter- and intra-country, and varying degrees of specialization exist. Although clinical pharmacy is well developed in some countries, it is still in infancy stages in others. In addition, there is disparity in the actual definition of clinical pharmacy throughout the world. CONCLUSIONS: Since very few data have been published regarding hospital pharmacy practice on an international scale, we suggest a survey be conducted to objectively capture this information and increase awareness of clinical pharmacy in this setting.

Acute postoperative hypertension: a review of therapeutic options.

PURPOSE: The pathophysiology and treatment of acute postoperative hypertension (APH) are discussed. SUMMARY: APH is a significant elevation in arterial blood pressure (BP) during the immediate postoperative period. The predominant underlying mechanism appears to be sympathetic activation. APH may lead to serious neurologic, cardiovascular, or surgical-site complications and often requires intervention and management. Postoperative hypertension lasts less than six hours in most patients. Reversible or treatable causes of hypertension, including pain, anxiety, hypothermia, and hypoxemia, should be considered and treated before the implementation of antihypertensive therapy. The ideal agent for treating APH is intravenously administered, is fast acting, and has a short duration of action, allowing the rapid and safe adjustment of therapy to achieve a targeted BP range. Sodium nitroprusside has long been considered the standard therapy and has many of the ideal characteristics. However, because of the need for invasive hemodynamic monitoring and concerns about toxicity in patients given sodium nitroprusside, several newer agents may be preferable in routine clinical practice. Labetalol, nicardipine, and nitroglycerin have been widely studied or used. Hydralazine, esmolol, fenoldopam, angiotensin-converting-enzyme inhibitors, and clonidine may also be useful treatment options. CONCLUSION: When treatment of APH is necessary, therapy should be individualized for the patient. No one agent is preferred, but effective options include sodium nitroprusside, nitroglycerin, labetalol, and nicardipine.