Pharmacist interventions improve fluid balance in fluid-restricted patients requiring parenteral nutrition.

Many intensive care unit (ICU) patients require parenteral nutrition (PN) and fluid restriction, making delivery of adequate nutrition difficult. We studied the effects of pharmacist interventions on fluid balance in fluid-restricted ICU patients requiring PN. Twenty patients were randomized to the treatment group (dextrose 70% injection [D70W] plus 15% amino acids for PN, 25-mL piggybacks, selected drugs added to the PN solution) or the control group (D70W plus 10% amino acids, 50- or 100-mL piggybacks). Each group contained 10 patients and they were not significantly different for age, gender, weight, hospital days, and serum albumin concentration. The duration (9.3 +/- 1.2 vs. 9.7 +/- 2.4 d) and doses of PN (29 +/- 6.8 vs. 28.7 +/- 6.9 kcal/kg/d; 1.1 +/- 0.3 vs. 1.1 +/- 0.4 g/kg/d protein) were similar between treatment and control groups. Mean fluid intake (3112 +/- 1146 vs. 3498 +/- 1111 mL/d), fluid balance (146 +/- 1581 vs. 708 +/- 1402 mL/d), and cumulative fluid balance (1358 vs. 6867 mL) were all significantly lower in the treatment group. Mean fluid output was similar between the two groups. Pharmacist interventions can significantly decrease intake and result in a better fluid balance in fluid-restricted ICU patients who require PN.

Cost considerations of intravenously administered histamine2-receptor antagonists.

The cost of intravenously administered histamine2 (H2)-receptor antagonists to hospitalized patients is high. Costs can be expressed as either direct or indirect. Direct costs include drug cost, labor costs (pharmacy/nursing time), and the materials required for iv administration of these agents. Indirect costs include adverse effects, drug interactions, and allergic reactions. Due to the high percentage of total cost for labor and materials associated with the iv H2-receptor antagonists, a reduction in drug cost, although certainly desired, is unlikely to substantially reduce the amount charged the patient per intravenous dose administered or the daily cost of therapy. However, if less frequent dosing were required to achieve similar therapeutic effects, the daily therapy cost for iv H2-receptor antagonists could be substantially reduced. Assuming that cimetidine, ranitidine, and famotidine are equally effective and safe, our cost analyses at the University of Tennessee Medical Center/William F. Bowld Hospital indicate that famotidine administered q12h, regardless of the iv administration technique used, is the most cost-effective H2-receptor antagonist and is the drug of choice.

Method for testing the sterility of total nutrient admixtures.

A test for determining the sterility of a total nutrient admixture (TNA) containing equal quantities of 10% fat emulsion (Liposyn II), 8.5% amino acids injection, and 50% dextrose injection using the USP membrane filtration procedure was developed and evaluated. Membrane filter selection was determined by analysis of flow rates, membrane fluid compatibility, bubble point stability, and rinse fluid requirements. Microbial challenges employing five organisms (Bacillus subtilis, Escherichia coli, Candida albicans, Staphylococcus aureus, and Pseudomonas aeruginosa) and both soybean casein digest and fluid thioglycollate media were used to confirm the ability of the test to detect low-level microbial contamination. A polyvinylidene fluoride membrane was determined to be the most appropriate of the membrane types studied because of its superior flow rate and membrane-fluid compatibility. Bubble point testing revealed no detrimental effects on the membrane. The potential problem of haziness caused by retention of the TNA by the membrane with subsequent release in the culture media (which could result in false-positive growth determinations) was diminished by using a sterile 0.1% peptone solution rinse and careful observation techniques. Performance of the sterility test by six hospital pharmacists required an average of 14.2 minutes. Sterility testing of alternate TNAs compounded with Intralipid and Nutralipid was not feasible because of prolonged filtration times. The basic USP membrane filtration procedure for large-volume injections can be used by hospital pharmacists for testing the sterility of TNAs. When fat emulsions are used in compounding, sterility-testing procedures specific to the emulsion product used should be developed and evaluated.

Drug utilization review of parenteral clindamycin therapy.

A concurrent drug utilization review was conducted to evaluate the appropriateness of parenteral clindamycin use, the incidence of gastrointestinal side effects, and to implement, if necessary, corrective actions to improve parenteral clindamycin use. Criteria for the appropriate use of clindamycin were prepared, reviewed, and approved by the P & T Committee of the City of Memphis Hospital (CMH) and University of Tennessee Medical Center/William F. Bowld Hospital (UTMCH). Forty-five patients were included in the audit. Overall, in 43/45 (96%) of the patients audited, clindamycin use was deemed appropriate. This audit provided the opportunity for positive reinforcement of physician prescribing practices and helped to foster a cooperative, rather than an adversarial relationship, between pharmacists and physicians involved in drug utilization review.