Pharmacy residents' preparedness for the emotional challenges of patient care.

PURPOSE: Results of a survey to determine levels of pharmacy resident exposure to and preparedness for emotionally unsettling clinical scenarios are presented. METHODS: A pretested electronic survey was distributed to 1501 U.S. pharmacy residency program directors (RPDs), who were asked to complete the survey and forward it to residents in their programs. Both respondent groups provided perspectives on pharmacy residents' frequency of exposure to and preparedness for nine scenarios that could potentially be emotionally unsettling to pharmacy residents (e.g., a patient's death, participation in a response to a cardiorespiratory arrest). RPDs and residents were queried regarding training methods used by their programs to prepare trainees to cope with emotionally unsettling events. RESULTS: A total of 940 responses were received. Overall, resident-reported ex posure to the nine scenarios listed in the survey was infrequent. Majorities of both RPDs and residents (85.2% and 67.1%, respectively) indicated that residents could be better prepared for the emotional challenges of patient care. The most common method of training was a one-on-one discussion between a preceptor and a resident on an as-needed basis. No training was reported by 30% and 40% of RPDs and residents, respectively. CONCLUSION: The majority of RPD and resident respondents indicated that residents could be better prepared for the emotional challenges of patient care. The most commonly reported method of training for coping with emotional challenges was a one-on-one discussion between a preceptor and a resident on an as-needed basis.

Vancomycin clearance in high-volume venovenous hemofiltration.

OBJECTIVE: To report the pharmacokinetic and pharmacodynamic properties of vancomycin in 4 patients undergoing high-volume continuous venovenous hemofiltration (CVVH). CASE SUMMARY: Data from 4 patients prescribed high-volume CVVH for acute renal failure treated with vancomycin were analyzed. Vancomycin plasma concentrations were measured 4 and 24 hours after the end of a 1-hour vancomycin infusion. The mean therapy fluid rate on initiation of vancomycin was 56.2 mL/kg/h (range 48.0-65.5). The mean loading dose of vancomycin was 18.3 mg/kg (range 14.7-19.7). Median vancomycin concentration 4 hours after the dose was 18.1 mg/L (range 13.1-30.0). At 24 hours after the dose, only 1 patient had a detectable vancomycin concentration (5.2 mg/L). DISCUSSION: There was a large variability in the clearance of vancomycin in this patient population. Current strategies for dosing vancomycin may lead to subtherapeutic trough concentrations. Vancomycin dosing in this patient population should be based on a detailed assessment of the CVVH prescription, vancomycin concentrations, and clinical needs and response. CONCLUSIONS: An initial vancomycin dose of 20-25 mg/kg with frequent monitoring and adjustment is recommended for patients receiving high-volume CVVH.

Preventing the harm of a closer look: contrast-induced nephropathy in adults.

Contrast media is administered to many patients in hospitals nationwide. Although the use of contrast and dyes is widespread and has a well accepted use among the medical profession, contrast-induced nephropathy can be a common and potentially harmful complication. Identifying patients at risk, attempting to minimize risk, and using preventative strategies should be priorities to decrease the harmful effects that are associated with the administration of contrast media. This article provides a general overview of contrast-induced nephropathy and a brief review of the risk factors and prophylactic treatment.

Current controversies in critical illness-related corticosteroid insufficiency and glucocorticoid supplementation.

The stress response, which is triggered by a number of factors, including surgery, results in activation of the hypothalamic pituitary adrenal axis and subsequent release of cortisol from the adrenal glands. Critical illness-related corticosteroid insufficiency is an inadequate corticosteroid response relative to a patient's illness; patients with critical illness-related corticosteroid insufficiency have both insufficient circulating cortisol and impaired cellular use of glucocorticoids. Corticosteroids, such as hydrocortisone, have been cited to improve survival, oxygenation, duration of mechanical ventilation, and intensive care unit-free days in critically ill patients. Perioperative glucocorticoid supplementation is also recommended in patients with secondary adrenal insufficiency due to chronic corticosteroid use.

Interrater variability of a severity-of-illness score in critically ill adults.

BACKGROUND: Critically ill patients often require sedation and analgesia. Scales have been developed to provide clinicians with sedation targets. Daily interruption of continuous infusions of sedatives and sedation protocols improve patients' outcomes. However, perceived instability of a patient's condition can prevent implementation of appropriate sedation targets and daily interruption of sedation. OBJECTIVE: To evaluate the interrater variability of a severity-of-illness score developed to help nurses determine patient-specific sedation targets and identify candidates for daily interruption of sedation. METHODS: The severity-of-illness score was implemented as part of an institutional protocol, and bedside nurses in the medical intensive care unit were taught how to determine and use the score. Bedside nurses recorded the score daily in patients' medical records. For study purposes, a study nurse who made rounds with the medical team and a pulmonary/critical care fellow physician also independently determined the score. RESULTS: A total of 38 assessments of severity-of-illness scores in 10 different patients were made during the study period. For the 24 assessments made by all 3 observers, the kappa coefficient for agreement for the severity-of-illness score was 0.58. CONCLUSIONS: The severity-of-illness score had good interrater variability as a tool for determining sedation targets and identifying candidates for daily interruption of sedation. Future study on how use of the score affects sedative dosing and outcomes is needed.

Effects of a pharmacist-to-dose computerized request on promptness of antimicrobial therapy.

OBJECTIVES: To examine the effects of computerized requests for pharmacist-to-dose (PTD), an advanced clinical decision support tool for dosing guidance, on antimicrobial therapy with vancomycin and aminoglycosides, describe PTD request utilization, and identify factors that may prolong this process. DESIGN: A retrospective review was conducted of patients hospitalized from Jan 2004 to Jun 2006 with suspected pneumonia who received vancomycin, tobramycin, or gentamicin via PTD (study) or routine provider order entry (control). MEASUREMENTS: The primary endpoint was time to pharmacist completion of PTD request. Secondary data points included medication turn-around times for first doses of vancomycin or aminoglycosides and for first doses of any antibiotic, dose adjustment for renal dysfunction, medication errors, and time of order entry. Multivariate analysis was conducted to identify predictors of total time to pharmacist verification and time to administration of first doses of vancomycin or aminoglycosides. RESULTS: Median time for pharmacist completion of PTD requests was 29 minutes. Delays were noted in the study group (n = 49) by comparison with the control group (n = 48) for median time to first dose of vancomycin or aminoglycoside (185 vs. 138 min, p = 0.45) and for any antibiotic (134 vs. 118 min, p = 0.42), respectively. Fewer medication errors were reported in the study group (5 vs. 18 errors, p = 0.002). In a multivariate model, PTD was not significantly predictive of time to pharmacy verification or medication turn-around time. CONCLUSIONS: Pharmacists completed pharmacist-to-dose consultations for dosing guidance of vancomycin and aminoglycosides within a median of 30 minutes. Implementation of a computerized request for clinical pharmacists to provide medication-related clinical decision support increased medication turn-around time of vancomycin and aminoglycosides and reduced medication errors. Consultation of clinical pharmacists by computerized request for initial antibiotic dosing of medications with narrow therapeutic windows is an option for medication-related clinical decision support but providers should be aware that consultation may delay medication turn-around time.

Recombinant human erythropoietin therapy in critically ill Jehovah's Witnesses.

Blood transfusions and blood products are often given as a life-saving measure in patients with critical illness. However, some patients, such as Jehovah's Witnesses, may refuse their administration due to religious beliefs. Jehovah's Witnesses accept most available medical treatments, but not blood transfusions or blood products due to their religion's interpretation of several passages from the Bible. Since recombinant human erythropoietin (rHuEPO) became available, several cases have been reported in which rHuEPO was successfully administered to critically ill Jehovah's Witnesses. Administration of rHuEPO in combination with other blood conservation techniques has been shown to increase hemoglobin levels and survival in patients who experienced trauma, burns, general surgery, or gastrointestinal hemorrhage. We performed a literature search of the MEDLINE and International Pharmaceutical Abstracts databases of rHuEPO therapy in the Jehovah's Witness population. Fourteen cases were identified in which rHuEPO was administered to Jehovah's Witnesses who required the drug for critical care resuscitation as an alternative to blood products. In each clinical situation, rHuEPO enhanced erythropoiesis; however, time to the start of treatment, dosages, route of administration, and treatment duration varied widely. Supplementation with adjunctive agents, such as iron, folic acid, and vitamin B12, was also beneficial. Use of rHuEPO in Jehovah's Witnesses may provide an alternative to blood transfusions or blood products. Other alternatives, such as hemoglobin-based oxygen carriers and perfluorocarbons, are also being explored.

Delirium dilemma.

With understanding of diagnostic criteria as well as predisposing and precipitating factors, clinicians can impact the morbidity and mortality of delirium.

Pharmacy resident participation in cardiopulmonary resuscitation events.

PURPOSE: An electronically administered cross-sectional survey was conducted to establish the rate of pharmacy resident participation in cardiopulmonary resuscitation (CPR) events at pharmacy residency programs throughout the United States and Puerto Rico. METHODS: A 46-item questionnaire was developed and sent by e-mail to pharmacy residency program directors. The recipients were given one month to complete the survey. Responses were screened for duplicate answers, and the most complete survey was included in the analysis. The survey dealt with residency program demographics and sought information about required life-support certifications for pharmacy personnel, institution-specific training methods for medical emergencies employed by pharmacy departments, responsibilities of pharmacy personnel who respond to CPR events, and evaluation methods used to assess resident performance in CPR events. RESULTS: A total of 745 pharmacy residency directors were surveyed. Responses were received from 190 residency program directors, which represented 221 residency programs. The three most common residency program settings were community (not-for- profit) hospitals, college and university hospitals, and government hospitals. Thirty percent of respondents required pharmacy resident response to CPR events, while 38% made this opportunity optional. In 85% of programs that required or offered resident response to CPR events, there was a formal CPR team. The three primary roles fulfilled by pharmacists in medical emergencies were provision of drug information, drug admixture, and documentation; pharmacy resident duties mirrored these roles. CONCLUSION: Pharmacy resident response to CPR events was required in approximately 30% of responding pharmacy residency programs. Various methods were used in educating, assessing, and evaluating pharmacy residents in this role.

Supplemental glucocorticoid therapy.

Supplemental glucocorticoid therapy is a topic widely debated in the medical field. Patients present with various signs, symptoms and etiologies making diagnosis of the condition elusive. There is wide inter-patient variability in cortisol response during stress so defining normal response concentrations of cortisol is difficult. Deficiency of cortisol in acutely ill patients increases the potential of morbidity and mortality. Despite the conflicting evidence, if cortisol deficiency is identified, supplemental treatment with glucocorticoids is advocated. One aspect agreed on by all is the need for continued investigations in the requirement of supplemental glucocorticoids.

Pharmacokinetic alterations in obesity.

Although some medications have established dosing adjustments for obesity (Table 2), it remains unknown for the majority of medications if dosing adjustment is warranted. It is important to remember dosage adjustments may not be as simple as doubling an antibiotic dose because a patient is morbidly obese. Individualizing drug dosing is imperative in the obese, postoperative patient to ensure they simultaneously have therapeutic serum concentrations without drug toxicity. Much of what has been learned from studies in obese patients is that the pharmacokinetic alterations of medications are variable. Broad application of dosing guidelines even among medications within the same therapeutic class is likely not appropriate. An increased emphasis in researching the effects of obesity on the fate of medications is of paramount importance as the obese population grows. Practitioners should use caution and be vigilant in monitoring pharmacotherapy in obese individuals.