Current Practice Review in the Management of Acute Respiratory Distress Syndrome.

Acute respiratory distress syndrome (ARDS) presents as an acute inflammatory lung injury characterized by refractory hypoxemia and non-cardiac pulmonary edema. An estimated 10% of patients in the intensive care unit and 25% of those who are mechanically ventilated are diagnosed with ARDS. Increased awareness is warranted as mortality rates remain high and delays in diagnosing ARDS are common. The COVID-19 pandemic highlights the importance of understanding ARDS management. Treatment of ARDS can be challenging due to the complexity of the disease state and conflicting existing evidence. Therefore, it is imperative that pharmacists understand both pharmacologic and non-pharmacologic treatment strategies to optimize patient care. This narrative review provides a critical evaluation of current literature describing management practices for ARDS. A review of treatment modalities and supportive care strategies will be presented.

Evaluation of SOAP note performance in a pharmacotherapeutics course after implementation of a peer-review process.

INTRODUCTION: Subjective, objective, assessment, and plan (SOAP) notes are widely utilized within pharmacy curricula. Implementation of a peer-review process for these assignments may improve student competence. Evidence is lacking regarding correlation between student-to-student peer-review and faculty grades for SOAP notes and correlation of SOAP note peer-evaluation to individual performance. METHODS: Third year pharmacy students completed two SOAP notes in Pharmacotherapeutics IV. A peer-review process was implemented in spring 2020. After each SOAP note, students were assigned a peer's assignment to evaluate utilizing the same 50-point rubric as the faculty. SOAP note grades were compared between the 2019 and 2020 cohorts. RESULTS: Analysis included 98 students in spring 2019 and 92 students in 2020. SOAP note faculty grades were different between 2019 and 2020 for the first SOAP note (37.6 vs. 41.1, P < .001) but not for the second (42.3 vs. 42.7, P = .49). Peer-review grades were higher for both SOAP notes compared to faculty grades. Peer-review grades did not differ between the first and second SOAP notes (45.5 vs. 45.6) while faculty grades did (41.2 vs. 42.7). The difference in scores from peer-review compared to faculty grades was -4.4 points for the first SOAP note and - 2.9 points for the second SOAP note (P = .08). CONCLUSIONS: The peer-review process did not appear to improve SOAP note performance. Students tended to score better on the second note and appeared to gain proficiency in the peer evaluation process, suggesting a possible benefit of including additional SOAP notes.

Evaluation of the Impact of Prior-to-Admission Sleep Aid Prescribing Practices on Sleep and Delirium in the Intensive Care Unit.

BACKGROUND: Sleep disruptions in the intensive care unit (ICU) may lead to complications such as delirium. There is limited evidence addressing how sleep aid use before and during ICU admission affects outcomes. OBJECTIVE: The purpose of this study is to evaluate the impact of prior-to-admission sleep aid prescribing practices in the ICU on delirium and sleep outcomes. METHODS: A retrospective review was conducted of adult patients admitted to any ICU from January to June 2018 receiving a sleep aid prior to admission. Patients were categorized based on sleep aid continuation, discontinuation, or alteration during the ICU admission. The primary end point was the incidence of delirium. Secondary end points included the incidence of sleep-wake cycle disturbances, delirium scores, and ICU length of stay. RESULTS: A total of 291 patients were included with 109 in the continued group, 121 in the discontinued group, and 61 in the altered group. There was a similar incidence of delirium at 24 hours (P = 0.71), 48 hours (P = 0.60), 72 hours (P = 0.25), and 5 days (P = 0.48) after ICU admission. There was also no statistical difference in sleep-wake cycle disturbances or delirium scores at any time point. ICU length of stay was similar between the groups. CONCLUSION AND RELEVANCE: The incidence of delirium and sleep-wake cycle disturbances was not affected by differences in prior-to-admission sleep aid prescribing patterns during ICU admission.

ABC's of Vitamin Supplementation in Critical Illness.

Critical illness commonly presents as a systemic inflammatory process. Through this inflammation, there is an enhanced production of reactive oxygen and nitrogen species combined with marked reductions in protective plasma antioxidant concentrations. This imbalance is referred to as oxidative stress and is commonly encountered in numerous disease states in the critically ill including sepsis, trauma, acute respiratory distress syndrome, and burns. Oxidative stress can lead to cellular, tissue and organ damage as well as increased morbidity and mortality in critically ill patients. Supplementation with exogenous micronutrients to restore balance and antioxidant concentrations in critically ill patients has been considered for several decades. It is proposed that antioxidant vitamins, such as vitamins A and C, may minimize oxidative stress and improve clinical outcomes. Vitamin B formulations may play a role in curtailing lactic acidosis and are recently being evaluated as an acute phase reactant. However, few large, randomized trials specifically investigating the role of vitamin supplementation in the critically ill patient population are available. This article seeks to review recently published literature surrounding the role of supplementation of vitamins A, B and C in critically ill patients.

A web-based review game as a measure of overall course knowledge in pharmacotherapeutics.

BACKGROUND AND PURPOSE: Implementation of games is common in pharmacy education, but limited information exists about the relationship between students' game performances and course grades. Our study was designed to determine if scores on a comprehensive web-based review game correlate to overall pharmacotherapeutics course and course series grades. EDUCATIONAL ACTIVITY AND SETTING: Two cohorts of students in Pharmacotherapeutics IV, the last course in a four course series, were administered a web-based quiz review game (Kahoot!) at the end of the course. Student performance on the game was compared to grades throughout the Pharmacotherapeutics course sequence to determine if the games were reflective of the students' performances. All students enrolled in Pharmacotherapeutics IV in 2016 and 2017 were included in the analysis. Pearson correlation was performed on the scores from the review game compared to the grades in the pharmacotherapeutics course series. FINDINGS: A total of 197 students, 111 in the 2016 cohort and 86 in the 2017 cohort, were included in the analysis. The correlation coefficient (r) for the review scores and Pharmacotherapeutics IV course grade was 0.399 and 0.461 for the 2 cohorts (p < 0.001). Almost all component comparisons between the review scores and the other pharmacotherapeutics course grades were also significantly correlated (p < 0.01). SUMMARY: Student performance on the review game significantly correlated with pharmacotherapeutics course grades. Review games are fun tools to review course content and can serve as an effective method to determine student understanding, progression, and knowledge.

Enhancing Student Knowledge Through a Comprehensive Oncology Simulation.

Objective. To evaluate the impact of a comprehensive oncology simulation on pharmacy students' knowledge and perceptions related to oncology pharmacy practice. Methods. Third-year pharmacy students at the University of South Florida completed an ovarian cancer case-based simulation. Stations involved patient-specific order set completion, counseling, order verification, and aseptic technique. Pre- and post-simulation assessments regarding therapeutic knowledge and aseptic technique as well as perceptions of pharmacists' roles in oncology practice were evaluated. Results. All students (n=109, 100%) completed the pre- and post-simulation assessments. There was an increase in knowledge after the simulation, which was statistically significant in three of the six questions. Furthermore, students' perceptions regarding pharmacist roles and self-confidence in ability to prepare patient-specific regimens increased on a 5-point Likert scale from 3.8 and 3.2 to 4.5 and 4.2 on the post-assessment, respectively. Conclusion. Participation in the simulation improved students' oncology-related knowledge and perceived understanding of the roles of oncology pharmacists.

Using high-fidelity simulation to teach fundamental principles of cardiac catheterisation to pharmacy students.

Background: Pharmacy students often find the pathophysiology and treatment of comorbid heart conditions challenging to understand. The objective of this study is to evaluate the impact of a cardiac catheterisation lab simulation on pharmacy students' knowledge related to cardiology and critical care pharmacotherapy. Methods: Third-year pharmacy students at the University of South Florida completed a high-fidelity cardiac catheterisation simulation. Specific aspects within the activity involved review of clinical parameters and images during catheterisation, identification of access points for catheter insertion, review of the types of stents available and associated pharmacotherapeutic considerations, and discussion of protective measures to prevent radiation exposure. Students completed knowledge-based presimulation and postsimulation assessments regarding these aspects of cardiac catheterisation. Results: All students (n=111, 100%) completed the presimulation and postsimulation assessments. There was an increase in knowledge after the simulation, which was statistically significant in five out of nine questions, P<0.001. Based on course evaluations, students believed this activity enhanced their learning and ability to apply the material due to the close alignment and timing with their acute coronary syndrome lectures and the critical care module in the Pharmacotherapeutics course. Conclusions: Participation in the simulation improved students' knowledge related to cardiology pharmacotherapy and associated acute procedures.

A Case of Severe, Refractory Hypotension After Amlodipine Overdose.

Calcium channel blockers (CCBs) are responsible for a substantial portion of the mortality associated with cardiovascular medication overdose cases. Amlodipine, a dihydropyridine CCB, can cause prolonged hypotension in overdose. This report describes a severe amlodipine overdose case that was refractory to multiple therapeutic approaches. A 53-year-old male presented after ingesting eighty 10 mg amlodipine tablets in a suicide attempt. The patient was initially managed with calcium boluses, glucagon, multiple vasoactive agents, lipid emulsion infusions and hyperinsulinemic euglycemic therapy. Methylene blue boluses were initiated when hypotension persisted despite conventional treatments. Refractory hypotension prompted the use of plasmapheresis in an attempt to lower serum amlodipine levels. Finally, the patient was placed on extracorporeal membrane oxygenation (ECMO) to maintain perfusion while the effects of the amlodipine ingestion dissipated. Following an episode of asystole and pulseless electrical activity prior to the start of ECMO, the patient suffered an anoxic brain injury and suspected herniation prompting the family to withdraw medical care. There is limited evidence in the literature describing the refractory treatment modalities utilized in this patient. This report is unique as it describes the clinical course of a patient when a multitude of unique treatments were combined.

Evaluation of pharmacy students' knowledge and perceptions of pharmacogenetics before and after a simulation activity.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate students' knowledge and perceptions of the clinical application of pharmacogenetics through a simulation activity and to assess communication of pharmacogenetic-guided treatment recommendations utilizing standardized patients. EDUCATIONAL ACTIVITY AND SETTING: Third-year students in the four-year doctor of pharmacy (PharmD) program at University of South Florida College of Pharmacy completed a pharmacogenetics simulation involving a patient case review, interpretation of pharmacogenetic test results, completion of a situation, background, assessment, recommendation (SBAR) note with drug therapy recommendations, and patient counseling. Voluntary assessments were completed before and after the simulation, which included demographics, knowledge, and perceptions of students' ability to interpret and communicate pharmacogenetic results. FINDINGS: Response rates for the pre- and post-simulation assessments were 109 (98%) and 104 (94%), respectively. Correct responses in application-type questions improved after the simulation (74%) compared to before the simulation (44%, p < 0.01). Responses to perception questions shifted towards "strongly agree" or "agree" after the simulation (p < 0.01). DISCUSSION AND SUMMARY: The simulation gave students an opportunity to apply pharmacogenetics knowledge and allowed them to gain an appreciation of pharmacists' roles within the pharmacogenetics field.