Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care.

OBJECTIVE: To determine the cost-effectiveness and safety of a set of rational use guidelines for analgesia, sedation, and neuromuscular blockade in critically ill ventilated patients when compared with similar factors in standard prescribing. DESIGN: Prospective cost-benefit analysis. SETTING: Medical and surgical intensive care units (ICU) of a 350-bed tertiary care university hospital. PATIENTS: Patients admitted to our ICUs who required mechanical ventilation and continuous analgesics, sedatives, and/or neuromuscular junction blockers (NMJBs). There were 72 patients in the baseline and 84 patients in the follow-up groups. INTERVENTIONS: Prospective tracking of eligible baseline patients was followed by the development and introduction of guidelines and an academic detailing process to promote the use of guidelines. Several months after the introduction of guidelines, a second group of eligible follow-up patients was tracked. The use and effectiveness of analgesics, sedatives, and NMJBs, as well as cost and outcomes, were followed in both groups. Data were subsequently reviewed and analyzed. MEASUREMENTS AND MAIN RESULTS: We recorded data by means of Paradox and Excel databases and included demographics, costs, outcomes (including adverse drug reactions, functional status, ventilator time in hours, lengths of stay), and mortality rates. Data were subsequently analyzed via the Winks statistical data analysis program. Both groups were similar with regard to demographics. There was a statistically significant increase in severity of illness in the follow-up group without a statistically significant increase in mortality. Direct drug costs, ventilator time, and lengths of stay were reduced in the follow-up group. In addition, the use of NMJBs was reduced from 30% in the baseline group to 5% in the follow-up group. CONCLUSIONS: Rational use guidelines resulted in safe, cost-effective improvements in the provision of continuous analgesia, sedation, and neuromuscular blockade to critically ill patients requiring ventilator management when compared with similar factors in baseline prescribing strategies.

A pharmacoeconomic model to aid in the allocation of ambulatory clinical pharmacy services.

Drugs of choice in secondary prevention strategies reduce complication rates of certain diseases. Unfortunately, these strongly indicated drugs remain underused. A model was developed to predict the cost-effectiveness of clinical pharmacy services assumed to improve use of drugs of choice to unity in hypothetical cohorts of three diseases that commonly accompany hypertension and in which clear drugs of choice exist. Use of angiotensin-converting enzyme (ACE) inhibitors in patients with diabetes who have proteinuria, use of beta blockers after myocardial infarction, and use of ACE inhibitors in patients with asymptomatic left ventricular dysfunction were analyzed. Clinical pharmacy services could be cost-saving in all three diseases in this model if use of the drug of choice in standard practice did not exceed 0.899 in patients with diabetes who have proteinuria, 0.512 in patients after infarct, and 0.804 in patients with asymptomatic left ventricular dysfunction. This model may help decision makers by accessing local patient demographics and prescribing habits before any resource allocation.

Pharmacokinetics following a loading plus a continuous infusion of pralidoxime compared with the traditional short infusion regimen in human volunteers.

BACKGROUND: Many authors currently recommend infusing the adult dose (1 g) of pralidoxime over a 15-30 minute period. When administered in this manner, computer simulations predict that plasma pralidoxime concentrations will fall below 4 mg/L as early as one and one half hours after administration. The objective of this study was to assess whether a loading dose followed by a continuous infusion would maintain therapeutic levels longer than the traditional short infusion regimen of pralidoxime if the same total dose was administered. METHODS: Utilizing a randomized, crossover design, healthy volunteers were administered either 16 mg/kg of pralidoxime intravenous over 30 minutes or 4 mg/kg of pralidoxime intravenous over 15 minutes followed by 3.2 mg/kg/h for 3.75 h (for a total dose of 16 mg/kg). Pralidoxime levels were obtained at 0, 10, 20, 30, 60, 120, 180, 240, 300, and 390 minutes and patients were observed for vital sign changes and adverse effects. RESULTS: Seven subjects completed both arms of the study. One subject's data were excluded from pharmacokinetic analysis due to aberrant plasma pralidoxime analysis. The loading dose followed by the continuous infusion maintained therapeutic levels for 257.3 +/- 50.5 minutes whereas the short infusion maintained therapeutic levels for 118.1 +/- 52.1 (p < 0.001). Adverse effects were encountered during the short infusion regimen which did not occur during the continuous infusion. Dizziness or blurred vision occurred in all subjects during the short infusion regimen. Additionally, statistically significant increases in diastolic blood pressure occurred during the short infusion regimen. CONCLUSIONS: The results of this study indicate that a loading dose followed by a continuous infusion of pralidoxime maintains therapeutic concentrations for a longer period of time than the currently recommended short infusion regimen in healthy volunteers.