The impact of formulary reservations on drug utilization: a controlled trial.

A controlled trial was conducted in two teaching hospitals (A and B), with similar case mixes to determine the impact of reservations, which were educational in nature, on the utilization of oral ciprofloxacin. Over a two-month period the health records of all the patients who received the drug were reviewed, and information on utilization and demographics of patients receiving the drug was recorded. As well, the number of admissions to the two hospitals over this period were compared. If culture and sensitivity (C & S) results were available, appropriateness was assessed in accordance with criteria for use established at site A; in the absence of C & S information, consensus by two microbiologists was used. Over the two-month period a total of 136 patients received ciprofloxacin at the two institutions. At site A, which had reservations, the number of patients who continued to receive ciprofloxacin upon admission was significantly decreased relative to site B, which did not have reservations (14% vs. 36% respectively, p = .029). As well, when assessed by total number of admissions to the institutions, the number of patients receiving ciprofloxacin at site A was less than site B (1.5% vs. 2.6% respectively, p = .003)). While the utilization was decreased at site A vs. site B, the proportion of patients with therapy deemed to be appropriate was not different between the two sites. Educationally based reservations are an effective formulary tool for optimizing drug utilization.

Intraosseous infusion rates: comparison of various intraosseous sites versus peripheral intravenous sites in normovolemic and hypovolemic pigs - abstract

The tibial intraosseous (IO) site is useful for vascular access in paediatric resuscitation. However, alternate IO sites need to be considered for use in patients with lower extremity and abdominal trauma, and in those requiring multiple infusions. The infusion rates were determined at tibial, medial malleolar, distal femoral and humeral IO sites and at a peripheral intravenous (IV) site in 23 normovolemic and hypovolemic anaesthetised pigs (12 - 23 kg). IO cannulation was established with 18 gauge bone marrow needles and in peripheral vessels with ww gauge teflon catheters. Hypovolemia was established by acutely bleeding 2 mi/kg. Infusion rates were determined in random order under gravity and 300/mm Hg pressure. The infusion rates obtained (table given) were significantly different (MANOVA p = 0.0001) for gravity vs 300 mm Hg. Our study suggested 1) IV access is the most efficacious infusion method for volume resuscitation; 2) IO sites differ in the infusion rates obtained; 3) IO infusions provide reasonable alternatives for short-term vascular access (AU)

Multiple intraosseous sites versus peripheral intravenous sites in a pig model comparison of drug pharmacokinetics - abstract

The pharmacokinetics of injected sodium bicarbonate and radioactive tracers were studied from various intraosseous (IO) sites and a peripheral intravenous (IV) site. Anaesthetised piglets (12-23kg) were catheterised with peripheral 22-gauge IV catheters and 18-gauge bone marrow needles in the medial malleolar, tibial, femoral and humeral IO sites. Standardised aliquots of NaHCO3, (1meq/kg) and Tc-99m DTPA (600 micro-curies) were injected at randomly selected sites. The initial time and maximal level of CO2 rise after NaHCO3 injected were monitored using an end tidal CO2 monitor. The initial time to reach, and proportion of injected tracer in the central circulation were determined using radioactivity counter measure of carotid blood samples drawn at 1.5 second intervals for 1 minute and at 2, 5, 10, 20, 30, and 40, minutes. The following kinetics were determined: SAS analysis by ANOVA. KINETICS - DTPA time to carotid (sec); Tracer amount/Total dose (percentage total dose; Initial CO2 rise (sec);Maximal CO2 rise (mmHg);- IV - 12.8, .032, 12.8 9.6 respectively; HUMERUS - 12.0, .048, 12.0, 8.4 respectively; FEMUR - 13.5, .035, 12.6, 8.1 respectively; ANKLE - 18.6, .037, 13.6, 7.3 respectively; TIBIA - 17.3, .033, 12.9, 12.9 respectively. There was no statistically significant difference (p>.05) in the following: 1) Time of initial expired CO2 rise, 2) Maximal expired CO2 rise, 3) Time of tracer to reach the central circulation from IO and IV sites. Our study suggests: (1) IO and IV sites are similarly rapid means of injection delivery to the central circulation, (2) adjustments in dosages of medication may not be required to achieve the same IO effects as IV injection (AU)

Nebulized albuterol in acute childhood asthma: comparison of two doses.

Thirty-three children and adolescents from 5 to 17 years of age with moderate to severe acute asthma were given nebulized albuterol therapy in either a high (0.30 mg/kg body weight) or standard (0.15 mg/kg) dose administered at three hourly intervals in a randomized double-blind study. The high-dose hourly regimen resulted in significantly greater improvement in the forced expiratory volume in 1 second (FEV1). Furthermore, patients receiving the high dose showed a steady improvement in the FEV1 from the start to the end of the study, whereas FEV1 plateaued after the second dose in the standard-dose group. Although a rise in heart rate and a fall in serum potassium level occurred, neither of these changes nor other side effects were different in the two groups. The high-dose therapy resulted in much higher serum albuterol levels than the standard dose. There was no correlation between the drug levels and side effects or initial and subsequent FEV1. It is concluded that occasional hourly high-dose albuterol therapy should be considered for some pediatric patients with acute asthma of moderate severity, especially those who relapse between doses.