Corticosteroid use in ARDS and its application to evolving therapeutics for coronavirus disease 2019 (COVID-19): A systematic review.

Data regarding the use of corticosteroids for treatment of acute respiratory distress syndrome (ARDS) are conflicting. As the coronavirus disease 2019 (COVID-19) pandemic progresses, more literature supporting the use of corticosteroids for COVID-19 and non-COVID-19 ARDS have emerged. Glucocorticoids are proposed to attenuate the inflammatory response and prevent progression to the fibroproliferative phase of ARDS through their multiple mechanisms and anti-inflammatory properties. The purpose of this systematic review was to comprehensively evaluate the literature surrounding corticosteroid use in ARDS (non-COVID-19 and COVID-19) in addition to a narrative review of clinical considerations of corticosteroid use in these patient populations. OVID Medline and EMBASE were searched. Randomized controlled trials evaluating the use of corticosteroids for COVID-19 and non-COVID-19 ARDS in adult patients on mortality outcomes were included. Risk of bias was assessed with the Risk of Bias 2.0 tool. There were 388 studies identified, 15 of which met the inclusion criteria that included a total of 8877 patients. The studies included in our review reported a mortality benefit in 6/15 (40%) studies with benefit being seen at varying time points of mortality follow-up (ICU survival, hospital, and 28 and 60 days) in the COVID-19 and non-COVID-19 ARDS studies. The two non-COVID19 trials assessing lung injury score improvements found that corticosteroids led to significant improvements with corticosteroid use. The number of mechanical ventilation-free days significantly were found to be increased with the use of corticosteroids in all four studies that assessed this outcome. Corticosteroids are associated with improvements in mortality and ventilator-free days in critically ill patients with both COVID-19 and non-COVID-19 ARDS, and evidence suggests their use should be encouraged in these settings. However, due to substantial differences in the corticosteroid regimens utilized in these trials, questions still remain regarding the optimal corticosteroid agent, dose, and duration in patients with ARDS.

Pharmacists leadership in a medication shortage response: Illustrative examples from a health system response to the COVID-19 crisis.

As medication experts, clinical pharmacists play an active and dynamic role in a medication shortage response. Supplementing existing guidelines with an actionable framework of discrete activities to support effective medication shortage responses can expand the scope of pharmacy practice and improve patient care. Dissemination of best practices and illustrative, networked examples from health systems can support the adoption of innovative solutions. In this descriptive report, we document the translation of published shortage mitigation guidelines into system success through broad pharmacist engagement and the adaption and implementation of targeted strategies. The profound, wide-reaching medication shortages that accompanied the coronavirus disease 2019 (COVID-19) pandemic are used to highlight coordinated but distinct practices and how they have been combined to expand the influence of the pharmacy enterprise.

Analgesia and Sedation Strategies in Mechanically Ventilated Adults with COVID-19.

Evidence-based management of analgesia and sedation in COVID-19-associated acute respiratory distress syndrome remains limited. Non-guideline recommended analgesic and sedative medication regimens and deeper sedation targets have been employed for patients with COVID-19 due to exaggerated analgesia and sedation requirements with extended durations of mechanical ventilation. This, coupled with a desire to minimize nurse entry into COVID-19 patient rooms, marked obesity, altered end-organ function, and evolving medication shortages, presents numerous short- and long-term challenges. Alternative analgesic and sedative agents and regimens may pose safety risks and require judicious bedside management for appropriate use. The purpose of this commentary is to provide considerations and solutions for designing safe and effective analgesia and sedation strategies for adult patients with considerable ventilator dyssynchrony and sedation requirements, such as COVID-19.

Optimizing the correct timing of vancomycin level collection utilizing a vancomycin medication administration record (MAR) level order.

OBJECTIVE: Vancomycin, a commonly used antimicrobial, has a narrow therapeutic index; therefore, Therapeutic Drug Monitoring (TDM) is required. Although the Electronic Medical Record (EMR) may improve patient care, without appropriate optimization, it can contribute to incorrectly drawn vancomycin levels. For medication administration, nurses utilize the Medication Administration Record (MAR) for medication administration documentation and medication workflow guidance. Therefore, we hypothesized creating a MAR level order which would be incorporated into this already established medication workflow may improve the rate of correctly drawn vancomycin levels. MATERIALS AND METHODS: This was a multicenter, retrospective, pre-and post-intervention study which evaluated the effect of a Medication Administration Record (MAR) level order within the EMR on the correct timing of vancomycin level collection. Vancomycin levels were classified into pre-and post-intervention groups. The primary endpoint was the rate of incorrectly drawn levels, defined as a level being drawn early, a level being drawn late, a level drawn while infusing, or a missed level. RESULTS: A total of 1353 vancomycin levels were assessed, and 628 levels met inclusion criteria. Of the levels eligible for inclusion, 331 were in the pre-intervention period and 297 were in the post-intervention period. Levels in the post-intervention group utilizing the vancomycin MAR level order were less likely to be missed or drawn at an incorrect time (11.1 % vs 36 %, P < 0.01) and were less likely to require rescheduling (3.4 % vs 8.5 %, P < 0.01). CONCLUSION: Utilization of a vancomycin MAR level order was associated with a significant decrease in incorrectly drawn vancomycin levels.

Clinical outcomes of baloxavir versus oseltamivir in patients hospitalized with influenza A.

OBJECTIVES: To date, clinical trials evaluating baloxavir have excluded patients hospitalized with influenza infection and therefore this study sought to evaluate the efficacy of baloxavir in inpatients with influenza A. METHODS: This study was a multicentre, retrospective chart review of adult patients admitted to the hospital within the Yale New Haven Health System who received oseltamivir or baloxavir for the treatment of influenza A. Patients were screened for inclusion between January 2018 and April 2018 in the oseltamivir group, while patients in the baloxavir group were screened for inclusion between January 2019 and April 2019. Influenza A diagnosis was confirmed by RT-PCR using a nasopharyngeal swab specimen. RESULTS: Of the 2392 patients assessed, 790 met the inclusion criteria. There were 359 patients who received baloxavir and 431 patients who received oseltamivir. Patients who received baloxavir were younger compared with those who received oseltamivir [median = 69 (IQR = 57-81) years versus 77 (IQR = 62-86) years; P < 0.001]. Patients who received baloxavir had no significant difference in hospital length of stay [median = 4 (IQR = 3-6) days versus 5 (IQR = 3-6) days; P = 0.45] or 30 day all-cause mortality [12 (3.3%) versus 26 (6%); P = 0.079] compared with those who received oseltamivir. However, patients who received baloxavir had a significantly faster time to hypoxia resolution [median = 51.7 (IQR = 25.3-89.3) h versus 72 (IQR = 37.5-123) h; P < 0.001]. CONCLUSIONS: The results of this study support the use of baloxavir for the treatment of influenza A in hospitalized patients with the potential benefit of a faster time to resolution of hypoxia.

Implications for medication dosing for transgender patients: A review of the literature and recommendations for pharmacists.

PURPOSE: Transgender patients face considerable healthcare disparities. Improved means of recognizing transgender patients and understanding their medical needs is important to provide optimal care. The electronic medical record (EMR) of our health system allows for differentiation of gender identity, legal sex, and sex at birth. With EMR recognition of transgender patients, a recommendation for estimating creatinine clearance (CLcr) and ideal body weight (IBW) was needed to standardize medication dosing. SUMMARY: The literature was reviewed for evidence on the effect of gender-affirming hormone therapy on serum creatinine concentration and lean body mass. Findings informed a recommendation for drug dosing based on CLcr and IBW in transgender patients. Four studies that reported the effect of hormone therapy on biometric laboratory values were found. Three studies reported that values of transgender patients more closely resembled the standard values of their gender identity vs sex at birth after hormone therapy; 1 study reported a range of values that more closely resembled those associated with sex at birth while still overlapping with values associated with gender identity. Consequently, it was recommended that pharmacists dose medications based on CLcr and IBW calculations consistent with gender identity after a patient has been on hormone therapy for 6 months or longer. CONCLUSION: Providing optimal care to transgender patients includes considering the effect of gender-affirming hormone therapy on overall physiology. Consistently using the appropriate CLcr and IBW calculations for each patient ensures safe and effective care. Additional studies are needed to confirm the effect of hormone therapy on renal clearance and lean body mass.

Experience with integrating pharmacist documenters on cardiac arrest teams to improve quality.

OBJECTIVES: To determine if adding a clinical pharmacist to the cardiac arrest team in a documenter role improves completeness of documentation and quality of advanced cardiovascular life support (ACLS). SETTING: A 1541-bed, tertiary care, academic medical center with an integrated clinical pharmacy practice model. PRACTICE DESCRIPTION: In 2012, we identified documentation of resuscitation activities during cardiac arrest events and compliance with published ACLS guidelines as opportunities for systematic quality improvement at our tertiary care academic medical center. Although clinical pharmacists provided pharmacotherapy support through active participation on multidisciplinary patient care rounds, pharmacists were not routinely accountable for care provided during cardiac arrest events. PRACTICE INNOVATION: We integrated pharmacists on the cardiac arrest team in the unique role of documenter and pharmacotherapy consultant. The pharmacist documenter was responsible for recording all activities (e.g., medication administered, endotracheal intubation, vital signs), providing real-time quality assurance during the event, and assisting with any clinical or operational needs of the team. Participating pharmacists received didactic lectures, practical assessments, and a written examination to ensure baseline competency in ACLS and teamwork principles. EVALUATION: Using a before-and-after study design, we conducted a retrospective chart review to evaluate our pilot program. All cardiac arrest events requiring activation of the cardiac arrest team from January 2012 through December 2013 were included (n = 80). RESULTS: Pharmacists attended all cardiac arrest team events in the postintervention period during the scheduled coverage hours. The percentage of forms with all documentation components complete increased from 0% at baseline to 28% postintervention (P = 0.002). ACLS compliance also increased from 8% preintervention to 31% postintervention (P = 0.024). CONCLUSION: Implementation of a dedicated pharmacist for documentation and pharmacotherapy consultation during cardiac arrest events is associated with improved documentation completeness and ACLS compliance. This was achieved without funding or additional pharmacist resources.

A Comparison of Histamine Receptor Antagonists Versus Proton Pump Inhibitor Gastrointestinal Ulcer Prophylaxis in Kidney Transplant Recipients.

INTRODUCTION: There are several different agents that can be used for gastrointestinal (GI) ulcer prophylaxis in posttransplant recipients, such as histamine-2 receptor antagonists (H2RA) or proton pump inhibitors (PPIs). RESEARCH QUESTION: This study was conducted to compare the incidence of adverse kidney events in transplant recipients who received prophylaxis with H2RAs or PPIs. DESIGN: This retrospective study included all kidney transplant recipients from 3 transplant centers who were transplanted in 2009 through 2011. The primary objective was to compare the incidence of adverse events posttransplant, defined as the incidence of pneumonia, Clostridium difficile, hip fractures, GI bleeding, cytomegalovirus, organ rejection, and bacteremia. RESULTS: A total of 211 patients were included in the study; of which 35 were included in the PPI group and 176 were included in the H2RA group. There were no significant differences between groups in regard to incidence of GI bleeding events or other adverse events. DISCUSSION: These findings suggest there is a low incidence of GI ulcers and upper GI bleeding events after kidney transplantation with the use of H2RAs or PPIs. Additionally, there are similar rates of adverse events when comparing H2RAs versus PPIs for GI ulcer prophylaxis.