Hidden Fluids in Plain Sight: Identifying Intravenous Medication Classes as Contributors to Intensive Care Unit Fluid Intake.

Introduction: Fluid stewardship targets optimal fluid management to improve patient outcomes. Intravenous (IV) medications, flushes, and blood products, collectively referred to as hidden fluids, contribute to fluid intake in the intensive care unit (ICU). The impact of specific IV medications on fluid intake is unknown. Objective: Characterize IV medication classes based on contribution to ICU fluid intake by frequency of administration and total volume infused to identify targets for fluid stewardship. Methods: This multi-center, retrospective nested cohort study included patients admitted to a medical or surgical ICU between January 2017 and December 2018. The primary outcome was to identify the volume contribution of specific IV medication classes administered over the first 3 ICU days. Secondary outcomes were the administration frequency of these medications and their proportion of total daily volume intake over the first 3 ICU days. Results: The study included 210 patients. The largest mean administration volumes over the course of the first 3 ICU days were attributed to antibacterials (968 ± 846 mL), vitamins/minerals/electrolytes (416 ± 935 mL), pain/agitation/delirium agents (310 ± 512 mL), and vasoactive agents (282 ± 744 mL). The highest frequencies over the course of the first 3 ICU days were attributed to antibacterials (n = 180; 86%), pain/agitation/delirium agents (n = 143; 68%), vitamins/minerals/electrolytes (n = 123; 59%), and vasoactive agents (n = 96; 46%). IV medications contributed 2601 ± 2573 mL of fluid volume per patient over the first 3 ICU days, accounting for 42% ± 29% of overall volume. Conclusion: IV medications contribute over 40% of total fluid intake within the first 3 days of ICU admission, with antibacterials as top contributors by administration volume and frequency. Future research implementing fluid stewardship to ICU fluid sources, such as concentrating IV medications, switching IV medications to oral formulations, de-escalation of antibacterials, and reduction of maintenance fluids, should be performed to minimize hidden fluids from IV medications.

Productivity Tracking: A Survey of Critical Care Pharmacist Practices and Satisfaction.

Introduction: The position paper on critical care pharmacy services describes two tiers of responsibilities: essential and desirable activities. Activities are categorized into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Documentation of these activities can be important for justifying pharmacist positions, comparing pharmacy practice models, conducting performance evaluations, and tracking individual workload; however, limited recommendations are provided for standardized productivity tracking, and national practices remain largely uncharacterized. Objectives: The purpose of this survey was to describe documentation practices of critical care pharmacist activities. Methods: A cross-sectional survey was distributed via email to 1694 members of the ACCP critical care practice research network. The survey asked respondents to describe the methods used to document productivity as it relates to the 5 domains. Results: Seventy-nine (4.7%) critical care pharmacists from 63 institutions completed the survey. Intervention documentation was used for position justification and annual reviews among 54.4% and 44.1% of pharmacists, respectively. Pharmacists were routinely expected to perform additional responsibilities beyond patient care that contribute to overall productivity, but the percentage of institutions that track these activities as a measure of pharmacist productivity was relatively low: quality improvement (46%), research/scholarship (29%), training/education (38%), and professional development (27%). Documentation of these additional responsibilities and activities was primarily used for annual evaluations, but the majority of respondents answered that no standardized method for tracking activities existed. In multivariate regression, dedicated ICU pharmacists was a significant predictor for increased satisfaction (Exp(ß) 4.498, 95% CI 1.054-19.187, P = .042). Conclusion: Practice variation exists in how and for what intent critical care pharmacists track productivity. Further evaluation and standardization of productivity tracking may aid in position justification and practice model evaluation for dedicated ICU pharmacists in today's value-based era.

Effects of Propofol on Hemodynamic Profile in Adults Receiving Targeted Temperature Management.

Background: Propofol is a key component for the management of sedation and shivering during targeted temperature management (TTM) following cardiac arrest. The cardiac depressant effects of propofol have not been described during TTM and may be especially relevant given the stress to the myocardium following cardiac arrest. The purpose of this study is to describe hemodynamic changes associated with propofol administration during TTM. Methods: This single center, retrospective cohort study evaluated adult patients who received a propofol infusion for at least 30 minutes during TTM. The primary outcome was the change in cardiovascular Sequential Organ Failure Assessment (cvSOFA) score 30 minutes after propofol initiation. Secondary outcomes included change in systolic blood pressure (SBP), mean arterial pressure (MAP), heart rate (HR), and vasopressor requirements (VR) expressed as norepinephrine equivalents at 30, 60, 120, 180, and 240 minutes after propofol initiation. A multivariate regression was performed to assess the influence of propofol and body temperature on MAP, while controlling for vasopressor dose and cardiac arrest hospital prognosis (CAHP) score. Results: The cohort included 40 patients with a median CAHP score of 197. The goal temperature of 33°C was achieved for all patients. The median cvSOFA score was 1 at baseline and 0.5 at 30 minutes, with a non-significant change after propofol initiation (P = .96). SBP and MAP reductions were the greatest at 60 minutes (17 and 8 mmHg; P < .05 for both). The median change in HR at 120 minutes was -9 beats/minute from baseline. This reduction was sustained through 240 minutes (P < .05). No change in VR were seen at any time point. In multivariate regression, body temperature was the only characteristic independently associated with changes in MAP (coefficient 4.95, 95% CI 1.6-8.3). Conclusion: Administration of propofol during TTM did not affect cvSOFA score. The reductions in SBP, MAP, and HR did not have a corresponding change in vasopressor requirements and are likely not clinically meaningful. Propofol appears to be a safe choice for sedation in patients receiving targeted temperature management after cardiac arrest.

Beta-Adrenergic Blockade in Critical Illness.

Catecholamine upregulation is a core pathophysiological feature in critical illness. Sustained catecholamine ß-adrenergic induction produces adverse effects relevant to critical illness management. ß-blockers (ßB) have proposed roles in various critically ill disease states, including sepsis, trauma, burns, and cardiac arrest. Mounting evidence suggests ßB improve hemodynamic and metabolic parameters culminating in decreased burn healing time, reduced mortality in traumatic brain injury, and improved neurologic outcomes following cardiac arrest. In sepsis, ßB appear hemodynamically benign after acute resuscitation and may augment cardiac function. The emergence of ultra-rapid ßB provides new territory for ßB, and early data suggest significant improvements in mitigating atrial fibrillation in persistently tachycardic septic patients. This review summarizes the evidence regarding the pharmacotherapeutic role of ßB on relevant pathophysiology and clinical outcomes in various types of critical illness.

Angiotensin II for Near Drowning: A Case Series.

This case series describes the effect of angiotensin II administration on hemodynamics in patients with parenchymal lung injury due to submersion injury. CASE SUMMARY: A 33-year-old female and a 72-year-old female were both brought to the emergency department after incidents of near drowning. Upon arrival to the emergency department, both patients were hemodynamically unstable and were eventually intubated for airway protection. Imaging done by conventional chest radiograph for both patients revealed bilateral pulmonary edema. Due to their hemodynamic status, vasopressors were initiated for both patients and were quickly titrated, leading to the initiation of angiotensin II. In one patient, angiotensin II was initiated early in shock and resulted in rapid improvement of hemodynamics. In the other patient, angiotensin II was initiated later and a more muted response was observed. CONCLUSIONS: In patients with near drowning, angiotensin II appeared to improve hemodynamic status rapidly. This is the first case series to report the use of this new vasoactive agent in this population and poses noteworthy mechanistic considerations.

Pharmacist perceptions of CliftonStrengths® themes important for success in advanced cardiovascular life support.

WHAT IS KNOWN AND OBJECTIVE: Advanced Cardiovascular Life Support (ACLS) is an integrated, team-based approach to optimizing patient outcomes during acute cardiovascular events. Due to the fast-paced, high-stress environment, inherent strengths may impact performance and confidence with ACLS skills. The objective of this study was to assess pharmacist perceptions regarding strengths deemed important during emergency cardiovascular response. METHODS: An electronic survey was administered to members of the American College of Clinical Pharmacists Critical Care, Cardiology, Internal Medicine, Emergency Medicine and Pediatrics Practice and Research Network listservs. The survey assessed the top 5 strengths deemed important for being part of an emergency response team, a pharmacist's role in ACLS and a team leader's role in ACLS. The primary outcome was top strengths required for pharmacist involvement in ACLS. Descriptive statistics were used to present survey results. RESULTS: Of the 359 responses included, nearly all respondents had been certified by the American Heart Association in ACLS and/or Pediatric Advanced Life Support (PALS). The top CliftonStrengths® themes considered important for a pharmacist's role in ACLS were communication, adaptability, analytical, focus and responsibility. The top CliftonStrengths® themes considered important for the team leader's role in ACLS were communication, command, analytical, focus and adaptability. The top CliftonStrengths® themes important for an emergency response team were communication, adaptability, focus, analytical and command. WHAT IS NEW AND CONCLUSIONS: By determining the personality traits perceived to be associated with high performance in ACLS, approaches can be taken to personalize student learning in order to train "practice-ready" pharmacists that can be integral members of the ACLS team.

The Role of Statin Therapy in Hemorrhagic Stroke.

The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are the most widely utilized class of cholesterol-lowering agents, carrying multiple indications for both primary and secondary cardiovascular risk reduction. Concern was raised by previously published post hoc analyses and observational studies that noted an increased risk of hemorrhagic stroke in patients receiving a statin. Subsequent studies have demonstrated conflicting results regarding the role of statin therapy on hemorrhagic stroke risk and patient outcomes. New evidence suggests that statins taken prior to or continued during admission for intracerebral hemorrhage (ICH) may be associated with positive outcomes. Evidence also suggests deleterious outcomes resulting from the abrupt discontinuation of statins upon hospital admission for multiple disease states including ICH. Conflicting data also exist for the use of statins following aneurysmal subarachnoid hemorrhage (aSAH). Recent evidence suggests statins started during admission for aSAH confer no additional benefit in reducing delayed ischemic neurologic deficits despite initial positive results. Larger scale evaluation of the role of statin therapy following hemorrhagic stroke is warranted. The available literature is reviewed to provide guidance for therapeutic decision making.