Development of Machine Learning Models to Validate a Medication Regimen Complexity Scoring Tool for Critically Ill Patients

Introduction: The Medication Regimen Complexity -Intensive Care Unit (MRC-ICU) is the first tool for measuring medication regimen complexity in critically ill patients. This study tested machine learning (ML) models to investigate the relationship between medication regimen complexity and patient outcomes. Methods: This study was a single-center, retrospective observational evaluation of 130 adults admitted to the medical ICU. The MRC-ICU score was utilized to improve the inpatient model’s prediction accuracy. Three models were proposed: model I, demographic data without medication data; model II, demographic data and medication regimen complexity variables; and model III: demographic data and the MRC-ICU score. A total of 6 ML classifiers was developed: k-nearest neighbor (KNN), naïve Bayes (NB), random forest, support vector machine, neural network, and logistic classifier (LC). They were developed and tested using electronic health record data to predict inpatient mortality. Results: The results demonstrated that adding medication regimen complexity variables (model II) and the MRC-ICU score (model III) improved inpatient mortality prediction. The LC outperformed the other classifiers (KNN and NB), with an overall accuracy of 83%, sensitivity (Se) of 87%, specificity of 67%, positive predictive value of 93%, and negative predictive value of 46%. The APACHE III score and the MRC-ICU score at the 24-hour interval were the 2 most important variables. Conclusion and Relevance: Inclusion of the MRC-ICU score improved the prediction of patient outcomes on the previously established APACHE III score. This novel, proof-of-concept methodology shows promise for future application of the MRC-ICU scoring tool for patient outcome predictions

Angiotensin II for Near Drowning: A Case Series

Objective:. 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

Effect of inhaled iloprost on gas exchange in inhalation injury

Objective: Inhalation injury is an independent risk factor for mortality in burn patients. The purpose of this study was to observe the effect of inhaled iloprost on gas exchange in patients with inhalation injury and acute respiratory failure as measured by an improved PaO2/FiO2 ratio. Methods: Patients admitted to the burn intensive care unit from 2013 to 2014 meeting Berlin criteria for acute respiratory distress syndrome (ARDS) with a diagnosis of inhalation injury and who received inhaled iloprost were included. Medical records were reviewed to collect patient demographics, characterize iloprost prescribing practices, and observe changes in oxygenation and hemodynamic status after iloprost administration. Differences were evaluated using a t-test with cluster corrected standard errors. Results: A total of eight patients were included with 157 different PaO2/FiO2 ratios calculated. All patients had moderate or severe ARDS with a baseline PaO2/FiO2 ratio of 131.9 mmHg (IQR 119.3–197.3). Median duration of iloprost therapy was 5 days (IQR ± 7). A statistically significant increase in PaO2/FiO2 ratio was observed after iloprost administration with a mean increase of 9.7 mmHg (95% CI 1.8–17.7, p = 0.023). Inhaled iloprost had no effect on hemodynamic parameters. Conclusions: Inhaled iloprost for inhalation injury and ARDS after burn injury was associated with a small but statistically significant improvement in oxygenation. Keywords: Iloprost, Inhaled prostacyclin, Inhalation injur

Optimization of critical care pharmacy clinical services: A gap analysis approach

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time

Major publications in critical care pharmacotherapy literature in 2018.

PURPOSE: To summarize selected original critical care pharmacotherapy research published in 2018. MATERIALS AND METHODS: The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 32 journals monthly for impactful articles and reviewed 100 articles during 2018. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria were applied to all relevant articles included in the monthly CCPLU. Articles with a 1A grade, including one clinical practice guideline, two meta-analyses, and ten original research trials, were selected for review. RESULTS: Clinical practice guidelines for the management of pain, agitation, delirium, immobility, and sleep disruption were summarized. Meta-analyses on the role of corticosteroids in sepsis and early enteral nutrition were reviewed. Included original research trials evaluated corticosteroids in sepsis, enteral and parenteral nutrition in patients with shock, tenecteplase in acute ischemic stroke, antipsychotics for the treatment of intensive care unit delirium, vasopressors in cardiogenic shock, balanced crystalloids and saline for fluid administration, and meropenem and piperacillin-tazobactam for treatment of resistant Gram-negative organisms. CONCLUSION: This clinical review and expert commentary of impactful critical care pharmacotherapy publications in 2018 provides perspectives and insights for the critical care practitioner