An Evaluation of Adverse Drug Reactions Associated With Antipsychotic Use for the Treatment of Delirium in the Intensive Care Unit.

PURPOSE: This investigation evaluated the incidence, severity, and harm of adverse drug reactions (ADRs) associated with antipsychotic use for intensive care unit (ICU) delirium. METHODS: In this prospective, observational study patients were screened for development of delirium with the Intensive Care Delirium Screening Checklist (ICDSC). An ICDSC score of ≥4 was considered delirious. Patients with delirium were screened daily for ADRs. Suspected ADRs were evaluated for drug causality using 3 published, objective assessment tools. Suspected ADRs were considered positive when 2 of 3 instruments had an agreement rating of possible or greater. ADR severity was defined as mild/moderate or severe using the National Cancer Institute\u27s Common Terminology Criteria for Adverse Events scale. A modified National Coordinating Council Medication Error Reporting Index for Categorizing Errors categorized ADRs into no harm or harmful. RESULTS: Of 90 patients with delirium, 56 received antipsychotics. Ten suspected ADRs occurred attributed to antipsychotic use. QTc prolongation was the most observed ADR (50%). Patients with ADRs had higher mean Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (P = .038). Patients who received haloperidol experienced more severe (P = .048) ADRs. CONCLUSIONS: ADRs were observed in 18% of patients having delirium treated with antipsychotics with about half considered severe or harmful. A risk versus benefit assessment is needed before initiating antipsychotic therapy in ICU patients

Tips for Developing an Integrated Online and Simulation Course Based on 6-Years of Experience

Technological advancements, changes in pharmacy students’ learning preferences, and increased educational costs have necessitated the development and implementation of innovative teaching modalities. The University of Pittsburgh, School of Pharmacy has been using simulation-based learning throughout the curriculum for several years. To further advance this practice, a novel course was designed to teach students new concepts through online video lectures, slide sets and quizzes, and knowledge application during weekly practica time involving multiple patient cases taught with high fidelity simulation. While this course has been well received by students, it does require resources, organization, and time for development. In this article, we describe our experience developing, modifying, and sustaining this blended course with the hope that sharing our experiences over the past six years will lead to expediting successes at other institutions. Tips for success such as keeping online segments short, holding students accountable, thinking of simulation approaches beyond the mannequin, and developing standardized assessment tools are discussed. Overall the blended course of online learning and simulation is a unique educational experience akin to real-world pharmacy practice and is worth the effort with a goal of optimizing learning

Advancing interprofessional education through the use of high fidelity human patient simulators

Background: Modern medical care increasingly requires coordinated teamwork and communication between healthcare professionals of different disciplines. Unfortunately, healthcare professional students are rarely afforded the opportunity to learn effective methods of interprofessional (IP) communication and teamwork strategies during their education. The question of how to best incorporate IP interactions in the curricula of the schools of health professions remains unanswered. Objective: We aim to solve the lack of IP education in the pharmacy curricula through the use of high fidelity simulation (HFS) to allow teams of medical, pharmacy, nursing, physician assistant, and social work students to work together in a controlled environment to solve cases of complex medical and social issues. Methods: Once weekly for a 4-week time period, students worked together to complete complex simulation scenarios in small IP teams consisting of pharmacy, medical, nursing, social work, and physician assistant students. Student perception of the use of HFS was evaluated by a survey given at the conclusion of the HFS sessions. Team communication was evaluated through the use of Communication and Teamwork Skills (CATS) Assessment by 2 independent evaluators external to the project. Results: The CATS scores improved from the HFS sessions 1 to 2 (p = 0.01), 2 to 3 (p = 0.035), and overall from 1 to 4 (p = 0.001). The inter-rater reliability between evaluators was high (0.85, 95% CI 0.71, 0.99). Students perceived the HFS improved: their ability to communicate with other professionals (median =4); confidence in patient care in an IP team (median=4). It also stimulated student interest in IP work (median=4.5), and was an efficient use of student time (median=4.5) Conclusion: The use of HFS improved student teamwork and communication and was an accepted teaching modality. This method of exposing students of the health sciences to IP care should be incorporated throughout the curricula.Antecedentes: Los cuidados médicos modernos requieren cada día más trabajo en equipo coordinado y comunicación entre profesionales de la salud de diferentes disciplinas. Desafortunadamente, los estudiantes de profesiones de la salud rara vez pueden permitirse la oportunidad de aprender métodos efectivos de comunicación interprofesional (IP) y estrategias e trabajo en grupo durante su educación. La pregunta de cuál es la mejor forma de incorporar las interacciones IP en los curricula de las facultades de profesionales de la salud permanece sin respuesta. Objetivo: Intentamos resolver al falta de educación IP en el curriculum de farmacia mediante el uso de simulación de alta fidelidad (HFS) para permitir que equipos de médicos, farmacéuticos, enfermeras, auxiliares médicos, y trabajadores sociales trabajasen juntos en un ambiente controlado para resolver casos de problemas médicos y sociales complejos. Métodos: Una vez a la semana, durante un periodo de 4 semanas, los estudiantes trabajaron juntos para completar escenarios de simulación complejos en pequeños grupos IP consistentes en estudiantes de farmacia, medicina, enfermería, trabajo social, y auxiliar médico. Se evaluó la percepción de los estudiantes sobre el uso de la HFS mediante un cuestionario al final de las sesiones de HFS. La comunicación en equipo fue evaluada mediante el Communication and Teamwork Skills (CATS) independientemente por dos evaluadores externos al proyecto. Resultados: Las puntuaciones del CATS mejoraron de la sesión de HFS 1 a la 2 (p=0,01), de la 2 a la 3 (p=0,035), y en general de la 1 a la 4 (p=0,001). La fiabilidad inter-evaluadores fue alta (0,85; 95% CI 0,71 - 0,99). Los estudiantes percibieron que la HFS mejoraba: su capacidad de comunicar con otros profesionales (mediana=4); la confianza en la atención al paciente en un equipo IP (mediana=4). También estimuló el iteres de los estudiantes en el trabajo IP (mediana 4,5), y fue una utilización eficiente del tiempo del estudiante (mediana 4,5). Conclusión: El uso de HFS mejoró el trabajo en equipo y la comunicación de los estudiantes y fue una modalidad de enseñanza aceptada. Este método de exponer a los estudiantes de ciencias de la salud a la atención IP debería incorporarse en los curricula

Interpatient Variability in Dexmedetomidine Response: A Survey of the Literature

Fifty-five thousand patients are cared for in the intensive care unit (ICU) daily with sedation utilized to reduce anxiety and agitation while optimizing comfort. The Society of Critical Care Medicine (SCCM) released updated guidelines for management of pain, agitation, and delirium in the ICU and recommended nonbenzodiazepines, such as dexmedetomidine and propofol, as first line sedation agents. Dexmedetomidine, an alpha-2 agonist, offers many benefits yet its use is mired by the inability to consistently achieve sedation goals. Three hypotheses including patient traits/characteristics, pharmacokinetics in critically ill patients, and clinically relevant genetic polymorphisms that could affect dexmedetomidine response are presented. Studies in patient traits have yielded conflicting results regarding the role of race yet suggest that dexmedetomidine may produce more consistent results in less critically ill patients and with home antidepressant use. Pharmacokinetics of critically ill patients are reported as similar to healthy individuals yet wide, unexplained interpatient variability in dexmedetomidine serum levels exist. Genetic polymorphisms in both metabolism and receptor response have been evaluated in few studies, and the results remain inconclusive. To fully understand the role of dexmedetomidine, it is vital to further evaluate what prompts such marked interpatient variability in critically ill patients

Use of acetylcysteine for non-acetaminophen-induced acute liver failure

The purpose of this review was to evaluate the effectiveness of acetylcysteine in the treatment of acute liver failure not related to acetaminophen. A search of MEDLINE April 2003 through May 2012 using the Pub Med database was conducted using the keywords acetylcysteine and non-acetaminophen-induced acute liver failure or acetylcysteine and liver failure. All human case reports, case series, and research articles that discussed the use of acetylcysteine for non-acetaminophen induced liver failure were evaluated. A total of 263 articles were identified during this broad search with 11 articles included for review in this article; eight case reports, two retrospective trials, and one prospective, randomized, double-blind multi-center study. In conclusion, the data suggest marginal benefit of IV acetylcysteine in NAI-ALF with coma grades I-II; however, the routine use of acetylcysteine cannot be recommended. It may be considered in non-transplant centers while awaiting referral or when transplantation is not an option. Further studies are necessary to determine optimal dosing, duration, and criteria for patient selection

Interinstitutional simulation of patients with COVID-19 during a remote acute-care advanced pharmacy practice experience

Introduction: Faculty and staff from Duquesne University and the University of Pittsburgh Schools of Pharmacy created a simulation activity focused on the care of critically ill patients with coronavirus disease 2019 (COVID-19). Students on remote, short-term-care advanced pharmacy practice experiences (APPE) rotations from both universities worked in comingled teams and completed two educational electronic health record reviews, complex simulation sessions, and debriefs. Individually, students completed two educational electronic health record reviews and verbal patient presentations before and after the simulation sessions. Objectives: Evaluate the effects of a simulation activity during a remote short-term-care APPE on student confidence and knowledge surrounding the care of a critically ill patient with COVID-19. Methods: Student knowledge surrounding COVID-19 short-term-care treatment principles was assessed through pre-/postcase-based multiple-choice examinations and an intermittent clinical examination (ICE). Student confidence and perceptions were gathered through anonymous pre-/postsurveys. The written examination and patient presentation recordings were compared from baseline to the final assessment using the Wilcoxon signed-rank test. Results: In total, 92 students participated in the activity. There was a statistically significant improvement from baseline to the final assessment (preassessment median [interquartile range (IQR)]: 55.3% [50%-60.5%]; postassessment median [IQR]: 68.4 [60.5%-73.7%]; P \u3c.001) on the written examination. ICE total scores improved from baseline (preassessment median [range]: 33 [28-36] vs postassessment median [range]: 36.5 [29.5-43.52]; P =.004) as well as the objective (P \u3c.001), plan (P \u3c.001), and monitoring (P \u3c.001) subdomain scores. Student confidence reported on surveys improved from baseline in all domains. Conclusion: Remote simulation sessions improve student knowledge and confidence and provide an opportunity for students to experience caring for patients with COVID-19 in a safe environment. Collaboration between schools of pharmacy can be successfully employed to leverage resources and expertise to expand opportunities for students

Dexmedetomidine for facilitating mechanical ventilation extubation in difficult-to-wean ICU patients: systematic review and meta-analysis of clinical trials

Background: Agitation and delirium are common in mechanically ventilated adult intensive care unit (ICU) patients and may contribute to delayed extubation times. Difficult-to-wean ICU patients have been associated with an increased risk of longer ICU length of stays and mortality. The purpose of this systematic review and meta-analysis is to evaluate the evidence of dexmedetomidine facilitating successful mechanical ventilation extubation in difficult-to-wean ICU patients and clinical outcomes. Methods: A literature search was conducted using MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Global Health, Cochrane Central Register of Controlled Trials, Clinical Trial Registries, and the Health Technology Assessment Database from inception to December 5, 2019. Randomized controlled trials evaluating dexmedetomidine with the intended purpose to facilitate mechanical ventilation liberation in adult ICU patients (≥18 years) experiencing extubation failure were included. The primary outcome of time to extubation was evaluated using the weighted mean difference (WMD), with a random effects model. Secondary analyses included hospital and ICU length of stay, in-hospital mortality, hypotension, and bradycardia. Results: A total of 6 trials (n = 306 patients) were included. Dexmedetomidine significantly reduced the time to extubation (WMD: −11.61 hours, 95% CI: −16.5 to −6.7, P =.005) and ICU length of stay (WMD: −3.04 days; 95% CI: −4.66 to −1.43). Hypotension risk was increased with dexmedetomidine (risk ratio [RR]: 1.62, 95% CI: 1.05-2.51), but there was no difference in bradycardia risk (RR: 3.98, 95% CI: 0.70-22.78). No differences were observed in mortality rates (RR: 1.30, 95% CI: 0.45-3.75) or hospital length of stay (WMD: −2.67 days; 95% CI: −7.73 to 2.39). Conclusions: Dexmedetomidine was associated with a significant reduction in the time to extubation and shorter ICU stay in difficult-to-wean ICU patients. Although hypotension risk was increased with dexmedetomidine, no differences in other clinical outcomes were observed