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Midyear Clinical Pearls 2012

Midyear Clinical Pearls 2012. Tips for Responding to Codes. IV drug administration during out of hospital cardiac arrest Randomized to ACLS drugs vs. no ACLS drugs ROSC (40% vs. 25%; p<0.001) Survival to hospital discharge (10.5% vs. 9.2%; p=0.61)

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Midyear Clinical Pearls 2012

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  1. Midyear Clinical Pearls 2012

  2. Tips for Responding to Codes • IV drug administration during out of hospital cardiac arrest • Randomized to ACLS drugs vs. no ACLS drugs • ROSC (40% vs. 25%; p<0.001) • Survival to hospital discharge (10.5% vs. 9.2%; p=0.61) • Etomidate is not recommended for routine use in patients with evidence of septic shock • Adrenal suppression following etomidate administration has been observed in both children and adults • Associated with higher mortality in this patient population Kleinman et al. Circulation. 2010;122:S876-S908. Olasveengen et al. JAMA. 2009;302(20):2222-2229.

  3. WHY NOT? Calcium should only be used during pediatric CPR if there is another indication for use: Hypocalcemia Calcium channel blocker overdose Hypermagnesemia, hyperkalemia Pediatric Cardiopulmonary Resuscitation: Calcium is no longer recommended unless other indication for use • 2008 Report from National Registry of CPR • 1477 Pediatric CPRs • 45% received calcium, 55% received NO calcium • Calcium group had decreased survival to hospital discharge (adjusted OR=0.6, 95% CI 0.5-0.9) and worse neurological outcomes (adjusted OR=0.6, 95% CI 0.4-0.8) Reference: ACLS/PALS Update and Practical Tips. Presentation by Dr. Asad Patanwala, Pharm.D. University of Arizona College of Pharmacy. 2012 ASHP Midyear Conference.

  4. Lithium Toxicity: The SILENT Type • SILENT = Syndrome of Irreversible Lithium • Effectuated Neurotoxicity • Persistent neurologic sequelae that may develop • after resolution of acute lithium toxicity • Symptoms persist for at least 2 months • May be irreversible • Common Symptoms • Cerebellar dysfunction • Extrapyramidal symptoms • Symptoms of dementia

  5. Lithium Toxicity: The SILENT Type • Risk Factors • Chronic exposure to therapeutic concentrations of lithium • High lithium serum concentrations • Pre-existing neurologic disorders or fever • Drug interactions • ACE-I/ARBs, NSAIDs, thiazide diuretics • Non-dihydropyridine CCBs, antipsychotics • OUR ROLE • Although rare, be mindful of SILENT in patients who develop cerebellar dysfunction while on lithium • Monitor the safety and efficacy of lithium • Appropriate serum monitoring and dose adjustments • Minimize/eliminate DDIs

  6. Palliative Care • Palliative care should be viewed as a continuum of care • More than just a step before hospice

  7. Menstrual Migraine Short-term Prophylaxis Level A: Frovaptriptan 2.5 mg daily of BID More HA-free days Level B: Naratriptan 1 mg BID More HA-free days Level B: Zolmitriptan 2.5 mg BID or TID Decrease in attack frequency Note: Note yet FDA approved menstrual migraines

  8. KPC Resistance • Antimicrobial resistance among gram negative pathogens is on the rise.  • Optimal therapy for KPCs is unknown but it appears combination therapy provides a survival benefit. • Most significant improvement includes a carbapenem: tigecycline + carbapenem or colistin/polymixin b + carbapenem • Significantly higher mortality was seen with mono therapy compared with combination therapy.

  9. 2012 ASHP National Survey How does pharmacy look nation wide? • 87% Practice model change in near future • 83% Authority to adjust monitored medications • 60-70% Barcode technology • 60-90% Smart pump technology • 24% Ambulatory pharmacists work in clinic • 22% Counsel at discharge for at-risk patients • 19% No EMR • 17% Tech-check-check • 19% Portion of department residency trained • 11% Portion of department BCPS certified • 9% Follow up with at-risk patients post-discharge • 5% Pharmacy completes medication history

  10. Intranasal Formulations in the ED • MAD Nasal™ -Intranasal mucosal atomization device • Quick, effective administration • Max 1mL per nare (1/3mL per nare ideal) • Use highest drug concentration for lowest volume • If therapeutic response not seen after 2 intranasal doses, change route of therapy • Midazolam: 0.2-0.5mg/kg, max 10mg/dose • Fentanyl: 1-2mcg/kg, max 100mcg (50mcg/mL), may repeat after 5 min • Naloxone: 0.4-2mg/dose q1-2 min, max 10mg • Ketamine

  11. Carbapenems and Valproic Acid DDI • Breakthrough seizures may occur as a result of a drug-drug interaction between carbapenems and valproic acid.  • Typically, valproate is converted to valproate glucuronide, which is excreted.  Valproate is liberated from valproate glurudonide as well, and remains within the system.  • When administered concomitantly, carbapenems increase uridine 5’-diphosphate (UDP) glucuronic acid, which increases the metabolism to valproate glucuronide.  In addition, carbapenems inhibit acylpeptide hydrolase, which is responsible for liberating valproate from valproate glururonide.  • As a result, there is a decreased level of valproate.  This can last for up to 1 to 2 weeks after discontinuing carbapenem therapy.

  12. Lovenox Pearls • Lovenox if increased INR in patient with liver disease? • Although a patient’s INR appears to be within the therapeutic range, when they have liver disease, they are in an “auto anticoagulated state” but their risk of VTE appears to be equal to or GREATER than a normal patient due to a rebalanced hemostat. While there is no data on Lovenox/Heparin – at a minimum, patients should have SCD’s. • Lovenox Anti-Xa Levels • In obesity and renal failure, Anti-Xa levels may be useful to determine if patients are in the therapeutic range. A therapeutic level occurs 3-5 hours after the 3rd or 4th dose. Levels differ with dosing regimen: • 1mg/kg BID – (0.5-1 units/mL) • 1.5mg/kg Daily – (1.0-2.0 units/mL) • Prophylactic dosing – (0.15-0.5 units/mL)

  13. Hyperinsulinemia-Euglycemia (HIE) Used to treat CCB and BB toxicity When to start HIE 1. Crystalloids and atropine, Calcium salts (CCB) or Glucagon (BB), Catecholamines 2. Hyperinsulinemia-Euglycemia Dosing: Bolus: • Insulin 1 unit/kg IVP • Dextrose 25-50 grams IVP if BS less than 400mg/dL Infusion: • Insulin 0.5-1 units/kg/hr, then titrate insulin every 15 minutes (~max 10 units/kg/hr) • Dextrose infusion of 0.5-1 gram/kg/hr (Use D25W or D50W via central line) Monitoring HIE Efficacy Improving vitals / mental status Blood sugar: goal 100-250mg/dL (q15 minutes first hour, q30 minutes for 4 hours, q1h continuing for several hours after discontinuation of insulin) Potassium: Goal > 2.8meq/L (monitor hourly during insulin titration) When is HIE done? No clear recommendations

  14. Hyperinsulinemia-Euglycemia (HIE) Used to treat CCB and BB toxicity: A stressed myocardium becomes dependent on glucose for energy. Insulin facilitates glucose utilization in the ischemic/stressed heart When to start HIE Start after primary therapy with crystalloids and atropine, Calcium salts (CCB) or Glucagon (BB), and Catecholamines Add next step early in titration - Do not delay Dosing: The dose is much higher than seen with diabetic ketoacidosis Monitoring HIE Efficacy Additional monitoring parameters include: Urine output Improving lactate, pH Echocardiography When is HIE done? No clear recommendations Titrate off pressors first Titrate off insulin next (Mean duration of infusion was ~30 hours) Titrate off dextrose last (Mean duration of infusion was ~46 hours)

  15. Using CHA2DS2-VASc in determining needs for anticoagulation (AC) in patients with atrial fibrillation CHADS2 is not an effective tool for stratifying stroke risk in patients with low to intermediate risk CHA2DS2-VASc better stratifies these patients Helps to separate the patients with a CHADS2 score of 1 that are unlikely to benefit from AC Has been adopted by the European Society of Cardiology (ESC) CHA2DS2-VASc is now frequently being used over CHADS2 Changes are bolded on the left Disclaimer: no head to head trials between the two, must also be balanced with risk of bleeding Congestive heart failure- 1 point Hypertension- 1 point Age- 2 points for age > 75 Diabetes- 1 point Stroke- 2 points for previous stroke/TIA Vascular disease- 1 point Age- 1 point age 65-74 Sex category- 1 point for female Score: 0- Likely no drug therapy Score: 1- May consider antiplatelet or AC depending on risk factors and patient preference Score: 2- AC should be strongly considered

  16. CHA2DS2-VASc Benefit: True ‘low risk’ patients Limitation: More anticoagulation/bleeding ESC and CHEST stances? Chest. 2010;137:263-72

  17. Comprehensive Transitions of Care InitiativeCedars Sinai Medical Center; Los Angeles, CA Objective: Decrease drug related problems (DRPs) with pharmacists’ evaluation of patients’ drug therapy regimens at each care transition Background: Medication reconciliation across continuum required by TJC1 Pharmacists demonstrated improved clinical outcomes when involved in medication reconciliation at admission, discharge, and post-discharge2 1. The Joint Commission. 2011 National Patient Safety Goals. http://www.jointcommission.org/assets/1/18/2011‐2012_npsg_presentation_final_8‐4‐11.pdfAccessed September 21 2012. 2. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital‐based medication reconciliation practices. Arch Intern Med 2012, 23;172(14):1057‐69.

  18. Comprehensive Transitions of Care InitiativeCedars Sinai Medical Center; Los Angeles, CA Pharmacist medication reconciliation at each phase

  19. Comprehensive Transitions of Care InitiativeCedars Sinai Medical Center; Los Angeles, CA Results: Average DRP per patient: 2.4 – 7.3 60% of resolved DRPs classified as serious/life-threatening 23% of potential re-hospitalizations prevented 82% of medications taken as prescribed Lessons learned from initiative: Proper notification for discharge med rec challenging due to timing Formulate metrics for data collection early on Give specific examples to demonstrate impact!

  20. Pharmacists involvement in post-discharge callsCleveland Clinic; Cleveland, OH Background: Hospital discharge Chaotic and stressful Time-sensitive Involves many players Important information If hospital discharge process goes poorly… Readmissions Poor HCAHPS scores

  21. Pharmacists involvement in post-discharge callsCleveland Clinic; Cleveland, OH Program: Epic Inbasket message sent to pharmacy pool Response provided within 24 hours Floor pharmacist is paged if they were previously involved in patient’s care

  22. Pharmacists involvement in post-discharge callsCleveland Clinic; Cleveland, OH Bottom-line: Positive trends in HCAHPS scores

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