ICU Drug Research Articles

Cost-effectiveness analysis of pharmaceutical care in adult critically ill patients: based on a prospective cohort study.

The medication regimen for critically ill patients is complex and dynamic, leading to a high incidence of drug-related problems. This study aimed to assess the effectiveness and economic efficiency of pharmaceutical care for these patients. In this prospective cohort study conducted in a tertiary hospital, adult patients were assigned either to a clinical pharmaceutical care group or a control group based on existing clinical grouping rules. Health outcomes and economic indicators were collected, followed by a cost-effectiveness analysis. The acceptance rate for clinical pharmacist interventions was 89.31%. The pharmaceutical care group exhibited significant reductions in the rate of medication errors (40.65% vs. 61.69%, P < 0.001) and adverse drug events (44.52% vs. 56.45%, P = 0.020). The usage rates for special-grade antibiotics (85.16% vs. 91.13%, P = 0.009) and proton pump inhibitors (77.42% vs. 88.71%, P = 0.002) were also lower in the pharmaceutical care group. Secondary outcomes did not show significant differences in total hospital stay (21days vs. 22days, P = 0.092). However, ICU stay was significantly shorter (9days vs. 11days, P = 0.003) in the pharmaceutical care group. Cost-effectiveness analysis demonstrated that each 1% reduction in adverse drug events associated with ICU pharmaceutical care saved $226.75 in ICU hospitalization costs and $203.42 in total ICU drug costs. A 1% reduction in the medication error rate saved $128.57 in ICU hospitalization costs and $115.34 in total ICU drug costs. Pharmaceutical care significantly reduces adverse drug events and medication errors, promotes rational use of medications, decreases the length of ICU stay, and lowers treatment costs in critically ill patients, establishing a definitive advantage in terms of cost-effectiveness.

How COVID-19 has impacted the role of pharmacists around the world

All over the world pharmacists are standing up to the challenge of COVID-19 and showing their commitment to the communities they serve. As the COVID-19 pandemic has tested global health systems to their limits, pharmacy professionals have shown themselves to be an integral part of them. Community pharmacists have supported government initiatives to control the pandemic and have ensured patients continued to receive their medicines. Hospital pharmacists have been moving beyond their specialties to help provide critical care to patients while dealing with ICU drug shortages. Pharmaceutical scientists have been involved in finding effective vaccines and identifying effective treatments. In short, the pharmacy profession has been demonstrating expertise, strength, courage and dedication to care at the highest level.The International Pharmaceutical Federation (FIP), which represents the pharmacy profession globally, has a mission to advance pharmacy worldwide by sharing best pharmacy practice and innovation with the world. In this article, it describes how pharmacy has stepped up during the COVID-19 crisis by giving examples from several countries. It highlights, for example, how virtual practice became more prominent as face-to-face meetings became impossible, how pharmacists’ scope of practice has been extended, and how pharmacy educators have embraced digital technologies to teach and assess students remotely. In particular, the article highlights pharmacists’ involvement in the COVID-19 vaccination programmes in Australia, Canada, Germany, Ireland, Switzerland, the UK and the USA.As a result of all this, FIP sees an exciting future for the profession. Health ministers and heads of state have been praising pharmacists for their service, and FIP wants governments to translate this recognition into support for expanded roles and scientific research. It continues to gather data and intelligence to support an expansion of pharmacy practice, education and pharmaceutical workforce that builds on the profession's scientific base. All these advances are supported by scientific studies about our specialty.Finally, FIP expresses its worries about equity of access to medicines during the pandemic, as younger, healthier people in rich countries are vaccinated before people at greater risk in poor countries. It insists it will continue to advocate on this topic as a core component of its global vision.In this article, we share with readers a snapshot of how our profession around the world has adapted to the challenges posed by the COVID-19 pandemic, and our thoughts on the how it is affecting the evolution of pharmacy practice.

Challenges of Colistin Use in ICU and Therapeutic Drug Monitoring: A Literature Review.

The emerging resistance of Gram-negative bacteria is a growing problem worldwide. Together with the financial cost, limited efficacy, and local unavailability of newer antibiotics or their combinations, it has led to the reintroduction of colistin as a therapeutic alternative. Despite its protracted development and availability on the market, there is now a complex maze of questions surrounding colistin with a more or less straightforward relationship to its safety and efficacy. This review aims to offer a way to navigate this maze. We focus on summarizing the available literature regarding the use of colistin in critically ill patients, particularly on stability, pharmacokinetics, methods for determining plasma concentrations, and therapeutic drug monitoring benefits and limitations. Based on these data, we then highlight the main gaps in the available information and help define directions for future research on this drug. The first gap is the lack of data on the stability of intravenous and nebulization solutions at clinically relevant concentrations and under external conditions corresponding to clinical practice. Furthermore, pharmacokinetic-pharmacodynamic parameters should be validated using standardized dosing, including a loading dose. Based on the pharmacokinetic data obtained, a population model for critically ill patients should be developed. Finally, the interference of colistin with extracorporeal methods should be quantified.

Changes in Purchases for Intensive Care Medicines During the COVID-19 Pandemic: A Global Time Series Study

BackgroundDrug supply disruptions have increased during the COVID-19 pandemic, especially for medicines used in the ICU. Despite reported shortages in wealthy countries, global analyses of ICU drug purchasing during COVID-19 are limited.Research QuestionHas COVID-19 impacted global drug purchases of first-, second-, and third-choice agents used in intensive care?Study Design and MethodsWe conducted a cross-sectional time series study in a global pharmacy sales dataset comprising approximately 60% of the world’s population. We analyzed pandemic-related changes in units purchased per 1,000 population for 69 ICU agents. Interventional autoregressive integrated moving average models tested for significant changes when the pandemic was declared (March 2020) and during its first stage from April through August 2020, globally and by development status.ResultsRelative to 2019, ICU drug purchases increased by 23.6% (95% CI, 7.9%-37.9%) in March 2020 (P < .001) and then decreased by 10.3% (95% CI, –16.9% to –3.5%) from April through August (P = .006). Purchases for second-choice medicines changed the most, especially in developing countries (eg, 29.3% increase in March 2020). Despite similar relative changes (P = .88), absolute purchasing rates in developing nations remained low. The observed decrease from April through August 2020 was significant only in developed countries (–13.1%; 95% CI, –17.4% to –4.4%; P < .001). Country-level variation seemed unrelated to expected demand and health care infrastructure.InterpretationPurchases for intensive care medicines increased globally in the month of the COVID-19 pandemic declaration, but before peak infection rates. These changes were most pronounced for second-choice agents, suggesting that inexpensive, generic medicines may be purchased more easily in anticipation of pandemic-related ICU surges. Nevertheless, disparities in access persisted. Trends seemed unrelated to expected demand, and decreased purchasing from April through August 2020 may suggest overbuying. National and international policies are needed to ensure equitable drug purchasing during future pandemics.

Evidence-Based Guideline for Adult Sedation, Pain Assessment, and Analgesia in a Low Resource Setting Intensive Care Unit: Review Article.

BackgroundAgitation and anxiety occur frequently in ICU and affect about 30–80% of patients in ICU present with delirium worldwide, and it is associated with adverse clinical outcomes. This review aimed to systematically review articles and finally draw an evidence-based guideline for an area with limited resources.MethodsThe review was reported based on preferred reporting items for systemic and meta-analysis (PRISMA) protocol. We searched literature from PubMed, Google Scholar, and Medline database using keywords like the level of sedation, sedation score, pain assessment in ICU, and sedative drugs in ICU from an article published in English. After extraction with a patient population and exclusion, five randomized clinical trials, four systemic reviews and meta-analysis, four observation cohort study, and two practical guidelines were used for the review.ConclusionIn addition to high validity and reliability, RASS has the advantage of easiness to remember for nurses making it a preferred sedation assessment tool in an adult ICU setting. Light sedation with daily interruption was recommended with an aim of an awake and alert patient ready for the weaning trial. Propofol was preferred when sedation is for a short duration and when intermittent awakening is required. Ketamine is the preferred induction for asthmatic hypotensive and patient requiring prolonged continuous sedation. With a similar time for sedation, diazepam shows a shorter time for intubation compared to midazolam. Besides diazepam has shown a cheaper cost of sedation than midazolam. This makes it a drug of preference in a low resource setting.

Socioeconomic Factors and Intensive Care Unit-Related Cognitive Impairment.

We aimed to identify socioeconomic and clinical risk factors for post-intensive care unit (ICU)-related long-term cognitive impairment (LTCI). After delirium during ICU stay, LTCI has been increasingly recognized, but without attention to socioeconomic factors. We enrolled a prospective, multicenter cohort of ICU survivors with shock or respiratory failure from surgical and medical ICUs across 5 civilian and Veteran Affairs (VA) hospitals from 2010 to 2016. Our primary outcome was LTCI at 3- and 12 months post-hospital discharge defined by the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS) global score. Covariates adjusted using multivariable linear regression included age, sex, race, AHRQ socioeconomic index, Charlson comorbidity, Framingham stroke risk, Sequential Organ Failure Assessment, duration of coma, delirium, hypoxemia, sepsis, education level, hospital type, insurance status, discharge disposition, and ICU drug exposures. Of 1040 patients, 71% experienced delirium, and 47% and 41% of survivors had RBANS scores >1 standard deviation below normal at 3- and 12 months, respectively. Adjusted analysis indicated that delirium, non-White race, lower education, and civilian hospitals (as opposed to VA), were associated with at least a half standard deviation lower RBANS scores at 3- and 12 months (P ≤ 0.03). Sex, AHRQ socioeconomic index, insurance status, and discharge disposition were not associated with RBANS scores. Socioeconomic and clinical risk factors, such as race, education, hospital type, and delirium duration, were linked to worse PICS ICU-related, LTCI. Further efforts may focus on improved identification of higher-risk groups to promote survivorship through emerging improvements in cognitive rehabilitation.

Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU Drug Task Force.

During the coronavirus disease (COVID-19) global pandemic, urgent strategies to alleviate shortages are required. Evaluation of the feasibility, practicality, and value of drug conservation strategies and therapeutic alternatives requires a collaborative approach at the provincial level. The Ontario COVID-19 ICU Drug Task Force was directed to create recommendations suggesting drug conservation strategies and therapeutic alternatives for essential drugs at risk of shortage in the intensive care unit during the COVID-19 pandemic. Recommendations were rapidly developed using a modified Delphi method and evaluated on their ease of implementation, feasibility, and supportive evidence. This article describes the recommendations for drug conservation strategies and therapeutic alternatives for drugs at risk of shortage that are commonly used in the care of critically ill patients. Recommendations are identified as preferred and secondary ones that might be less desirable. Although the impetus for generating this document was the COVID-19 pandemic, recommendations should also be applicable for mitigating drug shortages outside of a pandemic. Proposed provincial strategies for drug conservation and therapeutic alternatives may not all be appropriate for every institution. Local implementation will require consultation from end-users and hospital administrators. Competing equipment shortages and available resources should be considered when evaluating the appropriateness of each strategy.

ОЦЕНКА ИСХОДНОГО СТАТУСА ПАЦИЕНТОВ С ПОЛИТРАВМОЙ КАК ОСНОВНОЙ КОМПОНЕНТ СТРАТЕГИИ АНАЛГОСЕДАЦИИ ПАЦИЕНТОВ В ОИТ

Известно, что хирургическое вмешательство вызывает воспалительную реакцию, величина которой зависит от типа операции и степени повреждения ткани [2]. Эта послеоперационная воспалительная реакция сопровождается депрессией клеточного иммунитета, что в свою очередь предрасполагает пациентов к послеоперационным инфекциям и сепсису. Еще одной проблемой, выявленной нами, является то, что оценка влияния препаратов в ОИТ начинается как бы «с чистого листа», без учета уже имеющихся изменений в соматическом, иммунном и гормональном состояниях, связанных как с самим фактом травмы, так и с фактом оперативного вмешательства и уже имеющимся влиянием препаратов для общей анестезии на пациентов с политравмой. Цель исследования. Определить исходный статус пациентов с политравмой при поступлении в ОИТ для разработки превентивной стратегии аналгоседации, что выполняется впервые.Материал и методы. В исследовании участвовали 78 пациентов с политравмой, находящихся в ОИТ, из которых 62,8% составили мужчины и 37,2% – женщины. Средний возраст всех пациентов – 52,2±3,5 года. Сбор анамнеза и жалоб пациентов включал в себя оценку по шкалам SOFA, GCS, MRS, MMSE. Оценивались уровни белка S-100 и цилиарный нейротрофический фактор (CNTF).Результаты и обсуждение. Оценив по шкале SOFA, мы установили, что лишь 30% пациентов с политравмой требуют перевода в ОИТ с длительной ИВЛ и аналгоседацией. Эти пациенты пребывают в состоянии выраженного иммунодефицита и требуют комплексного подхода к лечению. Заключение. Пациентам на длительной ИВЛ необходимо тщательно подбирать стратегию аналгоседации с учетом исходного состояния и биоритмологических особенностей. Необходимо тщательно подбирать режимы ИВЛ, следить за оксигенацией. Немаловажным этапом лечения является подбор нутритивной поддержки с наиболее ранним переходом на энтеральное питание. Заключительным этапом является индивидуальный подбор антибиотикотерапии для предотвращения осложнений ИВЛ.

Highlights from the literature

The Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) study, published in the New England Journal of Medicine , evaluated the use of prophylactic pantoprazole in patients at risk...

Highlights from the literature

The Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) study, published in the New England Journal of Medicine , evaluated the use of prophylactic pantoprazole in patients at risk...

Impact of Quality Bundle Enforcement by a Critical Care Pharmacist on Patient Outcome and Costs.

Surgical and medical ICU patients are at high risk of mortality and provide a significant cost to the healthcare system. The aim of this study is to describe the effect of pharmacist-led interventions on drug therapy and clinical strategies on ICU patient outcome and hospital costs. Before and after study in two French ICUs (16 and 10 beds). ICU patients. From January 1, 2013, to June 30, 2015, a pharmacist observation period was compared with an intervention period in which a critical care pharmacist provided recommendations to clinicians regarding sedative drugs and doses, choice of mechanical ventilation mode and related settings, antimicrobial de-escalation, and central venous and urinary catheters removal. Differences in ICU and hospital length of stay, duration of mechanical ventilation, mortality rate, and hospital costs per patient were quantified between groups with patients matched for severity of illness (Simplified Acute Physiology Score II) at admission. From the 1,519 and 1,268 admitted patients during the observation and intervention periods, respectively, 1,164 patients were evaluable in both groups after matching for Simplified Acute Physiology Score II score. The intervention period was associated with mean (95% CI) reductions in patient hospital length of stay (3.7 d [5.2-2.3 d]; p < 0.001), ICU length of stay (1.4 d [2.3-0.5 d]; p < 0.005), duration of mechanical ventilation (1.2 d [2.1-0.3 d]; p < 0.01), and hospital costs per stay (2,560 euros [3,728-1,392 euros]; p < 0.001). The overall cost savings were 10,840 euros (10,727-10,952 euros) per month, mostly due to reduced consumption of sedatives and antimicrobials. No impact on mortality rate was identified. Critical care pharmacist-led interventions were associated with decreases in ICU and hospital length of stays and ICU drug costs.

A study on the analysis of errors and their effects for evaluating the processes of prescribing and consuming drugs in ICU for the burns

A study on the analysis of errors and their effects for evaluating the processes of prescribing and consuming drugs in ICU for the burns

Construction and application of intensive care knowledge base in DoCare information system

Objective To construct multimedia intensive care knowledge base in DoCare information system, and provide an accurate, rapid and effective method to obtain nursing knowledge and technology for nurses to meet the needs of critical care practice. Methods The specific needs of ICU nurses in the intensive care knowledge base were investigated, and the intensive care knowledge base was constructed combined with other company. Results The main contents of intensive care knowledge base were ICU nursing management system, responsibilities of ICU nurses, ICU workflows, ICU common operating procedures, prevention and treatment of ICU common operating complications, the rescue process of ICU common diseases, knowledge of commonly used drugs in ICU, significance and nursing of common test items in ICU, prevention and control knowledge of hospital-acquired infection in ICU, commonly used nursing assessment tools in ICU and methods of use, differentiation and analysis of common arrhythmia, health education of ICU diseases, various nursing checklists, emergency plans, and ICU new knowledge and related guidelines. The text contents and operation videos were the main forms of the intensive care knowledge base, and the functions were searching, location searching and others. Conclusions The intensive care knowledge base is an effective way for ICU nurses to obtain new knowledge and skills, and make clinical decision quickly and accurately. Key words: Intensive care; Knowledge base; Nursing care; Information system

Improving intravenous drugs administration in ICU and reducing drug incompatibilities: a nurselead interdisciplinary program

Many intravenous (IV) drugs are required for complex and polypathologic critically ill ICU patients management. ICU nurses are daily confronted with drugs preparation and administration (solvent type and volume, infusion rate). They also have to deal with drugs physiochemical incompatibilities (PCI), especially as various IV medications are delivered via a single catheter lumen. PCI may induce a loss of drug efficiency, catheter thrombosis and embolism. Data about drugs PCI in ICU are scarce (1).

Analysis of drug safety in an intensive care unit

A failure mode, effects and criticality analysis (FMECA) was performed by a multidisciplinary team consisting of a clinical pharmacist, a physician, a nurse and a patient safety officer. The steps of the ICU drug process and their possible failure modes (FM) were identified. To each of these, a criticality index (CI, 1 to 810) that takes into account the occurrence, the severity and the detectability was assigned (Table 1). For CI higher than 100, improvement measures were considered and their impact estimated by recalculating the CI.

Predicting ICU admissions from attempted suicide presentations at an Emergency Department in Central Queensland

Emergency medicine physicians and psychiatric staff face a challenging job in risk stratifying patients presenting with suicide attempts to predict which patients need intensive care unit admission, hospital admission or can be discharged with psychiatry follow up. This study aims to analyse patients who were admitted to the intensive care unit or regular ward for suicide attempt, and the methods they employed in a rural Australian base hospital. We conducted a retrospective analysis of patients who presented with suicide attempts to the Rockhampton Base Hospital Emergency Department, Queensland Australia from 1 September 2007 to 31 August 2009. Multivariate logistic regression was undertaken to identify risk factors for ICU and regular ward admission, and predictors of suicide method. There were 570 patients presenting with suicide attempts, 74 of which were repeat suicide attempts. There was a 10- fold increase in the odds of intensive care unit or ICU admission (CI 1.45-81.9, p=0.02) for patients who presented with drug overdose. Increased age (OR=1.02, 95 per cent CI 1.00-1.03, p=0.05), drug overdose (OR=2.69, 95 per cent CI 1.37-5.29, p=0.004), and previous suicide attempt (OR=1.53, 95 per cent CI 1.03-2.28, p=0.03) were significantly correlated with hospital admission. Male patients (OR=2.76, 95 per cent CI 1.43-5.30, p=0.002) and Aboriginal patients (OR=3.38, 95 per cent CI 1.42-8.05, p=0.006) were more likely to choose hanging as a suicide method. We identified drug overdose as a strong predictor of ICU admission, while age, drug overdose and history of previous suicide attempts predict hospital admission. We recommend reviewing physician practices, especially safe medication, in suicide risk patients. Our study also highlights the need for continued close collaboration by acute care and community mental health providers for quality improvement.

Inotropic and Vasoactive Drugs in Pediatric ICU

Circulatory failure recognition and treatment represents an important issue in critically ill infants and children. Early diagnosis and prompt institution of adequate treatment may be life-saving for pediatric patients with cardiocirculatory instability in the setting of intensive care. However, the hemodynamic status of the critically ill child is poorly reflected by baseline vital parameters or laboratory blood tests. A reliable tool for diagnosis and monitoring of evolution of both heart performance and vascular status is strictly needed. Advanced hemodynamic monitoring consists - among others - of measuring cardiac output, predicting fluid responsiveness and calculating systemic oxygen delivery. Identification and quantifying of pulmonary edema has also been recently appreciated in pediatric critical care. In the last decade, the number of vasoactive drugs has increased, together with a better understanding of clinical application of both different monitoring devices and treatment strategies.

The initiation of antiretrovirals in critically ill patients

The use of antiretrovirals (ARVs) in critically ill patients is complicated. Although there are no prospective trials that address timing of initiation of these drugs in ICU, retrospective studies and prospective studies in more stable patients suggest that early initiation of treatment in these patients is probably benefcial. However, use of these drugs in an intensive care population has problems related to ARV administration, toxicities, drug interactions, altered pharmacokinetics of the drugs and the immune reconstitution infammatory syndrome, and initiation should be carefully weighed in each case. In addition to this, critically ill patients are often unable to give informed consent for HIV testing, or undergo appropriate counseling, which raises ethical issues, as well as problems related to post-ICU compliance with medications. This article summarises the evidence available for the use of ARVs in critically ill patients.

Missing emergency drugs in ICU - A clinician′s nightmare!

Missing emergency drugs in ICU - A clinician′s nightmare!

ICU Drug Expenditures Cut, at No Cost to Quality Outcomes

ICU Drug Expenditures Cut, at No Cost to Quality Outcomes