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Issue 6: Pulmonary & Critical Care Insider
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Compiled by Bharat Bajantri, MD, and librarian Sarah Ellsworth, MLS for the clinicians of the Pulmonary and Critical Care team of Parkview.
The goal of this newsletter is to give a brief summary of the most pertinent articles to everyday practice and an attempt to keep up with literature as best as possible. Newsletters go out every 1-2 months.
Summaries/Topics in this issue:
Wasted Blood in Hospital Setting
Blood Transfusions
MINT Trial
Epinephrine related death
Non-invasive Airway Management of Comatose Poisoned Emergency Patients
Angiotensin II (AT2) and Vasopressors
Angiotensin II for the Treatment of Refractory Shock
Smoking cessation
Pneumococcal vaccination
Intra Cranial Pressure Puls
Pulmonary Alveolar Proteinosis Following Severe COVID - 19 Infection: A Case Report
Get PDFA 67-year-old male, with a history of severe COVID-19 infection and exposure to talc was seen for worsening shortness of breath for months, requiring supplemental oxygen. He was treated for COVID-19 infection and suspected pneumonia with no improvement. His pulmonary function test (PFT) worsened and computed tomography (CT) showing bilateral airspace opacities with ground-glass opacities (GGO), also worsened over time. He underwent bronchoscopy, bronchoalveolar lavage and pathology revealed pulmonary alveolar proteinosis (PAP). He subsequently underwent whole lung lavage (WLL) which significantly improved his crazy paving pattern on CT and was successfully weaned off supplemental oxygen
Neuromuscular monitoring: A tutorial for pharmacists.
No full textDISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting 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.
PURPOSE: To describe neuromuscular monitoring modalities and highlight the importance of neuromuscular monitoring to clinical pharmacy practice.
SUMMARY: A growing body of literature and clinical practice guidelines have highlighted the importance of neuromuscular monitoring practices to ensure patient safety during surgery and in the intensive care unit. Understanding neuromuscular monitoring modalities can allow pharmacists to enhance participation in institutional discussions and optimization of neuromuscular blocker administration and reversal practices. We have described the various modalities of neuromuscular monitoring and considerations for using different modalities.
CONCLUSION: Neuromuscular monitoring should be performed whenever neuromuscular blocking agents are administered. This practice represents an evidence-based approach to minimizing the occurrence of residual neuromuscular blockade and its associated complications
Slay the Antibiotic Delay
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Background: Rapid Response nurses are educated to respond to emergent situations and provides support to the patient care team, often intervening to prevent patient complications. These specialty nurses are repeatedly called to place an intravenous (IV) for scheduled medications when the bedside nurses is unsuccessful or hesitant to place one. Prioritizing IV starts compete with emergent patient situations which frequently cause retiming of IV antibiotics. Objectives/Aim/Purpose: The purpose of this quality improvement project was to prevent IV medication delays including re-timing. Methods: Nurses were surveyed and identified reasons for delays and re-timing of IV antibiotics. A focus group was further surveyed and verified barriers to medication delays. A retrospective electronic medical record (EMR) report was created which included reason for delays or re-timing. Rapid response nurses tracked IV start requests, prior attempts to place IV by primary nurse, and level of difficulty in placement. Results: The EMR report provided baseline data regarding reasons for retiming and amount of time for delay. Further education was provided to ensure nursing knowledge for not only reasons of medication delays but criticality of consequences of delays in administration of antibiotic. The specifics obtained from the focus group as well as the rapid response data identified the opportunity for further education to improve IV skills. Conclusion: Statistically significant results of the quantifiable outcomes will not be available for some time. The increased awareness of IV medication delay, barriers and actions identified by nursing has empowered the team to increase their skills and knowledge to improve timeliness of antibiotics
Screening for diabetes distress and depression in routine clinical care for youth with type 1 diabetes.
No full textOBJECTIVE: The purpose of this study is to examine diabetes distress as a potential mediator of the relationship between depression symptoms and diabetes outcomes, including hemoglobin A1c (hemoglobin A1c [HbA1c]) and diabetes management behaviors in a clinical sample of adolescents and young adults.
METHODS: In a pediatric diabetes clinic, 716 youth (ages 12-21 years) completed measures of diabetes distress (Problem Areas in Diabetes-Teen [PAID-T]), a single-item of diabetes distress, and depression (Patient Health Questionnaire [PHQ-9]) as part of standard care. Electronic health records were extracted for the Six Habits and glycemic management (HbA1c).
RESULTS: Overall, 3.6% (n = 26) of adolescents had clinically elevated diabetes distress and depression symptoms, 5.0% had diabetes distress alone, 8.7% had depression symptoms alone, and 82.7% had neither clinical elevation of diabetes distress nor depression symptoms. Results of mediation analysis demonstrated diabetes distress (both full and single-item measures) fully mediated the relationship between depression symptoms and HbA1c (p \u3c .001). Also, mediation analysis results showcase incomplete mediation of the effect of the Six Habits score on HbA1c appears by PAID-T Diabetes Distress.
CONCLUSIONS: In a clinical sample of youth with type 1 diabetes, both depressive symptoms and diabetes distress are associated with HbA1c. Furthermore, diabetes distress fully mediates the relationship between depressive symptoms and HbA1c. As part of standard clinical care, the single-item screener for diabetes distress captured similar results as the full-scaled PAID-T. With limited clinical resources, providers may consider focusing assessment and interventions on the psychological factor of diabetes distress within the diabetes clinic to maximize the impact on glycemic control and consider the use of single-item screening to identify distress
Anticoagulation strategies after left ventricular thrombus.
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This medication use evaluation found that prescribing practices of DOAC and warfarin did not change after AHA guidance publication. Patients with HFrEF were more often discharged on warfarin, while those with Afib were more often discharged on DOACs. Those discharged on a DOAC had the highest incidence of LV thrombus resolution up to 6 months post-discharge. Physicians within Parkview Health do not routinely utilize a loading dose when discharging a patient on a DOAC
Factors Influencing Time to Definitive Care in Hip Fracture Patients in a Rural Health System.
No full textBACKGROUND: Current literature has not adequately addressed factors affecting wait times for hip fracture surgery in the rural setting.
OBJECTIVE: This study aims to assess the factors affecting admission, transit, and preoperative wait times that impact the timeliness of hip fracture surgery within a rural health system.
METHODS: A single-center retrospective cross-sectional study was conducted in a rural community comprising five community hospitals and two receiving hospitals. A trauma registry study included all hip fracture cases from 2019. Mean, standard deviation, median, and interquartile range were calculated for admission wait times, transit times to the receiving hospitals, and preoperative wait times in hours. Metrics based on means or medians were developed for these wait times.
RESULTS: A total of 163 patients met the inclusion criteria. The emergency department wait times before and after admission to the community hospitals were 1 hour and 2.5 hours, respectively. The transit times from the community hospitals, ranging from shorter to farther distances, to receiving hospitals were 40 minutes and 1 hour, respectively. The preoperative wait time for admitted and transferred patients was 12 hours.
CONCLUSION: Our study outlines a methodology for establishing wait time metrics that impact surgical timeliness for hip fracture patients within a rural healthcare system. We recommend conducting comparable studies with larger sample sizes across different healthcare systems
Issue 11: Pulmonary & Critical Care Insider
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Compiled by Bharat Bajantri, MD, and librarian Sarah Ellsworth, MLS for the clinicians of the Pulmonary and Critical Care team of Parkview.
The Pulmonary & Critical Care Insider newsletter was created by Dr. Bharat Bajantri, MD and Sarah Ellsworth, MLS in 2023 as a form of current awareness for current practice at our hospital, Parkview Health.
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Topics:
VIEWPOINTS:
Blood Pressure Measurement
Home Noninvasive Ventilation
ORIGINAL STUDY SUMMARY
Acute Pulmonary Embolism
The PEXIVAS trial
Respiratory Failure in hemorrhagic shock
SNAPSHOTS:
RBC Transfusions
New Small cell lung cancer Treatment
Evaluation of triple therapy use for COPD
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This retrospective, cross-sectional study found that nearly all patients were not administered pulmonary function testing prior to treatment with COPD triple therapy (inhaled corticosteroid plus long-acting muscarinic-antagonist plus long-acting beta-2-agonist). Additionally, the vast majority did not have a documented elevated eosinophil count. These represent good opportunities to optimize population-based care for COPD patients
The impact of sugammadex dosing and administration practices on potential cost savings for pharmacy departments.
No full textPURPOSE: Neuromuscular blocking agents (NMBAs) are commonly used during surgery, and restoring neuromuscular function at the end of surgery is vital in preventing complications of residual paralysis. Recent guidelines from the American Society of Anesthesiology recommend using sugammadex over neostigmine; however, sugammadex is significantly more expensive than neostigmine and may increase drug expenditure for pharmacy departments. This review summarizes evidence evaluating sugammadex dose adjustments and the potential of these dose adjustments to lead to cost savings for pharmacy departments.
SUMMARY: We found evidence suggesting that the manufacturer-recommended sugammadex dose may not be needed in many patients and that dosing based on an adjusted body weight or based on depth of neuromuscular blockade may lead to lower sugammadex usage. Combining sugammadex with neostigmine could also decrease the dose of sugammadex required. We have highlighted the importance of objective neuromuscular monitoring to guide sugammadex dosing and evaluation for residual neuromuscular blockade. Cost savings for pharmacy departments may be realized by these alternative dosing strategies and/or vial-splitting practices.
CONCLUSION: Implementing practices related to sugammadex vial splitting and dose adjustment based on body weight and depth of neuromuscular blockade shows potential benefits in terms of sugammadex cost savings