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Increasing pharmacist workload was associated with increased ICU length of stay, reduced quantity of interventions, and reduced intensity of interventions.
pubmed.ncbi.nlm.nih.gov/35678204/
@CritCareMed @SCCM @SCCM_CPP
#TwitteRx #PharmICU
pubmed.ncbi.nlm.nih.gov/35678204/
@CritCareMed @SCCM @SCCM_CPP
#TwitteRx #PharmICU
Increasing MRC-ICU score was associated with
1. Higher mortality
2. Longer LOS
3. More medication interventions
4. Increased intensity of medication interventions
^A compelling argument for DEDICATED pharmacotherapeutic expertise on the multiprofessional rounding team.
1. Higher mortality
2. Longer LOS
3. More medication interventions
4. Increased intensity of medication interventions
^A compelling argument for DEDICATED pharmacotherapeutic expertise on the multiprofessional rounding team.
The @SCCM @ASHP_Official @ACCP Joint Position Statement (pubmed.ncbi.nlm.nih.gov/32826496/) calls pharmacists “essential members of the multiprofessional critical care team,” but we have no standards for pharmacist workload ratios.
Now that the salty🧂debate on the TYPE of fluid to use in the ICU has largely been solved, how about the RATE of IVF? 🤔
Back to the BaSICS💦
✅The Balanced Solutions in Intensive Care Study📖 (BaSICS) ▶️compared 333mL/hr vs 999 mL/h
Does IVF rate impact 90-day mortality? 🤔
Back to the BaSICS💦
✅The Balanced Solutions in Intensive Care Study📖 (BaSICS) ▶️compared 333mL/hr vs 999 mL/h
Does IVF rate impact 90-day mortality? 🤔
💡 10, 520 ICU pts randomized 🏥
Fluid volume:
1162 mL in the SLOW infusion group 💦
vs. 1252 mL in the FASTer group
🛑NO difference in☝️ outcome: 90-day mortality (HR 1.03, CI, 0.96-1.11)
🛑No difference in✌️outcomes: RRT, AKI, ventilator free days, ICU/hospital LOS
Fluid volume:
1162 mL in the SLOW infusion group 💦
vs. 1252 mL in the FASTer group
🛑NO difference in☝️ outcome: 90-day mortality (HR 1.03, CI, 0.96-1.11)
🛑No difference in✌️outcomes: RRT, AKI, ventilator free days, ICU/hospital LOS
Notably, when reviewing this study, the baseline characteristics are a key 🔑 consideration
< 5% of the cohort in both groups had sepsis (⬇️ the generalizability in this population) 🦠
Patients with AKI or ESRD were excluded from the trial 💡
< 5% of the cohort in both groups had sepsis (⬇️ the generalizability in this population) 🦠
Patients with AKI or ESRD were excluded from the trial 💡
What medications 💊 are should be avoided 🛑 or used with caution ⚠️ in patients with Myasthenia Gravis? 🤔
See 👀 the thread 🧵below⤵️ that summarizes an amazing grand rounds presentation by @UKPharmRes PGY1 @AliW_PharmD on key 🔑 medication considerations in MG
See 👀 the thread 🧵below⤵️ that summarizes an amazing grand rounds presentation by @UKPharmRes PGY1 @AliW_PharmD on key 🔑 medication considerations in MG
1️⃣Antibiotics to avoid or use w/caution🦠 💊
🛑FQs = FDA BBW for ⤴️ risk of MG crisis ➡️ avoid use if possible
⚠️ Macrolides ⤴️ rate of MG crisis (case reports)
⚠️ AG linked to ⤴️ ICU acquired weakness & exacerbate ‼️ MG crisis
📝Risk⬆️ w/neomycin vs. tobramycin & amikacin
🛑FQs = FDA BBW for ⤴️ risk of MG crisis ➡️ avoid use if possible
⚠️ Macrolides ⤴️ rate of MG crisis (case reports)
⚠️ AG linked to ⤴️ ICU acquired weakness & exacerbate ‼️ MG crisis
📝Risk⬆️ w/neomycin vs. tobramycin & amikacin
Antibiotics considered to be SAFE alternatives to the above include
✅Beta-lactams
✅Tetracyclines
✅Linezolid
✅Bactrim
Ex. In an MG patient who presents 🏥 w/CAP 🫁 ➡️ choose ceftriaxone + doxycycline✅ OVER ceftriaxone + azithromycin🛑
✅Beta-lactams
✅Tetracyclines
✅Linezolid
✅Bactrim
Ex. In an MG patient who presents 🏥 w/CAP 🫁 ➡️ choose ceftriaxone + doxycycline✅ OVER ceftriaxone + azithromycin🛑
PGY1 Resident @NatalieHaddadRx will be presenting an exciting Grand Rounds topic today. Join us with live tweets starting at 11 am CST as she discusses the role of midodrine for vasopressor discontinuation!
Use of #midodrine has increased nearly 50% from 2011 through 2016, and its use has likely increased further in recent years. What is its role in vasopressor discontinuation?
Midodrine is a prodrug with its active metabolite desglymidodrine acting as an alpha-1 agonist. Its peak effect on blood pressure occurs in 1-2 hours with a half life of 3-4 hours. ⌛️
1/ Women in Critical Care:
👍 Just recorded #ISICEM roundtable w @frubulotta @ElisabethWaele @FlaviaSepsis & Dr. Juffermans. 🎥 🍿 on Sept 16th.
Let’s eliminate prejudice based on gender, sexual pref & color. Here is a Baker’s Dozen of Women ICU Leaders!
#heforshe #medtwitter
👍 Just recorded #ISICEM roundtable w @frubulotta @ElisabethWaele @FlaviaSepsis & Dr. Juffermans. 🎥 🍿 on Sept 16th.
Let’s eliminate prejudice based on gender, sexual pref & color. Here is a Baker’s Dozen of Women ICU Leaders!
#heforshe #medtwitter
2/ The first woman leader in Critical Care I discussed was Dr. Christina Jones from UK. She is a Biochemist, Nurse, Masters Social Work, PhD in Psychotherapy.
👊Mother of ICU Support Groups & ICU Diaries. As an expert, she shaped our field!
#sccm #esicm #pulmcc #ICUrehap
👊Mother of ICU Support Groups & ICU Diaries. As an expert, she shaped our field!
#sccm #esicm #pulmcc #ICUrehap
3/ 2nd world leader in Crit Care presented was Dr. Deborah Cook, from McMaster Univ in Canada. Seminal trials in Ulcer Proph, Bioethics, CCCTG trials, and now edifying us about how to provide healing in the dying process through her 3-Wishes Project.
#endoflife #palliativecare
#endoflife #palliativecare
Tip for new pharmacists; learn as MUCH as you can about diagnostic procedures as some play an important role in pharmacotherapy💊
1/
Ex: Lumbar puncture➡️procedure to collect CSF➡️assess for CNS🧠diseases (i.e meningitis, CNS leukemia)
‼️imperative to ✅ for timing ⏰ of LP
1/
Ex: Lumbar puncture➡️procedure to collect CSF➡️assess for CNS🧠diseases (i.e meningitis, CNS leukemia)
‼️imperative to ✅ for timing ⏰ of LP
B/c anticoagulants/antiplatelets must be discontinued🛑prior to an LP or else there is a risk of spinal hematoma🤯or intracranial hemorrhages🩸
🛑Apixaban/Riva 24-48 hrs before
🛑LMWH PPX 12 hrs and Tx dose 24 hours before
🛑Dabigatran 48 hrs before
🛑Warfarin until INR<1.4
🛑Apixaban/Riva 24-48 hrs before
🛑LMWH PPX 12 hrs and Tx dose 24 hours before
🛑Dabigatran 48 hrs before
🛑Warfarin until INR<1.4
Recommendations and infographic from in this awesome article below 👇🏻👇🏻
#oncopharm #pharmICU #TwitteRx #meded #MedTwitter
pn.bmj.com/content/practn…
#oncopharm #pharmICU #TwitteRx #meded #MedTwitter
pn.bmj.com/content/practn…
Mentor-Mentee SCCM CPP Spotlight: Dr. Andrea Newsome Sikora @AndreaSikora
“You should read better books.” 📚
The duality in this statement is a microcosm of mentorship:
You are enough right now & also you are capable of more.
An inspirational thread 👇🏻#PharmICU
“You should read better books.” 📚
The duality in this statement is a microcosm of mentorship:
You are enough right now & also you are capable of more.
An inspirational thread 👇🏻#PharmICU
Mentors have double vision. 👀
Seeing you as you are and may be and celebrate the process of becoming.
Mentors are loyal to the person you are growing into, which reminds Dr. Sikora of Rumi:
“If you are irritated by every rub, how will you be polished?”
#mentorship
Seeing you as you are and may be and celebrate the process of becoming.
Mentors are loyal to the person you are growing into, which reminds Dr. Sikora of Rumi:
“If you are irritated by every rub, how will you be polished?”
#mentorship
We have a personal and professional responsibility to develop mentor-mentee relationships. 🤝
Dr. Sikora states “Mentorship has been a continuous lesson in the values of loyalty, humility, honesty, gratitude, balance, passion, discipline & integrity.”
#gratitude
Dr. Sikora states “Mentorship has been a continuous lesson in the values of loyalty, humility, honesty, gratitude, balance, passion, discipline & integrity.”
#gratitude
Tips for you on your rotation in the ICU! 💉
How to 🧠 if a vasopressor is low, medium, or high dose? 🤷🏻♀️
Arbitrary & depend on dosing strategy but @md_hatton uses the rule of 🖐 ‘s (just move the decimal based on the pressor)
⬇️Low dose = <5
➡️Medium = 5-10
⬆️High = >10
How to 🧠 if a vasopressor is low, medium, or high dose? 🤷🏻♀️
Arbitrary & depend on dosing strategy but @md_hatton uses the rule of 🖐 ‘s (just move the decimal based on the pressor)
⬇️Low dose = <5
➡️Medium = 5-10
⬆️High = >10
Let’s take norepinephrine as an example: 💉 👩🏻⚕️
NE dose of <0.05 mcg/kg/min
▶️⬇️LOW dose
NE dose 0.05-0.1 mcg/kg/min
▶️➡️MEDIUM dose
NE dose >0.1 mcg/kg/min
▶️⬆️HIGH dose
Thanks @md_hatton for the pearl and
#tipsfornewinterns this week on rounds! #PharmICU #critcare
NE dose of <0.05 mcg/kg/min
▶️⬇️LOW dose
NE dose 0.05-0.1 mcg/kg/min
▶️➡️MEDIUM dose
NE dose >0.1 mcg/kg/min
▶️⬆️HIGH dose
Thanks @md_hatton for the pearl and
#tipsfornewinterns this week on rounds! #PharmICU #critcare
What other vasopressors pearls regarding dosing do you have to share? @camelpanda @BissellBrittany @DRxDray @mtbastin @MelanieLaine2 @CD_PharmD @HeavnerPharmD @accpcritprn @PharmacyToDose @PharmD_intheED @GilbertPharmD
SCCM CPP Mentor-Mentee program in action: 👏🏻
“Mentorship is a two-way street”
Dr. Carter(mentee) & Dr. Rose(mentor) have collaborated on scholarly projects 📚 in their area of shared specialty and broadened their professional networks 👥 as a result of their partnership. 🤝
“Mentorship is a two-way street”
Dr. Carter(mentee) & Dr. Rose(mentor) have collaborated on scholarly projects 📚 in their area of shared specialty and broadened their professional networks 👥 as a result of their partnership. 🤝
Both Dr. Rose and Dr. Carter feel that their successes were be attributed to having a proactive mentor who follows the program guidelines and keeps the mentee on track with goals. 🎖
Thank you for sharing your story @CRosePharmD @ccarterpharmd
#PharmICU #CritCare #mentorship
Thank you for sharing your story @CRosePharmD @ccarterpharmd
#PharmICU #CritCare #mentorship
Are you a SCCM CPP member 👀 for a mentor to help you navigate the #critcare workforce as a PGY2 Critical Care resident or new practitioner? 👩🏻⚕️
OR
Are you a practicing #critcare PharmD looking to serve as a mentor for a new trainee? 🙌🏼 #payitforward
OR
Are you a practicing #critcare PharmD looking to serve as a mentor for a new trainee? 🙌🏼 #payitforward
So many pressers to choose from, oh my! 🤯
Let us help you learn about the important differences between agents with our vasopressor pocket guide!✏️📋
Hoping this will help assist new residents:interns starting in July 😊
Let us help you learn about the important differences between agents with our vasopressor pocket guide!✏️📋
Hoping this will help assist new residents:interns starting in July 😊
✅Check out these awesome resources for additional in depth learning on vasopressors to get ready for July!
@PulmCrit @iBookCC (amazing podcast) podcasts.apple.com/ca/podcast/the…
Our favorite review article 💯 journals.sagepub.com/doi/full/10.11… #pharmICU
@SCCM VP Tool Box sccm.org/Communications…
@PulmCrit @iBookCC (amazing podcast) podcasts.apple.com/ca/podcast/the…
Our favorite review article 💯 journals.sagepub.com/doi/full/10.11… #pharmICU
@SCCM VP Tool Box sccm.org/Communications…
@EMHighAK @emdocsdotnet @long_brit Emdocs has a great review too emdocs.net/evidence-based…
Others include @Core_EM @EMSwami for some great podcasts/blog readings!
Others include @Core_EM @EMSwami for some great podcasts/blog readings!
My favorite pharmacist job description:
(1/4) I walk into the work room to ask my favorite resident about the meropenem order he put in.
He slams his fist against the table: "How do you always know?!" He shouts.
Everyone in the room jumps. Usually, he is so easygoing.
(1/4) I walk into the work room to ask my favorite resident about the meropenem order he put in.
He slams his fist against the table: "How do you always know?!" He shouts.
Everyone in the room jumps. Usually, he is so easygoing.
(2/4) "Know what?"
"How do you ALWAYS know?" He repeats. "Like the second I put an order in, you ask me about. It's like immediate!"
The fellow laughs, "Man- don't you realize that's the pharmacist's job? They look at all our orders to make sure we didn't jack anything up."
"How do you ALWAYS know?" He repeats. "Like the second I put an order in, you ask me about. It's like immediate!"
The fellow laughs, "Man- don't you realize that's the pharmacist's job? They look at all our orders to make sure we didn't jack anything up."
(3/4) He looks at me in disbelief, "Really?"
I show him my computer screen with his mero order. He shakes his head, "It was like superhuman. I couldn't figure it out."
"May I ask - what is it you thought I did all day?"
I show him my computer screen with his mero order. He shakes his head, "It was like superhuman. I couldn't figure it out."
"May I ask - what is it you thought I did all day?"
Despite the craziness, I appreciate how my residency still dedicates time to resident learning! Today was my #JClub on NON-Seda, thanks to my mentor @MikeA_42
In light of sedation shortages w/ #COVID19 any institutions trying “no sedation” strategies for pts on vents?
In light of sedation shortages w/ #COVID19 any institutions trying “no sedation” strategies for pts on vents?
🚨 New Guideline Published 🚨
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with COVID19 🦠
Tweetorial on key clinical recommendations 👇🏻#CCM #ICM #COVID19 @ESICM @SCCM @CritCareMed
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with COVID19 🦠
Tweetorial on key clinical recommendations 👇🏻#CCM #ICM #COVID19 @ESICM @SCCM @CritCareMed
1️⃣COVID19 Testing in the ICU 🔬
➡️If pt is intubated, lower respiratory tract samples preferred > upper respiratory tract 🧫
➡️➡️Lower respiratory samples, prefer endotracheal aspirate >> bronchial wash or bronchoalveolar lavage 🧪
➡️If pt is intubated, lower respiratory tract samples preferred > upper respiratory tract 🧫
➡️➡️Lower respiratory samples, prefer endotracheal aspirate >> bronchial wash or bronchoalveolar lavage 🧪
2️⃣Infection Control in the ICU
✅Recommend video-guided laryngoscopy for intubation
✅Aerosol-generating procedure➡️ require a negative pressure room & HCPs should wear fitted respirator masks + PPE
✅Non-ventilated OR non-aerosol-generating procedure➡️ med/surg masks + PPE
✅Recommend video-guided laryngoscopy for intubation
✅Aerosol-generating procedure➡️ require a negative pressure room & HCPs should wear fitted respirator masks + PPE
✅Non-ventilated OR non-aerosol-generating procedure➡️ med/surg masks + PPE
OLWLT🗣 MICU edition @HeavnerPharmD
Always have to keep an👁on💩movements in MICU patients esp w/↗️doses of opioids used for sedation😴➕pain🩹
Methylnaltrexone➡️mu-receptor antagonist🛑➡️used for refractory OIC
Very💰agent&dosing based on BW in obese can lead to↗️↗️drug cost‼️
Always have to keep an👁on💩movements in MICU patients esp w/↗️doses of opioids used for sedation😴➕pain🩹
Methylnaltrexone➡️mu-receptor antagonist🛑➡️used for refractory OIC
Very💰agent&dosing based on BW in obese can lead to↗️↗️drug cost‼️
On rounds, our pt would’ve required 1 + 1/2 12 mg vials BUT we 🤔 💭 to look up if fixed doses in obesity (>130kg)= similar efficacy
ncbi.nlm.nih.gov/pmc/articles/P…
This study found ICU pts >62 kg responded to 12mg FIXED dose (1 vial)>62kg & efficacy maintained when BW >114 kg! 👏👍
ncbi.nlm.nih.gov/pmc/articles/P…
This study found ICU pts >62 kg responded to 12mg FIXED dose (1 vial)>62kg & efficacy maintained when BW >114 kg! 👏👍
Responses (I.e 💩) were observed within4️⃣hours! And ADEs including abdominal pain were LOWER compared to placebo 🤩
Bottom line➡️ constipation REFRACTORY to senna, miralax, & suppository/enema➡️try methynaltrexone!
In pts >62 kg fixed dose 12mg is a💰saving initiative!
Bottom line➡️ constipation REFRACTORY to senna, miralax, & suppository/enema➡️try methynaltrexone!
In pts >62 kg fixed dose 12mg is a💰saving initiative!
Starting MICU with @HeavnerPharmD this month🥳! Month long series of #OLWLT (1 thing WE learned today😊)
Posterior Reversible Encephalopathy Syndrome(PRES)➡️serious🧠condition characterized by
🩺Hypertension 🤯headache ⚡️seizures & 👀 loss
TACROLIMOUS▶️immunosuppressant
1/
Posterior Reversible Encephalopathy Syndrome(PRES)➡️serious🧠condition characterized by
🩺Hypertension 🤯headache ⚡️seizures & 👀 loss
TACROLIMOUS▶️immunosuppressant
1/
used for GVHD prophylaxis in HSCT⤴️neurotoxicity&⤴️HTN perpetuating the risk of PRES🤯
During an episode of GVHD➡️ tac levels are often ⤴️ to prevent worsening GVHD BUT➡️⤴️inflammation⤴️tac🧠 penetration & risk of PRES😟
🛑Tac can lead to PRES even if levels are THERAPEUTIC🛑
During an episode of GVHD➡️ tac levels are often ⤴️ to prevent worsening GVHD BUT➡️⤴️inflammation⤴️tac🧠 penetration & risk of PRES😟
🛑Tac can lead to PRES even if levels are THERAPEUTIC🛑
Management is complex⚠️
🎯 is to balance risk of GVHD Vd worsening PRES
✅seizures➡️benzos
✅HTN▶️rapidly titratable anti-hypertensives
May PRES-ur luck by🔄 to cyclosporine➡️but risk for PRES still exists😬
Sirolimous/MMF➡️↘️risk of PRES, but efficacy 4️⃣ GVHD is questionable🧐
🎯 is to balance risk of GVHD Vd worsening PRES
✅seizures➡️benzos
✅HTN▶️rapidly titratable anti-hypertensives
May PRES-ur luck by🔄 to cyclosporine➡️but risk for PRES still exists😬
Sirolimous/MMF➡️↘️risk of PRES, but efficacy 4️⃣ GVHD is questionable🧐
