Pharmacotherapy
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Randomized Controlled Trial Comparative Study Clinical Trial
A pharmacoeconomic analysis of neuromuscular blocking agents in the operating room.
A cost-minimization analysis was performed to compare the direct costs of various neuromuscular blocking agents (NMBAs) in procedures of specific durations. Secondary objectives were to review the role of the NMBAs studied with respect to their place on our hospital formulary, and to develop a pharmacoeconomic methodology to be applied to other formulary decisions. Patients were stratified according to estimated length of surgical procedure; group 1 (55 patients) included surgeries estimated to take less than 2 hours, and group 2 (55 patients) included those estimated to be 2-4 hours long. ⋯ There were no differences in PACU times or costs. Based on these results, vecuronium or rocuronium is preferred over atracurium in procedures with an estimated duration of 2-4 hours. In the patient population evaluated, there were no significant cost differences among the three NMBAs in surgeries with an estimated duration of less than 2 hours.
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Comparative Study
The impact of practice guidelines on prescribing patterns of nondepolarizing neuromuscular blocking agents.
Guidelines for selecting nondepolarizing neuromuscular blocking agents (NNMBAs) were developed and implemented by an interdisciplinary team for use in our intensive care units. They suggest pancuronium as the drug of choice if the patient does not have renal insufficiency and is hemodynamically stable. If either of these criteria is not met and hepatic function is normal, vecuronium is recommended. ⋯ After guideline implementation, atracurium, vecuronium, and pancuronium were prescribed for 33% (8), 21% (5), and 46% (11) of patients, respectively, and use was inappropriate in 38% (3), 60% (3), and 0% of patients, respectively. Overall, the prevalence of inappropriate NNMBA selection decreased from 80% (20) to 25% (6). Further analysis is necessary to determine the associated pharmacoeconomic impact of decreased inappropriate NNMBA prescribing.
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Fosphenytoin is a phenytoin prodrug that received an approvable letter from the Food and Drug Administration in February 1996. It was designed to overcome many of the shortcomings associated with parenteral phenytoin sodium. Specifically, fosphenytoin is a highly water-soluble, phosphate ester of phenytoin that has no known pharmacologic activity before its conversion to phenytoin. ⋯ It is also well tolerated when given intramuscularly, and this is a valuable alternative route of administration when intravenous access or cardiographic monitoring is unavailable. Its pharmacoeconomic advantages over phenytoin have not been documented in formal studies to date, although the likelihood of savings based on cost-effectiveness analyses is high. Hence, fosphenytoin has the potential as a safe, well-tolerated, and effective means of delivering phenytoin parenterally in a variety of clinical settings.
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Pruritus is a common side effect after neuraxial administration of the opioids; particularly morphine sulfate. Ondansetron has been used to treat the pruritus in patients with cholestatic diseases or renal insufficiency, suggesting that pruritus may be mediated by serotonin. ⋯ Pruritus disappeared within few minutes in three of these patients. Future studies are necessary to evaluate the efficacy of ondansetron for the treatment as well as the prevention of this opioid-induced effect.