Pharmacotherapy
-
Trauma patients are routinely prescribed stress ulcer prophylaxis despite evidence suggesting such therapy be limited to patients with identifiable risk factors for bleeding. With surgeons' consensus, we developed and implemented trauma stress ulcer prophylaxis guidelines, and measured the impact of clinical pharmacists on implementing the guidelines and the effect of the guidelines on drug cost and frequency of major gastrointestinal bleeding. Two groups of 150 consecutive patients admitted with multiple trauma were evaluated before and after guideline implementation and stratified by Injury Severity Score (ISS) to minor (ISS < 9) or moderate to severe (ISS > or = 9) trauma groups. ⋯ Recommendations to discontinue therapy were accepted in 9 (60%) of 15 instances. The frequency of major gastrointestinal bleeding remained unchanged between groups (1/150 vs 0/150, p=1.0). Implementation of trauma stress ulcer prophylaxis guidelines limiting therapy to patients with risk factors for bleeding led to a 80% decrease in drug cost and did not affect the frequency of major gastrointestinal bleeding.
-
We assessed the ability of a graphic nomogram to adjust steady-state warfarin dosages and to predict international normalized ratios (INR) after a dosage change, compared with an anticoagulation clinic pharmacist and a Bayesian regression computer program. Study subjects were 108 men and 3 women receiving warfarin anticoagulation. In all patients the median absolute errors in predicted INR values for the nomogram, computer program, and pharmacist were 0.33, 0.46, and 0.48, respectively. ⋯ The nomogram was significantly more precise than the pharmacist (p=0.005) and computer (p=0.002). The ability to provide more precise dosage reductions of warfarin may be of clinical importance in light of current recommendations for higher-intensity warfarin therapy and maintenance of higher INR values. Prospective validation of the performance of this nomogram in a routine clinical setting is warranted.
-
We evaluated pregnancy outcomes in 234 women exposed to fluconazole, 492 exposed to a topically administered azole preparation, 88 exposed to an oral azole preparation other than fluconazole, and 1629 not exposed to any of these agents during the first trimester of pregnancy Relative risks of having a baby with a congenital disorder for women exposed to fluconazole, oral azoles, and topical azoles in the first trimester of pregnancy compared with those who were unexposed were 1.1 (95% CI 0.4-3.3), 2.1 (95% CI 0.7-6.8), and 0.6 (95% CI 0.2-1.6), respectively These results provide reassurance that fluconazole exposure in the first trimester of pregnancy does not materially increase the risk of congenital disorders in infants.
-
Pulmonary delivery of inhaled bronchodilators in mechanically ventilated patients is inefficient whether administered by metered-dose inhaler (MDI) or small-volume nebulizer. One of the factors that causes inefficient aerosol delivery is turbulent gas. Heliox (He:O2) is a blend of helium and oxygen that is less dense than air, making turbulent flow less likely. ⋯ Albuterol was administered by MDI with spacer, collected on a filter proximal to a test lung, and measured by high-performance liquid chromatography. Mean amount and percentage albuterol delivered were significantly (p<0.05) greater for 70% He:O2 (395+/-29 microg, 20+/-3.2%) than for 70% nitrogen:30% oxygen (241+/-29 microg,12+/-1.7%). Thus 70% He:O2 can increase the amount of albuterol delivered at the end of the endotracheal tube, suggesting a potential role for it in the care of critically ill ventilated patients.
-
We critically reviewed English-language articles indexed on MEDLINE from 1966-1998 and those cited in indexed articles describing or investigating administration of nitric oxide (NO) in adult respiratory distress syndrome (ARDS). Studies evaluating NO exclusively in the pediatric population and in conditions other than ARDS (chronic obstructive pulmonary disease, asthma, cardiac surgery, pulmonary hypertension) were excluded, as were those published exclusively as abstracts. Of the 22 papers selected, 5 studies were dose-response trials, eight were comparative, and the rest were noncomparative. ⋯ Several short-term noncomparative and small noncomparative prospective trials concluded that NO improves oxygenation and decreases pulmonary vasoconstriction without effects on systemic hemodynamics. However, evidence that NO improves outcomes in patients with ARDS is insufficient because mortality remained high, and the number of subjects in each study was low. Since improvements in oxygenation are not seen in all patients and outcomes or mortality might not be altered, NO should be reserved for selected patients in whom conventional therapy is not sufficient to maintain acceptable oxygenation levels.