Pharmacotherapy
-
Intravenous acetaminophen received United States Food and Drug Administration approval in November 2010 for the management of mild-to-moderate pain, management of moderate-to-severe pain with adjunctive opioid analgesics, and reduction of fever. Although intravenous acetaminophen generally improved pain relief and demonstrated opioid-sparing effects compared with placebo, it did not consistently reduce the frequency of opioid-related adverse events (e.g., postoperative nausea and vomiting). The safety and efficacy of intravenous acetaminophen as an antipyretic agent have been documented in adults and children; however, its cost is several-fold higher than that of the oral and rectal formulations. ⋯ In addition, its administration time (15-min infusion) and packaging (glass, single-use vial) have the potential to adversely affect patient flow in the postanesthesia care unit, create burden on patient care units, and lead to drug waste. Furthermore, 1 g of intravenous acetaminophen is formulated in 100 ml of solution, which may be an issue for patients with fluid restrictions. Given the clinical and economic evidence currently available, intravenous acetaminophen should not replace oral or rectal acetaminophen, but its use may be considered in a limited number of patients who cannot receive drugs orally and rectally and who cannot tolerate other parenteral nonopioid analgesic or antipyretic agents.
-
Intravenous unfractionated heparin (UFH) remains an important therapeutic agent, particularly in the inpatient setting, for anticoagulation. Historically, the activated partial thromboplastin time (aPTT) has been the primary laboratory test used to monitor and adjust UFH. The aPTT test has evolved since the 1950s, and the historical goal range of 1.5-2.5 times the control aPTT, which first gained favor in the 1970s, has fallen out of favor due to a high degree of variability in aPTT readings from one laboratory to another, and even from one reagent to another. ⋯ Clinical data from the last 10-20 years have begun to show that a conversion from aPTT to antifactor Xa monitoring may offer a smoother dose-response curve, such that levels remain more stable, requiring fewer blood samples and dosage adjustments. Given the minimal increased acquisition cost of the antifactor Xa reagents, it can be argued that the antifactor Xa is a cost-effective method for monitoring UFH. In this review, we discuss the relative advantages and disadvantages of the aPTT, antifactor Xa, and protamine titration tests, and provide a clinical framework to guide practitioners who are seeking to optimize UFH monitoring within their own institutions.
-
Randomized Controlled Trial
Effect of a pharmacist-managed hypertension program on health system costs: an evaluation of the Study of Cardiovascular Risk Intervention by Pharmacists-Hypertension (SCRIP-HTN).
To quantify the potential cost savings of a community pharmacy-based hypertension management program based on the results of the Study of Cardiovascular Risk Intervention by Pharmacists-Hypertension (SCRIP-HTN) study in terms of avoided cardiovascular events-myocardial infarction, stroke, and heart failure hospitalization, and to compare these cost savings with the cost of the pharmacist intervention program. ⋯ Our model found that community pharmacist interventions capable of reducing systolic blood pressure by 5.6 mm Hg within 6 months are cost saving and result in improved patient outcomes. Wider adoption of pharmacist-managed hypertension care for patients with diabetes and hypertension is encouraged.
-
To determine whether human immunodeficiency virus (HIV)-positive patients who received intravenous midazolam during an inpatient bronchoscopy procedure were more likely to experience severe prolonged sedation if they were taking antiretroviral therapy that included a protease inhibitor versus those who were not taking any antiretroviral therapy. ⋯ Although the interaction between intravenous midazolam and protease inhibitors is well known, this study was the first systematic evaluation, to our knowledge, of the risk of severe prolonged sedation in a cohort of hospitalized HIV-positive patients. Coadministration of protease inhibitors with intravenous midazolam was associated with severe prolonged sedation as well as increased length of hospital stay. Therefore, concomitant use of these drugs should be closely monitored, or alternative sedatives for procedural sedation should be considered.
-
Randomized Controlled Trial
Relationship between potential opioid-related adverse effects and hospital length of stay in patients receiving opioids after orthopedic surgery.
To determine whether there is an association between opioid-related adverse effects and postoperative hospital length of stay (p-LOS). ⋯ Constipation, emesis, and confusion were associated with increased p-LOS in patients receiving opioids after orthopedic surgery. In addition, there was a significant linear relationship between the number of adverse effects/patient and increased p-LOS, and the strength of the association increased as the number of adverse effects increased. Although the opioid dosages and adverse-effect rates were typical, these findings reinforce the need to balance pain management with risk of events.