Brian L Erstad

PMID: 1521404;Abstract:

The treatment of two common adverse effects of dapsone (methemoglobinemia and hemolytic anemia) is discussed, and a case of acute dapsone intoxication is described. A pregnant 29-year-old woman was admitted to an emergency room three hours after ingesting 50 tablets of dapsone (100 mg each) and six alcoholic drinks. One hour after admission 50 g of activated charcoal was given p.o., and 65 mg of methylene blue was given i.v. The patient was found to have a methemoglobin concentration of 25.1%. Arterial blood gases while the patient was breathing 4 L/min of oxygen by nasal cannula were PO2, 136 mm Hg (72.1% saturation); PCO2, 28.9 mm Hg; bicarbonate content, 18.9 mmol/L; and pH, 7.42. Oxygen therapy was changed to 100% oxygen by face mask, 50 g of activated charcoal in sorbitol was administered p.o., and another 65 mg of methylene blue was given i.v. Two more 50-g doses of activated charcoal in sorbitol were given (18.5 and 22 hours after dapsone ingestion). Methylene blue 130 mg was given 14 hours after dapsone ingestion, and 65 mg was given 21, 36, and 55.5 hours after ingestion. Methemoglobin concentrations never rose above 20% after the sixth dose of methylene blue. On hospital days 2 and 3, laboratory values were consistent with a diagnosis of hemolytic anemia; the patient received two units of packed red blood cells. The hematocrit decreased over the next three days to 23.9%, and the patient received four units of packed red blood cells. On day 8 oxygen therapy was changed to oxygen 2 L/min by nasal cannula, and on day 10 the patient was breathing room air. Oral doses of activated charcoal have been used to treat acute dapsone poisoning. Methylene blue acts as a cofactor for the nicotinamide adenine dinucleotide phosphate system to convert methemoglobin to hemoglobin. Methylene blue, however, sometimes aggravates the adverse effects of dapsone, particularly in patients with glucose 6-phosphate dehydrogenase deficiency. Total methylene blue dosages exceeding 4 mg/kg are more likely to aggravate the methemoglobinemia and possibly cause or aggravate an acute hemolytic state. Most cases of dapsone-induced methemoglobinemia and hemolysis resolve when the offending drug is discontinued. When methylene blue is required for symptomatic patients with an elevated methemoglobin concentration (more than 30%), careful monitoring of drug dosage and clinical progress is indicated.

PMID: 19497902;Abstract:

Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill. Copyright © 2009 American College of Chest Physicians.

PMID: 21275491;Abstract:

The field of critical care medicine began to flourish only within the last 40 years, yet it provides some of the best examples of collaborative pharmacy practice models and evidence for the value of pharmacist involvement in interdisciplinary practice. This collaborative approach is fostered by critical care organizations that have elected pharmacists into leadership positions and recognized pharmacists through various honors. There is substantial literature to support the value of the critical care pharmacist as a member of an interdisciplinary intensive care unit (ICU) team, particularly in terms of patient safety. Furthermore, a number of economic investigations have demonstrated cost savings or cost avoidance with pharmacist involvement. As the published evidence supporting pharmacist involvement in patient care activities in the ICU setting has increased, surveys have demonstrated an increase in the percentage of pharmacists performing clinical activities. In addition, substantial support of pharmacists has been provided by other clinicians, safety officers, and administrative personnel who have been involved with the initiation and expansion of critical care pharmacy services in their own institutions. Although there is still room for improvement in the range of pharmacist involvement, particularly with respect to interdisciplinary activities related to education and scholarship, pharmacists have become essential members of interdisciplinary care teams in ICU settings.

Abstract:

Concerns related to drug absorption are not limited to the oral route of administration. Medications given by various parenteral routes must also be absorbed to gain access to the systemic circulation. This article reviews the absorption characteristics of commonly administered medications by type and site of injection. The article focuses on four routes of parenteral injections: intramuscular, intralipomatous, subcutaneous, and intradermal. Differences in absorption relative to route or site of injection have been often demonstrated in studies, when such information was actively sought. Particularly important differences have been found with members of the following classes of medications: opiates, benzodiazepines, vaccines, insulins, and antiarrhythmics.

Abstract:

There is a paucity of literature regarding specific evaluation or testing procedures used in the experiential setting. The purpose of this investigation was to compare the results of paired baseline and end-rotation short-answer tests and determine the potential role of such testing in the student learning and evaluation process. The preceptor had students on rotations at this site for approximately ten years, which resulted in 86 pre/post examinations. There was significant improvement in the scores from baseline to end-rotation (10.51 ± 2.90 to 13.92 ± 2.50, P0.001). Students expressed concerns that the evaluation exercise would be used for grading purposes despite assurances to the contrary. The preceptor was concerned that the examinations would not be useful in assessing higher level cognitive skills that were rotation objectives. Based on these findings, the written examination will be used as interactive assessment instrument, not as a replacement for more subjective grading tools.