Brian L Erstad

PMID: 19017823;Abstract:

The intensive care unit (ICU) continues to be a major focus of decentralized pharmacy activities in health systems that care for critically ill patients. This is not surprising, given the need for rapid decision-making involving unstable patients, the large number of powerful medications typically used per patient, the high cost of many drugs used in the ICU and, most importantly, the evidence demonstrating the benefits of having a pharmacist as part of an interdisciplinary team. The purpose of this paper is to highlight important issues to consider when introducing or developing critical care pharmacy services beginning with the establishment of basic services and continuing through practitioner development, guideline/ protocol development and implementation, patient safety, residency training, and research.

PMID: 14625670;Abstract:

Objective: To derive recommendations for the dosing of commonly used medications in the morbidly obese patient in the ICU. Data sources: Articles were obtained through computerized searches involving MEDLINE. The bibliographies of retrieved publications and textbooks were reviewed for additional references. Study selection: All studies involving the pharmacokinetics or pharmacodynamics of medications in obese subjects or patients. Data extraction: The emphasis was on studies involving morbidly obese patients but, in the absence of such data, investigations involving lesser forms of obesity were extracted. Data synthesis: There is a paucity of data upon which to make recommendations for dosing commonly used medications in the morbidly obese patient in the ICU, although recommendations were provided based on the available information. Conclusions: There is clearly a need for more investigations involving dosing regimens of medications in the morbidly obese population. Until such studies are available, the clinician must try to derive the best dosing regimens for medications based on the limited pharmacokinetic data available for some agents and clinical judgement.

The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED).

PMID: 15061430;Abstract:

Purpose. The implications of recent studies for guidelines that pertain to stress ulcer prophylaxis in the postoperative period are discussed. Summary. The therapeutic guidelines on stress ulcer prophylaxis published by the American Society of Health-System Pharmacists (ASHP) provided clinicians with recommendations regarding appropriate candidates for stress ulcer prophylaxis and selection of a pharmacologic agent. Since these guidelines were published in 1999, additional research has been completed to resolve some of the controversial issues surrounding stress ulcer prophylaxis. The frequency of stress-induced bleeding in recent investigations continues to be highly variable, depending on the definition used to describe bleeding. In general, investigations that evaluate overt bleeding or bleeding without hemodynamic changes or blood transfusion report higher frequencies of bleeding than those that evaluate clinically important bleeding. Similar to that reported in the initial ASHP guidelines, the frequency of clinically important bleeding in recent investigations is low. In addition, the majority of recently published prospective studies and a meta-analysis have been unable to demonstrate a reduction in clinically important bleeding with pharmacologic agents. As a result, some experts have suggested that advances in critical care are more influential in the development of stress-induced bleeding than the use of pharmacologic agents. Recently published investigations support the effectiveness of institution-specific guidelines to help clinicians identify appropriate candidates for stress ulcer prophylaxis. The selection of an optimal pharmacologic agent for stress ulcer prophylaxis continues to be debated. The majority of recent studies have involved the administration of proton-pump inhibitors (PPIs). In general, these studies have demonstrated that PPIs are at least as effective as histamine H2-receptor antagonists at increasing gastric pH, but adequately powered studies investigating the endpoint of clinically important bleeding are needed. Similar to the initial ASHP guidelines, the development of institution-specific guidelines is recommended to identify the most appropriate pharmacologic treatment. Conclusion. The frequency of clinically important bleeding reported in recent studies is low. The majority of recently published prospective studies and meta-analyses found little significant reduction in bleeding with pharmacologic prophylaxis.

PMID: 19820588;Abstract:

Background: Vancomycin has been recommended as the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia with a desired trough concentration of 15 to 20 mg/L. The purpose of this study was to evaluate the initial dosing of vancomycin for MRSA pneumonia in critically ill adult trauma patients. Methods: Critically ill adult trauma patients were retrospectively identified for inclusion into the study. Patients initiated at a dose of 1 g intravenously (i.v.) every 8 hours were compared with patients initiated at a dose of 1 g i.v. every 12 hours. Baseline continuous demographic variables and steady-state vancomycin trough concentrations were compared between the two groups using a Student's t test (α = 0.05). Results: There were 36 patients who satisfied criteria for inclusion, 17 patients in the 1 g every 8 hour group and 19 patients in the 1 g every 12 hour group. The mean steady-state trough concentration was higher in the 1 g every 8 hour group versus the 1 g every 12 hour group (11.1 vs. 6.8 mg/L, p = 0.014). A steady-state trough concentration greater than 15 mg/L was achieved in 23.5% of the patients in the 1 g every 8 hour group and none of the patients in the 1 g every 12 hour group. Conclusion: A vancomycin regimen of 1 g i.v. every 12 hours in critically ill trauma patients with MRSA pneumonia and normal renal function is unlikely to achieve trough concentrations of 15 to 20 mg/L. Doses of at least 1 g i.v. every 8 hours are needed. coypright © 2009 by Lippincott Williams & Wilkins.