Brian L Erstad

Introduction:Successful management of a disaster or pandemic requires implementation of pre-existing plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective, and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this chapter are important for all of those involved in a large-scale disaster or pandemic including front line clinicians, hospital administrators, and public health or government officials. Specifically, this paper focuses on surge logistics, those elements that provide the capability to deliver mass critical care. Methodology:The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic and the articles screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, observational or used flawed modeling and hence the level of evidence on which to base recommendations was poor therefore not permitting the development of evidence based recommendations. The Surge Capacity panel subsequently followed the American College of Chest Physician's (ACCP) Guidelines Oversight Committee's methodology to develop expert opinion suggestions utilizing a modified Delphi process. Results:This paper presents 22 suggestions pertaining to surge capability mass critical care including: requirements for equipment, supplies and pharmaceuticals, staff preparation and organization, methods of mitigating overwhelming patient loads, the role of deployable critical care services and use of transportation assets to support the surge response. Conclusions:Critical care response to a disaster relies careful planning for staff and resource augmentation and involves many agencies. Maximizing use of regional resources including staff, equipment and supplies extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve pre-determined goals. Specialized physician oversight is necessary and if not available on site it may be provided through remote consultation. Triage by experienced providers, reverse triage, and service de-escalation may be used to minimize ICU resource consumption. During temporary loss of infrastructure or overwhelming of hospital resources, deployable critical care services should be considered.

PMID: 9758312;Abstract:

Thromboembolic complications are frequent in patients with multiple trauma. The efficacy of unfractionated heparin for venous thrombosis prophylaxis has not been established. Based on limited prospective data, low- molecular-weight heparin appears to be more effective than unfractionated heparin and at least as effective as compression devices for preventing thromboembolic complications in these patients. Vena cava filters should be considered in high-risk patients who cannot receive anticoagulant therapy, but long-term filter use without concomitant anticoagulant therapy is associated with a substantial risk of recurrent thromboembolism.

PMID: 2337037;Abstract:

Amiodarone has been reported to increase phenytoin levels. This study was designed to evaluate the pharmacokinetic basis of this interaction at steady-state. Pharmacokinetic parameters for phenytoin were determined after 14 days of oral phenytoin, 2 to 4 mg/kg/day, before and after oral amiodarone, 200 mg dairy for 6 weeks in 7 healthy male subjects. During amiodarone therapy, area under the serum concentration time curve for phenytoin was increased from 208 ± 82.8 (mean ± standard deviation) to 292 ± 108 mg · hr/liter (p = 0.015). Both the maximum and 24-hour phenytoin concentrations were increased from 10.75 ± 3.75 and 6.67 ± 3.51 μg/ml to 14.26 ± 3.97 (p = 0.016) and 10.27 ± 4.67 μg/ml (p = 0.012), respectively, during concomitant amiodarone treatment. Amiodarone caused a decrease in the oral clearance of phenytoin from 1.29 ± 0.30 to 0.93 ± 0.25 liters/ hr (p = 0.002). These results were due to a reduction in phenytoin metabolism by amiodarone as evidenced by a decrease in the urinary excretion of the principal metabolite of phenytoin, 5-(p-hydroxyphenyl)-5-phenylhydantoin, 149 ± 39.7 to 99.3 ± 40.0 mg (p = 0.041) and no change in the unbound fraction of the total phenytoin concentration expressed as a percentage, 10.3 ± 2.7 versus 10.7 ± 2.1% (p = 0.28) during coadministration of amiodarone. The alterations in phenytoin pharmacokinetics suggest that steady-state doses of phenytoin of 2 to 4 mg/kg/day should be reduced at least 25% when amiodarone is concurrently administered. All dosage reductions should be guided by clinical and therapeutic drug monitoring. © 1990.

Abstract:

Objectives: The primary purpose of this pilot study was to help justify the positions of clinical pharmacists by identifying and describing the interventions most likely to have the greatest impact on patient care in terms of severity of medication-related problems and associated costs. A secondary objective was to identify potential problems related to data collection and cost estimation, to allow appropriate changes in documentation procedures for future data collection. Methods: All clinical interventions by staff pharmacists reported at a university medical centre during the period September to November 2001 were analyzed retrospectively. The focus was on interventions that prevented adverse drug events (described as very serious and serious on documentation forms). The cost impact was analyzed in terms of cost savings attained by shortening a planned course of drug therapy and cost avoidance achieved by avoiding adverse drug events. Results: Five pharmacists reported a total of 47 interventions. Approximately twice as many of the avoided adverse drug events were deemed serious as were deemed very serious. A substantial proportion of the interventions (21 [45%]) took approximately 15 to 30 min to perform. Order clarification and corrections and provision of drug information accounted for the most interventions (17 [36%] and 15 [32%], respectively). Approximately 60% of all interventions were classified as subtherapeutic dosing (10 [21%]), untreated disease states (6 [13%]), potential overdose (6 [13%]), and failure to receive drug (5 [11%]). According to published work on the cost of adverse drug events, the total cost avoidance for the 33 preventable adverse drug events reported by pharmacists in this study was US$84,631 and the cost-benefit ratio was 1.2. One of the problems noted in the economic analysis was the difficulty in assigning more specific cost figures to each of the interventions that was estimated to result in more than US$1000 in cost savings. Conclusions: Pharmacists can play an important role in preventing medication-related problems (particularly adverse drug events), and the interventions they perform are cost-beneficial.