重症监护病房中肝性脑病患者的药学监护

目的:探讨临床药师为重症监护室(ICU)患者提供药学监护的工作要点。方法:参与1例ICU肝性脑病患者的用药方案的制订、疗效的评估、不良反应的监测。结果:通过药学监护,提高了患者用药的安全性和有效性。结论:临床药师为患者提供药学监护,有利于提高药物治疗水平。     

重症监护病房患者低磷血症的临床分析

目的探讨低磷血症对重症监护病房(ICU)内患者的影响。方法回顾性调查ICU内患者,血磷<0.30 mmol/L的患者进入重度低磷血症组,血磷0.30⁰.80 mmol/L的患者进入轻中度低磷血症组,血磷正常30例患者作为对照组。观察各组患者的血糖、血钾、血钠、血钙、血白细胞、白蛋白、急性生理功能和慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、机械通气时间、病死率等指标。结果重度低磷血症组APACHEⅡ评分、机械通气时间、病死率均较血磷正常组明显增高(P<0.05),其余各组间各指标均无明显差异。结论重度低磷血症提示患者病情严重,预后不良。发现低磷应及时纠正,可能对改善患者预后有益。     

Potential Risk Factors Associated with Thrombocytop in a Surgical Intensive Care Unit

We conducted a retrospective chart review of 193 patients admitted during a 3-month period to determine the frequency of and potential risk factors associated with thrombocytopenia, and the association of acquired thrombocytopenia with length of stay in a surgical-trauma intensive care unit (SICU) and mortality. All records were reviewed beginning 24 hours after admission. Patients were followed for the duration of SICU stay or until death. Data collected and analyzed as potential risk factors for thrombocytopenia were age, gender, admitting diagnosis, classification (trauma, surgical, medical), APACHE II score, medical history, all scheduled drugs with start and stop dates, select laboratory values, arterial or central line placement, and complications. Thrombocytopenia occurred in 25 (13%) patients. These patients were more likely (p<0.05) than those without thrombocytopenia to have the following potential risk factors: presence of a central or arterial line (76% vs 46%, p<0.025), nonsurgical diagnosis (60% vs 37%, p<0.05), diagnosis of sepsis (p<0.001), and administration of phenytoin (p<0.01), piperacillin (p<0.005), imipenem-cilastatin (p<0.001), and vancomycin (p<0.005). A longer SICU stay (mean 21 vs 4.5 days, p<0.05) and increased mortality (16% vs 4%, p<0.05) were significantly associated with thrombocytopenia. Cefazolin administration was significantly associated with nonthrombocytopenia (p<0.05). Factors not associated with thrombocytopenia were age, gender, and administration of histamine₂-receptor antagonists, heparin, enoxaparin, penicillins, ceftazidime, ceftriaxone, chloramphenicol, and amphotericin B. A central or arterial line was the only factor associated with the development of thrombocytopenia in a multiple linear regression analysis (p=0.0003, multiple r=0.2580). Thrombocytopenia is not a common occurrence in the SICU, but is associated with a longer SICU stay and increased mortality.     

Scoping Review of Interventions Associated with Cost Avoidance Able to Be Performed in the Intensive Care Unit and Emergency Department

A framework for evaluating pharmacists’ impact on cost avoidance in the intensive care unit (ICU) and emergency department (ED) has not been established. This scoping review was registered (CRD42018091217) and conducted to identify, aggregate, and qualitatively describe the highest quality evidence for cost avoidance generated by clinical pharmacists on interventions performed in an ICU or ED. Searches were conducted in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception until April 2018. The level of evidence (LOE) for each specific category of intervention was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation evidence-to-decision framework. The risks of bias for articles were evaluated using Newcastle Ottawa and Cochrane Collaboration tools. The values from all interventions were inflated to 2018 U.S. dollars using the consumer price index for medical care. Of the 464 articles initially identified, 371 were excluded and 93 were included. After reviewing references from the articles included, an additional 71 articles were also reviewed. The 38 cost intervention categories were supported by varying LOEs: IA (0 categories), IB (1 category), IIA (4 categories), IIB (0 categories), III (27 categories), and IV (6 categories), and articles mostly displayed low to moderate risks of bias. Pharmacists generate cost avoidance through a variety of interventions in critically and emergently ill patients. The quality of evidence supporting specific cost avoidance values is generally low. Quantification of and factors associated with the cost avoidance generated from pharmacists caring for these patients are of paramount importance.     

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice

Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population.In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes.There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.     

Opioids and Infections in the Intensive Care Unit Should Clinicians and Patients be Concerned?

There is a large body of experimental evidence in research animals and in vitro models that opioids suppress the immune system. If this effect occurs in acute human disease, then patients cared for in Intensive Care Units (ICUs) would be a particularly vulnerable population. ICU patients have the most severe forms of acute infection, have the greatest risk of acquiring new infections in the hospital, and are exposed to high doses of opioids for long periods of time. We review the epidemiology of ICU infections and the pharmacoepidemiology of opioid use in critically ill patients. We critique the limited human research examining the relationship between opioids and infection and make recommendations on designing future clinical studies that could close the knowledge gap about the true hazards of opioid use in hospitalized patients. Grant support for S Roy: NIH RO1 DA12104, RO1 DA022935, KO2 DA015349, P50 DA11806, and T32 DA0709 (codirector). Presented in a shortened version as an oral presentation at the Society for Neuroimmune Pharmacology meeting in Charleston, SC, USA in March 2008.     

冠心病重症监护病房(CCU)患者药学监护点探讨

目的研究入住CCU病房患者的药学监护点。方法专职临床药师随医师查房1年,做查房记录,对危重及特殊患者建住院药历和对患者做住院用药交代。结果总结出CCU患者药学监护点。结论执行药学监护点保障患者用药安全、有效。     

探讨对ICU谵妄患者行强化护理的临床效果

目的:探讨对ICU谵妄患者行强化护理的临床效果。方法:选取某院2015年2月~2017年2月共60例谵妄患者作为研究对象,以随机分配为原则,分为观察组和对照组各30例。对照组采用常规护理的方式,观察组在此基础上应用强化护理,对比两组患者的临床疗效。结果:观察组患者治疗总有效率、APACHEⅡ评分高于对照组患者,差异明显(P0.05),具备统计学意义;观察组患者ICU病房监护时间短于对照组患者,差异明显(P0.05),具备统计学意义。结论:对ICU谵妄患者进行强化护理具有良好的临床疗效,治疗有效率高,大大减少了ICU监护时间,值得在临床推广应用。     

新生儿重症监护室开展药学监护的体会

目的:探索临床药师参与制订治疗方案、实施药学监护的路径。方法:临床药师通过在新生儿重症监护室实施药学监护,参与临床治疗,与医师、护士组成治疗团队。结果:通过药学监护,促进合理用药,降低了药品不良反应的发生率,提高了临床治疗的有效率和成功率。结论:临床药学服务尚有待发展,临床药师在综合治疗中与医护人员形成治疗团队意义重大。     

Errors Associated with IV Infusions in Critical Care

Background

All medication errors are serious, but those associated with the IV route of administration often result in the most severe outcomes. According to the literature, IV medications are associated with 54% of potential adverse events, and 56% of medication errors.

Objectives

To determine the type and frequency of errors associated with prescribing, documenting, and administering IV infusions, and to also determine if a correlation exists between the incidence of errors and either the time of day (day versus night) or the day of the week (weekday versus weekend) in an academic medicosurgical intensive care unit without computerized order entry or documentation.

Methods

As part of a quality improvement initiative, a prospective, observational audit was conducted for all IV infusions administered to critically ill patients during 40 randomly selected shifts over a 7-month period in 2007. For each IV infusion, data were collected from 3 sources: direct observation of administration of the medication to the patient, the medication administration record, and the patient’s medical chart. The primary outcome was the occurrence of any infusion-related errors, defined as any errors of omission or commission in the context of IV medication therapy that harmed or could have harmed the patient.

Results

It was determined that up to 21 separate errors might occur in association with a single dose of an IV medication. In total, 1882 IV infusions were evaluated, and 5641 errors were identified. Omissions or discrepancies related to documentation accounted for 92.7% of all errors. The most common errors identified via each of the 3 data sources were incomplete labelling of IV tubing (1779 or 31.5% of all errors), omission of infusion diluent from the medication administration record (474 or 8.4% of all errors), and discrepancy between the medication order as recorded in the patient’s chart and the IV medication that was being infused (105 or 1.9% of all errors).

Conclusions

Strict definitions of errors and direct observation methods allowed identification of errors at every step of the medication administration process that was evaluated. Documentation discrepancies were the most prevalent type of errors in this paper-based system.     

Risk for Delirium Tremens in Patients with Alcohol Withdrawal Syndrome

To determine the characteristics associated with an increased risk for delirium tremens (DT) we performed a case-control study at the detoxification units of two hospitals. Cases met DSM-IV criteria for DT. For each case (n = 15), 3 controls (n = 45) were chosen. Eligibility criteria were applied equally to cases and controls. Cases were more likely than controls to report a prior complicated withdrawal (DT or alcohol withdrawal seizure) (53 vs. 27%, OR 3.1, 95% CI 0.94–10.55), have a systolic blood pressure greater than 145 mm Hg on admission (60 vs. 27%, OR 4.1, 95% CI 1.21–14.06), and have comorbidity scores of at least 1 (60 vs. 18%, OR 6.9, 95% CI 1.92–25.08). Zero cases (0%) and 15 (33%) controls had no prior complicated withdrawals and no adverse clinical features (systolic blood pressure >145 or comorbidity score >1). Compared to this group, the odds of being a case and having both prior complicated withdrawal and at least 1 adverse clinical feature was 44.8 (95% CI 4.36–460). Elevated blood pressure, prior complicated alcohol withdrawal and medical comorbidity, alone and in combination, are associated with an increased risk of delirium tremens.     

儿童重症监护病房病原菌检测和抗菌药物使用调查分析

目的：分析重症监护病房（PICU）患儿病原菌分布和抗菌药物应用情况,为促进合理用药提供依据。方法：回顾性调查2014年10月至2016年10月无锡市儿童医院PICU使用抗菌药物患儿住院病历,分析病原菌检测结果、主要诊断和抗菌药物应用状况。结果：226例使用抗菌药物的患儿共送检362份标本,检出68株细菌和真菌,阳性率18.78%。按检出率排序前3位为大肠埃希菌（27.94%）、金黄色葡萄球菌（22.06%）和肺炎克雷伯菌（13.24%）。有感染诊断的199例患儿中呼吸道感染占73.37%。226例患儿共使用263例次抗菌药物,其中联合用药36例,占15.93%,使用第三代头孢菌素（含酶抑制剂的复方制剂）及氧头孢烯类抗菌药物187例,占71.10%。不合理医嘱排名前3位分别为遴选药品不适宜31条（41.89%）,适应证不适宜15条（20.27%）,用法用量不适宜14条（18.92%）。抗菌药物费用占总药品费用34.03%。结论：无锡市儿童医院PICU病原学送检率较高,但部分患儿存在适应症不适宜、用法用量不适宜、更换药品不合理等现象,需要加强抗菌药物合理使用的管理。     

重症加强治疗病房的细菌耐药监测

目的了解重症加强治疗病房（ICU）医院获得性细菌感染的病原菌及耐药情况。方法对ICU2007年1月至2009年3月所有细菌分离株及其耐药进行监测和分析。结果细菌总数703株,革兰阴性杆菌69.7%,革兰阳性球菌17.6%,真菌12.5%;革兰阳性菌中,耐甲氧西林金黄色葡萄球菌（MRSA）占金黄色葡萄球菌的99%,耐甲氧西林凝固酶阴性葡萄球菌（MRCN）占凝固酶阴性葡萄球菌94%;革兰阴性菌中,铜绿假单胞菌、嗜麦芽寡养单胞菌、不动杆菌属、大肠埃希菌、粘质沙雷菌、肺炎克雷伯菌、脑膜脓毒金黄杆菌、少动鞘氨醇单胞菌、洋葱伯克霍尔德菌分别占31.4%、18%、13.7%、9.3%、6.5%、6.1%、4.7%、3.6%和2.8%,其他菌占4.1%;亚胺培南、阿米卡星、头孢他啶、环丙沙星对G-菌的敏感率分别为58.8%、53.5%、46.1%和57.5%;万古霉素对MRSA、MRCN及肠球菌属的敏感率均为100%。结论 ICU感染以革兰阴性菌感染为主,细菌耐药率明显升高,监测细菌分布及耐药性变化非常重要。     

临床药师在儿童心脏病重症监护病房的药学实践

目的:探讨临床药师在儿童心脏病重症监护病房患者药物治疗中所发挥的作用。方法:结合典型案例,临床药师从药物配伍及滴注速度、抗感染药及肠外营养药合理应用等方面进行用药干预与监护,协助医师制定、调整用药方案。结果与结论:临床药师深入临床,开展药学监护工作,提高了药物疗效,减少了药品不良反应的发生。临床药师应发挥自身特长,促进了临床合理用药。临床药师应发挥自己的特长,不断提高专业素质、加强团队合作,在实践中积累经验,以便为临床治疗提供正确、全面的用药建议。