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In this episode I’ll:

1. Discuss an article about opioid and sedative requirements in patients that use stimulants.

2. Answer the drug information question “How do you treat mannitol extravasation?”

3. Share a resource from the Institute for Safe Medication Practices on anticoagulation safety.

The article for this episode recently appeared in a weekly literature digest for members of my Critical Care Pharmacy Academy. Every week I send Academy members a summary of the most important critical care pharmacy articles, including my analysis of where the article fits in practice. The literature summary is brief, relevant, and presented in audio and video format. You can find out more at pharmacyjoe.com/academy.

Article

Analgesia and Sedation Requirements in Mechanically Ventilated Trauma Patients With Acute, Preinjury Use of Cocaine and/or Amphetamines

Lead author: Bridgette Kram

Published in the March 2017 issue of Anesthesia & Analgesia

Background

Many clinicians empirically increase the initial dose of opioids and sedatives for patients with positive urine drug screens. The authors of this study sought to determine whether ventilated trauma patients with a positive urine drug screen (UDS) for cocaine and/or amphetamines have increased opioid and sedative requirements.

Methods

The study was a single-center retrospective cohort of patients admitted to an adult level 1 trauma center. The primary end point was the daily morphine equivalent received during mechanical ventilation for patients with a positive UDS for cocaine and/or amphetamines compared with patients with a negative UDS. Secondary end points included the sedative dose (benzodiazepines, propofol, and dexmedetomidine), duration of mechanical ventilation, ICU and hospital length of stay, and in-hospital mortality.

Results

In univariate, multivariate, and propensity score-adjusted analyses, pre-injury stimulant use was not associated with opioid or sedative dose.

Conclusion

The authors concluded:

For trauma patients presenting with acute, preinjury use of cocaine and/or amphetamines, analgesic and sedative requirements are variables and may not be greater than those patients presenting with a stimulant-negative UDS to achieve desirable pain control and depth of sedation, although this observation should be interpreted cautiously in light of the wide CI observed in the propensity score–adjusted model. Although unexpected, these findings indicate that empirically increasing analgesic and sedative doses based on positive UDS results for these stimulants may not be necessary.

Discussion

This is a surprising finding to me since I have encountered many patients who have a history of stimulant use and appear to have unusually high opioid and sedative requirements in order to tolerate mechanical ventilation. Given the known adverse effects from oversedation such as delirium, and the rapidly titratable effects of opioids and sedatives, it makes sense to not increase opioid or sedative doses for patients with stimulant-positive urine drug screens.

Drug information question

Q: How do you treat mannitol extravasation?

A: With hyaluronidase.

If mannitol extravasation occurs, dilute 1mL of 150 units/mL of hyaluronidase with 9 mL normal saline for a final concentration of 15 units/mL. Administer multiple small subcutaneous injections of this solution around the area of extravasation.

Resource

The Institute for Safe Medication Practices (ISMP) has released a Medication Safety Self Assessment ® for Antithrombotic Therapy. This assessment is a revision of the 2005 tool to include questions on the newer anticoagulants.

The assessment consists of 115 questions, many of which represent system improvements and safeguards that ISMP has recommended in response to analysis of medication errors, problems identified during on-site consultations with hospitals, and guidelines in the medical literature.

To complete the assessment, ISMP recommends each organization:

1. Establish a multidisciplinary team.

2. Assess the use of antithrombotic agents through a consensus vote from all team members after thoroughly investigating the level of implementation for each self-assessment item.

3. Document your progress toward improvement by re-assessing your use of antithrombotic agents with this tool on a regular basis.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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