In this episode I’ll:

1. Discuss an article about vasopressors and pressure ulcers in critical care.

2. Answer the drug information question: “How long should I hold etanercept before surgery?”

3. Share a resource I use to obtain pictures of the chemical structure of medications.

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Article

Vasopressors and development of pressure ulcers in adult critical care patients

Lead author: Jill Cox

Published in the American Journal of Critical Care in November 2015

Background

Vasopressors provide life-saving support for many critically ill patients. Given their vasoconstrictive effects it would seem they would also play a role in the development of pressure ulcers.

Purpose

The purpose of this study was to examine associations between type, dose, and duration of vasopressors (norepinephrine, epinephrine, vasopressin, phenylephrine, dopamine) and development of pressure ulcers in critically ill medical, surgical and cardiothoracic patients. A secondary goal was to examine predictors of the development of pressure ulcers in these patients.

Methods

The study was a retrospective sample of 306 medical, surgical and cardiothoracic patients who received vasopressors in 2012 in Englewood Hospital and Medical Center in New Jersey.

Results

Norepinephrine and vasopressin were found to be significantly associated with the development of pressure ulcers. When multivariate analysis was applied variables that were significant predictors of the development of pressure ulcers were:

Cardiac arrest (odds ratio [OR] = 3.894)

Mechanical ventilation longer than 72 hours (OR = 23.604)

Hours of MAP less than 60 mm Hg while receiving vasopressors (OR = 1.096)

Administration of vasopressin (OR = 4.816)

Cardiac diagnosis at time of ICU admission (OR = 0.035)

Conclusion

The authors concluded that:

The addition of vasopressin administered concomitantly with a first-line agent (often norepinephrine) may represent the point at which the risk for pressure ulcers escalates and may be an early warning to heighten strategies to prevent pressure ulcers. Conversely, because vasopressors cannot be terminated to avert development of pressure ulcers, these findings may add to the body of knowledge on factors that potentially contribute to the development of unavoidable pressure ulcers.

The Institute for Healthcare Improvement, National Quality Forum, and Center for Medicare & Medicaid Services have proclaimed that pressure ulcers are “Never Events“. While most pressure ulcers are avoidable, studies like these support the growing idea that some pressure ulcers in critically ill patients are in fact unavoidable.

Drug information question

Q: How long should I hold etanercept before surgery?

A: 1 week.

Biologic therapies such as etanercept are associated with an increased risk in the development of infection. There is no data from randomized trials that can guide the decision of how long to hold these agents prior to surgery. Current recommendations are to withhold these types of medications for 1 to 4 weeks prior to surgery, depending on their half-life.

Resource

Something I recently noticed about Lactmed is that each medication monograph has a picture of the medication’s chemical structure. This image is in the public domain and may be copied with attribution. Occasionally I’ll look at the structure of a medication to guess at cross-allergenicity or cross-reactivity with laboratory testing. Using a source like Lactmed for this is more reliable than an alternative like Wikipedia.

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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