Brian L Erstad

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Scholarly Contributions

Books

• Erstad, B. L., & Edwards, C. J. (2021). Basic Skills in Interpreting Laboratory Data. American Society of Health Systems Pharmacists.
• Erstad, B. L. (2016). Critical Care Pharmacotherapy. ACCP.

Chapters

• Erstad, B. L., & Fazel, M. T. (2020). Step VI: Maximize Experiential Education.. In The ACCP Field Guide to Becoming a Standout Pharmacy Residency Candidate. Third Edition.(pp 91-114). Lenexa, Kansas: American College of Clinical Pharmacy (ACCP).
• Fazel, M. T., & Erstad, B. L. (2016). Step VI: Maximize Experiential Education. In The ACCP Field Guide to Becoming a Standout Pharmacy Residency Candidate, Second Edition(pp 91-114). Lenexa, Kansas: American College of Clinical Pharmacy (ACCP).
• Barletta, J. F., Dauenhauer, A., Aljuhani, O., & Erstad, B. L. (2015). ICU Pharmacotherapy in Special Populations. In Current Concepts in Critical Care(pp 31-52). Society of Critical Care Medicine.
• Erstad, B. L. (2015). Why Study Pharmacy. In Pharmacy for the Curious. Curious Academic Publishing.
• Erstad, B. L. (2014). Hypovolemic Shock. In Pharmacotherapy.
• Erstad, B. L. (2014). Intra-Abdominal Infections. In Pharmacotherapy Principles and Practice Study Guide: A Case-Based Care Plan Approach..
• Erstad, B. L. (2014). Sepsis. In Pharmacotherapy Principles and Practice Study Guide: A Case-Based Care Plan Approach..

Journals/Publications

• Cornelison, B., Erstad, B., & Edwards, C. (2024). Accuracy of a chatbot in answering questions that patients should ask before taking a new medication. J Am Pharm Assoc, 64(4). doi:10.1016/j.japh.2024.102110
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  Background: The potential uses of artificial intelligence have extended into the fields of health care delivery and education. However, challenges are associated with introducing innovative technologies into health care, particularly with respect to information quality. Objective: This study aimed to evaluate the accuracy of answers provided by a chatbot in response to questions that patients should ask before taking a new medication. Methods: Twelve questions obtained from the Agency for Healthcare Research and Quality were asked to a chatbot for the top 20 drugs. Two reviewers independently evaluated and rated each response on a 6-point scale for accuracy and a 3-point scale for completeness with a score of 2 considered adequate. Accuracy was determined using clinical expertise and a drug information database. After the independent reviews, answers were compared, and discrepancies were assigned a consensus score. Results: Of 240 responses, 222 (92.5%) were assessed as completely accurate. Of the inaccurate responses, 10 (4.2%) were mostly accurate, 5 (2.1%) were more accurate than inaccurate, 2 (0.8%) were equal parts accurate and inaccurate, and 1 (0.4%) was more inaccurate than accurate. Of the 240 responses, 194 (80.8%) were comprehensively complete. There were 235 (97.9%) responses that scored 2 or higher. Five responses (2.1%) were considered incomplete. Conclusion: Using a chatbot to answer questions commonly asked by patients is mostly accurate but may include inaccurate information or lack valuable information for patients.
• Edwards, C., & Erstad, B. (2024). Evaluation of a Generative Language Model Tool for Writing Examination Questions. Am J Pharm Educ, 88(4). doi:10.1016/j.ajpe.2024.100684
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  Objective: To describe an evaluation of a generative language model tool to write examination questions for a new elective course focused on the interpretation of common clinical laboratory results being developed as an elective for students in a Bachelor of Science in Pharmaceutical Sciences program. Methods: A total of 100 multiple-choice questions were generated using a publicly available large language model for a course dealing with common laboratory values. Two independent evaluators with extensive training and experience in writing multiple-choice questions evaluated each question for appropriate formatting, clarity, correctness, relevancy, and difficulty. For each question, a final dichotomous judgment was assigned by each reviewer, usable as written or not usable written. Results: The major finding of this study was that a generative language model (ChatGPT 3.5) could generate multiple-choice questions for assessing common laboratory value information but only about half the questions (50% and 57% for the 2 evaluators) were deemed usable without modification. General agreement between evaluator comments was common (62% of comments) with more than 1 correct answer being the most common reason for commenting on the lack of usability (N = 27). Conclusion: The generally positive findings of this study suggest that the use of a generative language model tool for developing examination questions is deserving of further investigation.
• Erstad, B. (2024). Recommended Methods of Drug Dosing Adjustment for Patients With Renal Impairment. Ann Pharmacother, 58(9). doi:10.1177/10600280231217098
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  Since 2020, there have been changes in Food and Drug Administration guidance and in recommendations by national organizations with a focus on kidney diseases pertaining to the choice of equations used to estimate creatinine clearance and glomerular filtration rate in patients with renal impairment. This includes a recommendation by the National Kidney Foundation to avoid the use of the Cockcroft-Gault equation for drug dosing in patients with renal impairment. This commentary provides an overview of recent recommendations concerning kidney function assessment that have important implications for drug dosing in patients with renal impairment and provides suggestions for implementing these recommendations.
• Erstad, B. L. (2024). Evolution of critical care pharmacy practice: A study to remember. JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY, 7(4), 332-334. doi:10.1002/jac5.1941
• Erstad, B. L., & Glenn, M. J. (2024). Management of Critically Ill Patients Receiving Medications for Opioid Use Disorder. CHEST, 165, 356-67. doi:10.1016/j.chest.2023.10.024
• Erstad, B., Franks, A., & Zillich, A. (2024). Best-Practice Strategies for Faculty Evaluations: A Focus on Pharmacy Departments or Divisions with Both Tenure and Nontenure-Track Faculty Members. Am J Pharm Educ, 88(10). doi:10.1016/j.ajpe.2024.101270
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  There are unique challenges associated with the evaluation of faculty in pharmacy departments or divisions that have a mix of nontenure-track and tenure-track faculty members. Such evaluations are intended to provide feedback on performance and personal growth but have the potential to demotivate faculty and add to existing stress if improperly performed. The purpose of this commentary is to suggest best practices for department chairs involved in performing evaluations of faculty in pharmacy departments or divisions that have a mix of nontenure-track and tenure-track faculty members. The paper is intended to help ensure these evaluations not only capture the quality and quantity of each faculty member's full range of activities and responsibilities but also are conducted in a supportive and constructive fashion. This commentary is targeted at new department chairs, new faculty members unfamiliar with academic evaluation processes, and departments contemplating changes in their existing evaluation procedures.
• Gagnon, D., Glenn, M., Quaye, A., & Erstad, B. (2024). Buprenorphine in the Intensive Care Unit: Commentary on the Unanswered Questions. Ann Pharmacother. doi:10.1177/10600280241254528
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  The removal of the X-waiver in the Mainstreaming Addiction Treatment (MAT) Act of 2023 has substantial implications for buprenorphine prescribing as one of the options to treat opioid use disorder. The purpose of this commentary is to discuss the unanswered questions regarding buprenorphine in the intensive care unit (ICU) including how the passage of the MAT Act will affect ICU providers, which patients should receive buprenorphine, what is the most appropriate route of administration and dose of buprenorphine, what medications interact with buprenorphine, and how can transitions of care be optimized for these patients.
• Groth, C., Droege, C., Sarangarm, P., Cucci, M., Gustafson, K., Connor, K., Kaukeinen, K., Acquisto, N., Chui, S., Dixit, D., Flannery, A., Glass, N., Horng, H., Heavner, M., Kinney, J., Peppard, W., Sikora, A., & Erstad, B. (2024). Multicenter Retrospective Review of Ketamine Use in Pediatric Intensive Care Units (Ketamine-PICU Study). Crti Care Res Pract, 2024. doi:10.1155/2024/6626899
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  Objective. Describe continuous infusion (CI) ketamine practices in pediatric intensive care units (PICUs) and evaluate its effect on pain/sedation scores, exposure to analgesics/sedatives, and adverse effects (AEs). Methods. Multicenter, retrospective, observational study in children
• Abraham, I., Obeng-Kusi, M., Roe, D., & Erstad, B. L. (2023). Comparative efficacy of later-line therapies for metastatic colorectal cancer (mCRC) using novel methods for patient survival data reconstruction and network meta-analysis (NMA) of survival curves.. Journal of Clinical Oncology, 41(16_suppl), e15611-e15611. doi:10.1200/jco.2023.41.16_suppl.e15611
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  e15611 Background: NMAs of cancer treatments are usually based on the proportional hazard assumption (PHA) which implies a constant hazard ratio as well as treatment effect on only scale parameter and therefore not reflecting clinical dynamics of survival outcomes over time. Multivariate NMA which does not rely on the PHA is often constrained by lack of individual patient-level data (IPD). We applied a novel method of reconstructing pseudo-IPD from published survival curves that enabled application of a dynamic method of NMA of survival curves without PHA constraint to compare the efficacy of 6 later-line therapies for metastatic colorectal cancer (mCRC), compared to placebo. Methods: We identified 8 phase II/III trials reporting the efficacy of 6 later-line therapies for mCRC from PubMed, Embase, Scopus and Cochrane Library. Trial survival curves were reconstructed based on pseudo-IPD generated using the Guyot method, and the estimated survival proportions and hazard ratios (HRs) over 12 months (12m) of follow up were calculated using a random effects lognormal distribution model with placebo as the common comparator. Results: Compared to placebo, 12m PFS HRs varied from 0.29 (95%CrI = 0.19-0.44) for TAS+bevacizumab to 0.72 (95%CrI = 0.62-0.85) for atezolizumab. Similarly, OS HRs ranged from 0.55 (95%CrI = 0.26-0.92) for TAS+bevacizumab to 1.01 (95%CrI = 0.79-1.20) for atezolizumab (Table). Conclusions: In this NMA of survival curves, all therapies except atezolizumab were superior to placebo in PFS and OS over 12m follow up period. TAS+bevacizumab provided the highest survival advantage over placebo, with fruquintinib, regorafenib, and TAS-102 also showing survival benefits. TAS+bevacizumab may be the preferred choice for later-line mCRC treatment. [Table: see text]
• Alamer, A., Aleissa, M. M., Almangour, T. A., Almulhim, A. S., Alsowaida, Y. S., Eljaaly, K., Erstad, B. L., Kalbasi, A., & Thabit, A. K. (2023). Echinocandin exposures in obese patients: A scoping review and clinical perspectives. American Journal of Health-System Pharmacy, 80(15), 967-973. doi:10.1093/ajhp/zxad021
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  Echinocandins are favored drugs for the treatment of fungal infections. There is growing evidence that obese patients treated with echinocandins have lower exposures due to pharmacokinetic (PK) alterations. We conducted a scoping review to characterize, evaluate, and summarize the available evidence on echinocandins exposures in obese patients.A comprehensive search of PubMed, Embase, and Cochrane Library for studies on echinocandins published from database inception to October 28, 2022, was conducted using PRISMA-ScR methodology. A total of 25 studies comprising more than 3,174 subjects (8 micafungin studies, 7 caspofungin studies, 9 anidulafungin studies, and 1 rezafungin study) were included in this review. Seventeen studies reported lower echinocandins exposures in overweight and obese individuals compared with normal-weight individuals; the authors of these studies recommended dose adjustments. Conversely, 8 studies did not find significant differences in echinocandin exposure among subjects in varying body weight categories. Clinicians may consider dose adjustments of echinocandins in obese patients; however, there is limited evidence on the ideal dose adjustment strategy to overcome the low echinocandins exposures in obese patients.This scoping review shed light on a growing body of evidence indicating that obese patients have lower echinocandin exposures relative to targeted PK indices, which may lead to negative therapeutic implications. Currently, a lack of high-quality evidence impedes reaching consensus on recommendations for echinocandin dosing adjustment in obese patients. Future research evaluating the optimal echinocandin dosing strategy for obese patients is needed.
• Bauer, S. R., Erstad, B. L., & Gellatly, R. M. (2023). Precision fluid and vasoactive drug therapy for critically ill patients. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 43(11), 1182-1193. doi:10.1002/phar.2763
• Bolesta, S., Burry, L., Perreault, M. M., Gélinas, C., Smith, K. E., Eadie, R., Carini, F. C., Saltarelli, K., Mitchell, J., Harpel, J., Stewart, R., Riker, R. R., Fraser, G. L., & Erstad, B. L. (2023). International Analgesia and Sedation Weaning and Withdrawal Practices in Critically Ill Adults: The Adult Iatrogenic Withdrawal Study in the ICU*. Critical Care Medicine, 51(11), 1502-1514. doi:10.1097/ccm.0000000000005951
• Bolesta, S., Smith, K., Gelinas, C., Perreault, M., Burry, L., Eadie, R., Carini, F., Riker, R., & Erstad, B. (2023). 962: OBSERVATION OF OPIOID AND SEDATIVE USE IN MECHANICALLY VENTILATED ADULTS: AN ALERT-ICU SUBSTUDY. Critical Care Medicine, 52(1), S453-S453. doi:10.1097/01.ccm.0001002012.25699.e3
• Burns, K. E., Castor, T., Devlin, J. W., Erstad, B. L., Kress, J. P., Massaro, A., Selvan, K., Train, S. E., Vassaur, J., & Wu, T. T. (2023). Critical Care Pharmacist Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS. Annals of Pharmacotherapy, 57(11), 106002802311604. doi:10.1177/10600280231160437
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  Background: Current critical care pharmacist (CCP) practices and perceptions related to neuromuscular infusion (NMBI) use for acute respiratory distress syndrome (ARDS) maybe different with the COVID-19 pandemic and the publication of 2020 NMBI practice guidelines. Objective: To evaluate CCP practices and perceptions regarding NMBI use for patients with moderate-severe ARDS. Methods: We developed, tested, and electronically administered a questionnaire (7 parent-, 42 sub-questions) to 409 American College of Clinical Pharmacy (ACCP) Critical Care Practice and Research Network members in 12 geographically diverse states. The questionnaire focused on adults with moderate-severe ARDS (PaO 2 :FiO 2
• Erstad, B. L. (2023). Hepatorenal Syndrome With Acute Kidney Injury: Diagnosis and Medical Management. Annals of Pharmacotherapy, 58(2), 106002802311776. doi:10.1177/10600280231177698
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  To review the current definitions and diagnostic criteria for acute kidney injury (AKI) and type 1 hepatorenal syndrome (HRS) now termed HRS-AKI and discuss the challenges in deciding the most appropriate medication regimens to treat patients with HRS-AKI.PubMed (inception to April 2023) with bibliographies of retrieved articles searched for additional articles; organizational websites for clinical practice guidelines (CPGs).Randomized controlled trials (RCTs) evaluating albumin and vasoconstrictors for HRS-AKI.A major change in the most recent revision of definitions and diagnostic criteria for HRS-AKI is the elimination of the set cutoff serum creatinine values for AKI. This change should be considered when comparing studies of HRS-AKI over time. Albumin has been administered to both vasoconstrictor treatment and placebo groups in all recent RCTs; however, there has never been a large RCT evaluating a no-albumin group. Most prospective trials comparing a midodrine/octreotide combination or norepinephrine to placebo or terlipressin have enrolled less than 100 patients limiting any conclusions regarding clinically important outcomes. Terlipressin with albumin has shown mixed results for complete HRS-AKI reversal with no reductions in crude mortality but adverse effect concerns involving ischemic and pulmonary events.Type 1 hepatorenal syndrome with acute kidney injury is a potentially life-threatening syndrome with diagnostic and treatment challenges. Albumin plus a vasoconstrictor has become the routine HRS-AKI treatment even though there has not been a large RCT evaluating a no-albumin group. Terlipressin is the vasoconstrictor of choice for HRS-AKI in current CPGs, but it has adverse effect concerns and, until recently, was not available in the United States.In conjunction with changes in the definitions and diagnostic criteria for HRS-AKI, debate continues regarding the optimal therapy for HRS-AKI, particularly considering recent trials demonstrating ischemic and pulmonary adverse events with terlipressin used in combination with albumin.
• Erstad, B. L. (2023). Recommendations for Assessing the Quality of Clinical Faculty Members’ Journal Publications. Am J Pharm Educ. doi:10.1016/j.ajpe.2023.100575
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  Evaluation of clinical faculty involves an assessment of the quality of their publications in addition to quantity (number) of publications. In contrast to assessing quantity, assessing quality is difficult. The purpose of this paper is to discuss practical considerations and provide recommendations related to quality of publications that clinical faculty members should bear in mind as part of their overall scholarship activity. College and schools of pharmacy may not provide written criteria for assessing quality of publications, so it is important that clinical faculty members seek guidance from their department chair or direct supervisor, experienced colleagues, and formal or informal mentors or advisors. One criterion for assessing quality is whether a publication was evaluated through a peer-review process although there are other considerations including dissemination of the paper via search engines such as PubMed. Clinical faculty also need to consider authorship order on their papers and potential journals for submission.
• Erstad, B. L., & Davis, L. E. (2023). Fixed Versus Body-Sized-Based Dosing of Monoclonal Antibodies. Annals of Pharmacotherapy, 58(1), 106002802311706. doi:10.1177/10600280231170650
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  Monoclonal antibody products are an increasing portion of novel drug approvals. The labeling of initial drug approvals frequently involves body-size-based rather than fixed-dose administration regimens for adults without clear rationale for doing so. This presents challenges when prescribing these products for patients with extremes of body habitus who constitute a small portion of enrollment in pre-approval investigations. Fixed-dose regimens allow for standardized preparation with the potential to reduce the risk of calculation errors, drug waste, and make home administration more practical. Fixed-dose rather than body-size-based monoclonal antibody regimens should serve as the initial approach in early phase 1 clinical trials.
• Erstad, B. L., & Erstad, B. L. (2023). Peripheral intravenous administration of 23.4% sodium chloride solution: A plea for caution. American Journal of Health-System Pharmacy, 80(15), 1032-1035. doi:10.1093/ajhp/zxad103
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  Journal Article Corrected proof Peripheral intravenous administration of 23.4% sodium chloride solution: A plea for caution Get access Brian L Erstad, PharmD, FASHP, FCCP, MCCM Brian L Erstad, PharmD, FASHP, FCCP, MCCM Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA Address correspondence to Dr. Erstad (erstad@pharmacy.arizona.edu). Twitter: @BrianErstad Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, zxad103, https://doi.org/10.1093/ajhp/zxad103 Published: 11 May 2023 Article history Published: 11 May 2023 Corrected and typeset: 19 May 2023
• Erstad, B. L., & Nix, D. E. (2023). Medication dosing in adult patients with reduced lean body mass and kidney injury: A focus on cystatin C. American Journal of Health-System Pharmacy, 80(12), 712-718. doi:10.1093/ajhp/zxad058
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  Abstract Purpose Creatinine-based estimates of glomerular filtration rate (GFR) have been the standard for classifying kidney function and guiding drug dosing for over 5 decades. There have been many efforts to compare and improve different methods to estimate GFR. The National Kidney Foundation recently updated the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations without race for creatinine (CKD-EPIcr_R) and creatinine and cystatin C (CKD-EPIcr-cys_R), and the 2012 CKD-EPI equation based on cystatin C (CKD-EPIcys) remains. The focus of this review is to highlight the importance of muscle atrophy as a cause for overestimation of GFR when using creatinine-based methods. Summary Patients with liver disease, protein malnutrition, inactivity, denervation, or extensive weight loss may exhibit markedly lower creatinine excretion and serum creatinine concentration, leading to overestimation of GFR or creatinine clearance when using the Cockcroft-Gault equation or CKD-EPIcr (deindexed). In some cases, estimated GFR appears to exceed the physiological normal range (eg, >150 mL/min/1.73 m2). Use of cystatin C is recommended when low muscle mass is suspected. One would expect discordance between the estimates such that CKD-EPIcys < CKD-EPIcr-cys < CKD-EPIcr ≈ Cockcroft-Gault creatinine clearance. Clinical evaluation can then occur to determine which estimate is likely accurate and should be used for drug dosing. Conclusion In the setting of significant muscle atrophy and stable serum creatinine levels, use of cystatin C is recommended, and the resulting estimate can be used to calibrate interpretation of future serum creatinine measurements.
• Erstad, B. L., Youmans, S. L., & Crismon, M. L. (2023). Navigating the Path to Careers in Academic Pharmacy Administration. Am J Pharm Educ. doi:10.1016/j.ajpe.2022.09.006
• Martin, J. R., Yu, M., & Erstad, B. L. (2023). Adverse effects of nonsteroidal anti-inflammatory drugs in critically ill patients: A scoping review. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 80(6), 348-358.
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  Nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended as opioid-sparing agents. The objective of this scoping review was to conduct a thorough search of the current literature to determine whether in adult critically ill patients there is an association between exposure to NSAIDs vs no NSAIDs and the subsequent development of serious adverse events, particularly gastrointestinal bleeding and acute kidney injury (AKI).
• Obeng-Kusi, M., Erstad, B. L., Roe, D. J., & Abraham, I. (2023). Cost-utility analyses of later-line treatments for metastatic colorectal cancer (mCRC) by network meta-analysis (NMA) approach: Conventional constant hazard ratio vs novel survival curves methodologies.. Journal of Clinical Oncology, 41(16_suppl), e18928-e18928. doi:10.1200/jco.2023.41.16_suppl.e18928
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  e18928 Background: Cost-utility analyses of later-line treatments for metastatic colorectal cancer (mCRC) differ based on network meta-analysis (NMA) approach: conventional constant hazard ratio vs novel survival curves methodologies. Methods: We conducted a CUA estimating the incremental cost utility ratio (ICUR) over a 5-year time horizon from the US payer perspective. The 3-state partitioned survival models included efficacy inputs from a novel one-step multivariate NMA of progression-free and overall survival curves and from a conventional constant hazard ratio NMA. Utilities, as well as drug acquisition, administration, adverse event, monitoring and end of life costs were sourced from literature. We compared results and examined statistical factors in either approach that may explain the observed results. Results: The multivariate NMA produced lower estimates of survival benefits over placebo compared to the NMA based on constant hazard ratios, at the same incremental costs (Table). This reduction in incremental benefits led to higher estimates of cost-effectiveness and cost-utility when using the multivariate NMA. Probabilistic sensitivity analyses showed greater uncertainty in the model based on the constant hazard NMA. Conclusions: The multivariate NMA produced lower estimates of survival benefits over placebo compared to the NMA based on constant hazard ratios, at the same incremental costs (Table). This reduction in incremental benefits led to higher estimates of cost-effectiveness and cost-utility when using the multivariate NMA. Probabilistic sensitivity analyses showed greater uncertainty in the model based on the constant hazard NMA. [Table: see text]
• Zerr, B., Vázquez, A., & Erstad, B. L. (2023). Infection risk and management strategies for patients with cirrhosis taking proton pump inhibitors. American Journal of Health-System Pharmacy, 80(15), 967-973. doi:10.1093/ajhp/zxad089
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  Abstract Purpose The purpose of this review is to discuss infectious disease–related adverse effects associated with long-term proton pump inhibitor (PPI) therapy in patients with cirrhosis and to provide recommendations for appropriate use and choice of PPI when such therapy is indicated. Summary Long-term PPI therapy in patients with cirrhosis increases the risk of infections, with infections in turn increasing the risk of mortality in this patient population. Expert recommendations include restricting long-term PPI use in cirrhosis to patients with appropriate gastrointestinal indications, using a PPI for the shortest possible duration and at the lowest possible dose, and avoiding PPIs with unfavorable pharmacogenetic properties. Conclusion Long-term PPI use in patients with cirrhosis has been associated with increased infections. The risk of adverse effects in observational studies, including decompensation, severe infection (especially spontaneous bacterial peritonitis), and increased mortality, appears to increase as the dose and duration of PPI increase.
• Abraham, I. L., Alrawashdh, N., McBride, A., Persky, D. O., Sweasy, J., & Erstad, B. L. (2022). Cost-effectiveness and economic burden analyses of all first-line treatments of chronic lymphocytic leukemia. Value in Health, 25, 1685-1695.
• Abraham, I., Erstad, B., Obeng-Kusi, M., & Roe, D. J. (2022). Comparative value-based pricing of an Ebola vaccine in resource-constrained countries based on cost-effectiveness analysis. Journal of Medical Economics, 25(1), 894-902. doi:10.1080/13696998.2022.2091858
• Barletta, J. F., & Erstad, B. L. (2022). Pitfalls and pearls with drug dosing in the critically ill obese patient: 10 statements to guide ICU practitioners. J Crit Care, 71(154105). doi:10.1016/j.jcrc.2022.154105
• Bolesta, S., Smith, K. E., Gélinas, C., Perreault, M. M., Burry, L., Eadie, R., Carini, F., Harpel, J., Stewart, R. D., Riker, R. R., Erstad, B. L., Bolesta, S., Smith, K., Gélinas, C., Perreault, M., Burry, L., Eadie, R., Carini, F., Harpel, J., , Stewart, R., et al. (2022). 813: OPIOID AND SEDATIVE USE IN ADULT ICUS: ADULT IATROGENIC WITHDRAWAL STUDY IN THE ICU (ALERT-ICU). Critical Care Medicine, 51(1), 398-398. doi:10.1097/01.ccm.0000908980.77598.a5
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  Introduction: Iatrogenic withdrawal syndrome (IWS) is associated with large doses and prolonged use of opioids-sedatives. This study aimed to determine current utilization patterns of opioids-sedatives in adult ICUs that may be associated with IWS. We hypothesized that cumulative doses would increase with prolonged ICU stay. Methods: We conducted an international, observational, point prevalence study on a single date between June 1 and September 30, 2021 for adult ICU patients (≥ 18 years). Demographic data, medication exposures in the preceding 24 hours, and outcomes were collected following institutional ethics approval. The primary outcome was the proportion of patients receiving continuous parenteral opioids-sedatives for ≥ 72 hours. We defined continuous use as continuous IV infusion, scheduled intermittent injections, or as needed parenteral doses with at least half of the possible doses administered in 24 hours. Outcomes were compared between patients receiving opioids-sedatives < 72 and ≥ 72 hours. Parametric and nonparametric statistical analyses were performed using IBM SPSS Statistics version 28.0.0 (Armonk, New York) according to level of measurement, data distribution and assumptions. The a priori alpha was 5%. Results: There were 1506 patients who received parenteral opioids-sedatives in 229 ICUs at 87 hospitals in 11 countries. Median ICU stay was 6 (IQR; 12) days, 31% had ARDS, and 71% were invasively mechanically ventilated. Continuous opioids were administered to 50% (647/1305), sedatives to 52% (600/1151), and both to 37% (561/1506) of patients ≥ 72-hr, with 84% receiving continuous IV infusion opioids and 98% sedatives ≥ 72-hr (p< 0.001). All median 24-hr total opioid-sedative doses were significantly greater when used ≥ 72 hr. There was no difference in opioid-sedative dose reduction in the previous 24-hr, but significantly more patients on opioids-sedatives < 72-hr received > 50% dose reductions (61% vs. 38%; p< 0.001) and had enteral opioids-sedatives initiated in the previous 24-hr (24% vs. 15%; p< 0.001). Three of 9 patients assessed had IWS, all of whom received opioids-sedatives ≥ 72-hr. Conclusions: Half of adult ICU patients receive continuous parenteral opioids-sedatives for ≥ 72-hr at higher doses than earlier in admission, which may increase the risk of IWS.
• Edwards, C., Lam, J., Gardiner, J. E., & Erstad, B. L. (2022). Quality of critical care clinical practice guidelines involving pharmacotherapy recommendations. American Journal of Health-System Pharmacy, 79(21), 1919-1924. doi:10.1093/ajhp/zxac193
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  Abstract Purpose To assess the quality of critical care clinical practice guidelines (CPGs) involving pharmacotherapy recommendations. Methods A systematic electronic search was performed using PubMed, MEDLINE, and Embase for critical care CPGs published between 2012 and 2022 and involving pharmacotherapy recommendations. The Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument was employed to appraise CPG quality through independent assessment by 2 appraisers. Results Twenty-one CPGs were evaluated. The number of recommendations in each guideline ranged from 2 to 250, with a total of 1,604 recommendations. The number of strong (vs weak) recommendations in each guideline ranged from 0 to 31, with a total of 116 strong recommendations, or 7.23% of the total number of recommendations. There was at least 1 pharmacist author for 9 (43%) of the guidelines. The AGREE II domains for which mean quality scores of evaluated guidelines were highest were scope and purpose (0.88; 95% CI, 0.85-0.92), rigor of development (0.80; 95% CI, 0.77-0.83), clarity of presentation (0.84; 95% CI, 0.81-0.87), and editorial independence (0.86; 95% CI, 0.79-0.94), while those for which mean scores were lowest were stakeholder involvement (0.69; 95% CI, 0.63-0.75) and applicability (0.49; 95% CI, 0.43-0.55). Involvement of a pharmacist in CPG development was associated with significantly higher scoring for stakeholder involvement (P = 0.0356). Conclusion Strong recommendations accounted for less than 10% of the recommendations in the evaluated CPGs. Moreover, there are concerns related to guideline applicability (ie, advice or tools for putting recommendations into practice) and stakeholder involvement (ie, inclusion of individuals from all relevant groups). It is important to involve pharmacists in CPGs with pharmacotherapy recommendations.
• Erstad, B. L. (2022). How interprofessional is your interprofessional organization?. JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY, 5(12), 1232-1235. doi:10.1002/jac5.1683
• Erstad, B. L. (2022). Increasing the odds of finding a position after postgraduate year two training. JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY, 5(9), 932-933. doi:10.1002/jac5.1630
• Erstad, B. L. (2022). Normal saline or balanced salt solutions for fluid administration with a focus on critical care and emergency medicine settings.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 79(3), 199-203. doi:10.1093/ajhp/zxab319
• Erstad, B. L. (2022). Professional volunteerism: Try it, you will like it. JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY, 5(4), 388-389. doi:10.1002/jac5.1600
• Erstad, B. L. (2022). Response to Murray et al.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 79(2), 16. doi:10.1093/ajhp/zxab357
• Erstad, B. L. (2022). Why Do the Mechanistic Actions of Albumin Not Translate Into Tangible Clinical Benefits?. Annals of Pharmacotherapy, 57(6), 746-750. doi:10.1177/10600280221126629
• Erstad, B. L., & Barletta, J. F. (2022). Challenges With Using a Weight-Based Approach to Bolus Fluid Dosing in Obese Critically Ill Patients. Annals of Pharmacotherapy, 57(5), 609-616. doi:10.1177/10600280221125169
• Erstad, B. L., & Barletta, J. F. (2022). Dilemmas Related to Direct-Acting Oral Anticoagulant Administration in Patients With Extreme Obesity. Annals of Pharmacotherapy, 57(6), 727-737. doi:10.1177/10600280221130456
• Erstad, B. L., & Barletta, J. F. (2022). Drug dosing in hospitalized obese patients with COVID-19.. Critical care (London, England), 26(1), 60. doi:10.1186/s13054-022-03941-1
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  Obesity is highly prevalent in hospitalized patients admitted with COVID-19. Evidence based guidelines are available for COVID-19-related therapies but dosing information specific to patients with obesity is lacking. Failure to account for the pharmacokinetic alterations that exist in this population can lead to underdosing, and treatment failure, or overdosing, resulting in an adverse effect. The objective of this manuscript is to provide clinicians with guidance for making dosing decisions for medications used in the treatment of patients with COVID-19. A detailed literature search was conducted for medications listed in evidence-based guidelines from the National Institutes of Health with an emphasis on pharmacokinetics, dosing and obesity. Retrieved manuscripts were evaluated and the following prioritization strategy was used to form the decision framework for recommendations: clinical outcome data > pharmacokinetic studies > adverse effects > physicochemical properties. Most randomized controlled studies included a substantial number of patients who were obese but few had large numbers of patients more extreme forms of obesity. Pharmacokinetic data have described alterations with volume of distribution and clearance but this variability does not appear to warrant dosing modifications. Future studies should provide more information on size descriptors and stratification of data according to obesity and body habitus.
• Erstad, B. L., & Barletta, J. F. (2022). Implications of obesity for drug administration and absorption from subcutaneous and intramuscular injections: A primer. American Journal of Health-System Pharmacy, 79(15), 1236-1244. doi:10.1093/ajhp/zxac058
• Erstad, B. L., & Barletta, J. F. (2022). Pharmacologic venous thromboembolism prophylaxis in obese trauma patients. American Journal of Health-System Pharmacy, 80(5), 258-266. doi:10.1093/ajhp/zxac353
• Erstad, B. L., & Nix, D. E. (2022). Considerations When Using Body Mass Index as a Size Descriptor. Annals of Pharmacotherapy, 57(1), 107-109. doi:10.1177/10600280221097968
• Erstad, B. L., Jakowenko, N. D., & Kopp, B. J. (2022). Appraising the use of tranexamic acid in traumatic and non‐traumatic intracranial hemorrhage: A narrative review. Journal of the American College of Emergency Physicians Open, 3(4). doi:10.1002/emp2.12777
• Erstad, B. L., Jakowenko, N. D., Murata, J., & Kopp, B. J. (2022). Influence of Timing and Catecholamine Requirements on Vasopressin Responsiveness in Critically ill Patients with Septic Shock. Journal of Intensive Care Medicine, 37(11), 1512-1519. doi:10.1177/08850666221081836
• Erstad, B. L., Kopp, B. J., & Lenney, M. (2022). Balanced Salt Solutions for Critically Ill Patients: Nonplused and Back to Basics. Annals of Pharmacotherapy, 56(12), 1365-1375. doi:10.1177/10600280221084380
• Erstad, B. L., Matthias, K. R., & Nix, D. E. (2022). Vancomycin Dosing in Patients with Obesity. American Journal of Health-System Pharmacists, 79(22), 2058-2069. doi:10.1093/ajhp/zxac229
• Erstad, B. L., Matthias, K. R., & Nix, D. E. (2022). Vancomycin dosing in patients with obesity. American Journal of Health-System Pharmacy, 79(22), 2058-2069. doi:10.1093/ajhp/zxac229
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  The most appropriate vancomycin dosing regimen for adult obese patients is unclear, and recommendations concerning the most appropriate size descriptor and dosing interval for weight-based load and maintenance dosing regimens is yet to be determined.1 A recently published consensus guideline recommending 24-hour area under the curve (AUC24)–based dosing and monitoring includes recommendations for dosing obese patients.2 The issue of vancomycin dosing in patients with obesity is an important one since, according to the Centers for Disease Control and Prevention (CDC), the prevalence of obesity in the United States increased from 30.5% in 1999-2000 to 42.4% in 2017-2018, with the prevalence of severe obesity increasing from 4.7% to 9.2%.3 As noted in the consensus guideline, there is substantial interpatient variability in vancomycin exposure due to factors such as individual comorbidities and care setting (eg, critical care, noncritical care), and the risk of vancomycin nephrotoxicity may increase with inappropriate extended-interval dosing (intervals of ≥12 hours) based on total body weight (TBW), leading to supratherapeutic exposure (ie, AUC24 of >600 mg · h/L, assuming a vancomycin minimum inhibitory concentration [MIC] of 1 mg/L) in patients with obesity.2 The purpose of this commentary is to provide clinicians, particularly newer practitioners, with an overview of the seminal studies concerning vancomycin dosing in obese patients and expand on the obesity-related dosing recommendations provided in the recently published guideline. For the purposes of this article, definitions of obesity expressed as body mass index (BMI) are those of CDC, with class 1 obesity defined as a BMI of 30 to
• Erstad, B. L., Romero, A. V., & Barletta, J. F. (2022). Weight and size descriptors for drug dosing: Too many options and too many errors. American Journal of Health-System Pharmacy, 79(15), 1236-1244. doi:10.1093/ajhp/zxac283
• Lenney, M., Kopp, B. J., & Erstad, B. L. (2022). Effect of fixed-dose hydrocortisone on vasopressor dose and mean arterial pressure in obese and nonobese patients with septic shock. American Journal of Health-System Pharmacy, 79(Supplement_3), S94-S99. doi:10.1093/ajhp/zxac156
• Martin, J., Yu, M., & Erstad, B. L. (2022). Adverse effects of nonsteroidal anti-inflammatory drugs in critically ill patients: A scoping review. American Journal of Health-System Pharmacy, 80(6), 348-358. doi:10.1093/ajhp/zxac377
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  Abstract Purpose Nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended as opioid-sparing agents. The objective of this scoping review was to conduct a thorough search of the current literature to determine whether in adult critically ill patients there is an association between exposure to NSAIDs vs no NSAIDs and the subsequent development of serious adverse events, particularly gastrointestinal bleeding and acute kidney injury (AKI). Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews was utilized as a guideline for reporting. Searches were performed in PubMed (National Library of Medicine), Cochrane Library (Wiley), EMBASE (Elsevier), Stat!Ref (Teton), and Access Pharmacy (McGraw Hill) for articles published from January 2016 to August 2022. Results Of the 3,062 citations and titles identified in the search, 2,737 titles remained after removal of duplicates, 2,588 were excluded at title and abstract screening, and 149 articles remained for full-text review. None of the studies involved heterogeneous groups of critically ill patients in nonspecialty intensive care unit settings. Most studies evaluated were conducted in the perioperative setting and had limited adverse events reporting, particularly with respect to serious NSAID-related adverse effects of concern in critically ill patients. Conclusion In published studies primarily involving perioperative patients, there is insufficient detail concerning the definitions and reporting of NSAID-related serious adverse events such as bleeding and AKI. These events are of particular concern in heterogeneous critically ill patient populations predisposed to such complications. In most (if not all) critically ill patients, sustained dosing of NSAIDs should be avoided regardless of COX-1 selectivity due to the paucity of safety data.
• Place, E. M., Perona, S. J., Nguyen, P. T., Kang, N., Erstad, B. L., & Alrashed, M. A. (2022). Clinical outcomes of concomitant use of enteral and intravenous sedatives and analgesics in mechanically ventilated patients with COVID-19.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 79(Suppl 1), S21-S26. doi:10.1093/ajhp/zxab385
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  To evaluate potential differences in days on mechanical ventilation for patients with coronavirus disease 2019 (COVID-19) based on route of administration of analgesic and sedative medications: intravenous (IV) alone vs IV + enteral (EN)..This institutional review board-approved study evaluated ventilation time and fentanyl or midazolam requirements with or without concurrent EN hydromorphone and lorazepam. Patients were included in the study if they were 18 to 89 years old and were admitted to the intensive care unit with a positive severe acute respiratory syndrome coronavirus 2 reverse transcription and polymerase chain reaction or antigen test and respiratory failure requiring invasive mechanical ventilation for more than 72 hours. In total, 100 patients were evaluated, 60 in the IV-only group and 40 in the IV + EN group. There was not a significant difference in ventilation time between the groups (mean [SD], 19.6 [12.8] days for IV + EN vs 15.6 [11.2] days for IV only; P = 0.104). However, fentanyl (2,064 [847] μg vs 2,443 [779] μg; P < 0.001) and midazolam (137 [72] mg vs 158 [70] mg; P = 0.004) requirements on day 3 were significantly higher in the IV-only group, and the increase in fentanyl requirements from day 1 to day 3 was greater in the IV-only group than in the IV + EN group (378 [625] μg vs 34 [971] μg; P = 0.033)..Addition of EN analgesic and sedative medications to those administered by the IV route did not change the duration of mechanical ventilation in patients with COVID-19, but the combination may reduce IV opioid requirements, decreasing the impact of IV medication shortages.
• Tang, A. L., Kopp, B. J., & Erstad, B. L. (2022). Antibiotic prophylaxis for traumatic facial fractures.. Journal of clinical pharmacy and therapeutics, 47(3), 386-395. doi:10.1111/jcpt.13530
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  The purpose of this paper is to discuss the limitations of the evidence supporting the SIS recommendations for antibiotic prescribing in patients with traumatic facial fractures and to provide suggestions for clinical decision-making and further research in this area given the wide variation in prescribing practices..The Surgical Infection Society (SIS) recently published guidelines on antibiotic use in patients with traumatic facial fractures. The guidelines recommend against the use of prophylactic antibiotics for all adult patients with mandibular or non-mandibular facial fractures undergoing non-operative or operative procedures. Despite the available evidence, surveys conducted in the United States and the United Kingdom prior to the publication of the SIS guidelines demonstrate substantial preoperative, intraoperative and postoperative prophylactic prescribing of antibiotics for patients with facial fractures undergoing surgery..With the exception of strong recommendations based on moderate-quality evidence to avoid prolonged postoperative antibiotic prophylaxis, the weak recommendations in the guidelines are a function of low-quality evidence. A logical choice for a narrow-spectrum antibiotic is cefazolin administered within 1 h of surgery and no longer than 24 h after surgery, since it is the gold standard of comparison based on clinical practice guidelines concerning antibiotic prophylaxis.
• Train, S., Burns, K. E., Erstad, B. L., Massaro, A. F., Wu, T., Vassaur, J., Selvan, K., Kress, J. P., & Devlin, J. W. (2022). Physicians' attitudes and perceptions of neuromuscular blocker infusions in ARDS. J Crit Care, 22(154165). doi:10.1016/j.jcrc.2022.154165
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  The perceptions and practices of ICU physicians regarding initiating neuromuscular blocker infusions (NMBI) in acute respiratory distress syndrome (ARDS) may not be evidence-based amidst the surge of severe ARDS during the SARS-CoV-2 pandemic and new practice guidelines. We identified ICU physicians' perspectives and practices regarding NMBI use in adults with moderate-severe ARDS.After extensive development and testing, an electronic survey was distributed to 342 ICU physicians from three geographically-diverse U.S. health systems(n = 12 hospitals).The 173/342 (50.5%) respondents (75% medical) somewhat/strongly agreed a NMBI should be reserved until: after a trial of deep sedation (142, 82%) or proning (59, 34%) and be dose-titrated based on train-of-four monitoring (107, 62%). Of 14 potential NMBI risks, 2 were frequently reported to be of high/very high concern: prolonged muscle weakness with steroid use (135, 79%) and paralysis awareness due to inadequate sedation (114, 67%). Absence of dyssychrony (93, 56%) and use ≥48 h (87, 53%) were preferred NMBI stopping criteria. COVID-19 + ARDS patients were twice as likely to receive a NMBI (56 ± 37 vs. 28 ± 19%, p < 0.01).Most intensivists agreed NMBI in ARDS should be reserved until after a deep sedation trial. Stopping criteria remain poorly defined. Unique considerations exist regarding the role of paralysis in COVID-19+ ARDS.
• Viswesh, V., Sikora, A., Sarangarm, P., Peppard, W. J., Kruer, R. M., Kinney, J., Kaukeinen, K., Horng, H., Heavner, M. S., Gustafson, K. A., Groth, C. M., Glass, N. E., Flannery, A. H., Erstad, B. L., Droege, C. A., Dixit, D., Cucci, M. D., Connor, K. A., Chui, S. H., & Acquisto, N. M. (2022). Multicenter Retrospective Review of Ketamine Use in the ICU.. Critical care explorations, 4(2), e0633. doi:10.1097/cce.0000000000000633
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  The response of ICU patients to continuously infused ketamine when it is used for analgesia and/or sedation remains poorly established..To describe continuous infusion (CI) ketamine use in critically ill patients, including indications, dose and duration, adverse effects, patient outcomes, time in goal pain/sedation score range, exposure to analgesics/sedatives, and delirium..Multicenter, retrospective, observational study from twenty-five diverse institutions in the United States. Patients receiving CI ketamine between January 2014 and December 2017..Chart review evaluating institutional and patient demographics, ketamine indication, dose, administration, and adverse effects. Pain/sedation scores, cumulative doses of sedatives and analgesics, and delirium screenings in the 24 hours prior to ketamine were compared with those at 0-24 hours and 25-48 hours after..A total of 390 patients were included (median age, 54.5 yr; interquartile range, 39-65 yr; 61% males). Primary ICU types were medical (35.3%), surgical (23.3%), and trauma (17.7%). Most common indications were analgesia/sedation (n = 357, 91.5%). Starting doses were 0.2 mg/kg/hr (0.1-0.5 mg/kg/hr) and continued for 1.6 days (0.6-2.9 d). Hemodynamics in the first 4 hours after ketamine were variable (hypertension 24.0%, hypotension 23.5%, tachycardia 19.5%, bradycardia 2.3%); other adverse effects were minimal. Compared with 24 hours prior, there was a significant increase in proportion of time spent within goal pain score after ketamine initiation (24 hr prior: 68.9% [66.7-72.6%], 0-24 hr: 78.6% [74.3-82.5%], 25-48 hr: 80.3% [74.6-84.3%]; p < 0.001) and time spent within goal sedation score (24 hr prior: 57.1% [52.5-60.0%], 0-24 hr: 64.1% [60.7-67.2%], 25-48 hr: 68.9% [65.5-79.5%]; p < 0.001). There was also a significant reduction in IV morphine (mg) equivalents (24 hr prior: 120 [25-400], 0-24 hr: 118 [10-363], 25-48 hr: 80 [5-328]; p < 0.005), midazolam (mg) equivalents (24 hr prior: 11 [4-67], 0-24 hr: 6 [0-68], 25-48 hr: 3 [0-57]; p < 0.001), propofol (mg) (24 hr prior: 942 [223-4,018], 0-24 hr: 160 [0-2,776], 25-48 hr: 0 [0-1,859]; p < 0.001), and dexmedetomidine (µg) (24 hr prior: 1,025 [276-1,925], 0-24 hr: 285 [0-1,283], 25-48 hr: 0 [0-826]; p < 0.001). There was no difference in proportion of time spent positive for delirium (24 hr prior: 43.0% [17.0-47.0%], 0-24 hr: 39.5% [27.0-43.8%], 25-48 hr: 0% [0-43.7%]; p = 0.233). Limitations to these data include lack of a comparator group, potential for confounders and selection bias, and varying pain and sedation practices that may have changed since completion of the study..There is variability in the use of CI ketamine. Hemodynamic instability was the most common adverse effect. In the 48 hours after ketamine initiation compared with the 24 hours prior, proportion of time spent in goal pain/sedation score range increased and exposure to other analgesics/sedatives decreased.
• Abraham, I. L., McBride, A., Erstad, B. L., Slack, M. K., & Almutairi, A. (2021). Association of immune checkpoint inhibitors and the risk of immune-related colitis among elderly patients with advanced melanoma: real-world evidence from the SEER-Medicare database. Therapeutic Advances in Drug Safety.
• Abraham, I., Almutairi, A. R., Erstad, B. L., McBride, A., & Slack, M. (2021). Association of immune-checkpoint inhibitors and the risk of immune-related colitis among elderly patients with advanced melanoma: real-world evidence from the SEER–Medicare database. Therapeutic Advances in Drug Safety, 12, 204209862199127. doi:10.1177/2042098621991279
• Abraham, I., Almutairi, A. R., Erstad, B. L., McBride, A., & Slack, M. (2021). Immune checkpoint inhibitors-associated risk of immune-related hypothyroidism in older patients with advanced melanoma: a real-world analysis of US SEER-Medicare data. Expert Opinion on Drug Safety, 20(4), 489-497. doi:10.1080/14740338.2021.1877272
• Abraham, I., Oh, M., Erstad, B. L., Alsowaida, Y. S., Almulhim, A. S., & Abraham, I. (2021). Sensorineural hearing loss with macrolide antibiotics exposure: a meta-analysis of the association.. The International journal of pharmacy practice, 29(1), 21-28. doi:10.1111/ijpp.12670
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  Macrolide antibiotics are among the most commonly used antibiotics; the association of macrolide antibiotics exposure with sensorineural hearing loss (SNHL) has been hypothesized. A systematic search was conducted in PubMed, EMBASE and Cochrane Library from inception to 15 July 2019 to identify studies used macrolide antibiotics for any indication. The results were reported as odds ratio (OR) with 95% confidence interval (CI) using random-effects model to derive the association of macrolide antibiotics exposure with SNHL. The objective of this meta-analysis was to estimate the association of macrolide antibiotics exposure and SNHL from up-to-date evidence..Nine studies met the inclusion criteria. There was no statistically significant association between macrolide antibiotics exposure and SNHL; the OR was 1.20 (95% CI: 0.96 to 1.49). No significant association was found with any of the subgroup meta-analyses..Whilst the frequency of SNHL was higher with macrolide antibiotics exposure compared with controls, overall, no association was found between macrolide antibiotics and SNHL.
• Barletta, J. F., & Erstad, B. L. (2021). Response to ‘Drug dosage in patients with obesity: Investigation of lean body mass’. Anaesthesia and Intensive Care, 49(6), 489-489. doi:10.1177/0310057x211034521
• Devlin, J. W., Train, S., Burns, K. E., Massaro, A. F., Vasseur, J., Selvan, K., Kress, J. P., & Erstad, B. L. (2021). 950: CRITICAL CARE PHARMACIST ATTITUDES AND PERCEPTIONS OF NEUROMUSCULAR BLOCKER INFUSIONS IN ARDS. Critical Care Medicine, 50(1), 472-472. doi:10.1097/01.ccm.0000810124.49603.b5
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  Train, Sarah1; Burns, Karen E.A.2; Erstad, Brian3; Massaro, Anthony4; Vasseur, John5; Selvan, Kavitha6; Kress, John7; Devlin, John8 Author Information
• Erstad, B. L. (2021). Albumin for cirrhosis-related complications.. Journal of clinical pharmacy and therapeutics, 46(4), 887-894. doi:10.1111/jcpt.13461
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  The purpose of this paper was to discuss the limitations of the studies serving as the evidence for recommendations in clinical practice guidelines concerning albumin use for cirrhosis-related complications, review relevant studies published since the guidelines and suggest directions for future investigations..There are no recent comprehensive clinical practice guidelines concerning albumin. Instead, more recent albumin guidelines reflect areas of specialty practice such as those by American and European associations for the study of the liver and liver disease. Studies published since the guidelines are useful for helping to define the most appropriate indications for albumin with respect to cirrhosis-related complications, as well as directions for future research..Albumin has a long history of attempts to define appropriate uses by meta-analysis, but given the high cost and episodic shortages of albumin, there is a need for adequately powered randomized controlled trials using current state-of-the-art care evaluating the use of albumin to prevent or treat cirrhosis-related complications.
• Erstad, B. L. (2021). Caring for the COVID Patient: A Clinical Pharmacist's Perspective.. The Annals of pharmacotherapy, 55(3), 413-414. doi:10.1177/1060028020954224
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  Physicians and nurses have received many accolades in commercial and scientific media for their heroic efforts in caring for patients with COVID-19. These accolades are appropriate and deserved. However, there are a number of clinical pharmacists involved in the daily care of patients who are caring and competent practitioners, and also deserve our thanks and praise. The purpose of this article is to provide the impactful comments of a front-line, critical care pharmacist dedicated to providing the best possible care for patients with COVID-19 in a medical intensive care unit.
• Erstad, B. L. (2021). Ethical Decision-Making in the Pharmacists’ Patient Care Process. The American Journal of Pharmaceutical Education. doi:10.5688/ajpe8655
• Erstad, B. L. (2021). Predicted body weight: A rose by any other name.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 78(8), 751-753. doi:10.1093/ajhp/zxab013
• Erstad, B. L. (2021). Serum Albumin Levels: Who Needs Them?. The Annals of pharmacotherapy, 55(6), 798-804. doi:10.1177/1060028020959348
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  The purpose of this critical narrative review is to discuss common indications for ordering serum albumin levels in adult critically ill patients, evaluate the literature supporting these indications, and provide recommendations for the appropriate ordering of serum albumin levels..PubMed (1966 to August 2020), Cochrane Library, and current clinical practice guidelines were used, and bibliographies of retrieved articles were searched for additional articles..Current clinical practice guidelines were the preferred source of recommendations regarding serum albumin levels for guiding albumin administration and for nutritional monitoring. When current comprehensive reviews were available, they served as a baseline information with supplementation by subsequent studies..Serum albumin is a general marker of severity of illness, and hypoalbuminemia is associated with poor patient outcome, but albumin is an acute phase protein, so levels vacillate in critically ill patients in conjunction with illness fluctuations. The most common reasons for ordering serum albumin levels in intensive care unit (ICU) settings are to guide albumin administration, to estimate free phenytoin or calcium levels, for nutritional monitoring, and for severity-of-illness assessment..Because hypoalbuminemia is common in the ICU setting, inappropriate ordering of serum albumin levels may lead to unnecessary albumin administration or excessive macronutrient administration in nutritional regimens, leading to possible adverse effects and added costs..With the exception of the need to order serum albumin levels as a component of selected severity-of-illness scoring systems, there is little evidence or justification for routinely ordering levels in critically ill patients.
• Erstad, B. L. (2021). So, you want a letter of recommendation?. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 78(2), 93-94. doi:10.1093/ajhp/zxaa333
• Erstad, B. L. (2021). Usefulness of the Biomarker TIMP-2•IGFBP7 for Acute Kidney Injury Assessment in Critically Ill Patients: A Narrative Review.. The Annals of pharmacotherapy, 10600280211005425. doi:10.1177/10600280211005425
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  To review the clinical usefulness of the biomarker TIMP-2•IGFBP7 in adult, general medical-surgical intensive care unit (ICU) settings..PubMed (1946 to mid-February 2021) and EMBASE (1947 to mid-February 2021) with bibliographies of retrieved articles reviewed for additional articles..Studies evaluating use of the urinary TIMP-2•IGFBP7 assay in adult patients in ICU settings..Studies published after investigations leading to TIMP-2•IGFBP7 assay approval confirm the appropriateness of considerations discussed in product labeling, such as use of the test within 12 hours of assessment, use of a dichotomous 0.3 (ng/mL)2/1000 cutoff, and use only in combination with other assessments of acute kidney injury (AKI). However, as a biomarker routinely used for early identification of patients at risk for AKI in mixed ICU populations, the additional resources required for TIMP-2•IGFBP monitoring are difficult to justify because of limited data demonstrating usefulness in preventing or ameliorating AKI and its attendant complications..Biomarkers are potentially useful not only for assessment and diagnosis of AKI, but also for practitioners involved in the management of nephrotoxic medications and medications needing adjustment for decreased kidney function..Although there is evidence to suggest that the urinary TIMP-2•IGFBP7 biomarker is helpful in predicting AKI progression in general medical-surgical ICU patients when used within 12 hours of patient assessment in combination with routine testing, including serum creatinine and urine output, there is little evidence that its use leads to improvements in clinically important patient outcomes.
• Erstad, B. L., & Barletta, J. F. (2021). Dosing of neuromuscular blocking agents in patients with obesity: A narrative review.. Anaesthesia and intensive care, 49(2), 98-104. doi:10.1177/0310057x20968573
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  There is no consensus on which weight clinicians should use for weight-based dosing of neuromuscular blocking agents (NMBAs), as exemplified by differing or absent recommendations in clinical practice guidelines. The purpose of this paper is to review studies that evaluated various size descriptors for weight-based dosing of succinylcholine and non-depolarising NMBAs, and to provide recommendations for the descriptors of choice for the weight-based dosing of these agents in patients with obesity. All of the studies conducted to date involving depolarising and non-depolarising NMBAs in patients with obesity have assessed single doses or short-term infusions conducted in perioperative settings. Recognising that any final dosing regimen must take into account patient-specific considerations, the available evidence suggests that actual body weight is the size descriptor of choice for weight-based dosing of succinylcholine and that ideal body weight, or an adjusted (or lean) body weight, is the size descriptor of choice for weight-based dosing of non-depolarising NMBAs.
• Erstad, B. L., & Barletta, J. F. (2021). Drug dosing in the critically ill obese patient: a focus on medications for hemodynamic support and prophylaxis.. Critical care (London, England), 25(1), 77. doi:10.1186/s13054-021-03495-8
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  Medications used for supportive care or prophylaxis constitute a significant portion of drug utilization in the intensive care unit. Evidence-based guidelines are available for many aspects of supportive care but drug doses listed are typically for patients with normal body habitus and not morbid obesity. Failure to account for the pharmacokinetic changes that occur with obesity can lead to an incorrect dose and treatment failure or toxicity. This paper is intended to help clinicians design initial dosing regimens in critically ill obese patients for medications commonly used for hemodynamic support or prophylaxis. A detailed literature search of medications used for supportive care or prophylaxis listed in practice guidelines was conducted with an emphasis on obesity, pharmacokinetics and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided. For medications used for hemodynamic support, a similar strategy can be used as in non-obese patients. Similarly, medications for stress ulcer prophylaxis do not need to be adjusted. Anticoagulants for venous thromboembolism prophylaxis, on the other hand, require an individualized approach where higher doses are necessary.
• Erstad, B. L., & Huckleberry, Y. (2021). Extremely hypo-osmolar intravenous solutions to treat hypernatremia: The time has come to stop. American Journal of Health-System Pharmacy, 79(13), 1122-1125. doi:10.1093/ajhp/zxab480
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  Hypernatremia due to inadequate intake of water or water loss in excess of sodium is a relatively common problem in the intensive care unit setting and often necessitates free water replacement by intravenous (IV) administration (after initial resuscitation with isotonic solutions if hemodynamic instability is present) in patients unable to receive free water by the oral or enteral route. In adults, there is little high-level evidence on which to base treatment recommendations, with much of the available literature having its basis in observational and retrospective studies involving children with hypernatremia.1 Hypotonic IV fluid infusions are preferred for free water replacement when oral or enteral administration is not possible, because they allow for slower, more easily titratable infusion rates, which should help to decrease the risk of complications such as cerebral edema, a rare (occurring in less than 1% of patients) but potentially life-threatening complication of treatment.2,3...
• Erstad, B., Sweasy, J., Alrawashdh, N., McBride, A., Persky, D. O., & Abraham, I. (2021). Survival trends in chronic lymphocytic leukemia in the era of oral targeted therapies in the United States: SEER database analyses (1985 to 2017).. Journal of Clinical Oncology, 39(15_suppl), 7524-7524. doi:10.1200/jco.2021.39.15_suppl.7524
• Kang, N., Alrashed, M., Place, E. M., Nguyên, P., & Erstad, B. L. (2021). Clinical outcomes of concomitant use of enteral and parenteral analgesics/sedatives in mechanically ventilated COVID-19 patients. American Journal of Health-System Pharmacy, 79(Supplement_1), S21-S26. doi:10.1093/ajhp/zxab385
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  Introduction: Mechanically ventilated COVID-19 patients have unusually high requirements for analgesics and sedatives compared to non-COVID 19 patients, and the need for higher dosages coupled with prolonged infusions can contribute to critical drug shortages. In an attempt to preserve the limited supply of the injectable formulations at our institution, use of enteral opioids and benzodiazepines was implemented. Research Question or Hypothesis: To evaluate potential differences in clinical effect and analgesic/sedative usage between two groups of mechanically ventilated COVID-19 patients based on route of administration: IV+enteral versus IV alone. Study Design: Retrospective cohort study Methods: This IRB-approved study evaluated ventilation time and fentanyl or midazolam usage when used concurrently with enteral hydromorphone and lorazepam. Inclusion criteria: 18-89 years old patients admitted to ICU with positive SARS-CoV-2 RT-PCR or antigen test and respiratory failure requiring invasive mechanical ventilation for >72 hours. Exclusion criteria: pregnancy or breast-feeding, and chronic opioid or benzodiazepine use within 30 days prior to admission. Data were collected in Microsoft Excel for initial analyses with subsequent inferential testing (Student's t-tests) performed using STATA® 13.1, College Station, TX. Significance for all testing was defined as alpha less than 0.05. Results: One hundred patients were evaluated, 55 in IV+enteral group and 45 in IV only group. There was no significant difference in ventilation time between two groups (20.7±13 vs. 16.5±12 days, p=0.1068). However, there was a statistically significant increase in fentanyl (1869.2±850.5 vs. 2281.6±853.4, p=0.0002) and midazolam (126±76.7 vs. 148.9±77.2, p=0.0061) requirements on day 3 in IV alone group and increase in fentanyl requirements when compared to IV+enteral group (33±842 vs.-412.4±673.6, p= 0.0050). Conclusion: Duration of mechanical ventilation in patients with COVID-19 is not reduced with combined IV+enteral compared to IV only analgesics/sedatives, but the combination may reduce IV analgesic requirements ameliorating the impact of IV shortages.
• Kiser, T. H., Erstad, B. L., & Bauer, S. R. (2021). Critical care essentials for pharmacy trainees and new clinical practitioners.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 78(13), 1176-1183. doi:10.1093/ajhp/zxaa417
• Lansburg, J. M., Kopp, B. J., Erstad, B. L., Buckley, M. S., & Agarwal, S. K. (2021). Clinical Pharmacist-Led Impact on Inappropriate Albumin Utilization and Associated Costs in General Ward Patients.. The Annals of pharmacotherapy, 55(1), 44-51. doi:10.1177/1060028020935575
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  Inappropriate albumin use in clinical practice remains problematic. Health-systems face continued challenges in promoting cost-appropriate use..To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin use in general ward patients..A retrospective cohort study evaluated all adult (≥18 years) general ward patients administered ≥1 dose of albumin at a university medical center over a 2-year period. The intervention consisted of a clinical pharmacist-led strategy intervening on all albumin orders not in accordance with institutional guidelines. The primary end point was to compare inappropriate albumin utilization before and after implementation. Secondary end points compared the rates of inappropriate albumin use adjusted for hospital admission and patient-days as well as associated costs by appropriateness between study periods..A total of 4420 patients were screened, with 1971 (44.6%) patients meeting inclusion criteria. The clinical pharmacist strategy significantly reduced inappropriate albumin (grams) utilization by 86.0% (P < 0.001). A 7-fold reduction of inappropriate albumin administered adjusted for the number of patient admissions was found from the preimplementation period following clinical pharmacist intervention strategy implementation (415.3 ± 83.2 vs 57.5 ± 34.2 g per 100 general ward hospital admissions, respectively; P < 0.001). Also, the adjusted inappropriate albumin rate was reduced from 62.2 ± 12.3 to 8.6 ± 5.2 g per 100 patient-days in the preimplementation and postimplementation periods, respectively (P < 0.001). Annual cost savings were $421 455 overall, with $341 930 resulting from mitigation of inappropriate use..Clinical pharmacist-led interventions significantly reduced inappropriate albumin use and costs in hospitalized patients.
• Lenney, M., Kopp, B. J., & Erstad, B. L. (2021). 1430: EFFICACY OF FIXED DOSE HYDROCORTISONE FOR SEPTIC SHOCK IN OBESE AND NON-OBESE PATIENTS. Critical Care Medicine, 50(1), 717-717. doi:10.1097/01.ccm.0000812044.94838.38
• Murata, J., Kopp, B., Jakowenko, N., & Erstad, B. (2021). 1523: INFLUENCE OF TIMING AND CATECHOLAMINE REQUIREMENTS ON VASOPRESSIN RESPONSIVENESS IN SEPTIC SHOCK. Critical Care Medicine, 50(1), 765-765. doi:10.1097/01.ccm.0000812416.72169.3d
• Narayan, S. W., Abraham, I., Erstad, B. L., Haas, C. E., Sanders, A., & Patanwala, A. E. (2021). Methods used to attribute costs avoided from pharmacist interventions in acute care: A scoping review. American Journal of Health-System Pharmacy, 78(17), 1576-1590. doi:10.1093/ajhp/zxab214
• Nix, D. E., & Erstad, B. L. (2021). Assessment of Kidney Function in Patients With Extreme Obesity: A Narrative Review.. The Annals of pharmacotherapy, 55(1), 80-88. doi:10.1177/1060028020935580
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  To discuss the evidence and caveats associated with estimated and measured creatinine clearance (eClCr and mClCr) and glomerular filtration rate (eGFR and mGFR) assessments of kidney function in patients with more extreme forms of obesity..PubMed (1976 to mid-May 2020) was used, with bibliographies of retrieved articles searched for additional articles..Articles using gold standard mGFR to evaluate eClCr, mClCr, and eGFR assessments of kidney function in patients with more extreme forms of obesity were included..The overestimation of GFR by mClCr is well established, but mClCr is an alternative to mGFR assessments for determining medication dosing in patients with extremes of body size or muscle mass, or in patients receiving narrow therapeutic index medications when eGFR is likely to be inaccurate. The vast majority of studies comparing eGFR assessments with gold standard indicators of kidney function were attempts to validate eGFR equations for diagnosing and staging chronic kidney disease (CKD)..For dosing medications in patients with stable kidney function and extreme obesity, a deindexed 4-variable Modification of Diet in Renal Disease or CKD Epidemiology Collaboration equation is an alternative to Cockcroft-Gault. Consistent use of the same equation by provider and between providers within any given setting is of paramount importance..In patients with extreme obesity and stable kidney function, eClCr or eGFR using deindexed values provides estimates of function for dosing adjustments of medications with elimination by the kidneys, but more research is needed with respect to the best size descriptor to use with estimating equations.
• Nix, D. E., & Erstad, B. L. (2021). Caveats in Kidney Function Assessment.. The Annals of pharmacotherapy, 10600280211000347. doi:10.1177/10600280211000347
• Nix, D. E., & Erstad, B. L. (2021). Creatinine Assessment in Non-Steady-State Conditions: A Critical Review.. The Annals of pharmacotherapy, 1060028021999644. doi:10.1177/1060028021999644
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  To discuss methods for the assessment of creatinine clearance (Clcr) when serum creatinine (SCr) is not at steady state in order to estimate kidney function and apply the estimate to kidney function staging for clinical assessment or drug dosing..A PubMed search was conducted from 1976 to mid-January 2021 with other articles identified through review of bibliographies of retrieved articles and citations in Scopus..Articles assessing Clcr under non-steady-state conditions and studies evaluating predictive equations were selected..When SCr is systematically changing (ie, trending up or down), kinetic methods to estimate Clcr are appropriate. Estimates from kinetic methods should be individual based and not indexed to body surface area, and careful monitoring is required to confirm predictions as the situation evolves. Standard methods intended for steady-state conditions should not be used to estimate Clcr in patients with unstable SCr..Creatinine continues to be a monitoring parameter of choice and is an important variable in all the commonly used equations for estimating Clcr and most important for estimating glomerular filtration rate. However, standard methods of estimating Clcr for medication dosing are not accurate under non-steady-state conditions..The methods for kinetic clearance estimation and standards methods for clearance estimation, such as the Cockcroft-Gault equation, are mutually exclusive. There are no benefits of using the kinetic method in patients with stable SCr concentrations, and standard equations are not appropriate with unstable SCr concentrations.
• Patanwala, A. E., Narayan, S. W., Haas, C. E., Abraham, I., Sanders, A. B., & Erstad, B. L. (2021). Proposed guidance on cost-avoidance studies in pharmacy practice. American Journal of Health-System Pharmacy, 78(17), 1559-1567. doi:10.1093/ajhp/zxab211
• Patanwala, A., Sanders, A. B., Hess, C. E., Erstad, B. L., Abraham, I. L., & Narayan, S. (2021). Methods used to attribute costs avoided from pharmacist interventions in acute care: a scoping review.. American Journal of Health-System Pharmacy.
• Roe, D. J., Obeng-kusi, M., Habila, M. A., Erstad, B., & Abraham, I. (2021). Economic evaluation using dynamic transition modeling of ebola virus vaccination in lower-and-middle-income countries.. Journal of medical economics, 24(sup1), 1-13. doi:10.1080/13696998.2021.2002092
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  With the increasing occurrence of infectious diseases in lower-and-middle-income countries (LMICs), emergency preparedness is essential for rapid response and mitigation. Economic evaluations of mitigation technologies and strategies have been recommended for inclusion in emergency preparedness plans. We aimed to perform an economic evaluation using dynamic transition modeling of ebola virus disease (EVD) vaccination in a hypothetical community of 1,000 persons in the Democratic Republic of Congo (DRC)..Using a modified SEIR (Susceptible, Exposed, Infectious, Recovered, with Death added [SEIR-D]) model that accounted for death and epidemiological data from an EVD outbreak in the DRC, we modeled the transmission of EVD in a hypothetical population of 1,000. With our model, we estimated the cost-effectiveness of an EVD vaccine and an EVD vaccination intervention..The results showed vaccinating 50% of the population at risk prevented 670 cases, 538 deaths, and 22,022 disability-adjusted life years (DALYs). The vaccine was found to be cost-effective with an incremental cost-effectiveness ratio (ICER) of $95.63 per DALY averted. We also determined the minimum required vaccination coverage for cost-effectiveness to be 40%. Sensitivity analysis showed our model to be fairly robust, assuring relatively consistent results even with variations in such input parameters as cost of screening, as well as transmission, infection, incubation, and case fatality rates..EVD vaccination in our hypothetical population was found to be cost-effective from the payer perspective. Our model presents an efficient and reliable approach for conducting economic evaluations of infectious disease interventions as part of an emergency preparedness plan.
• Stratton, T. P., & Erstad, B. L. (2021). Teaching Ethics: See One, Do One, … Teach One?. The American Journal of Pharmaceutical Education. doi:10.5688/ajpe8503
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  All faculty members should have a general understanding of the field of ethics, regardless of any formal training, since instruction and training in ethical decision-making is an accreditation expectation. Additionally, whether they recognize it or not, pharmacy faculty members are involved in ethical decision-making on an almost daily basis. The aims of the current commentary are to expand on a basic approach to ethical decision-making using examples involving students or faculty members in each of the triad areas of teaching, research, and service, and serve as a starting point to enable all faculty to teach students how to work through an ethical dilemma. In particular, this commentary will focus on the initial steps involved in determining if an ethical dilemma exists, determining the facts related to the dilemma by identifying technical facts and legal constraints, and identifying the principles and values that play a role in the situation decide which are in conflict. References are provided for more in-depth review of ethics subject matter beyond the scope of this commentary.
• Sweitzer, N. K., Klimecki, W. T., Karnes, J. H., Abraham, I., Sweitzer, N. K., Slack, M. K., Ramos, K. S., Lee, C. S., Klimecki, W. T., Karnes, J. H., Gharaibeh, M., Erstad, B. L., Alkhatib, N. S., & Abraham, I. (2021). Ex Ante Economic Evaluation of Arg389 Genetically Targeted Treatment with Bucindolol versus Empirical Treatment with Carvedilol in NYHA III/IV Heart Failure.. American Journal of Cardiovascular Drugs, 21(2), 205-217. doi:10.1007/s40256-020-00425-x
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  The Beta-Blocker Evaluation Survival Trial showed no survival benefit for bucindolol in New York Heart Association (NYHA) class III/IV heart failure (HF) with reduced ejection fraction, but subanalyses suggested survival benefits for non-Black subjects and Arg389 homozygotes. We conducted an ex ante economic evaluation of Arg389 targeted treatment with bucindolol versus carvidolol, complementing a previous ex ante economic evaluation of bucindolol preceded by genetic testing for the Arg389 polymorphism, in which genetic testing prevailed economically over no testing. A decision tree analysis with an 18-month time horizon was performed to estimate the cost effectiveness/cost utility of trajectories of 100%, 50%, and 0% of patients genetically tested for Arg389 and comparing bucindolol with empirical carvedilol treatment as per prior BEST subanalyses. Incremental cost-effectiveness/cost-utility ratios (ICERs/ICURs) were estimated. Race-based analyses for non-White subjects at 100% testing showed a loss of (0.04) life-years and (0.03) quality-adjusted life-years (QALYs) at an incremental cost of $2185, yielding a negative ICER of ($54,625)/life-year and ICUR of ($72,833)/QALY lost; at 50%, the analyses showed a loss of (0.27) life-years and (0.16) QALYs at an incremental cost of $1843, yielding a negative ICER of ($6826)/life-year and ICUR of ($11,519)/QALY lost; at 0%, the analyses showed a loss of (0.33) life-years and (0.30) QALYs at an incremental cost of $1459, yielding a negative ICER of ($4421)/life-year and ICUR of ($4863)/QALY lost. Arg389 homozygote analyses at 100% testing showed incremental gains of 0.02 life-years and 0.02 QALYs at an incremental cost of $378, yielding an ICER of 18,900/life-year and ICUR of $18,900/QALY gained; at 50%, the analyses showed a loss of (0.24) life-years and (0.09) QALYs at an incremental cost of $1039, yielding a negative ICER of ($4329)/life-year and ICUR of ($9336)/QALY lost; at 0%, the analyses showed a loss of (0.33) life-years and (0.30) QALYs at an incremental cost of $1459, yielding a negative ICER of ($4421)/life-year and ICUR of ($4863)/QALY lost. This independent ex ante economic evaluation suggests that genetically targeted treatment with bucindolol is unlikely to yield clinicoeconomic benefits over empirical treatment with carvedilol in NYHA III/IV HF.
• Viswesh, V., Hassell, K., Erstad, B. L., & Coyne, L. (2021). Ten Tips for Pharmacy Faculty Members for Successfully Navigating Promotion and Tenure. The American Journal of Pharmaceutical Education, 85(1). doi:10.5688/ajpe8414
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  The purpose of this paper is to summarize ten key tips or recommendations for successful navigation of the promotion and tenure process. The ten key tips to successful promotion and tenure are: (1) Know institutional expectations, (2) Develop action plan at least 2-3 years in advance, (3) Identify YOUR balance of teaching, scholarship, service, (4) Synergize activities and develop a niche, (5) Prioritize time to activities of high-impact to P&T, (6) Track achievements in format expected for P&T application, (7) Seek out faculty development on P&T, (8) Meet with mentor(s) regularly to review progress, (9) Have a well-written personal statement, and (10) Have final dossier reviewed by colleagues. Faculty members are more likely to be successful through timely and appropriate planning, balancing and synergizing activities, tracking activities and achievements, developing a well-written personal statement, and requesting help from experienced colleagues.
• Viswesh, V., Hassell, K., Erstad, B. L., & Coyne, L. (2021). Ten Tips for Pharmacy Faculty Members for Successfully Navigating Promotion and Tenure.. American journal of pharmaceutical education, 85(1), 8414. doi:10.5688/ajpe8414
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  This paper presents 10 key tips or recommendations for successful navigation of the promotion and tenure process. The 10 key tips are: know institutional expectations, develop an action plan at least two to three years in advance; identify your balance of teaching, scholarship, service; synergize activities and develop a niche; prioritize time to activities of high-impact to promotion and tenure; track achievements in the format expected for promotion and tenure application; seek out faculty guidance on promotion and tenure; meet with mentor(s) regularly to review progress; have a well-written personal statement; and have your final dossier reviewed by colleagues. Faculty members are more likely to be successful through timely and appropriate planning, balancing and synergizing activities, tracking activities and achievements, developing a well-written personal statement, and requesting help from experienced colleagues.
• Viswesh, V., Sarangarm, P., Rappaport, S., Peppard, W., Newsome, A. S., Kruer, R., Kaukeinen, K., Horng, H., Heavner, M., Gustafson, K., Groth, C. M., Glass, N., Flannery, A. H., Erstad, B. L., Droege, C. A., Dixit, D., Cucci, M., Connor, K., Chui, S. H., & Acquisto, N. M. (2021). 861: Multicenter Retrospective Review of Ketamine Use in Pediatric ICU Patients (Ketamine-PICU Study). Critical Care Medicine, 49(1), 427-427. doi:10.1097/01.ccm.0000729332.64276.a8
• Wagner, P., Thienhaus, O. J., Schlager, E., Romero, A. J., Miller, R. C., Liaupsin, C., Erstad, B. L., & Brazeau, G. A. (2021). Equity for and Inclusion of Non-Tenure-Track Pharmacy Faculty Within Academia. The American Journal of Pharmaceutical Education, 85(3). doi:10.5688/ajpe8428
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  Although there are at least twice as many non-tenure-track first-time pharmacy faculty as tenured and tenure-track first-time pharmacy faculty entering academia based on data collected from 2013 to 2019, there are ongoing equity, inclusion, and advancement issues between these categories of faculty that require consideration. Contracts with clear descriptions of responsibilities are needed along with regular evaluations and promotion opportunities based on the faculty member’s performance of the assigned responsibilities, appropriate compensation including fringe benefits, inclusion in institutional voting and governance, and due process protections against abrupt termination. Further, universities and schools and colleges of pharmacy should foster a culture that values all faculty regardless of rank or position. The purpose of this commentary is to describe ongoing efforts and lessons learned by one public university with a college of pharmacy that has non-tenure-track and tenure-track faculty. Our hope is to provide insight into how these experiences could be used as a basis to inform changes in policy by other universities with a school or college of pharmacy, as well as to inform possible changes to the Academy’s policies.
• Wagner, P., Thienhaus, O. J., Schlager, E., Romero, A. J., Miller, R. C., Liaupsin, C., Erstad, B. L., & Brazeau, G. A. (2021). Equity for and Inclusion of Non-Tenure-Track Pharmacy Faculty Within Academia.. American journal of pharmaceutical education, 85(3), 8428. doi:10.5688/ajpe8428
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  Although there are at least twice as many non-tenure-track first-time pharmacy faculty as tenured and tenure-track first-time pharmacy faculty entering academia based on data collected from 2013 to 2019, there are ongoing equity, inclusion, and advancement issues between these categories of faculty that require consideration. Contracts with clear descriptions of responsibilities are needed along with regular evaluations and promotion opportunities based on the faculty member's performance of the assigned responsibilities, appropriate compensation including fringe benefits, inclusion in institutional voting and governance, and due process protections against abrupt termination. Further, universities and schools and colleges of pharmacy should foster a culture that values all faculty regardless of rank or position. The purpose of this commentary is to describe ongoing efforts and lessons learned by one public university with a college of pharmacy that has non-tenure-track and tenure-track faculty. Our hope is to provide insight into how these experiences could be used as a basis to inform changes in policy by other universities with a school or college of pharmacy, as well as to inform possible changes to the Academy's policies.
• Xie, C., Campbell, A. M., Vraney, J., Erstad, B. L., Oman, N., Oman, N., Vraney, J., Erstad, B. L., Xie, C., & Campbell, A. M. (2021). Initiation of Oseltamivir in Critically Ill Patients: Variations in Prescribing Practices.. The Annals of pharmacotherapy, 55(2), 265-266. doi:10.1177/1060028020942513
• Abraham, I., Patanwala, A. E., Oh, M., Erstad, B. L., Almutairi, A. R., Alkhatib, N. S., & Abraham, I. (2020). Cost Analysis of Adjunctive Hydrocortisone Therapy for Septic Shock: U.S. Payer Perspective.. Critical care medicine, 48(10), e906-e911. doi:10.1097/ccm.0000000000004501
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  To conduct a cost analysis of adjunctive hydrocortisone therapy for severe septic shock from the perspective of a third-party payer in the United States..Estimates of outcomes were aggregate data from the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and Activated Protein C and Corticosteroids for Human Septic Shock trials. In these trials, the outcomes of interests were ICU length of stay, vasopressor-free days, ventilation-free days, and the proportion of patients receiving blood transfusion. Each outcome was monetized into a set of mutually exclusive components and was aggregated to estimate the cost-per-patient based on each trial. Cost inputs for each outcome were obtained from literature and adjusted based on the medical care consumer price index. To estimate the budget impact using adjunctive hydrocortisone therapy, per-patient avoided cost was multiplied by expected septic shock annual incidence. Deterministic one-way sensitivity analysis evaluated the robustness of the findings, and Monte Carlo simulation estimated 95% CI of the findings..A total of 103 medical-surgical ICU (69 for Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and 34 for Activated Protein C and Corticosteroids for Human Septic Shock)..Adults greater than or equal to 18 years old with septic shock..Adjunctive hydrocortisone therapy (hydrocortisone at a dose of 200 mg/d for 7 d for Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and hydrocortisone at a 50 mg IV bolus every 6 hr and fludrocortisone as a 50 μg tablet once daily)..Per Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock, adjunctive hydrocortisone therapy showed a 90-day monetized benefit of $8,111 (95% CI, $3,914-$12,307) per patient, driven by improvements in ICU-free days, vasopressor-free days, ventilation-free days, and blood transfusion proportion. The total estimated annual impact of adjunctive hydrocortisone therapy, in 2019 dollars, was $750 million. Per Activated Protein C and Corticosteroids for Human Septic Shock, adjunctive hydrocortisone therapy showed a 90-day monetized benefit of $25,539 per patient (95% CI, $22,853-$28,224), driven by improvements in ICU free-days, vasopressor-free days, and ventilation-free days. The total estimated annual impact of adjunctive hydrocortisone therapy, in 2019 dollars, was $2.3 billion. The deterministic one-way sensitivity analysis showed the cost of ICU stays to be the most influential factor in both analyses. The sensitivity analysis using the reported median showed a greater monetized benefit of $10,658 (Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock) and $30,911 (Activated Protein C and Corticosteroids for Human Septic Shock) per patient..Using adjunctive hydrocortisone therapy yields a significant monetized benefit based on inputs from the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock and Activated Protein C and Corticosteroids for Human Septic Shock trials.
• Abraham, I., Slack, M. K., Mcbride, A., Erstad, B. L., Almutairi, A. R., & Abraham, I. (2020). Potential Immune-Related Adverse Events Associated With Monotherapy and Combination Therapy of Ipilimumab, Nivolumab, and Pembrolizumab for Advanced Melanoma: A Systematic Review and Meta-Analysis.. Frontiers in oncology, 10, 91. doi:10.3389/fonc.2020.00091
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  Background: The use of ipilimumab, nivolumab, and pembrolizumab as monotherapies or in combination has transformed the management of advanced melanoma even though these drugs are associated with a new profile of immune-related adverse events (irAEs). The incidence of irAEs from clinical trials of these agents is an important factor for clinicians when treating patients with advanced melanoma. In the current study, we aimed to profile the incidence of potential irAEs of these agents when used as monotherapy and as combination therapy. Methods: We searched the Medline, Embase, and Cochrane databases; clinicaltrials.gov; and websites of regulatory agencies in the USA, Europe, Australia, and Japan for phase 1-3 trials of ipilimumab, nivolumab, and pembrolizumab for advanced melanoma. Random effect meta-analysis was utilized to profile the incidence of potential irAEs. Results: A total of 58 reports of 35 trials including 6,331 patients with advanced melanoma and reporting irAE data were included in the meta-analyses. We found higher incidences of potential irAEs in combination therapies vs. monotherapies for most of the types of irAEs. Among the monotherapies, ipilimumab users had the most frequent incidence of potential irAEs related to the gastrointestinal system (diarrhea, 29%; and colitis, 8%) and skin (rash, 31%; pruritus, 27%; and dermatitis, 10%), with hypophysitis in 4% of the patients. The most frequent potential irAEs among nivolumab users were maculopapular rash (13%), erythema (4%), hepatitis (3%), and infusion-related reactions (3%), while they were arthralgia (12%), hypothyroidism (8%), and hyperglycemia (6%), among pembrolizumab users. Conclusion: Especially the combination therapies tend to elevate the incidence of potential irAEs. Clinicians should be vigilant about irAEs following combination therapy as well as gastrointestinal and skin irAEs following ipilimumab therapy, in addition to being aware of potential irAEs leading to hyperglycemia, thyroid, hepatic, and musculoskeletal disorders following nivolumab and pembrolizumab therapy.
• Abraham, I., Slack, M. K., Ramos, K. S., Mcbride, A., Erstad, B. L., Bhattacharjee, S., Alkhatib, N. S., & Abraham, I. (2020). Pricing methods in outcome-based contracting: integration analysis of the six dimensions (6 δs).. Journal of medical economics, 23(11), 1266-1272. doi:10.1080/13696998.2020.1815031
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  Six Delta is a six-dimensional independent platform for outcome-based pricing/contracting. The six dimensions have been described separately: (δ1) cost-effectiveness analysis and cost-utility analysis-based pricing; (δ2) willingness-to-pay-based pricing; (δ3) reference-based pricing; (δ4) safety-based pricing; (δ5) risk of efficacy failure-based pricing; and (δ6) adherence-based pricing. The final step is to integrate the various dimension-specific pricing estimates into a composite estimate termed the All-Dimensional Price (ADP). We describe the methodology for this integration and present a proof-of-concept application to the treatment of non-small cell lung cancer (NSCLC) with EGFR mutation with osimertinib..For better accuracy in estimating the ADP, we used the prices generated from the six dimensions at scenario levels, not at the dimension-specific price (DSP) level. We pooled the price estimates and performed Monte Carlo Simulations (MCS) for the price scenarios generated by the six dimensions. We used the results of the proof-of-concept exercise involving osimertinib in NSCLC with EGFR mutation to estimate the ADP in two hypothetical contracts: 1-year (2019-2020) and 2-year contract (2019-2021)..The average of the 30-day prescription estimates from the six dimensions averaged $10,819 (SD=$8,486) for the 1-year contract and $10,730 (SD=$8,500) for the 2-year contract. MCS yielded for the 1-year contract an ADP of $10,959 (or -25.02% the 2018 WAC price) and an ADP for the 2-year contract was $10,788 (or -26.19% the 2018 WAC price)..We demonstrated that the integration of the prices from the six dimensions of the Six Delta platform and market conditions is feasible and yields multidimensional prices estimates to support outcome-based pricing/contracting.
• Abraham, I., Slack, M. K., Ramos, K. S., Mcbride, A., Erstad, B. L., Bhattacharjee, S., Alkhatib, N. S., & Abraham, I. (2020). Pricing methods in outcome-based contracting: δ1: cost effectiveness analysis and cost-utility analysis-based pricing.. Journal of medical economics, 23(11), 1215-1222. doi:10.1080/13696998.2020.1815025
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  Six Delta is a six-dimensional independent platform for outcome-based pricing/contracting. The first dimension (δ1) estimates prices on the basis of cost-effectiveness (CEA) and cost-utility analysis (CUA). We describe this dimension's methodology and present a proof-of-concept application to the treatment of non-small cell lung cancer (NSCLC) with EGFR mutation with osimertinib..CEA and CUA were performed using established methods. Probabilistic sensitivity analyses (PSA) were performed to generate cost-effectiveness acceptability curves (CEAC), specifically the PSA incremental cost-effectiveness (PSA ICER) and incremental cost-utility ratio generated CEACs (PSA ICUR). Price of treatment was estimated at three certainty levels (0%, turning point%, 100%). The marketed drug price at turning point was used to estimate prices at 0% and 100% certainty levels, as per PSA ICER and PSA ICUR-generated CEACs. The resulting prices were pooled, inflated, and simulated by Monte Carlo Simulation (MCS) methods to estimate the dimension-specific price based on CEA and CUA (DSPCEA/CUA). A proof-of-concept exercise with osimertinib in NSCLC was performed for two hypothetical outcome-based contracts: 1-year (2019-2020) and 2-years (2019-2021)..Turning points were estimated at the 50% certainty level in both PSA ICER and ICUR-generated CEACS. At these points, the wholesale acquisition cost for osimertinib was $14,616 (30-day prescription); inflated by 0.44% for 1-year and by 0.72% for 2-year contracts. Additional prices at 0% and 100% certainty levels were quantified based on the PSA ICER and ICUR-generated CEACs. The MCS yielded a DSPCEA/CUA of $16,391 for the 1-year contract and a DSPCEA/CUA at $16,677 for the 2-year contract for a 30-day prescription..We demonstrated that conventional CEA and CUA methods generate price estimates at varying levels of certainty that can be integrated into our proposed Six Delta platform for outcome-based pricing/contracting.
• Abraham, I., Slack, M. K., Ramos, K. S., Mcbride, A., Erstad, B. L., Bhattacharjee, S., Alkhatib, N. S., & Abraham, I. (2020). Pricing methods in outcome-based contracting: δ2: willingness-to-pay-based pricing.. Journal of medical economics, 23(11), 1223-1229. doi:10.1080/13696998.2020.1815026
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  Six Delta is a six-dimensional independent platform for outcome-based pricing/contracting. The second dimension (δ2) estimates prices on the basis of four willingness-to-pay (WTP) thresholds. We describe this dimension's methodology and present a proof-of-concept application to the treatment of non-small cell lung cancer (NSCLC) with EGFR mutation with osimertinib..Eight WTP scenarios based on four levels of real gross domestic product per capita (3 × GDP/capita) and two market conditions (monopolistic versus competitive) were assumed. The incremental cost-utility ratio (ICUR) was applied to differently to both markets. In the monopolistic market, assuming no competitors, the cost/QALY ratio for a drug was used; whereas in the competitive market, assuming competitors, the incremental cost-utility ratio (ICUR) was applied. One-way sensitivity analyses were performed and predictive equations were specified to estimate the prices of treatment for the resulting eight WTP scenarios; for which subsequently the average and standard deviation were calculated. A gamma distribution was specified and Monte Carlo Simulation (MCS) was applied to estimate the dimension-specific price based on WTP (DSPWTP). A proof-of-concept exercise with osimertinib in NSCLC was performed for two hypothetical outcome-based contracts: 1-year (2019-2020) and 2-year (2019-2021). The 2018 wholesale acquisition cost (WAC) of $14,616 (30-day prescription) was used to estimate the DSPWTP for each contract..The 1-year estimates averaged $4,654 (SD=$6,462) and the MCS yielded a DSPWTP of $4,547 or -68.89% of the 2018 WAC for a 30-day prescription. The 2-year estimates averaged $4,7667 (SD=$6,480) with the MCS generating a DSPWTP of $4,704 or -67.82% of the WAC..We demonstrated that WTP-based methods that include various WTP thresholds and market conditions generate price estimates across these thresholds and market conditions that can be integrated into our proposed Six Delta platform for outcome-based pricing/contracting.
• Abraham, I., Slack, M. K., Ramos, K. S., Mcbride, A., Erstad, B. L., Bhattacharjee, S., Alkhatib, N. S., & Abraham, I. (2020). Pricing methods in outcome-based contracting: δ3: reference-based pricing.. Journal of medical economics, 23(11), 1230-1236. doi:10.1080/13696998.2020.1815027
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  Six Delta is a six-dimensional independent platform for outcome-based pricing/contracting. The third dimension (δ3) estimates prices on the basis of international drug price referencing methods. We describe this dimension's methodology and present a proof-of-concept application to the treatment of non-small cell lung cancer (NSCLC) with EGFR mutation with osimertinib..The reference-based pricing dimension utilizes a six-step method: (1) selecting foreign countries based on a set of four criteria (drug is available in the foreign country, price information is available in the foreign country, foreign countries are members within the organization for Economic Co-operation and Development, pricing methods in the foreign countries involve value assessment); (2) adjusting for exchange rates; (3) generating reference price (RP) scenarios; (4) adjusting with the medical inflation rate; (5) pooling all generated RP scenarios and calculating average and standard deviation (SD); (6) and Monte Carlo Simulation (MCS) to estimate the dimension-specific DSPReference. A proof-of-concept exercise with osimertinib in NSCLC was performed for two hypothetical outcome-based contracts: 1-year (2019-2020) and 2-year (2019-2021)..The United Kingdom and Canada met the four criteria. For the osimertinib 1-year contract price, the average of eight RP scenarios, adjusted for inflation by 0.44%, was $8,892 (SD = $2,606) for a 30-day prescription. MCS yielded a DSPReference estimate of $9,395 or -35.72% of the wholesale acquisition cost (WAC) of $14,616. For the 2-year contract, the average, adjusted for inflation by 0.72%, was $8,928 (SD = $2,610). MCS yielded a DSPReference estimate of $9,442 or -35.40% of the WAC of $14,616..We demonstrated that international price referencing methods can be integrated into our proposed Six Delta platform for outcome-based pricing/contracting.
• Abraham, I., Slack, M. K., Ramos, K. S., Mcbride, A., Erstad, B. L., Bhattacharjee, S., Alkhatib, N. S., & Abraham, I. (2020). Pricing methods in outcome-based contracting: δ4: safety-based pricing.. Journal of medical economics, 23(11), 1237-1245. doi:10.1080/13696998.2020.1815028
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  Six Delta is a six-dimensional independent platform for outcome-based pricing/contracting. The fourth dimension (δ4) estimates prices on the basis of assessments of the safety of the drug using an ex ante analysis based on clinical trial data. We describe this dimension's methodology and present a proof-of-concept application to the treatment of non-small cell lung cancer (NSCLC) with EGFR mutation with osimertinib..The safety-based pricing dimension utilizes a four-step method: 1) pooling adverse events (AE), standardizing, estimating 95%Cis, and adjusting for time; 2) estimating correction factors and corrected probabilities of AEs; 3) estimating the probability of at least one adverse event (AE) occurring and leading to treatment discontinuation; and 4) estimating ranges for payback percentages and performing Monte Carlo Simulation to estimate a DSPSafety. A proof-of-concept exercise with osimertinib in NSCLC was performed for two hypothetical outcome-based contracts: 1-year (2019-2020) and 2-year (2019-2021). We estimated the DSPSafety based on the grade 3/4 AEs observed for osimertinib and standard of care. The 2018 wholesale acquisition cost (WAC) of osimertinib at $14,616 for a 30-day prescription was used..AEs3/4 were retrieved from the FLAURA trial. In the 1-year contract, the DSPSafety of osimertinib was estimated at $14,627 (or +0.08% the 2018 WAC) for a 30-day prescription. In the 2-year contract, the DSPSafety of osimertinib was estimated at $14,516 (or -0.68% the 2018 WAC) for a 30-day prescription..We demonstrated that ex ante pricing methods-based paybacks for safety issues leading to treatment discontinuation can be integrated into our proposed Six Delta platform for outcome-based pricing/contracting.
• Alkhatib, N. S., Erstad, B. L., Ramos, K. S., McBride, A., Bhattacharjee, S., Slack, M., & Abraham, I. (2020). Pricing methods in outcome-based contracting: δ6: adherence-based pricing. Journal of Medical Economics, 23(11), 1256-1265. doi:10.1080/13696998.2020.1815030
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  Six Delta is a six-dimensional independent platform for outcome-based pricing/contracting. The second dimension (δ2) estimates prices on the basis of four willingness-to-pay (WTP) thresholds. We describe this dimension's methodology and present a proof-of-concept application to the treatment of non-small cell lung cancer (NSCLC) with EGFR mutation with osimertinib.Eight WTP scenarios based on four levels of real gross domestic product per capita (3 × GDP/capita) and two market conditions (monopolistic versus competitive) were assumed. The incremental cost-utility ratio (ICUR) was applied to differently to both markets. In the monopolistic market, assuming no competitors, the cost/QALY ratio for a drug was used; whereas in the competitive market, assuming competitors, the incremental cost-utility ratio (ICUR) was applied. One-way sensitivity analyses were performed and predictive equations were specified to estimate the prices of treatment for the resulting eight WTP scenarios; for which subsequently the average and standard deviation were calculated. A gamma distribution was specified and Monte Carlo Simulation (MCS) was applied to estimate the dimension-specific price based on WTP (DSPWTP). A proof-of-concept exercise with osimertinib in NSCLC was performed for two hypothetical outcome-based contracts: 1-year (2019-2020) and 2-year (2019-2021). The 2018 wholesale acquisition cost (WAC) of $14,616 (30-day prescription) was used to estimate the DSPWTP for each contract.The 1-year estimates averaged $4,654 (SD=$6,462) and the MCS yielded a DSPWTP of $4,547 or -68.89% of the 2018 WAC for a 30-day prescription. The 2-year estimates averaged $4,7667 (SD=$6,480) with the MCS generating a DSPWTP of $4,704 or -67.82% of the WAC.We demonstrated that WTP-based methods that include various WTP thresholds and market conditions generate price estimates across these thresholds and market conditions that can be integrated into our proposed Six Delta platform for outcome-based pricing/contracting.
• Billheimer, D., Abraham, I., Slack, M. K., Ramos, K. S., Mcbride, A., Erstad, B. L., Billheimer, D., Bhattacharjee, S., Alkhatib, N. S., & Abraham, I. (2020). Pricing methods in outcome-based contracting: δ5: risk of efficacy failure-based pricing.. Journal of medical economics, 23(11), 1246-1255. doi:10.1080/13696998.2020.1815029
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  Six Delta is a six-dimensional independent platform for outcome-based pricing/contracting. The fifth dimension (δ5) estimates prices on the basis of the risk of efficacy failure of a drug. We describe this dimension's methodology and present a proof-of-concept application to the treatment of non-small cell lung cancer (NSCLC) with EGFR mutation with osimertinib..The risk of efficacy failure pricing dimension utilizes a seven-step method: (1) defining risk; (2) extracting data; (3) predicting models; (4) performing Monte Carlo Simulation (MCS) to estimate risk of efficacy failure; 5) estimating ranges for a payback; (6) adjusting for medical inflation; and (7) performing Monte Carlo Simulation (MCS) to estimate the DSPRisk of efficacy failure. A proof-of-concept exercise with osimertinib in NSCLC was performed for two hypothetical outcome-based contracts: 1-year (2019-2020) and 2-year (2019-2021). We estimated the risk of efficacy failure for osimertinib in terms of overall and progression-free survival versus standard of care. We used the estimated risk to estimate the price reduction on the wholesale acquisition cost (WAC) for the two hypothetical contracts: a 1-year (2019-2020) and 2-year contract (2019-2021). From this we estimated the DSPRisk of efficacy failure..Based on the risk of OS and PFS efficacy failure for osimertinib in OS and PFS, in the 1-year contract, the DSPRisk of efficacy failure was estimated at $12,652 (or -13.44% the 2018 WAC) for a 30-day prescription. For the 2-year contract (2019-2021), the DSPRisk of efficacy failure was estimated at $13,019 (or -10.93% the 2018 WAC)..We demonstrated that pricing methods based on risk of efficacy failure methods can be integrated into our proposed Six Delta platform for outcome-based pricing/contracting.
• Edwards, C. J., Miller, A., Erstad, B. L., Edwards, C. J., & Cobb, J. P. (2020). The pharmacist's role in disaster research response.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 77(13), 1054-1059. doi:10.1093/ajhp/zxaa093
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  The need for high-quality research during disaster responses has been well described in the literature, and such research is supported by efforts at the federal level through the National Institutes of Health Disaster Research Response (DR2) Program. This article describes the fourth DR2 workshop with a specific focus on opportunities for pharmacists to get involved with disaster research efforts..Pharmacists have historically played a significant role in disaster planning and response, and there are a number of opportunities for pharmacists to bring their unique perspective, positioning, and skills to disaster research response (ie, onsite and other research on the medical and public health aspects of disasters and public health emergencies). In February 2019, the fourth DR2 workshop was held in Tucson, AZ, in conjunction with the University of Arizona College of Medicine-Tucson, the university's Mel and Enid Zuckerman College of Public Health, University of Arizona College of Pharmacy, and the university's Bio5 Institute to explore clinical and population-based research in a simulated disaster setting. This article describes the workshop and discusses several opportunities for pharmacists to design, lead, and support research efforts during disaster scenarios through involvement in research areas including clinical, operational, educational, and logistic aspects of pharmacy practice..Due to their positioning throughout health systems, unique perspective, training, and skills, pharmacists are uniquely situated to play an important role in disaster research response.
• Erstad, B. L. (2020). Beyond academic integrity.. Journal of the American Pharmacists Association : JAPhA, 60(5), e20. doi:10.1016/j.japh.2020.03.004
• Erstad, B. L. (2020). Justification of the value of critical care pharmacists: Still a work in progress?. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 77(22), 1906-1909. doi:10.1093/ajhp/zxaa250
• Erstad, B. L. (2020). Raising the interprofessional bar in your specialty interprofessional health care organization. Journal of the American College of Clinical Pharmacy, 3(2), 398-399. doi:10.1002/jac5.1173
• Erstad, B. L. (2020). The Revised Starling Equation: The Debate of Albumin Versus Crystalloids Continues.. The Annals of pharmacotherapy, 54(9), 921-927. doi:10.1177/1060028020907084
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  Objectives: The purpose of this critical narrative review is to discuss the revised Starling equation for microvascular fluid exchange and the associated implications for intravenous fluid administration. Data Sources: PubMed (1946 to December 2019) and EMBASE (1947 to December 2019) were used, and bibliographies of retrieved articles were searched for additional articles. Study Selection and Data Extraction: Articles pertaining to the revised Starling equation and microvascular fluid exchange. Additionally, prospective human studies involving the disposition and oncotic action of radiolabeled albumin and large randomized trials comparing fluid requirements associated with isotonic crystalloid and albumin administration were included. Data Synthesis: In the revised Starling equation, oncotic forces act across the endothelial cell layer, more specifically between the fluid in the vessel lumen and the protein-sparse subglycocalyx space. The revised Starling equation and radiolabeled investigations of albumin necessitate a reconsideration of conventional views of the plasma-expanding properties of exogenous albumin. Large clinical trials demonstrate that the administration of iso-oncotic or hyper-oncotic albumin solutions in patients undergoing resuscitation does not have the reductions in fluid requirements anticipated from a traditional understanding of the oncotic actions of albumin. Relevance to Patient Care and Clinical Practice: When used as a resuscitation fluid, albumin does not have the degree of plasma expansion or intravascular retention commonly used to justify its use. Conclusions: The principles underlying the revised Starling equation in conjunction with data from radiolabeled studies of albumin and large clinical trials demonstrate that albumin does not have the perceived degree of plasma expansion or duration of intravascular retention beyond crystalloid solutions predicted by the classic Starling equation.
• Erstad, B. L. (2020). What it means to be a Clinical Pharmacist: An n of one study. JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY, 3(6), 1006-1008. doi:10.1002/jac5.1272
• Erstad, B. L., & Barletta, J. F. (2020). Drug dosing in the critically ill obese patient-a focus on sedation, analgesia, and delirium.. Critical care (London, England), 24(1), 315. doi:10.1186/s13054-020-03040-z
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  Practice guidelines provide clear evidence-based recommendations for the use of drug therapy to manage pain, agitation, and delirium associated with critical illness. Dosing recommendations however are often based on strategies used in patients with normal body habitus. Recommendations specific to critically ill patients with extreme obesity are lacking. Nonetheless, clinicians must craft dosing regimens for this population. This paper is intended to help clinicians design initial dosing regimens for medications commonly used in the management of pain, agitation, and delirium in critically ill patients with extreme obesity. A detailed literature search was conducted with an emphasis on obesity, pharmacokinetics, and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided.
• Erstad, B. L., & Eastman, C. (2020). Availability of information for dosing commonly used medications in special ICU populations.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 77(7), 529-534. doi:10.1093/ajhp/zxaa022
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  Medication product labeling was reviewed to determine if sufficient information is available to appropriately calculate dosing regimens for special intensive care unit (ICU) populations, including patients at extremes of body habitus and patients receiving hemodialysis, continuous renal replacement therapy (CRRT), or extracorporeal membrane oxygenation (ECMO)..The labeling of the 100 most commonly used injectable medications in the adult ICUs of an academic medical center in Arizona were evaluated. Any information related to adult weight-based dosing, weight descriptors, dosing of patients at extremes of weight (body mass index of 40 kg/m2), and dosing of patients receiving hemodialysis, CRRT, or ECMO was extracted from Food and Drug Administration-approved product labeling. Information was ranked for dosing usefulness on a scale of 0 to 3; an information usefulness score of 2 or greater was considered minimally adequate for dosing special ICU populations..Among the 100 medications evaluated, the labeling of 47 provided information on weight-based dosing, with the labeling of 30% referring to a specific weight descriptor. The labeling of 15 medications had information on dosing for patients at extremes of body habitus: underweight (3 medications), obesity (12 medications), and extreme obesity (2 medications), with the labeling of 8 medications receiving an information usefulness score of ≥2 (2, 6, and 1 medication in the respective categories). Among the 42 medications whose labeling provided hemodialysis-related dosing information, the labeled information of 52% was assigned a usefulness score of ≥2; among the 3 medications with CRRT-related dosing information, the labeling of 1 received a score of ≥2. ECMO-related dosing information was available for 2 medications, with 1 score of ≥2 assigned..Information in the product labeling of injectable medications commonly used in the ICU is limited and generally inadequate for calculating an appropriate dose for special ICU populations.
• Erstad, B. L., & Webb, C. E. (2020). A brief history of pharmacy specialization in the United States. JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY, 3(8), 1464-1470. doi:10.1002/jac5.1324
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  Abstract The origins of pharmacy specialization has its beginning in the efforts of Harvey A. K. Whitney, Sr. through his leadership in establishing progressive hospital pharmacy services and hospital‐focused programs and policies within the nation's professional pharmacy organizations. Later, Donald Francke spoke of specialization in the hospital pharmacy setting as a natural outgrowth of practice activities that required more time and specialized expertise. A broader national discussion and eventual codification of specialty recognition and attendant certification within pharmacy began in 1971 with a policy statement approved by the APhA House of Delegates that led to the creation of a Task Force on Specialties in Pharmacy followed by the creation of the Board of Pharmaceutical Specialties (BPS). Given that specialization in any health profession is primarily a function of the reality of ever‐increasing scientific and technological developments, debate regarding the need, types, and value of specialization in pharmacy seem destined to be driven not by intra‐ or inter‐professional debates within pharmacy, but by the needs, expectations, and values of patients and health care systems.
• Lansburg, J. M., Erstad, B. L., Buckley, M. S., & Agarwal, S. K. (2020). Hyperoncotic Albumin Reduces Net Fluid Loss Associated With Hemodialysis.. Hospital pharmacy, 55(2), 130-134. doi:10.1177/0018578719828331
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  Purpose: The purpose of this study was to compare the volume of fluid removal associated with and without 25% albumin administration in conjunction with hemodialysis. Methods: This retrospective, cohort study was conducted at a large academic medical center over a 6-month period to compare the net fluid amount removed (mL) during hemodialysis between patients administered 25% albumin and those without albumin. Results: A total of 238 patients consisting of 973 unique hemodialysis sessions were evaluated. The mean overall net fluid removed by hemodialysis in the 25% albumin and no albumin groups were 1242 mL and 1899 mL, P < .001, respectively. No albumin group had significantly higher mean fluid losses compared with 25% albumin for a total dose of either 25 g (P = .001) or 50 g (P = .001). There were no significant differences in mean fluid loss between the no albumin group and patients receiving 75 g or 100 g of albumin. Post hoc analysis failed to demonstrate a dose-dependent response in those patients receiving 25% albumin and no albumin. Conclusion: Hyperoncotic albumin administered during hemodialysis sessions reduced net fluid loss associated with hemodialysis. The findings of this study do not support the routine use of 25% albumin to improve fluid removal during dialysis.
• Martin, J. R., Martin, J. R., Erstad, B. L., & Campbell, A. M. (2020). Corticosteroid Tapering Regimens in Rheumatic Disease: A Systematic Review.. Jcr-journal of Clinical Rheumatology, 26(2), 41-47. doi:10.1097/rhu.0000000000000917
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  Background/objective Corticosteroids have long been used to effectively treat rheumatic disorders, but adverse effects associated with extended-duration regimens generate disagreement among clinicians regarding optimal tapering strategies. The objective of this systematic review was to assess clinical outcomes of differing tapering regimens after corticosteroid monotherapy in adults with rheumatic disorders. Methods A systematic review of Medline/PubMed, Embase, Cochrane, International Pharmaceutical Abstracts, Web of Science, Scopus, Global Index Medicus, American College of Rheumatology, gray literature, and reference lists up to June 27, 2018, was conducted by 2 authors. Randomized controlled trials, case-control studies, and prospective observational studies comparing at least 2 tapering strategies of medium- to high-dose (>7.5 mg but ≤100 mg oral prednisone equivalent daily), extended-duration (≥10 days) corticosteroids were included if they reported at least 1 efficacy and 1 adverse effect parameter. Results Two studies met criteria for the review, which included 62 patients. One study examined a prednisolone versus a modified release prednisone taper for giant cell arteritis and suggested 80% (n = 4) and 85.7% (n = 6) remission rates, respectively, at 26 weeks. The other study examined a methylprednisolone versus a prednisone taper for polymyalgia rheumatica and reported 100% and 89% remission rates, respectively, at 26 weeks. Adverse effects reported between the 2 studies included sleep, hyperglycemia, infection, and fractures. However, the studies were not powered to detect differences in these outcomes. Conclusions There is no high-level evidence to guide tapering until discontinuation after extended courses of medium- to high-dose treatment regimens, as current guidelines rely heavily on expert opinion and small case series with a trial-and-error approach. This review supports the need for additional research to shift tapering recommendations to a more evidence-based practice.
• Veve, J. R., Smothers, Z. P., Muzyk, A. J., Erstad, B. L., Collins, K., & Bratberg, J. P. (2020). Pharmacists and the opioid crisis: A narrative review of pharmacists' practice roles. Journal of the American College of Clinical Pharmacy, 3(2), 478-484. doi:10.1002/jac5.1171
• Viswesh, V., Sarangarm, P., Peppard, W., Newsome, A. S., Kruer, R., Kinney, J., Kaukeinen, K., Horng, H., Heavner, M., Gustafson, K., Groth, C. M., Glass, N., Flannery, A. H., Erstad, B. L., Droege, C., Dixit, D., Cucci, M., Connor, K., Chui, S. H., & Acquisto, N. M. (2020). 48: EFFECTS OF KETAMINE ON PAIN, SEDATION, AND DELIRIUM IN THE INTENSIVE CARE UNIT (KETAMINE-ICU STUDY). Critical Care Medicine, 48(1), 24-24. doi:10.1097/01.ccm.0000618692.88404.95
• Viswesh, V., Sarangarm, P., Peppard, W., Newsome, A. S., Kruer, R., Kinney, J., Kaukeinen, K., Horng, H., Heavner, M., Gustafson, K., Groth, C. M., Glass, N., Flannery, A. H., Erstad, B. L., Droege, C., Dixit, D., Cucci, M., Connor, K., Chui, S. H., & Acquisto, N. M. (2020). 959: MULTICENTER RETROSPECTIVE REVIEW OF KETAMINE USE IN THE INTENSIVE CARE UNIT (KETAMINE-ICU STUDY). Critical Care Medicine, 48(1), 459-459. doi:10.1097/01.ccm.0000633372.54294.d8
• Wicks, L. M., Saggar, R. C., Richards, E. C., Lansburg, J. M., Kopp, B. J., Knutson, K. D., Erstad, B. L., Buckley, M. S., & Agarwal, S. K. (2020). Clinical Pharmacist-Led Impact on Inappropriate Albumin Use and Costs in the Critically Ill.. The Annals of pharmacotherapy, 54(2), 105-112. doi:10.1177/1060028019877471
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  Background:Optimal albumin use in the intensive care unit (ICU) remains challenging with inappropriate use approaching 50%. No published reports have described clinical pharmacist impact aimed at mitigating inappropriate albumin use in the ICU. Objective: To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin in the ICU. Methods: A retrospective cohort study evaluated all adult (≥18 years) ICU patients administered albumin at an academic medical center over a 2-year period. Institutional guidelines were developed with clinical pharmacists targeting inappropriate albumin use. The primary end point was to compare inappropriate use of albumin administered before and after pharmacist intervention implementation. Secondary analyses compared the overall albumin use between study periods. In-hospital mortality, length of stay, and albumin-related costs between study periods were also compared. Results: A total of 4419 patients were identified, with 2448 (55.4%) critically ill patients included. The pharmacist-led strategy resulted in a 50.9% reduction of inappropriate albumin use (P < 0.001). The rate of inappropriate albumin use was 44.3 ± 10.5 and 5.5 ± 2.9 g per patient-day in the preimplementation and postimplementation periods, respectively (P < 0.001). Costs associated with overall and inappropriate albumin use in the ICU decreased by 34.8% and 87.1%, respectively. Total annual cost-savings was $355 393 in the ICUs. No differences in clinical outcomes were found. Conclusion and Relevance: Clinical pharmacist-led interventions reduced overall and inappropriate albumin use and costs without negatively affecting clinical outcomes.
• Williamson, D. R., Geiling, J. A., Williamson, D., Maves, R. C., Kanji, S., Geiling, J., Erstad, B. L., Dichter, J. R., Christian, M. D., Burry, L. D., & Barletta, J. F. (2020). It Takes a Village…: Contending With Drug Shortages During Disasters.. Chest, 158(6), 2414-2424. doi:10.1016/j.chest.2020.08.015
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  Critical drug shortages have been widely documented during the coronavirus disease 2019 (COVID-19) pandemic, particularly for IV sedatives used to facilitate mechanical ventilation. Surges in volume of patients requiring mechanical ventilation coupled with prolonged ventilator days and the high sedative dosing requirements observed quickly led to the depletion of "just-in-time" inventories typically maintained by institutions. This manuscript describes drug shortages in the context of global, manufacturing, regional and institutional perspectives in times of a worldwide crisis such as a pandemic. We describe etiologic factors that lead to drug shortages including issues related to supply (eg, manufacturing difficulties, supply chain breakdowns) and variables that influence demand (eg, volatile prescribing practices, anecdotal or low-level data, hoarding). In addition, we describe methods to mitigate drug shortages as well as conservation strategies for sedatives, analgesics and neuromuscular blockers that could readily be applied at the bedside. The COVID-19 pandemic has accentuated the need for a coordinated, multi-pronged approach to optimize medication availability as individual or unilateral efforts are unlikely to be successful.
• Xie, C., Finger, J., Erstad, B. L., & Basken, R. (2020). Targeted Temperature Management: Quantifying the Extent of Serum Electrolyte and Blood Glucose Shifts in Postcardiac Arrest Patients.. Therapeutic hypothermia and temperature management, 10(1), 76-81. doi:10.1089/ther.2018.0044
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  This study aims to quantify the extent of electrolyte (potassium, magnesium, and phosphorus) and blood glucose changes during targeted temperature management (TTM), with insight on electrolyte replacements and insulin administration. This was a 3-year retrospective study of patients who underwent TTM via Arctic Sun. Electrolyte and blood glucose values in addition to electrolyte replacements and insulin administrations were collected before, during, and post-TTM. The primary analysis assessed changes in electrolyte and blood glucose values during and after TTM, and the secondary analysis assessed changes before and during, and before and after TTM. The secondary analysis also incorporated amount of electrolyte replacements and insulin administrations patients received before, during, and post-TTM. Sixty patients were included for analysis. Comparing levels during to after TTM, there was a significant increase in potassium (3.7 [0.7]-4.4 [0.7] mmol/L, p < 0.001) and decrease in blood glucose (192 [135]-134 [55] mg/dL, p = 0.001). Comparing levels before to during TTM, there was a significant decrease in potassium (4.3 [0.7]-3.7 [0.7] mmol/L, p < 0.001) and phosphorus (4.8 [3.2]-3.4 [1.5] mg/dL, p = 0.003). Comparing levels before to after TTM, there was a significant decrease in phosphorus (4.5 [2.9]-3.3 [1.2] mmol/L, p = 0.026) and blood glucose (219 [35]-134 [55] mg/dL, p < 0.001). Patients received on average potassium 102 mEq, magnesium 1.9 g, phosphorus 9 mmol, and insulin 94 units. Potassium significantly decreased during and significantly increased after TTM. Phosphorus significantly decreased during TTM and blood glucose significantly decreased after TTM. There were no significant changes in magnesium during the defined time period.
• Abraham, I., Patanwala, A. E., Oh, M., Erstad, B. L., Alsaid, N., Almutairi, A. R., & Abraham, I. (2019). 1651: COST ANALYSIS OF ADJUNCTIVE HYDROCORTISONE THERAPY FOR SEPTIC SHOCK FROM THE U.S. PAYER PERSPECTIVE. Critical Care Medicine, 47, 800. doi:10.1097/01.ccm.0000552391.78431.6d
• Erstad, B. L. (2019). Attempts to Limit Opioid Prescribing in Critically Ill Patients: Not So Easy, Not So Fast.. The Annals of pharmacotherapy, 53(7), 716-725. doi:10.1177/1060028018824724
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  To discuss why opioids have been considered the long-standing first-line therapy for treating acute, severe nociceptive pain in critically ill patients and discuss considerations for limiting opioid overuse in the intensive care unit setting..Articles were identified through searches of PubMed and EMBASE from database inception until December 2018. Additional references were located through a review of the bibliographies of articles and clinical practice guidelines..Original research articles excluding case reports were included if they concerned nonopioid agents for pain management in critically ill patients. The focus was on studies not included in the most recent pain management guidelines..Ten studies were retrieved. Nonopioid therapies or opioid-sparing therapies have been touted as possible alternatives for critically ill patients, but they have particular adverse effects concerns in critically ill patients, often lack parenteral dosage forms, and frequently require dose adjustment or avoidance in patients with renal or hepatic dysfunction. Relevance to Patient Care and Clinical Practice: There is a well-recognized opioid epidemic that has been the subject of much discussion. Attempts to control the epidemic have focused on limiting opioid prescribing and using nonopioid alternatives, but there are special considerations when treating severe pain in critically ill patients that often preclude nonopioid analgesics..There continues to be an unmet need for medications that are as effective as opioids for severe nociceptive pain in critically ill patients but without the adverse effect and abuse concerns. Until such medications are available, clinicians need to optimize prescribing of opioid and nonopioid analgesics.
• Erstad, B. L. (2019). Implications of the opioid epidemic for critical care practice. Journal of the American College of Clinical Pharmacy, 2(2), 161-166. doi:10.1002/jac5.1052
• Erstad, B. L. (2019). The Conscience of a Pharmacist.. American journal of pharmaceutical education, 83(2), 7301. doi:10.5688/ajpe7301
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  The purpose of this commentary is to attempt to provide some insight into conscience-clause cases from the perspective of a pharmacist and an academician. Health professionals, including pharmacists, have a social contract with the patients we serve in which the patients give us a level of status not given to non-professionals, and, in return, we agree to put the interests of our patients above our own. Therefore, any discussion of a right-to-refuse service needs to begin with a discussion of the duties and responsibilities of the health professional to the patient.
• Erstad, B. L., Xie, C., Oman, N., Vraney, J., & Campbell, A. M. (2019). Oseltamivir prescribing practices for influenza and associated outcomes in the critically ill patient. Journal of the Intensive Care Society.
• Lafever, M., Fruhling, L., & Erstad, B. L. (2019). Enhancing Educational and Leadership Opportunities for Second-Year Pharmacy Residents.. American journal of pharmaceutical education, 83(10), 7099. doi:10.5688/ajpe7099
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  Leadership is a critical aspect of residency training; however, little guidance is provided in the literature regarding practical implementation of leadership training within residency programming. Programming was developed within a second-year (PGY-2) critical care residency program to meet the educational and leadership needs of the residents. The format of the meetings has evolved over time from a journal club-style format to an interdisciplinary format discussing far more than literature. With the residents taking the lead in the biweekly educational sessions, there is great opportunity for leadership development. Similar programming has the potential to strengthen residency experiences for residents in other programs.
• Patanwala, A. E., Kopp, B. J., Erstad, B. L., & Aljuhani, O. (2019). Corrigendum to "Methocarbamol use is associated with decreased hospital length of stay in trauma patients with closed rib fractures" [Am J Surg 214/4 (2018) 738-742].. American journal of surgery, 218(2), 446. doi:10.1016/j.amjsurg.2019.02.001
• Weibel, K., Erstad, B. L., & Aramaki, T. (2019). Integration of an Academic Medical Center and a Large Health System: Implications for Pharmacy.. Hospital pharmacy, 54(3), 170-174. doi:10.1177/0018578718823735
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  Objective: To provide lessons learned for colleges of pharmacy and large health systems that are contemplating or in the process of undergoing integration. Method: This report describes the merger of an academic medical center and large health system with a focus on the implications of the merger for pharmacy from the perspectives of both a college of pharmacy and a health system's pharmacy services. Results: Overarching pharmacy issues to consider include having an administrator from the college of pharmacy directly involved in the merger negotiation discussions, having at least one high-level administrator from the college of pharmacy and one high-level pharmacy administrator from the health system involved in ongoing discussions about implications of the merger and changes that are likely to affect teaching, research, and clinical service activities, having focused discussions between college and health system pharmacy administrators on the implications of the merger on experiential and research-related activities, and anticipating concerns by clinical faculty members affected by the merger. Conclusion: The integration of a college of pharmacy and a large health system during the acquisition of an academic medical center can be challenging for both organizations, but appropriate pre- and post-merger discussions between college and health system pharmacy administrators that include a strategic planning component can assuage concerns and problems that are likely to arise, increasing the likelihood of a mutually beneficial collaboration.
• Abraham, I. L., Abraham, I. L., Bootman, J. L., Bootman, J. L., Alsaid, N. S., Alsaid, N. S., Erstad, B. L., Erstad, B. L., Slack, M. K., Slack, M. K., Alberts, D. S., Alberts, D. S., McBride, A., McBride, A., Gharaibeh, M., & Gharaibeh, M. (2018). Economic evaluation for USA of systemic chemotherapies in first-line treatment of metastatic pancreatic cancer.. PharmacoEconomics, 36, 1273-1284.
• Abraham, I. L., Abraham, I. L., Bootman, J. L., Bootman, J. L., Alsaid, N. S., Alsaid, N. S., Slack, M. K., Slack, M. K., Erstad, B. L., Erstad, B. L., Alberts, D. S., Alberts, D. S., McBride, A., McBride, A., Gharaibeh, M., & Gharaibeh, M. (2018). Economic evaluation for the UK of systemic chemotherapies in first-line treatment of metastatic pancreatic cancer.. PharmacoEconomics, 36, 1333-1343.
• Abraham, I., Alkhatib, N. S., Erstad, B., Gharaibeh, M., Karnes, J. H., Klimecki, W., Ramos, K., Slack, M., & Sweitzer, N. K. (2018). Ex ante economic evaluation of genetic testing for the ARG389 beta1-adrenergic receptor polymorphism to support bucindolol treatment decisions in Stage III/IV heart failure. Expert Review of Precision Medicine and Drug Development, 3(5), 319-329. doi:10.1080/23808993.2018.1526079
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  Background: Sub-analyses from the BEST trial in heart failure (HF) indicated that Arg389 homozygote patients may respond to bucindolol. Bucindolol is currently being evaluated in Arg389 genotype patients in the GENETIC-AF trial. Our aim is to conduct ex ante economic evaluations of Arg389 genetic testing to support β-blocker treatment in HF.Methods: Using survival results from two BEST sub-analyses, we constructed a decision-tree model (time-horizon 18 months, divided into three 6-month cycles) to estimate the cost-effectiveness/utility of Arg389 genetic testing with bucindolol or carvedilol versus no testing and empirical bucindolol. Costs of bucindolol and genetic testing were set conservatively at 1.5x carvedilol cost and $250, respectively. Incremental cost-effectiveness (ICER) and cost-utility ratios (ICUR) were estimated.Results: Per one BEST sub-analysis, Arg389 genetic testing was associated with incremental gains of 0.29 life-years (LYs) and 0.27 quality-adjusted life years (QALYs) at incremental costs of $726; yielding ICER of US$2,503/LY and ICUR of US$2,688/QALY gained. Per a different BEST sub-analysis, Arg-389 genetic testing was associated with incremental gains of 0.35LYs and 0.32QALYs at savings of (US$1,081); for ICER of (US$3,089)/LY and ICUR of (US$3,378)/QALY gained.Conclusions: Assuming conservative cost estimates, Arg389 genetic testing to inform bucindolol versus carvedilol treatment decisions prevailed economically over bucindolol treatment without genetic testing.
• Alkhatib, N., Alkhatib, N., Abraham, I. L., Ramos, K., Ramos, K., Sweitzer, N. K., Gharaibeh, M., Gharaibeh, M., Klimecki, W., Slack, M. K., Slack, M. K., Karnes, J. H., Erstad, B. L., Erstad, B. L., Erstad, B. L., Karnes, J. H., Karnes, J. H., Slack, M. K., Gharaibeh, M., , Klimecki, W., et al. (2018). Economic evaluation of genetic testing for Arg389 in the management of stage III/IV heart failure.. Expert Review of Precision Medicine and Drug Development, 3, 319-329.
• Biggs, A. D., French, R. N., Shirazi, F. M., Kopp, B. J., Khobrani, M. A., Huckleberry, Y. C., French, R. N., Erstad, B. L., Dudley, S. W., & Biggs, A. D. (2018). Intentional use of carbapenem antibiotics for valproic acid toxicity: A case report.. Journal of clinical pharmacy and therapeutics, 43(5), 723-725. doi:10.1111/jcpt.12705
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  The interaction between valproic acid (VPA) and carbapenem antibiotics is well described with previous reports suggesting a reduction in VPA half-life between 47% and 90%. As described in this case, this interaction might be beneficial in the setting of toxic VPA ingestion..An intubated, unresponsive patient arrived via emergency medical services after toxic VPA ingestion. Meropenem was prescribed for a suspected pneumonia and to take advantage of the VPA interaction. We observed a 56% decline in half-life with short-term meropenem dosing and an improvement in mental status shortly after administration..Our findings suggest a potential role for short-term carbapenem therapy for VPA overdose.
• Erstad, B. L. (2018). Albumin disposition in critically Ill patients.. Journal of clinical pharmacy and therapeutics, 43(5), 746-751. doi:10.1111/jcpt.12742
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  The purpose of this critical narrative review is to analyse studies evaluating the disposition of albumin in critically ill patients and to compare the findings to studies involving healthy subjects and less severely ill patients..PubMed and EMBASE were reviewed for prospective studies involving the disposition of radiolabelled albumin. Studies of normal volunteers, patients undergoing surgical procedures and critically ill patients indicate a relationship between increasing disease acuity or severity and increasing transcapillary escape of albumin. In the only study that directly compared the disposition of radiolabelled albumin in healthy subjects and patients with septic shock, the transcapillary escape rate of albumin was more than twice as rapid in the patients with shock..Limited studies suggest that increasing disease severity increases transcapillary escape of albumin. Only one study compared the disposition of radiolabelled albumin in healthy subjects and critically ill patients. More studies are needed in subsets of critically ill patients.
• Erstad, B. L., Eljaaly, K., & Alshehri, S. (2018). Systematic Review and Meta-analysis of the Safety of Antistaphylococcal Penicillins Compared to Cefazolin.. Antimicrobial agents and chemotherapy, 62(4), e01816-17. doi:10.1128/aac.01816-17
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  Recent studies and experience suggest that cefazolin might be equally as effective as antistaphylococcal penicillins for methicillin-susceptible Staphylococcus aureus (MSSA), with a better safety profile and lower cost. The objective of these meta-analyses was to compare the safeties of antistaphylococcal penicillins and cefazolin. The PubMed, Embase, and International Pharmaceutical Abstracts databases and websites for clinical trial registries through 23 June 2017 were searched. In addition, recent abstracts from infectious disease and pharmacy conferences were reviewed. We estimated Peto odds ratios (ORs) with 95% confidence intervals (CIs) using random-effects models. One analysis focused on hospitalized patients, and the other focused on outpatients. Eleven retrospective studies of hospitalized patients and three retrospective studies of outpatients were included. In hospitalized patients, lower rates of nephrotoxicity (Peto OR, 0.225; 95% CI, 0.127 to 0.513), acute interstitial nephritis (Peto OR, 0.189; 95% CI, 0.053 to 0.675), hepatotoxicity (Peto OR, 0.160; 95% CI, 0.066 to 0.387), and drug discontinuation due to adverse reactions (Peto OR, 0.192; 95% CI, 0.089 to 0.414) were found with cefazolin. In outpatients, lower rates of nephrotoxicity (Peto OR, 0.372; 95% CI, 0.192 to 0.722), hepatotoxicity (Peto OR, 0.313; 95% CI, 0.156 to 0.627), and hypersensitivity reactions (Peto OR, 0.372; 95% CI, 0.201 to 0.687) were observed with cefazolin. Compared to antistaphylococcal penicillins, cefazolin was associated with significant reductions in nephrotoxicity and hepatotoxicity in hospitalized patients and outpatients. Additionally, cefazolin was associated with lower likelihoods of discontinuation due to side effects in hospitalized patients and hypersensitivity reactions in outpatients. Cefazolin should be considered a first-line option for patients with MSSA infections for which efficacy is presumed to be similar to that of antistaphylococcal penicillin therapy.
• Oxnam, M. G., Oxnam, M. G., Miller, T. P., Erstad, B. L., & Draugalis, J. R. (2018). Issues and Opportunities on Implementing an Online Faculty Review System.. American journal of pharmaceutical education, 82(3), 6911. doi:10.5688/ajpe6911
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  Intensifying accountability pressures have led to an increased attention to assessments of teaching, but teaching generally represents only a portion of faculty duties. Less attention has been paid to how evaluations of faculty members can be used to gather data on teaching, research, clinical work, and outreach to integrate clinical and academic contributions and fill in information gaps in strategic areas such as technology transfer and commercialization where universities are being pressed to do more. Online reporting systems can enable departments to gather comprehensive data on faculty activities that can be aggregated for accreditation assessments, program reviews, and strategic planning. As detailed in our case study of implementing such a system at a research university, online annual reviews can also be used to publicize faculty achievements, to document departmental achievements, foster interdisciplinary and community collaborations, recognize service contributions (and disparities), and provide a comprehensive baseline for salary and budgetary investments.
• Patanwala, A. E., Erstad, B. L., & Aljuhani, O. (2018). A cross-sectional study of predictors of pain control during the transition from the surgical intensive care unit to surgical ward.. Australian critical care : official journal of the Confederation of Australian Critical Care Nurses, 31(3), 159-164. doi:10.1016/j.aucc.2018.01.002
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  The transition of patients from the intensive care unit (ICU) to the ward is a complicated process and patients may be at risk of increased levels of pain..The primary objective was to identify predictors of pain during the transition from the surgical ICU to the surgical ward. The secondary objective was to describe the patient pain experience during this transition..This was a cross-sectional study conducted at an academic medical centre in the United States. Patients who were discharged from the ICU were interviewed regarding their pain during transition from ICU to the ward using the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R). The primary outcome measures were the total score of this validated instrument (0-180 points) and score of the pain severity and sleep interference subscale (0-50 points). Predictors of pain control during this 24-h transition period were identified using linear regression analysis..A total of 50 patients were included. After transition from the ICU, the median score on the APS-POQ-R was 45 (Q1 29 to Q3 74), and the median score on the pain severity and sleep interference subscale was 23 (Q1 15 to Q3 30). After adjusting for sex in a multivariate model, mean pain score in the preceding 24 h of ICU stay explained 31% of the variation in total APS-POQ-R score and 39% of variation in the pain severity and sleep interference subscale. Age, sex, race, type of surgery, number of surgeries, and opioid dose in the 24-h period before transfer were not significantly associated with either outcome measure. The worst pain experienced by patients during transfer was severe (i.e. score ≥7 on 0 to 10 scale) in 90% (n = 45) of patients. For 70% (n = 35) of patients, severe pain persisted for more than 50% of the time during the transition period..Pain scores in the last 24 h of ICU stay is a predictor of total APS-POQ-R score and pain severity and sleep interference subscale score.
• Patanwala, A. E., Erstad, B. L., Bakhsh, H. T., & Aljuhani, O. (2018). Effect of Acetaminophen on the Prevention of Acute Kidney Injury in Patients With Sepsis.. The Annals of pharmacotherapy, 52(1), 48-53. doi:10.1177/1060028017728298
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  Acute kidney injury (AKI) commonly occurs in patients with sepsis. Acetaminophen (APAP) has been shown to inhibit lipid peroxidation and, thus, may be renal protective in patients with sepsis..The objective of this study was to determine the effect of APAP on AKI in patients with sepsis..This was a retrospective cohort study conducted at 2 affiliated academic medical centers in the United States. Adult patients who were admitted to the intensive care unit with a diagnosis of severe sepsis were included. Patients were categorized based on whether APAP was received within the first 7 days of hospitalization (APAP or no APAP groups). The primary outcome measure was occurrence or increase in AKI stage from admission. Multivariate logistic regression analyses were used to adjust for potential confounders..There were 238 patients who were included in the study cohort. Of these, 122 received APAP and 116 did not receive APAP. AKI or exacerbation occurred in 16.4% (n = 20) of patients in the APAP group and 19.8% (n = 23) of patients in the no APAP group ( P = 0.505). After adjusting for the most important confounders, there was no significant association between APAP use and AKI (odds ratio = 1.2; 95% CI = 0.6-2.4; P = 0.639)..APAP use in critically ill patients with sepsis may not reduce the occurrence or exacerbation of AKI.
• Ringler, C., Patanwala, A. E., Lee, J. K., Kopp, B. J., Huckleberry, Y., Fruhling, L., & Erstad, B. L. (2018). 975: WEIGHT-BASED RESPONSE TO STRESS-DOSE STEROIDS IN PATIENTS WITH SEPTIC SHOCK. Critical Care Medicine, 46, 471. doi:10.1097/01.ccm.0000528982.64716.33
• Seaman, S. M., Patanwala, A. E., Kopp, B. J., & Erstad, B. L. (2018). Heparin dosing for venous thromboembolism prophylaxis in obese hospitalized patients: An observational study.. Thrombosis research, 169, 152-156. doi:10.1016/j.thromres.2018.07.027
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  To compare rates of VTE occurrence in obese versus non-obese hospitalized patients who received UFH 5000 units subcutaneously q8 h..This was a retrospective cohort study conducted in an academic medical center in the United States. Consecutive adult patients who were hospitalized during a 1-year time frame (2015) receiving UFH 5000 units subcutaneously q8 h for VTE prophylaxis. The primary outcome was occurrence of VTE during hospitalization. This was compared between obese (body mass index ≥30 kg/m2) and non-obese (body mass index 0.99)..UFH 5000 units subcutaneously q8 h may be sufficient for prevention of VTE in obese patients.
• Xie, C., Finger, J., Erstad, B. L., & Basken, R. (2018). 267: THE IMPACT OF THERAPEUTIC HYPOTHERMIA ON SERUM ELECTROLYTES AND BLOOD GLUCOSE. Critical Care Medicine, 46, 116. doi:10.1097/01.ccm.0000528286.95390.51
• Abraham, I. L., Yun, S., Raz, Y., Kutbi, H. I., Gharaibeh, M., Huckleberry, Y., Aljabri, A., Erstad, B. L., & Karnes, J. H. (2017). Medical Management of Heparin-Induced Thrombocytopenia: Pharmacoeconomic Considerations. Blood e-letter (19 June, 2017). Blood.
• Abraham, I., Sweitzer, N. K., Sweitzer, N. K., Slack, M. K., Ramos, K. S., Erstad, B. L., Alsaid, N., & Abraham, I. (2017). Classification of Causes of Hospitalization For Heart Failure Patients In Cost-Effectiveness and Cost-Utility Evaluations of Pharmacotherapeutic, Surgical, and Managed-Care Interventions: Systematic Review. Value in Health, 20(9), A740. doi:10.1016/j.jval.2017.08.2043
• Erstad, B. L. (2017). Improving Medication Dosing in the Obese Patient.. Clinical drug investigation, 37(1), 1-6. doi:10.1007/s40261-016-0461-4
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  The purpose of this paper is to provide clinicians with important considerations and caveats when evaluating published literature on medication dosing in obese subjects, since much of this literature involves short-term pharmacokinetic or pharmacodynamic studies that are not designed to look at clinically important outcomes. A secondary objective is to suggest improvements in the reporting of dosing information derived from clinical studies and incorporated into product information labeling that should help clinicians design medication-specific dosing regimens for patients with obesity. Data sources included published studies, review papers, and clinical practice guidelines concerning drug dosing of subjects with obesity. Medication dosing recommendations in product labeling typically are derived from studies of normal healthy volunteers and patients with single-system disease states or patients in a specialized setting (e.g. operating room, intensive care unit). Even in studies with relatively large sample sizes there are often relatively few subjects with extremes of body composition such as patients with a body mass index (BMI) greater than 40 kg/m2, so the appropriateness of labeled dosing information for these subjects is particularly ill-defined. Investigations of medication labeling information have demonstrated the inadequacy of this information for dosing patients of more extreme body size. Clinical investigations of drugs should be designed and the results reported in a manner that allows for meaningful recommendations for drug dosing in patients with varying degrees of obesity. Until and when such studies are routinely performed, there are steps that can be taken by the pharmaceutical industry, clinicians, and governmental agencies to help insure optimal drug dosing in obesity.
• Erstad, B. L., Campbell, A. M., Erstad, B. L., & Campbell, A. M. (2017). Tapering Regimens Following Medium to High Dose Extended Duration Corticosteroid Monotherapy in Adults with Rheumatic Disease: A Systematic Review. Pharmacotherapy, 37(6), e38-e70. doi:10.1002/phar.1964
• Erstad, B. L., Mayersohn, M., & Nix, D. E. (2017). Should estimates of glomerular filtration rate and Creatinine Clearance be Indexed to Body Surface Area for drug dosing?. American Journal of Health-Systems Pharmacists, 74(21), 1814-19. doi:https://doi.org/10.2146/ajhp160467
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  Under consideration - Revisions submitted 10/2016
• Jedlowski, P. M., Fazel, M. T., Erstad, B. L., & Cravens, R. B. (2017). Evaluation and Treatment of Acute and Subacute Hearing Loss: A Review of Pharmacotherapy.. Pharmacotherapy, 37(12), 1600-1616. doi:10.1002/phar.2044
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  Among various forms of hearing loss, there are acute (within 72 hrs) or subacute (weeks to months) presentations that may be reversible with early pharmacological intervention. The workup of a patient presenting with hypoacusia includes the usual history and physical examination in conjunction with an audiometric assessment in order to categorize the hearing loss as conductive, sensorineural, or mixed. Sudden sensorineural hearing loss and autoimmune inner ear disease are acute and subacute forms of sensorineural hypoacusia most likely to be reversed with prompt pharmacological intervention. Systemic or local corticosteroid therapy has the most evidence of benefit in patients with sudden sensorineural hypoacusia and is the best available first line therapy noted in clinical practice guidelines. Alternative immunosuppressant therapies have not been well studied, and many have serious toxicities that further complicate the benefit-risk assessment. There are no randomized comparisons of corticosteroid dosing regimens that evaluated clinically important outcomes, so expert opinion must serve as the basis for dosing recommendations. Clinicians need to involve patients with hypoacusia in the shared decision-making process, since partial or complete reversal of hearing loss can have substantial quality-of-life implications for affected patients.
• Martin, J. R., Patanwala, A. E., Martin, J. R., & Erstad, B. L. (2017). Ketamine for Analgosedation in the Intensive Care Unit: A Systematic Review.. Journal of intensive care medicine, 32(6), 387-395. doi:10.1177/0885066615620592
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  To evaluate the evidence for the use of intravenous ketamine for analgosedation in the intensive care unit..MEDLINE and EMBASE were queried from inception until July 2015. Search terms used included ketamine, intensive care, and critical care. The search retrieved 584 articles to be screened for inclusion. The intent was to include randomized controlled studies using sustained intravenous infusions (>24 hours) of ketamine in the critically ill patients..One trial evaluated opioid consumption as an outcome in postoperative critically ill patients who were randomized to ketamine or saline infusions. The mean cumulative morphine consumption at 48 hours was significantly lower in the ketamine group (58 ± 35 mg) compared to the morphine-only group (80 ± 37 mg; P < .05). Other trials showed the potential safety of ketamine in terms of cerebral hemodynamics in patients with traumatic brain injury, improved gastrointestinal motility, and decreased vasopressor requirements. The observational study and case reports suggest that ketamine is safe and effective and may have a role in patients who are refractory to other therapies..Ketamine use may decrease analgesic consumption in the intensive care unit. Additional trials are needed to further delineate the role of ketamine for analgosedation.
• Murray, M. J., Tescher, A. N., Sands, K., Rochwerg, B., Pino, R. M., Patterson, A. J., Nix, S. A., Murray, M. J., Murray, C. F., Mehta, S., Meade, M. O., Mcmanus, C., Mcgee, W. T., Jordan, C. J., Jacobi, J., Gray, A. W., Erstad, B. L., Deblock, H. F., & Arbour, R. (2017). Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient: 2016 update-executive summary.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 74(2), 76-78. doi:10.2146/ajhp160803
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  These guidelines update the 2002 version of “Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient.” A task force comprising 17 members of the Society of Critical Care Medicine (SCCM) with particular expertise in the use of neuromuscular blocking
• Nix, D. E., Mayersohn, M., & Erstad, B. L. (2017). Should estimates of glomerular filtration rate and creatinine clearance be indexed to body surface area for drug dosing?. American Journal of Health-System Pharmacy, 74(21), 1814-1819. doi:10.2146/ajhp160467
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  Should estimates of glomerular filtration rate and creatinine clearance be indexed to body surface area for drug dosing? David E. Nix, Pharm.D., David E. Nix, Pharm.D. Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ Address correspondence to Dr. Nix (nix@pharmacy.arizona.edu). Search for other works by this author on: Oxford Academic Google Scholar Michael Mayersohn, Ph.D., Michael Mayersohn, Ph.D. Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ Search for other works by this author on: Oxford Academic Google Scholar Brian L. Erstad, Pharm.D. Brian L. Erstad, Pharm.D. Department of Pharmacy Practice & Science, College of Pharmacy, University of Arizona, Tucson, AZ Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 74, Issue 21, 1 November 2017, Pages 1814–1819, https://doi.org/10.2146/ajhp160467 Published: 01 November 2017
• Olsen, K. M., Mueller, E. W., Maclaren, R., Lat, I., Haas, C. E., Gonzales, J. P., Erstad, B. L., Brophy, G. M., Bauer, S. R., Barletta, J. F., & Abraham, P. E. (2017). Development of the Critical Care Pharmacotherapy Trials Network.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 74(5), 287-293. doi:10.2146/ajhp160028
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  The development of the Critical Care Pharmacotherapy Trials Network (CCPTN) as a model for practice-based pharmacotherapy research is described..The CCPTN was formed in 2010 as a collaborative research network dedicated to scientific investigation in the field of critical care pharmacotherapy. The CCPTN organizational structure is consistent with many professional pharmacy and interdisciplinary organizations and organized into 3 primary domains: executive committee, working committees, and network membership. The network membership consists of critical care investigators dedicated to the mission and vision of the CCPTN and is open to anyone expressing an interest in contributing to high-level research. Network member sites represent the breadth of U.S. critical care practice environments. In addition, network members include individuals with demonstrated expertise in patient safety, administration, research design, grantsmanship, database management, peer review, and scientific writing. In 2015, there were more than 100 site investigators from around the United States and Canada. Projects to date have yielded numerous abstracts, platform presentations, and peer-reviewed publications in high-impact journals. The CCPTN has expanded to form collaborations with researchers in the United Kingdom, Australia, and New Zealand. The CCPTN has identified new potential partnerships and field-based areas for inquiry. Numerous opportunities for continued growth and scientific inquiry in the field of critical care pharmacotherapy research exist for the CCPTN to foster in the coming years..The CCPTN has been a successful model for practice-based pharmacotherapy research and assists its members in expanding critical care pharmacotherapy knowledge.
• Patanwala, A. E., Kopp, B. J., Erstad, B. L., & Aljuhani, O. (2017). Methocarbamol use is associated with decreased hospital length of stay in trauma patients with closed rib fractures.. American journal of surgery, 214(4), 738-742. doi:10.1016/j.amjsurg.2017.01.003
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  The objective of this study was to evaluate the effect of methocarbamol on hospital length of stay in patients with closed rib fracture injuries..This was a retrospective cohort study conducted in an academic medical center in the United States. Adult trauma patients, who sustained closed rib fractures, were included. Patients were categorized based on whether they received methocarbamol or not during admission. The primary outcome of interest was time to hospital discharge in days (i.e. length of hospital stay). A Cox Proportional Hazards Model was constructed to determine if methocarbamol use was associated with a greater likelihood of earlier discharge..A total of 592 patients were included in the final study cohort. Of these, 329 received methocarbamol and 263 did not receive methocarbamol. In the Cox Proportional Hazards Model methocarbamol use was associated with a greater likelihood of being discharged from the hospital (HR 1.47, 95% CI 1.21 to 1.78, p < 0.001). ..The use of methocarbamol after traumatic rib fractures may result in a reduction in the length of hospital stay.
• Patanwala, A. E., Murphy, J. E., & Erstad, B. L. (2017). Student use of flipped classroom videos in a therapeutics course.. Currents in pharmacy teaching & learning, 9(1), 50-54. doi:10.1016/j.cptl.2016.08.043
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  To evaluate the extent of student use of flipped classroom videos..This was a cross-sectional study conducted in a college of pharmacy therapeutics course in the Unites States. In one section of the course (four sessions) all content was provided in the form of lecture videos that students had to watch prior to class. Class time was spent discussing patient cases. For half of the sessions, there was an electronic quiz due prior to class. The outcome measure was video view time in minutes. Adequate video view time was defined as viewing ≥75% of total video duration. Video view time was compared with or without quizzes using the Wilcoxon signed-rank test..There were 100 students in the class and all were included in the study. Overall, 74 students had adequate video view time prior to session 1, which decreased to 53 students for session 2, 53 students for session 3, and 36 students for session 4. Median video view time was greater when a quiz was required [80 minutes (IQR: 38-114) versus 69 minutes (IQR: 3-105), p < 0.001]. The mean score on the exam was 84 ± 8 points (out of 100). There was a significant association between video view time (per 50% increment) and score on the exam (coefficient 2.52; 95% CI: 0.79-4.26; p = 0.005; model R2 = 7.8%)..Student preparation prior to the flipped classroom is low and decreases with time. Preparation is higher when there is a quiz required.
• Abraham, I., Slack, M. K., Mcbride, A., Gharaibeh, M., Erstad, B. L., Alberts, D. S., & Abraham, I. (2016). Economic Evaluation for the United Kingdom of Systemic Chemotherapies as First-Line Treatment for Metastatic Pancreatic Cancer. Value in Health, 19(7), A354. doi:10.1016/j.jval.2016.09.044
• Erstad, B. L. (2016). Value-Based Medicine: Dollars and Sense.. Critical care medicine, 44(2), 375-80. doi:10.1097/ccm.0000000000001559
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  With ever-increasing total healthcare expenditures and expenditures on new pharmaceuticals, there is a temptation to enact relatively simple silo-based, cost-control measures such as attempts to control a burgeoning health-system medication budget by limiting physician and ultimately patient access to medications without considering cost-effectiveness or overall value. Such an approach with a singular focus on dollars does not make sense. The challenge is to think beyond a pure dollars approach in a specialty of health care where the high cost of care is acknowledged but the dynamics are not always understood. This will take a thoughtful, coordinated effort by a team of dedicated health professionals that includes a clinical pharmacist with expertise in optimal and comprehensive medication management.
• Erstad, B. L., Radosevich, J. J., Patanwala, A. E., & Erstad, B. L. (2016). Norepinephrine Dosing in Obese and Nonobese Patients With Septic Shock.. American journal of critical care : an official publication, American Association of Critical-Care Nurses, 25(1), 27-32. doi:10.4037/ajcc2016667
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  Whether or not norepinephrine infusions for support of hemodynamic status in patients with septic shock should be weight based is unknown. This situation is particularly pertinent in patients who are extremely overweight or obese..To compare dosing requirements and effect of norepinephrine on blood pressure in obese and nonobese patients with septic shock..In a retrospective cohort study, data on adult patients with septic shock who received norepinephrine infusion for support of hemodynamic status in a tertiary care, academic medical center were analyzed. Patients were categorized as obese (body mass index ≥ 30) or nonobese (body mass index < 30). The primary outcome was dosing requirements of norepinephrine at 60 minutes after the start of the infusion. The secondary outcome was the log-transformed ratio of mean arterial pressure to norepinephrine..The final cohort consisted of 100 obese and 100 nonobese patients. Mean norepinephrine infusion rate at 60 minutes was 0.09 (SD, 0.08) μg/kg per minute in the obese group and 0.13 (SD, 0.14) μg/kg per minute in the nonobese group (P = .006). The non-weight-based dose at 60 minutes was 9 μg/min in obese patients and 8 μg/min in nonobese patients (P = .72). The log transformed mean arterial pressure to norepinephrine ratio at 60 minutes was 2.5 (SD, 0.9) in obese patients and 2.5 (SD, 0.8) in nonobese patients (P = .54) CONCLUSIONS: Compared with nonobese patients, obese patients with septic shock require lower weight-based doses of norepinephrine and similar total norepinephrine doses.
• Honkonen, M. N., Mcneill, P., Jasensky, A., Honkonen, M. N., & Erstad, B. L. (2016). Readmissions related to antihypertensive medications used in chronic hemodialysis.. Renal failure, 38(1), 40-5. doi:10.3109/0886022x.2015.1103655
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  In hemodialysis, hypertension is treated by removing excess fluid and antihypertensive therapy. Commonly, the antihypertensives used to treat hypertension in earlier stages of kidney disease are continued as the patient progresses into end-stage renal disease and begins dialysis, without much evidence for benefit..This study is a single center, retrospective chart review that included hemodialysis patients admitted for congestive heart failure (CHF), fluid overload, or pulmonary edema as determined by ICD-9 code (428.x, 276.6, 518.4, 506.1). The primary objective was to determine if the number or class of antihypertensives used in the chronic hemodialysis population increased the number of readmissions related to CHF, fluid overload, or pulmonary edema. Patients were separated into two groups based on total number of antihypertensive medications, less than or equal to 2 medications for group 1 and greater than two medications for group 2. The primary endpoint was 30-day readmission for CHF, fluid overload, or pulmonary edema..For the study period, 85 individual patient charts met inclusion criteria. Group 1 (n = 44) experienced seven readmissions (16%) and group 2 (n = 41) experienced eight readmissions (18%) (p = 0.663). The most common antihypertensives at discharge were ACE inhibitors for group 1 (45%) and dihydropyridine calcium channel blockers for group 2 (66%). No difference in systolic blood pressures before, during and after hemodialysis was found between groups..Antihypertensive medications continue to play an important role in the hemodialysis population. This study suggests that drug class and quantity of antihypertensives do not alter readmission rate in the setting of fluid overload.
• Karnes, J. H., Raz, Y., Abraham, I., Yun, S., Raz, Y., Kutbi, H. I., Karnes, J. H., Huckleberry, Y., Gharaibeh, M., Erstad, B. L., Aljabri, A., & Abraham, I. (2016). Abstract 15582: Cost-effectiveness of Anticoagulants for the Management of Suspected Heparin-induced Thrombocytopenia in the US. Circulation, 134.
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  Introduction: Despite the availability of multiple non-heparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT), little data are available comparing the cost effectiveness of these agents. This analysis is particularly important considering differences in risks of adverse effects, routes of administration, requirements for phlebotomy and laboratory monitoring, and overall drug costs. We conducted a cost-effectiveness analysis of argatroban, bivalirudin, and fondaparinux for the treatment of suspected HIT. Methods: A three-arm decision-tree model was developed that employs standard practices for anticoagulation monitoring. We incorporated published data on drug efficacy and probability of HIT-related thromboembolism and major bleeding. We considered both institutional costs and Average Wholesale Price (AWP) and performed probabilistic sensitivity analysis (PSA) to address any uncertainty in model parameters. Results: Using institutional costs, fondaparinux outperformed both argatroban and bivalirudin in terms of cost ($151 vs. $1,250 and $1,466, respectively) and adverse events averted (0.9989 vs. 0.9957 and 0.9947, respectively). Results were consistent when AWP was used, with fondaparinux being less expensive ($555 vs. $3,081 and $2,187, respectively) and more effective in terms of adverse events averted (0.9989 vs. 0.9957 and 0.9947, respectively). The PSA confirmed our findings using both institutional costs and AWP. Conclusions: Fondaparinux subcutaneous injection afforded significant advantages in terms of cost savings and adverse events averted compared to intravenous argatroban or bivalirudin infusions. Our data strongly suggest potential cost savings with fondaparinux and underscore the critical need for larger clinical studies of fondaparinux in the treatment of suspected HIT.
• Karnes, J. H., Raz, Y., Abraham, I., Yun, S., Raz, Y., Kutbi, H. I., Karnes, J. H., Huckleberry, Y., Gharaibeh, M., Erstad, B. L., Aljabri, A., & Abraham, I. (2016). Cost-effectiveness of anticoagulants for suspected heparin-induced thrombocytopenia in the United States.. Blood, 128(26), 3043-3051. doi:10.1182/blood-2016-07-728030
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  Despite the availability of multiple nonheparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT), few data are available comparing the cost-effectiveness of these agents. This analysis is particularly important when considering differences in the risk of adverse effects, routes of administration, requirements for phlebotomy and laboratory monitoring, and overall drug costs. We conducted a cost-effectiveness analysis of argatroban, bivalirudin, and fondaparinux for the treatment of suspected HIT from the institutional perspective. A 3-arm decision-tree model was developed that employs standard practices for anticoagulation monitoring. We incorporated published data on drug efficacy and probability of HIT-related thromboembolism and major bleeding. We considered both institutional costs and average wholesale price (AWP) and performed probabilistic sensitivity analyses (PSA) to address any uncertainty in model parameters. Using institutional costs, fondaparinux prevailed over both argatroban and bivalirudin in terms of cost ($151 vs $1250 and $1466, respectively) and adverse events averted (0.9989 vs 0.9957 and 0.9947, respectively). Results were consistent when AWP was used, with fondaparinux being less expensive ($555 vs $3081 and $2187, respectively) and more effective in terms of adverse events averted (0.9989 vs 0.9957 and 0.9947, respectively). The PSA confirmed our findings using both institutional costs and AWP. In conclusion, fondaparinux subcutaneous injection afforded significant advantages in terms of cost savings and adverse events averted compared with IV argatroban or bivalirudin infusions. Our data strongly suggest potential cost savings with fondaparinux and underscore the critical need for larger clinical studies of fondaparinux in the treatment of suspected HIT.
• Patanwala, A. E., & Erstad, B. L. (2016). Comparison of Dexmedetomidine Versus Propofol on Hospital Costs and Length of Stay.. Journal of intensive care medicine, 31(7), 466-70. doi:10.1177/0885066614544452
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  The objective of this evaluation was to compare total hospital costs and length of stay of critically ill patients who received dexmedetomidine versus propofol for sedation in the intensive care unit (ICU)..This was a retrospective quality improvement evaluation at a tertiary care, academic medical center in the United States. Data were retrieved for patients discharged between April 2012 and June 2013. Patients were included if they were admitted to the ICU, were 18 years of age or older, and received dexmedetomidine or propofol for sedation. Multivariate regression models were developed to determine the association between sedative type and hospital costs, ICU length of stay, and hospital length of stay..The final cohort included 3294 patients. Of these, 2685 received propofol and 609 received dexmedetomidine. The median hospital cost was US$31 041 (interquartile range [IQR] US$17 963-US$57 826) in the propofol group and US$46 716 (IQR US$31 247 to US$85 490) in the dexmedetomidine group (P < .001). The median ICU length of stay was 2 days (IQR 1-6 days) and 4 days (IQR 2-9 days) in the propofol and dexmedetomidine groups, respectively (P < .001). Overall, hospital length of stay was 8 days (IQR 4-15 days) and 9 days (IQR 5-18 days) in the 2 groups, respectively (P < .001). In the multivariate analyses, dexmedetomidine use was associated with increased costs, ICU length of stay, and hospital length of stay (P < .001 for each outcome)..In this academic medical center, dexmedetomidine use was associated with higher costs when compared to propofol for sedation in the ICU. Also, use of dexmedetomidine was associated with increased lengths of ICU and hospital stay. Future prospective trials are needed to confirm these findings.
• Patanwala, A. E., & Erstad, B. L. (2016). Ketamine for analgosedation in critically ill patients.. Journal of critical care, 35, 145-9. doi:10.1016/j.jcrc.2016.05.016
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  The purpose of this narrative review is to provide practical and useful guidance for clinicians considering the use of intravenous ketamine for its analgosedative properties in adult, critically ill patients..MEDLINE was searched from inception until January 2016. Articles related to the pharmacological properties of ketamine were retrieved. Information pertaining to pharmacology, pharmacokinetics, dosing regimens, adverse effects, and outcomes was obtained from relevant studies..Although the primary mechanism for ketamine's pharmacological effects is N-methyl-d-aspartate blockade, there are several potential mechanisms of action. It has a very large volume of distribution due to its lipophilicity, which can lead to drug accumulation with sustained infusions. Ketamine has several advantages compared with conventional sedatives such as preserving pharyngeal and laryngeal protective reflexes, lowering airway resistance, increasing lung compliance, and being less likely to produce respiratory depression. It causes sympathetic stimulation, which is also unlike other sedatives and analgesics. There are psychotomimetic effects, which are a concern in terms of delirium. Dosing and monitoring recommendations are provided..Ketamine has a unique pharmacological profile compared with more traditional agents such as opioids, which makes it an appealing alternative agent for analgosedation in the intensive care unit setting.
• Patanwala, A. E., Kopp, B. J., Erstad, B. L., & Aljuhani, O. (2016). 840: METHOCARBAMOL DECREASES HOSPITAL LENGTH OF STAY IN TRAUMA PATIENTS WITH RIB FRACTURES. Critical Care Medicine, 44, 286. doi:10.1097/01.ccm.0000509516.97132.c1
• Radosevich, J. J., Nix, D. E., & Erstad, B. L. (2016). Evaluation of the Treatment of Candiduria at an Academic Medical Center.. American journal of therapeutics, 23(6), e1774-e1780. doi:10.1097/mjt.0000000000000021
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  To evaluate the epidemiology, management, and outcomes associated with candiduria in intensive care unit (ICU) and medical ward (MW) patients. This was a retrospective cohort study conducted in a tertiary care academic medical center. Adult patients aged between 18 and 75 years who were admitted for at least 5 days with a urinary culture that grew a Candida species between July 2010 and June 2011 were included. Medical records were retrospectively reviewed. Laboratory data, urinary symptoms, risk factors for urinary and invasive candidiasis, treatment, and patient outcomes were collected and evaluated. Sixty-seven ICU and 65 MW patients met the inclusion criteria. ICU patients were more likely to have risk factors for invasive candidiasis and candiduria. Candida albicans and Candida glabrata were the most frequently identified urinary isolates. Antifungal therapy was commonly initiated despite rapid replacement or removal of urinary drainage devices and a lack of patient reported symptoms. Fluconazole was the most commonly used antifungal agent, followed by micafungin. Hospital length of stay did not vary significantly between the ICU and MW groups (P = 0.0628). All-cause mortality was higher in the ICU patients compared with that of the MW patients (22.4% vs. 3.1%, P = 0.0012). Differences exist between ICU and MW patients that develop candiduria with respect to risk factors, and outcomes. Antifungals, including fluconazole and micafungin, were often used inappropriately (ie, asymptomatic patients) in this patient cohort. Efforts to improve healthcare provider awareness of the contemporary recommendations to manage candiduria are necessary to improve patient care and antifungal use.
• Radosevich, J. J., Patanwala, A. E., & Erstad, B. L. (2016). Hepatotoxicity in Obese Versus Nonobese Patients With Acetaminophen Poisoning Who Are Treated With Intravenous N-Acetylcysteine.. American journal of therapeutics, 23(3), e714-9. doi:10.1097/01.mjt.0000434043.62372.00
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  There is limited information regarding the outcomes associated with acetaminophen (APAP) poisoning in obese individuals. It is possible that patients who are obese are more susceptible to APAP-induced liver injury, thereby diminishing the efficacy of antidotes such as N-acetylcysteine (NAC). We evaluated the outcomes associated with APAP poisoning in obese versus nonobese adults who are treated with intravenous (IV) NAC. This was a retrospective cohort study conducted in a tertiary care, academic medical center. Adult patients with APAP toxicity, who were treated with IV NAC between June 2005 and August 2012, were included. The patients were categorized into 2 groups based on their body mass index (BMI): (1) obese (BMI ≥ 30.0 kg/m) versus (2) nonobese (BMI 18.5-24.9 kg/m). The primary outcome measure was the proportion of patients who developed hepatotoxicity (aspartate aminotransferase or alanine aminotransferase >1000 IU/L). A total of 80 patients were included in the final cohort (40 in each group). The median BMI for the obese and nonobese groups was 34.5 kg/m [interquartile range (IQR) 31.4-40.2] and 22.4 kg/m (IQR 21.2-23.9), respectively (P < 0.001). Other than more white patients being present in the nonobese group, there were no other baseline differences between groups with regard to demographics, liver function tests, or coagulation studies. Obese patients received a median IV NAC dose of 291.5 mg/kg (IQR 270.8-300.7) compared with 300 mg/kg (IQR 287.8-301.9) in the nonobese group (P = 0.07). Hepatotoxicity occurred in 27.5% of the obese patients and 37.5% of the nonobese patients (P = 0.34). No adverse drug effects were noted in either group. Obese and nonobese patients being treated with IV NAC for APAP toxicity experienced similar rates of hepatotoxicity.
• Sakles, J. C., Roe, D. J., Patanwala, A. E., & Erstad, B. L. (2016). Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department.. Pharmacotherapy, 36(1), 57-63. doi:10.1002/phar.1683
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  To compare succinylcholine and rocuronium regarding mortality in patients with traumatic brain injury (TBI) who are intubated in the emergency department (ED)..This was a retrospective cohort study conducted in an academic ED in the United States. Adult patients with TBI who underwent rapid sequence intubation (RSI) in the ED with rocuronium or succinylcholine between October 2010 and October 2014 were included. The main outcome of interest was in-hospital mortality. Subjects were stratified based on severity of injury using head abbreviated injury scores. The high-severity group had a severe or critical head injury (score 4 or higher); the low-severity group had a less than severe head injury (score lower than 4)..The final study cohort included 233 patients who were underwent RSI with succinylcholine (149 patients) or rocuronium (84 patients). In patients who received rocuronium, mortality was 22% (12/54) and 23% (7/30) in the low-severity and high-severity categories, respectively (difference 1%, 95% confidence interval [CI] -18% to 20%). In patients who received succinylcholine, mortality was 14% (14/103) and 44% (20/46) in the low-severity and high-severity categories, respectively (difference 30%, 95% CI 14-46). In the multivariate analysis after adjusting for important confounders, there was no significant association between succinylcholine and mortality in the low-severity category (odds ratio [OR] 0.75, 95% CI 0.29-1.92). However, in patients in the high-severity category, succinylcholine was associated with increased mortality compared with rocuronium (OR 4.10, 95% CI 1.18-14.12)..In severely brain-injured patients undergoing RSI in the ED, succinylcholine was associated with increased mortality compared with rocuronium.
• Tescher, A., Sands, M. K., Rochwerg, B., Pino, R., Patterson, A., Nix, S., Murray, M. J., Murray, C. F., Mehta, S., Meade, M., Mcmanus, C., Mcgee, W., Jordan, C., Jacobi, J., Gray, A., Erstad, B., Deblock, H., Arbour, R., Murray, M. J., , Jacobi, J., et al. (2016). Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient.. Critical care medicine, 44(11), 2079-2103. doi:10.1097/ccm.0000000000002027
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  To update the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient.".A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided..Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions..The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents. The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn. In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents. Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death.
• Weber, R. J., Mann, H. J., & Erstad, B. L. (2016). Developing a Business Plan for Critical Care Pharmacy Services.. Hospital pharmacy, 51(10), 856-862. doi:10.1310/hpj5110-856
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  Critical care medicine has grown from a small group of physicians participating in patient care rounds in surgical and medical intensive care units (ICUs) to a highly technical, interdisciplinary team. Pharmacy's growth in the area of critical care is as exponential. Today's ICU requires a comprehensive pharmaceutical service that includes both operational and clinical services to meet patient medication needs. This article provides the elements for a business plan to justify critical care pharmacy services by describing the pertinent background and benefit of ICU pharmacy services, detailing a current assessment of ICU pharmacy services, listing the essential ICU pharmacy services, describing service metrics, and delineating an appropriate timeline for implementing an ICU pharmacy service. The structure and approach of this business plan can be applied to a variety of pharmacy services. By following the format and information listed in this article, the pharmacy director can move closer to developing patient-centered pharmacy services for ICU patients.
• Wienbar, R., Rager, M. L., Hilaire, M. L., Haines, S. L., Franks, A. M., Erstad, B. L., Engle, J. P., Burke, J. M., Bingham, A. L., & Ashjian, E. J. (2016). A Self-Assessment Guide for Resident Teaching Experiences.. Pharmacotherapy, 36(6), e58-79. doi:10.1002/phar.1768
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  The 2015 American College of Clinical Pharmacy (ACCP) Educational Affairs Committee was charged with developing a self-assessment guide for residency programs to quantitatively and qualitatively evaluate the outcomes of resident teaching curricula. After extensively reviewing the literature, the committee developed assessment rubrics modeled after the 2013 ACCP white paper titled "Guidelines for Resident Teaching Experiences" and the revised American Society of Health-System Pharmacists (ASHP) 2014 accreditation standards for PGY1 residencies, which place greater emphasis on the teaching and learning curriculum (TLC) than the previous accreditation standards. The self-assessment guide developed by the present committee can serve as an assessment tool for both basic and expanded TLCs. It provides the criteria for program goals, mentoring, directed readings with topic discussions, teaching experiences, and assessment methodology. For an expanded TLC, the committee has provided additional guidance on developing a teaching philosophy, becoming involved in interactive seminars, expanding teaching experiences, developing courses, and serving on academic committees. All the guidelines listed in the present paper use the measures "not present," "developing," and "well developed" so that residency program directors can self-assess along the continuum and identify areas of excellence and areas for improvement. Residency program directors should consider using this new assessment tool to measure program quality and outcomes of residency teaching experiences. Results of the assessment will help residency programs focus on areas within the TLC that will potentially benefit from additional attention and possible modification.
• Balling, L. M., Erstad, B. L., & Weibel, K. J. (2015). Impact of a Transition-of-Care Pharmacist During Hospital Discharge. J Am Pharm Assoc, 55, 443-448.
• Erstad, B. L. (2015). Designing Drug Regimens for Special Intensive Care Unit Populations. World J Crit Care, 4, 139-151.
• Patanwala, A. E., Martin, J. R., & Erstad, B. L. (2015). Ketamine for Analgosedation in the Intensive Care Unit: A Systematic Review. Journal of intensive care medicine.
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  To evaluate the evidence for the use of intravenous ketamine for analgosedation in the intensive care unit.
• Radosevich, J. J., Patanwala, A. E., Frey, P. D., Paddock, H., & Erstad, B. L. (2015). Higher insulin infusion rate but not 24-hour insulin consumption is associated with hypoglycemia in critically ill patients.. Diab Res Clin Pract, 110, 322-327.
• Raz, Y., Abraham, I., Yun, S., Raz, Y., Kutbi, H. I., Huckleberry, Y., Gharaibeh, M., Erstad, B. L., Aljabri, A., & Abraham, I. (2015). Cost-Effectiveness Evaluation for the US of Fondaparinux Compared to Argatroban in the Management of Suspected HIT. Blood, 126(23), 4727-4727. doi:10.1182/blood.v126.23.4727.4727
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  Introduction. The relative efficacy and safety of fondaparinux and argatroban in the management of suspected heparin-induced thrombocytopenia (HIT) have been documented. We conducted a cost-effectiveness analysis of both agents in terms of cost and adverse events averted. Methods. We developed a two-armed decision tree model to simulate a cohort of patients with suspected or confirmed HIT managed with argatroban or fondaparinux, using published efficacy data and probabilities of developing HIT-related VTE or major bleeding. The primary base case analysis considered our institutional cost while the secondary analysis used the Average Wholesale Price. Probabilistic sensitivity analysis (PSA) was performed to confirm findings and one-way sensitivity analysis to evaluate additional scenarios. Results. In the primary base case analysis, fondaparinux dominated argatroban treatment as it was less expensive in managing suspected HIT ($154 vs. $2,064) and more effective in terms of adverse events averted (0.998878 vs. 0.995739). This was confirmed in PSA in terms of both cost ($154 vs. $1,999) and adverse events averted (0.9988711 vs. 0.9957212). Sensitivity analysis showed that the total costs of argatroban would never be less than fondaparinux based on our assumptions. In the secondary analysis, fondaparinux was less expensive ($362 vs. $3722) and more effective in terms of adverse event averted (0.998878 vs. 0.995739). The PSA confirmed these findings both in terms of cost ($343 vs. $3477) adverse events averted. (0.9988711 vs. 0.9957212). Conclusions. The cost savings from a once-daily SC fondaparinux injection with limited laboratory monitoring are more advantageous than IV argatroban infusion that requires continuous titration. Disclosures Off Label Use: Fondaparinux is used as "off-label" for the management of patients with suspected or confirmed HIT.
• Sakles, J. C., Roe, D. J., Patanwala, A. E., & Erstad, B. L. (2015). 31 Succinylcholine Is Associated With Increased Mortality When Used for Rapid Sequence Intubation of Severely Head Injured Patients in the Emergency Department. Annals of Emergency Medicine, 66(4), S11. doi:10.1016/j.annemergmed.2015.07.060
• Barletta, J. F., Kanji, S., MacLaren, R., Lat, I., Erstad, B. L., & , f. t. (2014). Pharmacoepidemiology of stress ulcer prophylaxis in the United States and Canada. Journal of critical care.
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  This study sought to identify the medication class most commonly prescribed for stress ulcer prophylaxis (SUP), assess trends in SUP utilization, and report the use of acid suppressive therapy stratified by bleeding risk.
• Camamo, J. M., Weibel, K., O'Keeffe, T., Huckleberry, Y., Kopp, B. J., Diven, C., & Erstad, B. L. (2014). Cost savings with interventions to reduce aerosolized bronchodilator use in mechanically ventilated patients. Journal of critical care, 29(5), 814-6.
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  The purpose of this evaluation is to describe the cost savings associated with multimodal interventions aimed at reducing aerosolized bronchodilator use in mechanically ventilated patients without adversely affecting costs associated with length of stay (LOS).
• Einav, S., Hick, J. L., Hanfling, D., Erstad, B. L., Toner, E. S., Branson, R. D., Kanter, R. K., Kissoon, N., Dichter, J. R., Devereaux, A. V., & Christian, M. D. (2014). Surge Capacity Logistics: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest.
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  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.
• Engle, J. P., Erstad, B. L., Anderson, D. C., Bucklin, M. H., Chan, A., Donaldson, A. R., Hagemann, T. M., O'Connell, M. B., Rodgers, P. T., Tennant, S., & Thomas, Z. (2014). Minimum qualifications for clinical pharmacy practice faculty. Pharmacotherapy, 34(5), e38-44.
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  The American College of Clinical Pharmacy 2013 Educational Affairs Committee was charged with developing recommendations for the minimum qualifications required for clinical pharmacy practice faculty in United States colleges and schools of pharmacy with respect to education, postgraduate training, board certification, and other experiences. From a review of the literature, the committee recommends that clinical pharmacy practice faculty possess the following minimum qualifications, noting that, for some positions, additional qualifications may be necessary. Clinical pharmacy practice faculty should possess the Doctor of Pharmacy degree from an Accreditation Council for Pharmacy Education–accredited institution. In addition, faculty should have completed a postgraduate year one (PGY1) residency or possess at least 3 years of direct patient care experience. Faculty who practice in identified areas of pharmacotherapy specialization, as identified by American Society of Health-System Pharmacists postgraduate year two (PGY2) residency guidelines, should have completed a PGY2 residency in that area of specialty practice. Alternatively, faculty should have completed a minimum of a PGY1 residency and 1 additional year of practice, with at least 50% of time spent in their area of specialization, which is documented in a portfolio, or 4 years of direct patient care in their area of specialization, which is documented in a portfolio. Fellowship training or a graduate degree (e.g., Ph.D.) should be required for research-intensive clinical faculty positions. All faculty should obtain structured teaching experience during or after postgraduate training, preferably through a formal teaching certificate program or through activities documented in a teaching portfolio. A baseline record of scholarship should be obtained before hire as clinical pharmacy practice faculty through exposure in postgraduate programs or previous employment. Faculty should be board certified before hire or attain board certification within 2 years of hire through the Board of Pharmacy Specialties (BPS) or, if appropriate for the practice area, through a nonBPS-certifying agency. If no certification exists in the area of specialty, the faculty member should develop a portfolio with evidence of excellence in clinical practice, teaching, and scholarship.
• Erstad, B. L. (2014). Stress ulcer prophylaxis: It's that same old wine in a brand new bottle. Critical Care Medicine, 42(4), 979-980.
• Erstad, B. L., McKinney, C. B., Patanwala, A. E., & Sakles, J. C. (2014). Retrospective Analysis of Etomidate Versus Ketamine for First-pass Intubation Success in an Academic Emergency Department. Academic Emergency Medicine, 21(1), 87-91. doi:10.1111/acem.12292
• Mckinney, C. B., Erstad, B. L., & Aljuhani, O. A. (2014). Opioid requirements in mechanically ventilated trauma patients receiving dexmedetomidine versus propofol.. Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 21(3), 111-4. doi:10.1097/jtn.0000000000000041
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  Proponents of dexmedetomidine often cite the agent's analgesic properties as one of its main advantages over propofol and benzodiazepines. However, there are very limited studies utilizing endpoints such as analgesic requirements to provide supporting evidence for these claims. The primary purpose of this retrospective study was to compare opioid analgesic requirements in trauma patients receiving nonconcurrent dexmedetomidine and propofol for sedation while being weaned from mechanical ventilation. Total analgesic requirements were similar between dexmedetomidine and propofol within 48 hours of sedative initiation in adult trauma patients (P > .05).
• Patanwala, A. E., & Erstad, B. L. (2014). Comparison of Dexmedetomidine Versus Propofol on Hospital Costs and Length of Stay. Journal of intensive care medicine.
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  The objective of this evaluation was to compare total hospital costs and length of stay of critically ill patients who received dexmedetomidine versus propofol for sedation in the intensive care unit (ICU).
• Patanwala, A. E., Holmes, K. L., & Erstad, B. L. (2014). Analgesic response to morphine in obese and morbidly obese patients in the emergency department. Emergency Medicine Journal, 31(2), 139-142.
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  Abstract: Objective: The primary objective of this study was to compare the analgesic response to morphine in non-obese, obese and morbidly obese patients for acute pain. Methods: This was a retrospective cohort study conducted in a tertiary care emergency department in the USA. Consecutive adults who received intravenous morphine 4 mg for pain were included. Patients were categorised into three groups based on body mass index (BMI): non-obese (18.5-29.9 kg/m 2); obese (30.0-39.9 kg/m2); and morbidly obese (≥40 kg/m2). Baseline and post-dose pain scores were recorded. Pain was measured on a 0-10 numerical rating scale (0=no pain; 10=worst possible pain). Analgesic response was defined as the difference between the initial pain score and post-dose pain score. Results: 300 patients were included in the study (100 in each group). The median baseline pain scores were 8.5, 8 and 8.5 in the non-obese, obese and morbidly obese groups, respectively (p=0.464). The median analgesic response after morphine administration was 2, 3 and 2 in the non-obese, obese and morbidly obese groups, respectively (p=0.160). In the linear regression analysis (R2=0.006), BMI was not predictive of analgesic response (coefficient -0.020; p=0.199). Conclusions: Obesity status did not influence analgesic response to a fixed dose of morphine. This suggests that obese and morbidly obese patients do not require a higher dose of morphine for acute pain reduction compared to non-obese patients.
• Patanwala, A. E., McKinney, C. B., Erstad, B. L., & Sakles, J. C. (2014). Retrospective analysis of etomidate versus ketamine for first-pass intubation success in an academic emergency department. Academic Emergency Medicine, 21(1), 87-91.
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  Abstract: Objectives The objective of this study was to compare first-pass intubation success between patients who received etomidate versus ketamine for rapid sequence intubation (RSI) in the emergency department (ED). Methods This was a retrospective analysis of prospectively collected data recorded in a quality improvement database between July 1, 2007, and December 31, 2012. The study was conducted in an academic ED in the United States. All patients who received etomidate or ketamine as part of RSI were included. The primary outcome measure was first-pass success. A multivariate analysis was conducted to determine if sedative type was associated with first-pass success, after adjusting for potential confounders and baseline differences. Results The final cohort consisted of 2,098 RSI procedures using either etomidate (n = 1,983) or ketamine (n = 115). First-pass success occurred in 77.0% of patients in the etomidate group and 79.1% of patients in the ketamine group (difference = -2.1%; 95% CI = -5.5% to 9.8%). In the multivariate analysis, after adjusting for potential confounders, sedative type was not associated with first-pass success (odds ratio = 0.89; 95% CI = 0.5 to 1.5; p = 0.632). Conclusions Etomidate and ketamine are associated with equivalent first-pass success when used in RSI. Ketamine may be an appropriate alternative to etomidate for RSI in the ED. © 2013 by the Society for Academic Emergency Medicine. ©.
• Radosevich, J. J., Patanwala, A. E., Paddock, H., Lee, Y. G., Frey, P., & Erstad, B. L. (2014). 340: INCREASING WEIGHT-BASED DOSING OF INSULIN IS ASSOCIATED WITH HYPOGLYCEMIA IN CRITICALLY ILL PATIENTS. Critical Care Medicine, 42, A1442. doi:10.1097/01.ccm.0000457837.69524.2f
• Stolte, S. K., Schwartz, A. H., Ressler, J. C., Nemire, R. E., Lockman, P. R., Erstad, B. L., Divall, M. V., Conway, J. M., & Cain, J. (2014). Report of the 2013-2014 Academic Affairs Committee.. American journal of pharmaceutical education, 78(10), S23. doi:10.5688/ajpe7810s23
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  BACKGROUND AND CHARGES According to the Bylaws of the American Association of Colleges of Pharmacy (AACP), the Academic Affairs Committee shall consider: the intellectual, social, and personal aspects of pharmaceutical education. It is expected to identify practices, procedures, and guidelines that will aid faculties in developing students to their maximum potential. It will also be concerned with curriculum analysis, development, and evaluation beginning with the pre-professional level and extending through professional and graduate education. The Committee shall seek to identify issues and problems affecting the administrative and financial aspects of member institutions. The Academic Affairs Committee shall extend its attention beyond intra-institutional matters of colleges of pharmacy to include interdisciplinary concerns with the communities of higher education and especially with those elements concerned with health education. To provide direction on how academic pharmacy should engage in technology-enabled education and to elaborate on AACP's role in the development of new educational resources, technologies and learning models, President Peggy Piascik charged the Committee to consider the following questions: 1. Is there a place for Massive Online Open Courses (MOOCs) in pharmacy education? If so, what are the opportunities and barriers for developing and implementing a platform for online courses across the academy? 2. What is the potential role of games in pharmacy education? How can AACP assist colleges and schools in developing and implementing this technology? In which areas of the curriculum, do games have the most potential for impact? 3. How can AACP educate and assist schools and colleges in adopting learning analytics to maximize the use of big data for programmatic and curricular priorities? 4. How can the Academy assist faculty in scholarship endeavors with regard to the following emerging technology issues? Potential areas may include: * Quality assurance methods in technology-enabled teaching and learning * Accreditation standards revision that supports innovation in educational technology learning and assessment models * Recognition within the promotion and tenure process to faculty who are innovators in advancing technology-enabled education In August 2013, Committee members were provided with resources and background literature to read prior to the standing Committee meeting. Members were also assigned to sub-groups to delve deeper into the literature pertaining to topics of the charge. Group one considered the topics of MOOCs and gamification of learning, while group two examined learning analytics and faculty scholarship regarding emerging technology issues. At the standing meeting on October 28-29,2013 in Washington, D.C., the Committee as a whole engaged in critical dialog while considering each of the charge questions and developed recommendations, policy statements, and suggestions as appropriate. At the conclusion of the meeting, Committee members were divided into four subgroups of two members each to write and elaborate on specific sections of the committee's work. The purpose of this report is 1) to provide requisite background literature and information regarding the charges, and 2) to provide recommendations to AACP and the Academy pertaining to these emerging issues. INTRODUCTION Higher education is facing a myriad of challenges due to a rapidly-changing technological environment. The 2012-2013 Argus Commission studied "game changers" likely to influence pharmacy education. (1) A major theme of their report was using instructional (information) technology to its fullest capability to create better instruction and to develop and use analytics for guiding and directing faculty and students. The New Media Consortium's (NMC) 2013 Higher Education Report (2) frames new and emerging technologies in a manner that allows education leaders, policy makers, and faculty to understand the potential impact on teaching, learning, and research. …
• Tang, A., Shearin, A. E., Patanwala, A. E., & Erstad, B. L. (2014). Predictors of hypotension associated with propofol in trauma patients.. Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 21(1), 4-8. doi:10.1097/jtn.0000000000000022
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  Propofol use may lead to hypotension in trauma patients intubated in the emergency department. In this study, predictors of hypotension were identified. We hypothesized that demographic variables could be associated with hypotension. Hypotension occurred in 33 of 200 patients. In the multivariate analysis, hypotension was associated with patient age greater than 55 years (odds ratios [OR], 3.61; 95% confidence interval [CI], 1.32-9.86; P = .012), obesity (OR, 2.66; 95% CI, 1.08-6.55; P = .034), and lower baseline blood pressure (OR, 1.59 [per 10-mm Hg decrease]; 95% CI, 1.29-1.96; P = .000). Age greater than 55 years, obesity, and lower baseline systolic blood pressure are associated with a higher risk of propofol-induced hypotension in trauma patients.
• Erstad, B., & Erstad, B. L. (0). Dyspepsia: initial evaluation and treatment. Journal of the American Pharmaceutical Association (Washington,D.C. : 1996), 42(3).
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  To provide recommendations for the initial evaluation and management of dyspepsia.
• Erstad, B., Patanwala, A. E., Holmes, K. L., & Erstad, B. L. (2013). Analgesic response to morphine in obese and morbidly obese patients in the emergency department. Emergency medicine journal : EMJ.
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  OBJECTIVE: The primary objective of this study was to compare the analgesic response to morphine in non-obese, obese and morbidly obese patients for acute pain. METHODS: This was a retrospective cohort study conducted in a tertiary care emergency department in the USA. Consecutive adults who received intravenous morphine 4 mg for pain were included. Patients were categorised into three groups based on body mass index (BMI): non-obese (18.5-29.9 kg/m(2)); obese (30.0-39.9 kg/m(2)); and morbidly obese (≥40 kg/m(2)). Baseline and post-dose pain scores were recorded. Pain was measured on a 0-10 numerical rating scale (0=no pain; 10=worst possible pain). Analgesic response was defined as the difference between the initial pain score and post-dose pain score. RESULTS: 300 patients were included in the study (100 in each group). The median baseline pain scores were 8.5, 8 and 8.5 in the non-obese, obese and morbidly obese groups, respectively (p=0.464). The median analgesic response after morphine administration was 2, 3 and 2 in the non-obese, obese and morbidly obese groups, respectively (p=0.160). In the linear regression analysis (R(2)=0.006), BMI was not predictive of analgesic response (coefficient -0.020; p=0.199). CONCLUSIONS: Obesity status did not influence analgesic response to a fixed dose of morphine. This suggests that obese and morbidly obese patients do not require a higher dose of morphine for acute pain reduction compared to non-obese patients.
• Erstad, B., Traylor, B. R., Patanwala, A. E., Sakles, J. C., & Erstad, B. L. (2013). Under-dosing of etomidate for rapid sequence intubation in the emergency department. Current drug safety, 8(4).
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  Objective: The objective of this study was to determine if patients who weigh ≥100 kg are more likely to receive under-dosing of etomidate compared to those who weigh
• Jasiak, K. D., Middleton, E. A., Camamo, J. M., Erstad, B. L., Snyder, L. S., & Huckleberry, Y. C. (2013). Evaluation of discontinuation of atypical antipsychotics prescribed for ICU delirium. Journal of Pharmacy Practice, 26(3), 253-256.
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  PMID: 23184410;Abstract: A number of trials suggest that short-term use of atypical antipsychotics may be useful in the treatment of delirium associated with critical illness. However, long-term use of such agents for this indication has not been studied and may be associated with risks of adverse effects as well as unnecessary health care costs. A retrospective study of prescribing patterns of atypical antipsychotics initiated for the treatment of intensive care unit (ICU) delirium was performed to identify whether these agents were being discontinued prior to or upon hospital discharge. Of the 59 patients who met inclusion criteria and survived to hospital discharge, 28 (47%) were continued on the atypical antipsychotic upon discharge from the medical ICU. For those continued on the agent, 20 patients (71.4%) were prescribed continued therapy as an outpatient. Inpatient costs for atypical antipsychotics during the 9-month study period were increased by approximately $888. Annual cost of the medication as outpatient therapy is assessed at approximately $45 107. Although short-term trials of atypical antipsychotics may be useful for ICU delirium, caution is advised regarding potential adverse effects and added health care costs when use is prolonged. © The Author(s) 2012.
• Maclaren, R., Lat, I., Kanji, S., Erstad, B. L., & Barletta, J. F. (2013). 737: CURRENT TRENDS IN THE USE OF STRESS ULCER PROPHYLAXIS- A MULTICENTER STUDY. Critical Care Medicine, 41, A182. doi:10.1097/01.ccm.0000439975.66795.e0
• O'keeffe, T., Weibel, K., O'keeffe, T., Erstad, B. L., & Camamo, J. M. (2013). 409: Cost Savings With Interventions to Reduce Aerosolized Bronchodilator Use in Ventilated Patients. Critical Care Medicine, 41, A98. doi:10.1097/01.ccm.0000439553.94867.28
• Patanwala, A. E., & Erstad, B. L. (2013). 864: Comparison of dexmedetomidine versus propofol for patients in the intensive care unit. Critical Care Medicine, 41, A216. doi:10.1097/01.ccm.0000440102.11632.25
• Pitman, E. P., Musselman, T., Maclean, L. G., Johnson, J. K., Gant, K. O., Erstad, B. L., Chesnut, R. J., Brazeau, G. A., & Bradley-baker, L. R. (2013). Report of the 2012-2013 professional affairs committee: tables of influence-is pharmacy hungry enough?. American journal of pharmaceutical education, 77(10), S21. doi:10.5688/ajpe7710s21
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  BACKGROUND AND CHARGES According to the Bylaws of AACP, the Professional Affairs Committee is to study issues associated with the professional practice as they relate to pharmaceutical education, and to establish and improve working relationships with all other organizations in the field of health affairs. The Committee is also encouraged to address related agenda items relevant to its Bylaws charge and to identify issues for consideration by subsequent committees, task forces, commissions, or other groups. President J. Lyle Bootman charged the 2012-2013 American Association of Colleges of Pharmacy (AACP) Standing Committees with issues related to transforming healthcare. (1) President Bootman encourages AACP institutional and individual members to "get to all the right tables of influence at the right time" and recognizes the local/state partnerships that member schools/ colleges have with other stakeholders in health care can and does result in improving health care. Specifically, the 2012-2013 Professional Affairs Committee is charged to: (1) Identify successful practices in the development and maintenance of effective relationships between state pharmacy organizations and schools/ colleges of pharmacy and (2) Recommend strategies related to state and local policy developments to optimally position pharmacists in health reform initiatives. Members of the Professional Affairs Committee (PAC) include faculty from multiple disciplines from various schools/colleges of pharmacy as well as two executive directors of state pharmacy associations from the National Alliance of State Pharmacy Associations (NASPA). Prior to an in-person meeting of the committee, pertinent background information and resource materials were distributed and a conference call was held to develop a strategy, for addressing committee charges. The majority of committee members met for a day and a half in Crystal City, Virginia on October 29-30,2012 to discuss the various facets related to this issue as well as to develop a process and strategies for addressing the charges. The committee members not able to meet in person were teleconferenced in during the Virginia meeting to provide their input. Following the process development and delegation of assignments related to the committee charges, the PAC communicated via electronic communications as well as through personal exchanges via telephone and email. The result is the following report, which discusses the elements and importance of a recognized relationship between pharmacy organizations, specifically professional organizations at the state level and boards of pharmacy as well as successful practices and strategies to guide the academy to be present and active at the "tables of influence" that will enhance the profession and improve patient care. INTRODUCTION The PAC believes the recommendations in this report are fundamental to the association's future. We approached our charges with the understanding of addressing inter-connectivity, reform, and transformation. Jim Collins' Good to Great (2) premise includes the thought that a 'good' performance is often the enemy of achieving greatness. The Committee discussed this concept and identified that in the past, schools/colleges of pharmacy have been comfortable with competitive pools of applicants and high placement rates thanks in large part to the numerous opportunities and demand for pharmacists. This comfort level, along with the different missions of schools/colleges of pharmacy, professional associations, and state boards of pharmacy has prevented our profession from working together in an effective united effort to make sure that we are at the "right tables of influence at the right time." This has contributed to our profession now struggling with our identity and place in a dynamic healthcare environment. The pharmacy profession has been left out of important discussions needed for recognizing the value that pharmacists must bring to providing patient care in an integrated team approach, as well as enhancing public health issues and society at large. …
• Radosevich, J. J., Patanwala, A. E., & Erstad, B. L. (2013). Emerging pharmacological agents to improve survival from traumatic brain injury. Brain Injury, 27(13-14), 1492-1499.
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  PMID: 24205899;Abstract: Objective: To review emerging pharmacological agents for the treatment of traumatic brain injury with regard to survival outcomes and provide recommendations regarding their use. Methods: An Ovid MEDLINE (up to May 2013) and the Cochrane Central Register of Controlled Trials (up to May 2013) search was conducted to identify emerging pharmacological therapies for the treatment of traumatic brain injury. The search was limited to English language and humans. Pharmacological agents that were evaluated with respect to survival as an outcome were included. Main results: Based on the search, the investigators identified the following new therapies: beta-receptor antagonists, erythropoiesis stimulating agents, hydroxymethylglutaryl-CoA reductase inhibitors (statins) and progesterone. With the exception of progesterone, which was studied in several small, randomized, controlled trials, the remaining agents were primarily studied in observational retrospective cohorts. For each of the agents identified, a potential increase in survival was noted. Conclusions: Emerging pharmacological agents represent promising treatment options for traumatic brain injury to improve survival. Most of these agents are commercially available for other indications. However, limitations in study design, sample size, duration of treatment, timing of treatment and inclusion of heterogeneous patient populations make it difficult to draw definitive conclusions from the literature. © 2013 Informa UK Ltd.
• Radosevich, J. J., Patanwala, A. E., & Erstad, B. L. (2013). Hepatotoxicity in obese versus nonobese patients with acetaminophen poisoning who are treated with intravenous N-acetylcysteine. American Journal of Therapeutics.
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  Abstract: There is limited information regarding the outcomes associated with acetaminophen (APAP) poisoning in obese individuals. It is possible that patients who are obese are more susceptible to APAP-induced liver injury, thereby diminishing the efficacy of antidotes such as N-acetylcysteine (NAC). We evaluated the outcomes associated with APAP poisoning in obese versus nonobese adults who are treated with intravenous (IV) NAC. This was a retrospective cohort study conducted in a tertiary care, academic medical center. Adult patients with APAP toxicity, who were treated with IV NAC between June 2005 and August 2012, were included. The patients were categorized into 2 groups based on their body mass index (BMI): (1) obese (BMI ≥ 30.0 kg/m) versus (2) nonobese (BMI 18.5-24.9 kg/m). The primary outcome measure was the proportion of patients who developed hepatotoxicity (aspartate aminotransferase or alanine aminotransferase >1000 IU/L). A total of 80 patients were included in the final cohort (40 in each group). The median BMI for the obese and nonobese groups was 34.5 kg/m [interquartile range (IQR) 31.4-40.2] and 22.4 kg/m (IQR 21.2-23.9), respectively (P < 0.001). Other than more white patients being present in the nonobese group, there were no other baseline differences between groups with regard to demographics, liver function tests, or coagulation studies. Obese patients received a median IV NAC dose of 291.5 mg/kg (IQR 270.8-300.7) compared with 300 mg/kg (IQR 287.8-301.9) in the nonobese group (P = 0.07). Hepatotoxicity occurred in 27.5% of the obese patients and 37.5% of the nonobese patients (P = 0.34). No adverse drug effects were noted in either group. Obese and nonobese patients being treated with IV NAC for APAP toxicity experienced similar rates of hepatotoxicity.
• Traylor, B. R., Patanwala, A. E., Sakles, J. C., & Erstad, B. L. (2013). Under-dosing of etomidate for rapid sequence intubation in the emergency department. Current Clinical Pharmacology, 8(4), 253-256.
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  Abstract: Objective: The objective of this study was to determine if patients who weigh ≥100 kg are more likely to receive under-dosing of etomidate compared to those who weigh
• Watt, J. M., Sakles, J. C., Rhee, P., Patanwala, A. E., Faucett, E. A., Erstad, B. L., Amini, R., & Amini, A. (2013). Effect of a pharmacist on timing of postintubation sedative and analgesic use in trauma resuscitations.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 70(17), 1513-7. doi:10.2146/ajhp120673
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  Pharmacists' impact in reducing the time interval from intubation to sedative and analgesic use during trauma patient resuscitations is investigated..A retrospective cohort study was conducted at a level 1 trauma center to compare medication-use outcomes in consecutive cases in which trauma patients underwent rocuronium-assisted rapid-sequence intubation (RSI) and subsequent sedation and analgesia with or without a pharmacist's participation on the resuscitation team. The primary and secondary outcomes were, respectively, the time to sedative provision and the time to analgesic provision after intubation..Relative to resuscitation cases not involving a pharmacist, the presence of the pharmacist during RSI was associated with decreased mean times to provision of postintubation sedation (9 minutes versus 28 minutes, p = 0.007) and analgesia (21 minutes versus 44 minutes, p = 0.057). The cumulative proportions of patients receiving appropriate sedation 5, 10, and 15 minutes after intubation were 11%, 26%, and 41% in the pharmacist-absent group and 33%, 53%, and 63% in the pharmacist-present group (p = 0.009, 0.008, and 0.045, respectively); for postintubation analgesic use, the corresponding figures were 9%, 14%, and 23% in the pharmacist-absent group and 17%, 30%, and 43% in the pharmacist-present group (p = 0.236, 0.066, and 0.039, respectively)..The presence of a pharmacist during RSI procedures was associated with decreased times to postintubation sedative and analgesic use, indicating that pharmacist participation in trauma-resuscitation responses can facilitate appropriate drug therapy.
• Attridge, R. L., Duvall, L., Erstad, B., Johnson, S. G., Kayser, S. R., Kiser, T. H., Moote, R., Reed, B. N., & Rodgers, J. E. (2012). Key Articles and Guidelines in the Management of Pulmonary Arterial Hypertension: 2011 Update. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 32(6), e134-e169. doi:10.1002/j.1875-9114.2012.01105.x
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  Pharmacotherapeutic approaches for the management of pulmonary arterial hypertension (PAH) have expanded greatly in the last 10 years. Pulmonary arterial hypertension is a relatively rare disease and is associated with myriad disease processes. The older term for PAH, primary PAH, has been changed to represent these differences and to distinguish it from postcapillary PAH associated with left-sided heart failure. Limitations in evaluating treatment approaches for PAH include its rarity, the small number of patients included in clinical trials, and issues regarding the use of placebo-controlled trials in a disease with such a high mortality rate if left untreated. Management options include the use of prostacyclin and prostacyclin analogues, endothelin receptor antagonists, and phosphodiesterase inhibitors, as well as traditional background therapy with diuretics, digoxin, calcium channel blockers, and warfarin. Numerous drugs are under investigation to evaluate their possible roles in management. Combination therapy is increasingly becoming a standard approach to therapy, with mounting literature to document effectiveness. Current or emerging roles for the pharmacist in the management of PAH largely involves ensuring access to drug therapy, facilitating specialty pharmacy dispensing, and providing patient counseling. Newer roles may include future drug development, optimized use of investigational drugs, and specialized disease management programs. This compilation includes a series of articles identifying important literature in cardiovascular pharmacotherapy. This bibliography focuses on pharmacotherapeutic management of pulmonary arterial hypertension (PAH). Most of the cited works present the results of significant human clinical studies that have shaped the management of patients with PAH. Limited primary literature is available for some topics, so in addition, consensus documents prepared by expert panels are reviewed. This compilation may serve as a teaching tool, reference resource, or update of the literature for pharmacy clinicians, physicians, and students.
• Baggs, J. H., Patanwala, A. E., Williams, E. M., & Erstad, B. L. (2012). Dosing of 3-Factor Prothrombin Complex Concentrate for International Normalized Ratio Reversal. Annals of Pharmacotherapy, 46(1), 51-56. doi:10.1345/aph.1q588
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  BACKGROUND: Three-factor prothrombin complex concentrate (PCC) is commonly used for reversal of international normalized ratio (INR) in patients who are bleeding or require emergency surgery. However, there is little information regarding the optimal dosing strategy for achieving adequate INR reversal. OBJECTIVE: To determine whether patients with higher initial INR levels are less likely to achieve adequate INR reversal after receiving 3-factor PCC. METHODS: A retrospective cohort study was conducted in a tertiary care medical center in the US. Patients who received 3-factor PCC were grouped into 2 categories based on degree of INR reversal after PCC infusion: (1) adequate reversal (final INR ≤1.5) or (2) inadequate reversal (final INR >1.5). Initial INR was compared between the 2 groups using the Wilcoxon rank-sum test. A multivariate logistic regression analysis was used to adjust for confounders and determine predictors of adequate INR reversal. RESULTS: Fifty patients met criteria for inclusion in the final analyses. Of these, 58% achieved adequate reversal after PCC. There were no significant differences in patient demographics or in vitamin K or fresh frozen plasma (FFP) use between the 2 groups. Median PCC dose was also similar between the adequate and inadequate reversal groups (25.2 vs 24.5 units/kg, respectively; p = 0.2). The group that did not achieve adequate reversal had a significantly higher initial INR (3.5 vs 2.5, p = 0.012) prior to PCC administration. In the multivariate logistic regression analysis, initial INR was a significant predictor of adequate INR reversal (ie, reversal less likely as INR increases) after adjusting for PCC dose and concurrent use of vitamin K or FFP (OR = 0.38; 95% CI 0.17 to 0.87; p = 0.02). CONCLUSIONS: Patients with a higher initial INR are less likely to achieve adequate INR reversal after receiving 3-factor PCC and may require higher doses than were used in the study.
• Baggs, J. H., Patanwala, A. E., Williams, E. M., & Erstad, B. L. (2012). Dosing of 3-factor prothrombin complex concentrate for international normalized ratio reversal. Annals of Pharmacotherapy, 46(1), 51-56.
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  PMID: 22190253;Abstract: Background: Three-factor prothrombin complex concentrate (PCC) is commonly used for reversal of international normalized ratio (INR) in patients who are bleeding or require emergency surgery. However, there is little information regarding the optimal dosing strategy for achieving adequate INR reversal. Objective: To determine whether patients with higher initial INR levels are less likely to achieve adequate INR reversal after receiving 3-factor PCC. Methods: A retrospective cohort study was conducted in a tertiary care medical center in the US. Patients who received 3-factor PCC were grouped into 2 categories based on degree of INR reversal after PCC infusion: (1) adequate reversal (final INR 21.5) or (2) inadequate reversal (final INR >1.5). Initial INR was compared between the 2 groups using the Wilcoxon rank-sum test. A multivariate logistic regression analysis was used to adjust for confounders and determine predictors of adequate INR reversal. Results: Fifty patients met criteria for inclusion in the final analyses. Of these, 58% achieved adequate reversal after PCC. There were no significant differences in patient demographics or in vitamin K or fresh frozen plasma (FFP) use between the 2 groups. Median PCC dose was also similar between the adequate and inadequate reversal groups (25.2 vs 24.5 units/kg, respectively; p = 0.2). The group that did not achieve adequate reversal had a significantly higher initial INR (3.5 vs 2.5, p = 0.012) prior to PCC administration. In the multivariate logistic regression analysis, initial INR was a significant predictor of adequate INR reversal (ie, reversal less likely as INR increases) after adjusting for PCC dose and concurrent use of vitamin K or FFP (OR = 0.38; 95% CI 0.17 to 0.87; p = 0.02). Conclusions: Patients with a higher initial INR are less likely to achieve adequate INR reversal after receiving 3-factor PCC and may require higher doses than were used in the study.
• Bloom, J. W., Doungngern, T., Erstad, B., & Huckleberry, Y. (2012). Effect of Albumin on Diuretic Response to Furosemide in Patients With Hypoalbuminemia. American Journal of Critical Care, 21(4), 280-286. doi:10.4037/ajcc2012999
• Doungngern, T., Huckleberry, Y., Bloom, J. W., & Erstad, B. (2012). Effect of albumin on diuretic response to furosemide in patients with hypoalbuminemia. American Journal of Critical Care, 21(4), 280-286.
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  PMID: 22751371;Abstract: Background Albumin is broadly prescribed for critically ill patients although it does not have a mortality benefit over crystalloids. One common use of albumin is to promote diuresis. Objectives To compare urine output in patients treated with furosemide with and without albumin and to assess other variables possibly associated with enhanced diuresis. Methods A retrospective study was conducted on patients in a medical intensive care unit who received furosemide therapy as a continuous infusion with and without 25% albumin for more than 6 hours. Primary end points were urine output and net fluid loss. Results A total of 31 patients were included in the final analysis. Mean urine output in patients treated with furosemide alone did not differ significantly from output in patients treated with furo -semide plus albumin at 6, 24, and 48 hours: mean output, 1119 (SD, 597) mL vs 1201 (SD, 612) mL, P= .56; 4323 (SD, 1717) mL vs 4615 (SD, 1741) mL, P = .42; and 7563 mL (SD, 2766) vs 7432 (SD, 2324) mL, P = .94, respectively. Additionally, net fluid loss did not differ significantly between the 2 groups at 6, 24, and 48 hours. Higher concentrations of serum albumin did not improve urine output. The only independent variable significantly associated with enhanced urine output at 24 and 48 hours was increased fluid intake. Conclusion Addition of albumin to a furosemide infusion did not enhance diuresis obtained with furosemide alone in critically ill patients. © 2012 American Association of Critical-Care Nurses.
• Erstad, B. L. (2012). Drug Dosing in the Critically Ill Obese Patient. Critical Care Management of the Obese Patient, 195-207.
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  Abstract: Unfortunately, research related to drug dosing in overweight and obese patients has not kept pace with studies concerning the epidemiology and complications of obesity. The pivotal trials leading to drug approval typically include relatively few patients with extremes of weight relative to height. They usually focus on patients in non-ICU settings, and in some cases specifically exclude patients beyond a predefined weight. Furthermore, when the results of clinical trials are reported, patient weights are usually expressed in terms of summary statistics. Although patient weight is often the focus of discussions of drugs administered using weight-based dosing regimens, other factors such as height and body composition must be taken into account. As much as possible and practical, the way in which weight is estimated, measured, recorded, and utilized for drug dosing should be standardized to reduce variability that might lead to dosing errors. © 2012 John Wiley & Sons, Ltd.
• Erstad, B. L. (2012). Obesity in critical illness: What weight or why weight?. Critical Care Medicine, 40(5), 1657-1659.
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  PMID: 22511147;
• Erstad, B. L., Patanwala, A. E., & Theodorou, A. A. (2012). Comparison of methods for the detection of medication safety events in the critically ill. Current Drug Safety, 7(3), 238-246.
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  PMID: 22950987;Abstract: Purpose: To categorize and synthesize medication safety event detection methods in the critically ill in order to provide clinicians and administrators with approaches to event detection that are intended to expand and complement traditional voluntary reporting systems. Methods: A literature search of OvidMEDLINE was performed to identify articles related to medication safety involving critically ill patients in the intensive care unit setting. The inclusion of articles was restricted to comparative studies. The bibliographies of all retrieved articles were reviewed to obtain additional articles of relevance. The various event detection methods were compared by: evidence supporting their use; number, type and severity of events detected; phase of the medication use process in which events were detected; and ease and cost of implementation. Major limitations of each method were also collated. Results: There are a number of methods that can be used to identify medication safety events in the critically ill. These can broadly be categorized as: 1) voluntary reporting, 2) record review, 3) rules/triggers and 4) direct observation and 5) interviews/surveys. Relatively few studies have directly compared these assessment methods in the ICU setting, although the limitations of the traditional voluntary reporting system as the sole method of event detection are well established. Although not truly dichotomous, these methods can be broken down into more proactive and reactive approaches. Rules/triggers and direct observation of the medication use process in the ICU are examples of proactive approaches to event detection, while the traditional unsolicited voluntary reporting is typically reactive. However, each of the event detection methods has advantages and disadvantages, so the methods should not be considered mutually exclusive with respect to obtaining information about medication safety. Conclusions: Given the limitations of traditional voluntary reporting systems, a multimodal approach used to identify medication safety events is most likely to capture the largest number and type of events. We would advise not trying to implement additional approaches beyond voluntary reporting systems all at once. This would be difficult and costly. Rather, we suggest a systematic implementation of additional event detection approaches that takes into account hospitalspecific considerations. © 2012 Bentham Science Publishers.
• Erstad, B., Patanwala, A. E., Sanders, A. B., Thomas, M. C., Acquisto, N. M., Weant, K. A., Baker, S. N., Merritt, E. M., & Erstad, B. L. (2012). A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Annals of emergency medicine, 59(5).
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  The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED).
• Johnson, S. G., Kayser, S. R., Attridge, R. L., Duvall, L., Kiser, T. H., Moote, R., Reed, B. N., Rodgers, J. E., & Erstad, B. (2012). Key articles and guidelines in the management of pulmonary arterial hypertension: 2011 update.. Pharmacotherapy, 32(6), e134-169.
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  PMID: 22467427;Abstract: Pharmacotherapeutic approaches for the management of pulmonary arterial hypertension (PAH) have expanded greatly in the last 10 years. Pulmonary arterial hypertension is a relatively rare disease and is associated with myriad disease processes. The older term for PAH, primary PAH, has been changed to represent these differences and to distinguish it from postcapillary PAH associated with left-sided heart failure. Limitations in evaluating treatment approaches for PAH include its rarity, the small number of patients included in clinical trials, and issues regarding the use of placebo-controlled trials in a disease with such a high mortality rate if left untreated. Management options include the use of prostacyclin and prostacyclin analogues, endothelin receptor antagonists, and phosphodiesterase inhibitors, as well as traditional background therapy with diuretics, digoxin, calcium channel blockers, and warfarin. Numerous drugs are under investigation to evaluate their possible roles in management. Combination therapy is increasingly becoming a standard approach to therapy, with mounting literature to document effectiveness. Current or emerging roles for the pharmacist in the management of PAH largely involves ensuring access to drug therapy, facilitating specialty pharmacy dispensing, and providing patient counseling. Newer roles may include future drug development, optimized use of investigational drugs, and specialized disease management programs. This compilation includes a series of articles identifying important literature in cardiovascular pharmacotherapy. This bibliography focuses on pharmacotherapeutic management of pulmonary arterial hypertension (PAH). Most of the cited works present the results of significant human clinical studies that have shaped the management of patients with PAH. Limited primary literature is available for some topics, so in addition, consensus documents prepared by expert panels are reviewed. This compilation may serve as a teaching tool, reference resource, or update of the literature for pharmacy clinicians, physicians, and students. © 2012 Pharmacotherapy Publications, Inc.
• Patanwala, A. E., Barletta, J. F., & Erstad, B. L. (2012). Pharmacoepidemiology and patient safety in the critically ill. Pharmaceuticals Policy and Law, 14(1), 93-104.
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  Abstract: Critically ill patients are at the greatest risk of experiencing preventable and non-preventable adverse drug events (ADEs) compared to other patient populations. Information on ADEs concerning these patients is derived from a wide spectrum of sources such as surveillance studies involving large databases to landmark clinical investigations. Historically there has been a lack of consistency with regard to definitions of commonly used terms such as medication error, ADE, and preventability, which is a fundamental to appropriately conduct and interpret results of epidemiological investigations in this setting. However, attempts have been made to standardize this terminology by national organizations. The increased risk of ADEs in the critically ill patient population is due to a variety of reasons, which include the routine use of the intravenous route of drug administration, medications with a low therapeutic index and high complexity, 'off-label' use and an environment that may be conducive to errors. Reporting of ADEs is largely voluntary and is generally underreported and skewed towards the most serious events. Other methods for surveillance of ADEs in the critical care setting include medical record review and direct observation. Each of these methods has their own limitations and the data obtained can vary depending on the method used. A combination of data from all of these methods is likely to produce the most comprehensive information to improve patient safety. © 2012 - Network of Centres for Study of Pharmaceutical Law. All rights reserved.
• Patanwala, A. E., Barletta, J. F., & Erstad, B. L. (2012). Pharmacoepidemiology and patient safety in the critically ill. Pharmaceuticals, Policy and Law, 14(1), 93-104. doi:10.3233/ppl-2011-0344
• Sakles, J. C., Patanwala, A. E., Mckinney, C. B., & Erstad, B. L. (2012). 61: EFFECT OF ETOMIDATE VERSUS KETAMINE ON INTUBATION SUCCESS IN THE EMERGENCY DEPARTMENT. Critical Care Medicine, 40, 1-328. doi:10.1097/01.ccm.0000424317.62485.11
• Snyder, L. S., Erstad, B. L., Jasiak, K. D., Middleton, E. A., Camamo, J. M., & Huckleberry, Y. C. (2012). Evaluation of Discontinuation of Atypical Antipsychotics Prescribed for ICU Delirium. Journal of Pharmacy Practice, 26(3), 253-256. doi:10.1177/0897190012465987
• Acquisto, N. M., Erstad, B. L., & Patanwala, A. E. (2011). Prothrombin Complex Concentrate for Critical Bleeding. Annals of Pharmacotherapy, 45(7-8), 990-999. doi:10.1345/aph.1q096
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  Objective: To review the evidence supporting the use of prothrombin complex concentrate (PCC) as a hemostatic agent in individuals without hemophilia. Data Sources: Articles were identified through a search of Ovid/MEDLINE (up to April 2011) and Cochrane Central Register of Controlled Trials (up to April 2011). The search terms used were prothrombin complex concentrate, hemorrhage, and bleeding. Study Selection and Data Extraction: The search was limited to comparative studies. Bibliographies of retrieved articles were reviewed to obtain additional articles. The intent of the search was to identify original research comparing PCC to fresh frozen plasma (FFP) or recombinant factor VIIa for the management of bleeding in patients without hemophilia. Data Synthesis: PCCs are recommended as an alternative to FFP and recombinant factor VIIa for the treatment of serious or life-threatening bleeding related to vitamin K antagonist therapy. Studies in this setting have shown that PCCs are safe and effective and provide prompt reduction of international normalized ratio (INR) compared to FFP. However, most trials are uncontrolled, and the primary outcomes in these studies have been INR reduction rather than hemostatic effect. Other common off-label uses include coagulopathy due to hepatic failure and traumatic hemorrhage; however, there is insufficient evidence to support use of PCC in these settings. Advantages of PCC include the low drug volume required compared to FFP. The use of PCC may be associated with thromboembolic complications. Conclusions: PCC is a safe and effective alternative to FFP and provides rapid reversal of INR in patients on vitamin K antagonist therapy. These agents may be advantageous compared to FFP in patients with volume restrictions. Comparative trials are needed to compare the various PCC products, FPP, and recombinant factor VIIa with regard to clinically significant outcomes such as hemostatic effect.
• Erstad, B. L. (2011). Colloids and renal dysfunction: Another brick in the wall of safety concerns. Critical Care Medicine, 39(6), 1565-1566.
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  PMID: 21610625;
• Erstad, B. L., Haas, C. E., O'Keeffe, T., Hokula, C. A., Parrinello, K., & Theodorou, A. A. (2011). Interdisciplinary patient care in the intensive care unit: Focus on the pharmacist. Pharmacotherapy, 31(2), 128-137.
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  PMID: 21275491;Abstract: The field of critical care medicine began to flourish only within the last 40 years, yet it provides some of the best examples of collaborative pharmacy practice models and evidence for the value of pharmacist involvement in interdisciplinary practice. This collaborative approach is fostered by critical care organizations that have elected pharmacists into leadership positions and recognized pharmacists through various honors. There is substantial literature to support the value of the critical care pharmacist as a member of an interdisciplinary intensive care unit (ICU) team, particularly in terms of patient safety. Furthermore, a number of economic investigations have demonstrated cost savings or cost avoidance with pharmacist involvement. As the published evidence supporting pharmacist involvement in patient care activities in the ICU setting has increased, surveys have demonstrated an increase in the percentage of pharmacists performing clinical activities. In addition, substantial support of pharmacists has been provided by other clinicians, safety officers, and administrative personnel who have been involved with the initiation and expansion of critical care pharmacy services in their own institutions. Although there is still room for improvement in the range of pharmacist involvement, particularly with respect to interdisciplinary activities related to education and scholarship, pharmacists have become essential members of interdisciplinary care teams in ICU settings.
• Erstad, B. L., Matthias, K. R., & Nix, D. E. (2011). Vancomycin clearance in overweight and obese patients. American Journal of Health-System Pharmacy, 68(19), 1776-1777. doi:10.2146/ajhp110214
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  We read with interest the recent article by Leong et al.[1][1] concerning the use of adjusted body weight (AdjBW) for determining clearance (CL) of vancomycin in overweight and obese patients. Several previous publications involving the pharmacokinetics of vancomycin in this population have
• Erstad, B., Patanwala, A. E., Acquisto, N. M., & Erstad, B. L. (2011). Prothrombin complex concentrate for critical bleeding. The Annals of pharmacotherapy, 45(7-8).
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  To review the evidence supporting the use of prothrombin complex concentrate (PCC) as a hemostatic agent in individuals without hemophilia.
• Erstad, B., Patanwala, A. E., Biggs, A. D., & Erstad, B. L. (2011). Patient weight as a predictor of pain response to morphine in the emergency department. Journal of pharmacy practice, 24(1).
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  There is little evidence that patient weight is associated with pain response to morphine in the emergency department (ED). The primary outcome of this study is to identify demographic variables including patient weight that are associated with an adequate pain reduction after the first dose of morphine.
• Erstad, B., Patanwala, A. E., Hays, D. P., Sanders, A. B., & Erstad, B. L. (2011). Severity and probability of harm of medication errors intercepted by an emergency department pharmacist. The International journal of pharmacy practice, 19(5).
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  OBJECTIVES  The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined. METHODS  The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process. KEY FINDINGS  There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18%), significant (n = 160; 67%) and serious (n = 35; 15%). The final classification of MEs by probability of harm was as follows: none (n = 13; 6%), very low (n = 96; 41%), low (n = 84; 35%), medium (n = 41; 17%) and high (n = 3; 1%). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5%, kappa = 0.35) and probability of harm (agreement = 76.8%, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1%). CONCLUSIONS  A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm.
• Erstad, B., Patanwala, A. E., Stahle, S. A., Sakles, J. C., & Erstad, B. L. (2011). Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 18(1).
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  The objective was to determine the effect of paralytic type and dose on first-attempt rapid sequence intubation (RSI) success in the emergency department (ED).
• Nix, D. E., Matthias, K. R., & Erstad, B. L. (2011). Vancomycin clearance in overweight and obese patients. American Journal of Health-System Pharmacy, 68(19), 1776-1777.
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  PMID: 21930634;
• Patanwala, A. E., Acquisto, N. M., & Erstad, B. L. (2011). Prothrombin complex concentrate for critical bleeding. Annals of Pharmacotherapy, 45(7-8), 990-999.
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  PMID: 21730276;Abstract: OBJECTIVE: To review the evidence supporting the use of prothrombin complex concentrate (PCC) as a hemostatic agent in individuals without hemophilia. DATA SOURCES: Articles were identified through a search of Ovid/MEDLINE (up to April 2011) and Cochrane Central Register of Controlled Trials (up to April 2011). The search terms used were prothrombin complex concentrate, hemorrhage, and bleeding. STUDY SELECTION AND DATA EXTRACTION: The search was limited to comparative studies. Bibliographies of retrieved articles were reviewed to obtain additional articles. The intent of the search was to identify original research comparing PCC to fresh frozen plasma (FFP) or recombinant factor VIIa for the management of bleeding in patients without hemophilia. DATA SYNTHESIS: PCCs are recommended as an alternative to FFP and recombinant factor VIIa for the treatment of serious or life-threatening bleeding related to vitamin K antagonist therapy. Studies in this setting have shown that PCCs are safe and effective and provide prompt reduction of international normalized ratio (INR) compared to FFP. However, most trials are uncontrolled, and the primary outcomes in these studies have been INR reduction rather than hemostatic effect. Other common off-label uses include coagulopathy due to hepatic failure and traumatic hemorrhage; however, there is insufficient evidence to support use of PCC in these settings. Advantages of PCC include the low drug volume required compared to FFP. The use of PCC may be associated with thrombo-embolic complications. CONCLUSIONS: PCC is a safe and effective alternative to FFP and provides rapid reversal of INR in patients on vitamin K antagonist therapy. These agents may be advantageous compared to FFP in patients with volume restrictions. Comparative trials are needed to compare the various PCC products, FPP, and recombinant factor VIIa with regard to clinically significant outcomes such as hemostatic effect.
• Patanwala, A. E., Biggs, A. D., & Erstad, B. L. (2011). Patient weight as a predictor of pain response to morphine in the emergency department. Journal of Pharmacy Practice, 24(1), 109-113.
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  PMID: 21507879;Abstract: Study Objectives: There is little evidence that patient weight is associated with pain response to morphine in the emergency department (ED). The primary outcome of this study is to identify demographic variables including patient weight that are associated with an adequate pain reduction after the first dose of morphine. Methods: A retrospective chart review of all patients with severe nontraumatic abdominal pain receiving intravenous morphine was conducted in our ED over a 3-month time period. Pain score, using an 11-point verbal numerical pain scale (0-10), was measured before and after each dose of morphine. Adequate response was defined as a ≥ 4-point reduction from baseline pain score. Results: A total of 105 patients were included in the analysis. Univariate logistic regression analyses stratified by dose (2 or 4 mg) showed that patient weight was not predictive of adequate pain response after the first dose of morphine (2 mg: odds ratio = 1; 95% confidence interval 0.97-1.03; P = .88; 4 mg: odds ratio = 1; 95% confidence interval 0.97-1.03; P = .86). Conclusions: Patient weight may not predict pain response to morphine in the ED. Dosing strategies based on patient weight may not be necessary in this patient population. © The Author(s) 2011.
• Patanwala, A. E., Hays, D. P., Sanders, A. B., & Erstad, B. L. (2011). Severity and probability of harm of medication errors intercepted by an emergency department pharmacist. International Journal of Pharmacy Practice, 19(5), 358-362.
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  PMID: 21899616;Abstract: Objectives The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined. Methods The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process. Key findings There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18%), significant (n = 160; 67%) and serious (n = 35; 15%). The final classification of MEs by probability of harm was as follows: none (n = 13; 6%), very low (n = 96; 41%), low (n = 84; 35%), medium (n = 41; 17%) and high (n = 3; 1%). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5%, kappa = 0.35) and probability of harm (agreement = 76.8%, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1%). Conclusions A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm. © 2011 Royal Pharmaceutical Society.
• Patanwala, A. E., Sanders, A. B., Weant, K. A., Erstad, B. L., Weant, K. A., Thomas, M. C., Sanders, A. B., Patanwala, A. E., Merritt, E., Erstad, B. L., Baker, S. N., & Acquisto, N. M. (2011). 219 A Prospective, Multicenter Study of Medication Errors Intercepted by Emergency Department Pharmacists. Annals of Emergency Medicine, 58(4), S251. doi:10.1016/j.annemergmed.2011.06.248
• Patanwala, A. E., Stahle, S. A., Sakles, J. C., & Erstad, B. L. (2011). Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Academic Emergency Medicine, 18(1), 11-14.
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  PMID: 21182564;Abstract: Objectives: The objective was to determine the effect of paralytic type and dose on first-attempt rapid sequence intubation (RSI) success in the emergency department (ED). Methods: This was a retrospective evaluation of information collected prospectively in a quality improvement database between July 1, 2007, and October 31, 2008. Information regarding all intubations performed in a tertiary care ED was recorded in this database. All RSI performed using succinylcholine or rocuronium were included. Logistic regression was used to analyze the effect of paralytic type and dosing, as well as age, sex, body mass index, physician experience, device type, and presence of difficult airway predictors on first attempt RSI success. Results: A total of 327 RSI were included in the final analyses. All patients received etomidate as the induction sedative and were successfully intubated. Of these, 113 and 214 intubations were performed using succinylcholine and rocuronium, respectively. The rate of first-attempt intubation success was similar between the succinylcholine and rocuronium groups (72.6% vs. 72.9%, p = 0.95). Median doses used for succinylcholine and rocuronium were 1.65 mg/kg (interquartile range [IQR] = 1.26-1.95 mg/kg) and 1.19 mg/kg (IQR = 1-1.45 mg/kg), respectively. In the univariate logistic regression analyses, variables predictive of first-attempt intubation success were laryngeal view (more success if Grade 1 or 2 compared to Grade 3 or 4 of the Cormack-Lehane classification, odds ratio [OR] = 55.18, 95% confidence interval [CI] = 18.87 to 161.39), intubation device (less success if direct laryngoscopy, OR = 0.57, 95% CI = 0.34 to 0.96), and presence of a difficult airway predictor (OR = 0.55, 95% CI = 0.31 to 0.99). In the multivariate analysis, the only variable predictive of first-attempt intubation success was laryngeal view. Conclusions: Succinylcholine and rocuronium are equivalent with regard to first-attempt intubation success in the ED when dosed according to the ranges used in this study. © 2010 by the Society for Academic Emergency Medicine.
• Amini, A., Erstad, B. L., & Patanwala, A. E. (2010). Use of hypertonic saline injection in trauma. American Journal of Health-System Pharmacy, 67(22), 1920-1928. doi:10.2146/ajhp090523
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  The use of hypertonic saline injection in trauma patients is discussed. Patients with hemorrhage, burns, and traumatic brain injury (TBI) may develop hypovolemic shock and require resuscitation. Compared with conventional isotonic crystalloids, hypertonic saline has several advantages, including hemodynamic, immune-modulating, and antiinflammatory effects, for use in trauma patients for resuscitation. In addition, hypertonic saline is also used in patients with TBI to reduce intracranial pressure (ICP). Overall, studies have not shown a difference in mortality or other clinically important outcomes with the use of hypertonic saline for resuscitation in trauma patients; however, most of these studies were not adequately powered to show significant differences. A recent Cochrane review concluded that there is no evidence that hypertonic crystalloids are better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients. Two recent trials that were adequately powered to investigate a mortality endpoint were halted for futility. A few small randomized controlled studies found that hypertonic saline was more effective than mannitol as a hyperosmolar agent for ICP reduction. Recent guidelines from the American Burn Association have suggested that hypertonic saline may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia. One of the main concerns with the use of hypertonic saline is its potential to cause central pontine myelinolysis due to a rapid increase in serum sodium levels. There is no evidence that hypertonic saline provides any additional benefit over isotonic crystalloid solutions for trauma resuscitation. Hypertonic saline may be more effective than mannitol at reducing ICP in patients with TBI.
• Erstad, B. L. (2010). Developing models for pharmacy practice [1]. American Journal of Health-System Pharmacy, 67(1), 23-24.
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  PMID: 20044362;
• Erstad, B. L. (2010). Developing models for pharmacy practice. American Journal of Health-System Pharmacy, 67(1), 23-24. doi:10.2146/ajhp090540
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  All hospital and health-system pharmacists have a stake in The Pharmacy Practice Model Initiative (PPMI) sponsored by ASHP and the ASHP Research and Education Foundation, given that one of its major objectives is to “determine patient care-related services that should be consistently provided by departments of pharmacy.” 1 Pharmacists must define their own destiny rather than wait for others to define it for them. A cursory Internet search for definitions of “practice of medicine” and “practice of pharmacy” illustrates common perceptions of the two professions. Words used to describe “practice of medicine” are patient-focused (e.g., preventing, healing, curing), whereas hits for “practice of pharmacy” refer the searcher to “pharmacy,” which is defined in product-focused terms such as dispensing and preparing. Thus, I welcome the PPMI and hope here to bring some insight into the discussion. The characteristics of any model depend in part on whether it is intended to be general or specific, which depends in turn on whether the modeler is—in the terminology of one geneticist 2— more a “lumper” or a “splitter.” Although the PPMI refers to the singular form of model (i.e., lumping), it seems clear that multiple models (i.e., splitting) will be needed to foster local changes—at the regional, hospital, or health-system level, for example— to the overarching model. Pharmacist specialists in areas such as critical care, oncology, pediatrics, or transplantation, for instance, would have a practice model with somewhat different components or emphases than that used by generalist pharmacists in the same institution, but all models would be consistent with the “big” model.
• Erstad, B. L., Keim, S. M., & Patanwala, A. E. (2010). Intravenous Opioids for Severe Acute Pain in the Emergency Department. Annals of Pharmacotherapy, 44(11), 1800-1809. doi:10.1345/aph.1p438
• Erstad, B. L., Patanwala, A. E., & Biggs, A. D. (2010). Patient Weight as a Predictor of Pain Response to Morphine in the Emergency Department. Journal of Pharmacy Practice, 24(1), 109-113. doi:10.1177/0897190010362772
• Erstad, B., Patanwala, A. E., Amini, A., & Erstad, B. L. (2010). Use of hypertonic saline injection in trauma. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 67(22).
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  The use of hypertonic saline injection in trauma patients is discussed.
• Erstad, B., Patanwala, A. E., Keim, S. M., & Erstad, B. L. (2010). Intravenous opioids for severe acute pain in the emergency department. The Annals of pharmacotherapy, 44(11).
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  To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy.
• Erstad, B., Patanwala, A. E., Warholak, T. L., Sanders, A. B., & Erstad, B. L. (2010). A prospective observational study of medication errors in a tertiary care emergency department. Annals of emergency medicine, 55(6).
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  We determine the rate and severity of medication errors, as well as factors associated with error occurrence in the emergency department (ED).
• Hennings, S., Romero, A., Erstad, B. L., Franke, H., & Theodorou, A. (2010). A Comparison of Automated Infusion Device Technology to Prevent Medication Errors in Pediatric and Adult Intensive Care Unit Patients. Hospital Pharmacy, 45(6), 464-471. doi:10.1310/hpj4506-464
• Hennings, S., Romero, A., Erstad, B. L., Franke, H., & Theodorou, A. A. (2010). A comparison of automated infusion device technology to prevent medication errors in pediatric and adult intensive care unit patients. Hospital Pharmacy, 45(6), 464-471.
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  Abstract: Objective: To compare possible differences in the proportion of medication errors associated with high-risk medications that were avoided by the use of automated infusion device (AID) technology in pediatric and adult intensive care unit (ICU) patients. A secondary purpose was to investigate the number of serious adverse drug events (ADEs) identified by root-cause analyses (RCA).Method: The study included pediatric and adult patients receiving high-risk medications by continuous infusion in an academic medical center with mixed medical-surgical ICUs. A retrospective evaluation of 1 year's data collected prospectively in an AID database was used to compare the proportion of medication errors avoided based on reprogramming events (2.5 times limit as a low threshold) and overrides (10 times limit as high). Information obtained from RCAs was used to compare the proportion of serious ADEs that occurred during the 5-year periods before and after AID implementation.Results: The pediatric population was 1.68 times (95% confidence interval [CI], 1.18 to 2.38) more likely to require a reprogramming event than the adult acute care population for all high-risk medications combined. Significantly more reprogramming events occurred in the pediatric patients with potassium (relative risk [RR], 2.77; 95% CI, 1.15 to 6.68) and insulin (RR, 2.73; 95% CI, 1.15 to 6.45) infusions. Additionally, there were more overrides in the pediatric compared to the adult population for the high-risk medications (RR, 1.82; 95% CI, 1.32 to 2.53). The number of serious adverse or sentinel events as identified in RCAs decreased from six before (four deemed preventable by AID technology) to three (zero preventable) after AID implementation.Conclusions: This study demonstrates that AID technology when properly used leads to reductions in medication errors and possibly serious ADEs in critically ill patients receiving high-risk medications. The technology appears to be particularly beneficial in pediatric patients with weight-based dosing strategies. However, the potential for clinicians to override the alerts remains a concern. © 2010 Thomas Land Publishers, Inc.
• Jacques, K. A., & Erstad, B. L. (2010). Availability of information for dosing injectable medications in underweight or obese patients. American Journal of Health-System Pharmacy, 67(22), 1948-1950.
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  PMID: 21048212;Abstract: Purpose. Product information and pivotal studies on newly marketed injectable medications were reviewed to determine whether a weight descriptor was included and if information was provided for dosing patients with extremes of body weight. Methods. Products with new drug applications approved by the Food and Drug Administration between January 1, 2004, and January 30, 2009, were evaluated. Any information related to weight descriptors or dosing of patients with extremes of weight (body mass index of 40 kg/m2) relative to age and height was extracted from the product labeling or pivotal studies. Pharmaceutical companies were contacted if pivotal studies had not been published. The information was evaluated with a dosing usefulness score of 0-3; a score of 2 or greater was considered minimally adequate for dosing patients with extremes of weight. Results. Of the 84 medications evaluated, some reference to weight descriptors was found for 23 (27%). None had a calculated usefulness score of 2 or above based on information from product information or pivotal trials. Conclusion. Information from product labeling and pivotal studies involving newly marketed injectable medications is inadequate for dosing patients with extremes of weight.
• Lat, I., Foster, D. R., & Erstad, B. (2010). Drug-induced acute liver failure and gastrointestinal complications. Critical Care Medicine, 38(6 SUPPL.), S175-S187.
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  PMID: 20502172;Abstract: The objective of this article is to describe adverse drug events related to the liver and gastrointestinal tract in critically ill patients. PubMed and other resources were used to identify information related to drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis in critically ill patients. This information was reviewed, and data regarding pathophysiology, common drug causes, and guidelines for prevention and management were collected and summarized. In cases in which data in critically ill patients were unavailable, data were extrapolated from other patient populations. Drug-induced acute liver failure can be caused by many drugs routinely used in the intensive care unit and may be associated with significant morbidity and mortality. Drug-related hypomotility and constipation and drug-related diarrhea are reported with many drugs, and these are common adverse drug events in critically ill patients that can substantially complicate the care of these patients. Drug-induced gastrointestinal bleeding and drug-induced pancreatitis occur less frequently, can range in disease severity, and can be associated with morbidity and mortality. Many drugs used in critically ill patients are associated with adverse drug events related to the liver and gastrointestinal tract. Critical care clinicians should be aware of common drug causes of drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis, and should be familiar with the prevention and management of these diverse conditions. Copyright © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.
• Patanwala, A. E., Amini, A., & Erstad, B. L. (2010). Use of hypertonic saline injection in trauma. American Journal of Health-System Pharmacy, 67(22), 1920-1928.
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  PMID: 21048208;Abstract: Purpose. The use of hypertonic saline injection in trauma patients is discussed. Summary. Patients with hemorrhage, burns, and traumatic brain injury (TBI) may develop hypovolemic shock and require resuscitation. Compared with conventional isotonic crystalloids, hypertonic saline has several advantages, including hemodynamic, immune-modulating, and antiinflammatory effects, for use in trauma patients for resuscitation. In addition, hypertonic saline is also used in patients with TBI to reduce intracranial pressure (ICP). Overall, studies have not shown a difference in mortality or other clinically important outcomes with the use of hypertonic saline for resuscitation in trauma patients; however, most of these studies were not adequately powered to show significant differences. A recent Cochrane review concluded that there is no evidence that hypertonic crystalloids are better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients. Two recent trials that were adequately powered to investigate a mortality endpoint were halted for futility. A few small randomized controlled studies found that hypertonic saline was more effective than mannitol as a hyperosmolar agent for ICP reduction. Recent guidelines from the American Burn Association have suggested that hypertonic saline may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia. One of the main concerns with the use of hypertonic saline is its potential to cause central pontine myelinolysis due to a rapid increase in serum sodium levels. Conclusion. There is no evidence that hypertonic saline provides any additional benefit over isotonic crystalloid solutions for trauma resuscitation. Hypertonic saline may be more effective than mannitol at reducing ICP in patients with TBI. Copyright © 2010, American Society of Health-System Pharmacists, Inc. All rights reserved.
• Patanwala, A. E., Keim, S. M., & Erstad, B. L. (2010). Intravenous opioids for severe acute pain in the emergency department. Annals of Pharmacotherapy, 44(11), 1800-1809.
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  PMID: 20978218;Abstract: OBJECTIVE: To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy. DATA SOURCES: Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department. STUDY SELECTION AND DATA EXTRACTION: The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED. DATA SYNTHESIS: At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction. CONCLUSIONS: Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.
• Erstad, B. L., Brophy, G. M., Martin, S. J., Haas, C. E., Devlin, J. W., Welage, L. S., & Dager, W. E. (2009). Key articles and guidelines relative to intensive care unit pharmacotherapy: 2009 Update. Pharmacotherapy, 29(10), 1228-1269.
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  PMID: 19792995;Abstract: Compilations of key articles and guidelines in a particular clinical practice area are useful not only to clinicians who practice in that area, but also to all clinicians. We compiled pertinent articles and guidelines pertaining to drug therapy in the intensive care setting from the perspective of experienced critical care pharmacists. A broad assembly of practitioners with expertise in various areas of intensive care unit pharmacology were involved in the compilation of this update.
• Erstad, B. L., Puntillo, K., Gilbert, H. C., Grap, M. J., Denise, L. i., Medina, J., Mularski, R. A., Pasero, C., Varkey, B., & Sessler, C. N. (2009). Pain management principles in the critically ill. Chest, 135(4), 1075-1086.
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  PMID: 19349403;Abstract: This article addresses conventional pharmacologic and nonpharmacologic treatment of pain in patients in ICUs. For the critically ill patient, opioids have been the mainstay of pain control. The optimal choice of opioid and dosing regimen for a specific patient varies depending on factors such as the pharmacokinetics and physicochemical characteristics of an opioid and the body's handling of the opioid, concomitant sedative regimen, potential or actual adverse drug events, and development of tolerance. The clinician must appreciate that favorable pharmacokinetic properties such as a short-elimination half-life do not necessarily translate into clinical advantages in the ICU setting. A variety of medications have been proposed as alternatives or adjuncts to the opioids for pain control that have unique considerations when contemplated for use in the critically ill patient. Most have been relatively unstudied in the ICU setting, and many have limitations with respect to availability of the GI route of administration in patients with questionable GI absorptive function. Nonpharmacologic, complementary therapies are low cost, easy to provide, and safe, and many clinicians can implement them with little difficulty or resources. However, the evidence base for their effectiveness is limited. At present, insufficient research evidence is available to support a broad implementation of nonpharmacologic therapies in ICUs. Copyright © 2009 American College of Chest Physicians.
• Erstad, B., Patanwala, A. E., Norris, C. J., Nix, D. E., Kopp, B. J., & Erstad, B. L. (2009). Vancomycin dosing for pneumonia in critically ill trauma patients. The Journal of trauma, 67(4).
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  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.
• Fernandez, J., Erstad, B. L., Petty, W., & Nix, D. E. (2009). Time to positive culture and identification for Candida blood stream infections. Diagnostic Microbiology and Infectious Disease, 64(4), 402-407.
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  PMID: 19446982;Abstract: Candidemia and delay to appropriate therapy contribute to increased morbidity and mortality. Current literature addresses the delay between blood culture collection and final identification; however, it fails to delineate differences among species. The purpose of this study was to quantify the time to yeast detection and identification relative to blood culture collection and determine whether differences exist among species. In this retrospective study, all cases of Candida isolation for 2 years were reviewed. The time delays between blood culture and detection of Candida growth were quantified as well as the additional time required for final species identification. Initiation of antifungal therapy was assessed in relation to culture collection, detection of yeast, and final identification. The appropriateness of therapy at each time point was also analyzed. Most Candida infections were caused by either Candida albicans (n = 43) or Candida glabrata (n = 27). Mean time to positive yeast detection for C. albicans was 35.3 ± 18.1 h, whereas that of C. glabrata was 80.0 ± 22.4 h (P < 0.0001). Mean time to final identification for C. albicans was 85.8 ± 30.9, whereas that of C. glabrata was 154 ± 43.8 h (P < 0.0001). Mean time to appropriate therapy for C. albicans isolates was 43.3 ± 27.6 h compared with 98.1 ± 38.3 h (P < 0.0001) for C. glabrata isolates. The time delay between blood culture collection and yeast detection as well as final identification was significantly longer for C. glabrata isolates when compared with C. albicans. As a result, mean time to appropriate antifungal therapy was significantly longer in patients with C. glabrata isolates. © 2009 Elsevier Inc. All rights reserved.
• Mularski, R. A., Puntillo, K., Varkey, B., Erstad, B. L., Grap, M. J., Gilbert, H. C., Denise, L. i., Medina, J., Pasero, C., & Sessler, C. N. (2009). Pain management within the palliative and end-of-life care experience in the ICU. Chest, 135(5), 1360-1369.
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  PMID: 19420206;Abstract: In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss. Copyright © 2009 American College of Chest Physicians.
• Pasero, C., Puntillo, K., Denise, L. i., Mularski, R. A., Grap, M. J., Erstad, B. L., Varkey, B., Gilbert, H. C., Medina, J., & Sessler, C. N. (2009). Structured approaches to pain management in the ICU. Chest, 135(6), 1665-1672.
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  PMID: 19497902;Abstract: Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill. Copyright © 2009 American College of Chest Physicians.
• Patanwala, A. E., Norris, C. J., Nix, D. E., Kopp, B. J., & Erstad, B. L. (2009). Vancomycin dosing for pneumonia in critically ill trauma patients. Journal of Trauma - Injury, Infection and Critical Care, 67(4), 802-804.
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  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.
• Puntillo, K., Pasero, C., Denise, L. i., Mularski, R. A., Grap, M. J., Erstad, B. L., Varkey, B., Gilbert, H. C., Medina, J., & Sessler, C. N. (2009). Evaluation of pain in ICU patients. Chest, 135(4), 1069-1074.
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  PMID: 19349402;Abstract: Pain is a common and distressing symptom in ICU patients. Yet a major challenge exists in assessing and evaluating the pain. Although the patient's self-report of pain is the "gold standard" for pain assessment, other methods must be considered when patients are unable to self-report. Currently only two pain behavior instruments have been tested for their reliability, validity, and feasibility of use in ICUs: the pain behavior scale and the Critical-Care Pain Observation Tool. Other tools, albeit with less validity testing, include the pain assessment, intervention, and notation (PAIN) algorithm and a pain behaviors checklist. When established tools are insufficient to evaluate a patient's pain, alternative methods of augmenting a pain evaluation should be considered. These can include the completion of a pain risk profile, use of surrogates, or performance of an analgesic trial. Meticulous attention to the evaluation of a critically ill patient's pain provides the basis for selection of pain interventions and the subsequent assessment of the intervention's effectiveness. Copyright © 2009 American College of Chest Physicians.
• Warholak-jackson, T., Sanders, A. B., Patanwala, A. E., & Erstad, B. L. (2009). 140: A Prospective Observational Study of Medication Errors in a Tertiary Care Academic Emergency Department. Annals of Emergency Medicine, 54(3), S44. doi:10.1016/j.annemergmed.2009.06.167
• Zosel, A., Wise, R., Weitz, J. I., Varney, S., Tomassoni, A. J., Todd, K. H., Sivilotti, M. L., Seifert, S. A., Seger, D., Schneider, S. M., Schaeffer, T., Rhyee, S., Phua, D., Olson, K. R., O'malley, G., Mlynarchek, S., Miller, K., Lavonas, E., Huang, D. T., , Hoppe, J., et al. (2009). Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care.. Annals of emergency medicine, 54(3), 386-394.e1. doi:10.1016/j.annemergmed.2009.01.023
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  We developed recommendations for antidote stocking at hospitals that provide emergency care..An expert panel representing diverse perspectives (clinical pharmacology, clinical toxicology, critical care medicine, clinical pharmacy, emergency medicine, internal medicine, pediatrics, poison centers, pulmonary medicine, and hospital accreditation) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for the quantity of an antidote that should be stocked and the acceptable period for delivery of each antidote..The panel recommended consideration of 24 antidotes for stocking. The panel recommended that 12 of the antidotes be available for immediate administration on patient arrival. In most hospitals, this period requires that the antidote be stocked in the emergency department. Another 9 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel identified additional antidotes that should be stocked by the hospital but are not usually needed within the first hour of treatment. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine the need for antidote stocking in that hospital..The antidote expert recommendations provide a tool to be used in creating practices for appropriate and adequate antidote stocking in hospitals that provide emergency care.
• Erstad, B. L. (2008). A Primer on Critical Care Pharmacy Services. Annals of Pharmacotherapy, 42(12), 1871-1881. doi:10.1345/aph.1l375
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  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.
• Erstad, B. L. (2008). A primer on critical care pharmacy services. Annals of Pharmacotherapy, 42(12), 1871-1881.
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  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.
• Erstad, B., & Erstad, B. L. (2008). A primer on critical care pharmacy services. The Annals of pharmacotherapy, 42(12).
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  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.
• Erstad, B., Patanwala, A. E., Jarzyna, D. L., Miller, M. D., & Erstad, B. L. (2008). Comparison of opioid requirements and analgesic response in opioid-tolerant versus opioid-naïve patients after total knee arthroplasty. Pharmacotherapy, 28(12).
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  To compare opioid requirements in opioid-tolerant and opioid-naïve patients after total knee arthroplasty, and to compare pain scores, sedation scores, and adverse effects between the groups.
• Patanwala, A. E., Jarzyna, D. L., Miller, M. D., & Erstad, B. L. (2008). Comparison of opioid requirements and analgesic response in opioid-tolerant versus opioid-naïve patients after total knee arthroplasty. Pharmacotherapy, 28(12), 1453-1460.
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  PMID: 19025426;Abstract: Study Objectives. To compare opioid requirements in opioid-tolerant and opioid-naïve patients after total knee arthroplasty, and to compare pain scores, sedation scores, and adverse effects between the groups. Design. Prospective, observational study. Setting. Academic medical center. Patients. Twenty-nine patients aged 18 years or older who underwent elective total knee arthroplasty between October 1, 2005, and June 31, 2007. Measurements and Main Results. Patients were classified on the basis of their daily opioid consumption during the week before surgery: those who required 10 mg or less of oral morphine equivalent were considered opioid naïve (20 patients), and those who required at least 30 mg of oral morphine equivalent were opioid tolerant (nine patients). Postoperative opioid consumption, pain scores, sedation scores, and adverse effects were compared between the two groups up to 48 hours after discharge from the postanesthesia care unit (PACU). Postoperative opioid consumption (in intravenous morphine equivalents) was significantly greater in the opioid-tolerant group than in the opioid-naïve group in the PACU (median 56 vs 8.2 mg, p=0.0013), during the first 24 hours after discharge from the PACU (108 vs 20.5 mg, p=0.0004), and 24-48 hours after discharge from the PACU (152.3 vs 25 mg, p=0.0001). Pain scores, assessed by using a verbal numeric scale from 0-10, were significantly greater in the opioid-tolerant group than in the opioid-naïve group during the first 24 hours after discharge from the PACU (5.9 vs 4.1, p=0.03). We observed no significant difference in pain scores during the other time periods studied. Sedation scores and adverse effects were similar between groups. Conclusion. After total knee arthroplasty, patients tolerant to opioids required significantly more opioids in the PACU and up to 48 hours after discharge from the PACU than did opioid-naïve patients. Opioid-tolerant patients also experienced greater pain during the first 24 hours after discharge from the PACU; however, sedation scores and adverse effects did not appear to be significantly different at any of the time periods studied. Clinicians need to be aggressive with pain management immediately after surgery and ensure that patients restart any opioid treatment at home as soon as possible.
• Rubinson, L., Hick, J. L., Curtis, J. R., Branson, R. D., Burns, S., Christian, M. D., Devereaux, A. V., Dichter, J. R., Talmor, D., Erstad, B., Medina, J., & Geiling, J. A. (2008). Definitive care for the critically III during a disaster: Medical resources for surge capacity. Chest, 133(5 SUPPL.), 32S-50S.
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  PMID: 18460505;Abstract: Background: Mass numbers of critically ill disaster victims will stress the abilities of health-care systems to maintain usual critical care services for all in need. To enhance the number of patients who can receive life-sustaining interventions, the Task Force on Mass Critical Care (hereafter termed the Task Force) has suggested a framework for providing limited, essential critical care, termed emergency mass critical care (EMCC). This article suggests medical equipment, concepts to expand treatment spaces, and staffing models for EMCC. Methods: Consensus suggestions for EMCC were derived from published clinical practice guidelines and medical resource utilization data for the everyday critical care conditions that are anticipated to predominate during mass critical care events. When necessary, expert opinion was used. Task Force major suggestions: The Task Force makes the following suggestions: (1) one mechanical ventilator that meets specific characteristics, as well as a set of consumable and durable medical equipment, should be provided for each EMCC patient; (2) EMCC should be provided in hospitals or similarly equipped structures; after ICUs, postanesthesia care units, and emergency departments all reach capacity, hospital locations should be repurposed for EMCC in the following order: (A) step-down units and large procedure suites, (B) telemetry units, and (C) hospital wards; and (3) hospitals can extend the provision of critical care using non-critical care personnel via a deliberate model of delegation to match staff competencies with patient needs. Discussion: By using the Task Force suggestions for adequate supplies of medical equipment, appropriate treatment space, and trained staff, communities may better prepare to deliver augmented essential critical care in response to disasters.
• Buckley, M. S., Erstad, B. L., Kopp, B. J., Theodorou, A. A., & Priestley, G. (2007). Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. Pediatric Critical Care Medicine, 8(2), 145-152.
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  PMID: 17273111;Abstract: OBJECTIVE: To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated. DESIGN: Prospective, direct observation study. SETTING: A 16-bed pediatric medical/surgical ICU at a tertiary care academic medical center. PATIENTS: One enrolled nurse caring for at least one pediatric ICU patient age
• Duby, J. J., Erstad, B. L., Abarca, J., Camamo, J. M., Huckleberry, Y., & Bramblett, S. N. (2007). Impact of delayed initiation of erythropoietin in critically ill patients. BMC Blood Disorders, 7.
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  Abstract: Background: The purpose of this study was to evaluate the impact of recombinant human erythropoietin (rHuEPO) use for anemia of critical illness at a practice site where delayed initiation is common. Methods: Retrospective medical record review involving patients treated with rHuEPO for anemia of critical illness. Those patients given rHuEPO or diagnosed with end-stage renal disease (ESRD) prior to ICU admission were excluded. The primary endpoints were rHuEPO use and RBC transfusion patterns. Results: Complete data were collected for consecutive admissions of 126 patients. Average age (SD) and APACHE II score were 56.5 (18.6) years and 25 (7.8), respectively. The median ICU (IQR) and hospital length of stay (LOS) were 24 (11.25, 39) and 29 (17, 44.75) days, respectively. Treatment with rHuEPO was started an average of 12.5 +/- 10.5 days after ICU admission and given for 3.8 +/- 3.8 doses. Eighty percent of patients were transfused with an average total of 5.42 +/- 5.08 units received. RBC exposure inversely correlated with a lower mean hemoglobin response to rHuEPO. ICU LOS (p < 0.0001), hemoglobin at 24 hours (p = 0.055), transfusion within 48 hours of admit (p < 0.0001), and postoperative status (p = 0.019) were the best predictors of transfusion requirements (r2 = 0.37). Conclusion: Delayed initiation of rHuEPO for anemia of critical illness resulted in comparable hemoglobin and transfusion benefits. Future studies are needed to establish clinical benefit and role in therapy. RBC exposure may blunt the erythropoietic effects of rHuEPO, potentially frustrating benefits to those of greatest apparent need. © 2007 Duby et al; licensee BioMed Central Ltd.
• Duby, J. J., Erstad, B. L., Kopp, B. J., & Mrsan, M. (2007). Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. American Journal of Health-System Pharmacy, 64(23), 2483-2487. doi:10.2146/ajhp060674
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  Purpose. The cost implications of and potential adverse events prevented by the interventions of a critical care pharmacist were studied. Methods. A decentralized clinical pharmacist assigned to a surgical intensive care unit (ICU) documented all interventions made from mid-October 2003 through February 2004 using a standardized written form. The data were retrospectively evaluated and the following information was extracted: amount of time spent performing various clinical activities, how drug-related problems were identified (e.g., order entry versus chart review), and a general description of the interventions. The interventions were independently reviewed by two other clinical pharmacists to determine whether an actual or potential adverse drug event (ADE) would have occurred without the intervention, the probability that an ADE would have occurred without the intervention, the type of intervention, and potential cost avoidance of the intervention. Once the evaluations were completed, the data obtained from order entry and verification activities were compared with the data obtained during other clinical functions. Results. A total of 129 interventions were documented over 4.5 months. The majority of interventions were identified during chart review (40%) and patient care rounds (39%). The potential cost avoidance of the documented interventions was $205,919–$280,421. Interventions identified during patient care rounds and chart review were most likely to achieve the greatest impact on cost avoidance. Conclusion. Among the interventions performed and documented by a clinical pharmacist in an ICU, patient care rounds and chart-review activities were associated with the greatest number of interventions and the greatest potential cost avoidance.
• Erstad, B., Patanwala, A. E., Duby, J., Waters, D., & Erstad, B. L. (2007). Opioid conversions in acute care. The Annals of pharmacotherapy, 41(2).
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  To discuss the historical basis and limitations of opioid conversion tables, review the relevant literature, and establish an evidence-based equianalgesic dose ratio (EDR) table for performing conversions in the acute care setting.
• Kopp, B. J., Mrsan, M., Erstad, B. L., & Duby, J. J. (2007). Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. American Journal of Health-System Pharmacy, 64(23), 2483-2487.
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  PMID: 18029956;Abstract: Purpose. The cost implications of and potential adverse events prevented by the interventions of a critical care pharmacist were studied. Methods. A decentralized clinical pharmacist assigned to a surgical intensive care unit (ICU) documented all interventions made from mid-October 2003 through February 2004 using a standardized written form. The data were retrospectively evaluated and the following information was extracted: amount of time spent performing various clinical activities, how drug-related problems were identified (e.g., order entry versus chart review), and a general description of the interventions. The interventions were independently reviewed by two other clinical pharmacists to determine whether an actual or potential adverse drug event (ADE) would have occurred without the intervention, the probability that an ADE would have occurred without the intervention, the type of intervention, and potential cost avoidance of the intervention. Once the evaluations were completed, the data obtained from order entry and verification activities were compared with the data obtained during other clinical functions. Results. A total of 129 interventions were documented over 4.5 months. The majority of interventions were identified during chart review (40%) and patient care rounds (39%).The potential cost avoidance of the documented interventions was $205,919-$280,421. Interventions identified during patient care rounds and chart review were most likely to achieve the greatest impact on cost avoidance. Conclusion. Among the interventions performed and documented by a clinical pharmacist in an ICU, patient care rounds and chart-review activities were associated with the greatest number of interventions and the greatest potential cost avoidance. Copyright © 2007, American Society of Health-System Pharmacists, Inc. All rights reserved.
• Patanwala, A. E., Duby, J. J., Waters, D., & Erstad, B. L. (2007). Opioid Conversions in Acute Care. Annals of Pharmacotherapy, 41(2), 255-267. doi:10.1345/aph.1h421
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  Objective: To discuss the historical basis and limitations of opioid conversion tables, review the relevant literature, and establish an evidence-based equianalgesic dose ratio (EDR) table for performing conversions in the acute care setting. Data Sources: Articles were identified through searches of MEDLINE (1966–January 2007) using the key words opioid, tolerance, conversion, dose, equianalgesic, equipotent, acute care, morphine, hydromorphone, fentanyl, methadone, and oxycodone. Additional references were located through a review of the bibliographies of articles cited and references cited in conversion tables. Study Selection and Data Extraction: All data sources identified were evaluated, and all information deemed relevant was included, with the exception of case series and case reports when higher level evidence was available. Data Synthesis: Opioid conversion tables are published in major textbooks, medical references, national guidelines, and review articles. Some conversion tables do not accurately reflect the dose ratios for which evidence is available. There is marginal evidence-based clinical data to support the dose ratios cited in these tables, particularly in the acute care setting where the clinical status of patients often changes rapidly. The barriers when performing route and opioid-to-opioid conversions in the acute care setting are formidable, but EDRs are provided, based on the best available evidence. Conclusions: In the acute care setting, calculation of dose ratios for opioids, based solely on opioid conversion tables, is an oversimplification of pain management, with a potential for adverse consequences. The calculation of EDRs is one step in an interdisciplinary process that must take into account patient- and institution-specific factors.
• Patanwala, A. E., Duby, J., Waters, D., & Erstad, B. L. (2007). Opioid conversions in acute care. Annals of Pharmacotherapy, 41(2), 255-267.
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  PMID: 17299011;Abstract: OBJECTIVE: To discuss the historical basis and limitations of opioid conversion tables, review the relevant literature, and establish an evidence-based equianalgesic dose ratio (EDR) table for performing conversions in the acute care setting. DATA SOURCES: Articles were identified through searches of MEDLINE (1966-January 2007) using the key words opioid, tolerance, conversion, dose, equianalgesie, equipotent, acute care, morphine, hydromorphone, fentanyl, methadone, and oxycodone. Additional references were located through a review of the bibliographies of articles cited and references cited in conversion tables. STUDY SELECTION AND DATA EXTRACTION: All data sources identified were evaluated, and all information deemed relevant was included, with the exception of case series and case reports when higher level evidence was available. DATA SYNTHESIS: Opioid conversion tables are published in major textbooks, medical references, national guidelines, and review articles. Some conversion tables do not accurately reflect the dose ratios for which evidence is available. There is marginal evidence-based clinical data to support the dose ratios cited in these tables, particularly in the acute care setting where the clinical status of patients often changes rapidly. The barriers when performing route and opioid-to-opioid conversions in the acute care setting are formidable, but EDRs are provided, based on the best available evidence. CONCLUSIONS: In the acute care setting, calculation of dose ratios for opioids, based solely on opioid conversion tables, is an oversimplification of pain management, with a potential for adverse consequences. The calculation of EDRs is one step in an interdisciplinary process that must take into account patient- and institution-specific factors.
• Patanwala, A. E., Erstad, B. L., & Nix, D. E. (2007). Cost-effectiveness of linezolid and vancomycin in the treatment of surgical site infections. Current Medical Research and Opinion, 23(1), 185-193.
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  PMID: 17257479;Abstract: Objective: This decision-analytic study was intended to determine the expected cost-effectiveness of linezolid compared to vancomycin for treating surgical site infections (SSIs) caused by methicillin-resistant Staphyloccocus aureus (MRSA) from the perspective of a tertiary-care academic medical center. Research Design and Methods: This study is a cost-effectiveness analysis based on a modeling approach for the treatment of MRSA SSIs. Three clinical scenarios were considered in the decision analysis: (1) treatment with intravenous (IV) vancomycin during hospitalization and after discharge with home-care follow-up; (2) treatment with IV vancomycin during hospitalization, followed by oral linezolid after discharge; (3) treatment with oral linezolid during hospitalization and after discharge. Cost data was obtained from internal and external sources. Cure rate probabilities for MRSA SSIs were obtained from records at the medical center and from results of a randomized, multicenter trial. Healthcare costs for each scenario were obtained from the medical center, healthcare buying groups, and national databases. The robustness of the baseline cost-effectiveness determination was evaluated using sensitivity analyses over a broad range of costs and probabilities. Results: Treatment with oral linezolid during hospitalization and after discharge (scenario 3) was associated with lower costs ($8923, $11 479, and $12 481, respectively) and greater effectiveness (0.867, 0.787, and 0.707, respectively) compared to the IV vancomycin/oral linezolid switch (scenario 2) and IV vancomycin (scenario 1), so it dominated the latter options in the base-case, incremental cost-effectiveness analysis ($10 292, $14 486, and $17653 per MRSA SSI cure, respectively). Furthermore, the sensitivity analysis demonstrated that the IV vancomycin/oral linezolid (scenario 2) option would be the expected cost-effective choice only if the length of hospitalization for this scenario was less than 6 days or if the probability of cure with oral linezolid (scenario 3) was less than or equal to 0.72; otherwise, the oral linezolid option was dominant. A major limitation of this study is the utilization of probability estimates from both institutional and published research sources. Additionally, the success rates for linezolid were obtained from one relatively small randomized, open-label trial. Conclusions: Using decision-analytic modeling, treatment with oral linezolid during hospitalization and after discharge is expected to be the most cost-effective approach for treating SSIs caused by MRSA. © 2007 Librapharm Limited. All rights reserved: reproduction in whole or part not permitted.
• Ruth, J. T., Ruth, J. T., Nix, D. E., Matthias, K. R., Koopman, E., Hayes, M. M., Erstad, B. L., & Demeure, M. J. (2007). End-of-procedure cefazolin concentrations after administration for prevention of surgical-site infection.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 64(18), 1927-34. doi:10.2146/ajhp070047
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  The adequacy of end-of-procedure free cefazolin concentrations after administration for the prevention of surgical-site infection (SSI) and compliance with national guidelines for antimicrobial prophylaxis for SSI were assessed..Patients undergoing elective surgery and receiving cefazolin for perioperative antimicrobial prophylaxis were prospectively enrolled. Antibiotic administration was controlled by the surgeon and usage was recorded. For each patient, a single blood sample for cefazolin serum free and total concentrations was obtained within 15 minutes of wound closure. A free serum concentration threshold of 4 microg/mL was arbitrarily chosen based on the minimum inhibitory concentration required to inhibit 90% of strains of methicillin-susceptible Staphylococcus aureus and Escherichia coli..Fifty-seven subjects were enrolled, and noncompliance with published guidelines was observed for 26% of patients. Forty-six subjects had serum samples available for assay, 21.7% of whom had end-of-procedure free cefazolin concentrations of
• Erstad, A. J., Erstad, B. L., & Nix, D. E. (2006). Accuracy and reproducibility of small-volume injections from various-sized syringes. American Journal of Health-System Pharmacy, 63(8), 748-750.
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  PMID: 16595816;
• Erstad, B. L., & Schultz, J. M. (2006). Prophylactic antibiotic compliance with published guidelines. Journal of Pharmacy Practice, 19(5), 301-305.
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  Abstract: Purpose: To examine the rate of compliance with National Surgical Infection Prevention Project performance measures and compliance with American Society of Health-System Pharmacists guidelines for procedures not covered by these measures and to evaluate noncompliance for explanatory factors. Methods: A retrospective review of all patients receiving prophylactic antibiotics for Class I (clean) or Class II (clean-contaminated) surgical procedures. Information collected included antibiotic ordered, antibiotic given, dose of antibiotic, time of administration, time of incision, time of closure, duration of procedure, need for re-dosing during the procedure, documentation of re-dosing administered, and antibiotic discontinuation. Results: Choice of antibiotic for prophylaxis was appropriate in 99% of the 568 procedures. Antibiotic was administered too early in 94 of 527 (17.8%) patients. Prophylactic antibiotics were inappropriately continued for more than 24 hours in 43 of 216 (20%) patients undergoing noncardiothoracic procedures and for more than 48 hours in 4 of 10 (40%) in patients undergoing cardiothoracic surgery. Conclusion: Although improvements in key performance measures related to prophylactic antibiotic agent selection, timing of administration, and discontinuation have been made compared to data collected in a larger multicenter study conducted at the beginning of this century, there remains considerable room for improvement. © 2006 Sage Publications.
• Erstad, B. L., Erstad, A. J., & Nix, D. E. (2006). Accuracy and reproducibility of small-volume injections from various-sized syringes. American Journal of Health-System Pharmacy, 63(8), 748-750. doi:10.2146/ajhp050438
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  Most of the published studies of potential dosing errors associated with various-sized syringes have involved insulin.1,–5 Some of the earliest studies of insulin administration found decreased accuracy of delivered doses with syringes that had detachable versus nondetachable needles,1,2 leading to the routine use of fixed-needle syringes. Subsequent in vitro and in vivo studies demonstrated inaccuracy when the delivery of small volumes of insulin was evaluated.3,4 Fewer studies have investigated the accuracy of various types of non-insulin syringes with detachable needles. The studies that are available found potential variability in low-dose delivery volumes due to dead space and technical limitations associated with the measurement of small volumes of liquids.6,–8 We hypothesized that if large syringes were used to inject small volumes of medication, the volumes of medication administered would be less accurate and more variable than those administered with smaller syringes. The purpose of this study was to investigate the accuracy and reproducibility of small-volume injections using various-sized syringes.
• Erstad, B., Patanwala, A. E., Abarca, J., Huckleberry, Y., & Erstad, B. L. (2006). Pharmacologic management of constipation in the critically ill patient. Pharmacotherapy, 26(7).
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  To compare the effectiveness of common laxatives in producing a bowel movement in patients admitted to a medical intensive care unit (MICU).
• Kopp, B. J., Erstad, B. L., Allen, M. E., Theodorou, A. A., & Priestley, G. (2006). Medication errors and adverse drug events in an intensive care unit: Direct observation approach for detection. Critical Care Medicine, 34(2), 415-425.
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  PMID: 16424723;Abstract: Objective: To determine the incidence and preventability of medication errors and potential/actual adverse drug events. To evaluate system failures leading to error occurrence. Design: Prospective, direct observation study. Setting: Tertiary care academic medical center. Patients: Patients in a medical/surgical intensive care unit. Interventions: Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort. Measurements and Main Results: The observers identified 185 incidents during a pilot period and four phases totaling 16.5 days (33 12-hr shifts). Two independent evaluators concluded that 13 of 35 (37%) actual adverse drug events were nonpreventable (i.e., not medication errors). An additional 40 of the remaining 172 medication errors were judged not to be clinically important. Of the 132 medication errors classified as clinically important, 110 (83%) led to potential adverse drug events and 22 (17%) led to actual, preventable adverse drug events. There was one error (i.e., resulting in a potential or actual, preventable adverse drug event) for every five doses of medication administered. The potential adverse drug events mostly occurred in the administration and dispensing stages of the medication use process (34% in each); all of the actual, preventable adverse drug events occurred in the prescribing (77%) and administration (23%) stages. Errors of omission accounted for the majority of potential and actual, preventable adverse drug events (23%), followed by errors due to wrong dose (20%), wrong drug (16%), wrong administration technique (15%), and drug-drug interaction (10%). Conclusions: Using a direct observation approach, we found a higher incidence of potential and actual, preventable adverse drug events and an increased ratio of potential to actual, preventable adverse drug events compared with studies that used chart reviews and solicited incident reporting. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable. There was one preventable error for every five doses of medication administered; most errors were due to dose omission, wrong dose, wrong drug, wrong technique, or interactions. Copyright © 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.
• Nix, D. E., Erstad, B. L., Nakazato, P. Z., Barletta, J. F., Matthias, K. R., & Krueger, T. S. (2006). Estimation of creatinine clearance in end-stage liver disease. Annals of Pharmacotherapy, 40(5), 900-908.
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  PMID: 16670359;Abstract: BACKGROUND: Estimation of renal function in patients with end-stage liver disease (ESLD) is complicated by several factors. OBJECTIVE: To develop a practical and relatively inexpensive method for estimating creatinine production and clearance in patients with ESLD. METHODS: Serum creatinine concentrations and urinary excretion of creatinine were measured in 27 patients with moderate-to-severe liver disease with the goal of developing equations to predict creatinine clearance from serum creatinine. Subjects were studied during an initial evaluation for a liver transplant program. Two 24 hour urine specimens were collected along with 3 serum samples over a 2 day evaluation period. Serum and urine creatinine concentrations were determined using both a modified Jaff́ (autoanalyzer) method and an HPLC method. The data were analyzed using nonlinear mixed-effects modeling. RESULTS: Considering both statistical criteria and physiological conventions through allometric scaling theory, creatinine clearance (mL/min) in males can be estimated as (80/serum creatinine) × (actual body weight/70)0.75. For females, the same equation is valid, but the result is multiplied by 0.661. A simplified equation without the exponent is presented, along with equations that are appropriate when an HPLC assay is used for greater specificity. CONCLUSIONS: These equations offer potential for improved estimation of creatinine clearance in patients with liver impairment; however, they need further validation using an independent group of subjects.
• Patanwala, A. E., Abarca, J., Huckleberry, Y., & Erstad, B. L. (2006). Pharmacologic management of constipation in the critically ill patient. Pharmacotherapy, 26(7 I), 896-902.
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  PMID: 16803421;Abstract: Study Objective. To compare the effectiveness of common laxatives in producing a bowel movement in patients admitted to a medical intensive care unit (MICU). Design. Retrospective medical record review. Setting. MICU of an academic medical center. Patients. Ninety-five patients admitted to the MICU from July 1-October 31, 2004. Measurements and Main Results. Fifty patients satisfied the inclusion criteria. Patient-specific data such as age, weight, sex, length of MICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) II score, dietary intake, opioid intake, laxative intake, and bowel movements were recorded during the first 96 hours of admission. Logistic regression analysis was used to compare patients who did and did not have a bowel movement. Of the 50 patients, 25 did not have a bowel movement during the first 96 hours of MICU admission. Patients given a stimulant laxative (senna, bisacodyl) and/or an osmotic laxative (lactulose, milk of magnesia) were more likely to have a bowel movement (odds ratio [OR] 26.6, 95% confidence interval [CI] 3.2-221, p=0.002). Opioid intake, expressed as logarithmic morphine equivalents, was negatively associated with occurrence of a bowel movement (OR 0.76, 95% CI 0.59-0.97, p=0.027). Disease severity, as determined by APACHE II score, was also negatively associated with a bowel movement (OR 0.84, 95% CI 0.7-0.99, p=0.04). Conclusion. Critically ill patients have a high frequency of constipation, and opioid therapy is a significant risk factor. Routine administration of stimulant or osmotic laxatives should be considered for this patient population.
• Camamo, J. M., McCoy, R. H., & Erstad, B. L. (2005). Retrospective evaluation of inhaled prostaglandins in patients with acute respiratory distress syndrome. Pharmacotherapy, 25(2), 184-190.
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  PMID: 15767234;Abstract: Study Objectives. To determine whether use of inhaled alprostadil (PGE 1) or epoprostenol (PGI2) significantly improved oxygenation in patients with acute respiratory distress syndrome (ARDS), and to determine whether differences between the two drugs exist with regard to oxygenation, duration of mechanical ventilation and hospitalization, adverse effects, and survival. Design. Retrospective chart review. Setting. A 360-bed tertiary care teaching facility with medical and surgical intensive care units. Patients. Twenty-seven patients admitted to the hospital who received either PGI2 or PGE1 for a primary or secondary diagnosis of ARDS. Measurements and Main Results. Seventeen patients received inhaled PGE 1 and 10 received inhaled PGI2. There were no significant changes in the ratio of arterial partial pressure of oxygen (PaO 2):fraction of inspired oxygen (FiO2) and in the PaO 2, from baseline to any time point that was analyzed during treatment, for patients receiving either PGE1 (p=0.2120 and 0.3399, respectively) or PGI2 (p=0.1655 and 0.0784, respectively). Conclusion. No statistically significant improvement in oxygenation was observed in patients receiving either PGE1 or PGI2. In addition, no significant differences were found between the two prostaglandins for the variables studied. Until positive results from large, prospective studies are available, we recommend that these inhaled prostaglandins not be used to treat ARDS.
• Erstad, B. L. (2005). What is the evidence for using hemostatic agents in surgery?. Haemostasis in Spine Surgery, 28-33.
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  Abstract: The pharmacological methods used to achieve systemic hemostasis have generated much discussion due to concerns of serious adverse effects (e.g., thromboembolic complications) and costs of therapy in addition to efficacy considerations. There are a limited number of well-controlled trials involving pharmacological hemostasis for spine surgery. In the largest doubleblinded randomized controlled trial to date involving spine surgery, there was a trend toward reduced homologous transfusion in patients receiving aprotinin, but the only statistically significant result (p
• Erstad, B. L., Martin, S. J., Brophy, G. M., Haas, C. E., Jacobi, J., Welage, L. S., & Thomas, M. C. (2005). Key articles and guidelines relative to intensive care unit pharmacology - 2004. Pharmacotherapy, 25(4), 585-610.
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  PMID: 15977919;Abstract: Compilations of key articles and guidelines in a particular clinical practice area are useful not only to clinicians who practice in that area, but to all clinicians. We compiled pertinent articles and guidelines pertaining to drug therapy in the intensive care setting from the perspective of actively practicing critical care pharmacists. This document differs from the original 2002 version in that a broader assembly of intensive care practitioners was involved in the compilation.
• Erstad, B., Camamo, J. M., McCoy, R. H., & Erstad, B. L. (2005). Retrospective evaluation of inhaled prostaglandins in patients with acute respiratory distress syndrome. Pharmacotherapy, 25(2).
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  To determine whether use of inhaled alprostadil (PGE 1 ) or epoprostenol (PGI 2 ) significantly improved oxygenation in patients with acute respiratory distress syndrome (ARDS), and to determine whether differences between the two drugs exist with regard to oxygenation, duration of mechanical ventilation and hospitalization, adverse effects, and survival.
• Olson, L. M., Desai, S., Soto, M. L., Namazifard, S., Quelland, A. K., & Erstad, B. L. (2005). Evaluation of pharmacists' interventions at a university teaching hospital. Canadian Journal of Hospital Pharmacy, 58(1), 20-25.
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  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.
• Slikker Jr., W., Young, J. F., Corley, R. A., Dorman, D. C., Conolly, R. B., Knudsen, T. B., Erstad, B. L., Luecke, R. H., Faustman, E. M., Timchalk, C., & Mattison, D. R. (2005). Improving predictive modeling in pediatric drug development: Pharmacokinetics, pharmacodynamics, and mechanistic modeling. Annals of the New York Academy of Sciences, 1053, 505-518.
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  PMID: 16179559;Abstract: A workshop was conducted on November 18-19, 2004, to address the issue of improving predictive models for drug delivery to developing humans. Although considerable progress has been made for adult humans, large gaps remain for predicting pharmacokinetic/pharmacodynamic (PK/PD) outcome in children because most adult models have not been tested during development. The goals of the meeting included a description of when, during development, infants/children become adultlike in handling drugs. The issue of incorporating the most recent advances into the predictive models was also addressed: both the use of imaging approaches and genomic information were considered. Disease state, as exemplified by obesity, was addressed as a modifier of drug pharmacokinetics and pharmacodynamics during development. Issues addressed in this workshop should be considered in the development of new predictive and mechanistic models of drug kinetics and dynamics in the developing human. © 2005 New York Academy of Sciences.
• Theodorou, A. A., Priestley, G., Kopp, B. J., Erstad, B. L., & Buckley, M. S. (2005). AN EVALUATION OF MEDICATION ERRORS AND ADVERSE DRUG EVENTS (ADES) IN A PEDIATRIC ICU.: 244-T. Critical Care Medicine, 33, A173. doi:10.1097/00003246-200512002-00612
• Allen, M. E., Erstad, B. L., & Kopp, B. J. (2004). Stress ulcer prophylaxis in the postoperative period. American Journal of Health-System Pharmacy, 61(6), 588-596. doi:10.1093/ajhp/61.6.588
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  The implications of recent studies for guidelines that pertain to stress ulcer prophylaxis in the postoperative period are discussed.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.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.
• Allen, M. E., Kopp, B. J., & Erstad, B. L. (2004). Stress ulcer prophylaxis in the postoperative period. American Journal of Health-System Pharmacy, 61(6), 588-596.
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  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.
• Ashby, D. M., Woods, T. M., Brennan, C., Colgan, K. J., Devereaux, D. S., Erstad, B. L., Ivey, M. F., Phillips, M. S., Puckett, W. H., Senst, B. L., Silvester, J. A., Manasse Jr., H. R., Nolen, A. L., & Schneider, P. J. (2004). Actions of the ASHP Board of Directors - Meeting of April 14-16, 2004. American Journal of Health-System Pharmacy, 61(13), 1400-1401.
• Ashby, D. M., Woods, T. M., Brennan, C., Colgan, K. J., Devereaux, D. S., Erstad, B. L., Ivey, M. F., Phillips, M. S., Puckett, W. H., Senst, B. L., Silvester, J. A., Manasse Jr., H. R., Nolen, A. L., & Schneider, P. J. (2004). Actions of the ASHP Board of Directors - Meeting of January 15-16, 2004. American Journal of Health-System Pharmacy, 61(9), 946-950.
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  PMID: 15156972;
• Erstad, B. L. (2004). Cost-effectiveness of proton pump inhibitor therapy for acute peptic ulcer-related bleeding. Critical Care Medicine, 32(6), 1277-1283.
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  PMID: 15187506;Abstract: Objective: The purpose of this investigation was to perform a cost-effectiveness analysis of adjunctive oral and intravenous proton pump inhibitor (PPI) therapies for patients with acute peptic ulcer-related bleeding of sufficient severity to warrant hospitalisation. Design: Cost-effectiveness investigation. Four clinical scenarios were considered: scenario 1, diagnostic endoscopy with oral PPI therapy; scenario 2, diagnostic and therapeutic endoscopy with high-dose intravenous PPI therapy; scenario 3, diagnostic and therapeutic endoscopy available with oral PPI therapy; and scenario 4, diagnostic and therapeutic endoscopy (no PPI). Effectiveness was evaluated in terms of episodes of bleeding averted and quality-adjusted life years. Setting: University teaching hospital in the United States. Patients: Hospitalised patients with acute peptic ulcer bleeding. Interventions: None. Measurements and Main Results: Therapeutic endoscopy with high-dose intravenous PPI therapy (scenario 2) was the most cost-effective approach in terms of bleeding episode averted ($8,490 vs. $10,201 for scenario 1, $8,756 for scenario 3, and $12,459 for scenario 4) and per quality-adjusted life year ($4,810 vs. $5,533 for scenario 1, $4,946 for scenario 3, and $5,876 for scenario 4). The high-dose intravenous PPI scenario was the dominant approach as evidenced by both superior effectiveness and lower costs over the range of probability and cost variables used in the sensitivity analysis. However, the dominance would be lost if the purchase cost of the intravenous PPI was substantially higher than the baseline cost assumed in this investigation ($61 per 3-day course of therapy). Conclusion: High-dose intravenous PPI therapy in conjunction with therapeutic endoscopy is the most cost-effective approach for the management of hospitalized patients with acute peptic ulcer bleeding.
• Erstad, B. L. (2004). Dosing of medications in morbidly obese patients in the intensive care unit setting. Intensive Care Medicine, 30(1), 18-32.
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  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.
• Erstad, B. L. (2004). What is the evidence for using hemostatic agents in surgery?. European Spine Journal, 13(SUPPL. 1), S28-S33.
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  PMID: 15133722;PMCID: PMC3592183;Abstract: The pharmacological methods used to achieve systemic hemostasis have generated much discussion due to concerns of serious adverse effects (e.g., thromboembolic complications) and costs of therapy in addition to efficacy considerations. There are a limited number of well-controlled trials involving pharmacological hemostasis for spine surgery. In the largest double-blinded randomized controlled trial to date involving spine surgery, there was a trend toward reduced homologous transfusion in patients receiving aprotinin, but the only statistically significant result (p
• Erstad, B. L., Armstrong, E. P., & Adams, R. J. (2004). Prescribing and self-administration of morphine in Hispanic and non Hispanic Caucasian patients treated with patient-controlled analgesia.. Journal of Pain and Palliative Care Pharmacotherapy, 18(2), 29-38. doi:10.1080/j354v18n02_03
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  The purpose of this study was to determine whether differences in either prescribing or self-administration of morphine exist between Hispanic and White (Caucasian) post-operative patients treated with patient-controlled analgesia (PCA). A review of the medical records of 30 Hispanic and 30 White patients who received postoperative PCA was conducted. Both prescribed and self-administered morphine were analyzed using a two-sided, two-sample Student's t-test. No differences in the amount of morphine prescribed (11.23 +/- 3.22 mg/hr in Hispanic patients, 11.05 +/- 4.28 mg/hr in White patients; p = 0.8503) or self-administered (2.58 +/- 2.02 mg/hr in Hispanic patients, 3.32 +/- 3.00 mg/hr in White patients; p = 0.2711) were discovered. This study identified no statistically significant difference in either opioid prescribing or self-administration between Hispanic and White post-operative patients.
• Erstad, B., & Erstad, B. L. (2004). Cost-effectiveness of proton pump inhibitor therapy for acute peptic ulcer-related bleeding. Critical care medicine, 32(6).
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  The purpose of this investigation was to perform a cost-effectiveness analysis of adjunctive oral and intravenous proton pump inhibitor (PPI) therapies for patients with acute peptic ulcer-related bleeding of sufficient severity to warrant hospitalization.
• Herout, P. M., & Erstad, B. L. (2004). Medication errors involving continuously infused medications in a surgical intensive care unit. Critical Care Medicine, 32(2), 428-432.
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  PMID: 14758159;Abstract: Objective: To document the incidence of medication errors related to medications administered by continuous infusion. Design: Observational study. Setting: Sixteen-bed surgical intensive care unit. Measurements and Main Results: All continuous infusions in the surgical intensive care unit were evaluated at least once daily for correct flow-sheet charting, concentration, infusion rate, and dose administered, as well as patients' heights and weights (actual, ideal, and "dry"). Collected information was examined to determine the error rate, types of errors occurring, and weight used for dose calculation. Variations inpatient weight measures were compared. Seventy-one patients with 202 total infusions were observed. Errors involving continuously infused medications in our surgical intensive care unit occurred at a rate of 105.9 per 1,000 patient days. For nonweight-based infusions, 94% of doses were delivered correctly. Slightly >10% of the doses administered for weight-based infusions (dose based on dry body weight) were incorrect. Significant differences were found between the weight measurements recorded, but this did not translate into statistically significant differences in the apparent calculated doses delivered. Conclusions: Medications delivered by continuous infusion, particularly those that are weight based, can contribute to medication errors in the intensive care unit. A large proportion (87.6%) of doses for weight-based infusions was calculated based on estimated or unreliable admission weights. There were no severe consequences resulting from the errors observed in this 1 month investigation; however, depending on the pharmacokinetic characteristics of the drug being administered, there is a potential to deliver artificially low or high doses resulting in subtherapeutic or adverse effects.
• Pajoumand, M., Erstad, B. L., & Camamo, J. M. (2004). Use of Epoetin Alfa in Critically III Patients. Annals of Pharmacotherapy, 38(4), 641-648.
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  PMID: 14966258;Abstract: OBJECTIVE: To discuss the controversies regarding the use of epoetin alfa (EPO) for reducing red blood cell (RBC) transfusions in critically ill patients with anemia. DATA SOURCES: A MEDLINE search (1966-July 2003) was conducted using the search terms anemia; critical illness; erythropoietin; epoetin alfa; and erythropoietin, recombinant. References of selected articles were reviewed for studies that may have been missed by the computerized search. STUDY SELECTION AND DATA EXTRACTION: Studies pertaining to the use of EPO for anemia of critical illness with an emphasis on data obtained from controlled trials. DATA SYNTHESIS: Anemia is a common complication in patients admitted to the intensive care unit (ICU). Two prospective, randomized studies have demonstrated decreased transfusion requirements associated with EPO administration in medical/surgical patients who were in the ICU for at least 3 days and had hematocrit concentrations
• Pajoumand, M., Erstad, B. L., & Camamo, J. M. (2004). Use of Epoetin Alfa in Critically III Patients. Annals of Pharmacotherapy, 38(4), 641-648. doi:10.1345/aph.1d368
• Erstad, B. L. (2003). Osmolality and osmolarity: Narrowing the terminology gap. Pharmacotherapy, 23(9 I), 1085-1086.
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  PMID: 14524639;
• Erstad, B. L. (2003). The cost of enhanced acid suppression. Pharmacotherapy, 23(10 I), 94S-100S.
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  PMID: 14587964;Abstract: Peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), and upper gastrointestinal bleeding are conditions that can make large demands on health care resources. Acid suppression is common therapy for these conditions. The economic implications of managing Helicobacter pylori-related PUD, GERD, and upper gastrointestinal bleeds were considered by several investigators. Economic analyses of drug regimens for PUD show that eradication is more cost effective than H2-receptor antagonist (H2RA) maintenance therapy. Although various eradication regimens have been compared, the results depend on a number of assumptions that preclude general conclusions regarding cost-effectiveness. Economic analyses related to GERD are hindered by the often chronic, relapsing nature of the disease, particularly once therapy is discontinued. Therefore, as with PUD, results of the economic analyses depend largely on initial assumptions relative to the model employed. With regard to upper gastrointestinal bleeding, proton pump inhibitors (PPIs) are potent acid suppressors that may help prevent rebleeding that was managed endoscopically. Further clinical and economic investigations of PPIs for stress ulcer prophylaxis are necessary. Cost-effectiveness studies comparing PPIs and H 2RAs should focus on overall costs of managing these conditions and include economic benefits of preventing complications, and not on drug-acquisition costs alone.
• Erstad, B. L., Huckleberry, Y., & Thomas, M. C. (2003). Dosage conversions as a potential cause of adverse drug events. American Journal of Health-System Pharmacy, 60(2), 189-191. doi:10.1093/ajhp/60.2.189
• Erstad, B., & Erstad, B. L. (2003). The cost of enhanced acid suppression. Pharmacotherapy, 23(10 Pt 2).
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  Peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), and upper gastrointestinal bleeding are conditions that can make large demands on health care resources. Acid suppression is common therapy for these conditions. The economic implications of managing Helicobacter pylori-related PUD, GERD, and upper gastrointestinal bleeds were considered by several investigators. Economic analyses of drug regimens for PUD show that eradication is more cost effective than H2-receptor antagonist (H2RA) maintenance therapy. Although various eradication regimens have been compared, the results depend on a number of assumptions that preclude general conclusions regarding cost-effectiveness. Economic analyses related to GERD are hindered by the often chronic, relapsing nature of the disease, particularly once therapy is discontinued. Therefore, as with PUD, results of the economic analyses depend largely on initial assumptions relative to the model employed. With regard to upper gastrointestinal bleeding, proton pump inhibitors (PPIs) are potent acid suppressors that may help prevent rebleeding that was managed endoscopically. Further clinical and economic investigations of PPIs for stress ulcer prophylaxis are necessary. Cost-effectiveness studies comparing PPIs and H2RAs should focus on overall costs of managing these conditions and include economic benefits of preventing complications, and not on drug-acquisition costs alone.
• Herrier, R. N., Yan, J., Umhoefer, S., Shepherd, M. F., Shane, R. R., Sellers, J. A., Schumock, G. T., Rich, D. S., Nelson, B. A., Mutnick, A. H., Mohassel, M. R., Matuschka, P. R., Malyuk, D., Lau, A., Hudson, T. J., Herrier, R. N., Hammond, R. W., Gordon, W. L., Erstad, B. L., , Eggleston, S. T., et al. (2003). ASHP guidelines on documenting pharmaceutical care in patient medical records.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 60(7), 705-7. doi:10.1093/ajhp/60.7.705
• Huckleberry, Y., Thomas, M. C., & Erstad, B. L. (2003). Dosage conversions as a potential cause of adverse drug events. American Journal of Health-System Pharmacy, 60(2), 189-191.
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  PMID: 12561664;
• Thomas, M. C., & Erstad, B. L. (2003). Safety of enteral naloxone and i.v. neostigmine when used to relieve constipation. American Journal of Health-System Pharmacy, 60(12), 1264-1267.
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  PMID: 12845923;
• Barletta, J. F., Erstad, B. L., & Fortune, J. B. (2002). Stress ulcer prophylaxis in trauma patients. Critical Care, 6(6), 526-530.
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  PMID: 12493075;PMCID: PMC153440;Abstract: Introduction. A number of issues concerning stress ulcer prophylaxis remain unresolved despite numerous randomized, controlled trials and several meta-analyses. The role of stress ulcer prophylaxis, particularly in trauma patients, is further complicated by the lack of trials utilizing clinically important bleeding as an endpoint. Given the lack of consensus regarding stress ulcer prophylaxis in trauma patients, prescribing practices at Level I trauma centers in the United States were assessed. Materials and methods. A survey was developed that contained questions related to institutional prescribing and evaluation of stress ulcer prophylaxis. The survey was intended to delineate these practices at the 188 Level I trauma centers (at the time of the present survey) in the United States. Results. One hundred and nineteen surveys were returned, yielding a response rate of 63%. Eighty-six percent stated that medications for stress ulcer prophylaxis are used in a vast majority of trauma patients admitted to the intensive care unit. Sixty-five percent stated that there is one preferred medication. For these institutions, histamine-2-blockers were the most popular at 71%. Thirty-nine percent stated that greater than 50% of patients remain on stress ulcer prophylaxis following discharge from the intensive care unit. Conclusion. The lack of consensus with regards to appropriate stress ulcer prophylaxis is apparent in this survey of Level I trauma centers. For those institutions with a preferred agent, histamine-2-blockers were most common.
• Bolesta, S., & Erstad, B. L. (2002). The Use of Metoclopramide in Ileus: A Look at Duration of Therapy. Hospital Pharmacy, 37(9), 949-952. doi:10.1177/001857870203700914
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  Purpose The authors conducted a retrospective chart review to determine if metoclopramide was being used properly for ileus and if it caused any adverse effects. Methods All adult patients admitted to the institution's ICUs between November 10, 2000 and January 31, 2001 were evaluated for enrollment. Data was obtained from medication administration records, patient flow sheets, the computer-based laboratory and report systems, and a database of adverse drug events. Bowel movements were used to assess effectiveness. The primary end-point was the length of time metoclopramide was continued after the first bowel movement. A secondary endpoint was the occurrence of any adverse effects related to metoclopramide administration. Results There were a total of 32 patients who received metoclopramide for ileus during the time period studied. The average number of days people received metoclopramide was 11.5 ± 7.3 days. The mean time to first bowel movement was 1.7 ± 1.4 days. Patients had therapy continued after first bowel movement for an average of 10.7 ± 7.1 days. Extrapyramidal symptoms possibly occurred in 3% of the patients. Conclusion The results suggest that metoclopramide was used for the treatment of ileus in ICU patients for prolonged periods of time. This overuse may place patients at risk for adverse events and may also occur at other institutions.
• Bolesta, S., & Erstad, B. L. (2002). The use of metoclopramide in ileus: A look at duration of therapy. Hospital Pharmacy, 37(9), 949-952.
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  Abstract: Purpose: The authors conducted a retrospective chart review to determine if metoclopramide was being used properly for ileus and if it caused any adverse effects. Methods: All adult patients admitted to the institution's ICUs between November 10, 2000 and January 31, 2001 were evaluated for enrollment. Data was obtained from medication administration records, patient flow sheets, the computer-based laboratory and report systems, and a database of adverse drug events. Bowel movements were used to assess effectiveness. The primary endpoint was the length of time metoclopramide was continued after the first bowel movement. A secondary endpoint was the occurrence of any adverse effects related to metoclopramide administration. Results: There were a total of 32 patients who received metoclopramide for ileus during the time period studied. The average number of days people received metoclopramide was 11.5 ± 7.3 days. The mean time to first bowel movement was 1.7 ± 1.4 days. Patients had therapy continued after first bowel movement for an average of 10.7 ± 7.1 days. Extrapyramidal symptoms possibly occurred in 3% of the patients. Conclusion: The results suggest that metoclopramide was used for the treatment of ileus in ICU patients for prolonged periods of time. This overuse may place patients at risk for adverse events and may also occur at other institutions.
• Erstad, B. L. (2002). Dyspepsia: initial evaluation and treatment.. Journal of the American Pharmaceutical Association (Washington,D.C. : 1996), 42(3), 460-468.
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  PMID: 12030633;Abstract: OBJECTIVE: To provide recommendations for the initial evaluation and management of dyspepsia. DATA SOURCES: Articles identified through a MEDLINE search for human studies published in English between 1966 and June 2001, using the primary search term dyspepsia and the secondary search terms diagnosis, complications, and treatment; textbooks with information on the diagnosis and management of gastrointestinal (GI) disorders; and bibliographies of retrieved publications and textbooks. STUDY SELECTION: Articles that focused on dyspepsia as well as factors suggestive of more complicated GI disorders that would require pharmacists to refer patients to a physician. DATA EXTRACTION: Performed by the author manually. DATA SYNTHESIS: Functional dyspepsia (i.e., upset stomach or indigestion with no identifiable lesion) is a common complaint that may be relieved by medications, including antacids, histamine2-receptor antagonists, proton pump inhibitors, and promotility agents. However, therapy should not mask important warning signs and symptoms of more complicated diseases, as that could delay both diagnosis and more definitive treatment. Peptic ulcer disease and gastroesophageal reflux disease each account for about 20% of patients presenting with dyspepsia. Gastric cancer is an important disease to consider in the differential diagnosis of dyspepsia in patients older than 45 years, especially elderly patients (65 years and older). CONCLUSION: Nonprescription medications can relieve functional dyspepsia, but pharmacists must be aware of common features of diseases that require patient referral to a physician for further evaluation.
• Erstad, B. L. (2002). Implications of prion-induced diseases for animal-derived pharmaceutical products. American Journal of Health-System Pharmacy, 59(3), 254-260.
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  PMID: 11862637;Abstract: Abstract: The implications of prion-induced diseases for the use of medications that theoretically could harbor the infectious pathogens are discussed. Prions have been identified as protein particles that lack nucleic acids. There is evidence that prions cause the transmissible neurodegenerative diseases known as transmissible spongiform encephalopathies. Of these diseases, bovine spongiform encephalopathy (BSE) and the human spongiform encephalopathy to which it has been linked, new variant Creutzfeldt-Jakob disease (CJD), have generated the most attention. The first cases of new variant CJD appeared in Britain in the mid-1990s. Ingestion of prion-infected beef remains the only known cause of new variant CJD. No cases of BSE or new variant CJD have been documented in the United States. The time from exposure to the development of clinical sequelae appears to be about 10 years. The median duration of illness is 14 months, and the outcome is invariably death. There is no treatment; currently the only available approach is prevention. There is no reliable method of predicting the number of new cases that might occur because of lack of definitive information on the efficiency of transmission from animals to humans and the number of people currently infected and at risk for infection. The infectivity of medications and plasma fractionation products containing material from cattle with BSE is unknown, but the risk is believed to be very low. No cases of such transmission have been identified. Guidelines to keep the risk of transmission via medications low have been promulgated by FDA, and further research is warranted. There have been no reports of medications or plasma fractionation products being contaminated with the prions that cause new variant CJD. Ongoing vigilance and research are appropriate, however.
• Erstad, B. L. (2002). Implications of prion-induced diseases for animal-derived pharmaceutical products. American Journal of Health-System Pharmacy, 59(3), 254-260. doi:10.1093/ajhp/59.3.254
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  The implications of prion-induced diseases for the use of medications that theoretically could harbor the infectious pathogens are discussed. Prions have been identified as protein particles that lack nucleic acids. There is evidence that prions cause the transmissible neurodegenerative diseases known as transmissible spongiform encephalopathies. Of these diseases, bovine spongiform encephalopathy (BSE) and the human spongiform encephalopathy to which it has been linked, new variant Creutzfeldt-Jakob disease (CJD), have generated the most attention. The first cases of new variant CJD appeared in Britain in the mid-1990s. Ingestion of prion-infected beef remains the only known cause of new variant CJD. No cases of BSE or new variant CJD have been documented in the United States. The time from exposure to the development of clinical sequelae appears to be about 10 years. The median duration of illness is 14 months, and the outcome is invariably death. There is no treatment; currently the only available approach is prevention. There is no reliable method of predicting the number of new cases that might occur because of lack of definitive information on the efficiency of transmission from animals to humans and the number of people currently infected and at risk for infection. The infectivity of medications and plasma fractionation products containing material from cattle with BSE is unknown, but the risk is believed to be very low. No cases of such transmission have been identified. Guidelines to keep the risk of transmission via medications low have been promulgated by FDA, and further research is warranted. There have been no reports of medications or plasma fractionation products being contaminated with the prions that cause new variant CJD. Ongoing vigilance and research are appropriate, however.
• Erstad, B. L. (2002). Laboratory monitoring: Back to basics. American Journal of Pharmaceutical Education, 66(2), 199-203.
• Erstad, B. L. (2002). Principles and Practice of Pharmacology for Anaesthetists, Fourth Edition By T. N. Calvey and N. E. Williams Published by Blackwell Science, P. O. Box 30, 82 Winter Sport Lane, Williston, VT 05495, 2001. vii + 357 p. Price $159.95. American Journal of Health-system Pharmacy, 59(16), 1575-1576.
• Erstad, B. L. (2002). Principles and Practice of Pharmacology for Anaesthetists, Fourth Edition. American Journal of Health-system Pharmacy, 59(16), 1575-1576. doi:10.1093/ajhp/59.16.1575a
• Erstad, B. L. (2002). Which weight for weight-based dosage regimens in obese patients?. American Journal of Health-System Pharmacy, 59(21), 2105-2110.
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  PMID: 12434728;
• Erstad, B. L., Jordan, C. J., & Thomas, M. C. (2002). Key articles and guidelines relative to intensive care unit pharmacology. Pharmacotherapy, 22(12 I), 1594-1610.
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  PMID: 12495169;Abstract: Compilations of key articles and guidelines in a particular clinical practice area are useful not only to clinicians who practice in that area, but to all clinicians. We compiled pertinent articles and guidelines pertaining to drug therapy in the intensive care unit setting from the perspective of an actively practicing critical care pharmacist. This document also may serve to stimulate other experienced clinicians to undertake a similar endeavor in their practice areas.
• Erstad, B., & Erstad, B. L. (2002). Implications of prion-induced diseases for animal-derived pharmaceutical products. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 59(3).
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  The implications of prion-induced diseases for the use of medications that theoretically could harbor the infectious pathogens are discussed. Prions have been identified as protein particles that lack nucleic acids. There is evidence that prions cause the transmissible neurodegenerative diseases known as transmissible spongiform encephalopathies. Of these diseases, bovine spongiform encephalopathy (BSE) and the human spongiform encephalopathy to which it has been linked, new variant Creutzfeldt-Jakob disease (CJD), have generated the most attention. The first cases of new variant CJD appeared in Britain in the mid-1990s. Ingestion of prion-infected beef remains the only known cause of new variant CJD. No cases of BSE or new variant CJD have been documented in the United States. The time from exposure to the development of clinical sequelae appears to be about 10 years. The median duration of illness is 14 months, and the outcome is invariably death. There is no treatment; currently the only available approach is prevention. There is no reliable method of predicting the number of new cases that might occur because of lack of definitive information on the efficiency of transmission from animals to humans and the number of people currently infected and at risk for infection. The infectivity of medications and plasma fractionation products containing material from cattle with BSE is unknown, but the risk is believed to be very low. No cases of such transmission have been identified. Guidelines to keep the risk of transmission via medications low have been promulgated by FDA, and further research is warranted. There have been no reports of medications or plasma fractionation products being contaminated with the prions that cause new variant CJD. Ongoing vigilance and research are appropriate, however.
• Jordan, C. J., & Erstad, B. L. (2002). CLINICAL AND ECONOMIC CONSEQUENCES OF ACUTE PEPTIC ULCER RELATED BLEEDING: 587. Critical Care Medicine, 30(Supplement), A148. doi:10.1097/00003246-200212001-00505
• Keim, S. M., Erstad, B. L., Sakles, J. C., & Davis, V. (2002). Etomidate for procedural sedation in the emergency department. Pharmacotherapy, 22(5), 586-592.
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  PMID: 12013357;Abstract: Study Objective. To review our experience with etomidate in nonintubated patients in the emergency department. Design. A 2-year retrospective chart review of consecutive patients receiving etomidate for sedation. Setting. Emergency department of a university-based teaching hospital. Patients. Forty-eight patients who underwent painful procedures in the emergency department. Measurements and Main Results. Demographics, dosing information, recovery times, and adverse events were abstracted using a standardized data collection form. Forty-eight nonintubated patients were sedated with etomidate. Mean age was 34 years (range 6-80 yrs); 38 were men and 10 women; two were children. The mean initial dose of etomidate was 13 mg. Adverse events occurred in 11 (21%) patients. None sustained any substantial morbidity as indicated by need for intubation, prolonged emergency department stay, or hospital admission. Conclusion. Although controversial, etomidate holds promise as a potent sedative agent for patients undergoing painful procedures in the emergency department. A large prospective evaluation is needed to document the performance and complications of this agent.
• Murray, M. J., Cowen, J., DeBlock, H., Erstad, B., Gray Jr., A. W., Tescher, A. N., McGee, W. T., Prielipp, R. C., Susla, G., Jacobi, J., Nasraway Jr., S. A., & Lumb, P. D. (2002). Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Critical Care Medicine, 30(1), 142-156.
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  PMID: 11902255;
• Calabrese, A. D., Erstad, B. L., Brandl, K., Barletta, J. F., Kane, S. L., & Sherman, D. S. (2001). Medication administration errors in adult patients in the ICU. Intensive Care Medicine, 27(10), 1592-1598.
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  PMID: 11685299;Abstract: Objective: To quantify the incidence and specify the types of medication administration errors from a list of error-prone medications and to determine if patient harm resulted from these errors. Design: An observational evaluation. Setting: Five intensive care units (ICUs) in the United States. Patients and participants: Eight hundred fifty-one patients who were at least 18 years of age and admitted to surgical, medical or mixed ICUs during a 3 month period were included. Interventions: None. Measurements and results: A list of error-prone medications was adapted from the literature and evaluated for medication errors and patient harm. Of 5,744 observations in 851 patients, 187 (3.3%) medication administration errors were detected the therapeutic classes most commonly associated with errors were vasoactive drugs 61 (32.6%) and sedative/analgesics 48 (25.7%). The most common type of error was wrong infusion rate with 71 (40.1%) errors. Twenty-one errors did not reach the patient and 159 reached the patient but did not result in harm, increased monitoring or intervention. Five errors required increased patient monitoring and two required intervention. None of the errors resulted in patient death. Conclusions: This multicenter evaluation found fewer medication administration errors than the published literature, possibly due to the varying observational techniques and pharmacist involvement. Lorazepam and wrong infusion rates are associated with errors that occurred frequently, resulted in the greatest potential for harm and were common oversights in the system. These errors should be considered potential areas for betterment in the medication use process to improve patient safety.
• Erstad, B. L. (2001). Antifibrinolytic agents and desmopressin as hemostatic agents in cardiac surgery. Annals of Pharmacotherapy, 35(9), 1075-1084.
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  PMID: 11573859;Abstract: OBJECTIVE: To review the use of systemic hemostatic medications for reducing bleeding and transfusion requirements with cardiac surgery. DATA SOURCES: Articles were obtained through computerized searches involving MEDLINE (from 1966 to September 2000). Additionally, several textbooks containing information on the diagnosis and management of bleeding associated with cardiac surgery were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. STUDY SELECTION: Due to the large number of randomized investigations involving systemic hemostatic medications for reducing bleeding associated with cardiac surgery, the article selection process focused on recent randomized controlled trials, metaanalyses, and pharmacoeconomic evaluations. DATA EXTRACTION: The primary outcomes extracted from the literature were blood loss and associated transfusion requirements, although other outcome measures such as mortality were extracted when available. DATA SYNTHESIS: Although the majority of investigations for reducing cardiac bleeding and transfusion requirements have involved aprotinin, evidence from recent meta-analyses and randomized trials indicates that the synthetic antifibrinolytic agents, aminocaproic acid and tranexamic acid, have similar clinical efficacy. Additionally, aminocaproic acid (and to a lesser extent tranexamic acid) is much less costly. More comparative information of hemostatic agents is needed relative to other outcomes (e.g., reoperation rates, myocardial infarction, stroke). There is insufficient evidence to recommend the use of desmopressin for reducing bleeding and transfusion requirements in cardiac surgery, although certain subsets of patients may benefit from its use. CONCLUSIONS: Of the medications that have been used to reduce bleeding and transfusion requirements with cardiac surgery, the antifibrinolytic agents have the best evidence supporting their use. Aminocaproic acid is the least costly therapy based on medication costs and transfusion requirements.
• Erstad, B. L. (2001). Octreotide for Acute Variceal Bleeding. Annals of Pharmacotherapy, 35(5), 618-626. doi:10.1345/aph.10316
• Erstad, B. L. (2001). Octreotide for acute variceal bleeding. Annals of Pharmacotherapy, 35(5), 618-626.
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  PMID: 11346068;Abstract: OBJECTIVE: To review the use of octreotide for acute variceal bleeding. DATA SOURCES: Articles were obtained through computerized searches involving MEDLINE (from 1997 to October 2000). Additionally, several textbooks containing information on the diagnosis and management of acute variceal bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. STUDY SELECTION: All randomized studies and pharmacoeconomic evaluations that used octreotide therapy for acute variceal bleeding were considered. Randomized controlled trials and meta-analyses involving other therapies for treating variceal bleeding were also reviewed for possible inclusion. DATA EXTRACTION: The primary outcomes extracted from the literature were persistent or recurrent bleeding, need for endoscopic intervention or balloon tamponade, and mortality. DATA SYNTHESIS: Although both endoscopic therapies and medications are used to control bleeding and rebleeding episodes, the endoscopic approach has the additional goal of obliterating the varix. Since rebleeding episodes are common as long as the varix is present, endoscopic and medication therapies cannot be considered interchangeable based on bleeding control alone. However, octreotide by continuous intravenous infusion has demonstrated effectiveness in reducing blood loss and transfusion requirements as both an initial intervention (until definitive sclerotherapy can be performed) or as adjunctive therapy to endoscopic measures. Octreotide can be started quickly, has a relatively rapid onset of action, and does not require someone with endoscopy training to initiate. Additionally, octreotide is relatively free of significant adverse effects. CONCLUSIONS: While additional investigations are needed, particularly in the area of pharmacoeconomics, there is substantial evidence that octreotide is an efficacious therapy with relatively few adverse effects when used in the management of acute variceal bleeding.
• Erstad, B. L. (2001). Proton-pump inhibitors for acute peptic ulcer bleeding. Annals of Pharmacotherapy, 35(6), 730-740.
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  PMID: 11408992;Abstract: OBJECTIVE: To review the use of proton-pump inhibitors for acute peptic ulcer bleeding. DATA SOURCES: Articles were obtained through computerized searches of MEDLINE (1966-September 2000). Additionally, several textbooks containing information on the diagnosis and management of acute peptic ulcer bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. STUDY SELECTION: All randomized studies and pharmacoeconomic evaluations that used proton-pump inhibitor therapy for acute peptic ulcer bleeding were included. Randomized controlled trials and meta-analyses involving other therapies for treating peptic ulcer bleeding were also reviewed for possible inclusion. DATA EXTRACTION: The primary outcomes extracted from the literature were persistent or recurrent bleeding, transfusion requirements, need for endoscopic intervention or surgery, length of stay, and mortality. DATA SYNTHESIS: Data from double-blind, placebo-controlled trials involving more than 1000 patients demonstrate that short-term, high-dose omeprazole therapy is effective for reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding. The patients most likely to benefit from this therapy are hospitalized patients at high risk for rebleeding and patients in whom endoscopic evaluation must be delayed or is unavailable. CONCLUSIONS: Omeprazole (and likely other proton-pump inhibitors) is useful in reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding, although better delineation of appropriate candidates is needed.
• Erstad, B. L. (2001). Systemic hemostatic medications for reducing surgical blood loss. Annals of Pharmacotherapy, 35(7-8), 925-934.
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  PMID: 11485146;Abstract: OBJECTIVE: To review randomized trials involving the use of systemic hemostatic medications for reducing surgical blood loss. DATA SOURCES: Articles were obtained through searches of MEDLINE (1966-September 2000). The bibliographies of retrieved publications were reviewed for additional references. STUDY SELECTION: All randomized studies and pharmacoeconomic evaluations that involved medications used for systemic hemostasis in the perioperative period were included. DATA EXTRACTION: Randomized studies involving conjugated estrogens, aminocaproic acid, tranexamic acid, desmopressin, and aprotinin for systemic hemostasis were extracted. Studies of proton-pump inhibitors for upper gastrointestinal bleeding and octreotide for variceal bleeding were excluded, as were trials involving the use of any hemostatic agent for cardiovascular surgery. The primary outcome under review was a reduction in bleeding as defined by reduced transfusion requirements. DATA SYNTHESIS: There is limited efficacy and toxicity information concerning the use of conjugated estrogens for reducing surgery-related bleeding. Similarly, there are a limited number of randomized studies involving aminocaproic acid and tranexamic acid, and with the exception of tranexamic acid for reducing transfusion requirements with knee surgery, the study results are either conflicting or negative. For desmopressin, evidence from a substantial number of randomized trials documents its lack of efficacy. Aprotinin has reduced bleeding and transfusion requirements in a number of randomized studies involving patients undergoing orthopedic surgery, but cost-effectiveness studies are needed to better define its therapeutic role. Trials of aprotinin during hepatic surgery have yielded conflicting results. CONCLUSIONS: Most hemostatic medications used for reducing surgery-related bleeding have limited or contradictory evidence of efficacy.
• Patrick, K. L., Erstad, B. L., & Armstrong, E. P. (2001). Comparison of preoperative skin preparation products.. Pharmacotherapy, 21(3), 345-50. doi:10.1592/phco.21.3.345.34196
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  We compared application, drying, and removal times as well as user satisfaction of four preoperative skin preparation products. All products were applied to 25 subjects, allowed to dry, and removed. Operating room personnel who applied the products were asked to complete a user-satisfaction survey. Application and drying times were longest with the povidone iodine paint and scrub product (p
• Barletta, J. F., Erstad, B. L., Loew, M., & Keim, S. M. (2000). A prospective study of pain control in the emergency department. American Journal of Therapeutics, 7(4), 251-255.
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  PMID: 11486159;Abstract: The most common complaint in the emergency department is pain. The management of acute pain, however, has not been well studied. This prospective study was designed to assess pain intensity and relief along with satisfaction in the emergency department. Adult patients with a primary complaint of acute pain were asked to complete a two-part questionnaire administered by a research assistant. The first part was completed on arrival and the second part on discharge from the emergency department. The respondents were not permitted to see the first part of the questionnaire while completing the second. The questionnaire used an unmarked, horizontal 10-cm visual analog scale along with short answer questions to measure pain, relief, and satisfaction. Choice of drug therapy was decided by the physician according to usual treatment methods. Fifty-seven people presented with the chief complaint of pain. Of those, 30 (53%) were treated with medications. The mean level of pain on admission for treated patients was 6.64 compared with a mean level of pain on discharge of 4.02 (P = .0001). Untreated patients had a mean admission visual analog scale score of 4.19. Compared with treated patients, this difference was statistically significant (P = .001). A mean visual analog scale score of 5.43, representing the mean amount of pain relief, was reported among treated patients. Treated patients also reported a visual analog scale score of 6.46 in overall satisfaction with pain management. The results of this study indicate that there is a significant and clinical difference in levels of pain and satisfaction between admission and discharge in these patients in the emergency department. © 2000 Lippincott Williams & Wilkins, Inc.
• Barletta, J. F., Johnson, S. B., Nix, D. E., Nix, L. C., & Erstad, B. L. (2000). Population pharmacokinetics of aminoglycosides in critically ill trauma patients on once-daily regimens. Journal of Trauma - Injury, Infection and Critical Care, 49(5), 869-872.
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  PMID: 11086778;Abstract: Background: Once-daily dosing regimens of aminoglycosides are routinely used in critically ill trauma patients. However, the pharmacokinetic parameters are variable in these patients. The purpose of this study was to evaluate the pharmacokinetics of aminoglycosides in critically ill trauma patients receiving once-daily dosing regimens. Methods: At least two aminoglycoside concentrations were measured in each patient. Population pharmacokinetic parameters were estimated on the basis of a one-compartment structural model and the program nonlinear mixed effects modeling. Results: Fifty-three aminoglycoside concentrations from 19 patients were analyzed. The aminoglycoside clearance was 5.47 L/h. The mean volume of distribution was 22.2 L (0.3 L/kg). The mean half-life was 2.9 hours. Serum-aminoglycoside concentrations were undetectable for longer than 12 hours in 4 of 19 patients. Weight, age, or serum creatinine did not significantly explain the variability. Conclusion: There is marked variability in aminoglycoside pharmacokinetic parameters in critically ill trauma patients. This may lead to prolonged drug-free intervals. Individualized dosing of critically ill trauma patients on the basis of at least two serum-aminoglycoside concentrations seems indicated when using once-daily dosing regimens.
• Erstad, B. L. (2000). Enteral Nutrition Support in Acute Pancreatitis. Annals of Pharmacotherapy, 34(4), 514-521. doi:10.1345/aph.19144
• Erstad, B. L. (2000). Enteral nutrition support in acute pancreatitis. Annals of Pharmacotherapy, 34(4), 514-521.
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  PMID: 10772439;Abstract: OBJECTIVE: To review the controversies surrounding the use of nutritional interventions, particularly enteral support, in patients with acute pancreatitis. DATA SOURCES: Articles were obtained through a MEDLINE search (1966-June 1999). Additionally, several textbooks containing information on the diagnosis and management of acute pancreatitis were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. STUDY SELECTION: All original investigations in humans pertaining to the use of enteral nutritional support in acute pancreatitis were reviewed for inclusion. Studies that investigated parenteral nutrition in acute pancreatitis were also reviewed, with preference given to controlled comparisons with enteral regimens or no nutritional support. DATA EXTRACTION: The primary outcomes extracted from the literature were time to oral feeding tolerance, complications (e.g., infection) associated with nutritional support, and length of stay. DATA SYNTHESIS: The duration of pancreatitis and time to oral feedings is similar whether patients receive enteral (i.e., jejunal tube feedings) or parenteral nutrition. Additionally, complications, length of stay, and costs are either similar or decreased with enteral versus parenteral nutrition. CONCLUSIONS: Current evidence suggests that the enteral rather than parenteral route should be used to provide nutrition to patients with acute pancreatitis. Parenteral nutrition should be reserved for patients in whom nasojejunal feeding is not possible.
• Erstad, B. L., & Barletta, J. F. (2000). Treatment of hypertension in the perioperative patient. Annals of Pharmacotherapy, 34(1), 66-79.
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  PMID: 10669188;Abstract: OBJECTIVE: To review studies and drug therapy relating to the treatment of hypertension in perioperative patients. DATA SOURCES: Articles were selected from a MEDLINE search (1966-August 1998), and several textbooks on hypertension and surgery were reviewed. In addition, bibliographies of all articles and textbook chapters were studied for articles not found in the computerized searches. STUDY SELECTION: Clinical studies involving hypertension in the perioperative setting were included. The initial search was limited to studies conducted in humans and published in English. DATA EXTRACTION: Information regarding drug therapy was reviewed and guidelines were constructed for managing surgical patients with acute blood pressure elevations. DATA SYNTHESIS: Although nitroprusside and nitroglycerin, with their short onset of action and duration of effect, are indicated for hypertensive emergencies, a variety of agents are available for hypertensive urgencies. An algorithm that can be used as a template for the development of intrainstitutional guidelines is provided. CONCLUSIONS: Due to the scarcity of comparative trials, decisions involving agents for the treatment of perioperative hypertension must often be made based on combined efficacy, toxicity, cost, and convenience considerations.
• Erstad, B. L. (1999). Concerns with defining appropriate uses of albumin by meta-analysis. American Journal of Health-System Pharmacy, 56(14), 1451-1454.
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  PMID: 10428455;
• Erstad, B. L. (1999). Concerns with defining appropriate uses of albumin by meta-analysis. American Journal of Health-System Pharmacy, 56(14), 1451-1454. doi:10.1093/ajhp/56.14.1451
• Erstad, B. L. (1999). General therapeutic considerations in patients with acute renal failure. American Journal of Pharmaceutical Education, 63(2), 209-213.
• Erstad, B. L. (1999). Pharmacoeconomic comparison of an albumin-furosemide complex versus sequential therapy for renal insufficiency. Clinical Therapeutics, 21(8), 1380-1386.
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  PMID: 10485509;Abstract: The purpose of this economic analysis was to develop an economic model using intra-institutional cost data for acute, oliguric renal insufficiency treated with either an albumin-furosemide complex or albumin followed by furosemide (sequential therapy). The perspective of this study was from the standpoint of the institution (University Medical Center, a teaching hospital). The decision tree and sensitivity analyses demonstrated that the albumin-furosemide complex would be more effective and less costly than sequential therapy for a range of outcome probabilities. Using effectiveness assumptions from published literature, the complex could avoid dialysis in 27% of patients compared with 8% of patients receiving sequential therapy. The complex would also be less costly ($7778 vs $8748). In terms of cost- effectiveness, the complex is $28,807 per averted dialysis compared with $109,350 for sequential therapy.
• Erstad, B. L., & Armstrong, D. K. (1999). The application of animal models to critical care patients. Critical Care Medicine, 27(9), 2045-2046.
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  PMID: 10507650;
• Erstad, B. L., & Favre, J. K. (1999). Written testing of students in the experiential setting. American Journal of Pharmaceutical Education, 63(4), 426-429.
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  Abstract: There is a paucity of literature regarding specific evaluation or testing procedures used in the experiential setting. The purpose of this investigation was to compare the results of paired baseline and end-rotation short-answer tests and determine the potential role of such testing in the student learning and evaluation process. The preceptor had students on rotations at this site for approximately ten years, which resulted in 86 pre/post examinations. There was significant improvement in the scores from baseline to end-rotation (10.51 ± 2.90 to 13.92 ± 2.50, P
• Erstad, B. L., & Tong, T. G. (1999). Evaluation of learning skills development and computer-assisted learning strategies associated with an orientation program. American Journal of Pharmaceutical Education, 63(2), 182-185.
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  Abstract: The promotion of the importance of self-learning skills to students has paralleled the increasing use of computer technologies both in and out of the classroom. The purpose of this investigation was to evaluate an extended orientation session for incoming pharmacy students that included instruction in learning skills development and the use of computer-assisted instructional strategies. Pre- and post-assessment surveys containing questions with Likert-type response scales were completed by the students. Overall, the students found the sessions to be useful, with statistically significant improvements noted in their perceptions of the importance of learning techniques and use of the Internet for health-related purposes. Learning skills development and computer-assisted learning strategies are important aspects of a student's education, and this can be emphasized and initiated during orientation programs for incoming students.
• Erstad, B. L., Barletta, J. F., Jacobi, J., Killian, A. D., Kramer, K. M., & Martin, S. J. (1999). Survey of stress ulcer prophylaxis. Critical Care, 3(6), 145-149.
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  Abstract: Background: No surveys of stress ulcer prophylaxis prescribing in the USA have been conducted since 1995. Since that time, the most comprehensive meta-analysis and largest randomized study to date concerning stress ulcer prophylaxis have been published. Results: Three hundred sixty-eight surveys were sent to all members of the Section of Pharmacy and Pharmacology of the Society of Critical Care Medicine. One hundred fifty-three (42%) surveys were returned. Representatives from 86% of institutions stated that medications for stress ulcer prophylaxis are used in a majority (>90%) of patients admitted to the intensive care unit (ICU). Twenty-two per cent of institutions have recommendations for both ICU and non-ICU settings. Fifty- eight per cent of institutions stated that there was one preferred medication for stress ulcer prophylaxis, and in 77% of these histamine-2-antagonists were the most popular. Conclusions: There are wide variations in prescribing practices for stress ulcer prophylaxis. Institutions should consult published literature and use pre-existing guidelines as templates for developing their own guidelines.
• Erstad, B. L., Costa, C. M., Daller, J. A., & Fortune, J. B. (1999). Lack of hematologic effects of recent ethanol ingestion by trauma patients. American Journal of Therapeutics, 6(6), 299-302.
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  PMID: 11329113;Abstract: A retrospective investigation was conducted to determine if acute ethanol (EtOH) ingestion before injury leads to hematologic impairment as noted by coagulation and transfusion parameters. Patients older than 18 years of age were grouped according to the presence or absence of detectable EtOH concentrations in the blood, with further subdivision based on an Injury Severity Score of 8 or less or 9 or more. The following direct and indirect indicators of hematologic function were studied: volume of resuscitation fluids administered (including blood products), prothrombin time, partial thromboplastin time, and hematocrit. Of the 304 patients who were evaluated, 152 had detectable EtOH concentrations and 136 had undetectable EtOH concentrations; 16 patients had not been tested for blood EtOH concentrations and were excluded from the analysis. There were no significant differences between groups with regard to blood or fluid requirements or coagulation parameters. Detectable blood EtOH concentrations in trauma patients are not associated with significant changes in transfusion requirements or coagulation parameters compared to patients without detectable EtOH concentrations.
• Erstad, B. L., Richards, H., Rose, S., Nakazato, P., & Fortune, J. (1999). Influence of 25% human serum albumin on total and ionized calcium concentrations in vivo. Critical Care Medicine, 27(1 SUPPL.), A59.
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  Abstract: Introduction: A inverse correlation has been found between changes in ionized calcium concentrations (physiologically active form) and the addition of albumin in vitro, which may explain adverse cardiovascular effects attributed to exogenous albumin in vivo. The purpose of this investigation was to determine the interaction (if any) between exogenous 25% albumin administration and calcium concentrations in unstable patients. Methods: Following a retrospective analysis involving critically ill patients in which no effect of 25% albumin on ionized calcium concentrations was noted, nine patients were studied prospectively. With one exception, all patients were studied in the ICU. Concentrations of albumin, total and ionized calcium were obtained within one hour prior to the start of a 25% 100 mL albumin infusion given over less than one-half hour, and then at the end and six hours after the infusion. The commercially-available albumin product was tested to ensure that it did not contain substantial amounts of calcium. No other albumin-containing products were administered during the study periods. Results: There were no significant differences in either the ionized or total calcium concentrations obtained before and after the administration of albumin. Ionized calcium in mMol/L*Total calcium in mg/dL Pre/1 h post/6 h post Pre/1 h post/6 h post Concentrations 1.09(0.23)/1.06(0.22)/1.06(0.21) 8.1(0.7)/8.2(0.8)/8.3(.9)*all values expressed as mean (SD); no significant differences by ANOVA Conclusions: In patients receiving relatively rapid infusions of 25% albumin, it appears that circulating calcium concentrations are well-regulated by homeostatic mechanisms. Albumin infusions had no effect on either ionized or total calcium concentrations, although it is possible that temporary changes of questionable clinical importance may have occurred between measurement periods.
• Erstad, B. L., Richards, H., Rose, S., Nakazato, P., & Fortune, J. (1999). Influence of twenty-five per cent human serum albumin on total and ionized calcium concentrations in vivo. Critical Care, 3(4), 117-121.
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  Abstract: Background: A inverse correlation has been found between changes in ionized calcium concentrations and the addition of albumin in vitro, which may explain adverse cardiovascular effects attributed to exogenous albumin in vivo. The purpose of this investigation was to determine the interaction (if any) between exogenous 25% albumin administration (100 ml given over
• Erstad, B. L. (1998). Venous thromboembolism in multiple trauma patients. Pharmacotherapy, 18(5), 1011-1023.
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  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.
• Erstad, B. L. (1997). Evaluation of Practice Site Learning Experience for Entry-Level Doctor of Pharmacy Students.. The American Journal of Pharmaceutical Education, 61(1), 87-90.
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  The purpose of this investigation was to evaluate an entry-level learning experience involving 55 pharmacy students and to determine if explicit pre-site discussion of intended outcome objectives added value to the experience. All students were required to complete a daily log and a written summary of the experience. Students were also given a preand post-site self-assessment survey concerning their awareness, understanding, and mastery of the desired outcomes. With a few important exceptions (no pre-site discussion group), the students indicated through written reports and answering of surveys an increased awareness and understanding of the desired outcomes as a result of the program. The students were particularly interested in interacting with patients and lack of such interaction was often associated with negative impressions of the experience. An analysis of written reports indicated such programs are most likely to be successful when the desired objectives are discussed with students before the visit and when the student is exposed to a variety of experiences, particularly interactions with patients.
• Erstad, B. L., & McIntyre Jr., K. E. (1997). Prospective, randomized comparison of ampicillin/sulbactam and cefoxitin for diabetic foot infections. Vascular Surgery, 31(4), 419-426.
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  Abstract: The purpose of this prospective, randomized, double-blind investigation was to compare two different parenteral antibiotics (ampicillin/sulbactam and cefoxitin) in conjunction with appropriate surgical procedures for treatment of patients with diabetic foot infections on a vascular surgery service. Thirty-six patients with diabetes mellitus who required hospitalization to treat foot infections were randomized into one of two treatment groups. There were 18 patients with similar baseline characteristics randomized to each treatment group. The Chi-square test was used for clinical and bacteriological comparisons, the Wilcoxon rank sum test was used for comparing duration of hospitalization and clinical signs and symptoms, and Fisher's Exact Test (two-tailed) was used to compare treatment outcomes of the two groups. Based on intention-to-treat analysis, there was no significant difference in treatment outcome (cure + improved) between the ampicillin/sulbactam (15/17) and cefoxitin groups (16/17). Similarly, no significant differences in bacteriologic response were noted. Both ampicillin/sulbactam and cefoxitin, when combined with appropriate surgical interventions, are safe and effective therapies for treating foot infections in patients with diabetes mellitus.
• Erstad, B. L., & McIntyre, K. E. (1997). Prospective, Randomized Comparison of Ampicillin/Sulbactam and Cefoxitin for Diabetic Foot Infections. Vascular Surgery, 31(4), 419-426. doi:10.1177/153857449703100403
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  The purpose of this prospective, randomized, double-blind investigation was to compare two different parenteral antibiotics (ampicillin/sulbactam and cefoxitin) in conjunction with appropriate surgical procedures for treatment of patients with diabetic foot infec tions on a vascular surgery service. Thirty-six patients with diabetes mellitus who required hospitalization to treat foot infections were randomized into one of two treatment groups. There were 18 patients with similar baseline characteristics random ized to each treatment group. The Chi-square test was used for clinical and bacteriolog ical comparisons, the Wilcoxon rank sum test was used for comparing duration of hospi talization and clinical signs and symptoms, and Fisher's Exact Test (two-tailed) was used to compare treatment outcomes of the two groups. Based on intention-to-treat analysis, there was no significant difference in treatment outcome (cure + improved) between the ampicillin/sulbactam (15/17) and cefoxitin groups (16/17). Similarly, no significant differences in bacteriologic response were noted. Both ampicillin/sulbactam and cefoxitin, when combined with appropriate surgical interventions, are safe and effective therapies for treating foot infections in patients with diabetes mellitus.
• Erstad, B. L., Camamo, J. M., Miller, M. J., Webber, A. M., & Fortune, J. (1997). Impacting cost and appropriateness of stress ulcer prophylaxis at a university medical center. Critical Care Medicine, 25(10), 1678-1684.
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  PMID: 9377882;Abstract: Objective: To determine the appropriateness and medication cost of stress ulcer prophylaxis before and after a targeted educational intervention. Design: In the preintervention cohort (phase 1), 264 patients were evaluated over 2 months, using stress ulcer prophylaxis guidelines developed by s comprehensive literature search. Targeted educational programs were subsequently used to inform trauma housestaff on appropriate usage of stress ulcer prophylaxis medications with emphasis on using sucralfate. The postintervention cohort (phase 2) involved concurrent evaluation of 279 patients. Length of inappropriate stress ulcer prophylaxis (i.e., did not meet approved guidelines) between phases was com pared using a Student's t- test for independent samples (α = .05). Setting: A 365-bed university medical center. Patients: Patients admitted to any of the intensive care units and all patients who were placed on histamine-2-antagonists or sucralfate for stress ulcer prophylaxis. Interventions: Educational intervention regarding appropriate stress ulcer prophylaxis directed at the trauma service. Measurements and Main Results: Patient demographics in the two phases were similar and there was no difference in the number of patient risk factors for stress-induced bleeding. The mean length of inappropriate stress ulcer prophylaxis was 5.78 ± 4.36 days in phase 1 and 4.66 ± 3.10 days in phase 2 (p < .05). Eighty-nine patients in phase 1 received inappropriate stress ulcer prophylaxis for a drug cost of $2,272.00 (mean $25.53 ± 25.52) compared with 90 patients in phase 2 with a drug cost of $1,417.00 (mean $15.75 ± 13.06). Three patients in each phase had clinically important bleeding (hemodynamic compromise or transfusion); all were receiving ranitidine. The mean total cost (fixed and variable) of hospitalization was $69,288.00 and $74,709.00 for the three patients who bled in each phase compared with $19,850.00 and $15,812.00 for all patients admitted to the intensive care unit in phases 1 and 2, respectively. The mean length of hospital stay was 30.00 days and 29.33 days for the three patients who bled in each phase compared with 11.54 days and 10.27 days for all patients admitted to the intensive care unit in phases 1 and 2, respectively. Conclusions: Cost savings are associated with more appropriate stress ulcer prophylaxis. Clinically important bleeding is uncommon but results in prolonged hospital stays and increased costs.
• Erstad, B. L., Chopda, S., & Esser, M. J. (1997). Prescribing of analgesics in trauma patients. American Journal of Therapeutics, 4(1), 27-30.
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  PMID: 10423587;Abstract: Objective: To evaluate whether initial orders of pain medications by physicians for trauma patients were in accordance with published guidelines. Design: Concurrent, nonrandomized investigation conducted over 4 months. Materials and Methods: All adult trauma patients admitted to the intensive care unit within 12 hours of injury who stayed for at least 1 hour were eligible for study admission. Patients with injuries prohibiting accurate pain assessment (e.g., Glasgow Coma Score
• Maloney, M. E., Camamo, J. M., Crinnion, C., Johnson, S. B., & Erstad, B. L. (1997). Development of algorithms for treating patients in the intensive care unit. American Journal of Health-System Pharmacy, 54(16), 1841-1845. doi:10.1093/ajhp/54.16.1841
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  Journal Article Development of algorithms for treating patients in the intensive care unit Get access Marie Maloney, Pharm.D., Marie Maloney, Pharm.D. Clinical Pharmacists for Medical Information and Policy Development Clinical Pharmacists for Medical Information and Policy Development, Arizona Health Sciences Center, University of Arizona (UA), Tucson Search for other works by this author on: Oxford Academic Google Scholar James Camamo, Pharm.D., James Camamo, Pharm.D. Clinical Pharmacists for Medical Information and Policy Development Clinical Pharmacists for Medical Information and Policy Development, Arizona Health Sciences Center, University of Arizona (UA), Tucson Search for other works by this author on: Oxford Academic Google Scholar Cara Crinnion, Pharm.D., Cara Crinnion, Pharm.D. Pharmacy Resident Arizona Health Sciences Center, UA, at the time of this project Search for other works by this author on: Oxford Academic Google Scholar Steven B. Johnson, M.D., Steven B. Johnson, M.D. Assistant Professor Arizona Health Sciences Center, UA Search for other works by this author on: Oxford Academic Google Scholar Brian L. Erstad, Pharm.D. Brian L. Erstad, Pharm.D. Associate Professor Arizona Health Sciences Center, UA Address reprint requests to Dr. Erstad at the College of Pharmacy, University of Arizona, P.O. Box 210207, Tucson, AZ 85721-0207. Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 54, Issue 16, 15 August 1997, Pages 1841–1845, https://doi.org/10.1093/ajhp/54.16.1841 Published: 15 August 1997
• Maloney, M., Camamo, J., Crinnion, C., Johnson, S. B., & Erstad, B. L. (1997). Development of algorithms for treating patients in the intensive care unit. American Journal of Health-System Pharmacy, 54(16), 1841-1845.
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  PMID: 9269522;
• Rappaport, W. D., Rappaport, W. D., Meeks, M. L., Levinson, M. L., Erstad, B. L., & Chow, H. H. (1997). Site-specific pharmacokinetics and pharmacodynamics of intramuscular meperidine in elderly postoperative patients.. The Annals of pharmacotherapy, 31(1), 23-8. doi:10.1177/106002809703100102
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  To examine and compare the pharmacokinetics and pharmacodynamics of meperidine when administered intramuscularly at gluteal and deltoid sites in elderly postoperative patients..Prospective, randomized investigation..Tertiary care university teaching hospital..Fourteen patients 60 years of age or older who were undergoing general surgery..A single dose of meperidine 0.75 mg/kg given intramuscularly at either a deltoid or gluteal site..Pharmacokinetic (based on concentration-time curves) and pharmacodynamic (i.e., pain scales, need for additional pain medication) comparisons were made, based on site of meperidine injection..No statistically significant differences were found in the maximum plasma concentration, volume of distribution, or clearance of meperidine by site of injection. Substantial interpatient variability in pharmacokinetic parameters was noted for both sites (range of maximum concentrations: 191-500 ng/mL gluteal, 166-374 ng/mL deltoid). Although pain scores were similar for the two groups, four of the patients in the group given gluteal injection required additional breakthrough pain management within 4 hours of meperidine injection compared with one patient in the group given deltoid injection..There is no obvious relationship between meperidine pharmacokinetic and pharmacodynamic parameters, regardless of intramuscular injection site. Breakthrough pain is common when patients are given intramuscular injections postoperatively, particularly when the gluteal route is used. When meperidine is used for analgesia in elderly postoperative patients, consideration should be given to more rapid and predictable routes (e.g., intravenous injection) of meperidine administration.
• Erstad, B. L. (1996). Management consultation. American Journal of Health-System Pharmacy, 53(22), 2696+2699.
• Erstad, B. L. (1996). Using residency standards to prepare staff pharmacists for patient care activities.. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 53(22), 2696, 2699.
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  PMID: 9072179;
• Erstad, B. L. (1996). Viral infectivity of albumin and plasma protein fraction. Pharmacotherapy, 16(6 I), 996-1001.
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  PMID: 8947970;Abstract: Original research, reviews, anti case reports discussing viral infectivity of blood- and plasma-derived products were reviewed to determine the potential viral infectivity of human serum albumin (HSA) and plasma protein fraction (PPF). Data concerning vital infectivity, vital screening anti inactivation procedures, and viral outbreaks associated with blood and plasma products were extracted and evaluated for pertinence to HSA and PPF. The starting material used for fractionation, the manufacturing process, postmanufacturing handling, and immunocompetence of HSA or PPF recipients were assessed to determine risk of symptomatic viral disease after transfusion. Both HSA and PPF are manufactured with pasteurization procedures that have led to an excellent viral safety record based on 50 years of clinical use. One outbreak of hepatitis B was associated with PPF as a result of an unreliable manufacturing process that has been corrected. The pasteurization process is effective in eradicating known viral pathogens when good manufacturing practices are followed. Continued surveillance of such products is warranted for viruses not included in routine screening procedures and for those that are resistant to current inactivation methods.
• Erstad, B. L., Chandler, M. H., Davis-Ninno, S., Gong, W. C., Holcombe, B. J., Phelps, S. J., Pruemer, J. M., Richards, A. L., II, L. S., Williams, R. B., & Witmer, D. R. (1996). ASHP Section of Clinical Specialists report to the House of Delegates. American Journal of Health-System Pharmacy, 53(7), 791-792.
• Erstad, B. L., Grier, D. G., Scott, M. E., Esser, M. J., & Joshi, P. (1996). Recognition and treatment of ethanol abuse in trauma patients. Heart and Lung: Journal of Acute and Critical Care, 25(4), 330-336.
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  PMID: 8836750;Abstract: Objective: To evaluate physicians' recognition of possible ethanol-related complications in trauma patients, and to compare benzodiazepine requirements in patients with positive and negative blood-ethanol concentrations. Design: Retrospective investigation. Setting: University medical center (level I trauma center). Patients: One hundred thirty-one trauma patients more than 18 years of age who were admitted for at least 24 hours. Outcome measures: (1) Physicians' recognition of ethanol (EtOH) as a potential factor complicating patient recovery in trauma patients admitted with positive blood-EtOH concentrations. (2) The amount of benzodiazepines administered to trauma patients with positive EtOH-blood concentrations compared to trauma patients with no detectable EtOH in their blood. Results: The presence of EtOH in the blood or the potential for EtOH withdrawal was mentioned in the progress notes of approximately one fourth of the patients with positive blood-EtOH concentrations. Thiamine was administered in 8.2% of patients with EtOH-related injuries. Benzodiazepine requirements were significantly higher in patients with positive versus negative blood-EtOH concentrations. Conclusions: Prompt recognition and charting of suspected ethanol abuse is recommended, in conjunction with prompt administration of thiamine. It should be anticipated that patients with positive blood-ethanol concentrations will require higher doses of benzodiazepines compared to trauma patients without ethanol-related injuries.
• Carl, J. L., Erstad, B. L., Murphy, J. E., & Slack, M. K. (1995). Fluid delivery from infusion-pump syringes. American Journal of Health-System Pharmacy, 52(13), 1428-1432.
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  PMID: 7671041;Abstract: Fluid-delivery rates of five small-volume infusion-pump syringes were compared. The study consisted of a comparison of the infusion-pump syringes in their respective infusion pumps (1) set for continuous delivery at 1 mL/hr, (2) set for continuous delivery at 3 mL/hr, and (3) set to deliver 1- mL bolus volumes during continuous delivery at 4 mL/hr. The Lifecare prefilled 30-mL syringe (Abbott), the DBL 30-mL syringe no. 770205 (DBL Inc.), and the Pump-Jet 30-mL syringe no. 1931 (International Medication Systems) were tested in the Lifecare PCA Plus II infusion pump no. 4100 (Abbott). The 30-mL Pump-Jet syringe no. 1911 (International Medication Systems) and the DBL 30-mL syringe no. 709700 (DBL Inc.) were tested in the Stratofuse PCA infusion pump (Baxter). The infusion pumps were set to deliver fluid continuously at 1 mL/hr for 30 hours, and the solutions were collected separately and weighed. The procedure was repeated with the infusion rate set at 3 mL/hr for 10 hours. For the third part of the study, each syringe was tested to deliver 1-mL boluses with 0, 5, 15, and 25 mL removed from the syringe. The solutions were collected and weighed before and after each bolus was delivered. The volume of solution collected was calculated by using the specific gravity of the solution. The syringes delivered significantly different volumes during the first hour of infusion at both the 1- and 3- mL/hr rates. Differences also existed across time for most of the syringes. Bolus volumes varied greatly after infusion of 0 or 5 mL of fluid but were acceptable for the remainder of the infusions. Significant differences were also observed between the pumps for all tests. The five infusion-pump syringes tested did not deliver fluid accurately or consistently for 30 hours at 1 mL/hr or 10 hours at 3 mL/hr. The syringes' delivery of intermittent 1- mL bolus volumes during continuous delivery at 4 mL/hr depended on the amount of fluid already delivered and the infusion pump used.
• Cotugno, C. L., & Erstad, B. L. (1995). Management of alcohol withdrawal. American Journal of Health-System Pharmacy, 52(7), 697-709. doi:10.1093/ajhp/52.7.697
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  The diagnosis, evaluation and assessment, supportive care, and pharmacologic treatment of acute alcohol withdrawal are reviewed. Patients in alcohol withdrawal have decreased or stopped their heavy, prolonged ingestion of alcohol and have subsequently begun to have at least two of the following symptoms: autonomic hyperactivity, tremor, nausea or vomiting, hallucinations, psychomotor agitation, anxiety, and grand mal seizures. Evaluation of the patient at risk for alcohol withdrawal should include a complete history and physical examination; laboratory tests are often indicated. The patient's progress should be assessed before, during, and after therapy, preferably with a validated instrument. After the initial evaluation and assessment but before the administration of dextrose-containing solutions, a 100-mg dose of thiamine hydrochloride should be given by i.m. or i.v. injection. Routine supplementation with calcium, magnesium, and phosphate is questionable. The need for fluid and electrolyte administration varies depending on losses. Most patients in alcohol withdrawal can be managed with supportive care alone, but for more severe or complicated withdrawal, pharmacologic therapy may be necessary. Benzodiazepines, especially diazepam and chlordiazepoxide, are the drugs of choice. Barbiturates, β-blockers, and antipsychotics are generally not recommended as first-line therapy. Several drugs in other classes, including carbamazepine and clonidine, have been shown to be about as effective as benzodiazepines in a few studies, but the studies were small, the patients were usually in mild withdrawal, and validated instruments for assessing withdrawal were often not used. Some agents, such as β-blockers, may play a role as adjuncts to, not replacements for, benzodiazepine therapy. For patients in alcohol withdrawal who do not respond to supportive care, benzodiazepines are the treatment of choice.
• Erstad, B. L., & Cotugno, C. L. (1995). Management of alcohol withdrawal. American Journal of Health-System Pharmacy, 52(7), 697-709.
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  PMID: 7627738;Abstract: The diagnosis, evaluation and assessment, supportive care, and pharmacologic treatment of acute alcohol withdrawal are reviewed. Patients in alcohol withdrawal have decreased or stopped their heavy, prolonged ingestion of alcohol and have subsequently begun to have at least two of the following symptoms: autonomic hyperactivity, tremor, nausea or vomiting, hallucinations, psychomotor agitation, anxiety, and grand real seizures. Evaluation of the patient at risk for alcohol withdrawal should include a complete history and physical examination; laboratory tests are often indicated. The patient's progress should be assessed before, during, and after therapy, preferably with a validated instrument. After the initial evaluation and assessment but before the administration of dextrose- containing solutions, a 100-mg dose of thiamine hydrochloride should be given by i.m. or i.v. injection. Routine supplementation with calcium, magnesium, and phosphate is questionable. The need for fluid and electrolyte administration varies depending on losses. Most patients in alcohol withdrawal can be managed with supportive care alone, but for more severe or complicated withdrawal, pharmacologic therapy may be necessary. Benzodiazepines, especially diazepam and chlordiazepoxide, are the drugs of choice. Barbiturates, β-blockers, and antipsychotics are generally not recommended as first-line therapy. Several drugs in other classes, including carbamazepine and clonidine, have been shown to be about as effective as benzodiazepines in a few studies, but the studies were small, the patients were usually in mild withdrawal, and validated instruments for assessing withdrawal were often not used. Some agents, such as β-blockers, may play a role as adjuncts to, not replacements for, benzodiazepine therapy. For patients in alcohol withdrawal who do not respond to supportive care, benzodiazepines are the treatment of choice.
• Newsom, L., Erstad, B. L., Nakazato, P. Z., & Daller, J. A. (1995). Falsely decreased total serum calcium concentration associated with iron dextran injection. Pharmacotherapy, 15(6 I), 789-792.
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  PMID: 8602390;Abstract: We cared for a patient in whom iron dextran administration interfered with the determination of total serum calcium concentration. An unexpected elevation in serum phosphorus concentration also occurred after the iron dextran infusion. A MEDLINE search from 1966 to present was conducted, and the manufacturer of the iron dextran was contacted for information related to these findings. Several drugs and diseases were found that may decrease serum calcium and increase phosphorus concentrations. We found one anecdotal citation of iron dextran interfering with serum calcium concentrations, but no reports of interference with serum phosphorus concentrations. Doses of iron dextran in excess of 250 mg may cause a false decrease in total calcium concentration more than 4 hours after the infusion is completed. A false increase in serum phosphorus concentrations after the infusion requires further investigation.
• O'Connell, H., & Erstad, B. L. (1995). Comparison of predicted and measured energy expenditure in mechanically ventilated obese patients. Journal of Pharmacy Technology, 11(2), 47-49.
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  Abstract: Objective: To test the appropriateness of using actual body weight (ABW), ideal body weight (IBW), or an adjusted weight for predicting caloric requirements in moderately obese, mechanically ventilated patients receiving parenteral or enteral nutrition. Design: Prospective, nonrandomized pilot study involving seven patients. Setting: University medical center. Main Outcome Measures: Predicted caloric requirements based on ABW, IBW, or an adjusted weight were compared with measured requirements by indirect calorimetry after parenteral nutrition or tube feedings were at goal rate for 24-72 hours. Results: Mean differences between predicted and measured energy requirements for ABW, IBW, and adjusted weight were 821 ± 556 (p < 0.05), - 256 ± 493, and 182 ± 501 kcal/d, respectively. Conclusions: Until additional studies are available, IBW or adjusted weight should be used for calculating caloric requirements in the moderately obese patient being mechanically ventilated when actual measurements are not available.
• Stricker, R. B., Vermeulen Jr., L. C., Ratko, T. A., Matuszewski, K. A., Erstad, B. L., & Brecher, M. E. (1995). What about plasma? [2]. Archives of Internal Medicine, 155(16), 1817-.
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  PMID: 7654119;
• Vermeulen Jr., L. C., Ratko, T. A., Erstad, B. L., Brecher, M. E., & Matuszewski, K. A. (1995). A paradigm for consensus: The University Hospital Consortium guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. Archives of Internal Medicine, 155(4), 373-379.
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  PMID: 7848020;Abstract: Objective: To develop contemporary, comprehensive guidelines for the appropriate and efficient use of albumin, nonprotein colloid, and crystalloid solutions. Design: A systematic, literature-based, consensus exercise employing a modified Delphi method. Participants: Thirty-one medical and allied health professionals from 26 University Hospital Consortium (Oak Brook, Ill) member institutions were initially chosen to participate. Participants were selected on the basis of their recognized research in the use of albumin, nonprotein colloid, and crystalloid solutions, and/or experience in the review of appropriateness of such use. A total of 24 participants completed the exercise. Main Outcome Measures: Group responses were statistically analyzed in an iterative consensus development process. Five separate questionnaire rounds were designed to establish criteria for the appropriate use of albumin, nonprotein colloid, and crystalloid solutions. Results: Consensus guidelines were developed outlining the appropriate use of these products for 12 clinical indications, including hemorrhagic shock, nonhemorrhagic (maldistributive) shock, hepatic resection, thermal injury, cerebral ischemia, nutritional intervention, cardiac surgery, hyperbilirubinemia of the newborn, cirrhosis and paracentesis, nephrotic syndrome, organ transplantation, and plasmapheresis. Conclusions: The Delphi method, a systematic, literature-based consensus process, was shown to be useful in the development of complex clinical practice guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. It is anticipated that the guidelines will assist health care providers to develop local institutional policies and procedures for the appropriate and efficient use of albumin and albumin alternatives. Institutions reviewing and updating existing local guidelines may use the University Hospital Consortium guidelines as a model for comparison.
• Vermeulen, L. C., Ratko, T. A., Matuszewski, K. A., Erstad, B. L., & Brecher, M. E. (1995). What About Plasma?-Reply. JAMA Internal Medicine, 155(16), 1817-1817. doi:10.1001/archinte.1995.00430160171021
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  In reply We appreciate Stricker's comment on our article 1 ; however, the principal purpose of our report was to describe a novel process for developing consensus and only secondarily to present a set of guidelines. It should be noted that our guidelines focused only on colloid and crystalloid solutions. With the exception of a brief mention in the hemorrhagic shock criteria, indications for other blood products such as plasma and packed red blood cells were not considered. There are numerous indications (such as thrombotic thrombocytopenic purpura) for which plasma, red blood cells, or platelets are clearly the volume replacement of choice. It would seem that a global qualifier to the guidelines stating that "crystalloid and colloid solutions should not be considered substitutes for blood or blood components when oxygen-carrying capacity is reduced and/or when replenishment of specific factors or platelets is required" would have been desirable. While practice guidelines are
• Whipple, J. K., Lewis, K. S., Quebbeman, E. J., Esser, M. J., Gottlieb, M. S., McKindley, D. S., Hess, M., Boucher, B. A., Jancik, J. T., Wesley, L. C., Erstad, B., & Ausman, R. K. (1995). Current patterns of prescribing and administering morphine in trauma patients. Pharmacotherapy, 15(2), 210-215.
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  PMID: 7624268;Abstract: We attempted to characterize the current prescribing practices and administration patterns for intravenous intermittent morphine in trauma patients in a multicenter, open prospective, observational study. The subjects were 141 patients admitted to the surgical intensive care units (ICU) of five United States trauma centers within 12 hours of injury who received intermittent intravenous morphine for pain relief. The study was conducted from April 15, 1992, to February 15, 1993. Data obtained during the first 32 hours of the ICU stay included morphine regimen, doses administered, and time between doses. One hundred sixty-one orders were prescribed by surgeons. The most frequently ordered dose was 2-4 mg and the most frequently ordered interval was every hour as necessary. There was no relationship between the severity of injury and the minimum close ordered. During the 492 nursing shifts studied, 1257 doses were administered. Of these, 44% were at or below the minimum amount prescribed by the surgeons. Thirty three percent of the patients received a dose at an interval of more than 3 hours. We concluded that small amounts of narcotic analgesics are given to severely injured patients, and amount ordered is not affected by the severity of injury.
• Yim, J. M., Vermeulen, L. C., Erstad, B. L., Matuszewski, K. A., Burnett, D. A., & Vlasses, P. H. (1995). Albumin and nonprotein colloid solution use in US academic health centers. Archives of Internal Medicine, 155(22), 2450-2455.
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  PMID: 7503604;Abstract: Background: Crystalloids, nonprotein colloids (NPCs), and albumin are used for many indications. The use of the least costly agent in situations where these products are clinically interchangeable can reduce health care costs. Objectives: To characterize the prescribing of albumin and NPC. To evaluate the appropriateness and cost implications of their use. Methods: An observational study conducted in 15 academic health centers from April 11 through May 6, 1994, to assess the appropriateness of albumin and NPC use, based on 'model' consensus-derived indication guidelines. Results: A total of 969 case report forms were evaluated. Albumin and NPCs were administered in 83% and 17% of the cases, respectively. Albumin and NPCs were administered mostly in the intensive care (50%) or operating room (31%) settings. The most common prescribers of these products were surgeons (45%) and anesthesiologists (20%). In 87% of cases, albumin or NPC was administered to reach a defined end point (eg, to achieve a target physiological state or to resolve a pathophysiological condition). Only one albumin recipient experienced an adverse event; no adverse events were noted with NPC administration. Approximately $203 000 was spent on albumin and NPC therapy for the 969 cases; $49 702 (24%) was spent on appropriate administrations, $124 939 (62%) on inappropriate administrations, and $28 014 (14%) on unevaluated indications. Conclusions: Evaluated against model guidelines, most of the albumin and NPC use in the study was found to be inappropriate. The need for institutions to define and implement guidelines that focus on the cost-efficient use of these agents is recommended in an increasingly cost-conscious health care environment.
• Erstad, B. L. (1994). A rational approach to the management of acute pain states (part 1). Hospital Formulary, 29(7), 516-525.
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  Abstract: Several classes of drugs can be used in the management of acute pain: acetaminophen, salicylates, miscellaneous mild analgesics, nonsteroidal anti- inflammatory drugs (NSAIDs), and opioids. In part one of this two-part series, agents used to treat mild pain states will be explored. For this condition, acetaminophen and aspirin remain the standards of comparison. These agents are inexpensive and their adverse effect profiles are well described. For patients unable to take acetaminophen or aspirin, a variety of NSAIDs are available. This article reviews the advantages and disadvantages of the various agents and their role within the analgesic armamentarium for management of mild, acute pain states. Next month, in part two of this two- part series, the use of opioids will be explored.
• Erstad, B. L. (1994). A rational approach to the management of acute pain states (part 2). Hospital Formulary, 29(8), 586-588+591.
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  Abstract: Several classes of drugs can be used in the management of acute pain: acetaminophen, salicylates, miscellaneous mild analgesics, nonsteroidal anti- inflammatory drugs (NSAIDs), and opioids. Last month, the role of acetaminophen, salicylates, and NSAIDs was explored. This month, in the conclusion of the series, the role of opioids is discussed. Opioids are used for more severe pain states, with morphine being an inexpensive standard of comparison for this class of compounds. Also presented is this article is a sample formulary of analgesic agents and regimens for consideration by clinicians involved in direct patient care or in the formulary decision- making process.
• Erstad, B. L. (1994). Fluid replacement therapy.. The Journal of practical nursing, 44(3), 24-31; quiz 31.
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  PMID: 7932251;
• Erstad, B. L. (1994). Oxygen transport goals in the resuscitation of critically ill patients. Annals of Pharmacotherapy, 28(11), 1273-1284.
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  PMID: 7849343;Abstract: OBJECTIVE: To discuss the limitations of conventional monitoring techniques of shock and examine more recent monitoring techniques that are used to titrate therapies to attain supranormal oxygen transport goals. DATA SOURCES: Review articles and investigations published since 1973. STUDY SELECTION: Articles were selected if they examined the monitoring or treatment of shock. Emphasis was placed on finding investigations involving humans that used innovative methods to assess and treat inadequate tissue perfusion. DATA EXTRACTION: Data were extracted primarily from original investigations and review articles published in or translated into English. DATA SYNTHESIS: The conventional monitoring of shock often fails to detect inadequate tissue perfusion, which may lead to inadequate resuscitation of patients, resulting in increased morbidity and mortality. Attainment of supranormal values for oxygen transport variables has been associated with improved outcomes, especially in patients with hypovolemic shock or septic shock. Additionally, interventions used to increase these variables to supranormal values have resulted in improved survival in high-risk preoperative patients with hypovolemic or septic shock, but not in severely ill postoperative patients with multiple complications. CONCLUSIONS: Efforts to increase oxygen transport variables to supranormal values cannot be recommended routinely for all critically ill patients. Preoperative patients in early stages of hypovolemic or septic shock may benefit from therapies titrated to achieve supranormal goals, but patients in later stages of illnesses may be harmed by such attempts. Questions remain regarding how quickly and how long the oxygen transport variables should be elevated. The most effective and least toxic therapeutic interventions for increasing the variables need to be determined.
• Erstad, B. L., Draugalis, J. R., Waldrop, S. M., Scheurer, L., & Namanny, M. D. (1994). Patients' perceptions of increased pharmacy contact. Pharmacotherapy, 14(6 I), 724-728.
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  PMID: 7885976;Abstract: This prospective, randomized study was conducted to determine if increased patient contact between pharmacists and patients would result in greater patient awareness and satisfaction with their hospital stay and particularly with pharmacists and pharmacy services. Eligible patients were randomized to receive either the usual pharmacy care with minimum contact with the pharmacist, or expanded services based on increased contact with the pharmacist. A questionnaire was used to determine patient awareness and satisfaction. Statistically significant differences were found between the groups on awareness and satisfaction with pharmacy services scales as well as total scores. Total patient scores were highly reliable, with an α coefficient of 0.87. In addition, comments by patients in the group with increased contact were overwhelmingly positive, in contrast to those receiving usual care. Patients desire and appreciate greater contact with pharmacists.
• Lipsy, R. J., Lipsy, R. J., & Erstad, B. L. (1994). Adverse Gastrointestinal Effects of Nonsteroidal Anti-Inflammatory Drugs:. Journal of Pharmacy Practice, 7(4), 144-153. doi:10.1177/089719009400700403
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  There are a substantial number of adverse reactions attributable to nonsteroidal anti-inflammatory drug (NSAID) therapy, particularly of the gastrointestinal (GI) tract. The stomach is most commonl...
• Rappaport, W. D., Rappaport, W. D., & Erstad, B. L. (1994). Subcapsular hematoma after laparoscopic cholecystectomy, associated with ketorolac administration.. Pharmacotherapy, 14(5), 613-615. doi:10.1002/j.1875-9114.1994.tb02859.x
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  Ketorolac is the first injectable nonsteroidal antiinflammatory drug used as an analgesic in the perioperative period. Its adverse effect profile is different from that of the opioid analgesics; in particular, in its lack of respiratory depressive actions. However, ketorolac has risks associated with its perioperative administration, including episodes of substantial gastrointestinal bleeding. A patient undergoing elective laparoscopic cholecystectomy developed a subcapsular hepatic hematoma shortly after receiving a dose of injectable ketorolac. No evidence of parenchymal injury was found on laparoscopy, which argues against iatrogenic trauma. Clinicians should be aware that ketorolac may cause or aggravate bleeding, and it should be used with caution in perioperative patients.
• Rappaport, W. D., Rollins, C. J., Rappaport, W. D., Erstad, B. L., & Campbell, D. J. (1994). Albumin and prealbumin concentrations in patients receiving postoperative parenteral nutrition.. Pharmacotherapy, 14(4), 458-462. doi:10.1002/j.1875-9114.1994.tb02837.x
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  This prospective, nonrandomized study was conducted to compare the increases in albumin and prealbumin concentrations in postoperative patients given adequate nutrition support. All surgery patients at least 18 years of age and who required parenteral nutrition were included. Of 86 patients evaluated, 16 met all criteria for study entry. Blood for albumin concentrations was drawn within 48 hours of beginning parenteral nutrition and then weekly. Blood for prealbumin concentrations was drawn within 48 hours of beginning parenteral nutrition and then twice weekly. Albumin concentrations increased from 2.00 +/- 0.35 to 2.21 +/- 0.42 g/dl (NS). Prealbumin concentrations increased from 11.97 +/- 6.31 to 17.29 +/- 8.93 mg/dl (p = 0.017). All but one prealbumin concentration was in the normal range for our laboratory when parenteral nutrition was discontinued. None of the albumin concentrations were ever in the normal range. The prealbumin concentration is a better indicator than albumin of nutrition status in the postoperative patient. Since prealbumin concentrations typically rise into the normal range within a week after adequate caloric supplementation, clinicians may avoid unnecessary increases in protein-calorie intake and laboratory testing of nutrition status by using this measurement.
• Erstad, B. L. (1993). How to be an effective clerkship or internship preceptor. American Journal of Hospital Pharmacy, 50(3), 434+439.
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  PMID: 8442450;
• Erstad, B. L., & Meeks, M. L. (1993). Influence of injection site and route on medication absorption. Hospital Pharmacy, 28(9), 853-856+858.
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  Abstract: Concerns related to drug absorption are not limited to the oral route of administration. Medications given by various parenteral routes must also be absorbed to gain access to the systemic circulation. This article reviews the absorption characteristics of commonly administered medications by type and site of injection. The article focuses on four routes of parenteral injections: intramuscular, intralipomatous, subcutaneous, and intradermal. Differences in absorption relative to route or site of injection have been often demonstrated in studies, when such information was actively sought. Particularly important differences have been found with members of the following classes of medications: opiates, benzodiazepines, vaccines, insulins, and antiarrhythmics.
• Erstad, B. L., Harlander, D. K., & Daller, J. A. (1993). Hematologic effects of ethanol consumption in trauma patients. Annals of Pharmacotherapy, 27(7-8), 889-891.
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  PMID: 8364272;Abstract: OBJECTIVE: To determine the effects of ethanol (EtOH) ingestion by trauma patients on the hematologic system as evidenced by coagulation abnormalities and transfusion requirements. DESIGN: Retrospective chart review. The injury severity score (ISS) was determined for each patient. Patients were grouped according to presence of EtOH (+EtOH) and absence of EtOH (-EtOH) with further subdivision based on an ISS ≤8 or ≥9. SETTING: University medical center. PATIENTS: All adult trauma patients admitted during a one-month period. MAIN OUTCOME MEASURES: The volume of resuscitation fluids (including blood products) administered, laboratory parameters indicative of bleeding, and length of stay. RESULTS: Of 104 evaluable patients, 38 had measurable EtOH concentrations, 46 had undetectable EtOH concentrations, and the remaining 20 patients had not been tested. Although isolated, statistically significant differences were found among groups for some of the outcome measures, there were no clinically important differences. CONCLUSIONS: EtOH ingestion prior to injury did not appear to cause significant alterations in the hematologic system of trauma patients, but a larger study is needed to confirm these findings.
• Erstad, B. L., Snyder, B. A., & Kramer, T. H. (1993). Epidural, intrathecal, and patient-controlled analgesic use in a University Medical Center. Journal of Pharmacy Technology, 9(4), 141-143.
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  PMID: 10171510;Abstract: Objective: To determine the number and profile of surgical patients receiving epidural, intrathecal, and patient-controlled analgesia. Design: Two-month audit of epidural, intrathecal, and patient-controlled analgesia. Setting: A 300-bed, tertiary care, university medical center. Patients: All patients undergoing surgery and receiving epidural, intrathecal, or patient- controlled analgesia. Results: Of 1123 operations performed during the two- month audit, 185 patients (16 percent) received one of the three forms of analgesia studied. Sixty-three percent of the 185 patients received patient- controlled analgesia and 33 percent received epidural injections for pain control. The most common types of surgery associated with the use of these specialized pain-control techniques were obstetric/gynecologic, orthopedic, general, urologic, and cardiothoracic. Conclusions: Specialized forms of analgesia are becoming increasingly common. Our audit defined the number of patients receiving such therapies according to type of surgery. Collection of such information by other institutions should allow for targeted evaluations of cost-effectiveness (e.g., drug use evaluations).
• Erstad, B. L., Snyder, B., & Kramer, T. H. (1993). Epidural, Intrathecal, and Patient-Controlled Analgesic Use in a University Medical Center. Journal of Pharmacy Technology, 9(4), 141-143. doi:10.1177/875512259300900402
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  Objective To determine the number and profile of surgical patients receiving epidural, intrathecal, and patient-controlled analgesia. Design Two-month audit of epidural, intrathecal, and patient-controlled analgesia. Setting A 300-bed, tertiary care, university medical center. Patients All patients undergoing surgery and receiving epidural, intrathecal, or patient-controlled analgesia. Results Of 1123 operations performed during the two-month audit, 185 patients (16 percent) received one of the three forms of analgesia studied. Sixty-three percent of the 185 patients received patient-controlled analgesia and 33 percent received epidural injections for pain control. The most common types of surgery associated with the use of these specialized pain-control techniques were obstetric/gynecologic, orthopedic, general, urologic, and cardiothoracic. Conclusions Specialized forms of analgesia are becoming increasingly common. Our audit defined the number of patients receiving such therapies according to type of surgery. Collection of such information by other institutions should allow for targeted evaluations of cost-effectiveness (e.g., drug use evaluations).
• Gales, B. J., & Erstad, B. L. (1993). Adverse reactions to human serum albumin. Annals of Pharmacotherapy, 27(1), 87-94.
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  PMID: 8431628;Abstract: OBJECTIVE: To describe the adverse effects associated with human serum albumin (HSA) administration. DATA SOURCES: A MEDLINE search and bibliography scanning were used to identify pertinent review articles, clinical studies, and case reports. STUDY SELECTION: Emphasis was placed on reporting the results of human studies with the primary objective of investigating adverse effects attributable to HSA administration. Clinical trials that reported the occurrence of adverse effects possibly associated with HSA were also reviewed. Animal data were included where pertinent. DATA EXTRACTION: Although isolated case reports were reviewed, data were primarily extracted from human studies involving large series of patients or studies that were randomized and prospective in nature. DATA SYNTHESIS: Alterations in coagulation, renal, cardiovascular, and pulmonary functions were identified as potential adverse effects following the administration of HSA. Occurrences of hypersensitivity reactions, trace metal loading, and serum amino acid alterations associated with these infusions were also noted and are described here. Pulmonary and cardiovascular systems appear to be particularly prone to complications from excessive HSA administration. Adverse effects such as HSA- induced hypersensitivity reactions may be severe, but occur infrequently. CONCLUSIONS: Controlled studies involving large numbers of patients are not currently available for an accurate assessment of the incidence of adverse effects attributable to HSA administration. Many of the reported reactions appear to be extensions of albumin's pharmacologic activities and would be expected to worsen following large doses of HSA.
• Whipple, J. K., Wesley, L. C., Quebbeman, E. J., Mckindley, D. S., Lewis, K. S., Jancik, J. T., Hess, M., Gottlieb, M. S., Esser, M. J., Erstad, B. L., Boucher, B. A., & Ausman, R. K. (1993). MORPHINE USE IN SEVERE INJURY: A CASE OF HOMEOPATHY. Journal of Trauma-injury Infection and Critical Care, 35(2), 329. doi:10.1097/00005373-199308000-00074
• Erstad, B. L. (1992). Dapsone-induced methemoglobinemia and hemolytic anemia. Clinical Pharmacy, 11(9), 800-805.
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  PMID: 1521404;Abstract: The treatment of two common adverse effects of dapsone (methemoglobinemia and hemolytic anemia) is discussed, and a case of acute dapsone intoxication is described. A pregnant 29-year-old woman was admitted to an emergency room three hours after ingesting 50 tablets of dapsone (100 mg each) and six alcoholic drinks. One hour after admission 50 g of activated charcoal was given p.o., and 65 mg of methylene blue was given i.v. The patient was found to have a methemoglobin concentration of 25.1%. Arterial blood gases while the patient was breathing 4 L/min of oxygen by nasal cannula were PO2, 136 mm Hg (72.1% saturation); PCO2, 28.9 mm Hg; bicarbonate content, 18.9 mmol/L; and pH, 7.42. Oxygen therapy was changed to 100% oxygen by face mask, 50 g of activated charcoal in sorbitol was administered p.o., and another 65 mg of methylene blue was given i.v. Two more 50-g doses of activated charcoal in sorbitol were given (18.5 and 22 hours after dapsone ingestion). Methylene blue 130 mg was given 14 hours after dapsone ingestion, and 65 mg was given 21, 36, and 55.5 hours after ingestion. Methemoglobin concentrations never rose above 20% after the sixth dose of methylene blue. On hospital days 2 and 3, laboratory values were consistent with a diagnosis of hemolytic anemia; the patient received two units of packed red blood cells. The hematocrit decreased over the next three days to 23.9%, and the patient received four units of packed red blood cells. On day 8 oxygen therapy was changed to oxygen 2 L/min by nasal cannula, and on day 10 the patient was breathing room air. Oral doses of activated charcoal have been used to treat acute dapsone poisoning. Methylene blue acts as a cofactor for the nicotinamide adenine dinucleotide phosphate system to convert methemoglobin to hemoglobin. Methylene blue, however, sometimes aggravates the adverse effects of dapsone, particularly in patients with glucose 6-phosphate dehydrogenase deficiency. Total methylene blue dosages exceeding 4 mg/kg are more likely to aggravate the methemoglobinemia and possibly cause or aggravate an acute hemolytic state. Most cases of dapsone-induced methemoglobinemia and hemolysis resolve when the offending drug is discontinued. When methylene blue is required for symptomatic patients with an elevated methemoglobin concentration (more than 30%), careful monitoring of drug dosage and clinical progress is indicated.
• Erstad, B. L. (1992). Serum albumin concentrations: Who needs them?. Annals of Pharmacotherapy, 26(9), 1134-1138.
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  PMID: 1421681;Abstract: OBJECTIVE: To examine the multiple factors that influence serum albumin concentrations and to discuss settings in which the monitoring of such concentrations provides clinically useful information. DATA SOURCES: Original investigations, review articles, books, and abstracts published in English. STUDY SELECTION: Studies pertaining to factors affecting serum albumin concentration were chosen based on general applicability. Recommendations related to the appropriate monitoring of albumin concentrations were based on studies performed in the clinical setting with direct applicability to patient care. DATA EXTRACTION: Data on factors affecting serum albumin concentration were extracted from studies that resulted in similar conclusions regardless of assay technique. Appropriate indications for albumin monitoring were derived from studies demonstrating direct clinical relevance. DATA SYNTHESIS: A number of factors may influence serum albumin concentration and ultimately affect interpretation of the concentration. Serum albumin concentrations generally are useful in the institutional setting shortly after admission or preoperatively to determine patient prognosis. Albumin concentrations have limited merit for predicting the free fractions of various hormones, electrolytes, and drugs. When used as an indicator of nutritional support, albumin concentrations are most helpful when measured over longer periods in relatively stable patients. CONCLUSIONS: Serum albumin determinations should be limited to those situations in which the concentrations are likely to provide clinically useful information. Such situations are limited.
• Erstad, B. L., Witte, C. L., & Talkington, D. F. (1992). Toxic shock-like syndrome. Pharmacotherapy, 12(1), 23-27.
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  PMID: 1549535;Abstract: Invasive group A streptococcal infection has important diagnostic and therapeutic implications in patients with necrotizing fasciitis. We cared for a man with the full-blown syndrome in whom many features of toxic shock syndrome were present, including profound hypotension and renal failure. The diagnostic similarities of toxic shock syndrome and the toxic shock-like syndrome caused by group A Streptococcus could have led to inappropriate treatment. Successful therapy in our patient included high doses initially of broad-spectrum antibiotics, repeated operative debridement of the lower leg (the affected limb), and ultimately, reconstructive surgery consisting primarily of split-thickness skin grafts. The reemergence of invasive streptococcal infections may relate to changes either in virulence factors of the causative streptococcus or in exotoxins elaborated by this microorganism. A causative relationship between an exotoxin produced by group A Streptococcus and the toxic shock-like syndrome has not yet been established.
• Gales, B. J., & Erstad, B. L. (1992). Albumin audit results and guidelines for use. Journal of Pharmacy Technology, 8(3), 125-129.
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  PMID: 10119446;Abstract: Objective: To identify patients receiving albumin, develop guidelines for albumin use, and examine distribution and billing procedures. Design: Case series. Setting: Tertiary care center. Patients: All patients received albumin in a four-week period. Patients were identified concurrently using intensive care unit surveys and the pharmacy computer system, and retrospectively using billing statements. Data were analyzed from 73 of 79 patients (92.4 percent); 6 (7.6 percent) had no record of albumin being ordered or administered. Pediatric patient data were used only in the financial calculations. Data Collection: Demographics and albumin dosages were recorded for all patients. Prescribing service and indications for use were recorded in adults. Albumin administered was compared with the amount billed to each patient. Main Results: Sixty adult patients aged 14-91 y (median 62) received 1-69 units (median 4 units [1 unit=12.5 g albumin]) and 470 total units. Surgical services prescribed albumin in 73 percent and medical services in 27 percent of the patients. Common indications for albumin included volume expansion (65 percent), as intraoperative fluid (13 percent), and to increase urine output (10 percent). The pharmacy computer system identified 63 percent of the patients. Of these, 13 percent were not billed for albumin they received. Examinations of patient billing statements found that up to $17,740 a year (15 percent) of albumin administered is not billed. The floor-stock distribution system used in the intensive care units contributed to most errors. Conclusions: Recommendations addressing the problems identified in this audit were made to the pharmacy, medical, nursing, and billing departments. Guidelines for albumin use were formulated and approved by the hospital's pharmacy and therapeutics committee.
• Neumayer, L. A., Neumayer, L. A., & Erstad, B. L. (1992). Massive Gastrointestinal Bleeding Associated With Ketorolac Administration. Journal of Pharmacy Practice, 5(3), xi-xii. doi:10.1177/089719009200500303
• Daller, J. A., Erstad, B., Rosado, L., Otto, C., & Putnam, C. W. (1991). Aminophylline antagonizes the neuromuscular blockade of pancuronium but not vecuronium. Critical Care Medicine, 19(7), 983-985.
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  PMID: 1675977;
• Nolan Jr., P. E., Erstad, B. L., Hoyer, G. L., Bliss, M., Gear, K., & Marcus, F. I. (1991). Reply. The American Journal of Cardiology, 67(4), 328-329.
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  PMID: 1990811;
• Rappaport, W. D., Rappaport, W. D., Gales, B. J., & Erstad, B. L. (1991). The Use of Albumin in Clinical Practice. JAMA Internal Medicine, 151(5), 901-911. doi:10.1001/archinte.1991.00400050051011
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  The use of albumin in the clinical setting continues to generate controversy. Periodic shortages and the high cost of albumin have compelled many hospitals to develop guidelines regarding albumin administration. Our purpose is to review the human studies involving albumin. Particular emphasis will be placed on comparative trials involving albumin and the less expensive crystalloid solutions. It is hoped that this review will assist the clinician in making judgments concerning the appropriate use of albumin. (Arch Intern Med. 1991;151:901-911)
• Nolan Jr., P. E., Erstad, B. L., Hoyer, G. L., Bliss, M., Gear, K., & Marcus, F. I. (1990). Steady-state interaction between amiodarone and phenytoin in normal subjects. The American Journal of Cardiology, 65(18), 1252-1257.
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  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.
• Erstad, B. L. (1989). Severe Cardiovascular Adverse Effects in Association with Acute, High-Dose Corticosteroid Administration. DICP, 23(12), 1019-1023. doi:10.1177/106002808902301215
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  Severe cardiovascular adverse reactions including death have been associated with high-dose intravenous corticosteroid therapy. Some of the patients appeared to have acute hypersensitivity reactions to the corticosteroid, with rashes and bronchospasm; other problems included arrhythmias and myocardial infarctions. Most of the patients had underlying renal disease and/or were undergoing renal transplantation. All of the patients having the cardiovascular reactions associated with the corticosteroid received individual doses of at least 250 mg of methylprednisolone or its equivalent. The doses were usually administered over a 30-minute period or less. A cause-effect relationship between high-dose corticosteroid therapy and severe cardiovascular reactions has not been scientifically proved by a controlled trial, but caution is advised when high-dose corticosteroid therapy is administered.
• Erstad, B. L. (1989). Severe cardiovascular adverse effects in association with acute, high-dose corticosteroid administration. DICP, Annals of Pharmacotherapy, 23(12), 1019-1023.
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  PMID: 2690471;Abstract: Severe cardiovascular adverse reactions including death have been associated with high-dose intravenous corticosteroid therapy. Some of the patients appeared to have acute hypersensitivity reactions to the corticosteroid, with rashes and bronchospasm; other problems included arrhythmias and myocardial infarctions. Most of the patients had underlying renal disease and/or were undergoing renal transplantation. All of the patients having the cardiovascular reactions associated with the corticosteroid received individual doses of at least 250 mg of methylprednisolone or its equivalent. The doses were usually administered over a 30-minute period or less. A cause-effect relationship between high-dose corticosteroid therapy and severe cardiovascular reactions has not been scientifically proved by a controlled trial, but caution is advised when high-dose corticosteroid therapy is administered.
• Katz, M. D., & Erstad, B. L. (1989). Octreotide, a new somatostatin analogue. Clinical Pharmacy, 8(4), 255-273.
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  PMID: 2653711;Abstract: The chemistry, pharmacology, pharmacokinetics, clinical uses, adverse effects and drug interactions, dosage, availability and cost, and indications for use of octreotide, a new synthetic analogue of the peptide hormone somatostatin (SS), are reviewed. Like SS, octreotide suppresses secretion of pituitary growth hormone (GH) and thyrotropin and decreases release of a variety of pancreatic islet cell hormones including insulin, glucagon, and vasoactive intestinal peptide (VIP). Octreotide also reduces splanchnic blood flow, gastric acid secretion, GI motility, and pancreatic exocrine function and alters the absorption of water, electrolytes, and nutrients from the GI tract. The elimination half-life of i.v. octreotide is 72-98 minutes, compared with 2-3 minutes for i.v. SS. Usual administration of octreotide is by the i.v. or s.c. route. Octreotide has been studied in the treatment of hormone-secreting pituitary tumors and pancreatic islet cell tumors. Octreotide therapy lowers GH secretion and improves clinical symptoms in patients with acromegaly and may suppress clinical symptoms to a greater degree than bromocriptine. Patients with carcinoid syndrome and VIP-secreting tumors (vipomas) have had substantial improvement in clinical symptoms with administration of octreotide. This agent does not appear to be effective in the treatment of nonvariceal upper GI bleeding and acute pancreatitis; its relative usefulness in the treatment of variceal bleeding is not established. Adverse effects associated with octreotide therapy generally have been mild, including pain or burning at the injection site, abdominal pain, and diarrhea. Octreotide has been shown to interfere with absorption of oral cyclosporine. Standard initial therapy is octreotide acetate 50-100 μg s.c. every 8-12 hours, with titration based on clinical and biochemical effects. Up to 3000 μg/day of octreotide acetate has been administered to patients with acromegaly without serious adverse effect. Octreotide is marketed under the brand name Sandostatin and is available in 1-mL ampuls containing 50, 100, and 500 μg of octreotide acetate. Because the conditions for which octreotide appears to be most effective are uncommon, the drug should be considered for addition to the formulary in tertiary-care institutions only; addition of octreotide to the formulary of a community hospital is probably unnecessary. The synthetic analogue octreotide is longer acting and more specific in pharmacologic action than SS. However, because there are few large, controlled trials evaluating the effectiveness of octreotide, clinicians should observe patients closely for adverse effects and drug interactions.
• Nolan Jr., P. E., Marcus, F. I., Erstad, B. L., Hoyer, G. L., Furman, C., & Kirsten, E. B. (1989). Effects of coadministration of propafenone on the pharmacokinetics of digoxin in healthy volunteer subjects. Journal of Clinical Pharmacology, 29(1), 46-52.
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  PMID: 2708548;Abstract: Previous reports have suggested an interaction between propafenone and digoxin. We investigated the pharmacokinetics of IV digoxin when given alone (Phase I), after pretreatment with propafenone 150 mg every 8 hours for seven days (Phase II), and after propafenone 300 mg every 8 hours for 7 days (Phase III). The total body clearance of digoxin during Phase I was 2.45 ml/min/kg and was 2.17 ml/min/kg during Phase II (NS) and decreased to 1.92 ml/min/kg during Phase III (P
• Erstad, B. L. (1988). Sucralfate in the Prophylaxis and Treatment of Stress-Induced Bleeding. The Journal of pharmacy technology, 4(4), 138-143. doi:10.1177/875512258800400405
• Erstad, B. L., Katz, M. D., & Rose, C. (1988). Treatment of Severe Cryptosporidium-Related Diarrhea with Octreotide in a Patient with AIDS. Drug Intelligence & Clinical Pharmacy, 22(2), 134-136. doi:10.1177/106002808802200206
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  Cryptosporidiosis commonly causes severe diarrhea in immunosuppressed patients. There currently are no antiparasitic drugs consistently effective for this infection. This case describes a 26-year-old hemophiliac patient with acquired immunodeficiency syndrome and cryptosporidiosis whose diarrhea improved with continuous intravenous administration of a long-acting somatostatin analog, octreotide. Somatostatin has a variety of inhibitory effects on gastrointestinal hormones as well as a possible nonspecific effect on gastrointestinal mucosal fluid and electrolyte secretion. The somatostatin analog should be considered for patients with secretory diarrhea refractory to other forms of therapy.
• Katz, M. D., Erstad, B. L., & Rose, C. (1988). Treatment of severe cryptosporidium-related diarrhea with octreotide in a patient with AIDS. Drug Intelligence and Clinical Pharmacy, 22(2), 134-136.
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  PMID: 2894964;Abstract: Cryptosporidiosis commonly causes severe diarrhea in immunosuppressed patients. There currently are no antiparasitic drugs consistently effective for this infection. This case describes a 26-year-old hemophiliac patient with acquired immunodeficiency syndrome and cryptosporidiosis whose diarrhea improved with continuous intravenous administration of a long-acting somatostatin analog, octreotide. Somatostatin has a variety of inhibitory effects of gastrointestinal hormones as well as a possible nonspecific effect on gastrointestinal mucosal fluid and electrolyte secretion. The somatostatin analog should be considered for patients with secretory diarrhea refractory to other forms of therapy.

Presentations

• Fazel, M. T., & Erstad, B. L. (2021, Oct). BEYOND COGNITIVE SKILLS: ADDRESSING THE AFFECTIVE COMPONENTS OF EFFECTIVE PRECEPTORSHIP. ASHP National Pharmacy Preceptors Conference. Virtual: ASHP.
• Erstad, B. L. (2020, 12). Beyond the Basics - Mastering Common Laboratory Results. Midyear Clinical Meeting. Virtual: American Society of Health Systems Pharmacists.
• Acquisto, N., Erstad, B. L., & Edwards, C. J. (2019, Winter). Codes that make you tachycardic. ASHP's Midyear Clinical Meeting. Las Vegas, NV: ASHP.
• Patanwala, A. E., Erstad, B. L., Roe, D., & Sakles, J. C. (2015, October). Succinylcholine is associated with increased mortality when used for rapid sequence intubation of severely head injured patients in the emergency department. ACEP Research Forum. Boston, MA.

Poster Presentations

• Abraham, I. L., Erstad, B. L., Sweasy, J., Persky, D. O., McBride, A., & Alrawashdh, N. (2021). Survival trends in chronic lymphocytic leukemia across treatment eras: SEER database analyses (1985 to 2017).. American Society of Clinical Oncology Annual MeetingAmerican Society of Clinical Oncology.
• Abraham, I. L., Erstad, B. L., Sweitzer, N., Ramox, K., Alsaid, N., & Slack, M. K. (2017, Fall 2017). Classification of causes of hospitalization for heart failure patients in cost-effectiveness and cost-utility evaluations of pharmacotherapeutic, surgical, and managed-care interventions: Systematic Review. ISPOR Conference 2017. Glasgow, Scotland: ISPOR.
• Erstad, B. L., & Campbell, A. M. (2017, May). Tapering Regimens Following Medium to High Dose Extended Duration Corticosteroid Monotherapy in Adults with Rheumatic Disease: A Systematic Review. ACCP Virtual Poster Symposium.
• Patanwala, A. E., Aljuhani, O., Kopp, B., & Erstad, B. L. (2017, January). Methocarbamol Decreases Hospital Length of Stay in Trauma Patients with Rib Fractures. Society of Critical Care Medicine. Honolulu, HI.
• Aljuhani, O., Erstad, B. L., & Patanwala, A. E. (2016, May). Pain control during the transition from intensive care unit to general ward. ACCP Virtual Poster Symposium.
• Slack, M. K., Abraham, I. L., Alberts, D. S., Erstad, B. L., McBride, A., & Gharaibeh, M. (2016, October, 2016). Economic evaluation for the United Kingdom (UK) of systemtic chemotherapies as first-line treatment for metastatic pancreatic cancer (MPC). ISPOR 19th Annual European Congress. Vienna, Austria: ISPOR.
• Patanwala, A. E., Erstad, B. L., Roe, D., & Sakles, J. C. (2015, October). Succinylcholine is associated with increased mortality when used for rapid sequence intubation of severely head injured patients in the emergency department. American College of Emergency Physicians. Boston, MA.