Background and Objectives: The addition of a pharmacist to rapid response teams (RRT) has been shown to improve adherence to advanced cardiac life support protocols and to decrease mortality. A quality improvement study was initiated at a single center to evaluate the addition of a pharmacist to the RRT during cardiopulmonary arrest. Methods: Data were prospectively collected on pharmacy response time and interventions performed. In addition, a pre-and post-intervention survey of the interprofessional medical emergency response improvement team (MERIT) was performed to assess the perception of pharmacist involvement. Results: From April to November 2019, the pharmacists responded to 19 RRT activations for cardiopulmonary arrest. An average of 29.8 minutes were spent at each event and an average of 5.5 interventions per event were made. The most common intervention made by pharmacists was medication procurement (54 interventions), followed by providing drug information (14 interventions). Pharmacists also ensured medication reimbursement (13 interventions). The majority of the MERIT strongly agreed or agreed that the addition of a pharmacist to RRT activations improved teamwork (83.1%), decreased medication turnaround time (84.6%), decreased medication errors (66.7%), and may have prevented a poor outcome (71.8%) in the post-implementation survey. Conclusion: Overall, pharmacists demonstrated value as a member of the RRT during cardiopulmonary arrest. The addition of a pharmacist was well received by interprofessional members of the MERIT.
Background: Small studies have described the off-label use of intravenous (IV) olanzapine for the management of acute agitation. Objective: The purpose of this study was to evaluate the efficacy and safety of IV olanzapine to manage acutely agitated patients with neurological injuries. Methods: This was a retrospective analysis of IV olanzapine use in patients admitted to the neurotrauma and neurovascular intensive care units at a single academic center. The primary endpoint was the requirement of additional IV olanzapine, IV benzodiazepine, or IV haloperidol within 60 minutes from the time of first IV olanzapine dose. Secondary safety endpoints included QTc prolongation and respiratory depression. Results: Forty-six patients received IV olanzapine during the study period. One patient required an additional dose of IV olanzapine and two patients received benzodiazepine or antipsychotic agents within 60 minutes of IV olanzapine administration. One patient had a post-administration QTc level >500 ms. Two patients had an increased oxygen requirement, but none required intubation. Conclusion: IV olanzapine appears to be efficacious in reducing the need for sedatives and antipsychotics with low risk for QTc prolongation and respiratory depression in acutely agitated patients with neurological injuries.
Introduction: Guidelines for post-arrest care recommend use of short acting sedation, but there is currently significant practice variation. We tested whether benzodiazepine use was associated with delayed awakening in this population. Methods: We performed a retrospective cohort study at a large academic medical center including comatose patients hospitalized after resuscitation from in- or out-of-hospital cardiac arrest from January 2010 to September 2019. We excluded patients with cardiac arrest secondary to primary neurological event or trauma, those with severe cerebral edema on initial head imaging, those who were awake post-arrest and those with severe shock for whom benzodiazepines might have been chosen for hemodynamic reasons. We extracted all medication information from the electronic medical record and standard clinical and outcome information from a prospective registry maintained at our center. We considered patients to be exposed to benzodiazepines if they received > 10mg midazolam equivalents in the first 72 hours after cardiac arrest and censored cumulative mediation data at awakening for those who awakened before 72 hours. Our primary outcome of interest was days from arrest to awakening, which we defined as following verbal commands. We compared median time to awakening across sedation groups, then performed Cox regression to test the independent association of benzodiazepine exposure with time to awakening after adjusting for age, sex, weight, presenting rhythm, arrest location, initial serum creatinine, initial shock severity, initial neurological examination and presence of epileptiform. Results: Overall, 2,778 patients presented during the study period of which 621 met inclusion criteria for analysis and 209/621 (34%) awakened after a median of 4 [IQR 3 - 7] days. Patients who received benzodiazepines for sedation awakened significantly later than those who did not (5 days vs. 3 days, P=0.004). In adjusted regression, benzodiazepine exposure was independently associated with delayed awakening (adjusted hazard ratio 0.64 (95% CI 0.44 - 0.94)). Conclusion: Benzodiazepine exposure is associated with delayed awakening in comatose survivors of cardiac arrest.
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