Best practices of pain, agitation, and delirium (PAD) management require coordinated, bundled care among an interprofessional intensive care unit (ICU) team. Clinical pharmacists are essential health care team members in optimizing sedation and analgesia management in critically ill patients. The purpose of this systematic review is to summarize the clinical impact of pharmacist‐led interventions targeting PAD in mechanically ventilated adult ICU patients. A literature search was conducted using MEDLINE, EMBASE, CINAHL, SCOPUS, and the Cochrane Central Register of Controlled Trials between January 1, 2000 and September 1, 2022. Randomized controlled trials, quasi‐experimental, or observational studies comparing pharmacist‐led interventions aimed at PAD management best practices and usual care in adult (≥18 years) ICU patients were included. Clinical (mechanical ventilation duration, hospital length of stay, and mortality) and economic outcomes as well as sedation and analgesia utilization were evaluated. A total of 1418 citations were identified with 9 studies (n = 3769 patients) meeting eligibility. The types of pharmacist‐led intervention strategies were inconsistent among included studies. Four of the 9 studies showed that pharmacist‐led interventions were associated with a significant reduction in mechanical ventilation duration ranging from 4.0 to 8.5 days compared with approximately 5.6 to 14.0 days in the control groups. Three (50%) of 6 studies evaluating length of stay showed significant reductions with the intervention group compared with controls. No impact on mortality and ICU‐acquired delirium/coma rates was shown. The pharmacist‐led intervention group was also associated with significant reductions in opioid analgesia and sedative utilization. Only two studies evaluated the financial impact of the intervention group with one study finding a positive benefit attributed to decreased drug utilization, while the other report failed to find an impact on total hospital stay costs. Pharmacist‐led interventions promote PAD best practices in the ICU, although the impact on patient‐centered outcomes remains controversial.
Study Objective
Thromboelastography (TEG) offers a more dynamic assessment of hemostasis over activated partial thromboplastin time (aPTT). However, the clinical utility of TEG in monitoring bivalirudin during extracorporeal membrane oxygenation (ECMO) remains unknown. The purpose of this study was to evaluate the correlation between aPTT and TEG in adult ECMO patients anticoagulated with bivalirudin.
Design
Multicenter, retrospective, cohort study conducted over a 2‐year period.
Setting
Two academic university medical centers (Banner University Medical Center) in Phoenix and Tucson, AZ.
Patients
Adult patients requiring ECMO and bivalirudin therapy with ≥1 corresponding standard TEG and aPTT plasma samples drawn ≤4 h of each other were included. The primary endpoint was to determine the correlation coefficient between the standard TEG reaction (R) time and bivalirudin aPTT serum concentrations.
Measurements and Main Results
A total of 104 patients consisting of 848 concurrent laboratory assessments of R time and aPTT were included. A moderate correlation between TEG R time and aPTT was demonstrated in the study population (r = 0.41; p < 0.001). Overall, 502 (59.2%) concurrent assessments of TEG R time and aPTT values showed agreement on whether they were sub‐, supra‐, or therapeutic according to the institution's classification for bivalirudin. The 42.2% (n = 271/642) discordant TEG R times among “therapeutic” aPTT were almost equally distributed between subtherapeutic and supratherapeutic categories.
Conclusions
Moderate correlation was found between TEG R time and aPTT associated with bivalirudin during ECMO in critically ill adults. Further research is warranted to address the optimal test to guide clinical decision‐making for anticoagulation dosing in ECMO patients.
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