In this episode I’ll:
1. Discuss an article about the use of corticosteroids in patients with severe sepsis.
2. Answer the drug information question “Does nebulized albuterol cause hypokalemia at therapeutic asthma doses?”
3. Share a resource for learning about critical care pharmacy.
Article
Lead author: Didier Keh
Published in JAMA November 2016
Background
When refractory septic shock develops, hydrocortisone 200 mg IV daily is recommended by the Surviving Sepsis Guidelines. Because of the role of excessive inflammation in the pathophysiology of septic shock, steroids seem like a logical treatment. Early studies (before 1995) suggested that steroid use in shock was of no benefit and possibly harmful. Since then, researchers have investigated various dosage schemes of corticosteroids in shock, but evidence only supported their use in refractory septic shock. The authors of this study sought to determine whether hydrocortisone therapy in patients with severe sepsis prevented the development of septic shock.
Methods
The study was a multi-center double-blind, randomized clinical trial that took place in Germany and included 380 adult patients with severe sepsis who were not in septic shock. The primary outcome was the development of septic shock within 14 days. Secondary outcomes were the time until septic shock, mortality in the intensive care unit or hospital, survival up to 180 days, assessment of secondary infections, weaning failure, muscle weakness, and hyperglycemia.
Results
No significant differences were found between the corticosteroid and placebo groups for any of the primary or secondary measures. Numerically, more patients in the hydrocortisone group had a secondary infection, muscle weakness, and hyperglycemia.
Conclusion
The authors concluded:
Among adults with severe sepsis not in septic shock, use of hydrocortisone compared with placebo did not reduce the risk of septic shock within 14 days. These findings do not support the use of hydrocortisone in these patients.
Discussion
Finding the ideal subpopulation of septic patients to use corticosteroids in has been surprisingly vexing for researchers. With the role of inflammation in sepsis, it is hard to understand why steroids are not beneficial for everyone, and this likely explains the continuation of research in this area despite so many negative trial findings.
One trial to keep an eye out for is the ADjunctive coRticosteroid trEatment iN criticAlly ilL Patients With Septic Shock (ADRENAL) study. The study should complete in June 2017 and is planned to include 3800 patients with septic shock to determine the benefits of low-dose steroids in this group of patients.
Drug information question
Q: Does nebulized albuterol cause hypokalemia at therapeutic asthma doses?
A: Yes
A study published in 2013 found a statistically significant decrease in serum potassium level of 0.3 mEq/L. Patients were given albuterol 2.5 mg via nebulizer every 20 minutes for three doses. The mean serum potassium went from 4.6 to 4.3 mEq/L 60 minutes after albuterol. No hypokalemia related EKG changes were noted.
Resource
The resource I would like to share on this episode is Pharmacy Joe’s Critical Care Pharmacy Academy.
Here are some of the things pharmacists have told me that led me to create the Critical Care Pharmacy Academy:
Getting and staying ahead of the vast critical care medical literature is one of our greatest challenges. There are so many journals to scan, let alone articles to read to see where they fit into practice.
Pharmacists want practical, critical care pharmacy education, intended for practicing pharmacists. They want complex topics broken down into simple to remember and easy to apply concepts. They want skills they can apply at the bedside, not academic theory.
Some have told me they feel isolated in their practice at small hospitals, and they want to know how other pharmacists are approaching various critical care challenges.
The number one thing I have heard is how busy practicing pharmacists are these days. Between work, families, and fun, hardly anyone has hours to sift through the literature or read about a new skill.
Every month in the Academy, I publish a skill-based Masterclass where I take about an hour to dive deep into a practical, critical care skill. The Masterclasses are self-paced and broken up into 5-15 minute video segments. Patient assessment and airway pharmacology are two examples of current Masterclasses.
Every week, I scan the critical care literature and create a ~15-minute digest in video and audio formats of the most important articles. I include my opinion of where the article fits in clinical practice.
That’s a time commitment of only 2 hours per month for a pharmacist to develop critical care skills and stay ahead of the vast critical care literature developments.
There are also Academy members-only forums to ask and answer critical care pharmacy questions and learn how others are practicing critical care.
If you know of a colleague that might find the Academy useful, please share this episode with them!
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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