In this episode I’ll:
1. Discuss an article comparing early vasopressin to norepinephrine in septic shock.
2. Answer the drug information question “What options can be used in steroid-refractory severe reactive airway disease?”
3. Share a new resource for Pharmacy Nation.
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Before we begin, I’d like to share a pearl from my book, A Pharmacist’s Guide to Inpatient Medical Emergencies: Prepare labels ahead of time so as not to delay dispensing emergency medications during a code. If you are in a pinch, taping the empty vial to the syringe as a “label” is better than no label at all!
Article
Lead author: Anthony C Gordon
Published in JAMA in August 2016
Background
Norepinephrine is recommended as the first line vasopressor in septic shock in the most recent sepsis guidelines. In a 2014 retrospective single center review, early vasopressin use in septic shock was associated with fewer new onset arrhythmias.
Methods
The authors sought to evaluate early vasopressin vs norepinephrine effects on kidney failure in patients with septic shock. This study was a double-blind, randomized trial conducted in 18 general adult intensive care units in the UK.
Patients were randomly assigned to vasopressin or norepinephrine.
The primary outcome was kidney failure–free days during the 28-day period after randomization. Secondary outcomes included rates of renal replacement therapy, mortality, and serious adverse events.
Results
The median time to study drug initiation was 3.5 hours after diagnosis of shock. 57% of survivors in the vasopressin group never developed kidney failure, compared with 59.2% in the norepinephrine group. This difference was not statistically significant. The median number of kidney failure free days was 9 in the vasopressin group compared with 13 in the norepinephrine group. This difference was also not statistically significant. Mortality and serious adverse event rates were similar between groups.
Conclusion
The authors concluded:
Among adults with septic shock, the early use of vasopressin compared with norepinephrine did not improve the number of kidney failure–free days. Although these findings do not support the use of vasopressin to replace norepinephrine as initial treatment in this situation, the confidence interval included a potential clinically important benefit for vasopressin, and larger trials may be warranted to assess this further.
Discussion
Interestingly, the vasopressin in this study was allowed to be titrated up to a maximum of 0.06 units per minute. This is different than the fixed dose vasopressin that is recommended in the sepsis guidelines. For now, it seems that the vasopressor choice recommended in the sepsis guidelines is still the most appropriate. You can download a PDF that explains vasopressor choice in sepsis inside the free Pharmacy Nation Community.
Drug information question
Q: What options can be used in steroid-refractory severe reactive airway disease?
A: Magnesium, ketamine, and montelukast.
Evidence for these therapies is limited to case series / reports and theory.
Magnesium sulfate can be given 2 grams IV over 20 minutes.
Ketamine can be given 0.5 to 1 mg/kg slow IV push followed by 0.5 – 2 mg/kg/hr infusion.
Montelukast was shown to increase FEV1 by 15% when given IV. No IV preparation is available in the US and it is unknown if oral montelukast would have the same benefit.
Resource
The resource I’d like to share in this episode is an update that I have made to the pharmacyjoe.com website. I’ve made a free community area for listeners of the podcast. When you sign up for the free community access, you’ll get an invitation to the Pharmacy Nation Slack group, and immediate access to download all of the PDF resources I’ve made available so far:
Chapter 1 of A Pharmacist’s Guide to Inpatient Medical Emergencies
Chart of Vasopressor Choice in Sepsis
Critical Care Rotation Workflow Diagram
ISBAR Communication Tool
Journal Club Guidelines
Mechanism of Action – Pathophysiology Examples
Visual Antibiotic Coverage Guide
What A Pharmacist Should Know About Mechanical Ventilation
There is also a forum where you can make topic requests for future episodes.
Additionally, another forum exists as a Job Board. You can browse hospital pharmacy jobs from indeed.com. I also invite you to post any open positions that you have at your hospital on the job board as well.
I’ll conclude by sharing a story about my colleague, “Pharmacy Daniella” and the Pharmacy Nation Slack group. Daniella had a question about colistin dosing. She had tried to ask it to a peer at a local hospital, but he didn’t answer his phone. She had posted the question on an email listserv but had not gotten a sufficient response.
She had been a member of the Pharmacy Nation Slack group for a while but had yet to post a question. She put her question in the infectious disease channel of the Pharmacy Nation Slack group and it was promptly answered by “Pharmacy Justin”. Before the end of the day, “Pharmacy Nada” and “Pharmacy Riley” had chimed in as well. The Slack group is like a modern equivalent of an email listserv, making real-time group collaboration possible. You can sign up by going to pharmacynation.org.
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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