In this episode I’ll:
1. Discuss an article about delays in antimicrobial therapy in patients with septic shock.
2. Have a recent pharmacy student of mine answer the drug information question “What dose of IV diltiazem should be used to treat rapid Afib?”
3. Share a resource for assessing, preventing, and managing ICU delirium.
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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:
“Give meds in the most ready to admin form possible at codes. Include a flush & prime lines” #pharmacists https://t.co/w0tP1mmQW7
— Pharmacy Joe (@PharmacyJoe) August 29, 2016
Article
Patient and Organizational Factors Associated With Delays in Antimicrobial Therapy for Septic Shock
Lead author: Andre Amaral
Published ahead of print online in the journal Critical Care Medicine
Background
Time to first antibiotic is of particular interest in the context of caring for patients with septic shock. An often cited observational study associated each 1-hour delay in time to first antibiotic for septic shock patients with an 8% increase in mortality. The authors of this study sought to identify clinical and organizational factors associated with delays in antimicrobial therapy for septic shock.
Methods
This study was a retrospective cohort analysis of critically ill patients with septic shock across 24 ICUs. A total of 6,720 patients with septic shock were included in the analysis.
Results
The time to first antibiotic was delayed significantly in several groups:
24-minute delay per every 5 Acute Physiology Score point increase
16-minute delay per every ten years of age increase
35-minute delay if comorbidities were present
50-minute delay if hospital length of stay before onset of hypotension was < 3 days
121-minute delay if hospital length of stay before onset of hypotension was 3 to 7 days
130-minute delay if hospital length of stay before onset of hypotension was > 7 days
45-minute delay if the diagnosis was pneumonia
52-minute delay if the patient was admitted to an academic hospital
39-minute delay if the patient was transferred from a medical ward compared to a surgical ward
The time to first antibiotic was shortened significantly in two groups:
53 minute shorter time if the infection was community acquired
15 minute shorter time per every 1 degree (Celsius) increase in temperature
Conclusion
The authors concluded:
We identified clinical and organizational factors that can serve as evidence-based targets for future quality-improvement initiatives on antimicrobial timing. The observation that academic hospitals are more likely to delay antimicrobials should be further explored in future trials.
Discussion
Only 15.2% of patients in the study received antibiotics within the first 1 hour of care. This represents a tremendous opportunity for improvement in the real-world care of septic shock patients.
From the perspective of a hospital-based pharmacist responding to rapid response calls for septic patients, one particular group with delayed antibiotic timing caught my eye. The group with a 24-minute delay for every 5 APACHE score points.
The more acutely ill the patient is, the more the nurse & physician are forced to attend to immediately catastrophic patient management priorities such as profound hypotension or respiratory failure.
A pharmacist that obtains and prepares for immediate administration of antibiotics while the rest of the team is focused on these priorities may significantly decrease the time to first antibiotic for a critically ill patient. That is why if the rest of the team is tied up with immediately life-threatening patient management needs I will obtain the antibiotic, tubing, smart pump, prime the line, and give the antibiotic to the nurse in a ready to administer form.
Drug information question
This drug information question and answer is provided by a pharmacy student who recently completed my APPE rotation – “Pharmacy Gavin”. Shout out to Gavin for the excellent work answering this question!
Q: What dose of IV diltiazem should be used to treat rapid Afib?
A: A 10 mg standard dose or weight-based dosing (0.2-0.3 mg/kg) is appropriate; Consider 5 mg slow IV push if patient has severe hypotension. May repeat dose until 0.25 mg/kg is reached.
A recent retrospective review found that patients who received a standard 10 mg diltiazem dose had a non-inferior reduction (60.8% vs. 68.7%, p=0.082) in HR compared to a weight-based dose. There were some statistically significant baseline differences between groups since the standard dose group had a lower heart rate and weighed more.
Interestingly, there were similar rates of hypotension (< 90 mmHg) between both groups with the standard dose group having a slightly higher rate of hypotension (5.5% v 5.0%). Further, for patients who presented with hypotension, 80% of them improved their BP > 90 mmHg after diltiazem. This may be explained by slowing the HR enough that the ventricles were allowed more time to fill, which improved cardiac output.
Another article recommends diltiazem 5mg IV slow push over 2 minutes and further doses may be continued until 0.25 mg/kg if BP maintained.
Resource
The website icudelirium.org contains a large amount of material to support clinicians seeking to assess, prevent, and manage ICU delirium. The site is sponsored by Vanderbilt University Medical Center. I’ve used the site for its numerous resources including the email contact which put me in touch with a pharmacist at Vanderbilt when I had a specific question about how they structure their sedation protocol to minimize delirium.
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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