Volume 15 Issue 2 July 2015

Clinical Pharmacy and Pharmacology Section Newsletter

Society of Critical Care Medicine

Section Officers Chair Ishaq Lat, PharmD ( ishaq_Lat@rush.edu) Past-Chair Karen McAllen, PharmD, (karen.mcallen@sanofi.com) Chair-Elect Russ Roberts, PharmD (rroberts@tuftsmedicalcenter. org) Secretary/Treasurer Amy Dzierba, PharmD (ald9012@nyp.org) Members-at-Large Seth Bauer, PharmD (bauers@ccf.org) Erin Frazee, PharmD (frazee.erin@mayo.edu) Ty Kiser, PharmD (ty.kiser@ucdenver.edu)

MESSAGE FROM THE CHAIR Ishaq Lat, PharmD, FCCM, FCCP, BCPS Happy summer, everyone! I’m sure many of us are not sad to leave behind days spent shoveling snow and cold, wintry nights. As we transition into summer, July represents the ending of one academic year and the beginning of another. No doubt, many of us are inspired by the enthusiasm of a new class of residents and students as they work their way to our critical care experiential rotation. Eager to practice pharmaceutical care at the highest level and in a multidisciplinary environment, new residents and students represent the fresh face of our discipline and our profession. The commitment to teaching and mentoring is renewed every July as we dedicate ourselves to a fresh group of trainees. Symbolically, this represents an opportunity to evaluate where we have been and where we are going. Along these lines, there has been renewed energy to assess the current state of critical care pharmacy practice. With technology advancements, increasingly coordinated healthcare delivery models, and the emergence of a highly trained workforce, the time is right to evaluate how we want to shape the direction of critical care pharmacy practice. To this end, a task force has been created to update the pre-existing position paper on critical care pharmacy services. The task force consists of pharmacists from various practice settings, who are members of the CPP Section, the ACCP Critical Care PRN, and ASHP. They offer their perspectives as practicing critical care pharmacists. The intended audience will be critical care practitioners, pharmacy administrators, and hospital administrators. Some of the topics that will be addressed include: patient care services, position duties, and education and training. The position paper will be developed using the modified Delphi method to identify areas of broad agreement and form consensus statements. The task force is comprised of the following individuals:

Nicole Acquisto, PharmD, BCPS Clinical Pharmacist Specialist, Emergency Medicine University of Rochester Medical Center Assistant Professor, Emergency Medicine University of Rochester School of Medicine and Dentistry Rochester, NY

A. Kendall Gross, PharmD, BCPS Critical Care Pharmacist (Pharmacist II) Medical/Surgical and Cardiothoracic Intensive Care University of California, San Francisco Medical Center (UCSFMC) Department of Pharmaceutical Services San Francisco, CA

Patricia Meyer, PharmD, FASHP Associate Vice President Baylor Scott and White Health Temple, TX

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Michael Bentley, PharmD, FCCM, FCCP, FNAP Clinical Pharmacist Specialist, Cardiovascular and Critical Care Carilion Clinic, Department of Pharmacy Associate Professor, Medicine Virginia Tech Carilion School of Medicine Roanoke, VA

Judi Jacobi, PharmD, MCCM, FCCP, DNPAP, BCPS Critical Care Pharmacist Indiana University Health – Methodist Hospital Department of Pharmacy Indianapolis, IN

Christopher Paciullo, PharmD, BCPS Clinical Pharmacist Specialist, Cardiothoracic Surgery Emory University Hospital Emory Healthcare Department of Pharmacy Atlanta, GA

Scott Bolesta, PharmD, FCCM, BCPS Associate Professor, Pharmacy Practice Wilkes University, Nesbitt College of Pharmacy and Nursing Clinical Pharmacist, Internal Medicine/Critical Care Regional Hospital of Scranton Wilkes-Barre, PA

Ishaq Lat, PharmD, FCCM, FCCP, BCPS Associate Director, Clinical Pharmacy Services Pharmacist, Critical Care Rush University Medical Center Chicago, IL

Russ Roberts, PharmD Senior Clinical Pharmacy Specialist Tufts Medical Center Department of Pharmacy Boston, MA

Mitchell J. Daley, PharmD, BCPS Clinical Pharmacist Specialist, Critical Care University Hospital at Brackenridge, Seton Family Health Department of Pharmacy Services Austin, TX

Robert MacLaren, PharmD, MPH, FCCM, FCCP Professor, Pharmacy Practice Clinical Pharmacist Specialist, Critical Care University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora, CO

Joanna Stollings, PharmD, BCPS Clinical Pharmacist Specialist, MICU Vanderbilt University Medical Center Department of Pharmaceutical Services Nashville, TN

Sarah Day, PharmD, BCPS Clinical Pharmacist, Critical Care Doctors Hospital, OhioHealth Department of Pharmacy Columbus, OH

Jennifer McCann, PharmD, BCPS Clinical Pharmacist, Critical Care St. Vincent Indianapolis Hospital Indianapolis, IN

Scott Taylor, PharmD, MS, BCPS Pharmacy Manager Via Christi Regional Medical Center Clinical Assistant Professor University of Kansas, School of Medicine Wichita, KS

If you have questions regarding either the position paper or the CPP Section, please feel free to contact me at ishaq_lat@rush.edu. I would like to hear from you. Following are announcements, award opportunities, and other news from our CPP Section.

Volume 15 Issue 2 July 2015

CPP COMMITTEE CORNER

Communications Committee Simon Lam, PharmD, BCPS, FCCM (Chair), and Joanna Stollings, PharmD, BCPS (Chair-Elect) This issue introduces a new feature for the newsletter, Research Pearls. This section will provide a how-to tip or a clinical pearl related to research in each of the four annual issues of the CPP newsletter. A process, procedures, and an author submission checklist have been developed to facilitate submission of articles published in this newsletter to select peer-reviewed journals. If you have any questions regarding membership in the Communications Committee or contributions you would like to make to the CPP Section newsletter, please email either Sim Lam at lams@ccf.org or Joanna Stollings at joanna.stollings@vanderbilt.edu.

Education Committee Jeffrey Gonzales, PharmD, BCPS, FCCM (Chair), and Diana Mulherin, PharmD, BCPS (Chair-Elect) Congratulations to all CPP Section members who presented a poster or platform talk at the 2015 SCCM Annual Congress in Phoenix. The CPP Education Committee has collected these posters and presentations, and they are available in the CPP iRoom in the Committee Documents folder. If you have not already done so, please send a pdf of your poster or slides to Janie Faris at pjanefaris325@gmail.com. Links to available full posters can be found in the Appendix of the current newsletter (iRoom log-in may be required). The CPP Education Committee continues to partner with the Society on several key initiatives, including educational modules, a tool kit for protocol implementation, and journal club. Journal Club continues to be held the third Friday of every month at 2 PM ET. Open enrollment for the 2015-2016 academic year is now closed, and all presenters have been scheduled through a lottery system. We are pleased to announce that a new Journal Club format was approved to include three speakers per event to allow our members to stay current with new literature! If you would like to receive the monthly notification and Web link to access the Journal Club session, please contact Karen Berger at karenberger7@gmail.com or sccmcppjc@gmail.com. If you have questions or would like to become involved in the Education Committee, please contact Jeff Gonzales (jgonzale@rx.umaryland.edu) or Diana Mulherin (dianalynnwells@gmail.com).

Membership Committee Susan Hamblin, PharmD, BCPS (Chair), and Serena Harris, PharmD, BCPS (Chair-Elect)

Membership Database The section membership database contains practice information, research interests, speaking interests, and interest in the mentor-mentee program for the CPP Section. This database is only updated as frequently as members revisit the form. It is important to keep this information current to ensure accurate lists are generated for various committee uses. If you have not

Volume 15 Issue 2 July 2015

updated your membership database profile (Member Survey) in the past year, please take a few moments to complete the CPP Member Profile Update using the link on the home page of the iRoom. Mentor-Mentee Program The Mentor-Mentee Program continues to grow this year and provides guidance for mentees in the areas of clinical practice, teaching, research, and CPP involvement. All members are encouraged to participate in this program in some form. As the number of mentees has increased this year, several changes have been made to the method of collecting information from both mentors and mentees. Individuals who indicate interest in the program will now be sent a link to a Google form for completion. This should facilitate a more expeditious matching process in the future. Interest in the program can be indicated either when completing the membership database profile or by emailing Susan Hamblin (susan.hamblin@vanderbilt.edu) or Serena Harris (serena.harris@eskenazihealth.edu). Please note that the most expeditious method is direct email contact. We continue to emphasize the need for additional mentors in all areas and levels of practice as the mentee pool continues to expand. PGY2 Critical Care Resident and Fellowship Membership SCCM continues to offer reduced membership dues for trainees. The membership committee has provided the Society with a list of the current critical care, nutrition, and emergency medicine residency program directors, as well as fellowship directors. Those directors with residents in the previous year should receive information on this offer beginning in June.

Patient Safety Committee Elizabeth Sinclair, PharmD, BCPS (Chair), and Rachel Kruer, PharmD, BCPS (Chair-Elect) We are seeking applicants for our revised patient safety awards. Descriptions and eligibility criteria for the two awards are outlined below. The application can be found in the CPP iRoom under Committee Documents Patient Safety Committee CPP Patient Safety Awards 2015 Application. Please consider submitting an application for an award. Contact Elizabeth Sinclair (easincla@texaschildrens.org) with any questions. CPP Patient Safety Young Pharmacist Investigator Award Mission Statement and Goals The SCCM Excellence in Patient Safety Young Pharmacist Investigator Award recognizes an individual at the beginning of a pharmacy career whose research or quality improvement initiatives positively impact patient safety. This award seeks to highlight and encourage pharmacist-driven research and quality improvement efforts that optimize safe care for critically ill patients. The award will also promote dissemination of the objectives, methods, and outcomes of innovative patient safety research and interventions. Eligibility Criteria The applicant must be a pharmacist who is in residency or fellowship training, or who has completed his or her training within 10 years of the date of application. The applicant must be employed by a hospital or healthcare system, a member of SCCM, and the leader of the submitted project. Multidisciplinary collaboration with physicians, nurses, information technologists, administrators, and other healthcare professionals is welcome and strongly encouraged. Members who have served as the Chair or Chair-Elect of the CPP Patient Safety Committee or who have served on the CPP Executive Committee are not eligible until 3 years after their term has ended. Collaboration on the project with a member who has served as the Chair or Chair-Elect of the CPP Patient Safety Committee or who has served on the CPP Executive Committee does not affect the eligibility if the applicant meets all other criteria.

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CPP Innovations in Patient and Medication Safety Award Mission Statement and Goals The SCCM Innovations Patient and Medication Safety Award recognizes a health-system or an individual for designing and implementing a successful and novel program that promotes safe medication use and patient safety in the critical care setting. The goal of this award is to highlight patient safety improvements and to disseminate the objectives, methods, and outcomes of the program. Eligibility Criteria The applicant must be a pharmacist who is a member of SCCM and the leader of the submitted project. Multidisciplinary collaboration with physicians, nurses, information technologists, administrators, and other healthcare professionals is welcome and strongly encouraged. Members who have served as the Chair or Chair-Elect of the CPP Patient Safety Committee or who have served on the CPP Executive Committee are not eligible until 3 years after their term has ended. Collaboration on the project with a member who has served as the Chair or Chair-Elect of the CPP Patient Safety Committee or who has served on the CPP Executive Committee does not affect the eligibility if an applicant meets all other criteria.

Program Committee Marilyn Bulloch, PharmD (Chair), and Michaelia Cucci, PharmD (Chair-Elect) The SCCM CPP Program Committee has been busy in the first half of 2015. The committee would like to thank all members who have been instrumental in helping us work towards all of our charges.

Year in Review The planning for the Year in Review is well underway. The theme for the 2016 Year in Review will be critical care pharmacy 2020 – looking forward at the future of critical care pharmacy. The topics will focus on areas of interest (identified by committee members) that are shaping the future of critical care pharmacy. Topics include: 1) Emerging Infectious Diseases by Stephanie Bass; 2) Pharmacological Considerations for Machines and Devices in Intensive Care by Michaelia Dunn; and 3) Advances in Nutrition Support by Diana Mulherin. The Program Committee has matched each speaker with a mentor who has presented at the Year in Review during past Congresses. The committee will start proactively planning for the 2017 Year in Review in July. CPP members who have suggestions should email Marilyn Bulloch at novellm@gmail.com

Pre-Congress Symposium The committee is actively planning the 2016 Pre-Congress Symposium. The theme is Transitioning from Fantasyland to Tommorrowland – the evolution of critical care pharmacy to 2020 and beyond. Topics include: 1) Training Models for Critical Care Pharmacy in 2020 by Seth Bauer; 2) The ICU Pharmacy Matrix – technology for patient care in 2020 and beyond by Gourang Patel; and 3) Optimal Critical Care Services in 2020, a round table discussion on the Critical Care Pharmacy position paper with Ishaq Lat, Mitch Daley, and Scott Bolesta.

Recruitment Exchange The Third Annual Recruitment Exchange will be held at the 2016 SCCM Annual Congress in Orlando, Florida. This is a no-charge, informal event that allows institutions with available critical care pharmacy or related positions to meet with prospective candidates. The committee asks all CPP members to share this information with their institutions. This is a wonderful recruiting forum for institutions to recruit top candidates.

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The official date, time, and location will be announced in October 2015. Potential candidates are not required to register for the event. The committee does request that institutions send position information to cpprecruitmentexchange@gmail.com by December 31, 2015. However, onsite registrations will be welcome. All CPP members are encouraged to share information regarding the event with potential institutions and candidates. Questions about the event can be sent to cpprecruitmentexchange@gmail.com or Nei.scott@mayo.edu.

Visiting Clinical Professor The CPP Program Committee would like to encourage members to consider participating in the Visiting Clinical Professor (VCP) Program. Members who have identified a need for advancement of critical care pharmacy practice or teaching may apply on behalf of their medical center, university, or other institution. After application materials have been submitted and reviewed, the Program Committee will work to identify a VCP whose outstanding clinical practice and/or teaching best suits the applicant’s needs. The VCP will travel to the applicant’s location for a one- or two-day visit. During this time, the VCP can participate in patient care rounds, interact with pharmacy and other healthcare professionals, deliver a guest lecture, and participate in additional activities as proposed by the site. This program has been a rewarding experience for both the applicant and the VCP. Funding and reimbursement are available. The application is located on the CPP iRoom (click on the Committee Documents link on the left-hand side of the page and then on the VCP folder).

WHAT’S NEW? The VCP Program application deadline has been changed to a rolling deadline. Please email Michaelia Cucci (michaelia.dunn@gmail.com) or Marilyn Bulloch (novellm@gmail.com) if you have any questions about the application process.

Research Committee Mitch Daley, PharmD (Chair), and Heather Personett, PharmD (Chair-Elect) The CPP Research Committee has had a productive year, focused on maintaining and developing new services to meet the research needs of the CPP Section membership. In an effort to continue to grow opportunities for our members to participate in research, the committee is facilitating numerous research projects, including both surveys and retrospective reviews. Opportunities vary, but include topics such as the utilization of prothrombin complex concentrate and errors in care transition. If you are interested in getting involved with these opportunities, please contact Mitch Daley (mjdaley@seton.org).

Position Opening in Critical Care at

Your Institution?

Plan ahead to attend the 2016 CPP Recruitment Exchange

2016 SCCM Annual Congress

No Cost Forum

For more information, email:

cpprecruitmentexchange@gmail.com

Volume 15 Issue 2 July 2015

If you have your own research ideas, but are looking for additional resources, consider the following services available from the CPP Research Committee:

Grant funding opportunities: this service identifies non-SCCM grants available from professional organizations, industry and government. This document is updated twice each year and can be found in the iRoom under Non-SCCM Funding.

Research consultation for study design or analytical plan: the Research Consult Service is intended to be a contact for any aspect of your research project. You can utilize this service by emailing your inquiry to cppresearchconsult@gmail.com.

Feedback for your manuscript or grant proposal: utilize the Pre-Peer Review Service, in which the CPP Research Committee helps identify experts to provide peer review prior to a formal submission.

Finally, if you are looking for a concise way to remain up-to-date with over 20 scientific journals related to critical care pharmacotherapy, then review the literature updates on a monthly basis. These can be found on the iRoom under Committee Documents > Literature Updates. If you would like further information about any of these activities or would like to get involved in the Research Committee, please contact the Chair, Mitch Daley (mjdaley@seton.org), or Chair-Elect, Heather Personett (heather.personett@mayo.edu).

Pharmacotherapy Article Corticosteroids as Adjunctive Treatment in Patients with Severe Community-Acquired Pneumonia Sarah Welch, PharmD, and Gabrielle Gibson, PharmD, BCPS

Community-acquired pneumonia (CAP) is a common and serious condition that confers a high

morbidity and mortality. Approximately 20% to 60% of CAP patients will be admitted to the

hospital, with 10% to 22% requiring admission to the intensive care unit (ICU).1 Those admitted

to the ICU have a mortality risk of 22% to 54%.2 Factors such as critical illness-related

corticosteroid insufficiency and an exaggerated proinflammatory response have been

associated with higher mortality rates.3, 4 Elevated interleukin 6 (IL-6) levels have been shown

to persist to day 7 more frequently in nonsurvivors with pneumonia compared to survivors, and

elevated serum levels of tumor necrosis factor (TNF)-α and IL-6 correlate with worse multiple

organ failure and lung injury scores.5, 6 As such, guideline recommendations state that

corticosteroids (CS) may be considered as an additional treatment in patients who have relative

adrenal insufficiency; however, criteria for steroid replacement in patients presenting with CAP

remains controversial.7 Thus, this article will provide a review of available literature evaluating

the use of CS in the management of severe CAP.

The potential role for CS in modulating the systemic and pulmonary inflammatory response

was assessed in a small pilot study of 20 ICU patients with a diagnosis of CAP or hospital-

acquired pneumonia.8 Patients received methylprednisolone at a mean ± standard deviation

dose of 677±508 mg for 9±7 days prior to the investigation. Those who received CS had

significantly reduced levels of serum IL-6, C-reactive protein and bronchoalveolar lavage fluid

TNF-α and percentage neutrophil count; however, there was no difference in cytokine levels

with regard to survivors compared with nonsurvivors. Although the study was not powered to

detect the impact of CS on outcomes in pneumonia, the mortality rate in patients receiving CS

was 36% (4/11) compared to 67% (6/9) for patients not receiving CS (P=0.37). The dose of

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steroids administered in the study is much higher than what has been shown to be beneficial in

patients with septic shock, yet the authors did not comment on any observed adverse effects.

Overall, this study demonstrated that CS decreased systemic and lung inflammatory responses

and suggested a potential mortality benefit in patients with severe pneumonia.

Seeking to confirm the clinical benefit of CS, Confalonieri and colleagues randomized 46

patients to receive either hydrocortisone, 200-mg bolus followed by an infusion of 240 mg at a

rate of 10 mg/h for 7 days, or placebo.9 The study was stopped early after an interim analysis

demonstrated significant differences between the two groups for improvement in the ratio of

arterial oxygen concentration to the fraction of inspired oxygen (PaO2:FIO2) by study day 8

(P=0.002) and improvement in hospital mortality (P=0.009). Additionally, patients in the

hydrocortisone group had fewer major complications (26% vs. 78%, P<0.001) primarily driven

by fewer events of delayed septic shock (0% vs. 52%, P<0.001). Notably, patients in the

hydrocortisone group may have had a more severe pneumonia as evidenced by a lower

PaO2:FIO2, higher serum C-reactive protein level, and a higher chest radiograph score at

baseline.

As a follow-up to the dramatic results observed by Confalonieri et al, Salluh and colleagues

published their prospective, observational study of 111 patients with CAP who required ICU

admission and mechanical ventilation.10 Those who received CS had a longer ICU stay (15

days vs. 11 days, P=0.003) and a longer hospital stay (20 days vs. 14 days, P=0.023)

compared to those who did not receive CS (n=50). There was no difference in ICU or hospital

mortality between groups. On multivariable analysis, older age (odds ratio [OR] 1.04, 95%

confidence interval [CI] 1.01-1.07, P=0.015) and higher Acute Physiology and Chronic Health

Evaluation II score (OR 1.08, 95% CI 1.01-1.16, P=0.033) were found to be independent

predictors of mortality. In comparison to previous data, the majority of patients (62.2%) in this

study presented with septic shock at admission, which may suggest that the benefit of steroids

lies in preventing adrenal impairment associated with the development of septic shock.

In a 2007 retrospective cohort study by Garcia-Vidal and colleagues, patients with severe CAP

received either systemic steroids (methylprednisolone ≥24 mg/day or prednisone ≥30 mg/day)

administered at the time of CAP diagnosis (n=70) or no steroids (n=238).11 There was no

difference between groups in the primary outcome of 30-day mortality; however, on

multivariable analysis, CS use was found to be protective against 30-day mortality (OR 0.287,

CI 0.113-0.732), and the study confirmed severity of pneumonia as the only independent risk

factor associated with mortality (OR 2.92, 95% CI 1.26-6.77). Although the study patients had

severe CAP based on the authors’ classification, only 4% were admitted to the ICU, suggesting

a less severe pneumonia than in other studies.

In a patient population similar to that of Garcia-Vidal et al, Fernandez-Serrano and colleagues

conducted a prospective, double-blind controlled trial that randomized 56 patients to receive a

bolus of 200 mg methylprednisolone (MP) or placebo 30 minutes before the first dose of

antibiotics.12 Thereafter, patients either received a placebo or MP maintenance intravenous

infusion in a tapered fashion (20 mg/6 h for 3 days, then 20 mg/12 h for 3 days, then 20 mg/day

for 3 days). The MP group showed a trend toward fewer patients requiring mechanical

ventilation (1 [4.3%] vs. 5 [22.7%]), although this was not significant. No difference was

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detected in secondary outcomes. Patients receiving MP did have a more favorable

improvement of PaO2:FIO2, quicker resolution of fever, higher radiological improvement at 7

days, and a significant reduction in time to resolution of morbidity compared to the placebo

group (5 days vs. 7 days, P=0.02). This was the first study to evaluate a low-dose tapered

steroid regimen, which may prevent a rebound inflammatory phenomenon that has been

previously reported.12, 13

In 2015, Torres and colleagues published the results of a multicenter, double-blind, placebo-

controlled trial enrolling 120 patients with severe CAP.14 Patients were randomized to receive

either methylprednisolone (0.5 mg/kg per 12 hours) or placebo for 5 days and started within 36

hours of hospital admission. Overall, less treatment failure occurred in the MP group than in the

placebo group (13% vs. 31%, OR 0.34, 95% CI 0.14-0.87), primarily driven by less late

treatment failure (25% vs. 3% P=0.001) and a decrease in radiographic progression (15% vs.

2%, P=0.007). There were no differences in secondary clinical outcomes or adverse events.

Limitations of this study include more patients presenting with shock in the placebo group (30%

vs. 16%) as well as an increase in time (>4 hour) to first antibiotic dose in those presenting with

shock in the placebo group (39% vs. 20%). Additionally, only 24% of patients in the MP group

and 23% in the placebo group received antimicrobial regimens consisting of a macrolide.

Several studies have demonstrated a clinical benefit to the use of CS in patients with severe

CAP. Dose, duration, and choice of steroid differed markedly among the studies, making a

recommendation on the optimal CS regimen difficult. Additionally, although the majority of

patients in each study had severe CAP based on the Infectious Diseases Society of

America/American Thoracic Society criteria or Pneumonia Severity Index risk class, the

severity of illness among patients differed substantially. Two meta-analyses found that CS use

was associated with a mortality benefit in severe CAP, albeit with significant heterogeneity.13,14

Lastly, the use of CS appears to be safe, although no study has been adequately powered to

detect a difference in adverse events. In conclusion, CS reduced the inflammatory response

and is associated with improved clinical outcomes including mortality in patients with severe

CAP not presenting with shock.

References

1. Marston BJ, Plouffe JF, File TM Jr., et al. Incidence of community-acquired pneumonia

requiring hospitalization. Results of a population-based active surveillance Study in Ohio. The

Community-Based Pneumonia Incidence Study Group. Arch Intern Med. 1997;157(15):1709-

1718.

2. Leeper KV Jr., Torres A. Community-acquired pneumonia in the intensive care unit.

Clin Chest Med. 1995;16(1):155-171.

3. Christ-Crain M, Stolz D, Jutla S, et al. Free and total cortisol levels as predictors of

severity and outcome in community-acquired pneumonia. Am J Respir Crit Care Med.

2007;176(9):913-920.

4. Ramirez P, Ferrer M, Marti V, et al. Inflammatory biomarkers and prediction for

intensive care unit admission in severe community-acquired pneumonia. Crit Care Med.

2011;39(10):2211-2217.

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5. Monton C, Torres A, El-Ebiary M, Filella X, Xaubet A, de la Bellacasa JP. Cytokine

expression in severe pneumonia: a bronchoalveolar lavage study. Crit Care Med.

1999;27(9):1745-1753.

6. Puren AJ, Feldman C, Savage N, Becker PJ, Smith C. Patterns of cytokine expression in

community-acquired pneumonia. Chest. 1995;107(5):1342-1349.

7. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of

America/American Thoracic Society consensus guidelines on the management of community-

acquired pneumonia in adults. Clin Infect Dis. 2007;44 (Suppl 2):S27-S72.

8. Monton C, Ewig S, Torres A, et al. Role of glucocorticoids on inflammatory response in

nonimmunosuppressed patients with pneumonia: a pilot study. Eur Respir J. 1999;14(1):218-

220.

9. Confalonieri M, Urbino R, Potena A, et al. Hydrocortisone infusion for severe

community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med.

2005;171(3):242-248.

10. Salluh JI, Soares M, Coelho LM, et al. Impact of systemic corticosteroids on the clinical

course and outcomes of patients with severe community-acquired pneumonia: a cohort study. J

Crit Care. 2011;26(2):193-200.

11. Garcia-Vidal C, Calbo E, Pascual V, Ferrer C, Quintana S, Garau J. Effects of systemic

steroids in patients with severe community-acquired pneumonia. Eur Respir J. 2007;30(5):951-

956.

12. Fernandez-Serrano S, Dorca J, Garcia-Vidal C, et al. Effect of corticosteroids on the

clinical course of community-acquired pneumonia: a randomized controlled trial. Crit Care.

2011;15(2):R96.

13. Snijders D, Daniels JM, de Graaff CS, van der Werf TS, Boersma WG. Efficacy of

corticosteroids in community-acquired pneumonia: a randomized double-blinded clinical trial.

Am J Respir Crit Care Med. 2010;181(9):975-982.

14. Torres A, Sibila O, Ferrer M, et al. Effect of corticosteroids on treatment failure among

hospitalized patients with severe community-acquired pneumonia and high inflammatory

response: a randomized clinical trial. JAMA. 2015;313(7):677-686.

Member Spotlight: Christopher Morrison By: Calvin Tucker, PharmD, BCPS

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Christopher Morrison, PharmD, is a clinical specialist in the neurosciences intensive care unit and burn services at Jackson Memorial Hospital and voluntary assistant professor in the Department of Neurology/Division of Neurocritical Care at the University of Miami Miller School of Medicine. Jackson Memorial Hospital is a 1500-bed nonprofit academic medical system in Miami, Florida, that offers high level expert care to anyone who walks through its doors. With approximately 150 intensive care unit beds, Jackson Memorial offers the following critical care services: medical, surgical, burn, cardiovascular, cardiothoracic surgery, pediatric, neurological, trauma (in a level I trauma center), neonatology (in a level III neonatal intensive care unit) and transplant. Dr. Morrison received his doctor of pharmacy degree at the Medical University of South Carolina in 2006. He completed his PGY1 residency at Tampa General Hospital in 2007 and a PGY2 in critical care at Greenville Memorial Hospital in 2008. Dr. Morrison began working at Jackson Memorial Hospital in 2008 with the neurocritical care service and expanded to the burn service in 2012. In the past he has been the coordinator and residency program director for PGY2 critical care pharmacy residency at Jackson. Dr. Morrison provides education to healthcare practitioners about neurocritical care and burn pharmacotherapy. The passion that Dr. Morrison exhibits for teaching and education is unparalleled. He has a remarkable ability to explain complex topics and dedicates himself to the development of his students and residents. He is known for having a naturally intense personality, but is very personable and exhibits a noticeable passion for patient care. Dr. Morrison stresses the importance of a thorough understanding of the medical literature and its application to the appropriate patient population. He consistently serves as an advocate for the students and residents he trains, challenging them to practice at the highest level possible. Dr. Morrison exemplifies a commitment to teaching, service, evidence-based care, and multidisciplinary collaboration. In addition to his membership in the Society of Critical Care Medicine, Dr. Morrison is also a member of American Society of Health-System Pharmacists (ASHP), Florida Society of Health-System Pharmacists (FSHP), American Burn Association (ABA), and Neurocritical Care Society (NCS). He is member of the NCS Pharmacy Leadership Committee, NCS ENLS Credentialing committee, and FSHP Educational Affairs Council. His professional interests include the pharmacological management of traumatic brain injury, targeted temperature management, emergent reversal of life-threatening coagulopathy, refractory seizures, and burns.

Volume 15 Issue 2 July 2015

Mentor-Mentee Spotlight

Mahmoud Ammar, PharmD, BCPS This month’s Mentor-Mentee Spotlight features Bethany Kalich, PharmD, BCPS, and her mentor, Debra Skaar, PharmD, FCCM. Dr. Kalich did her pre-pharmacy course work at Texas A&M and earned her doctorate of pharmacy at the University of the Incarnate Word Feik School of Pharmacy in San Antonio, Texas. Dr. Kalich completed both her PGY1 pharmacy practice residency and PGY2 critical care residency at the University of North Carolina. She now is an assistant professor at the University of the Incarnate Word Feik School of Pharmacy and adjunct assistant professor in the Division of Cardiology at the University of Texas Health Science Center, San Antonio. Dr. Kalich teaches several pharmacy introductory courses and pharmacotherapeutics, including critical care and cardiovascular courses, at both universities. She is also the cardiology clinical pharmacist for the acute care and critical care units at University Health System in San Antonio. Her research interests include new onset atrial fibrillation associated with severe sepsis and septic shock, optimizing the safe and efficacious use of anti-arrhythmic drug therapy, and developing critical thinking skills in pharmacy students. Dr. Kalich became interested in the Mentor-Mentee Program to further develop her teaching and practice style. As a new faculty member who was just beginning to develop her teaching style, she sought an outside perspective to further her development. Additionally, she was interested in being mentored to become more involved with the Society of Critical Care Medicine (SCCM) and other clinical pharmacy organizations on a national level. Dr. Kalich is grateful to have Dr. Skaar as her mentor and believes that joining the Mentor-Mentee Program has been one of her wisest career decisions. Dr. Skaar obtained a bachelor of science degree from the University of Iowa and doctorate of pharmacy from the University of Minnesota. She earned her fellowship in critical care for her outstanding contributions to the field. Dr. Skaar is the associate professor of experimental and clinical pharmacology at University of Minnesota, where she teaches a critical care seminar and selected critical care-related topics in the curriculum. She is also the educational coordinator at University of Minnesota Medical Center. Dr. Skaar works with acute care students and manages their case presentations and educational experiences. She also serves on the University of Minnesota College of Pharmacy Admissions Committee and is the Accreditation Co-Chair, in addition to the Student Liaison for the American College of Clinical Pharmacy. She is also involved in SCCM activities. Dr. Skaar’s research interests include novel methods of managing anxiety in ventilated ICU patients. Dr. Skaar joined the Mentor-Mentee Program because she enjoys mentoring students and pharmacists early in their career. Dr. Skaar and Dr. Kalich were paired in the Mentor-Mentee Program based on their interest in professional development of new pharmacy clinical practitioners. They communicate several times a year and have conference call meetings, as well as communicating via email. During their discussions they talk about how to succeed in the classroom and how to overcome challenges that come with being a faculty member. Dr. Kalich discusses her career goals with Dr. Skaar and seeks advice on how to achieve them. They talk about research interests and how to set aside protected time to work on these projects. Moreover, they talk about the challenges of being a working mother and how to balance the desire to be an innovative professor, a valuable clinician, and a loving mother. Dr. Kalich encourages new clinical professionals to become involved in the Mentor-Mentee Program. She believes that many of us have mentors in the workplace, but that there is added value in an outside perspective on many of the difficult situations faced in our practices. Dr.

Volume 15 Issue 2 July 2015

Kalich’s advice for a successful mentor-mentee relationship is to keep in touch with the mentor and to stay organized. Dr. Kalich keeps a list of matters to discuss with Dr. Skaar in order to hold more efficient conference calls. Dr. Skaar believes the Mentor-Mentee Program is a valuable program where mentees can get honest and unbiased suggestions to help them navigate their careers with confidence. The program helps both the mentor and mentee to realize challenges in every career path. Mentees often fail to appreciate how successful and productive they have been, so having a mentor as cheerleader is important and motivating. Dr. Skaar enjoys maintaining relationships throughout her career, and hearing about Dr. Kalich’s career successes is a very rewarding experience. Dr. Skaar’s advice for a successful mentor-mentee relationship is to ensure an environment of complete trust and confidence in all communications, to schedule communication, to be supportive and positive especially when problems are not easily solved, to never judge a decision that differs from your own, to offer professional opportunities that advance the mentee’s career, and most importantly, to be interested in the mentee’s life beyond work. Overall, the Mentor-Mentee Program has been a rewarding experience for Drs. Kalich and Skaar, and they encourage practitioners to take advantage of this program. Dr. Kalich and Dr. Skaar are hoping to meet in person at the 2016 Critical Care Congress. All members of the CPP Section are welcome to participate in the Mentor-Mentee Program. If you are interested, please contact Susan Hamblin (susan.hamblin@vanderbilt.edu) or Serena Harris (serena.harris@eskenazihealth.edu).

Research Pearl Formulating Research Questions and Hypotheses Stephanie Bass, PharmD, BCPS

Identification and development of research questions are important steps in the research process. Development of a great question involves identifying knowledge deficits. Some practical strategies for identifying these deficits include considering conflicting practices, perplexing outcomes, or scarce resources. A starting point may be asking, “Why is it done this way here?” It is important to understand what has been studied previously in order to focus more precisely on new research ideas.

Once an idea is identified, a specific research question must be developed. The acronym PICO (population/patients, intervention, comparison, outcomes) can help frame a specific research question.1 These four elements should be as precise and detailed as possible. Next, the project should be evaluated on the likelihood of successful completion. The FINER criteria—feasible, interesting, novel, ethical, and relevant to current practice— have been suggested as a means of assessing this likelihood.2

The final step is to develop a testable hypothesis. A research hypothesis is a “statement that predicts the results of a study based on existing data and stated assumptions.”3

Establishing the hypothesis will also establish a “null hypothesis” for testing statistical significance. A fully developed research question, including a related hypothesis, can guide decisions about study design, methods, and analysis.

References: 1) Smith KM. Building upon existing evidence to shape future research endeavors. Am J

Health-Syst Pharm. 2008;65:1767-1774.

Volume 15 Issue 2 July 2015

2) Hulley S, Cummings S, Browner W, et al. Designing Clinical Research. 3rd ed.

Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

3) Lipowski E. Developing great research questions. Am J Health-Syst Pharm.

2008;65:1667-1670.

New Professional Development Program for Pharmacists from ACCP and SCCM

The American College of Clinical Pharmacy (ACCP), in collaboration with Society of Critical

Medicine (SCCM), is pleased to announce that the Board of Pharmacy Specialties has approved

a new eight-component professional development program for board-certified critical care

pharmacists (BCCCPs) seeking recertification credit, starting in 2016. All eight components of

the new program are designed to cover late-breaking guideline updates, challenging therapeutic

concepts and other core topics necessary to enhance patient care. Detailed information about

this program is available at http://www.accp.com/careers/bcccp.aspx.

BCCCPs will have more than 80 credit hours of programming in a variety of formats to select

from annually. The eight components are as follows:

1. ACCP/SCCM Critical Care Pharmacy Preparatory Review and Recertification Course

2. ACCP’s Critical Care Pharmacy Updates Plus Webinar

3. SCCM’s Monthly Critical Care Pharmacy Journal Club Webcasts

4. ACCP’s Critical Care Self-Assessment Program (CCSAP)

5. SCCM’s Critical Care Webcast Series

6. ACCP’s From Theory to Bedside: Clinical Reasoning Series in Critical Care

7. ACCP’s Fundamentals of Biostatistics and Study Design Workshop

8. SCCM’s iCritical Care Podcasts

BCCCPs may choose any combination of these components to earn the required number of

hours during their certification cycle. Each component, priced separately, will include a Web-

based posttest. To learn more about this new professional development program, visit

http://www.accp.com/careers/bcccp.aspx.

Questions? Contact ACCP at accp@accp.com.

Frequently Asked Questions Where can I find opportunities to collaborate on critical care research? The Critical Care Pharmacotherapy Trials Network (CCPTN) was formed in 2007 with the goal of advancing science and improving the outcomes of critically ill patients through excellence in pharmacotherapy-related clinical and translational research. CCPTN provides an opportunity to actively engage and utilize a multidimensional critical care research network. Specifically, the CCPTN can broaden study enrollment, applicability, and collaborative contribution. In addition, the it offers pharmacotherapy and research expert-level protocol review and facilitation, including considerations for formal grant submission. More information can be found at www.ccptn.org.

Volume 15 Issue 2 July 2015

Communications Committee members are charged with publishing the newsletter. Thanks to the following members:

Simon Lam (Chair) Jessica Crow Julie Kalabalik Joanna Stollings (Chair-Elect) Deepali Dixit Michael Kenes Seth Bauer (Member at Large) Chris Droege Desiree Kosmisky Katarzyna Adamczhk Diana Esaian Jason Makii Jerry Altshuler Stacey Folse Russell Mason Mahmoud Ammar Marian Gaviola Thomas Moran Abdalla Ammar Amanda Giancarelli Justin Muir Scott Benken Gabrielle Gibson Mona Patel Kim Berger Payal Gurnani Natalie Prater Prachi Bhatt John Hammer Kelli Rumbaugh Aida 'Rebecca' Bickley Drayton Hammond Abbi Smith Marilyn Bulloch Tudy Hodgman Tom Smoot Tram Cat Lauren Igneri Calvin Tucker Darlene Chaykosky Jessica Jones Sarah Welch Patrick Welch

Featured CPP Resources

Are you stuck on a research-related question? Consider reaching out to the experts in the CPP Research Committee by emailing cppresearchconsult@gmail.com

Do you have a manuscript or grant that you would like to be reviewed by a content expert? If so, consider emailing the Research Committee Chair at mjdaley@seton.org

Upcoming SCCM Congress Meetings – Save the Date!

2016 February 20-24 Orlando, Florida 2017 January 21-25 Honolulu, Hawaii 2018 February 24-28 San Antonio, Texas

Volume 15 Issue 2 July 2015

Appendix

Clinical Pharmacy and Pharmacology Section Member Abstracts (SCCM Congress 2015) – Links to Full Posters (iRoom log-in may be necessary)

Abstract Number

Title

Authors

28 Platelet Dysfunction on Thromboelastogram Is Associated with Increased Mortality in Head Trauma

Mitchell J. Daley

117

Impact of macrolide antibiotics on outcomes in ICU patients with acute exacerbations of COPD

Tyree H. Kiser

126

Glycemic variability with temperature changes during therapeutic hypothermia after cardiac arrest

Krystal K. Haase

151

Impact of computerized physician order entry on sedation depth and related outcomes in the ICU

Joel Feih, William J. Peppard

152

Evaluation of SAS-Based Symptom-Triggered Treatment of Alcohol Withdrawal in Critically Ill Patients

Phil Grgurich

178

Continuation of Amiodarone at Discharge for New-Onset Atrial Fibrillation in Critically Ill Patients

Robert Nietupski

190

Short-course of ranolazine prevents post-operative atrial fibrillation following cardiac surgeries

Drayton A. Hammond

194

Risk Factors for Dexmedetomidine-associated Hemodynamic Instability in Non-cardiac ICU Patients

Calvin J. Ice

200

Evaluation of pulmonary vasodilators in pediatric congenital cardiovascular care

Caitlin M. Aberle

263

Impact of induced hypothermia on cardiac arrest survival and associated initial rhythm

Lesly Jurado

280

External versus Internal Cooling for Therapeutic Hypothermia: Does the method matter?

Harminder Sikand

282

Anti-Shivering Medication Requirements in Therapeutic Normothermia: Surface vs. Endovascular Cooling

Andrew B. Kirk, Cara McDaniel

294

Implementation and expansion of an online critical care pharmacy journal club

Karen Berger, Aimee Christine LeClaire

336

Evaluation of glucose management software in critically ill patients with hyperglycemic crises

Kevin T. Ferguson, Maresa D. Glass

348

Efficacy of a nurse-driven, electronic, diabetic ketoacidosis protocol – A comparative analysis

Marybeth Boudreau

Volume 15 Issue 2 July 2015

362

Characteristics and outcomes of cancer patients admitted to the intensive care unit: a 5-year study

Lama Nazer

371

The Incidence of Ventilator-associated Pneumonia in the United States from 2008 to 2011

Bryan D Lizza

410

Proton pump inhibitors and the risk for hospital-acquired Clostridium difficile in ICU patients

Jeffrey F. Barletta

416 Evaluation of the use of steroids in cirrhotic patients with shock

Kevin R. Donahue

423

Use of PCC in patients with variceal bleeding requiring massive transfusion

Cassandra Baker

431

Efficacy and Safety of 4-Factor Prothrombin Complex Concentrate in Patients with Liver Disease

William Cang, Wan-Ting Huang

435

Evaluation of IgG versus IgG/IgM/IgA PF4 ELISA for diagnosis of HIT and argatroban usage

Kevin T. Ferguson, Maresa D. Glass

437

A Comparison of INR Reversal Between 4-Factor and 3-Factor Prothrombin Complex Concentrates

William Cang

442

Consequences of Treating False Positive Heparin-Induced Thrombocytopenia

Jacob Marler

443

Evaluation of Heparin Resistance in Patients Outside of the Operating Room

Scott D. Nei

459

Dose-adjusted enoxaparin for venous thromboembolism prophylaxis in trauma patients

Janise B. Phillips

460

Elevated risk of thomboembolic events after novel anticoagulation reversal protocol

Cassie A. Barton

464 Venous thromboembolism prophylaxis in patients post liver transplant

Mona K. Patel

465

Heparin induced thrombocytopenia in extracorporeal life support: a systematic review of argatroban

Zachary R. Smith

469

Impact of antibiotic setting of procalcitonin ordering on provider actions in medical intensive care

Stephanie Bass, Abdalla Ammar, Seth R. Bauer, Simon W. Lam

476

Colistin: The safety and efficacy of a loading dose, high dose maintenance regimen

Jessica Elefritz

479

MRSA-coverage de-escalation practices in patients with ventilator- associated pneumonia

Anthony Jaworski

481

Evaluation of Procalcitonin Utilization in Septic Patients in an Academic Intensive Care Unit

Megan Austin

Volume 15 Issue 2 July 2015

484

Characteristics and outcomes of critically ill cancer patients infected with Acinetobacter baumannii

Lama Nazer

490

Impact of the Joint Commission pneumonia core measures on antibiotic use in the Emergency Department

Marilyn N. Bulloch

500

Management of Staphylococcus aureus bacteremia through pharmacist prospective evaluation

Sarah Klemm

501

A Community Hospital's Experience with Procalcitonin: Reduction in the Use of Antibiotics

Martha J. Roberts

505

Clinical pharmacist interventions with procalcitonin while performing antibiotic stewardship

Gourang P. Patel

507

Efficacy of Extended-Infusion Cefepime and Meropenem in Trauma and Burn Intensive Care Unit Patients

Christina Wong

508

Influence of Colistin Dose on Global Cure in Patients with Gram- Negative Bacteremia

Stephanie Bass, Gabrielle A. Gibson, Seth R. Bauer, Simon W. Lam

512

Factors influencing antibiotic actions after procalcitonin result: a case control study.

Stephanie Bass, Abdalla Ammar, Seth R. Bauer, Simon W. Lam

514

Management of severe, resistant alcohol withdrawal with or without the addition of propofol

Adrian Wong

524

Factors associated with elevated vancomycin dosing in neurocritical care patients

Kimberley A. Harris

550 Can Adjusted Phenytoin Concentration Accurately Predict Free

Brittany Kaufman, Jeffrey F.

553

Treatment with Hypertonic Saline Alternating with Mannitol in Neurologic Emergencies

Nicole M. Grimmer

560

IV Acetaminophen Use and Associated Outcomes in Neurocritical Care Patients

Gretchen M. Brophy

565

Optimization of clopidogrel loading dose in patients undergoing carotid stent placement

Ginger Gamble

571

Safety profile of desmopressin in patients with acute intracranial hemorrhage

Karen Berger

585

Evaluating the transition from dexmedetomidine to clonidine for PAD management in the ICU

Kimberly Terry

587

Delirium in mechanically-ventilated intensive care patients: effect of sedation and risk factors

Marian Gaviola

Volume 15 Issue 2 July 2015

592

Sedation variability increases incidence of delirium in adult medical intensive care unit patients

Heather Torbic

594

Supplemental Melatonin and Delirium in the Intensive Care Unit: A Retrospective Study

Jennifer Cole

617

Pharmacokinetics (PK) of Daptomycin (DAP) in Critically Ill Trauma Patients

Prasad E. Abraham

622

Does QTc prolongation occur after initiation of haloperidol or quetiapine in the critically ill?

Michelle Horng

624

Prevalence and Factors Associated with Absence of Venous Thromboembolism Prophylaxis

Prasad E. Abraham

626

Pharmacokinetic analysis of once-daily vancomycin dosing during continuous renal replacement therapy

Meghann Luc, Megan Austin, William J. Peppard

630

Assessing bleeding associated with combined use of SSRI and dual antiplatelet therapy

Kayla Giang

631

Methylnaltrexone versus Naloxone for Opioid-Induced Constipation in the Medical Intensive Care Unit

Cristian Merchan

634

Implications of Atypical Antipsychotic Prescribing in the Intensive Care Unit

Bridgette L. Kram

639

Clinical outcomes of adjunctive ketamine for managing alcohol withdrawal syndrome

Adrian Wong

640

Comparison of continuous infusions of midazolam and pentobarbital for refractory status epilepticus

Melissa Chudow, Maresa D. Glass, Melissa Giarratano

641

Comparison of Two Guideline Based Pain and Agitation Protocols in Mechanically Ventilated Patients

Vishal Ooka

643

Pharmacoeconomic Analysis of Inhaled Epoprostenol vs Nitric Oxide for Severe, Refractory ARDS

Jennifer Wiedmar

648 Efficacy of Redosing Prophylactic Antibiotics for Prolonged Surgeries

Jeffrey A. Endicott

649

Population Pharmacokinetics of Meropenem in a Pediatric ICU Population

Jeffrey J. Cies

650

Retrospective evaluation of dexmedetomidine to facilitate mechanical ventilation extubation

Nicholas Peters

654

Transition from Dexmedetomidine to Enteral Clonidine for ICU Sedation: A Pilot Study

Elizabeth K. Glisic, David J. Gagnon

Volume 15 Issue 2 July 2015

655

Extended interval fondaparinux for VTE prophylaxis in critically ill patients with renal failure

Krista A. Wahby

657 Risk Factors for Adverse Hemodynamic Effects with Dexmedetomidine

Ahmed A. Mahmoud

680

Risk Factors for Death from Ventilator-Associated Pneumonia in the United States from 2008-2011

Bryan D Lizza

693

Inhaled Nitric Oxide versus Inhaled Epoprostenol for the Acute Management of Pulmonary Hypertension

Jessica George

713

Comparison of Inhaled Epoprostenol to Inhaled Nitric Oxide: A Non- inferiority Study

Stephanie Bass, Mahmoud A. Ammar, Seth R. Bauer, Simon W. Lam

733

Cisatracurium for Acute Respiratory Distress Syndrome: Patterns of Utilization

Andrew B. Kirk, Cara McDaniel

742

Sildenafil for Acute Pulmonary Hypertension after Cardiac Surgery

Justin J. Roth, Stacy Alan Voils

745

Assessment of a Sedation Titration Protocol for Patients Receiving Mechanical Ventilation

Serena Ann Harris

774

Clinical Outcomes of Neurocritical Care Patients Following a Bed Triage Workflow

Jessica Cowell, William J. Peppard

818

Optimization of intelligent infusion pump technology to minimize vasopressor pump programing errors

Mitchell J. Daley

822

Missed Opportunities for Intervention in the Comprehensive Management of Alcohol Withdrawal Syndrome

Jessica L. Johnson

827

Effect of Patient Controlled Analgesia (PCA) order set templates on safety events requiring naloxone

Rebecca Nashett

841

Hypoglycemia and adherence to an insulin infusion protocol in cardiac surgery vs other ICU patients

Andrea Jeanne Passarelli

853

Implementing Clinical Pharmacy Services in a Multidisciplinary Critical Care Recovery Center

Andrew C. Fritschle Hilliard

865

Effect of IV phosphate repletion guideline changes in ventilated patients in an intensive care unit

Jennifer Garber

873

Assessment of parenteral nutrition appropriateness after implementation of a qualification checklist

Stephen J. Lemon

Volume 15 Issue 2 July 2015

884

Evaluation of an updated insulin infusion protocol at a large academic medical center

Gabrielle A. Gibson, Seth R. Bauer

896

Venous Thromboembolism Prevention: Automating Risk Assessment & Clinical Decision Support in the EHR

Patricia L. Parker

904

Implementation of daily multidisciplinary ABCDE bundle rounds in a medical ICU

Patricia R. Louzon

931

Loop Diuretic Infusions With and Without Continuous Albumin Infusions in Acute Kidney Injury Patients

Katherine Johnson, Rohini Prashar, Imran Shafique, Sandeep Vetteth, Celeste Sejnowski, Mariann Churchwell, Rose Jung

934

Evaluation of vancomycin dosing and CVVH intensity on vancomycin trough concentrations attainment

Abdullah Alhammad

937

Use of Conivaptan and Tolvaptan for the Treatment of Hyponatremia in Critically Ill Adults

Caroline Der-Nigoghossian

938

Incidence and Characterization of Acute Renal Failure Following Acetaminophen Overdose

Joanna L. Stollings

939

Influence of 6% hydroxyethyl starch 130/0.4 on AKI and transfusion requirements in CT surgery

Lauren A. Igneri

960

Predicting the Progression to Septic Shock in Patients with a Candida Bloodstream Infection

Justin J. Roth

963 Tissue Dysoxia and Mortality in Septic Shock

Matthew J. Korobey

971

Pharmacist Impact On Time To Antibiotic Administration In Sepsis Patients In An Emergency Department

Vitaliy Nikitenko

980

Practices and Perceptions of ED and ICU RNs Regarding Initial IV Antibiotic Therapy for Septic Shock

Russel J. Roberts, Abdullah Alhammad

986

Outcomes in septic shock patients treated with continuous versus bolus stress-dose hydrocortisone

Amanda Liszewski

995

A multidisciplinary educational approach to decreasing time to antibiotic administration in sepsis

Lara Groetzinger, Ryan Rivosecchi

1001 Impact of body mass index on norepinephrine requirements and hemodynamics in septic shock

Krista A. Wahby, Kara Zacholski

1038 Impact of late fluid balance on outcomes in surgery trauma critically ill patients

Kathryn Elofson