Transcript Pharmacotherapy in the ACHD Patient: Why Are We Giving

Pharmacotherapy in the ACHD
Patient: Why Are We Giving
These?
Regine L. Caruthers, Pharm.D.
Clinical Pharmacy Specialist, Pediatric Cardiology
Adjunct Clinical Instructor
December 12, 2014
Conflicts of Interest
• Nothing to disclose
Learning Objectives
1. Describe the SCIP core measures related to
pharmacologic treatment and the clinical impact
of upcoming changes
2. Discuss the most recent guidelines regarding the
management of agitation and delirium for adults
patients in the intensive care unit (ICU) and the
impact on patient care
Surgical Care Improvement
Project (SCIP)
• National quality improvement project
dedicated to reducing surgical complications
• 4 SCIP core measures related to
pharmacologic therapy
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Postoperative blood glucose (SCIP-Inf-4)
Postoperative antibiotics (SCIP-Inf-3)
Beta-Blockers (SCIP-Card-2)
Intensive Care Unit (ICU) VTE Prophylaxis (SCIPVTE-2)
http://www.jointcommission.org/surgical_care_improvement_project/ - Accessed December 3, 2014.
SCIP Core Measures:
Changes as of January 1, 2015
• Retire several SCIP core measures
– Inf-3: Postoperative antibiotics
– Card-2: Beta-Blockers (SCIP-Card-2)
– VTE-2: Intensive Care Unit (ICU) VTE Prophylaxis
• Impact on clinical practice
– Best practices
– 2015 Flexible ORYX Performance Measure
Reporting Options
SCIP-Inf-4:
Postoperative Blood Glucose
• SCIP-Inf-4:
– The blood glucose levels ≤ 180 mg/dL collected
between 18 and 24 hours after Anesthesia End
Time
– If no blood glucose levels were collected during
this timeframe, blood glucose levels collected
between 12 and 18 hours after Anesthesia End
Time are to be used
SCIP-Inf-4:
Postoperative Blood Glucose
PASS
• All blood glucose levels
collected were ≤ 180 mg/dL
in the specified timeframe
• A single blood glucose level
> 180 mg/dL but ALL other
values after the higher
value were ≤ 180 mg/dL
prior to the endpoint of 24
hours after Anesthesia End
Time
FAIL
• A single blood glucose level
collected was > 180 mg/dL
and NO other values after
the higher value were ≤ 180
mg/dL prior to the endpoint
of 24 hours after Anesthesia
End Time
• Two or more blood glucose
levels > 180 mg/dL in the
specified time frame
• No blood glucose levels
SCIP-Inf-4:
Postoperative Blood Glucose
• Exceptions if documented
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–
–
–
Patient discharged
Patient expired
Patient left against medical advice
Patient underwent cardiopulmonary
resuscitation
– Patient had another surgery
SCIP-Inf-4:
Postoperative Blood Glucose
• Michigan Congenital Heart Center (CHC)
Practice
– Adult Postoperative Order Set: Blood glucose
level auto checked for 12 AM and for 12 hours
following order entry
– Initiate Pediatric CVICU SCIP Glucose
Management Flowchart if blood glucose is
greater than 150 mg/dL
• Dilemmas in patient care
SCIP-Inf-3:
Postoperative Antibiotics
• Prophylactic antibiotics must be
discontinued within 48 hours after coronary
artery bypass graft surgery or other cardiac
surgery
• Maintain therapeutic levels of antibiotic for a
few hours after closure of incision
• Prolonged administration increases risk of
Clostridium difficile infection and
antimicrobial resistance
SCIP-Card-2:
Beta-Blockers
• SCIP-Card-2: Surgery patients on betablocker therapy prior to arrival who received
a beta-blocker during the perioperative
period
• Continuous beta-blocker use is significantly
associated with lower 1-year mortality when
compared to patients whose beta-blocker
therapy was held/discontinued
Hoeks SE, Scholte Op, Reimer WJ, et al. Increase of 1-year mortality after perioperative beta-blocker withdrawal in
endovascular and vascular surgery patients. Eur J Vasc Endovasc Surg. 2007 Jan; 33(1): 13-9.
SCIP-VTE-2:
ICU VTE Prophylaxis
• SCIP-VTE-2: Surgery patients who received
appropriate VTE prophylaxis within 24 hours
prior to surgery to 24 hours after surgery
• Optimal start of pharmacologic prophylaxis
varies and must be balanced with the
efficacy versus bleeding potential
– Must document reasons for not administering
both mechanical and pharmacological
prophylaxis
Learning Objectives
1. Describe the SCIP core measures related to
pharmacologic treatment and the clinical impact
of upcoming changes
2. Discuss the most recent guidelines regarding the
management of agitation and delirium for adults
patients in the intensive care unit (ICU) and the
impact on patient care
Pain, Agitation and Delirium in
Adult Patients in the ICU
• Society of Critical Care Medicine (SCCM)
published updated guidelines in January
2013
• Statements and recommendations
– Pain and analgesia
– Agitation and sedation
– Delirium
• Strategies to optimize ICU outcomes
Barr J, Fraser GL, Puntillo K, et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium
in Adult Patients in the Intensive Care Unit. Critical Care Medicine. 2013; 41(1): 263-306.
Agitation and Sedation
• Agitation and anxiety are common in
critically ill adult patients
• Common causes include pain, delirium,
hypoxemia, hypotension, and withdrawal
from alcohol or other substances
• Prompt identification and treatment are key
in minimizing adverse clinical outcomes
Agitation and Sedation
• Sedation assessment tools
– Richmond Agitation-Sedation Scale (RASS) and
Sedation-Agitation Scale (ASA) most valid and
reliable
• Light levels of sedation are recommended
– Associated with shorter duration of mechanical
ventilation and decreased ICU LOS
– Not associated with increased incidence of
myocardial ischemia
• Daily sedation interruptions
Agitation and Sedation:
Treatment Options
• Nonbenzodiazepines
– Propofol
– Dexmedetomidine
• Benzodiazepines
– Midazolam
– Lorazepam
• Guidelines suggest using nonbenzodiazepine
sedative agents
Delirium
• Syndrome characterized by the acute onset
of cerebral dysfunction with a change or
fluctuation in baseline mental status,
inattention, and either disorganized thinking
or an altered level of consciousness
• Occurs in intubated and nonintubated ICU
patients
– Affects up to 80% of mechanically ventilated
patients
• Underlying pathophysiology is not known
Features of Delirium
• Disturbed level of consciousness with a
reduced ability to focus, sustain, or shift
attention
– Reduced clarity or awareness of environment
• Change in cognition or the development of
perceptual disturbance
– Memory deficit, disorientation, language
disturbance
– Hallucinations, delusions
Delirium: Other Symptoms
• Sleep disturbances
• Abnormal psychomotor activity
• Emotional disturbances
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Fear
Anxiety
Anger
Depression
Apathy
Euphoria
Subtypes of Delirium
• Hyperactive delirium
– Agitated
– Commonly associated with hallucinations and
delusions
• Hypoactive delirium
– Calm or lethargic
– Commonly associated with confusion and
sedation
– Often misdiagnosed
Delirium
• Risk factors for developing delirium
1.
2.
3.
4.
5.
Preexisting dementia
History of hypertension
History of alcoholism
High severity of illness at admission
Coma
• More research is needed to determine the
impact of age
Delirium
• Negatively impacts clinical outcomes
– Mortality
– Hospital LOS
– Long-term cognitive impairment
Delirium:
Monitoring and Assessment
• Recommend routine monitoring for delirium
at least once a shift, especially in patients at
moderate to high risk for delirium
– Severe sepsis or shock, mechanical ventilation,
receiving opioid or sedative medications
• The Confusion Assessment Method for the
ICU (CAM-ICU) and the Intensive Care
Delirium Screening Checklist (ICDSC) are
most valid and reliable
Delirium:
Nonpharmacologic Treatment
• Early mobilization
– Decrease incidence and duration of delirium
– Improve functional outcomes
• Promote sleep
– Optimize environment
– Guidelines: Do not recommend pharmacologic
therapies to assist with sleep
Delirium:
Pharmacologic Treatment
• Preventative treatment is not recommended
in the guidelines
• Treatment options
– Typical antipsychotic: Haloperidol (Haldol®)
– Atypical antipsychotics
• Quetiapine (Seroquel®)
• Ziprasidone (Geodon®)
– Cholinesterase inhibitor: Rivastigmine (Exelon®)
Delirium:
Pharmacologic Treatment
• Haloperidol
– Not proven to reduce the duration of delirium
– Although not recommended for treatment in the
updated guidelines, haloperidol continues to be
used in clinical practice
• Dose: 1-10 mg IV every 2 hours as needed
– Risk of extrapyramidal symptoms and QT
prolongation limit its use
Delirium: Treatment Options
• Quetiapine
– Guidelines: May reduce the duration of delirium
– Prospective, double-blind, placebo-controlled
study
• Quetiapine added to as needed haloperidol
• Quicker delirium resolution, decreased agitation and
increased rate of transfer to home/rehab
• Small sample size was a limitation (36 patients)
Devlin JW, Roberts RJ, Fong JJ, et al. Crit Care Med. 2010; 38(2): 419-427.
Delirium: Treatment Options
• Quetiapine (cont.)
– University of Michigan: Agent of choice in the
treatment of delirium in conjunction with
haloperidol as needed
• Dose: Initial: Quetiapine 50 mg PO q12hrs
– Risk for QT prolongation
Delirium: Treatment Options
• Ziprasidone
– Guidelines: Not discussed
– Randomized, double-blind, placebo-controlled
trial
• Compared haloperidol, ziprasidone, and placebo
• Antipsychotics did not improve the number of days
alive without delirium or coma
– Adverse outcomes did not increase
• Small sample size was a limitation (101 patients)
Girard TD, Pandharipande PP, Carson SS. Crit Care Med. 2010 Feb; 38(2): 428-37.
Delirium: Treatment Options
• Ziprasidone (cont.)
– The Modifying the Impact of ICU-Associated
Neurological Dysfunction-USA (MIND-USA)
Study
• Multi-center, double-blind, randomized, placebocontrolled trial
• Comparing haloperidol, ziprasidone, and placebo
• Evaluating improvement of short- and long-term
clinical outcomes (ICU LOS, incidence and severity of
delirium, duration of long-term neuropsychological
dysfunction, and quality of life at 90 days and one
year)
Delirium: Treatment Options
• Rivastigmine
– Guidelines: Not shown to reduce the duration of
delirium
– Multiple studies have not shown a difference
from placebo in critically ill adult patients
– May have a role in the elderly population with
dementia
Learning Objectives
1. Describe the SCIP core measures related to
pharmacologic treatment and the clinical impact
of upcoming changes
2. Discuss the most recent guidelines regarding the
management of agitation and delirium for adults
patients in the intensive care unit (ICU) and the
impact on patient care
APPENDIX
SCIP Core Measure:
Blood Glucose
12 AM
glucose
80-150
*No need to recheck if anesthesia end
time before noon
Yes
*Recheck at
T+12h
No
< 80
Yes
Give dextrose
and recheck
until OK
No
> 150
Yes
Insulin drip,
rechecks per
protocol
SCIP Core Measure:
Blood Glucose
T+12h
glucose
80-150
Yes
Do not recheck
unless clinical
concern
Yes
Give dextrose
and recheck
until OK
No
< 80
No
> 150
Yes
Insulin drip,
recheck per
protocol
Check
T+18h
glucose
SCIP Core Measure:
Blood Glucose
T+18h
glucose
80-150
Yes
Do not recheck
unless clinical
concern
Yes
Give dextrose
and recheck
until OK
No
< 80
No
> 150
Yes
Insulin drip,
recheck per
protocol