Brian L Erstad

Abstract:

Objective: To compare possible differences in the proportion of medication errors associated with high-risk medications that were avoided by the use of automated infusion device (AID) technology in pediatric and adult intensive care unit (ICU) patients. A secondary purpose was to investigate the number of serious adverse drug events (ADEs) identified by root-cause analyses (RCA).Method: The study included pediatric and adult patients receiving high-risk medications by continuous infusion in an academic medical center with mixed medical-surgical ICUs. A retrospective evaluation of 1 year's data collected prospectively in an AID database was used to compare the proportion of medication errors avoided based on reprogramming events (2.5 times limit as a low threshold) and overrides (10 times limit as high). Information obtained from RCAs was used to compare the proportion of serious ADEs that occurred during the 5-year periods before and after AID implementation.Results: The pediatric population was 1.68 times (95% confidence interval [CI], 1.18 to 2.38) more likely to require a reprogramming event than the adult acute care population for all high-risk medications combined. Significantly more reprogramming events occurred in the pediatric patients with potassium (relative risk [RR], 2.77; 95% CI, 1.15 to 6.68) and insulin (RR, 2.73; 95% CI, 1.15 to 6.45) infusions. Additionally, there were more overrides in the pediatric compared to the adult population for the high-risk medications (RR, 1.82; 95% CI, 1.32 to 2.53). The number of serious adverse or sentinel events as identified in RCAs decreased from six before (four deemed preventable by AID technology) to three (zero preventable) after AID implementation.Conclusions: This study demonstrates that AID technology when properly used leads to reductions in medication errors and possibly serious ADEs in critically ill patients receiving high-risk medications. The technology appears to be particularly beneficial in pediatric patients with weight-based dosing strategies. However, the potential for clinicians to override the alerts remains a concern. © 2010 Thomas Land Publishers, Inc.

PMID: 10485509;Abstract:

The purpose of this economic analysis was to develop an economic model using intra-institutional cost data for acute, oliguric renal insufficiency treated with either an albumin-furosemide complex or albumin followed by furosemide (sequential therapy). The perspective of this study was from the standpoint of the institution (University Medical Center, a teaching hospital). The decision tree and sensitivity analyses demonstrated that the albumin-furosemide complex would be more effective and less costly than sequential therapy for a range of outcome probabilities. Using effectiveness assumptions from published literature, the complex could avoid dialysis in 27% of patients compared with 8% of patients receiving sequential therapy. The complex would also be less costly ($7778 vs $8748). In terms of cost- effectiveness, the complex is $28,807 per averted dialysis compared with $109,350 for sequential therapy.

PMID: 21048208;Abstract:

Purpose. The use of hypertonic saline injection in trauma patients is discussed. Summary. Patients with hemorrhage, burns, and traumatic brain injury (TBI) may develop hypovolemic shock and require resuscitation. Compared with conventional isotonic crystalloids, hypertonic saline has several advantages, including hemodynamic, immune-modulating, and antiinflammatory effects, for use in trauma patients for resuscitation. In addition, hypertonic saline is also used in patients with TBI to reduce intracranial pressure (ICP). Overall, studies have not shown a difference in mortality or other clinically important outcomes with the use of hypertonic saline for resuscitation in trauma patients; however, most of these studies were not adequately powered to show significant differences. A recent Cochrane review concluded that there is no evidence that hypertonic crystalloids are better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients. Two recent trials that were adequately powered to investigate a mortality endpoint were halted for futility. A few small randomized controlled studies found that hypertonic saline was more effective than mannitol as a hyperosmolar agent for ICP reduction. Recent guidelines from the American Burn Association have suggested that hypertonic saline may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia. One of the main concerns with the use of hypertonic saline is its potential to cause central pontine myelinolysis due to a rapid increase in serum sodium levels. Conclusion. There is no evidence that hypertonic saline provides any additional benefit over isotonic crystalloid solutions for trauma resuscitation. Hypertonic saline may be more effective than mannitol at reducing ICP in patients with TBI. Copyright © 2010, American Society of Health-System Pharmacists, Inc. All rights reserved.

To compare the effectiveness of common laxatives in producing a bowel movement in patients admitted to a medical intensive care unit (MICU).