2014 critical and urgent care PSAP

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IMPORTANT INFORMATION ON THE RELEASE OF PSAP 2014 BOOK CRITICAL AND URGENT CARE BOOK FORMATS Print books: If you have purchased a print version of this book, it will be delivered on or near the release date to the address of record on your ACCP account If you have not received the print book within week of the release date, contact customer service by e-mailing accp@accp.com Online errata: Go to www.accp.com/docs/products/psap1315/errata.pdf Be sure to check the online errata before submitting a posttest E-Media Package: If you have purchased this package, follow these instructions to load the text and self-assessment questions in this book onto your e-reader, tablet, or Android phone PSAP Audio Companion: If you have purchased this package, follow these instructions to download these files onto a listening device or burn them onto an audio CD BOOK CONTENT Electronic annotation: This online book is provided as downloadable PDFs that can be saved to the desktop or printed The latest version of Adobe Reader (available free) offers functionality such as highlighting or adding “sticky notes” to the text Hyperlinks: This book contains both internal and external hypertext links (visible as underlined text in print book) Clicking on the intra-document links in the Table of Contents will take you to the page containing the selected content Clicking on external hyperlinks will take you away from the ACCP Web site to the outside resource, guidelines, tools, or other information you have selected Laboratory Reference Values: The last page of this book contains a table with reference ranges and abbreviations for common laboratory tests Use this table as a resource in completing the required posttest TESTING Available continuing pharmacy education (CPE) credits: This PSAP book carries a possible 23.0 hours of BCPS recertification credit This book is divided into three modules, Critical and Urgent Care I, Critical and Urgent Care II, and Critical and Urgent Care III You may complete one or all three modules for credit Tests may not be submitted more than one time BCPS test deadline: 11:59 p.m (Central) on May 15, 2014 ACPE test deadline: 11:59 p.m (Central) on January 14, 2017 Posttest access: Go to www.accp.com and sign in with your e-mail address and password Technical support is available from a.m to p.m (Central) weekdays by calling (913) 492-3311 PSAP products are listed on your My Account page Posttest answers: The explained answers – with rationale and supporting references – will be posted week after the BCPS test deadline, and available to anyone who has submitted a posttest or waived their right to receive credit from a posttest Go to www.accp.com and sign in with your e-mail address and password Then navigate to your My Account page You will see a link to the explained answers NOTE: Submitting the required posttest for BCPS recertification attests that you have completed the test as an individual effort and not in collaboration with any other individual or group Failure to complete this test as an individual effort may jeopardize your ability to use PSAP for BCPS recertification Statements of credit: Tests submitted for BCPS recertification credit will be processed, and CPE statements will be posted within 45 days after the close of the BCPS testing period Tests submitted for ACPE CPE will be processed and credit reports available immediately upon submission, starting 45 days after the close of the BCPS testing period Director of Professional Development: Nancy M Perrin, M.A., CAE Associate Director of Professional Development: Wafa Y Dahdal, Pharm.D., BCPS Recertification Project Manager: Edward Alderman, B.S., B.A Desktop Publisher/Graphic Designer: Jen DeYoe, B.F.A Medical Editor: Kimma Sheldon, Ph.D., M.A Information Technology Project Manager: Brent Paloutzian, A.A.S For ordering information or questions, write or call: Pharmacotherapy Self-Assessment Program American College of Clinical Pharmacy 13000 W 87th St Parkway Lenexa, KS 66215-4530 Telephone: (913) 492-3311 Fax: (913) 492-4922 E-mail: accp@accp.com NOTE: The editors and publisher of PSAP recognize that the development of this volume of material offers many opportunities for error Despite our best efforts, some errors may persist into print Drug dosage schedules are, we believe, accurate and in accordance with current standards Readers are advised, however, to check package inserts for the recommended dosages and contraindications This is especially important for new, infrequently used, and highly toxic drugs NOTE: To facilitate further learning and research, this publication incorporates print and live hyperlinks to Web sites administered by other organizations The URLs provided are those of third parties not affiliated in any way with ACCP ACCP assumes no liability for material downloaded from or accessed on these Web sites It is the responsibility of the reader to examine the copyright and licensing restrictions of linked pages and to secure all necessary permissions Library of Congress Control Number: 2013956447 ISBN-13: 978-1-880401-01-9 (PSAP 2014 BOOK 1, Critical and Urgent Care) Copyright ©2014 by the American College of Clinical Pharmacy All rights reserved This book is protected by copyright No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic or mechanical, including photocopy, without prior written permission of the American College of Clinical Pharmacy Print versions are produced in the United States of America To cite PSAP properly: Authors Chapter name In: Murphy JE, Lee MW, eds Pharmacotherapy Self-Assessment Program, 2014 Book Critical and Urgent Care Lenexa, KS: American College of Clinical Pharmacy, 2014:page range Table of Contents Preface Disclosure of Potential Conflicts of Interest Continuing Pharmacy Education and Program Instructions Critical and Urgent Care I Panel Antibiotic Use in Patients Receiving CRRT iii iv v By Kathryn A Connor, Pharm.D., BCPS, BCNSP Learning Objectives Introduction AKI Review Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter Assessing Kidney Function Management of AKI by CRRT Drug Dosing Considerations Conclusion References Self-Assessment Questions Cardiac Arrest and Advanced Cardiac Life Support By Kristen A Hesch, Pharm.D., BCPS Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in this Chapter Therapeutic Goals of ACLS Clinical Characteristics Emergency Care for Out-of-Hospital Cardiac Arrest Role of the Pharmacist in ACLS Drug Administration in Cardiac Arrest Pharmacotherapy of VF/Pulseless VT Pulseless Electrical Activity/Asystole Bradyarrhythmias Post-Cardiac Arrest Care Conclusion References Self-Assessment Questions 3 3 4 9 10 17 17 20 22 22 27 Off-label Drug Use in the ICU By Ishaq Lat, Pharm.D., FCCM, FCCP, BCPS; and Mitchell J Daley, Pharm.D., BCPS Acute Management of Burn Injury By Claire V Murphy, Pharm.D., BCPS Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter Burn Classification Metabolic Changes: the Ebb and Flow Goals of Care Metabolic Modulation Venous Thromboembolism Prophylaxis Sepsis and Infection Pharmacokinetic and Pharmacodynamic Considerations Conclusion References Self-Assessment Questions PSAP 2014 • Critical and Urgent Care 61 61 61 61 61 62 62 63 63 69 70 72 31 31 31 31 32 32 36 36 42 46 46 46 51 51 55 Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter The Critical Care Patient Examples of OLDU as Standard of Care Type of OLDU in the ICU Informed Consent for OLDU Approach to OLDU in the Critically Ill Conclusion References Self-Assessment Questions 77 77 77 77 78 79 82 84 86 87 89 89 93 Critical And Urgent Care II Panel 99 Thrombolytic Therapy in Acute Ischemic Stroke By Alexander J Ansara, Pharm.D., BCPS; and Dane Shiltz, Pharm.D., BCPS Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter Pathophysiology of AIS Diagnosis Thrombolytic Therapy Quality Improvement Initiatives Conclusion References Self-Assessment Questions i 101 101 101 101 102 103 104 106 118 119 119 124 Table of Contents Thrombotic and Bleeding Diatheses in Critically Ill Patients Care of the Kidney Transplant Recipient By Wesley D McMillian, Pharm.D., BCPS; and Joseph Aloi, Pharm.D., BCPS Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter Pretransplant Considerations Immediate Postoperative Course Early Posttransplant Course Conclusion References Self-Assessment Questions Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter Pathophysiology and Diagnosis Treatment Patients Taking Novel OACs Conclusion References Self-Assessment Questions By Samir J Patel, Pharm.D., BCPS 129 129 129 129 130 130 131 135 142 119 145 Severe Sepsis and Septic Shock By Seth R Bauer, Pharm.D., BCPS; and Simon W Lam, Pharm.D., BCPS Infection in Critically Ill Patients By Lisa Hall Zimmerman, Pharm.D., BCPS, BCNSP, FCCM; and Janie Faris, Pharm.D., BCPS Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter Clinical Evaluation Disease States Laboratory Diagnostic Strategies Treatment Goals Special Considerations Conclusion References Self-Assessment Questions Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter Diagnosis Quality Patient care Quality Improvement with a Care Bundle Conclusion References Self-Assessment Questions 149 149 149 149 150 151 152 162 163 163 166 166 170 By Victor Cohen, Pharm.D., BCPS, CGP; and Samantha P Jellinek-Cohen, Pharm.D., BCPS, CGP By Kara L Birrer, Pharm.D., BCPS PSAP 2014 • Critical and Urgent Care 219 219 219 219 220 221 221 229 230 230 232 Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Pain, Agitation, and Delirium in the ICU Learning Objectives Introduction Baseline Knowledge Statements Additional Reading Abbreviations in This Chapter Etiology, Pathophysiology, and Complications Assessment and Treatment of Pain Assessment and Treatment of Agitation Assessment and Treatment of Delirium Guideline Development Drug Shortage Implications Conclusion References Self-Assessment Questions Critical And Urgent Care III Panel 199 199 199 199 200 200 202 204 210 212 214 177 177 177 177 178 178 180 182 186 188 188 188 188 192 197 ii Learning Objectives Introduction Baseline Knowledge Statements Additional Readings Abbreviations in This Chapter Pathophysiology Clinical Evaluation Conclusion References Self-Assessment Questions 237 237 237 237 238 238 240 247 247 251 Reference Ranges for Common Laboratory Testsa 256 Table of Contents Preface The start of a new edition of the Pharmacotherapy SelfAssessment Program (PSAP) is truly an exciting time Our mission remains the same today as for the first edition – to provide evidence-based updates that will improve clinical pharmacy practice and patient outcomes However, to accomplish this, PSAP must reflect the changes in practice models, patient populations, and the overall health care environment This new edition introduces features and formats designed to enhance information access while accommodating individual learning styles PSAP remains a labor of love for the faculty panel chairs, authors, and expert and professional reviewers, as well as for us, the series editors We contribute to this endeavor because we are committed to the board certification process and the national recognition of the expertise of clinical pharmacists We are also dedicated to sharing the most up-to-date knowledge with our colleagues, and driven to create opportunities for board certified clinicians to participate in scholarly activity The PSAP 2014–2015 releases are each carefully developed to identify clinically relevant content, solid case-based examples, and fair but challenging self-assessment questions that allow the tester to demonstrate mastery of this important material For individual chapters, the focus continues to be on significant new information rather than a review of common knowledge about a topic Authors incorporate the latest national or international guidelines for management, landmark clinical trials, and content that integrate concepts of biostatistics, epidemiology, and health systems to cover all identified domains for the pharmacotherapy specialist In response to feedback from PSAP users, many authors have included case-based examples demonstrating the application of concepts, a treatment algorithm or decision tree, and a summative box with practice points or pearls On the first page of each chapter are listed the baseline knowledge presumed on the part of the reader and open-access literature resources that can provide this knowledge, if needed The process for developing selfassessment questions has been revised by carefully tying the questions to objectives and material presented in the books and incorporating a field-test process using panels of specialists It is our hope that these efforts will build on and improve PSAP’s reputation as a quality professional development tool for Board Certified Pharmacotherapy Specialists We extend our heartfelt appreciation to all the faculty panel chairs, authors, and reviewers for lending their time and expertise to this new series; and to ACCP Publications staff members for their ever-present willingness to help and guide the development of this new series John E Murphy and Mary Lee, series editors PSAP 2014 • Critical and Urgent Care iii Preface Disclosure of Potential Conflicts of Interest Consultancies: Theresa Allison (Arbor Pharmaceuticals); Edward Grace (Presbyterian College IRB, St Francis Hospital, Society of Infectious Diseases Pharmacists); Ishaq Lat (Critical Care Pharmacotherapy Trials Network); Samir Patel (Biotest Pharmaceuticals); Heather Johnson (Novartis); Kristina E Ward (State of Rhode Island Department of Health and Human Services, Abacus Group); Pharmacy and Health Sciences [spouse or significant other]); Edward Grace (Florida Pharmacists Association, Florida Society of Health System Pharmacists, Self Regional Hospital); Stephanie Nichols (Maine Occupational Therapists Association); Dane Shiltz (Butler University); David Volles (Cubist Pharmaceuticals); Nothing to Disclose: Joseph Aloi; Seth Bauer; Kathryn Connor; Mitchell Daley; Patricia Jane Faris; Kristen Hesch; Samantha Jellinek-Cohen; Simon Lam; Chigozie Mason; William Z Marcus; Melissa Marsinko; Joseph Mazur; Wesley McMillian; Claire V Murphy; Steven Pass; Theresa Phung; Mirembe Reed; Michael Remkus; Russel Roberts; Eimer M Sanchez; Dustin Spencer; Natasa Stevkovic; Said Sultan; Joseph Swanson; Mickala Thompson; Alana Whittaker; Katy H Wright; Lisa Zimmerman Stock Ownership: Jeffrey Fong (Teva, Inc.); Heather Johnson (Pfizer); Royalties: Victor Cohen (ASHP); Grants: Edward Grace (Department of Veterans Affairs); Jeffrey Fong (Merck, Hospira); Kristina E Ward (U.S Food and Drug Administration); Honoraria: Alexander Ansara (Boehringer-Ingelheim Pharmaceuticals, Bristol-Myers Squibb, Pfizer); Kara Birrer (University of Florida College of Pharmacy); Victor Cohen (Arnold and Marie Schwartz College of ROLE OF BPS: The Board of Pharmacy Specialties (BPS) is an autonomous division of the American Pharmacists Association (APhA) BPS is totally separate and distinct from ACCP The Board, through its specialty councils, is responsible for specialty examination content, administration, scoring, and all other aspects of its certification programs PSAP has been approved by BPS for use in BCPS recertification Information about the BPS recertification process is available at www.bpsweb.org/recertification/general.cfm Other questions regarding recertification should be directed to: Board of Pharmacy Specialties 2215 Constitution Avenue NW Washington, DC 20037 (202) 429-7591 www.bpsweb.org PSAP 2014 • Critical and Urgent Care iv Disclosure of Potential Conflicts of Interest Continuing Pharmacy Education and Program Instructions Continuing Pharmacy Education Credit: The American College of Clinical Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education (CPE) Purchasers who successfully complete all posttests for PSAP 2014 Book (Critical and Urgent Care) can earn 23.0 contact hours of continuing pharmacy education credit The universal activity numbers are: Critical and Urgent Care I – 0217-0000-14-001-H01-P, 7.5 contact hours; Critical and Urgent Care II – 0217-0000-14-002H01-P, 9.0 contact hours; and Critical and Urgent Care III – 0217-0000-14-003-H01-P, 6.5 contact hours schedule new opportunities for credits from upcoming ACCP professional development programs ACPE Continuing Pharmacy Education Credit: To receive ACPE CPE credit for a PSAP module, a posttest must be submitted within years after the book’s release The appropriate CPE credit will be awarded for test scores of 50% and greater Credits will be back-dated to the date of test submission Statements of ACPE CPE credit will be made available online within 45 days after the BCPS test deadline Posttest answers: The explained answers – with rationale and supporting references – will be posted online days after the BCPS test deadline Answers are available to anyone who has submitted a posttest or waived their right to receive credit from a posttest Go to www.accp com and sign in with your e-mail address and password Then navigate to your My Account page Your test will be displayed with correct and incorrect answers identified You will also see a hyperlink to a PDF file with the correct answers and explanations for that test BCPS Recertification Credit: To receive BCPS recertification CPE credit, a PSAP posttest must be submitted during the 4-month period after the book’s release The first page of each print and online book lists the deadline to submit a required posttest for BCPS recertification credit Tests submitted will be processed and the results posted online within 45 days of the test deadline Only completed tests are eligible for credit; no partial or incomplete tests will be processed Tests may not be submitted more than once The passing point for BCPS recertification is based on a statistical analysis of the answers submitted for each posttest module Recertification credits earned from a passing score will be forwarded to the Board of Pharmacy Specialties (BPS), and a printable online statement of CPE/BCPS recertification credit will be made available Questions regarding the number of hours required for BCPS recertification should be directed to BPS at (202) 429-7591 or www.bpsweb.org The ACCP Recertification Dashboard is a free online tool that can track recertification credits as they are earned and PSAP 2014 • Critical and Urgent Care Test Waivers: To receive electronic access to the explained answers without submitting a posttest, click on the PSAP product you have purchased You will see a link to the online waiver form By completing the waiver form for a module, you waive the opportunity to receive CPE credit for that module After you submit a waiver for a posttest, you will see a link to the PDF file that contains the answers for the module you waived Answers will be available starting days after the BCPS test deadline v Program Instructions Critical and Urgent Care I Panel Series Editors: Acute Management of Burn Injury John E Murphy, Pharm.D., FCCP, FASHP Professor of Pharmacy Practice and Science Associate Dean for Academic and Professional Affairs University of Arizona College of Pharmacy Tucson, Arizona Author Claire V Murphy, Pharm.D., BCPS Specialty Practice Pharmacist – Burn/Surgical Critical Care PGY2 Critical Care Residency Program Director Department of Pharmacy The Ohio State University Wexner Medical Center Columbus, Ohio Mary Wun-Len Lee, Pharm.D., FCCP, BCPS Vice President and Chief Academic Officer Pharmacy, Optometry, and Health Sciences Education Midwestern University Professor of Pharmacy Practice Midwestern University Chicago College of Pharmacy Downers Grove, Illinois Reviewers Said M Sultan, Pharm.D., BCPS Clinical Specialist, Critical Care Assistant Professor of Clinical Education Department of Pharmacy University of North Carolina Medical Center University of North Carolina Eshelman School of Pharmacy Chapel Hill, North Carolina Faculty Panel Chair Steven E Pass, Pharm.D., BCPS, FCCM, FCCP Associate Professor and Vice Chair for Residency Programs Department of Pharmacy Practice Texas Tech University Health Sciences Center School of Pharmacy Dallas, Texas Natasa Stevkovic, Pharm.D., BCPS Clinical Pharmacist, Trauma – Burn Critical Care CPE Education Coordinator Department of Pharmacy John H Stroger, Jr Hospital of Cook County Chicago, Illinois Cardiac Arrest and Advanced Cardiac Life Support Antibiotic Use in Patients Receiving CRRT Author Kristen A Hesch, Pharm.D., BCPS Assistant Professor Department of Pharmacy Practice Texas Tech University Health Sciences Center School of Pharmacy Dallas, Texas Author Kathryn A Connor, Pharm.D., BCPS, BCNSP Assistant Professor Department of Pharmacy Practice St John Fisher College Clinical Specialist Critical Care The University of Rochester Medical Center Rochester, New York Reviewers William Z Marcus, Pharm.D., BCPS Pharmacy Clinical Specialist Critical Care Renown Regional Medical Center Reno, Nevada Reviewers Mirembe Reed, Pharm.D., BCPS Clinical Pharmacy Specialist in Cardiology Pharmacy Department Steward St Elizabeth's Medical Center Boston, Massachusetts PSAP 2014 • Critical and Urgent Care David F Volles, Pharm.D., BCPS Pharmacy Clinical Coordinator Department of Pharmacy University of Virginia Health System Critical and Urgent Care I Box 3-3 Burn Center Treatment Protocol for Protection of the Dermis Box 3-2 SCORTEN: Severity-of-Illness Score to Estimate Risk of Death in TEN Initial evaluation is performed by the burn team The patient is transferred to the operating room, anesthetized in the supine position on a transport gurney turned prone onto an operating table covered with a heating blanket Wash all wounds with a rough washcloth moistened with normal saline solution No detergents are used All loose skin and blisters are removed All areas with target lesions or a Nikolsky sign are vigorously wiped to remove epithelium that is in the early signs of sloughing A porcine xenograft is meticulously applied to all raw surfaces and stapled in place The patient is then transferred from the operating table to an adjacent, warmed, air-fluidized (Clinitron) bed and returned to the supine position The anterior surface of the patient, including the hands, feet, and face, is cleansed and covered with a porcine xenograft The patient is admitted to the intensive care area of the burn unit Initial fluid resuscitation is not required (although it would be required in a thermal burn), but daily evaporative water loss may be extremely high on an airfluidized bed, so careful fluid and electrolyte monitoring is required If the patient is on TEN-related steroid therapy before referral, steroid administration is discontinued unless the patient is taking chronic steroids for a chronic medical condition, in which case steroids are tapered to pre-TEN dosing 10 Enteral alimentation is established through a nasogastric feeding tube 11 Systemic antibiotics are used only for specific infections 12 An intense pulmonary toilet is established 13 Physical therapy is initiated on the day after surgery 14 The xenograft is inspected continuously Small areas of dislodged xenograft are replaced in the intensive care unit Larger areas will undergo a repeat xenografting in the operating room 15 Pain is managed by a routine pain cocktail containing an opiate, hydroxyzine, and acetaminophen in cherry syrup Intravenous narcotics are given as needed for acute pain Usually, with the dermis covered, patients are pain free or experience little to no pain 16 Meticulous eye care is provided on an hourly basis, and an ophthalmologist provides a daily consultation to search for and remove conjunctival synechiae with a glass rod 17 Central venous and bladder catheters are avoided because they are a focus for infection 18 As the wound heals beneath it, the xenograft becomes brittle and desiccates These areas are trimmed each day Prognostic Factors (each given a score of 1) ■■ ■■ ■■ ■■ ■■ ■■ ■■ Age > 40 years Heart rate > 120 beats/minute Cancer or hematologic malignancy Involved body surface area > 10% BUN >10 mmol/L (28 mg/dL) Serum bicarbonate 14 mmol/L (252 mg/dL) No of Prognostic Factors Mortality Rate 0–1 3% 12% 35% 58% or more 90% TEN = toxic epidermal necrolysis Information from: Bastuji-Garin S, Fouchard N, Bertocchi M, et al SCORTEN: a severity-of-illness score for toxic epidermal necrolysis J Invest Dermatol 2000;115:149-53 Management of SJS and TEN Supportive Care There are no controlled prospective treatment study or generally accepted evidence-based guideline for the treatment of SJS and TEN; however, successful case series using the management protocol in Box 3-3 have been reported (Heimbach 1987) The two most important elements in SJS and TEN treatment are discontinuation of the offending drug and admission to a burn unit (Harr 2010; Heimbach 1987) Evidence suggests that the rapid institution of these two measures is associated with a more favorable prognosis Patients with extensive skin involvement require reverse isolation and a sterile environment Areas of skin erosion should be covered with nonadherent protective dressings such as petrolatum gauze (Harr 2010; Struck 2010) Respiratory distress may result from mucosal sloughing and edema and necessitate endotracheal intubation and ventilation (Barrera 1998) Because of its similarity to the management of extensive burns, transfer of TEN patients to a burn unit is suggested as best practice The largest trial to examine treatment in a burn unit versus traditional care found that 7-day mortality rates were 29.8% after transfer to a burn unit compared with 51.4% in standard care (p g/kg) and lowdose IVIG (total dose of IVIG < g/kg) in adults, and IVIG treatment in pediatric versus adult patients There were 17 studies with TEN patients (n=221) that met the inclusion criteria; however most studies had a mix of patients (i.e., SJS alone, SJS/TEN overlap, and TEN) The dosing of IVIG ranged from 0.05 g/kg-2 g/kg treated for a 2–5 days For all patients, mean age was 41.3 years; mean TBSA was 43.4%; mean time from diagnosis to treatment was 5.3 days; mean time from initiation of IVIG to response was 2.4 days; mean time from initiation of IVIG to remission was 10.9 days; and the mean hospital stay was 17.4 days A total of 44/221 patients died (19.9%) For observational controlled studies that compared IVIG and supportive care, the pooled OR for mortality was 1.00 (95% CI, 0.58–1.75; p=0.99) For high-dose IVIG versus supportive care, the pooled OR for mortality was 0.63 (95% CI, 0.27–1.44; p=0.27) In 12 separate studies, adults treated with high-dose IVIG (n=122) had significantly lower mortality than those treated with lowdose IVIG (n=12) (18.9% vs 50%, respectively; p=0.022) However, mortality was no longer associated with IVIG dose after adjustment in the multivariate logistic regression model (high vs low dose: OR 0.494; 95% CI, 0.106–2.300; p=0.369) (Huang 2012) When IVIG treatment was compared between pediatric patients (n=33) and adults (n=134), significantly lower mortality was seen in the younger group (0% vs 21.6%; p=0.001) In addition, shorter times were seen from IVIG initiation to skin healing (7.6 ± 2.6 and 13.1 ± 11.3; p< 0.021) and disease cessation (1.9 ±0.7 and 3.4 ± 2.5; p 90% 24–28 mEq/L 60%–85% m3/kg 4.5–8.0 SI Units 24–30 mmol/L 0.90 to fraction of > 70 (80–100 mm Hg) 30–50 mm Hg > 9.3 (11–13 kPa) pH Leukocyte esterase, nitrite, protein, blood, ketones, bilirubin, glucose Urinalysis Serum bicarbonate Oxygen saturation (Sao2) Partial pressure of oxygen (Po2) < 3.36 mmol/L < 130 mg/dL Low-density lipoprotein (LDL) cholesterol Venous > 1.04 mmol/L < 1.26 mmol/L < 5.18 mmol/L < 200 mg/dL SI Units 24–28 mmol/L Venous 4.4–11.3 × 109/L High-density lipoprotein (HDL) cholesterol > 40 mg/dL Cholesterol, total (TC) Reference Range 4.4–11.3 × 103 cells/mm3 White blood cell (WBC) count Serum Lipids 0.5%–2.5% Reticulocyte count 0.005–0.025 4.5–5.9 × 1012/L (men) 4.1–5.1 × 1012/L (women) 4.5–5.9 × 10 cells/mm (men) 4.1–5.1 × 106 cells/mm3 (women) Red blood cell (RBC) count 10–13 seconds 150–450 × 109/L 21–45 seconds 10–13 seconds 3 150,000–450,000/mm 21–45 seconds 80–960 fL 20.3–22 mmol/L 1.66–2.09 fmol/cell 8.7–11.2 mmol/L (men) 7.5–10 mmol/L (women) 0.42–0.5 (men) 0.36–0.45 (women) SI Units Prothrombin time (PT) Platelet count Partial thromboplastin time (PTT) 80–960 fL/cell 33–36 g/dL Mean corpuscular hemoglobin concentration (MCHC) Mean corpuscular volume (MCV) 27–33 pg/cell Mean corpuscular hemoglobin (MCH) 0.9–1.1 14–18 g/dL (men) 12–16 g/dL (women) Hemoglobin International normalized ratio (INR) 42%–50% (men) 36%–45% (women) Reference Range Hematocrit Hematology/Coagulation a Values given in this table are commonly accepted reference ranges compiled from many sources Patient-specific goals may differ depending on age, sex, clinical condition, and the laboratory methodology used to perform the assay Reprinted with kind permission from the American College of Clinical Pharmacy (ACCP) Copyright Pharmacotherapy Self-Assessment Program (PSAP) Reference Range Serum Chemistries Reference Ranges for Common Laboratory Testsa ... recertification credit This book is divided into three modules, Critical and Urgent Care I, Critical and Urgent Care II, and Critical and Urgent Care III You may complete one or all three modules for... posttests for PSAP 2014 Book (Critical and Urgent Care) can earn 23.0 contact hours of continuing pharmacy education credit The universal activity numbers are: Critical and Urgent Care I – 0217-0000-14-001-H01-P,... Massachusetts PSAP 2014 • Critical and Urgent Care David F Volles, Pharm.D., BCPS Pharmacy Clinical Coordinator Department of Pharmacy University of Virginia Health System Critical and Urgent Care I
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