In this episode I’ll:
1. Discuss an article about evidence based medicine
2. Answer a drug information question about IV compatibility
3. Share a resource for calculating a patient’s Candida Score
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Lead author: Gordon CS Smith
Published in British Medical Journal December 2003
Using high quality evidence to guide patient care decisions is of vital importance. However, for most patient care decisions, there is not a randomized controlled trial that you can look to for guidance. Patients with multiple co-mordbidities, at extremes of age, or who are pregnant are often excluded from trials. But patients like these exist, and you’ll need to make individualized decisions about their care.
This article is one of my favorites to have students and residents read to put evidence-based medicine in perspective.
To determine whether parachutes are effective in preventing death or major trauma related to gravitational challenge.
The study was a systematic review of randomized controlled trials. Medline, Web of Science, Embase, the Cochrane Library databases, appropriate internet sites and citation lists were examined for studies showing the effects of using a parachute during free fall. The primary outcome measure was death or major trauma, defined as an injury severity score > 15.
The authors were unable to identify any randomized controlled trials of parachute intervention.
The authors concluded that:
No randomized controlled trials of parachute use have been undertaken.
The basis for parachute use is purely observational, and its apparent efficacy could potentially be explained by a “healthy cohort” effect since individuals who jump out of airplanes without a parachute are likely to have psychiatric co-morbidities.
Individuals who insist that all interventions need to be validated by a randomized controlled trial need to come down to earth with a bump.
Drug information question
I’m often asked about IV compatibility in critical situations. It is not always practical to be leaving the bedside of a crashing patient to check on IV compatibility.
According to Trissel’s, with the lone exception of propofol and vasopressin (which have never been tested together) all the usual sedatives and vasopressors are compatible with each other at Y-site. This includes norepinephrine, epinephrine, phenylephrine, vasopressin, dopamine, fentanyl, midazolam, propofol, and dexmedetomidine. Assuming the patient has 2 IV sites, combining vasopressors and sedatives can leave the extra IV site open for IV push or antibiotic administration.
I’d like to share with you a calculator that I created for quickly determining a patient’s Candida Score. The Candida Score is useful for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% can be expected in patients with a Candida Score less than 3. Points are awarded based on whether the patient has sepsis, is receiving total parenteral nutrition, had surgery at the onset of ICU admission, and has candida simultaneously isolated from multiple noncontagious foci. This information can be useful when determining whether a patient with candida in a culture should receive anti-fungal therapy. You can find this calculator and others at pharmacyjoe.com/calculators.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.