Empirical gentamicin dosing based on serum creatinine levels in premature and term neonates [Clinical Research Reports]

Purpose

Empirical gentamicin dosing based on serum creatinine (SCr) levels in premature and term neonates was evaluated.

Methods

This single-center, retrospective cohort study was conducted in a standalone children’s hospital with a level IIIB, 44-bed neonatal intensive care unit (NICU). Data were abstracted and collected for all neonates admitted to the NICU from March 5, 2012, through March 5, 2014. Patients were included in the study if gentamicin was administered within the first 7 days of life, a trough gentamicin level was measured, and the neonate had a baseline SCr level measured within the first 24 hours of life. A series of logistic regressions was conducted to determine if gentamicin trough levels were influenced by gestational age (≤29 weeks [group 1], 30 weeks to 34 weeks and 6 days [group 2], and ≥35 weeks [group 3]) and SCr level (0.81–0.99 mg/dL [mildly elevated] and ≥1 mg/dL [elevated]).

Results

Of the 577 neonates reviewed during the study period, 507 met the inclusion criteria. Mildly elevated and elevated SCr levels were significantly associated with the presence of an elevated gentamicin trough (p < 0.001). When the effect of gestational age was evaluated, the data suggested that SCr is a strong predictor of elevated gentamicin troughs.

Conclusion

Neonates with a gestational age of ≥30 weeks who had an SCr level of ≥1 mg/dL within the first 12–24 hours of life were more likely to have an elevated gentamicin trough level than their counterparts with normal SCr levels.

Successful use of laboratory monitoring to facilitate an invasive procedure for a patient treated with dabigatran [Case Report]

Purpose

A case in which novel and traditional laboratory markers were successfully used to determine surgical intervention timing in an elderly patient receiving dabigatran for atrial fibrillation is reported.

Summary

An 86-year-old woman who was taking dabigatran for atrial fibrillation suffered a right femoral neck fracture requiring surgical intervention. Dabigatran was withheld once the patient was admitted to the hospital, and the pharmacy inpatient anticoagulation management team was consulted for guidance on determining appropriate scheduling of surgical intervention with regard to the time since her most recent dabigatran dose to minimize bleeding complications. The team recommended delaying surgery, as dabigatran clearance would likely take 3–5 days and an ecarin chromogenic assay (ECA) dabigatran value of <50 ng/mL would be desirable before surgical intervention. During her hospitalization, novel and traditional laboratory markers for dabigatran, such as ECA value, activated partial thromboplastin time, thrombin time, and prothrombin time, were measured and followed closely to determine the best time to perform surgical intervention to minimize bleeding risk. Renal dysfunction likely delayed dabigatran elimination in the patient and may have led to potential accumulation of dabigatran. The patient ultimately had to wait 5 days after the last dabigatran dose for surgical intervention.

Conclusion

Coagulation assay monitoring for dabigatran, with emphasis on an ECA dabigatran concentration of <50 ng/mL, was used to assess safety regarding bleeding risk before a nonemergent surgical procedure in an 86-year-old woman with a right femoral neck fracture.

Incorporation of lean methodology into pharmacy residency programs [Special Feature]

Purpose

The implementation of lean methodology into pharmacy residency programs at a community teaching hospital is described.

Summary

New Hanover Regional Medical Center, a community teaching hospital in southeastern North Carolina, fully adopted a lean culture in 2010. Given the success of lean strategies organizationally, this methodology was used to assist with the evaluation and development of its pharmacy residency programs in 2014. Lean tools and activities have also been incorporated into residency requirements and rotation learning activities. The majority of lean events correspond to the required competency areas evaluating leadership and management, teaching, and education. These events have included participation in and facilitation of various lean problem-solving and communication tools. The application of the 4 rules of lean has resulted in enhanced management of the programs and provides a set of tools by which continual quality improvement can be ensured. Regular communication and direct involvement of all invested parties have been critical in developing and sustaining new improvements. In addition to program enhancements, lean methodology offers novel methods by which residents may be incorporated into leadership activities.

Conclusion

The incorporation of lean methodology into pharmacy residency programs has translated into a variety of realized and potential benefits for the programs, the preceptors and residents, and the health system. Specific areas of growth have included quality-improvement processes, the expansion of leadership opportunities for residents, and improved communication among program directors, preceptors, and residents.