Background With a clinical pharmacists' participation in an intensive care unit (ICU) previous in... more Background With a clinical pharmacists' participation in an intensive care unit (ICU) previous international studies have shown a reduction of medication errors, drug costs and improvements of clinical outcomes. Still there is a lack of qualitative data on clinical pharmacists' impact on prescribing error rates in the ICU. Therefore, a new approach was developed relating prescribing errors to the number of monitored medications including physicians' approval on all prescribing errors. Objective This study investigates the influence of clinical pharmacists' medication review on the prescribing error rate in an ICU. Setting A controlled interventional study was conducted in a surgical ICU with one control phase (P0) and two intervention phases (P1 and P2). Method The investigation aimed to determine if the medication review by clinical pharmacists results in a significant reduction of prescribing errors related to a control period. In contrast to previous studies, prescribing errors detected by the clinical pharmacists, were only taken into account, if consent with the physicians was achieved. Secondary outcomes were the reduction of potentially severe prescribing errors, the number of days without systemic anti-infective therapy and the ICU length of stay. Throughout P0 the data was collected retrospectively without any intervention. During the intervention periods P1 and P2, two clinical pharmacists screened the medical records for prescribing errors and discussed them with the senior physician in charge. During P2 one clinical pharmacist attended ward rounds additionally. Main Outcome Measure The main outcome measure of this study was the number of prescribing errors detected related to the number of monitored medications. Results The incidence of prescribing errors was significantly reduced from 1660 in P0 to 622 in P1 respectively 401 in P2 (P0 vs. P1/P2 respectively; both p < 0.001; Fisher's Exact Test) in total, respective 14.12% in P0 vs. 5.13% in P1 and 3.25% in P2 related to the monitored medications (P0:11755; P1:12134; P2:12329). Conclusion Clinical pharmacists' interventions led to a significant reduction of prescribing errors in the ICU, contributing to a safer medication process. We strongly recommend a broad implementation of clinical pharmacists in ICUs.
The alpha(2)-adrenoceptor agonist clonidine is one of the most widely investigated substances in ... more The alpha(2)-adrenoceptor agonist clonidine is one of the most widely investigated substances in anaesthesia and pain therapy. Recently, numerous experimental and clinical studies have allowed a better understanding of its underlying mechanisms of action and interactions with other analgesic drugs. Several experimental studies have shown that clonidine may improve the analgesic effect of anti-inflammatory agents and also have significant peripheral antinociceptive effects. Volunteer and clinical studies have demonstrated analgesic effects of clonidine after systemic administration, whereas local administration of plain clonidine (e.g. intra-articular, intravenous regional) showed only limited clinical efficacy. The major clinical place of clonidine may thus be as an adjuvant to other analgesics, as shown in a number of studies in which clonidine has been investigated in combination with local anaesthetics, opioids and ketamine. An increasing number of studies have now investigated c...
Numerous experimental studies have shown that systemic or regional administration of analgesics p... more Numerous experimental studies have shown that systemic or regional administration of analgesics prior to a nociceptive stimulus results in a significant reduction of analgesic requirements compared with the administration of the same analgesic dose given after the nociceptive stimulus. This phenomenon is called &quot;preemptive analgesia&quot;. Recently several clinical studies have been conducted to determine whether &quot;preemptive analgesia&quot; also occurs in humans. Regional and systemic opioids, local anesthetics and non-steroidal anti-inflammatory drugs have been investigated so far. Most studies have failed to show a significant reduction in postoperative analgesic requirements with preemptive analgesia. Even in studies with positive results the reduction in analgesic requirements was limited and without clinical relevance. Further studies should focus on the questions which analgesics and which administration routes might provide clinically significant &quot;preemptive analgesia&quot; and how long analgesia should be prolonged into the postoperative period.
To evaluate the influence of the alpha2-adrenergic receptor agonist clonidine on creatinine clear... more To evaluate the influence of the alpha2-adrenergic receptor agonist clonidine on creatinine clearance as a measure of renal function. Prospective, double-blind, randomized, placebo-controlled clinical trial. University hospital. Patients undergoing coronary artery bypass graft surgery (n = 48) with normal risk. Administration of clonidine (4 micrograms/kg iv)) or placebo 1 hr before induction of anesthesia. Induction and maintenance of anesthesia (etomidate, midazolam, and fentanyl) and cardiopulmonary bypass technique (nonpulsatile, normothermic, intermittent cold blood cardioplegia) were standardized in all patients. The night before surgery and the first and third night after surgery, creatinine clearance was calculated from a 12-hr urine collection period. Venous blood samples for determination of plasma antidiuretic hormone (ADH) concentrations were taken the evening before surgery, immediately before induction of anesthesia and the evening after surgery (n = 16). Arterial catecholamine plasma concentrations were determined (high-performance liquid chromatography) before induction, 15 mins after induction of anesthesia, immediately after sternotomy, before initiation of cardiopulmonary bypass, as well as 5, 15, and 30 mins after initiation of cardiopulmonary bypass (n = 16). The total amount of anesthetics, infusions, transfusions, diuresis, and blood loss was not different between the groups. Creatinine clearance decreased over the first postoperative night from 98 +/- 18 (preoperatively) to 68 +/- 19 mL/min (p &lt; .05) in placebo-treated patients. Creatinine clearance remained unchanged in clonidine-treated patients (90 +/- 19 [preoperatively] to 92 +/- 17 mL/min). There was a significant difference in creatinine clearance between the groups during the first postoperative night (p &lt; .05; Mann-Whitney U test). In the third postoperative night, mean creatinine clearance of both groups was not different (75 +/- 31 vs. 86 +/- 28 mL/min). ADH concentrations were not different between the groups at any time, while plasma catecholamine concentrations were always significantly lower in clonidine-treated patients. Preoperative treatment with clonidine (4 microgram/kilogram) prevents the deterioration of renal function after cardiac surgery. This effect might be due to clonidine-induced reduction in the sympathetic nervous system response to coronary artery bypass graft surgery.
Zusammenfassung Die Ursachen akuter oberer Gastrointestinalblutungen bei Intensivpatienten sind... more Zusammenfassung Die Ursachen akuter oberer Gastrointestinalblutungen bei Intensivpatienten sind vielfältig: Ulkuskrankheit, Medikamenteneffekte, Sondenläsionen, akutes Nieren- oder Leberversagen und Streßläsionen. Die letzteren manifestieren sich typischerweise als multiple oberflächliche Mukosaerosionen, während Ulzerationen meist bei Patienten mit Schädelhirntrauma oder nach neurochirurgischen Eingriffen oder Verbrennungstrauma beobachtet werden. Nur bei Patienten mit intrakraniellen Läsionen kommt es regelmäßig zur Hyperazidität. Neuere Erkenntnisse haben deutlich gemacht, daß ein aktiv säuresezernierender Magen resistenter gegen Noxen ist als ein Magen mit nur basaler Säuresekretion. Aktive Säuresekretion erfordert ausreichende Sauerstoffzufuhr und ausreichenden ATP-Gehalt in der Magenmukosa. Hypotension und Schock führen zur Mukosaischämie und sind die bedeutsamsten Risikofaktoren der Streßblutung. Prophylaktische Maßnahmen zielen darauf ab, die Magensäure zu vermindern und insbesondere die protektiven Mechanismen zu stärken. Die wichtigste prophylaktische Maßnahme ist deshalb eine frühzeitige optimale Schocktherapie. Alle derzeit in Deutschland zugelassenen spezifischen medikamentösen Prophylaxeregimes haben sich in kontrollierten Studien als wirksam erwiesen. Für neurochirurgische Patienten konnte darüber hinaus eine überlegene Wirksamkeit von Pirenzepin gegenüber H2g;blutungsprophylaxe. Die bedeutsamste Nebenwirkung ist eine erhöhte Pneumonierate unter säuresupprimierender Streßblutungsprophylaxe. Diese Nebenwirkung beobachtet man bei langzeitbeatmeten Intensivpatienten mit einem Magensaft pH >4. Bei speziellen Risikogruppen werden bis zu 50% aller nosokomialen Pneumonien durch diese Nebenwirkung verursacht. Die bei längerfristig beatmeten Patienten beobachtete geringere Mortalität unter Sucralfat im Vergleich zu H2-Antagonisten/Antazida kann wahrscheinlich durch die verminderte Translokation von Bakterien aus dem Gastrointestinaltrakt erklärt werden.
... view on previous investigations on stress ulcer prophylaxis and how may they influence future... more ... view on previous investigations on stress ulcer prophylaxis and how may they influence futureresearch? ... prophylaxis during the last 10 yrs have not addressed the questions that are ... these studies used different approaches for the calculation, their conclusions are surprisingly ...
Background With a clinical pharmacists' participation in an intensive care unit (ICU) previous in... more Background With a clinical pharmacists' participation in an intensive care unit (ICU) previous international studies have shown a reduction of medication errors, drug costs and improvements of clinical outcomes. Still there is a lack of qualitative data on clinical pharmacists' impact on prescribing error rates in the ICU. Therefore, a new approach was developed relating prescribing errors to the number of monitored medications including physicians' approval on all prescribing errors. Objective This study investigates the influence of clinical pharmacists' medication review on the prescribing error rate in an ICU. Setting A controlled interventional study was conducted in a surgical ICU with one control phase (P0) and two intervention phases (P1 and P2). Method The investigation aimed to determine if the medication review by clinical pharmacists results in a significant reduction of prescribing errors related to a control period. In contrast to previous studies, prescribing errors detected by the clinical pharmacists, were only taken into account, if consent with the physicians was achieved. Secondary outcomes were the reduction of potentially severe prescribing errors, the number of days without systemic anti-infective therapy and the ICU length of stay. Throughout P0 the data was collected retrospectively without any intervention. During the intervention periods P1 and P2, two clinical pharmacists screened the medical records for prescribing errors and discussed them with the senior physician in charge. During P2 one clinical pharmacist attended ward rounds additionally. Main Outcome Measure The main outcome measure of this study was the number of prescribing errors detected related to the number of monitored medications. Results The incidence of prescribing errors was significantly reduced from 1660 in P0 to 622 in P1 respectively 401 in P2 (P0 vs. P1/P2 respectively; both p < 0.001; Fisher's Exact Test) in total, respective 14.12% in P0 vs. 5.13% in P1 and 3.25% in P2 related to the monitored medications (P0:11755; P1:12134; P2:12329). Conclusion Clinical pharmacists' interventions led to a significant reduction of prescribing errors in the ICU, contributing to a safer medication process. We strongly recommend a broad implementation of clinical pharmacists in ICUs.
The alpha(2)-adrenoceptor agonist clonidine is one of the most widely investigated substances in ... more The alpha(2)-adrenoceptor agonist clonidine is one of the most widely investigated substances in anaesthesia and pain therapy. Recently, numerous experimental and clinical studies have allowed a better understanding of its underlying mechanisms of action and interactions with other analgesic drugs. Several experimental studies have shown that clonidine may improve the analgesic effect of anti-inflammatory agents and also have significant peripheral antinociceptive effects. Volunteer and clinical studies have demonstrated analgesic effects of clonidine after systemic administration, whereas local administration of plain clonidine (e.g. intra-articular, intravenous regional) showed only limited clinical efficacy. The major clinical place of clonidine may thus be as an adjuvant to other analgesics, as shown in a number of studies in which clonidine has been investigated in combination with local anaesthetics, opioids and ketamine. An increasing number of studies have now investigated c...
Numerous experimental studies have shown that systemic or regional administration of analgesics p... more Numerous experimental studies have shown that systemic or regional administration of analgesics prior to a nociceptive stimulus results in a significant reduction of analgesic requirements compared with the administration of the same analgesic dose given after the nociceptive stimulus. This phenomenon is called &quot;preemptive analgesia&quot;. Recently several clinical studies have been conducted to determine whether &quot;preemptive analgesia&quot; also occurs in humans. Regional and systemic opioids, local anesthetics and non-steroidal anti-inflammatory drugs have been investigated so far. Most studies have failed to show a significant reduction in postoperative analgesic requirements with preemptive analgesia. Even in studies with positive results the reduction in analgesic requirements was limited and without clinical relevance. Further studies should focus on the questions which analgesics and which administration routes might provide clinically significant &quot;preemptive analgesia&quot; and how long analgesia should be prolonged into the postoperative period.
To evaluate the influence of the alpha2-adrenergic receptor agonist clonidine on creatinine clear... more To evaluate the influence of the alpha2-adrenergic receptor agonist clonidine on creatinine clearance as a measure of renal function. Prospective, double-blind, randomized, placebo-controlled clinical trial. University hospital. Patients undergoing coronary artery bypass graft surgery (n = 48) with normal risk. Administration of clonidine (4 micrograms/kg iv)) or placebo 1 hr before induction of anesthesia. Induction and maintenance of anesthesia (etomidate, midazolam, and fentanyl) and cardiopulmonary bypass technique (nonpulsatile, normothermic, intermittent cold blood cardioplegia) were standardized in all patients. The night before surgery and the first and third night after surgery, creatinine clearance was calculated from a 12-hr urine collection period. Venous blood samples for determination of plasma antidiuretic hormone (ADH) concentrations were taken the evening before surgery, immediately before induction of anesthesia and the evening after surgery (n = 16). Arterial catecholamine plasma concentrations were determined (high-performance liquid chromatography) before induction, 15 mins after induction of anesthesia, immediately after sternotomy, before initiation of cardiopulmonary bypass, as well as 5, 15, and 30 mins after initiation of cardiopulmonary bypass (n = 16). The total amount of anesthetics, infusions, transfusions, diuresis, and blood loss was not different between the groups. Creatinine clearance decreased over the first postoperative night from 98 +/- 18 (preoperatively) to 68 +/- 19 mL/min (p &lt; .05) in placebo-treated patients. Creatinine clearance remained unchanged in clonidine-treated patients (90 +/- 19 [preoperatively] to 92 +/- 17 mL/min). There was a significant difference in creatinine clearance between the groups during the first postoperative night (p &lt; .05; Mann-Whitney U test). In the third postoperative night, mean creatinine clearance of both groups was not different (75 +/- 31 vs. 86 +/- 28 mL/min). ADH concentrations were not different between the groups at any time, while plasma catecholamine concentrations were always significantly lower in clonidine-treated patients. Preoperative treatment with clonidine (4 microgram/kilogram) prevents the deterioration of renal function after cardiac surgery. This effect might be due to clonidine-induced reduction in the sympathetic nervous system response to coronary artery bypass graft surgery.
Zusammenfassung Die Ursachen akuter oberer Gastrointestinalblutungen bei Intensivpatienten sind... more Zusammenfassung Die Ursachen akuter oberer Gastrointestinalblutungen bei Intensivpatienten sind vielfältig: Ulkuskrankheit, Medikamenteneffekte, Sondenläsionen, akutes Nieren- oder Leberversagen und Streßläsionen. Die letzteren manifestieren sich typischerweise als multiple oberflächliche Mukosaerosionen, während Ulzerationen meist bei Patienten mit Schädelhirntrauma oder nach neurochirurgischen Eingriffen oder Verbrennungstrauma beobachtet werden. Nur bei Patienten mit intrakraniellen Läsionen kommt es regelmäßig zur Hyperazidität. Neuere Erkenntnisse haben deutlich gemacht, daß ein aktiv säuresezernierender Magen resistenter gegen Noxen ist als ein Magen mit nur basaler Säuresekretion. Aktive Säuresekretion erfordert ausreichende Sauerstoffzufuhr und ausreichenden ATP-Gehalt in der Magenmukosa. Hypotension und Schock führen zur Mukosaischämie und sind die bedeutsamsten Risikofaktoren der Streßblutung. Prophylaktische Maßnahmen zielen darauf ab, die Magensäure zu vermindern und insbesondere die protektiven Mechanismen zu stärken. Die wichtigste prophylaktische Maßnahme ist deshalb eine frühzeitige optimale Schocktherapie. Alle derzeit in Deutschland zugelassenen spezifischen medikamentösen Prophylaxeregimes haben sich in kontrollierten Studien als wirksam erwiesen. Für neurochirurgische Patienten konnte darüber hinaus eine überlegene Wirksamkeit von Pirenzepin gegenüber H2g;blutungsprophylaxe. Die bedeutsamste Nebenwirkung ist eine erhöhte Pneumonierate unter säuresupprimierender Streßblutungsprophylaxe. Diese Nebenwirkung beobachtet man bei langzeitbeatmeten Intensivpatienten mit einem Magensaft pH >4. Bei speziellen Risikogruppen werden bis zu 50% aller nosokomialen Pneumonien durch diese Nebenwirkung verursacht. Die bei längerfristig beatmeten Patienten beobachtete geringere Mortalität unter Sucralfat im Vergleich zu H2-Antagonisten/Antazida kann wahrscheinlich durch die verminderte Translokation von Bakterien aus dem Gastrointestinaltrakt erklärt werden.
... view on previous investigations on stress ulcer prophylaxis and how may they influence future... more ... view on previous investigations on stress ulcer prophylaxis and how may they influence futureresearch? ... prophylaxis during the last 10 yrs have not addressed the questions that are ... these studies used different approaches for the calculation, their conclusions are surprisingly ...
Uploads
Papers by Michael Tryba