Month: December 2012

Who, Pharm.D.

by empharmd, posted in EM PharmD Blog

Over the holiday, I began reading one of the William Osler biographies. While reading his inspiring and influential journey, which to this day continues to guide and lead others, I paused to reflect on my own profession. Although I’m searching for the pharmacy equivalent to such influential figures in medicine, our education methods are far more interesting.
Though books and lectures were a component of late 19th century and early 20th century medical education, Osler saw them more as tools opposed to staples.  Introducing “clerkships” to medical education in America, students were thrust into practice to study “…individuals – not diseases.”  No doubt, a reflection of the existing education of physicians in other countries during that time, but paving the way for todays education model and future directions (ie, Khan Academy, flipping the classroom, etc).
Pharmacy education on the other hand, lags behind. Specifically, in the amount of practical experience the average pharmacy student accumulates before graduation and the over reliance on lectures and textbooks. Just recently, more focus on pharmacy clerkships was implemented by increasing the required hours of practical experience.  Unfortunately, there are few teachers out there that can accommodate the vast class sizes of today’s schools of pharmacy.  Speaking from personal experience, one is left to either sit in the back of a pharmacy to ‘observe’ inappropriate habits of overwhelmed community pharmacists or be put to work counting and labeling.  Certainly, students with initiative can create their own learning opportunities, seeking volunteer clerkship with faculty, pursuing PGY1 and PGY2 residency, but similarly, the deficiency of opportunities lags behind the need of the students, and the profession.  The figure is in the neighborhood of 1 residency position for every 2 to 3 pharmacy students seeking a residency. Mind you, only about 20% of graduating pharmacists seek residency/post graduate training.
Pharmacy education needs to change, both prior to graduation and post graduation. Through the evolution of medical education led by pioneering figures, medicine itself has advanced remarkably over the past 120 years. Pharmacy education can do the same.  Pharmacy education must do the same. 
Since Doctor Who saved the universe from oblivion on Dec 21st (…cough, cough…), 2013 provides us, and the years to come, an opportunity to make a difference.  For me it is, among other things, the need for an evolution (perhaps a revolution) of pharmacy education.
“A difference, to be a difference, must make a difference.” –Gertrude Stein

Tale of the Comeback Kid: Procainamide in the ED

by Nadia I. Awad, posted in EM PharmD Blog

It seems as though the traditional “go-to” management of atrial fibrillation in the setting of rapid ventricular response in the emergency department involves rate control and anticoagulation.

Can we break this tradition and consider alternative therapeutic management in certain subpopulations of patients with dysrhythmias?

Recently, there has been some discussion regarding the use of rhythm control for new-onset atrial fibrillation, particularly procainamide, which used to be used back in the day and has started to make a comeback.

You may ask why. Here’s the story of the revived interest in the emergent use of procainamide in recent-onset atrial fibrillation as well as other dysrhythmias:

The Procainamide Comeback: Blasts from the Past and Hints for the Future
Indication
Recommendation
Proof
Conversion of recent-onset atrial fibrillation
Class Ia recommendation for our northern neighbors in Canada
·         One study demonstrated conversion rate of new-onset atrial fibrillation with the use of IV procainamide in nearly 52% of all patients.
·         Another study demonstrated 59.9% conversion rate in patients treated with IV procainamide using the Ottawa Protocol.
Wide-complex atrial fibrillation associated with Wolff-Parkinson-White (WPW) syndrome
Class I recommendation for management of atrial fibrillation in the setting of WPW as of 2011 ACCF/AHA/HRS guidelines
·         A review of various studies show amiodarone to not be the preferred treatment option for atrial fibrillation associated with WPW due to inducible proarrhythmias
·         Incidence was less with procainamide.
Stable monomorphic ventricular tachycardia
Class IIa recommendation (preferred over amiodarone [Class IIb]) based on 2010 AHA guidelines
·         One study demonstrated superiority of IV procainamide over IV lidocaine in terminating episodes of stable monomorphic ventricular tachycardia (79% versus 19%).

Interestingly enough, the Canadians seem to have a lot more to offer in terms of evidence surrounding the use of procainamide in the emergency department; perhaps we can adopt this practice more routinely when the situation arises.

To complete the preparation for the comeback of procainamide, let us now retrieve that vial sitting all the way in the back corner of the top shelf in your pharmacy and review the dosing just for kicks:

The loading dose of procainamide can be administered in a number of ways:

  • 20 to 50 mg/min IV OR 100 mg IV at a rate not exceeding 50 mg/min repeated every five minutes as needed to a total dose of 1 g
    • When a total of 500 mg has been given, one should wait ten minutes before continuing with administration to prevent profound hypotension.
  • Infusion of 17 mg/kg IV over one hour
    • In patients with renal dysfunction or congestive heart failure, loading dose should not exceed 12 mg/kg.

The maintenance dose of procainamide typically ranges between 1 and 4 mg/min administered via continuous IV infusion.

Procainamide is looking to redeem itself for use in the ED…are you up to the challenge?