Pharmacist Participation

in Codes
December 1, 2023
Kenedie Krout, PharmD
PGY1 Pharmacy Resident
Franciscan Health Indianapolis
Disclosure Statement

The speaker has no actual or potential

conflicts of interest in relation to this
presentation.
Objectives
01 02
Review treatment Explore the pharmacist's role
algorithms for in cardiac arrest situations
BLS/ACLS

03 04
Discuss the literature Recognize the monetary
around pharmacists' value of having a
expanding role on cardiac pharmacist attend rapid
arrest response teams response situations
Abbreviations
ACLS Advanced Cardiac Life Support
ADC Automated Dispensing Cabinet
ALPS Amiodarone Lidocaine Placebo Study
BLS Basic Life Support
CI Confidence Interval
CPR Cardiopulmonary Resuscitation
MRS Modified Rankin Scale
PEA Pulseless Electrical Activity
pVT Pulseless Ventricular Tachycardia
ROSC Return of Spontaneous Circulation
TTM Targeted Temperature Management
VF Ventricular Fibrillation
 Survival After Cardiac Arrest

Eur Heart J. 2022. doi: 10.1093/eurheartj/ehac414

 From

1990-2020

2.2-fold 1.2-fold
Increase in outside-of-hospital Increase in inside-of-hospital
cardiac arrest survival cardiac arrest survival

Eur Heart J. 2022. Doi: 10.1093/eurheartj/ehac414

What is a
Cardiac
Arrest?
 Cardiac Arrest:
● Definition: the cessation of
effective ventilation and
circulation

● Causes: cardiac, pulmonary,

and/or trauma

● These situations are

considered medical
emergencies!
Sharabi AF. 2023. PMID: 33085378
Who Will Respond?
The Code Team:
​
Nursing Staff Pulmonologist​
​
Respiratory Therapy Patient Care Technicians​
​
Cardiologist Pharmacists

Physician(s)
 Crash Cart Drug Tray

Aspirin tablets Dextrose 50% injection Diltiazem injection

Nitroglycerin spray or Epinephrine injection Lidocaine injection

sublingual tablets
Atropine injection Metoprolol injection
Amiodarone injection

Adenosine injection

ACLS Training Center. 2021

Closed-Loop Communication and its
Importance in Code Response

Sender initiates
message

Recipient accepts
Sender verifies
message and
reception of
acknowledges
message
understanding
Cardiac Arrest: The Pharmacist's Role
Medication Documentation
Draw up the appropriate Help time/document doses of
medications based on rhythm and medications
differential diagnosis- anticipate
Accessibility
Drug Information Pull medications from the automated
dispensing cabinet and communicate
Answer drug information with the satellite pharmacy for
questions and assess medications outside the code cart
appropriateness
 Basic Life Support
(BLS)

• Be prepared to administer high-

quality CPR

• Anticipate what the team may need

from their pharmacist

American Heart Association. 2020.

Advanced Cardiac Life
Support (ACLS)
• Let the team know that pharmacy is in attendance

• Identify or ask what rhythm the patient is in

• Anticipate what the team will need from you based

on patient presentation
 Adult Cardiac
Arrest Algorithm

American Heart Association. 2020.

American Heart Association. 2020.
 Shockable Rhythms
Ventricular Tachycardia

Ventricular Fibrillation

American Heart Association. ACLS. 2020.

 Non-Shockable Rhythms
Asystole

Pulseless Electrical
Activity (PEA)

American Heart Association. ACLS. 2020.

 Where to Find the Rhythm

Defibrillator. Heartsmart. 2023. / Silva, P. Diabetes News Journal. 2015

American Heart Association. 2020.
 Treating Cardiac
Arrest: Amiodarone
or Lidocaine?
 How Do They Work?
Amiodarone Lidocaine
Drug Class Antiarrhythmic Agent Antiarrhythmic Agent
Class III Class Ib
Local Anesthetic
Mechanism of Action Inhibits adrenergic Suppresses automaticity of
stimulation, affects sodium, conduction tissue by
potassium, and calcium increasing electrical
channels, prolongs action stimulation threshold of the
potential and refractory ventricle, Purkinje system, and
period in myocardial tissue spontaneous depolarization of
the ventricles during diastole
Common Uses Supraventricular arrhythmias Anesthesia
Ventricular arrythmias Interstitial cystitis
Ventricular arrythmias

Amiodarone. Lidocaine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. 2023.
 Comparative Effectiveness of Amiodarone and Lidocaine for the
Treatment of In-Hospital Cardiac Arrest (2023)
Background Research Question
● ACLS guidelines support either amiodarone ● Does treatment with amiodarone vs
or lidocaine for cardiac arrest caused by lidocaine therapy have differential
ventricular tachycardia or ventricular associations with outcomes among
fibrillation based on studies of out-of- adult patients with in-hospital cardiac
hospital cardiac arrest arrest from VT/VF?

Study Design Outcome Measures

● Retrospective, cohort study ● Primary outcome: ROSC
● Adult patients receiving amiodarone or
lidocaine for in-hospital cardiac arrest ● Secondary outcomes: 24-hour survival,
refractory to CPR and defibrillation survival to discharge, favorable
● N = 14,630 (10,058 amiodarone and 4,572 neurologic outcome
lidocaine)
Wagner, D., et al. Chest. 2023. doi: 10.1016/[Link].2022.10.024
 Results and Conclusions
Conclusions
1 ROSC: ANY documented return of
adequate circulation by palpation,
auscultations, doppler, or documented BP

Favorable Neurologic Outcome: cerebral

2 performance category at hospital
discharge=good cerebral performance or
moderate cerebral disability

Applicability
Lidocaine was associated with
better outcomes in patients with in-
hospital cardiac arrest from VT/VF
compared to amiodarone.
Wagner, D., et al. Chest. 2023. doi: 10.1016/[Link].2022.10.024
 Effect of Time to Treatment With Antiarrhythmic Drugs on the Return of
Spontaneous Circulation in Shock-Refractory Out-of-Hospital Cardiac Arrest (2022)

Background Research Question

● Secondary analysis of the ALPS trial data ● Is there an association between time to
● ALPS trial: amiodarone 300 mg vs lidocaine treatment and chance of achieving
120 mg vs placebo (NS) ROSC at hospital arrival?

Study Design Outcome Measures

● Randomized, controlled trial ● Primary outcome: ROSC at hospital
● Adults with out-of-hospital cardiac arrest arrival
refractory to at least 1 defibrillation
● N= 2,994 (1,046 placebo, 962 amiodarone, ● Secondary outcomes: relationship
986 lidocaine) between time to treatment and
treatment effect
Rahimi M, et al. doi: 10.1161/JAHA.121.023958. Epub 2022
 The ALPS Trial
Patient
Study Population Results
• Adults with out-of- • N=2,994
• 300 mg amiodarone
hospital cardiac arrest
vs • 1,091 had ROSC at
• 120 mg lidocaine hospital arrival
• Presenting with
vs
VT/VF
• Placebo (NS) • 342 amiodarone (31%)
• Refractory to at least • 390 lidocaine (35.7%)
1 defibrillation • 359 placebo (32.9%)

Rahimi M, et al. doi: 10.1161/JAHA.121.023958. Epub 2022

 Effect of Time to Treatment With Antiarrhythmic Drugs on the Return of Spontaneous
Circulation in Shock-Refractory Out-of-Hospital Cardiac Arrest (2022)

Background Research Question

● Secondary analysis of the ALPS trial data ● Is there an association between time to
● ALPS trial: amiodarone 300 mg vs lidocaine treatment and chance of achieving
120 mg vs placebo (NS) ROSC at hospital arrival?

Study Design Outcome Measures

● Randomized, controlled trial ● Primary outcome: ROSC at hospital
● Adults with out-of-hospital refractory cardiac arrival
arrest
● N= 2,994 (1,046 placebo, 962 amiodarone, ● Secondary outcomes: relationship
986 lidocaine) between time to treatment and
treatment effect
Rahimi M, et al. doi: 10.1161/JAHA.121.023958. Epub 2022
 Results and Conclusions
Conclusions

1 Time interval: from 911 call

to drug administration
Refractory: no response to at
2
least ONE defibrillation

Applicability
Probability of ROSC decreases as time to
treatment increases

Odds Ratio: Effect of amiodarone declines with longer

- Amiodarone: 0.90-0.94/min increase in time
- Lidocaine: 0.93-0.96/min increase in time
time to administration (>13.5 minutes)
- Placebo: 0.93-0.96/min increase in time

Rahimi M, et al. doi: 10.1161/JAHA.121.023958. Epub 2022

 A Randomized Trial of Epinephrine in Out-of-Hospital
Cardiac Arrest (2018)
Background Research Question
● Epinephrine in cardiac arrest: increased ● Does administration of epinephrine
diastolic pressure; increased coronary blood improve survival rates compared to
flow placebo in out-of-hospital cardiac
● Conflicting evidence on epinephrine use and arrest?
poor neurologic outcomes

Study Design Outcome Measures

● Randomized, double blind ● Primary outcome: survival rate at 30
● Allocated 1:1 (1 mg epinephrine vs placebo days
0.9% NS)
● Conducted by 5 ambulance services in the ● Secondary outcome: survival to
UK discharge with favorable neurologic
outcome
Perkins G.D. et al. New England Journal of Medicine 2018. doi: 10.1056/NEJMoa1806842
 Modified Rankin Scale for Neurologic Disability
0 No symptoms at all
1 No significant disability despite symptoms- able to carry
out all usual duties
2 Slight disability- unable to carry out all previous
What is it? activities but able to look after own affairs without
assistance
A scale (0-6) that 3 Moderate disability- requiring some help, but able to
measures the degree of walk without assistance
disability in daily activities 4 Moderately severe disability- unable to walk and attend
of individuals who have to bodily needs without assistance
suffered a neurologic 5 Severe disability- bedridden, incontinent and requiring
injury constant nursing care and attention
6 Dead

Broderick, J., et al., AHA. Stroke. 2017.

 Patient Demographics
Patients Baseline Characteristics Initial Cardiac Rhythms
• N= 8,014 • Age: 69.7 epinephrine; • Shockable: 19.2%
• 4,015 epinephrine 69.8 placebo epinephrine vs 18.7%
• 3,999 placebo • Male: ~65% placebo
• Female ~35% • Non-Shockable: 78.4%
epinephrine vs 79.5%
placebo
Cause Witness CPR
• Medical: 91.1% vs 92.3% • Unwitnessed: 37.3% vs • Bystander: 59.3%
• Traumatic: 1.6% vs 1.4% 37.6% vs 58.7%
• Drug overdose: 1.8% vs 1.8%• Bystander: 50.1% vs 49.2% • Paramedic: 11.3%
• Asphyxia: 2.9% vs 2.0% • Paramedic: 11.3% vs 11.8% vs 11.8%

Perkins G.D. et al. New England Journal of Medicine 2018. doi: 10.1056/NEJMoa1806842
 Results and Conclusions
Primary Outcome
Epinephrine Placebo Adjusted Odds
Ratio (95% CI)
30-Day Survival 130/4012 94/3995 1.47 (1.09-1.97)
(3.2%) (2.4%)
Absolute Risk Increase 0.89% (95% CI 0.17-1.61%)

Perkins G.D. et al. New England Journal of Medicine 2018. doi: 10.1056/NEJMoa1806842
 Results and Conclusions
Secondary Outcomes
Epinephrine Placebo Adjusted Odds
Ratio (95% CI)
Survival at 3 121/4009 86/3991 1.47 (1.08-
Months (3.0%) (2.2%) 2.00)

Favorable 82/3986 63/3979 1.39 (0.97-

Neurological (2.1%) (1.6%) 2.01)
Outcome at 3
Months

Perkins G.D. et al. New England Journal of Medicine 2018. doi: 10.1056/NEJMoa1806842
 Results and Conclusions

Modified Rankin Scale (0-6):

0 - No disability, 3 - Moderate disability; requires help but can walk independently, 6 - Death
Perkins G.D. et al. New England Journal of Medicine 2018. doi: 10.1056/NEJMoa1806842
 Literature Summary
Amiodarone vs Lidocaine was associated with better outcomes in patients with
Lidocaine for In- in-hospital cardiac arrest due to VT/VF
Hospital Cardiac
Arrest

Effect of Time to Probability of ROSC decreases as time to administration

Treatment with increases
Antiarrhythmic Drugs
Effect of amiodarone declines with longer time to
administration
Epinephrine vs Pre-hospital use of epinephrine increased rate of survival to 30
Placebo for ROSC days
Did not improve neurological outcomes or decrease ICU length
of stay
Treating Reversible
Causes of Cardiac
Arrest: Hs and Ts
 Non-Shockable Rhythms
Asystole

Pulseless Electrical
Activity (PEA)

American Heart Association. ACLS. 2020.

American Heart Association. 2020.
 H
Hypovolemia Hypoxia Hydrogen Ions Hypo/Hyper- Hypothermia
(acidosis) kalemia

Loss of Deprivation Perform an Check Hypothermic

fluid volume in of adequate arterial blood a potassium patients may
the circulatory oxygen supply gas (ABG) level not respond
system to drug
Ensure the Monitor T- or electrical
Look for patient has an waves therapy
blood loss open airway

Treatment Obtain Oxygenate Sodium Potassium Warm

IV access and Bicarbonate replacement the patient to
administer vs insulin, a core temp of
fluids Prevent fluids, >30° C
respiratory potassium
acidosis by binders,
adequate calcium
ventilation

Learn & Master ACLS/PALS. 2018

 T Toxins Tamponade Tension
Pneumothorax
Thrombosis
of the Heart
Thrombosis
of the Lungs
(MI) (PE)
Accidental or Fluid Air in the pleural Occlusion of Blockage
purposeful accumulation space blood flow of the main
overdose in the within a artery
pericardium Narrow coronary of the lung
QRS complex artery
Narrow QRS and rapid Narrow QRS
complex and heart rate ST- segment complex and
rapid heart rate changes rapid heart
rate

Treatment Support Recommended Recommended Percutaneous Fibrinolytic

circulation & treatment is treatment is coronary Therapy
possibly pericardiocentesis needle intervention
give antidote decompression Mechanical
and/or removal
Contact poison thoracostomy w/
control chest tube

Learn & Master ACLS/PALS. 2018

Patient Case
A 70-year old male is hospitalized after falling and breaking his left
hip. The patient has a past medical history significant for atrial
fibrillation, hypertension, hyperlipidemia, and frequent falls. The
patient's apixaban is on hold due to the need for surgical
intervention of the hip.

Home Medication List:

Lisinopril 20 mg daily
Apixaban 5 mg twice daily
Atorvastatin 40 mg daily
Daily Multivitamin
Patient Case Continued

Approximately 72-hours after the patient was admitted, he started

having severe chest pain and went into pulseless electrical
activity cardiac arrest.

What potential causes of cardiac arrest could be on the differential

for this patient? What is the treatment for the possible cause(s)?
 T Toxins Tamponade Tension
Pneumothorax
Thrombosis
of the Heart
Thrombosis
of the Lungs
(MI) (PE)
Accidental or Fluid Air in the pleural Occlusion of Blockage
purposeful accumulation space blood flow of the main
overdose in the within a artery
pericardium Narrow coronary of the lung
QRS complex artery
Narrow QRS and rapid Narrow QRS
complex and heart rate ST- segment complex and
rapid heart rate changes rapid heart
rate

Treatment Support Recommended Recommended Percutaneous Fibrinolytic

circulation & treatment is treatment is coronary Therapy
possibly pericardiocentesis needle intervention
give antidote decompression Mechanical
and/or removal
Contact poison thoracostomy w/
control chest tube

Learn & Master ACLS/PALS. 2018

 National Poison Control Call Statistics (2021)

T: Toxins
(ingestion)

National Capital Poison Center. 2021.

 Commonly Utilized Drug Antidotes

Acetaminophen Opioids Calcium channel blockers

Acetylcysteine Naloxone Calcium chloride
Calcium gluconate
High-dose insulin

Anticholinergics Beta Blockers Benzodiazepines

Physostigmine Atropine Flumazenil
IV glucagon
Calcium salts

Merck & Co. MSD Manual. 2023.

Flumazenil for Benzodiazepine Overdose
Mechanism of Action
• Competitively inhibits the activity at the benzodiazepine
receptor site on GABA complex
Use is controversial
• Most benzodiazepine overdoses can be treated with
supportive care
• Flumazenil has increased risk of side effects such as
withdrawal seizures and arrhythmias

Flumazenil. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. 2023.
 Summary of a Pharmacist's Role
in Cardiac Arrest
● Prepare and dispense medications

● Prepare bedside IV infusions

● Assist in medication administration/IV pump set up

● Collaborate with the team to ensure appropriate medication use

 Pharmacists' Added
Value to the Team: The
Literature
 Pharmacist Avoidance or Reduction in Medical Costs in Patients Presenting to the
Emergency Department: PHARM-EM Study (2021)
Background Research Question
● The role of pharmacists has shifted from ● How do pharmacists contribute to cost
preparing and dispensing medications to avoidance?
performing direct patient care.

Study Design Outcome Measures

● Multicenter, prospective, observational ● Primary outcome: quantity and type of
study interventions provided and their cost
● Participants were clinical pharmacists avoidance
● Real-time documentation of interventions

Rech MA., et al. Crit. Care Explor. 2021. doi: 10.1097/CCE.0000000000000406.

 Interventions

6 Categories of Interventions Frequent Interventions in This

Study
1. ADE Prevention
2. Resource Utilization 1. Dose adjustments (15.8%)
3. Individualization of Patient Care 2. Initiation of non-antimicrobial
4. Prophylaxis agents (12.2%)
5. Hands-on Care 3. Antimicrobial initiation and
6. Administrative and Supportive streamlining (9.8%)
Tasks 4. Bedside monitoring (8.6%)

Rech MA., et al. Crit. Care Explor. 2021. doi: 10.1097/CCE.0000000000000406.

 Individualization of Patient Care
• Dosage adjustment: continuous renal replacement therapy

• Dosage adjustment: no continuous renal replacement therapy

• Antimicrobial therapy initiation and streamlining

• Anticoagulant therapy management

• Initiation of nonantimicrobial therapy

• Antimicrobial pharmacokinetic evaluation

• Total parenteral nutrition management

Rech MA., et al. Crit. Care Explor. 2021. doi: 10.1097/CCE.0000000000000406.

 Results and Conclusions

88 pharmacists at 45 Performed 14,345

During 917 shifts
centers interventions

Resulting in cost
The annual potential
avoidance to Generated a potential
cost avoidance from
pharmacist salary cost avoidance of
one ED pharmacist
ratio of up $7,531,862
was $251,084.23
to $10.6:1

Rech MA., et al. Crit. Care Explor. 2021. Doi: 10.1097/CCE.0000000000000406.

Cost Avoidance: How
Does This Relate to
Pharmacist Code
Response?
 Interventions

6 Categories of Interventions Most Frequent Interventions in

This Study
1. ADE Prevention
2. Resource Utilization 1. Dose adjustments (15.8%)
3. Individualization of Patient Care 2. Initiation of non-antimicrobial
4. Prophylaxis agents (12.2%)
5. Hands-on Care 3. Antimicrobial initiation and
6. Administrative & Supportive Tasks streamlining (9.8%)
4. Bedside monitoring (8.6%)

Rech MA., et al. Crit. Care Explor. 2021. doi: 10.1097/CCE.0000000000000406.

 Hands-On Care and Cost Avoidance

1. Emergency code blue participation ($481,253)

2. Rapid response team participation ($68,711)
3. Emergency code stroke participation ($233,809)
4. Emergency code sepsis participation ($204,453
5. Emergency procedural sedation or RSI participation ($107,889)

Rech MA., et al. Crit. Care Explor. 2021. doi: 10.1097/CCE.0000000000000406.

 Evaluating Reduction in Medical Costs Associated with Pharmacists' Presence in the
Emergency Department (2023)
Background Research Question
● The role of pharmacists has shifted from ● How do pharmacists contribute to cost
preparing and dispensing medications to avoidance in the Emergency
performing direct patient care. Department?

Study Design Outcome Measures

● Single-center, retrospective, observational ● Primary outcome: total cost avoidance
study ● Secondary outcomes: annual estimate,
● 109-bed ED at urban academic medical per shift, number of interventions
center
● Data was collected through EMR
documentation
Poremba, M., et al. Am J Health Syst Pharm. 2023. doi: 10.1093/ajhp/zxac376
 Results and Conclusions

Interventions Cost Avoidance

● 894 interventions logged during 76 ● Total Cost Avoidance: $143,132
shifts

● Individualization - 284 (31.7%) ● Individualization - $36,507

● ADE prevention - 280 (31.3%) ● ADE prevention - $33,429
● Bedside response - 207 (23.1%) ● Bedside response - $59,773
● Resource utilization - 89 (10%) ● Resource utilization - $13,423

Poremba M., et al. Am J Health Syst Pharm. 2023. doi: 10.1093/ajhp/zxac376

 Results and Conclusions

Interventions Cost Avoidance

● 894 interventions logged during 76 ● Total Cost Avoidance: $143,132
shifts

● Individualization - 284 (31.7%) ● Individualization - $36,507

● ADE prevention - 280 (31.3%) ● ADE prevention - $33,429
● Bedside response - 207 (23.1%) ● Bedside response - $59,773
● Resource utilization - 89 (10%) ● Resource utilization - $13,423

Poremba, M., et al. Am J Health Syst Pharm. 2023. doi: 10.1093/ajhp/zxac376

 Cost Avoidance in Code Response
Broad domain: bedside response
Bedside monitoring 27 (3.0) $2,227 ($573 to $4,593)
Code blue response 5 (0.6) $185 ($60 to $305)
Code blue response + therapy
0 (0) $0
initiation
Medication teaching/discharge
28 (3.1) $22,088
education
Rapid response participation 64 (7.2) $12,672
Rapid sequence intubation 18 (2.0) $3,564
Stroke code participation 61 (6.8) $17,041 ($14,313 to $20,737)
Toxicology consult 4 (0.4) $1,996

Poremba, M., et al. Am J Health Syst Pharm. 2023. doi: 10.1093/ajhp/zxac376

 Secondary Outcomes

1. Annual estimate of cost avoidance per pharmacist:

$401,040
2. Median cost avoidance per shift: $1,671 ($1,025-$2,451)
3. Median number of interventions per shift: 11 (8-16)
240 shifts = full time employee

Poremba, M., et al. Am J Health Syst Pharm. 2023. doi: 10.1093/ajhp/zxac376

Pharmacist Response to
Codes and Improved
Patient Outcomes
 Experience With Integrating Pharmacist Documenters on Cardiac Arrest Teams to
Improve Quality (2018)
Background Research Question
● No previous study has reported impact of ● Does having a pharmacist as a
ACLS protocol deviations to the updated dedicated documenter and
ACLS algorithm pharmacotherapy consultant improve
● Compliance with the algorithm has been ACLS compliance?
reported low across multiple studies

Study Design Outcome Measures

● Retrospective chart review ● Primary outcome: percentage of
completed documents and percent
● 1,541-bed academic medical center adherence to treatment guidelines

● Before-and-after data collection model

Heavner, MS., et al. J Am Pharm Assoc (2003). 2018. doi: 10.1016/[Link].2017.08.003.

 Results
N = 80 cardiac arrest patients
P= 0.024

0% 28%
Complete documentation BEFORE Complete documentation AFTER
intervention of pharmacy intervention of
documenters pharmacy documenters

Heavner, MS., et al.J Am Pharm Assoc (2003). 2018. doi: 10.1016/[Link].2017.08.003.

 Results
N = 80 cardiac arrest patients
P= 0.002

8% 31%
ACLS compliance BEFORE ACLS compliance AFTER
intervention of pharmacotherapy intervention of pharmacotherapy
consultants consultants

Heavner, MS., et al.J Am Pharm Assoc (2003). 2018. doi: 10.1016/[Link].2017.08.003.

Post-Cardiac Arrest
Management: The
Pharmacist's Role
American Heart Association. 2020.
 Pharmacologic Interventions in
Post-Cardiac Arrest Care

TTM
Vasopressors
(pharmacokinetics)

Fluids &
Inotropes
Electrolytes

Treating Hs and Ts Antiepileptics

American Heart Association. 2020.

 Targeted Temperature Management:
Why Do We Do This?

Improve
neurologic
outcomes

Decrease Decrease
Prevent
cerebral cell inflammatory
ischemia
death responses
 What Does the
Literature Say About
Targeted Temperature
Management?
 Hypothermia Versus Normothermia After Out-of-Hospital
Cardiac Arrest (2021)
Background Research Question
● Targeted temperature management is ● Does targeted temperature management
recommended for patients after cardiac lead to decreased mortality and/or better
arrest, but evidence has low certainty. neurologic outcomes?

Study Design Outcome Measures

● Open-label trial ● Primary outcome: death at 6 months
● N=1,850 ● Secondary outcome: functional
● Assigned 1:1 to receive therapeutic outcome at 6 months
hypothermia (33°C) or normothermia
(≤37.5°C)

Dankiewicz, J., et al. N Engl J Med. 2021. doi: 10.1056/NEJMoa2100591.

 Results and Conclusions
Conclusions
1 Therapeutic hypothermia: 33°C
Normothermia: ≤37.5°C
2 Favorable Neurologic Outcome:
modified Rankin score less than 4 at 6
months
mRS (0-6; 0= no disability, 6=death)

Applicability
Targeted temperature management did
not lead to improved outcomes compared
to normothermia with early fever
treatment.
Dankiewicz, J., et al. N Engl J Med. 2021. doi: 10.1056/NEJMoa2100591.
Pharmacy Considerations for
Patients Undergoing Targeted
Temperature Management
 TTM: Electrolyte and Glucose Management

Electrolytes Glucose

• Hypothermia-induced diuresis • These patients have decrease

leads to electrolyte shifts insulin secretion and sensitivity

• Monitor magnesium, • Maintain a goal level of 140-

phosphorus, and potassium 180 mg/dL

• Rewarming has opposite effect

on electrolytes

University of Pennsylvania. UPHS. TTM. Clinical Practice Guidelines

 Literature Summary
Multicenter Study of Pharmacist Pharmacists generated a potential cost
Avoidance or Reduction in Medical avoidance of $7,531,862 with a cost
Costs (2021) avoidance to pharmacist salary ratio of up to
$10.6:1
Single Center Study Evaluating Pharmacists showed an annual estimate of
Reduction in Medical Costs (2023) cost avoidance per pharmacist of over
$401,000; saved ~$1,600 per shift
Pharmacist Documenters on Cardiac Pharmacy documenters and
Arrest Teams to Improve Quality pharmacotherapy consultants on cardiac
(2018) arrest teams improved documentation and
ACLS treatment compliance
Hypothermia Versus Normothermia TTM did not lead to improved outcomes
After Out-of-Hospital Cardiac Arrest compared to normothermia with fever
(2021) treatment
 Summary and Take Away
It is important to
Pharmacists play a recognize a
vital role on the patient's rhythm and
code response team identify treatment
algorithms

Pharmacists add
The pharmacist's
value to the team
role does not end
through drug
when the patient
knowledge and cost
achieves ROSC
avoidance
Pharmacist Participation
in Codes
Kenedie Krout, PharmD
PGY1 Pharmacy Resident
Franciscan Health Indianapolis