Critical Care Pharmacy Specialty Review and Recertification Course

Complex Case:
Complications after Cardiac Surgery – Glucose, Sedation and Thrombocytopenia

Paul M. Szumita, Pharm.D., BCCCP, BCPS, FCCM, FASHP

Clinical Pharmacy Practice Manager
Program Director - PGY2 Critical Care Pharmacy Residency
Brigham and Women’s Hospital
Department of Pharmacy Services l Pharmacy Administration; L-2
75 Francis Street, PBB-A4 l Boston, MA 02115-6110
Mobile: (617) 678-4761 l Facsimile: (617) 566-2396
pszumita@bwh.harvard.edu

Learning Objectives:

At the end of the presentation, the pharmacist should be able to:

• Develop appropriate treatment and monitoring plans for a complex post-cardiac surgery patient
to include pain, agitation and delirium, glucose management, and heparin-induced
thrombocytopenia.
• Explain the impact of critical illness on pre-existing conditions (e.g., endocrine disorders, pain).
• Summarize quality assurance and process improvement methods relevant to critical care.
• Assess the relationship between institutional guideline development and evidence-based critical
care literature.

Premise: You are a critical care clinical pharmacy specialist who practices in a cardiac surgery setting.
You have access to both inpatient and outpatient records through the electronic health system used at
your institution. You are responsible for evaluating and monitoring the patient’s therapy. You are also
responsible for providing comprehensive patient management, including recommendations, monitoring
and follow-up.

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PATIENT CASE

Initials DOB/Age Sex Race/Ethnicity Source

JM 70 y.o. F Caucasian Patient and medical
records

Chief Complaint/History of Present Illness (CC/HPI) (including symptom analysis for CC):

JM is a 70-year-old woman admitted to the cardiac surgery ICU directly from the operating room. She
is still intubated following non-emergent coronary artery bypass graft (CABG) surgery
– 5 days status-post non-STEMI

Past Medical History (major illnesses and surgeries)

Hypertension

Dyslipidemia

CAD s/p non-STEMI in 2009 underwent stent placement; Now s/p non-STEMI 5 days prior-
underwent catheterization revealing LAD lesion

Class II heart failure and angina (slight limitation of physical activity)

DM Type 2

Morbidly obese

Sleep apnea on BiPAP (Bilevel Positive Airway Pressure) therapy

Past Surgical History: no other surgical history

Current medication profile

Metoprolol Succinate 50 mg po daily

Home
Diltiazem ER 180 mg po daily
medications
Irbesartan 150 mg po daily
Aspirin 325 mg po daily
Rosuvastatin 10 mg po at bedtime
Multivitamin 1 capsule po daily
Metformin 1000 mg po twice daily

Drug Allergies/Adverse Effects: NKDA

Family Medical History: Family History: Premature coronary artery disease. Mother with MI.

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Social History of tobacco use. 30 pack-year cigarette smoking history. No cigarette
History use during the past month. married; three children The patient is retired.

Physical Examination Height and weight: 5 feet 2 inches, 100.9 kg

Pre-surgery Vital signs: Temperature: 98.4°F; Heart Rate: 82 bpm; Blood Pressure (right arm) 150/80 mm
Hg

Presentation Questions

Glucose Management
1. JM is a 70-year-old woman admitted to cardiac surgery ICU directly from the operating room,
still intubated following non-emergent coronary artery bypass graft (CABG) surgery.
• On IV propofol 33 mcg/kg/min
• 5 days status-post non-STEMI
• PMH: CAD, DM Type 2, morbidly obese
• Received glucose in the bypass fluid
• Intra-op glucose = 250 mg/dL, therefore IV insulin infusion was initiated.

What are JM’s risk factors for hyperglycemia in the ICU?

a. Preexisting diabetes
b. Stress of surgery
c. Preexisting diabetes and stress of surgery
d. Preexisting diabetes, stress of surgery, and iatrogenic causes (fluids and drugs)

[Domain.Task.Knowledge: 1.1.3; 1.6.1; 1.6.2; 1.6.7; 2.1.2; 2.5.1]

2. According to the 2012 guidelines for the use of insulin infusion for the management of
hyperglycemia in critically ill patients (American College of Critical Care Medicine – ACCM): what
is the suggested glucose that should trigger initiation of insulin therapy?
a. ≥200 mg/dL
b. ≥180 mg/dL
c. ≥ 140 mg/dL
d. ≥ 150 mg/dL

[Domain.Task.Knowledge: 1.4.2]

3. Which statement is true regarding glucose management in the ICU?

a. High glucose variability is associated with decreased mortality.
b. Patients with a preexisting diagnosis of diabetes may benefit from lower glucose goals
compared to patients without diabetes.
c. Patients without a preexisting diagnosis of diabetes may benefit from lower glucose goals
compared to patients with diabetes.
d. IV insulin protocols should not incorporate the “rate of change” in blood glucose and should
adjust based on the absolute value of the current glucose.

[Domain.Task.Knowledge: 1.3.6; 1.4.1; 1.4.2; 1.4.3; 1.7.4; 1.7.7; 1.8.4; 2.1.2]

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 4. You are a clinical pharmacist on ICU rounds, and your patient JM was converted from IV to
subcutaneous insulin yesterday. She receives a long-acting insulin 15 units subcutaneous at
bedtime, rapid-acting insulin subcutaneous 5 units before meals, and low-dose supplemental
subcutaneous insulin before meals. Her most recent fasting pre-meal blood glucose values are:
breakfast 95 mg/dL, lunch 101 mg/dL, and dinner 78 mg/dL. Which of the following do you
recommend based on these measurements?
a. Increase the low-dose supplemental insulin to a medium dose
b. Recommend discontinuing insulin regimen and restart home metformin
c. Reassess the insulin regimen because of the two fasting blood glucose levels < 100 mg/dL
d. Modify the insulin regimen because of the two fasting blood glucose <100 mg/dL

[Domain.Task.Knowledge: 1.1.1; 1.2.6; 1.3.2; 1.3.3; 1.3.4; 1.4.1; 1.4.2; 1.6. 1; 1.7.7; 1.8.4 ]

5. If the average time to target is longer than the published literature, what first step should be
taken to address this issue?
a. Perform a quality assessment analysis to identify needs
b. Convene a team to develop a guideline/protocol
c. Assess potential barriers to change in clinical practices
d. Assess sustainability of change in clinical practices

[Domain.Task.Knowledge: 2.1.2; 2.3.1; 2.3.2; 2.3.3; 2.4.1; 2.5.1]

Pain, Agitation and Delirium

6. Your institution recently implemented a pain-analgesia-delirium guideline based on the most

recent Society of Critical Care Medicine (SCCM) guidelines. What would be the most appropriate
quality assessment analysis?
a. Before and after analysis of compliance with guidelines for assessment of PAD, medication
utilization rates, and duration of mechanical ventilation
b. A propensity matched before and after analysis of compliance with guidelines for
assessment of PAD, medication utilization rates, and duration of mechanical ventilation
c. Before and after analysis of compliance with guidelines for assessment of PAD, medication
utilization rates, and ICU mortality
d. A propensity matched before and after analysis of guidelines for compliance with guidelines
for assessment of PAD, medication utilization rates, and ICU mortality

[Domain.Task.Knowledge: 1.4.2; 2.1.2; 2.3.1; 2.3.2; 2.3.3; 2.4.1; 2.5.1]

7. Which of the following would be the best option for JM based on her assessments [Critical Care
Pain Observational Tool (CPOT) = 5, RASS = +2, CAM-ICU = negative] and the current infusion
rate for IV propofol of 33 mcg/kg/min?
a. Change the propofol to dexmedetomidine with titration to achieve a goal RASS of 0
b. Give quetiapine 50 mg NG every 12 hr to achieve a goal RASS of 0 to -1 and negative CAM-
ICU
c. Give fentanyl 12.5-37.5 mcg as an IV bolus every 20 min prn CPOT >2
d. Increase the propofol infusion rate using a goal RASS of 0 to -1

[Domain.Task.Knowledge: 1.1.1; 1.2.6; 1.3.2; 1.3.3; 1.3.4; 1.4.1; 1.4.2; 1.6. 1; 1.7.7; 1.8.4]

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 8. JM currently is receiving IV norepinephrine 20 mcg/min, vasopressin 0.04 units/min,
epinephrine 5 mg/min, and propofol 75 mcg/kg/min, with fentanyl IV bolus doses prn CPOT >2.
Which of the following would be the best recommendation based on current medication
therapy, hemodynamics and vital signs?
MAP = 66 mm Hg
HR = 91 bpm
CPOT 0, RASS -3, CAM-ICU positive
a. Replace propofol with a dexmedetomidine infusion titrated to achieve a goal RASS of 0 to -1
and negative CAM-ICU
b. Replace propofol with a midazolam infusion titrated to achieve a goal RASS of 0 to -1 and
negative CAM-ICU
c. Titrate down the propofol infusion to achieve a goal RASS of 0 to-1 and negative CAM-ICU
d. Add quetiapine 50 mg NG every 12 hr to achieve a goal of negative CAM-ICU

[Domain.Task.Knowledge: 1.1.1; 1.2.6; 1.3.2; 1.3.3; 1.3.4; 1.4.1; 1.4.2; 1.6. 1; 1.7.7; 1.8.4]

Heparin Induced Thrombocytopenia

9. JM is now POD 3 and with a progressively decreasing platelet count from 210 cells/mm3 on
admission to 72 cells/mm3 on POD 3. She is currently on day 8 of unfractionated heparin (UFH)
exposure. Lab results include: SRA is negative, 4T score is medium and heparin PF4 antibody test
is positive, with no thrombosis detected. The ICU surgical intern asks you about discontinuing
heparin and starting direct thrombin inhibitor infusion (DTI). Along with continued monitoring of
continue platelets, which is the best recommendation for medication management?
a. Initiate DTI therapy and discontinue UFH
b. Do not initiate DTI, and continue UFH
c. Do not initiate DTI, and initiate fondaparinux
d. Initiate DTI and initiate bridge therapy with warfarin

[Domain.Task.Knowledge: 1.1.1; 1.2.6; 1.3.2; 1.3.3; 1.3.4; 1.4.1; 1.4.2; 1.6. 1; 1.7.7; 1.8.4]

10. You’ve noticed that your institution has been spending much more on direct thrombin inhibitors
(DTIs) for the management of heparin-induced thrombocytopenia (HIT) over the past year than
in previous years. You conduct a chart review and determine that most patients with negative
results from heparin/PF4 antibody tests are kept on DTIs for several days post result. Which of
the following practice guideline for patients with suspected HIT would be most appropriate to
create and implement at your institution?
a. A practice guideline recommending earlier transition of patients from DTIs to fondaparinux
based on a consensus among clinical leaders at the institution
b. A practice guideline recommending serial testing heparin/PF4 antibodies in all patients on
heparin based on consensus among clinical leaders at the institution
c. A practice guideline recommending transition from DTI to heparin based results of
heparin/PF4 antibody test results based on consensus among clinical leaders at the
institution
d. A practice guideline recommending continuing heparin in all patients until positive
heparin/PF4 antibody test results are obtained unless the 4T score exceeds 5 based on a
consensus among clinical leaders at the institution

[Domain.Task.Knowledge: 1.4.2]

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References for Further Study

Glucose Management

1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for
Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017; Epub ahead of print Jan 17:1-
67.
2. Jacobi J, Bircher N, Krinsley J et al. Guidelines for the use of an insulin infusion for the
management of hyperglycemia in critically ill patients. Crit Care Med. 2012 Dec; 40(12):3251-76.
3. Moghissi ES, Korytkowski MT, DiNardo M et al. American Association of Clinical Endocrinologists;
American Diabetes Association. American Association of Clinical Endocrinologists and American
Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009 May-
Jun; 15(4):353-69.
4. American Diabetes Association. Diabetes care in the hospital: standards of medical care in
diabetes—2019. Diabetes Care. 2019 Jan; 42(Supplement 1): S173-S181. Available at:
http://care.diabetesjournals.org/content/42/Supplement_1/S173.full-text.pdf (accessed 2019 Jan
3).

Pain, Agitation, Delirium in ICU patient

1. Devlin J, Skrobik Y, Gelinas C et al. Clinical practice guidelines for the management of pain,
agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care
Med. 2018; 46(9):e825-73.
2. Balas MC, Vasilevskis EE, Olsen KM et al. Effectiveness and safety of the awakening and breathing
coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med.
2014 May; 42(5):1024-36.
3. Reade MC1, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med. 2014 Jan 30;
370(5):444-54.

Heparin-Induced Thrombocytopenia

1. Linkins LA, Dans AL, Moores LK et al. Treatment and prevention of heparin-induced
thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9th ed: American
College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb; 141(2
Suppl):e495S-530S.
2. Cuker A, Gimothy PA, Crowther MA et al. Predictive value of the 4Ts scoring system for heparin-
induced thrombocytopenia: a systematic review and meta-analysis. Blood. 2012; 120(20):4160-
7.3. Cuker A, et al. American Society of Hematology 2018 guidelines for management of venous
thromboembolism: heparin-induced thrombocytopenia Blood Adv. 2018 Nov 27;2(22):3360-3392
1. Strutt JK, Mackey JE, Johnson SM et al. Assessment of the 4Ts pretest clinical scoring system as a
predictor of heparin-induced thrombocytopenia. Pharmacotherapy. Feb 2011; 31(2):138-145.
2. Warkentin TE , Linkins LA. Non-necrotizing heparin induced skin lesions and the 4Ts score. J
Thromb Haemost. 2010; 8 ( 7 ): 1483-1485.

Needs Assessment Techniques/Quality Assurance Process Improvement/Institutional Guideline

1. Oxman A, Flottorp S. An overview of strategies to promote implementation of evidence-based

health care. In: Silagy C, Haines A, eds. Evidence-based practice in primary care, 2nd ed. London:
BMJ books; 2001.
2. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of changes in
patients’ care. Lancet. 2003; 362:1225-30.

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3. Speroff T, O’Connor GT. Study designs for PDSA quality improvement research. Qual Manag
Health Care. 2004; 13:17–32.

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Answer Key:
1. D
2. D
3. C
4. C
5. A
6. B
7. C
8. C
9. B
10. C

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