Study objectiveThe objective of this study was to determine the impact of a 24/7 pharmacist (RPh) on time from order to the administration of four‐factor prothrombin concentrate complex (4F‐PCC) in the emergency department (ED).MethodsThis is a retrospective study that included patients who received 4F‐PCC in the ED for acute reversal of oral anticoagulation before and after the implementation of a 24/7 RPh. Patients for whom 4F‐PCC was ordered between May 1, 2014 and June 30, 2015 were in the pre‐RPh group and those between November 1, 2018 and December 31, 2019 were in the post‐RPh group. The primary end point was time from order to administration of 4F‐PCC. Time from arrival to administration of 4F‐PCC was also evaluated.ResultsOf 168 patients evaluated, 100 were included in the study (n = 33 pre‐RPh; n = 67 post‐RPh). The majority of patients were on warfarin (97.0% pre‐RPh and 73.1% post‐RPh) for atrial fibrillation. Both groups included trauma and intracranial hemorrhage patients. The mean time from order to 4F‐PCC administration was significantly shorter in the post‐RPh group (71.2 vs 35.2 minutes, P < .001, 95% confidence interval [CI] [27.013‐44.987]). In addition, the median time from arrival to 4F‐PCC administration was also shorter in the post‐RPh group (153 vs 106 minutes, P = .033).ConclusionsAt our institution, time from order, and from arrival, to administration of 4F‐PCC for reversal of oral anticoagulation in the setting of acute bleeding events in the ED was reduced by 36 minutes after the presence of a 24/7 pharmacist.

Background: Sulfonylurea poisoning can cause sustained hypoglycemia refractory to intravenous dextrose. Traditional treatment for sulfonylurea induced hypoglycemia includes intravenous dextrose and glucagon as well as diazoxide in refractory cases. Octreotide is recommended for sulfonylurea poisoning in adult and pediatric patients with laboratory evidence of hypoglycemia. Clinical Case: An 89 year-old female with chronic kidney disease stage III, hypothyroidism, and diabetes mellitus type II, hypertension who presented with intractable nausea and diarrhea. Patient had been taking cefdinir for an UTI the prior week. On CT scan of the abdomen, colitis was demonstrated. Clostridium Difficile Assay was positive. She was incidentally found to have profound hypoglycemia with a blood glucose level of 30 mg/dL. Patient had hypoglycemia unawareness. Despite receiving 4 ampules of dextrose 50%, glucose level did not significantly improve. In the ED, patient was afebrile and hemodynamically stable. Her labs were significant for a hyponatremia of 125 mmol/L with an acute kidney injury [AKI] (Cr 1.94 mg/dL from 1.5 mg/dL). Patient was placed initially on a dextrose 5% normal saline infusion, but glucose levels continued to decline after brief response. Due to poor IV access, internal jugular central line was placed and patient was placed on D10NS infusion with good glycemic response. Patient had taken sulfonylurea despite not eating appropriately for 2 days. After 24 hours on D10 normal saline infusion, patient was able to maintain normal to slightly hyperglycemic levels with consistent carbohydrate diet. Her nausea and diarrhea had considerably improved after starting vancomycin 125 mg every 6 hours. Sulfonyurea was indefinitely discontinued. Conclusion: Patients presenting with sulfonylurea induced hypoglycemia complicated by poor PO intake, AKI, and infection can be safely treated with supportive measures like proper hydration, and dextrose infusion medication is appropriately metabolized by body without the need for octreotide infusion. References:Glatstein M, Scolnik D, Bentur Y. Octreotide forthe treatment of sulfonylurea poisoning.Clin Toxicol (Phila). 2012 Nov;50(9):795-804. doi:10.3109/15563650.2012.734626. Epub 2012 Oct 10.