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CHAPTER 126: Rheumatology in the ICU 1241

Reporting Unusual or New Drug Interactions: MedWatch is a voluntary • Evans WE, McLeod HL. Drug therapy: pharmacogenomics—drug
program sponsored by the Food and Drug Administration for reporting disposition, drug targets, and side effects. N Engl J Med. 2003;348:538.
adverse events and problems with drugs and other products regulated by
this agency. Although it is not a direct information source, contributed • Krishnan V, Corbridge T, Murray P. Critical care pharmacology.
data collectively provide continuous new drug information. MedWatch is In: Hall JB, Schmidt GA, Wood LDH, eds. Principles of Critical
a major component of the FDA’s postmarketing drug product surveillance Care. 3rd ed. New York: McGraw-Hill; 2005:1547.
and has identified ADRs that were not apparent during preapproval clini- • Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to
cal trials (eg, cardiotoxic effects of astemizole). Reports are encouraged estimate glomerular filtration rate from serum creatinine: a new
even if the practitioner is not certain the product caused the event and prediction equation. Modification of Diet in Renal Disease Study
whether or not all details are available. The program utilizes a consoli- Group. Ann Intern Med. 1999;130:461.
dated reporting form (FDA form 3500), which may be submitted online • Matzke GR, Aronoff GR, Atkinson AJ et al. Drug dosing con-
or facsimile or mail. Reports can also be made over the phone 24 hours sideration in patients with acute and chronic kidney disease-a
a day 7 days a week. For more information or to report quality problems clinical update from Kidney Disease: Improving Global Outcomes
call 1-800-FDA-1088 or visit www.fda.gov/safety/MedWatch/default.htm. (KDIGO). Kidney Int. 2011;80:1122-1137.
Drug Manufacturer Information: The package insert that accompa- • National Institute of Health Pharmacogenetics Research Network’s
nies all products contains FDA-approved information regarding the PharmGKB: The Pharmacogenetics and the Pharmacogenomics
known properties and appropriate use of the drug. Contact infor- Knowledge Base. www.pharmgkb.org. Accessed on Nov 9, 2014.
mation (including toll-free telephone numbers) for pharmaceutical • Nelson DR. Cytochrome P450 Homepage. Hum Genomics.
companies can also generally be found in this insert or other 2009;4(1):59-65.
package labeling or through the hospital drug information center.
Pharmaceutical manufacturing companies usually have drug infor- • Nolin TD, Frye RF, Matzke GR. Hepatic drug metabolism and
mation support services that can provide up-to-date information transport in patients with kidney disease. Am J Kidney Dis.
pertinent to their products. Manufacturers are required to perform 2003;42:906-925.
postmarketing surveillance of their products and to collect informa- • Stevens LA comparative performance of the CKD epidemiology
tion about drug interactions and other ADRs. collaboration (CKD_EPI) and the modification of diet in renal dis-
ease (MDRD) Study equations for estimating GFR above 60ml/min.
Computerized Resources in the ICU: Application of computer technol- Am J Kidney Dis. 2010;56:486.
ogy to medical care can improve efficacy and decrease errors at every
step of drug administration. Computers can serve as a repository for
references. Availability of textbooks, journals, review services, and for- REFERENCES
mularies may be valuable at the time of drug prescription. While avail-
ability of all references by print may be prohibitive, online references Complete references available online at www.mhprofessional.com/hall
are easily accessible, such as Med-line (National Library of Medicine,
United States), MDConsult (LLC Ltd Liability Co., DE), Physician
Drug References, and UptoDate (UptoDate Inc, DE), to name a few.
112
Most institutions in the United States use computers to store patient CHAPTER Rheumatology in the ICU
medical records. A step further in the integration of computer technol-
ogy into medical practice is patient information capture. Real-time 126 Scott Vogelgesang
capture of patient data, such as vital signs, pulse oximetry, and Vijay Raveendran Pottathil
laboratory results, aids in the dissemination of information and more John A. Robinson
informed decisions for drug prescription and drug effect monitoring.
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Therapeutic drug monitoring can be more effectively regulated with
integration of patient data and drug administration. KEY POINTS
Recent advances in handheld devices make all of the aforementioned • Most ICU admissions for rheumatology patients are prompted by
systems even more convenient and portable. Software for handheld infection.
devices, such as Epocrates Rx (Epocrates, Inc., CA) and Medcalc, for
example, allow for quick and convenient references for patient data • New-onset rheumatic diseases rarely prompt ICU admission in the
interpretation. While computer technology continues to advance, the absence of a revealing prodrome.
major barriers to incorporation of these systems into the medical prac- • In most patients without a previously established collagen vascular
tice include the initial costs of the computer devices and software, the disease, suspected vasculitis will be explained by an alternative
time to install the appropriate software, the education and willingness diagnosis.
of health care professionals to use the technology available, and the • Serologic assessment of critically ill patients is a double-edged
real possibility of technical malfunction. Future trends in computer sword providing both enlightenment and misleading shadows. All
technology in the ICU involve expert systems that can simulate human serologic testing must be interpreted with a thorough understand-
judgment to aid in diagnostic and therapeutic decision making, and data ing of the patient’s clinical condition.
mining that can analyze large amounts of data to recognize relationships
that have not been otherwise discovered. • Inability to assign specific diagnostic labels to patients with severe
life-threatening autoimmune or inflammatory disease should not
delay therapeutic intervention.
• Not all ischemic skin lesions that appear to be vasculitis are.
KEY REFERENCES Vasculopathies of various causes should always be part of the
• Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. differential diagnosis.
2005;352:1112-1120. • Empiric trials with corticosteroids can be a rational approach to
• Cox ZL. Adverse drug events during AKI and its recovery. Clin J patient care when such trials are carried out appropriately and
Am Soc Nephrol. 2013;8:1070-1078. infection and malignancy have been excluded.

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