The ICU mortality rate and the 28-day mortality rate in the present study were higher than those reported in the PROWESS study. This difference may be due in part to the higher severity of illness among patients in the current study. The 28-day mortality rate was also higher than the hospital—ICU mortality rate of 45% observed in a previous Canadian study, in which the average APACHE II score was 31 and the mean number of dysfunctional organs was 3.4. Of note, the patients in the earlier Canadian study3 who had failure of 3 or more organs were at increased risk of death (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6-7.0, p = 0.002). The fact that half of the deaths in the current study occurred within 8 h of initiation of DAA suggests that these patients may have been moribund and therefore not suitable for DAA therapy. However, the first organ or system dysfunc­tion had to have developed no more than 48 h before DAA therapy was started, so it is unlikely that DAA was being used as a heroic measure in patients for whom conventional therapy was failing and whose first organ failure had developed many days previously.

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This drug-use evaluation was performed to evaluate the utilization and outcomes associated with DAA in a real-life clinical setting and to compare the results with those reported from clinical trials.

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Twenty-seven patients received DAA in the study period. With reference to the institution’s criteria for utilization, 26 (96%) of the patients who received DAA were eligible for this type of therapy.

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The health records of all patients in the ICU who received DAA from May 2003, when it was first used at this institution, until April 2007 were retrospectively evaluated. Patients who had received DAA were identified by searching the database of medication orders of the hospital’s information system. The health records of patients who had received DAA were reviewed by a pharmacist (Z.K.), and relevant data were collected using a predefined data collection tool. The primary objective was to evaluate the appropriateness of DAA utilization according to the institution’s criteria. …Read the rest of this article

INTRODUCTION

In the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study, mortality at 28 days after initiation of treatment was lower among adult patients with severe sepsis (associated with acute organ dysfunction) who were treated with drotrecogin alfa (activated) (DAA) than among those treated with placebo (absolute risk reduction 6.1%). In that study, the rate of serious bleeding associated with DAA was higher than that associated with placebo, but the difference was not significant (3.5% and 2.0%, p = 0.06); however, the risk of serious bleeding with DAA during clinical use has subsequently been reported to be higher. The cost associated with a 96-h course of treatment with DAA for a 70-kg patient is about $11 000. Given the high cost of the drug, the risk of serious bleeding, and the fact that the greatest benefit of DAA appears to be for patients with a higher risk of death (defined as an …Read the rest of this article

Unlike in Canada, where supplies usually arrive within a day of ordering, the maintenance of a sufficient medication inventory in Afghanistan can be challenging. Most orders take a week or more to arrive from Canada, and unforeseen events such as a broken-down plane or an operational need to ship nonmedical supplies more urgently may cause further delays. The military pharma­cist must occasionally be creative, using connections with counterparts from other countries to meet urgent demands. This may mean researching and providing guidance to the rest of the medical team on appropriate use of medications that are not normally available in Canada. This knowledge is just one reason why the presence of a pharmacist is so highly appreciated by the rest of the staff.

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Operation Athena is the name used for the Canadian Forces’ participation in the International Security Assistance Force in Afghanistan. The Role 3 Multination­al Medical Unit (R3 MMU) is the main medical facility in Afghanistan staffed by Canadians; it services a population of more than 14 000 military and civilian personnel of all nationalities. The medical unit is a multinational opera­tion, and, as such, the hospital staff come from a variety of countries in addition to Canada, including the United States, the United Kingdom, Denmark, the Netherlands, Australia, and New Zealand. Canada supplies one com­plete surgical team (orthopedic, oral maxillofacial, and general surgeons, as well as an anesthetist) and Denmark supplies another. Canada also provides an intensivist, 6 general practice physicians, half of the dental team, a pharmacist, a physiotherapist, and a mental health team (consisting of a psychiatrist, a social worker, and a men­tal health nurse), as well as general duty, operating room, and critical care nurses, medical technicians, laboratory and radiology technicians, and administrative staff.

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