POSITION

The American Society of Health‐System Pharmacists (ASHP) and the Society of Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists (hereinafter, pharmacists), and other health care providers. The emerging model of care allows for deeper professional relationships among health care providers and promotes a shared interest in and responsibility for direct patient care, indirect patient care, and service activities. ASHP and SHM encourage hospitalists, pharmacists, and health care executives to seek out ways to foster collaboration between hospitalists and pharmacists.

The purpose of this consensus statement is to promote an understanding of the ways hospitalists and pharmacists can jointly optimize the care provided to patients in hospitals, examine opportunities for improving hospitalistpharmacist alliances that enhance patient care, suggest future directions for collaboration, and identify aspects of such collaboration that warrant further research.

BACKGROUND

Increases in health care spending and the expanding influence of managed care in the late 1980s and early 1990s resulted in calls for more efficient health care. The movement toward greater efficiency resulted in more emphasis on ambulatory care, fewer hospital admissions, shortened hospital stays, and an overall increase in the acuity of illness of hospitalized patients. The emphasis on ambulatory care increased the number and complexity of physician office visits, and the changing characteristics of office‐ and hospital‐based care placed significant demands on primary care physicians and contributed to the rise of hospital medicine.

In 1996, the term hospitalist was introduced into the health care lexicon.1 A hospitalist was defined as an inpatient physician who manages the care of hospitalized patients and facilitates the transfer of their care back to the primary care physician. The Society of Hospital Medicine has since defined a hospitalist as a physician whose primary professional focus is the general medical care of hospitalized patients and whose activities may include patient care, teaching, research, and leadership related to hospital medicine.2

The past decade has seen rapid growth of the number of hospitalists and the use of hospitalists by US hospitals.3 In 2005, 70% of hospitals with more than 200 beds used hospitalist services, and there were more than 16,000 hospitalists in practice.4 An estimated 20,000 hospitalists were practicing at more than 2600 US hospitals in 2007.5

Initially, many physicians expressed concern about the potential for hospitalists to interfere in the relationship between the patient and the primary care physician, as well as about the potential negative impact on continuity of care.6 However, subsequent studies demonstrated increasing acceptance of hospitalists by primary care physicians, with as many as 89% considering the hospitalist model to be superior to the historical model of hospital care provided by primary care physicians or by specialists working on rotations.7, 8 Numerous studies demonstrate the value of hospitalists in improving quality of care, decreasing hospital costs and length of stay, and reducing hospital readmissions.921

As early as 1921, hospital pharmacists in the American Pharmaceutical Association (now the American Pharmacists Association) had formed a committee to address their distinct concerns. During the 1930s, hospital pharmacists began to organize state organizations and to adhere to a set of minimum standards of practice. In 1942, the American Society of Hospital Pharmacists (now the American Society of Health‐System Pharmacists) was formed to establish minimum standards of pharmaceutical services in hospitals, provide interchange among pharmacists, promote new pharmaceutical techniques, and aid the medical profession in extending the economic and rational use of medications.22 As of 2005, there were approximately 50,000 pharmacists practicing in US hospitals.23

The modern mission of hospital pharmacy departments is to ensure optimal outcomes from the use of medicines.24 Although the focus of hospital pharmacy has traditionally been on the safe dispensing of medications, direct patient care by pharmacists (clinical pharmacy) has always been a component of hospital pharmacy practice. Following the rise of pharmaceutical care in the 1980s,25 these pharmacist services have expanded greatly. It has been estimated that 35%‐40% of hospital pharmacists are devoted to providing clinical services.23 A systematic review in 2006 documented improved outcomes when clinical pharmacists interacted with the health care team on patient rounds, interviewed patients, reconciled medications, and provided discharge counseling and follow‐up.26 These findings support those of other studies in which specific clinical pharmacy services were associated with improved therapeutic and economic outcomes.2731

OPPORTUNITIES FOR COLLABORATION BETWEEN PHARMACISTS AND HOSPITALISTS

Pharmacists and hospitalists have shared interests that provide strong incentives for collaboration. All health care professionals share, first, a commitment to and responsibility for providing safe and effective patient care. Physicians, pharmacists, and other health care providers have long collaborated in providing direct patient care. The emerging hospitalist model of care offers more opportunities for collaboration because pharmacists and hospitalists also share interest in and responsibility for indirect patient care and service activitiesdeveloping the institutional policies, processes, and infrastructure that support patient care.

Direct patient care activities typically performed by hospitalists include obtaining patient histories, conducting physical examinations, making diagnoses, developing treatment plans, monitoring patients' responses to therapy, performing follow‐up hospital visits, participating in family meetings, and providing discharge instructions.32 Specific clinical pharmacy services that have been associated with improved health care outcomes include providing drug information, managing medication protocols and adverse drug reactions, participating in medical rounds, gathering admission medication histories, interviewing patients, reconciling patient medications, and providing discharge counseling and follow‐up.2631

Pharmacists should be involved in the care of hospitalized patients and can collaborate with hospitalists in numerous ways, including:

• Providing consultative services that foster appropriate, evidence‐based medication selection (eg, during rounds),

• Providing drug information to physicians, nurses, and other clinicians,

• Managing medication protocols under collaborative practice agreements,

• Assisting in the development of treatment protocols,

• Monitoring therapeutic responses (including laboratory test results),

• Continuously assessing for and managing adverse drug reactions,

• Gathering medication histories,

• Reconciling medications as patients move across the continuum of hospital care, and

• Providing patient and caretaker education, including discharge counseling and follow‐up.

Both hospitalists and pharmacists have a responsibility to ensure continuity as patients move across settings of care.

In addition to their direct patient care activities, hospitalists add value through their efforts in hospital service activities, student and resident education, and research. Typical service activities include participating in quality‐improvement and safety initiatives, developing institutional guidelines and protocols for the treatment of specific diseases, serving on hospital committees (eg, the pharmacy and therapeutics [P&T] committee), and working with others to introduce new technologies to the hospital setting.33, 34

Pharmacists also participate in hospital service activities, education, and research. For example, pharmacists serve on the P&T committee and are directly involved in managing the formulary system that guides an institution's medication use. As medication experts, pharmacists contribute to the development and implementation of patient care guidelines and other medication‐use policies. Pharmacist expertise is also integral to many quality‐improvement efforts (eg, surgical infection prophylaxis) and to technology initiatives (eg, bedside medication scanning and computerized prescriber‐order‐entry systems). Pharmacist provision of in‐service education on medications and medication use is invaluable for all health care providers.

These overlapping responsibilities provide hospitalists and pharmacists with opportunities to collaborate on activities that can have a profound effect on care in the hospital. Hospitalists and pharmacists can work together to ensure that care is evidence based, cost‐effective, and adherent to national guidelines; establish an institutional culture of safety; develop and implement quality‐improvement initiatives; meet accreditation standards; and, in many cases, foster the institution's education and research initiatives. Health professional education and research offers the opportunity to improve patient care provided not just by a single hospital but by other facilities as well.

OPPORTUNITIES TO IMPROVE COLLABORATION

ASHP and SHM believe that there are opportunities for improving collaboration between hospitalists and pharmacists. Barriers to collaboration include real and perceived professional boundaries, poor integration of technology systems, inadequate pharmacist and hospitalist staffing, time constraints, inadequate funding and resources, lack of third‐party compensation for clinical pharmacy services, and the competing obligations weighing on both professions.

Real and perceived professional boundaries can be addressed by clear communication and by enhanced interdisciplinary educational opportunities for all members of the health care team.3538 ASHP and SHM believe that while hospitalists should serve as the primary leaders of hospital care teams, all health care professionals should be willing to assume a leadership role in treating patients and, when appropriate, accept leadership by other team members. Like all members of the care team, pharmacists require timely access to hospitalists for consultation, as well as access to patient information. The vital flow of information and communication among health care providers should be conducive to collaborating and improving patient outcomes. ASHP and SHM believe that properly applied, well‐integrated technologies (eg, electronic medical records and personal digital assistants with clinical decision support systems, including drug information) can enhance communication among all members of the health care team.

Hospitalists and pharmacists can work together to overcome limitations created by inadequate funding and staffing by providing evidence to health care executives of the value of clinical pharmacist positions and pharmacisthospitalist collaboration. This evidence should examine the impact of these positions and such collaboration on therapeutic, safety, humanistic, and economic outcomes. Collaboration among all members of the health care team would also be encouraged by reforming the current fee‐for‐service reimbursement practices to base payment for care delivery on overall treatment goals (eg, a payment rate based on diagnosis).

CONCLUSIONS

An interdisciplinary approach to health care that includes physicians, pharmacists, nurses, and other health care professionals will improve the quality of patient care. Hospitalists and pharmacists need to collaborate with each other and with other health care professionals to optimize outcomes in hospitalized patients. ASHP and SHM believe that hospitalistpharmacist alliances should be encouraged and that the systems and technologies that enable collaboration and the incentives for such collaboration should be enhanced.

POSITION

The American Society of Health‐System Pharmacists (ASHP) and the Society of Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists (hereinafter, pharmacists), and other health care providers. The emerging model of care allows for deeper professional relationships among health care providers and promotes a shared interest in and responsibility for direct patient care, indirect patient care, and service activities. ASHP and SHM encourage hospitalists, pharmacists, and health care executives to seek out ways to foster collaboration between hospitalists and pharmacists.

The purpose of this consensus statement is to promote an understanding of the ways hospitalists and pharmacists can jointly optimize the care provided to patients in hospitals, examine opportunities for improving hospitalistpharmacist alliances that enhance patient care, suggest future directions for collaboration, and identify aspects of such collaboration that warrant further research.

BACKGROUND

Increases in health care spending and the expanding influence of managed care in the late 1980s and early 1990s resulted in calls for more efficient health care. The movement toward greater efficiency resulted in more emphasis on ambulatory care, fewer hospital admissions, shortened hospital stays, and an overall increase in the acuity of illness of hospitalized patients. The emphasis on ambulatory care increased the number and complexity of physician office visits, and the changing characteristics of office‐ and hospital‐based care placed significant demands on primary care physicians and contributed to the rise of hospital medicine.

In 1996, the term hospitalist was introduced into the health care lexicon.1 A hospitalist was defined as an inpatient physician who manages the care of hospitalized patients and facilitates the transfer of their care back to the primary care physician. The Society of Hospital Medicine has since defined a hospitalist as a physician whose primary professional focus is the general medical care of hospitalized patients and whose activities may include patient care, teaching, research, and leadership related to hospital medicine.2

The past decade has seen rapid growth of the number of hospitalists and the use of hospitalists by US hospitals.3 In 2005, 70% of hospitals with more than 200 beds used hospitalist services, and there were more than 16,000 hospitalists in practice.4 An estimated 20,000 hospitalists were practicing at more than 2600 US hospitals in 2007.5

Initially, many physicians expressed concern about the potential for hospitalists to interfere in the relationship between the patient and the primary care physician, as well as about the potential negative impact on continuity of care.6 However, subsequent studies demonstrated increasing acceptance of hospitalists by primary care physicians, with as many as 89% considering the hospitalist model to be superior to the historical model of hospital care provided by primary care physicians or by specialists working on rotations.7, 8 Numerous studies demonstrate the value of hospitalists in improving quality of care, decreasing hospital costs and length of stay, and reducing hospital readmissions.921

As early as 1921, hospital pharmacists in the American Pharmaceutical Association (now the American Pharmacists Association) had formed a committee to address their distinct concerns. During the 1930s, hospital pharmacists began to organize state organizations and to adhere to a set of minimum standards of practice. In 1942, the American Society of Hospital Pharmacists (now the American Society of Health‐System Pharmacists) was formed to establish minimum standards of pharmaceutical services in hospitals, provide interchange among pharmacists, promote new pharmaceutical techniques, and aid the medical profession in extending the economic and rational use of medications.22 As of 2005, there were approximately 50,000 pharmacists practicing in US hospitals.23

The modern mission of hospital pharmacy departments is to ensure optimal outcomes from the use of medicines.24 Although the focus of hospital pharmacy has traditionally been on the safe dispensing of medications, direct patient care by pharmacists (clinical pharmacy) has always been a component of hospital pharmacy practice. Following the rise of pharmaceutical care in the 1980s,25 these pharmacist services have expanded greatly. It has been estimated that 35%‐40% of hospital pharmacists are devoted to providing clinical services.23 A systematic review in 2006 documented improved outcomes when clinical pharmacists interacted with the health care team on patient rounds, interviewed patients, reconciled medications, and provided discharge counseling and follow‐up.26 These findings support those of other studies in which specific clinical pharmacy services were associated with improved therapeutic and economic outcomes.2731

OPPORTUNITIES FOR COLLABORATION BETWEEN PHARMACISTS AND HOSPITALISTS

Pharmacists and hospitalists have shared interests that provide strong incentives for collaboration. All health care professionals share, first, a commitment to and responsibility for providing safe and effective patient care. Physicians, pharmacists, and other health care providers have long collaborated in providing direct patient care. The emerging hospitalist model of care offers more opportunities for collaboration because pharmacists and hospitalists also share interest in and responsibility for indirect patient care and service activitiesdeveloping the institutional policies, processes, and infrastructure that support patient care.

Direct patient care activities typically performed by hospitalists include obtaining patient histories, conducting physical examinations, making diagnoses, developing treatment plans, monitoring patients' responses to therapy, performing follow‐up hospital visits, participating in family meetings, and providing discharge instructions.32 Specific clinical pharmacy services that have been associated with improved health care outcomes include providing drug information, managing medication protocols and adverse drug reactions, participating in medical rounds, gathering admission medication histories, interviewing patients, reconciling patient medications, and providing discharge counseling and follow‐up.2631

Pharmacists should be involved in the care of hospitalized patients and can collaborate with hospitalists in numerous ways, including:

• Providing consultative services that foster appropriate, evidence‐based medication selection (eg, during rounds),

• Providing drug information to physicians, nurses, and other clinicians,

• Managing medication protocols under collaborative practice agreements,

• Assisting in the development of treatment protocols,

• Monitoring therapeutic responses (including laboratory test results),

• Continuously assessing for and managing adverse drug reactions,

• Gathering medication histories,

• Reconciling medications as patients move across the continuum of hospital care, and

• Providing patient and caretaker education, including discharge counseling and follow‐up.

Both hospitalists and pharmacists have a responsibility to ensure continuity as patients move across settings of care.

In addition to their direct patient care activities, hospitalists add value through their efforts in hospital service activities, student and resident education, and research. Typical service activities include participating in quality‐improvement and safety initiatives, developing institutional guidelines and protocols for the treatment of specific diseases, serving on hospital committees (eg, the pharmacy and therapeutics [P&T] committee), and working with others to introduce new technologies to the hospital setting.33, 34

Pharmacists also participate in hospital service activities, education, and research. For example, pharmacists serve on the P&T committee and are directly involved in managing the formulary system that guides an institution's medication use. As medication experts, pharmacists contribute to the development and implementation of patient care guidelines and other medication‐use policies. Pharmacist expertise is also integral to many quality‐improvement efforts (eg, surgical infection prophylaxis) and to technology initiatives (eg, bedside medication scanning and computerized prescriber‐order‐entry systems). Pharmacist provision of in‐service education on medications and medication use is invaluable for all health care providers.

These overlapping responsibilities provide hospitalists and pharmacists with opportunities to collaborate on activities that can have a profound effect on care in the hospital. Hospitalists and pharmacists can work together to ensure that care is evidence based, cost‐effective, and adherent to national guidelines; establish an institutional culture of safety; develop and implement quality‐improvement initiatives; meet accreditation standards; and, in many cases, foster the institution's education and research initiatives. Health professional education and research offers the opportunity to improve patient care provided not just by a single hospital but by other facilities as well.

OPPORTUNITIES TO IMPROVE COLLABORATION

ASHP and SHM believe that there are opportunities for improving collaboration between hospitalists and pharmacists. Barriers to collaboration include real and perceived professional boundaries, poor integration of technology systems, inadequate pharmacist and hospitalist staffing, time constraints, inadequate funding and resources, lack of third‐party compensation for clinical pharmacy services, and the competing obligations weighing on both professions.

Real and perceived professional boundaries can be addressed by clear communication and by enhanced interdisciplinary educational opportunities for all members of the health care team.3538 ASHP and SHM believe that while hospitalists should serve as the primary leaders of hospital care teams, all health care professionals should be willing to assume a leadership role in treating patients and, when appropriate, accept leadership by other team members. Like all members of the care team, pharmacists require timely access to hospitalists for consultation, as well as access to patient information. The vital flow of information and communication among health care providers should be conducive to collaborating and improving patient outcomes. ASHP and SHM believe that properly applied, well‐integrated technologies (eg, electronic medical records and personal digital assistants with clinical decision support systems, including drug information) can enhance communication among all members of the health care team.

Hospitalists and pharmacists can work together to overcome limitations created by inadequate funding and staffing by providing evidence to health care executives of the value of clinical pharmacist positions and pharmacisthospitalist collaboration. This evidence should examine the impact of these positions and such collaboration on therapeutic, safety, humanistic, and economic outcomes. Collaboration among all members of the health care team would also be encouraged by reforming the current fee‐for‐service reimbursement practices to base payment for care delivery on overall treatment goals (eg, a payment rate based on diagnosis).

CONCLUSIONS

An interdisciplinary approach to health care that includes physicians, pharmacists, nurses, and other health care professionals will improve the quality of patient care. Hospitalists and pharmacists need to collaborate with each other and with other health care professionals to optimize outcomes in hospitalized patients. ASHP and SHM believe that hospitalistpharmacist alliances should be encouraged and that the systems and technologies that enable collaboration and the incentives for such collaboration should be enhanced.

POSITION

The American Society of Health‐System Pharmacists (ASHP) and the Society of Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists (hereinafter, pharmacists), and other health care providers. The emerging model of care allows for deeper professional relationships among health care providers and promotes a shared interest in and responsibility for direct patient care, indirect patient care, and service activities. ASHP and SHM encourage hospitalists, pharmacists, and health care executives to seek out ways to foster collaboration between hospitalists and pharmacists.

The purpose of this consensus statement is to promote an understanding of the ways hospitalists and pharmacists can jointly optimize the care provided to patients in hospitals, examine opportunities for improving hospitalistpharmacist alliances that enhance patient care, suggest future directions for collaboration, and identify aspects of such collaboration that warrant further research.

BACKGROUND

Increases in health care spending and the expanding influence of managed care in the late 1980s and early 1990s resulted in calls for more efficient health care. The movement toward greater efficiency resulted in more emphasis on ambulatory care, fewer hospital admissions, shortened hospital stays, and an overall increase in the acuity of illness of hospitalized patients. The emphasis on ambulatory care increased the number and complexity of physician office visits, and the changing characteristics of office‐ and hospital‐based care placed significant demands on primary care physicians and contributed to the rise of hospital medicine.

In 1996, the term hospitalist was introduced into the health care lexicon.1 A hospitalist was defined as an inpatient physician who manages the care of hospitalized patients and facilitates the transfer of their care back to the primary care physician. The Society of Hospital Medicine has since defined a hospitalist as a physician whose primary professional focus is the general medical care of hospitalized patients and whose activities may include patient care, teaching, research, and leadership related to hospital medicine.2

The past decade has seen rapid growth of the number of hospitalists and the use of hospitalists by US hospitals.3 In 2005, 70% of hospitals with more than 200 beds used hospitalist services, and there were more than 16,000 hospitalists in practice.4 An estimated 20,000 hospitalists were practicing at more than 2600 US hospitals in 2007.5

Initially, many physicians expressed concern about the potential for hospitalists to interfere in the relationship between the patient and the primary care physician, as well as about the potential negative impact on continuity of care.6 However, subsequent studies demonstrated increasing acceptance of hospitalists by primary care physicians, with as many as 89% considering the hospitalist model to be superior to the historical model of hospital care provided by primary care physicians or by specialists working on rotations.7, 8 Numerous studies demonstrate the value of hospitalists in improving quality of care, decreasing hospital costs and length of stay, and reducing hospital readmissions.921

As early as 1921, hospital pharmacists in the American Pharmaceutical Association (now the American Pharmacists Association) had formed a committee to address their distinct concerns. During the 1930s, hospital pharmacists began to organize state organizations and to adhere to a set of minimum standards of practice. In 1942, the American Society of Hospital Pharmacists (now the American Society of Health‐System Pharmacists) was formed to establish minimum standards of pharmaceutical services in hospitals, provide interchange among pharmacists, promote new pharmaceutical techniques, and aid the medical profession in extending the economic and rational use of medications.22 As of 2005, there were approximately 50,000 pharmacists practicing in US hospitals.23

The modern mission of hospital pharmacy departments is to ensure optimal outcomes from the use of medicines.24 Although the focus of hospital pharmacy has traditionally been on the safe dispensing of medications, direct patient care by pharmacists (clinical pharmacy) has always been a component of hospital pharmacy practice. Following the rise of pharmaceutical care in the 1980s,25 these pharmacist services have expanded greatly. It has been estimated that 35%‐40% of hospital pharmacists are devoted to providing clinical services.23 A systematic review in 2006 documented improved outcomes when clinical pharmacists interacted with the health care team on patient rounds, interviewed patients, reconciled medications, and provided discharge counseling and follow‐up.26 These findings support those of other studies in which specific clinical pharmacy services were associated with improved therapeutic and economic outcomes.2731

OPPORTUNITIES FOR COLLABORATION BETWEEN PHARMACISTS AND HOSPITALISTS

Pharmacists and hospitalists have shared interests that provide strong incentives for collaboration. All health care professionals share, first, a commitment to and responsibility for providing safe and effective patient care. Physicians, pharmacists, and other health care providers have long collaborated in providing direct patient care. The emerging hospitalist model of care offers more opportunities for collaboration because pharmacists and hospitalists also share interest in and responsibility for indirect patient care and service activitiesdeveloping the institutional policies, processes, and infrastructure that support patient care.

Direct patient care activities typically performed by hospitalists include obtaining patient histories, conducting physical examinations, making diagnoses, developing treatment plans, monitoring patients' responses to therapy, performing follow‐up hospital visits, participating in family meetings, and providing discharge instructions.32 Specific clinical pharmacy services that have been associated with improved health care outcomes include providing drug information, managing medication protocols and adverse drug reactions, participating in medical rounds, gathering admission medication histories, interviewing patients, reconciling patient medications, and providing discharge counseling and follow‐up.2631

Pharmacists should be involved in the care of hospitalized patients and can collaborate with hospitalists in numerous ways, including:

• Providing consultative services that foster appropriate, evidence‐based medication selection (eg, during rounds),

• Providing drug information to physicians, nurses, and other clinicians,

• Managing medication protocols under collaborative practice agreements,

• Assisting in the development of treatment protocols,

• Monitoring therapeutic responses (including laboratory test results),

• Continuously assessing for and managing adverse drug reactions,

• Gathering medication histories,

• Reconciling medications as patients move across the continuum of hospital care, and

• Providing patient and caretaker education, including discharge counseling and follow‐up.

Both hospitalists and pharmacists have a responsibility to ensure continuity as patients move across settings of care.

In addition to their direct patient care activities, hospitalists add value through their efforts in hospital service activities, student and resident education, and research. Typical service activities include participating in quality‐improvement and safety initiatives, developing institutional guidelines and protocols for the treatment of specific diseases, serving on hospital committees (eg, the pharmacy and therapeutics [P&T] committee), and working with others to introduce new technologies to the hospital setting.33, 34

Pharmacists also participate in hospital service activities, education, and research. For example, pharmacists serve on the P&T committee and are directly involved in managing the formulary system that guides an institution's medication use. As medication experts, pharmacists contribute to the development and implementation of patient care guidelines and other medication‐use policies. Pharmacist expertise is also integral to many quality‐improvement efforts (eg, surgical infection prophylaxis) and to technology initiatives (eg, bedside medication scanning and computerized prescriber‐order‐entry systems). Pharmacist provision of in‐service education on medications and medication use is invaluable for all health care providers.

These overlapping responsibilities provide hospitalists and pharmacists with opportunities to collaborate on activities that can have a profound effect on care in the hospital. Hospitalists and pharmacists can work together to ensure that care is evidence based, cost‐effective, and adherent to national guidelines; establish an institutional culture of safety; develop and implement quality‐improvement initiatives; meet accreditation standards; and, in many cases, foster the institution's education and research initiatives. Health professional education and research offers the opportunity to improve patient care provided not just by a single hospital but by other facilities as well.

OPPORTUNITIES TO IMPROVE COLLABORATION

ASHP and SHM believe that there are opportunities for improving collaboration between hospitalists and pharmacists. Barriers to collaboration include real and perceived professional boundaries, poor integration of technology systems, inadequate pharmacist and hospitalist staffing, time constraints, inadequate funding and resources, lack of third‐party compensation for clinical pharmacy services, and the competing obligations weighing on both professions.

Real and perceived professional boundaries can be addressed by clear communication and by enhanced interdisciplinary educational opportunities for all members of the health care team.3538 ASHP and SHM believe that while hospitalists should serve as the primary leaders of hospital care teams, all health care professionals should be willing to assume a leadership role in treating patients and, when appropriate, accept leadership by other team members. Like all members of the care team, pharmacists require timely access to hospitalists for consultation, as well as access to patient information. The vital flow of information and communication among health care providers should be conducive to collaborating and improving patient outcomes. ASHP and SHM believe that properly applied, well‐integrated technologies (eg, electronic medical records and personal digital assistants with clinical decision support systems, including drug information) can enhance communication among all members of the health care team.

Hospitalists and pharmacists can work together to overcome limitations created by inadequate funding and staffing by providing evidence to health care executives of the value of clinical pharmacist positions and pharmacisthospitalist collaboration. This evidence should examine the impact of these positions and such collaboration on therapeutic, safety, humanistic, and economic outcomes. Collaboration among all members of the health care team would also be encouraged by reforming the current fee‐for‐service reimbursement practices to base payment for care delivery on overall treatment goals (eg, a payment rate based on diagnosis).

CONCLUSIONS

An interdisciplinary approach to health care that includes physicians, pharmacists, nurses, and other health care professionals will improve the quality of patient care. Hospitalists and pharmacists need to collaborate with each other and with other health care professionals to optimize outcomes in hospitalized patients. ASHP and SHM believe that hospitalistpharmacist alliances should be encouraged and that the systems and technologies that enable collaboration and the incentives for such collaboration should be enhanced.

It had been a turbulent year. Death and disease in the family had taken a toll on my personal life. Though I was a newlywed, life was anything but bliss. That month I was the resident in the cardiac intensive care unit (CICU); a challenging rotation, where sleep was a luxury and the long nights on call added to the strain on my relationship with my wife. It was on one of those nights that I met Mr. and Mrs. Dubinski.

Mr. Dubinski was a pleasant man who looked younger than his 75 years. He had been brought to the hospital because his implantable cardioverter defibrillator (ICD) had fired twice that night. He was in good spirits and chatting amiably with his son. I asked him how he was doing. His pleasant expression changed to a worried one. I have been rather upset for the last few days, worried about my wife, he said.

It turned out that over the last few days Mrs. Dubinski had not been feeling well. This had troubled Mr. Dubinski, and he was often preoccupied with concerns about her. The couple had been married 55 years and had never spent a day apart. They had waited to seek medical advice. Her pain was intermittent, and they thought it would pass; they had some appointments coming up, and they thought they could wait it out. That night, Mrs. Dubinski had a particularly severe episode of pain that bothered her greatly and worried Mr. Dubinski even more. He said that he felt as though he was beginning to pass out, and as he began to faint, he felt a funny feeling in his chest. He had never had a shock from the ICD before, and he didn't know what happened. He sat down to compose himself and felt the same funny feeling in his chest again and also felt lightheaded. He described it, saying, I felt like I was going to explode from the inside. Concerned about his unusual symptoms and her worsening pain, Mr. and Mrs. Dubinski decided to come to the hospital.

Mr. Dubinski's electrocardiogram revealed many premature ventricular complexes (PVCs), and I suspected that one of these had triggered a malignant arrhythmia, which resulted in the device firing. He would need monitoring, and his ICD would be interrogated in the morning to ensure that it was functioning properly. I reassured Mr. Dubinski that the device seemed to have done what it was meant to do. It had almost certainly saved his life. He was relieved to hear this but wanted me to reassure his wife that even though he was going to the CICU, he was all right and it was nothing serious.

As I was wheeling Mr. Dubinski up, I walked past the nurse taking care of his wife. She pulled me aside for a moment and said, Looks like you'll be taking her, too; her troponin just came back at 5.96.

Mrs. Dubinski was a thin, older woman who looked uncomfortable. For about a week, she had been experiencing intermittent pain in her chest and abdomen and just felt that something was not right. Tonight her chest pain did not get better spontaneously, and she had a particularly long episode of pain that radiated to her left arm. She said she felt like she was going to explode from the inside. It was uncanny how she used the same words and expressions that her husband did. I suppose after 55 years of marriage, it should not have been surprising to me, but it was. When they had gotten to the emergency room Mrs. Dubinski had told the doctor about her own complaints. He ordered an electrocardiogram, which showed subtle changes consistent with myocardial ischemia. Her lab data confirmed that she was having a heart attack.

Mrs. Dubinski asked me what was going on. I gently explained to her that she was having a small heart attack. The stuttering episodes of chest pain in the past week probably meant that it had been coming on for a few days now. We could see some evidence of heart damage in her blood tests and the subtle changes in her electrocardiogram. I expected her to ask me more questions about the heart attack or what we were going to next. Instead, she said, Please don't tell my husband. It will only worry him more. I reassured her that I understood her concerns and told her that she was also going to be admitted to the CICU. She was fine with this, more worried about her husband than herself. Once in the CICU I kept my word to Mrs. Dubinski and told Mr. Dubinski a partial truththat his wife was being admitted for observation because we were worried about her.

I was genuinely touched by the deep bond between Mr. and Mrs. Dubinski. It amazed me to see that a man's heart could be stimulated by his wife's suffering in such a way that would have taken his life if not for his ICD. One could say that Mr. Dubinski was anxious about his wife's health, which led to an increased sympathetic drive and higher catecholamine levels. But as a young man at the beginning of a relationship with my wife, I thought there was much more here. Tonight, perhaps, because he cared so deeply, a PVC occurred right during the vulnerable period of the cardiac cycle in a person with a vulnerable heart, and a potentially lethal ventricular arrhythmia had ensued. And tonight my heart was also vulnerable, and I was moved. I thought of all the storms they must have weathered in their 55 years together and the love they had forged. It gave me hope for my own fledgling marriage and made me hope that one day my wife and I would be able to look back on many years of life together like Mr. and Mrs. Dubinski could, with 2 hearts beating as 1.

I had the privilege to know this couple for only 1 call night. By the time I was back on the CICU, Mrs. Dubinski had been transferred to another facility for angioplasty, and Mr. Dubinski had been discharged. Yet that was enough time for me to take part in the care of 2 amazing people and to witness the majesty of their love.

Note: Dubinski is a fictitious name.

It had been a turbulent year. Death and disease in the family had taken a toll on my personal life. Though I was a newlywed, life was anything but bliss. That month I was the resident in the cardiac intensive care unit (CICU); a challenging rotation, where sleep was a luxury and the long nights on call added to the strain on my relationship with my wife. It was on one of those nights that I met Mr. and Mrs. Dubinski.

Mr. Dubinski was a pleasant man who looked younger than his 75 years. He had been brought to the hospital because his implantable cardioverter defibrillator (ICD) had fired twice that night. He was in good spirits and chatting amiably with his son. I asked him how he was doing. His pleasant expression changed to a worried one. I have been rather upset for the last few days, worried about my wife, he said.

It turned out that over the last few days Mrs. Dubinski had not been feeling well. This had troubled Mr. Dubinski, and he was often preoccupied with concerns about her. The couple had been married 55 years and had never spent a day apart. They had waited to seek medical advice. Her pain was intermittent, and they thought it would pass; they had some appointments coming up, and they thought they could wait it out. That night, Mrs. Dubinski had a particularly severe episode of pain that bothered her greatly and worried Mr. Dubinski even more. He said that he felt as though he was beginning to pass out, and as he began to faint, he felt a funny feeling in his chest. He had never had a shock from the ICD before, and he didn't know what happened. He sat down to compose himself and felt the same funny feeling in his chest again and also felt lightheaded. He described it, saying, I felt like I was going to explode from the inside. Concerned about his unusual symptoms and her worsening pain, Mr. and Mrs. Dubinski decided to come to the hospital.

Mr. Dubinski's electrocardiogram revealed many premature ventricular complexes (PVCs), and I suspected that one of these had triggered a malignant arrhythmia, which resulted in the device firing. He would need monitoring, and his ICD would be interrogated in the morning to ensure that it was functioning properly. I reassured Mr. Dubinski that the device seemed to have done what it was meant to do. It had almost certainly saved his life. He was relieved to hear this but wanted me to reassure his wife that even though he was going to the CICU, he was all right and it was nothing serious.

As I was wheeling Mr. Dubinski up, I walked past the nurse taking care of his wife. She pulled me aside for a moment and said, Looks like you'll be taking her, too; her troponin just came back at 5.96.

Mrs. Dubinski was a thin, older woman who looked uncomfortable. For about a week, she had been experiencing intermittent pain in her chest and abdomen and just felt that something was not right. Tonight her chest pain did not get better spontaneously, and she had a particularly long episode of pain that radiated to her left arm. She said she felt like she was going to explode from the inside. It was uncanny how she used the same words and expressions that her husband did. I suppose after 55 years of marriage, it should not have been surprising to me, but it was. When they had gotten to the emergency room Mrs. Dubinski had told the doctor about her own complaints. He ordered an electrocardiogram, which showed subtle changes consistent with myocardial ischemia. Her lab data confirmed that she was having a heart attack.

Mrs. Dubinski asked me what was going on. I gently explained to her that she was having a small heart attack. The stuttering episodes of chest pain in the past week probably meant that it had been coming on for a few days now. We could see some evidence of heart damage in her blood tests and the subtle changes in her electrocardiogram. I expected her to ask me more questions about the heart attack or what we were going to next. Instead, she said, Please don't tell my husband. It will only worry him more. I reassured her that I understood her concerns and told her that she was also going to be admitted to the CICU. She was fine with this, more worried about her husband than herself. Once in the CICU I kept my word to Mrs. Dubinski and told Mr. Dubinski a partial truththat his wife was being admitted for observation because we were worried about her.

I was genuinely touched by the deep bond between Mr. and Mrs. Dubinski. It amazed me to see that a man's heart could be stimulated by his wife's suffering in such a way that would have taken his life if not for his ICD. One could say that Mr. Dubinski was anxious about his wife's health, which led to an increased sympathetic drive and higher catecholamine levels. But as a young man at the beginning of a relationship with my wife, I thought there was much more here. Tonight, perhaps, because he cared so deeply, a PVC occurred right during the vulnerable period of the cardiac cycle in a person with a vulnerable heart, and a potentially lethal ventricular arrhythmia had ensued. And tonight my heart was also vulnerable, and I was moved. I thought of all the storms they must have weathered in their 55 years together and the love they had forged. It gave me hope for my own fledgling marriage and made me hope that one day my wife and I would be able to look back on many years of life together like Mr. and Mrs. Dubinski could, with 2 hearts beating as 1.

I had the privilege to know this couple for only 1 call night. By the time I was back on the CICU, Mrs. Dubinski had been transferred to another facility for angioplasty, and Mr. Dubinski had been discharged. Yet that was enough time for me to take part in the care of 2 amazing people and to witness the majesty of their love.

Note: Dubinski is a fictitious name.

It had been a turbulent year. Death and disease in the family had taken a toll on my personal life. Though I was a newlywed, life was anything but bliss. That month I was the resident in the cardiac intensive care unit (CICU); a challenging rotation, where sleep was a luxury and the long nights on call added to the strain on my relationship with my wife. It was on one of those nights that I met Mr. and Mrs. Dubinski.

Mr. Dubinski was a pleasant man who looked younger than his 75 years. He had been brought to the hospital because his implantable cardioverter defibrillator (ICD) had fired twice that night. He was in good spirits and chatting amiably with his son. I asked him how he was doing. His pleasant expression changed to a worried one. I have been rather upset for the last few days, worried about my wife, he said.

It turned out that over the last few days Mrs. Dubinski had not been feeling well. This had troubled Mr. Dubinski, and he was often preoccupied with concerns about her. The couple had been married 55 years and had never spent a day apart. They had waited to seek medical advice. Her pain was intermittent, and they thought it would pass; they had some appointments coming up, and they thought they could wait it out. That night, Mrs. Dubinski had a particularly severe episode of pain that bothered her greatly and worried Mr. Dubinski even more. He said that he felt as though he was beginning to pass out, and as he began to faint, he felt a funny feeling in his chest. He had never had a shock from the ICD before, and he didn't know what happened. He sat down to compose himself and felt the same funny feeling in his chest again and also felt lightheaded. He described it, saying, I felt like I was going to explode from the inside. Concerned about his unusual symptoms and her worsening pain, Mr. and Mrs. Dubinski decided to come to the hospital.

Mr. Dubinski's electrocardiogram revealed many premature ventricular complexes (PVCs), and I suspected that one of these had triggered a malignant arrhythmia, which resulted in the device firing. He would need monitoring, and his ICD would be interrogated in the morning to ensure that it was functioning properly. I reassured Mr. Dubinski that the device seemed to have done what it was meant to do. It had almost certainly saved his life. He was relieved to hear this but wanted me to reassure his wife that even though he was going to the CICU, he was all right and it was nothing serious.

As I was wheeling Mr. Dubinski up, I walked past the nurse taking care of his wife. She pulled me aside for a moment and said, Looks like you'll be taking her, too; her troponin just came back at 5.96.

Mrs. Dubinski was a thin, older woman who looked uncomfortable. For about a week, she had been experiencing intermittent pain in her chest and abdomen and just felt that something was not right. Tonight her chest pain did not get better spontaneously, and she had a particularly long episode of pain that radiated to her left arm. She said she felt like she was going to explode from the inside. It was uncanny how she used the same words and expressions that her husband did. I suppose after 55 years of marriage, it should not have been surprising to me, but it was. When they had gotten to the emergency room Mrs. Dubinski had told the doctor about her own complaints. He ordered an electrocardiogram, which showed subtle changes consistent with myocardial ischemia. Her lab data confirmed that she was having a heart attack.

Mrs. Dubinski asked me what was going on. I gently explained to her that she was having a small heart attack. The stuttering episodes of chest pain in the past week probably meant that it had been coming on for a few days now. We could see some evidence of heart damage in her blood tests and the subtle changes in her electrocardiogram. I expected her to ask me more questions about the heart attack or what we were going to next. Instead, she said, Please don't tell my husband. It will only worry him more. I reassured her that I understood her concerns and told her that she was also going to be admitted to the CICU. She was fine with this, more worried about her husband than herself. Once in the CICU I kept my word to Mrs. Dubinski and told Mr. Dubinski a partial truththat his wife was being admitted for observation because we were worried about her.

I was genuinely touched by the deep bond between Mr. and Mrs. Dubinski. It amazed me to see that a man's heart could be stimulated by his wife's suffering in such a way that would have taken his life if not for his ICD. One could say that Mr. Dubinski was anxious about his wife's health, which led to an increased sympathetic drive and higher catecholamine levels. But as a young man at the beginning of a relationship with my wife, I thought there was much more here. Tonight, perhaps, because he cared so deeply, a PVC occurred right during the vulnerable period of the cardiac cycle in a person with a vulnerable heart, and a potentially lethal ventricular arrhythmia had ensued. And tonight my heart was also vulnerable, and I was moved. I thought of all the storms they must have weathered in their 55 years together and the love they had forged. It gave me hope for my own fledgling marriage and made me hope that one day my wife and I would be able to look back on many years of life together like Mr. and Mrs. Dubinski could, with 2 hearts beating as 1.

I had the privilege to know this couple for only 1 call night. By the time I was back on the CICU, Mrs. Dubinski had been transferred to another facility for angioplasty, and Mr. Dubinski had been discharged. Yet that was enough time for me to take part in the care of 2 amazing people and to witness the majesty of their love.

Note: Dubinski is a fictitious name.

Sedation is commonly administered to hospitalized children.16 An appropriate sedation level is needed to reduce agitation, to facilitate tolerance of invasive therapies, and to prevent invasive devices from being dislodged.16 Age and developmental level can significantly affect the effectiveness of sedation.13 Commonly used medications, such as benzodiazepines and opioids, can adequately sedate children but are difficult to titrate to reach an adequate or consistent level of sedation.13 Sedation of spontaneously breathing children is an even greater challenge because sedation can cause significant and variable respiratory depression and the need for mechanical ventilation.13

Dexmedetomidine (Precedex; Hospira Inc., Lake Forest, IL) is a centrally acting ₂‐adrenergic receptor agonist that provides a titratable level of sedation with little respiratory depression when delivered by continuous infusion.69 Dexmedetomidine is approved by the U.S. Food and Drug Administration for the short‐term (<24‐hour) sedation of critically ill adults in the ICU setting.47 Despite the potential utility of dexmedetomidine in pediatric critical care, only a few published case series have described its use in children,5, 1020 and no published reviews have examined its use in children for longer than 24 hours. Although the elimination half‐life of a single dose of dexmedetomidine is 3 hours, the duration of action following discontinuation of a continuous infusion in children is also unknown.21 Reported side effects in adults of the use of dexmedetomidine include hypotension and bradycardia, but the safety of prolonged infusions in children has not been reported.

In this study, we describe our experience with the use of dexmedetomidine for sedation of children hospitalized in the pediatric ICU. Dexmedetomidine was administered off‐label for a variety of indications and for durations allowed to exceed 24 hours. Our objective was to retrospectively evaluate the efficacy and complication profile of dexmedetomidine in this population.

MATERIALS AND METHODS

This study was approved by the Institutional Review Board at Connecticut Children's Medical Center, and the criteria for informed consent were waived because of its retrospective nature.

Dexmedetomidine was added to the formulary by the Pharmacy and Therapeutics Committee of the study institution in December 2003. Prescribing was restricted to the pediatric intensive care unit (ICU). We retrospectively examined the medical records of all children who received dexmedetomidine for sedation between December 2003 and October 2005. Patients were identified from pharmacy records maintained for quality improvement purposes. The chart abstraction was performed by 2 of the investigators (C.L.C. and D.K.). Audits for uniformity were performed twice during the data abstraction by the principal investigator (C.C.). Dexmedetomidine was administered in all cases without a loading dose. Data were collected regarding hospital course, medications received, amount and duration of dexmedetomidine received, and complications associated with use of dexmedetomidine. During the review period, hemodynamic variables (heart rate, systolic blood pressure, and diastolic blood pressure) were recorded at least hourly for patients receiving dexmedetomidine. Adverse events were defined as occurring during infusion of dexmedetomidine. These events were determined after examination of previous publications describing associated adverse events7, 9, 14 and included abnormalities in hemodynamic parameters (hypotension, hypertension, tachycardia and bradycardia) and respiratory parameters (bradypnea and tachypnea). Values below or above the 5% or 95% normal range for age were considered abnormal. The Pediatric Risk of Mortality (PRISM) III score was used to quantify illness severity on admission to the ICU.22 The effective dose of dexmedetomidine was defined as the dose the patient received for the longest period.

RESULTS

Dexmedetomidine was administered 74 times to 60 children (median age 1.5 years, range 0.117.2 years) during the study period. Most of the patients were male (57%); 53% were white, 23% were Hispanic, 16% were African American, and 8% were designated other. The median PRISM III score was 10 (017). The chronic illness profile and indications for admission are given in Table 1.

We found that dexmedetomidine was administered for 3 major indications: (1) as an additive supplementing ongoing sedation judged to be inadequate by the treating physician, (2) in anticipation of extubation to facilitate weaning of other sedation medications, and (3) in spontaneously breathing, nonintubated children to provide a titratable level of sedation without respiratory depression. Children could have more than 1 indication for using dexmedetomidine.

In 36 cases (49%), dexmedetomidine was administered for more than 24 hours. In all children the median effective dose for maintenance of adequate sedation was 0.7 g/kg per hour (range 0.22.5 g/kg per hour), with a median duration of therapy of 23 hours (range 3451 hours; Figs. 1 and 2). Children who received dexmedetomidine for at most 24 hours had a significantly lower effective dose (median 0.5 g/kg per hour, range 0.22.5 g/kg per hour) than did those who received dexmedetomidine for more than 24 hours (median 1 g/kg per hour, range 0.32 g/kg per hour; P = .006). Comparisons of demographics and outcomes based on duration of infusion are given in Table 2.

Figure 1

Figure 2

In 53% of cases (n = 39), the dexmedetomidine was used to supplement ongoing sedation that was judged inadequate. In these patients the median effective dose was 0.9 g/kg per hour (range 0.252 g/kg per hour), with a median duration of therapy of 66 hours (range 6451 hours). In this group of patients for whom dexmedetomidine was used to supplement ongoing sedation were 4 patients whose dexmedetomidine was stopped because it was perceived as ineffective by the treating physician. In this subset of patients (n = 4), the median maximal dose was 1.5 g/kg per hour (range 0.81.5 g/kg per hour), and the median duration of infusion was 62 hours (range 1098 hours).

In 41% of cases (n = 30), the dexmedetomidine was used in anticipation of extubation in order to facilitate the weaning off other sedative medications. In these patients, the median effective dose was 0.5 g/kg per hour (range 0.22.5 g/kg per hour), with a median duration of therapy of 14 hours (range 353 hours). A comparison of sedative use before and after dexmedetomidine showed a significant reduction in the use of fentanyl infusions (43% vs. 17%; P = .009) and scheduled lorazepam (30% vs. 10%; P = .02). The median time to extubation after stopping the infusion was 0.6 hours. In 7 children, dexmedetomidine was continued following extubation for a median of 19 hours (range 0.8243.5 hours).

In 26% of cases (n = 19), children were extubated and spontaneously breathing when the dexmedetomidine was initiated. Compared with intubated children, the children who were extubated and spontaneously breathing were significantly older (P = .02) and had a higher level of acute illness at admission, as quantified by the PRISM III score (P = .049). There were no significant differences in sex or race (Table 3). The median effective dose, maximum dose, and duration of dexmedetomidine use did not differ between intubated and nonintubated children (Table 3 and Fig. 2).

In most cases (74%), the dexmedetomidine was stopped because the child no longer required sedation. Other indications for stopping the dexmedetomidine were inadequate level of sedation (7%), need for a longer duration of sedation (16%), and response to an adverse effect (3%).

Most children (80%) experienced no adverse effects during the dexmedetomidine infusion. The most common adverse effects identified were hypotension (9% of all cases), hypertension (8% of all cases), and bradycardia (3% of all cases). Only 1 child developed more than 1 complication (bradycardia and hypertension). In 93% of children who experienced one of these adverse effects (n = 14 of 15), it either resolved without treatment (n = 9) or after withholding or decreasing the dose of dexmedetomidine (n = 5). One child received a fluid bolus for hypotension. The incidence of adverse effects did not differ based on indication for therapy, indication for ICU admission, or chronic disease. Children with cardiac disease or undergoing corrective cardiac surgery also did not have an increased incidence of adverse effects (26% vs. 18%; P = .51). The incidence of adverse effects did not increase with increased duration of therapy (Table 2). A comparison of those who experienced a complication and those who did not showed no differences in the maximal dose (0.6 0.2 vs. 0.8 0.4 g/kg per minute; P = .1) or the effective dose (0.6 0.2 vs. 0.8 0.4 g/kg per minute; P = .1) of dexmedetomidine. In those who experienced a complication, the mean dose of dexmedetomidine administered at the time of the complication was 0.7 0.3 g/kg per minute. When comparing the doses of dexmedetomidine administered at the time of complications, there were no difference in dose based on type of complication. However, patients with bradycardia had a somewhat higher dose (0.9 0.4 vs. 0.6 0.3 g/kg per minute; P = .89) than did patients who experienced other complications, although this was not statistically significant.

DISCUSSION

Dexmedetomidine may have a potentially useful role as a titratable, short‐acting sedative in hospitalized children. However, there are little data regarding pediatric dosage, efficacy, or safety. Off‐label usage of medications is common in pediatrics because of the relatively small number of children admitted to the hospital and the difficulties in performing large clinical trials of children. Clinicians in practice rely on small case series, such as this review, to provide useful information about safety, dosage, and potential duration of therapies. This study was performed in an ICU setting. However, the data can potentially be extrapolated to other hospitalized children.

Several authors have described the effectiveness of dexmedetomidine in children for short‐term or procedural sedation.5, 1016 In a prospective study by Berkenbosch et al.,12 48 children received a dexmedetomidine infusion of 0.51 g/kg per hour for noninvasive procedural sedation. In a retrospective review by Chrysostomou et al.,14 38 children received dexmedetomidine infusions of 0.10.75 g/kg per hour following cardiac or thoracic surgery. In a prospective study by Tobias et al.,5 mechanically ventilated children received a dose of 0.250.5 g/kg per hour for up to 24 hours. Dexmedetomidine was an effective sedative in all these pediatric case series.

In our cohort of children, dexmedetomidine appeared to be effective and to have few adverse effects when administered for durations allowed to exceed 24 hours. The drug's properties make it particularly promising for the maintenance of adequate sedation while weaning patients from mechanical ventilation. Unlike benzodiazepines and opioids, dexmedetomidine causes little respiratory depression and so allows for weaning from mechanical ventilation while simultaneously decreasing the dosage of longer‐acting sedative agents. Dexmedetomidine may also be useful as an additive to supplement ongoing sedation in spontaneously breathing children. This pharmacologic profile makes it an attractive sedative agent in the pediatric ICU setting. In this cohort, only a small number of children experienced adverse effects, none of which were associated with increased duration of therapy. Almost all these adverse effects resolved either spontaneously or by holding/lowering the dose of the infusion.

Previous case series in adults and previous case reports in children have suggested that dexmedetomidine may be used safely for longer than 24 hours.4, 8, 9, 1718 In studies by Shehabi et al. and Dasta et al.,89 a total of 66 adults received dexmedetomidine for median durations of 72 hours (range 35168 hours) and 54 hours (range 25124 hours), respectively. In these studies the number of adverse effects did not increased based on the duration of therapy. In the pediatric population, Hammer et al. reported 4 days of sedation of a child following tracheal reconstruction,18 and Finkel et al. described the prolonged use of dexmedetomidine in 2 children to facilitate weaning from opioids following heart transplantation.17 There were no complications reported in these pediatric case reports.

This is the first case series in children to describe the use of dexmedetomidine for longer than 24 hours. In larger adult studies, hypotension and bradycardia were the most common adverse effects noted with the use of dexmedetomidine.7 In a review of 136 adults by Dasta et al., 23% developed hypotension and 4% developed bradycardia.9 Chrysostomou et al. found that 15% of 33 adults admitted to the ICU following cardiac surgery developed hypotension.14 None of these patients became bradycardic.14 This incidence is similar to that found in our review.

This retrospective review had several limitations. Unfortunately, sedation scores were not routinely used in our institution during the period studied, nor were formal guidelines in place for the titration of sedation. These measures would have allowed us to better quantify effectiveness. In addition, these retrospectively collected data may not have accurately captured the adverse effects associated with dexmedetomidine infusions. The population examined was relatively small. Although there was not an increased incidence of adverse effects in certain subgroups (ie, cardiac), there was not a sufficient number of children in this review to definitively demonstrate safety.

In this cohort of children hospitalized in the ICU, dexmedetomidine appeared to be an effective sedative and to have few adverse effects when administered for relatively long durations. This pharmacologic profile makes it a potentially attractive medication in the hospital setting. Prospective studies are needed to critically examine the use of dexmedetomidine in the pediatric population.

Sedation is commonly administered to hospitalized children.16 An appropriate sedation level is needed to reduce agitation, to facilitate tolerance of invasive therapies, and to prevent invasive devices from being dislodged.16 Age and developmental level can significantly affect the effectiveness of sedation.13 Commonly used medications, such as benzodiazepines and opioids, can adequately sedate children but are difficult to titrate to reach an adequate or consistent level of sedation.13 Sedation of spontaneously breathing children is an even greater challenge because sedation can cause significant and variable respiratory depression and the need for mechanical ventilation.13

Dexmedetomidine (Precedex; Hospira Inc., Lake Forest, IL) is a centrally acting ₂‐adrenergic receptor agonist that provides a titratable level of sedation with little respiratory depression when delivered by continuous infusion.69 Dexmedetomidine is approved by the U.S. Food and Drug Administration for the short‐term (<24‐hour) sedation of critically ill adults in the ICU setting.47 Despite the potential utility of dexmedetomidine in pediatric critical care, only a few published case series have described its use in children,5, 1020 and no published reviews have examined its use in children for longer than 24 hours. Although the elimination half‐life of a single dose of dexmedetomidine is 3 hours, the duration of action following discontinuation of a continuous infusion in children is also unknown.21 Reported side effects in adults of the use of dexmedetomidine include hypotension and bradycardia, but the safety of prolonged infusions in children has not been reported.

In this study, we describe our experience with the use of dexmedetomidine for sedation of children hospitalized in the pediatric ICU. Dexmedetomidine was administered off‐label for a variety of indications and for durations allowed to exceed 24 hours. Our objective was to retrospectively evaluate the efficacy and complication profile of dexmedetomidine in this population.

MATERIALS AND METHODS

This study was approved by the Institutional Review Board at Connecticut Children's Medical Center, and the criteria for informed consent were waived because of its retrospective nature.

Dexmedetomidine was added to the formulary by the Pharmacy and Therapeutics Committee of the study institution in December 2003. Prescribing was restricted to the pediatric intensive care unit (ICU). We retrospectively examined the medical records of all children who received dexmedetomidine for sedation between December 2003 and October 2005. Patients were identified from pharmacy records maintained for quality improvement purposes. The chart abstraction was performed by 2 of the investigators (C.L.C. and D.K.). Audits for uniformity were performed twice during the data abstraction by the principal investigator (C.C.). Dexmedetomidine was administered in all cases without a loading dose. Data were collected regarding hospital course, medications received, amount and duration of dexmedetomidine received, and complications associated with use of dexmedetomidine. During the review period, hemodynamic variables (heart rate, systolic blood pressure, and diastolic blood pressure) were recorded at least hourly for patients receiving dexmedetomidine. Adverse events were defined as occurring during infusion of dexmedetomidine. These events were determined after examination of previous publications describing associated adverse events7, 9, 14 and included abnormalities in hemodynamic parameters (hypotension, hypertension, tachycardia and bradycardia) and respiratory parameters (bradypnea and tachypnea). Values below or above the 5% or 95% normal range for age were considered abnormal. The Pediatric Risk of Mortality (PRISM) III score was used to quantify illness severity on admission to the ICU.22 The effective dose of dexmedetomidine was defined as the dose the patient received for the longest period.

RESULTS

Dexmedetomidine was administered 74 times to 60 children (median age 1.5 years, range 0.117.2 years) during the study period. Most of the patients were male (57%); 53% were white, 23% were Hispanic, 16% were African American, and 8% were designated other. The median PRISM III score was 10 (017). The chronic illness profile and indications for admission are given in Table 1.

We found that dexmedetomidine was administered for 3 major indications: (1) as an additive supplementing ongoing sedation judged to be inadequate by the treating physician, (2) in anticipation of extubation to facilitate weaning of other sedation medications, and (3) in spontaneously breathing, nonintubated children to provide a titratable level of sedation without respiratory depression. Children could have more than 1 indication for using dexmedetomidine.

In 36 cases (49%), dexmedetomidine was administered for more than 24 hours. In all children the median effective dose for maintenance of adequate sedation was 0.7 g/kg per hour (range 0.22.5 g/kg per hour), with a median duration of therapy of 23 hours (range 3451 hours; Figs. 1 and 2). Children who received dexmedetomidine for at most 24 hours had a significantly lower effective dose (median 0.5 g/kg per hour, range 0.22.5 g/kg per hour) than did those who received dexmedetomidine for more than 24 hours (median 1 g/kg per hour, range 0.32 g/kg per hour; P = .006). Comparisons of demographics and outcomes based on duration of infusion are given in Table 2.

Figure 1

Figure 2

In 53% of cases (n = 39), the dexmedetomidine was used to supplement ongoing sedation that was judged inadequate. In these patients the median effective dose was 0.9 g/kg per hour (range 0.252 g/kg per hour), with a median duration of therapy of 66 hours (range 6451 hours). In this group of patients for whom dexmedetomidine was used to supplement ongoing sedation were 4 patients whose dexmedetomidine was stopped because it was perceived as ineffective by the treating physician. In this subset of patients (n = 4), the median maximal dose was 1.5 g/kg per hour (range 0.81.5 g/kg per hour), and the median duration of infusion was 62 hours (range 1098 hours).

In 41% of cases (n = 30), the dexmedetomidine was used in anticipation of extubation in order to facilitate the weaning off other sedative medications. In these patients, the median effective dose was 0.5 g/kg per hour (range 0.22.5 g/kg per hour), with a median duration of therapy of 14 hours (range 353 hours). A comparison of sedative use before and after dexmedetomidine showed a significant reduction in the use of fentanyl infusions (43% vs. 17%; P = .009) and scheduled lorazepam (30% vs. 10%; P = .02). The median time to extubation after stopping the infusion was 0.6 hours. In 7 children, dexmedetomidine was continued following extubation for a median of 19 hours (range 0.8243.5 hours).

In 26% of cases (n = 19), children were extubated and spontaneously breathing when the dexmedetomidine was initiated. Compared with intubated children, the children who were extubated and spontaneously breathing were significantly older (P = .02) and had a higher level of acute illness at admission, as quantified by the PRISM III score (P = .049). There were no significant differences in sex or race (Table 3). The median effective dose, maximum dose, and duration of dexmedetomidine use did not differ between intubated and nonintubated children (Table 3 and Fig. 2).

In most cases (74%), the dexmedetomidine was stopped because the child no longer required sedation. Other indications for stopping the dexmedetomidine were inadequate level of sedation (7%), need for a longer duration of sedation (16%), and response to an adverse effect (3%).

Most children (80%) experienced no adverse effects during the dexmedetomidine infusion. The most common adverse effects identified were hypotension (9% of all cases), hypertension (8% of all cases), and bradycardia (3% of all cases). Only 1 child developed more than 1 complication (bradycardia and hypertension). In 93% of children who experienced one of these adverse effects (n = 14 of 15), it either resolved without treatment (n = 9) or after withholding or decreasing the dose of dexmedetomidine (n = 5). One child received a fluid bolus for hypotension. The incidence of adverse effects did not differ based on indication for therapy, indication for ICU admission, or chronic disease. Children with cardiac disease or undergoing corrective cardiac surgery also did not have an increased incidence of adverse effects (26% vs. 18%; P = .51). The incidence of adverse effects did not increase with increased duration of therapy (Table 2). A comparison of those who experienced a complication and those who did not showed no differences in the maximal dose (0.6 0.2 vs. 0.8 0.4 g/kg per minute; P = .1) or the effective dose (0.6 0.2 vs. 0.8 0.4 g/kg per minute; P = .1) of dexmedetomidine. In those who experienced a complication, the mean dose of dexmedetomidine administered at the time of the complication was 0.7 0.3 g/kg per minute. When comparing the doses of dexmedetomidine administered at the time of complications, there were no difference in dose based on type of complication. However, patients with bradycardia had a somewhat higher dose (0.9 0.4 vs. 0.6 0.3 g/kg per minute; P = .89) than did patients who experienced other complications, although this was not statistically significant.

DISCUSSION

Dexmedetomidine may have a potentially useful role as a titratable, short‐acting sedative in hospitalized children. However, there are little data regarding pediatric dosage, efficacy, or safety. Off‐label usage of medications is common in pediatrics because of the relatively small number of children admitted to the hospital and the difficulties in performing large clinical trials of children. Clinicians in practice rely on small case series, such as this review, to provide useful information about safety, dosage, and potential duration of therapies. This study was performed in an ICU setting. However, the data can potentially be extrapolated to other hospitalized children.

Several authors have described the effectiveness of dexmedetomidine in children for short‐term or procedural sedation.5, 1016 In a prospective study by Berkenbosch et al.,12 48 children received a dexmedetomidine infusion of 0.51 g/kg per hour for noninvasive procedural sedation. In a retrospective review by Chrysostomou et al.,14 38 children received dexmedetomidine infusions of 0.10.75 g/kg per hour following cardiac or thoracic surgery. In a prospective study by Tobias et al.,5 mechanically ventilated children received a dose of 0.250.5 g/kg per hour for up to 24 hours. Dexmedetomidine was an effective sedative in all these pediatric case series.

In our cohort of children, dexmedetomidine appeared to be effective and to have few adverse effects when administered for durations allowed to exceed 24 hours. The drug's properties make it particularly promising for the maintenance of adequate sedation while weaning patients from mechanical ventilation. Unlike benzodiazepines and opioids, dexmedetomidine causes little respiratory depression and so allows for weaning from mechanical ventilation while simultaneously decreasing the dosage of longer‐acting sedative agents. Dexmedetomidine may also be useful as an additive to supplement ongoing sedation in spontaneously breathing children. This pharmacologic profile makes it an attractive sedative agent in the pediatric ICU setting. In this cohort, only a small number of children experienced adverse effects, none of which were associated with increased duration of therapy. Almost all these adverse effects resolved either spontaneously or by holding/lowering the dose of the infusion.

Previous case series in adults and previous case reports in children have suggested that dexmedetomidine may be used safely for longer than 24 hours.4, 8, 9, 1718 In studies by Shehabi et al. and Dasta et al.,89 a total of 66 adults received dexmedetomidine for median durations of 72 hours (range 35168 hours) and 54 hours (range 25124 hours), respectively. In these studies the number of adverse effects did not increased based on the duration of therapy. In the pediatric population, Hammer et al. reported 4 days of sedation of a child following tracheal reconstruction,18 and Finkel et al. described the prolonged use of dexmedetomidine in 2 children to facilitate weaning from opioids following heart transplantation.17 There were no complications reported in these pediatric case reports.

This is the first case series in children to describe the use of dexmedetomidine for longer than 24 hours. In larger adult studies, hypotension and bradycardia were the most common adverse effects noted with the use of dexmedetomidine.7 In a review of 136 adults by Dasta et al., 23% developed hypotension and 4% developed bradycardia.9 Chrysostomou et al. found that 15% of 33 adults admitted to the ICU following cardiac surgery developed hypotension.14 None of these patients became bradycardic.14 This incidence is similar to that found in our review.

This retrospective review had several limitations. Unfortunately, sedation scores were not routinely used in our institution during the period studied, nor were formal guidelines in place for the titration of sedation. These measures would have allowed us to better quantify effectiveness. In addition, these retrospectively collected data may not have accurately captured the adverse effects associated with dexmedetomidine infusions. The population examined was relatively small. Although there was not an increased incidence of adverse effects in certain subgroups (ie, cardiac), there was not a sufficient number of children in this review to definitively demonstrate safety.

In this cohort of children hospitalized in the ICU, dexmedetomidine appeared to be an effective sedative and to have few adverse effects when administered for relatively long durations. This pharmacologic profile makes it a potentially attractive medication in the hospital setting. Prospective studies are needed to critically examine the use of dexmedetomidine in the pediatric population.

Sedation is commonly administered to hospitalized children.16 An appropriate sedation level is needed to reduce agitation, to facilitate tolerance of invasive therapies, and to prevent invasive devices from being dislodged.16 Age and developmental level can significantly affect the effectiveness of sedation.13 Commonly used medications, such as benzodiazepines and opioids, can adequately sedate children but are difficult to titrate to reach an adequate or consistent level of sedation.13 Sedation of spontaneously breathing children is an even greater challenge because sedation can cause significant and variable respiratory depression and the need for mechanical ventilation.13

Dexmedetomidine (Precedex; Hospira Inc., Lake Forest, IL) is a centrally acting ₂‐adrenergic receptor agonist that provides a titratable level of sedation with little respiratory depression when delivered by continuous infusion.69 Dexmedetomidine is approved by the U.S. Food and Drug Administration for the short‐term (<24‐hour) sedation of critically ill adults in the ICU setting.47 Despite the potential utility of dexmedetomidine in pediatric critical care, only a few published case series have described its use in children,5, 1020 and no published reviews have examined its use in children for longer than 24 hours. Although the elimination half‐life of a single dose of dexmedetomidine is 3 hours, the duration of action following discontinuation of a continuous infusion in children is also unknown.21 Reported side effects in adults of the use of dexmedetomidine include hypotension and bradycardia, but the safety of prolonged infusions in children has not been reported.

In this study, we describe our experience with the use of dexmedetomidine for sedation of children hospitalized in the pediatric ICU. Dexmedetomidine was administered off‐label for a variety of indications and for durations allowed to exceed 24 hours. Our objective was to retrospectively evaluate the efficacy and complication profile of dexmedetomidine in this population.

MATERIALS AND METHODS

This study was approved by the Institutional Review Board at Connecticut Children's Medical Center, and the criteria for informed consent were waived because of its retrospective nature.

Dexmedetomidine was added to the formulary by the Pharmacy and Therapeutics Committee of the study institution in December 2003. Prescribing was restricted to the pediatric intensive care unit (ICU). We retrospectively examined the medical records of all children who received dexmedetomidine for sedation between December 2003 and October 2005. Patients were identified from pharmacy records maintained for quality improvement purposes. The chart abstraction was performed by 2 of the investigators (C.L.C. and D.K.). Audits for uniformity were performed twice during the data abstraction by the principal investigator (C.C.). Dexmedetomidine was administered in all cases without a loading dose. Data were collected regarding hospital course, medications received, amount and duration of dexmedetomidine received, and complications associated with use of dexmedetomidine. During the review period, hemodynamic variables (heart rate, systolic blood pressure, and diastolic blood pressure) were recorded at least hourly for patients receiving dexmedetomidine. Adverse events were defined as occurring during infusion of dexmedetomidine. These events were determined after examination of previous publications describing associated adverse events7, 9, 14 and included abnormalities in hemodynamic parameters (hypotension, hypertension, tachycardia and bradycardia) and respiratory parameters (bradypnea and tachypnea). Values below or above the 5% or 95% normal range for age were considered abnormal. The Pediatric Risk of Mortality (PRISM) III score was used to quantify illness severity on admission to the ICU.22 The effective dose of dexmedetomidine was defined as the dose the patient received for the longest period.

RESULTS

Dexmedetomidine was administered 74 times to 60 children (median age 1.5 years, range 0.117.2 years) during the study period. Most of the patients were male (57%); 53% were white, 23% were Hispanic, 16% were African American, and 8% were designated other. The median PRISM III score was 10 (017). The chronic illness profile and indications for admission are given in Table 1.

We found that dexmedetomidine was administered for 3 major indications: (1) as an additive supplementing ongoing sedation judged to be inadequate by the treating physician, (2) in anticipation of extubation to facilitate weaning of other sedation medications, and (3) in spontaneously breathing, nonintubated children to provide a titratable level of sedation without respiratory depression. Children could have more than 1 indication for using dexmedetomidine.

In 36 cases (49%), dexmedetomidine was administered for more than 24 hours. In all children the median effective dose for maintenance of adequate sedation was 0.7 g/kg per hour (range 0.22.5 g/kg per hour), with a median duration of therapy of 23 hours (range 3451 hours; Figs. 1 and 2). Children who received dexmedetomidine for at most 24 hours had a significantly lower effective dose (median 0.5 g/kg per hour, range 0.22.5 g/kg per hour) than did those who received dexmedetomidine for more than 24 hours (median 1 g/kg per hour, range 0.32 g/kg per hour; P = .006). Comparisons of demographics and outcomes based on duration of infusion are given in Table 2.

Figure 1

Figure 2

In 53% of cases (n = 39), the dexmedetomidine was used to supplement ongoing sedation that was judged inadequate. In these patients the median effective dose was 0.9 g/kg per hour (range 0.252 g/kg per hour), with a median duration of therapy of 66 hours (range 6451 hours). In this group of patients for whom dexmedetomidine was used to supplement ongoing sedation were 4 patients whose dexmedetomidine was stopped because it was perceived as ineffective by the treating physician. In this subset of patients (n = 4), the median maximal dose was 1.5 g/kg per hour (range 0.81.5 g/kg per hour), and the median duration of infusion was 62 hours (range 1098 hours).

In 41% of cases (n = 30), the dexmedetomidine was used in anticipation of extubation in order to facilitate the weaning off other sedative medications. In these patients, the median effective dose was 0.5 g/kg per hour (range 0.22.5 g/kg per hour), with a median duration of therapy of 14 hours (range 353 hours). A comparison of sedative use before and after dexmedetomidine showed a significant reduction in the use of fentanyl infusions (43% vs. 17%; P = .009) and scheduled lorazepam (30% vs. 10%; P = .02). The median time to extubation after stopping the infusion was 0.6 hours. In 7 children, dexmedetomidine was continued following extubation for a median of 19 hours (range 0.8243.5 hours).

In 26% of cases (n = 19), children were extubated and spontaneously breathing when the dexmedetomidine was initiated. Compared with intubated children, the children who were extubated and spontaneously breathing were significantly older (P = .02) and had a higher level of acute illness at admission, as quantified by the PRISM III score (P = .049). There were no significant differences in sex or race (Table 3). The median effective dose, maximum dose, and duration of dexmedetomidine use did not differ between intubated and nonintubated children (Table 3 and Fig. 2).

In most cases (74%), the dexmedetomidine was stopped because the child no longer required sedation. Other indications for stopping the dexmedetomidine were inadequate level of sedation (7%), need for a longer duration of sedation (16%), and response to an adverse effect (3%).

Most children (80%) experienced no adverse effects during the dexmedetomidine infusion. The most common adverse effects identified were hypotension (9% of all cases), hypertension (8% of all cases), and bradycardia (3% of all cases). Only 1 child developed more than 1 complication (bradycardia and hypertension). In 93% of children who experienced one of these adverse effects (n = 14 of 15), it either resolved without treatment (n = 9) or after withholding or decreasing the dose of dexmedetomidine (n = 5). One child received a fluid bolus for hypotension. The incidence of adverse effects did not differ based on indication for therapy, indication for ICU admission, or chronic disease. Children with cardiac disease or undergoing corrective cardiac surgery also did not have an increased incidence of adverse effects (26% vs. 18%; P = .51). The incidence of adverse effects did not increase with increased duration of therapy (Table 2). A comparison of those who experienced a complication and those who did not showed no differences in the maximal dose (0.6 0.2 vs. 0.8 0.4 g/kg per minute; P = .1) or the effective dose (0.6 0.2 vs. 0.8 0.4 g/kg per minute; P = .1) of dexmedetomidine. In those who experienced a complication, the mean dose of dexmedetomidine administered at the time of the complication was 0.7 0.3 g/kg per minute. When comparing the doses of dexmedetomidine administered at the time of complications, there were no difference in dose based on type of complication. However, patients with bradycardia had a somewhat higher dose (0.9 0.4 vs. 0.6 0.3 g/kg per minute; P = .89) than did patients who experienced other complications, although this was not statistically significant.

DISCUSSION

Dexmedetomidine may have a potentially useful role as a titratable, short‐acting sedative in hospitalized children. However, there are little data regarding pediatric dosage, efficacy, or safety. Off‐label usage of medications is common in pediatrics because of the relatively small number of children admitted to the hospital and the difficulties in performing large clinical trials of children. Clinicians in practice rely on small case series, such as this review, to provide useful information about safety, dosage, and potential duration of therapies. This study was performed in an ICU setting. However, the data can potentially be extrapolated to other hospitalized children.

Several authors have described the effectiveness of dexmedetomidine in children for short‐term or procedural sedation.5, 1016 In a prospective study by Berkenbosch et al.,12 48 children received a dexmedetomidine infusion of 0.51 g/kg per hour for noninvasive procedural sedation. In a retrospective review by Chrysostomou et al.,14 38 children received dexmedetomidine infusions of 0.10.75 g/kg per hour following cardiac or thoracic surgery. In a prospective study by Tobias et al.,5 mechanically ventilated children received a dose of 0.250.5 g/kg per hour for up to 24 hours. Dexmedetomidine was an effective sedative in all these pediatric case series.

In our cohort of children, dexmedetomidine appeared to be effective and to have few adverse effects when administered for durations allowed to exceed 24 hours. The drug's properties make it particularly promising for the maintenance of adequate sedation while weaning patients from mechanical ventilation. Unlike benzodiazepines and opioids, dexmedetomidine causes little respiratory depression and so allows for weaning from mechanical ventilation while simultaneously decreasing the dosage of longer‐acting sedative agents. Dexmedetomidine may also be useful as an additive to supplement ongoing sedation in spontaneously breathing children. This pharmacologic profile makes it an attractive sedative agent in the pediatric ICU setting. In this cohort, only a small number of children experienced adverse effects, none of which were associated with increased duration of therapy. Almost all these adverse effects resolved either spontaneously or by holding/lowering the dose of the infusion.

Previous case series in adults and previous case reports in children have suggested that dexmedetomidine may be used safely for longer than 24 hours.4, 8, 9, 1718 In studies by Shehabi et al. and Dasta et al.,89 a total of 66 adults received dexmedetomidine for median durations of 72 hours (range 35168 hours) and 54 hours (range 25124 hours), respectively. In these studies the number of adverse effects did not increased based on the duration of therapy. In the pediatric population, Hammer et al. reported 4 days of sedation of a child following tracheal reconstruction,18 and Finkel et al. described the prolonged use of dexmedetomidine in 2 children to facilitate weaning from opioids following heart transplantation.17 There were no complications reported in these pediatric case reports.

This is the first case series in children to describe the use of dexmedetomidine for longer than 24 hours. In larger adult studies, hypotension and bradycardia were the most common adverse effects noted with the use of dexmedetomidine.7 In a review of 136 adults by Dasta et al., 23% developed hypotension and 4% developed bradycardia.9 Chrysostomou et al. found that 15% of 33 adults admitted to the ICU following cardiac surgery developed hypotension.14 None of these patients became bradycardic.14 This incidence is similar to that found in our review.

This retrospective review had several limitations. Unfortunately, sedation scores were not routinely used in our institution during the period studied, nor were formal guidelines in place for the titration of sedation. These measures would have allowed us to better quantify effectiveness. In addition, these retrospectively collected data may not have accurately captured the adverse effects associated with dexmedetomidine infusions. The population examined was relatively small. Although there was not an increased incidence of adverse effects in certain subgroups (ie, cardiac), there was not a sufficient number of children in this review to definitively demonstrate safety.

In this cohort of children hospitalized in the ICU, dexmedetomidine appeared to be an effective sedative and to have few adverse effects when administered for relatively long durations. This pharmacologic profile makes it a potentially attractive medication in the hospital setting. Prospective studies are needed to critically examine the use of dexmedetomidine in the pediatric population.

Jaundice is an important clinical entity associated with a wide variety of differential diagnoses for which the prognosis differs depending on etiology. Recently, the etiological spectrum of unselected patients with jaundice has been reported.12 Among patients with cholestatic jaundice, abdominal ultrasound remains the primary investigation in order to distinguish extrahepatic biliary obstruction from intrahepatic disease.

Recent studies of patients with jaundice have included a limited number of patients with jaundice due to biliary obstruction and provided no analysis of the clinical characteristics and prognosis of these patients.12 Moreover, the prognosis of unselected patients with severe obstructive jaundice is unclear nowadays. The most common clinical presentation of malignant obstructive jaundice traditionally has been considered silent jaundice.35 However, the clinical features of malignant versus benign causes of jaundice have not been a focus of interest during the last decades, and it is not clear from the literature what proportion of patients with choledocholithiasis and jaundice present with silent jaundice. Studies on the prognosis of patients with jaundice were published more than 20 years ago, prior to major advances in imaging modalities and endoscopic treatment.614 Thus, we aimed to study the clinical features, etiology, and prognosis of patients presenting with obstructive jaundice in the current era of improved imaging and noninvasive treatment.

MATERIAL AND METHODS

Over a 2‐year period from the beginning of 2003 to the end of 2004, all adult patients with s‐bilirubin of 5.85 mg/dL (100 mol/l; reference value < 25 mol/L) were identified at the clinical laboratory serving the Sahlgrenska University Hospital (Gothenburg, Sweden), which analyzed the serum bilirubin of all patients in Gothenburg. Sahlgrenska University Hospital provides hospital services for all inhabitants of the city and comprises 3 hospitals (Sahlgrenska Hospital, stra Hospital, and Mlndal Hospital) that serve as community hospitals as well as a university hospital. The Gothenburg metropolitan area has 600,000 inhabitants.

The inclusion criteria for the study cohort were s‐bilirubin 100 mol/L at any point during the 2‐year period with evidence of dilated biliary ducts on abdominal ultrasound. A retrospective review of medical records was performed to retrieve information on the presence of abdominal pain associated with jaundice, computerized tomography (CT) and/or magnetic resonance cholangio‐pancreatography (MRCP) testing, and s‐AST, s‐ALT, s‐ALP, and bilirubin levels. The liver tests performed at the time that s‐bilirubin peaked during hospitalization were analyzed. Information about whether abdominal pain was associated with jaundice at the time of admission to the hospital, was obtained from medical records. The etiology of and treatment for the biliary obstruction were noted. Furthermore, the prognosis of the patients was analyzed. If a patient was discharged from the hospital, information about whether the patient was alive at the time of follow‐up was obtained from the Swedish National Registration of Inhabitants; if the patient had died outside the hospital, a death certificate was requested from the Cause of Death Register of the Swedish National Board of Health and Welfare. Patients were followed up in July 2005, providing a follow‐up period ranging from 6 months to 2.5 years.

RESULTS

Causes

The causes of the obstructive jaundice are shown in Table 1. Among the different types of malignancy causing obstructive jaundice, pancreatic cancer and cholangiocarcinoma were the most common, followed by the other malignancies category (Table 1). As shown in Table 2, a wide variety of other malignancies caused cases of biliary obstruction, although most were a result of metastases from gastrointestinal malignancies. Gallstone disease and biliary stricture were the most common benign causes. Less common causes are shown in Table 2. Patients with malignant versus benign obstructive jaundice were similar in age (Table 3). However, only 10 patients (6.5%) with malignant obstructive jaundice (OJ) were less than 50 years old, whereas 23 patients (26%) with benignly caused OJ were under the age of 50. Among the patients with malignancy, patients with pancreatic cancer were significantly older than those with cholangiocarcinoma (P = .04, Table 1). No other major age differences were observed in the etiological groups. Most patients with gallstone disease presenting with jaundice had experienced abdominal pain in association with jaundice, but the jaundice of 9% of the patients was painless (Fig. 1). This was in contrast with patients whose OJ was caused by different types of malignancies, a minority of whom experienced pain at presentation (Fig. 1). Table 3 shows a comparison of patients with a malignant obstruction and those with a benign obstruction. Abdominal pain associated with jaundice was less prevalent at presentation in patients with malignant obstructive jaundice compared with those with nonmalignant obstructive jaundice (34% vs. 71%; P < .0001; Table 3). In 4 patients, the cause of jaundice could not be determined from chart review. Three of these patients presented late in a generally bad condition; ultrasound showed dilated ducts, but these patients died in a few days, before further investigations had been performed (autopsies were not performed), and 1 patient refused further investigations. Thus, an etiological explanation was found for the obstruction of almost all patients.

Table 1.Demographics of Major Diagnostic Groups, Investigations Performed in Each Group, and Treatment and Prognosis

	Pancreatic cancer	Cholangio‐cancer	Other cancers	Papilla cancers	Biliary strictures	Gallstone disease	Other diagnoses	PSC
The results for age and survival in days are shown as medians with interquartile ranges in parentheses. F, female, M, male.
Total number	69	44	36	5	7	57	18	5
Age	73 (6782)	67 (5678)	67 (5975)	79 (7081)	80 (5184)	69 (4983)	72 (5285)	61 (3468)
Sex‐F/M	36/33	27/17	19/17	3/2	4/3	29/28	9/9	2/3
Surgery	10/69	10/44	1/36	3/5	0/7	21/57	4/18	1/5
Alive at follow‐up	3/69 (4.3%)	2/44 (4.5%)	2/36 (5.6%)	1/5 (20%)	6/7 (86%)	46/57 (80.1%)	12/18 (66%)	4/5 (80%)
Survival (days)	142 (58267)	166 (80300)	31 (1873)	257 (130380)	510 (455900)	558 (424665)	412 (103558)	570 (319676)

Table 2.Other Malignancies Causing Both Obstructive Jaundice and Intrahepatic Jaundice Not Classified Elsewhere and Other Causes of Jaundice Not Classified Elsewhere

Type of malignancy	Number of patients	Other cause of OJ not classified elsewhere	Number of patients
Colorectal cancer with liver metastases	9	Cholangitis	4
Liver metastases with unknown primary tumor	9	Papillary adenoma	4
Gastric cancer with liver metastases	5	Unknown cause	4
Small bowel cancer with liver metastases	2	Choledochal injury after cholecystectomy	2
Neuroendocrine tumor with liver metastases	2	Retroperitoneal fibrosis	1
Primary hepatocellular cancer	2	Mirizzis syndrome	1
Esophageal cancer with liver metastases	1	Chronic pancreatitis	1
Renal cancer with liver metastases	1	Duodenal diverticula	1
Lung cancer with liver metastases	1
Tuba uteri cancer with liver metastases	1
Prostate cancer with liver metastases	1
Chronic lymphatic leukemia with liver infiltrates	1
Liver cancer of unknown source	1

Table 3.Demographics, Liver Test Results, Investigations Undertaken, and Treatment of and Prognosis for patients with a Malignant Form of Obstructive Jaundice and a Nonmalignant Cause of Jaundice

	Malignant obstruction	Benign obstruction
The results are shown as medians with interquartile ranges in parentheses. * P < 0.05; P < 0.01; < 0.001. Liver laboratory values are expressed as multiples of the upper limit of normal (medians, with interquartile range in parentheses). The percentage of patients with abdominal pain at presentation is in parentheses. CT, computerized tomography; MRCP, magnetic resonance cholangio‐pancreatography; ERCP, endoscopic retrograde cholangio‐pancreatography; PTC, percutaneous transhepatic cholangiography.
Total number of patients	154	87
Female/male	85/69	44/43
Age	72 (6181)	69 (4983)
Abdominal pain at presentation	53/154 (34%)	62/87 (71%)
AST	3.3 (2.35.1)	3.3 (2.16.4)
ALT	3.1 (26)	4.3 (2.69.1)
ALP	9.9 (4.813.3)	5.9 (3.78.5)
Bilirubin	13.8 (1020)	7.1 (5.79.0)
CT	125/154 (81%)	47/87 (54%)
MRCP	47/154 (30%)	27/87 (31%)
ERCP	108/154 (70%)	67/87 (77%)
PTC	59/154 (38%)	7/87 (8%)
Surgery	24/154 (15.6%)*	26/87 (29.9%)
Alive at follow‐up	8/154 (5.2%)	68/87 (78%)

Figure 1

Prognosis

A total of 165 of the 241 patients (68.5%) died during follow‐up. Mortality was very high among patients with malignant obstructive jaundice, with only 8 of 154 patients (5.2%) alive at the end of follow‐up (Table 3). All these patients had been followed for at least 1 year (mean duration of follow‐up, 535 days). Among those who had survived at least 1 year, 1 patient with cholangiocarcinoma had undergone a liver transplantation, and another 5 patients had been operated on, 3 with pancreatic cancer, 1 with cholangiocarcinoma, 1 with a papilla Vateri cancer, and 1 with carcinoid syndrome with liver metastases. One patient with tuba uteri cancer who had received chemotherapy was also alive. The survival rates of the different etiological groups are shown in Table 1. Of 24 patients undergoing surgery for a malignant condition leading to obstructive jaundice, only 9 (37.5%) survived 1 year. The mortality in the total study group within 3 months of diagnosis was 32% (Table 5). The 3‐month, 6‐month, and 1‐year survival rates for the different etiological groups are given in Table 5. Generally, the patients with benign obstructive jaundice had a good prognosis. A total of 46 of 57 patients (80%) with gallstone disease were alive at the end of follow‐up. Only 3 patients with gallstone disease did not survive for 3 months after jaundice occurred. All these patients were very old, none died while hospitalized for jaundice, and only 1 death could be attributed to gallstone disease (cholangitis and sepsis) 1 month after the initial hospitalization. Figure 2A,B shows the mortality over time among the major etiological groups.

Table 5.Survival for 3, 6, and 12 Months of Patients in the Different Diagnostic Groups

	Pancreatic cancer	Cholangio cancer	Other cancers	Papilla cancer	Biliary strictures	Gallstone disease	Other diagnoses	PSC
Percentages are in parentheses.
3 months' survival	44/69 (63.8%)	32/44 (72.7%)	6/36 (16.7%)	4/5 (80%)	7/7 (100%)	54/57 (95%)	13/16 (81%)	5/5 (100%)
6 months' survival	28/69 (40.6%)	20/44 (45.5%)	5/36 (13.9%)	3/5 (60%)	7/7 (100%)	50/57 (88%)	11/16 (68%)	4/5 (80%)
12 months' survival	10/69 (14.5%)	9/44 (20.5%)	2/36 (5.6%)	2/5 (40%)	7/7 (100%)	47/57 (82%)	14/18 (77%)	4/5 (80%)

Figure 2

DISCUSSION

Our analysis of the causes of jaundice among unselected patients with a bilirubin level 5.85 mg/dL (100 mol/L) revealed that approximately one third of the cases were a result of obstructive jaundice. Studies published more than 20 years ago are available on the etiology and prognosis of these patients, reflecting the diagnostic techniques and hospital practice at that time.69 Furthermore, more recently published studies report the etiological spectrum of patients with obstructive jaundice in Africa and India.1012 In our study population, 154 of 241 patients (64%) had a malignancy, which is remarkably similar to the 61% and 65% of cases of obstructive jaundice due to malignancy reported in studies published more than 25 years ago from Denmark and Spain, respectively.67, 14

The results of the current study demonstrate the poor prognosis of patients with hepatobiliary malignancy that causes obstructive jaundice. The patients whose OJ was caused by a malignancy had a mortality rate of approximately 95% during the study's rather short follow‐up. Previous studies, mostly from the 1980s, found similarly dismal outcomes,1213 suggesting that the prognosis of these patients has not improved during the last 3 decades. Among patients hospitalized for malignant obstructive jaundice in Denmark in the 1970s and the beginning of the 1980s, 1‐year survival was reported to be 11%.14 Thus, unfortunately, the prognosis of patients presenting with jaundice caused by hepatobiliary cancer obstructing the biliary ducts (or due to liver metastases) does not seem to have improved during the last 3 decades. The most common cause of malignant obstructive jaundice in the current study was pancreatic cancer, which is in agreement what was reported in earlier studies.3, 1115 The poor prognosis of patients with pancreatic cancer is well known, but operative mortality is very low nowadays, and some series have reported 5‐year survival rates in the range of 10%30%.1620 The results of the current study suggest that the prognosis for patients with pancreatic cancer presenting with bilirubin 5.85 (100 mL/L) is worse than the 5‐year survival rates reported in recent studies.1620

In the current study patients with cholangiocarcinoma were almost one third of those with malignant obstructive jaundice, which is a higher proportion than that previously reported in series from Australia (9%), India (14%), and Denmark (17%).13, 11, 14 The increased proportion of patients with cholangiocarcinoma might reflect the recent observations of an increased incidence of cholangiocarcinoma in many countries.2122 Similar to the situation of patients with pancreatic cancer, very few patients with cholangiocancer will survive long term,2325 and as in the current study, the prognosis of these patients presenting with severe jaundice seems even worse. Mortality among our patients with malignancies other than pancreatic cancer and cholangiocancer was also very high, with only 5% surviving, mostly because of liver metastases. This is identical to the 1‐year survival of patients with liver metastases presenting with jaundice in Denmark more than 25 years ago.14 Although our patients might not be directly comparable to those seen in Denmark at that time, the results of the current study do suggest that the prognosis of patients with jaundice resulting from liver metastases has not improved over time, despite the considerable advances in diagnostic procedures during the last 2 or 3 decades. One of the limitations of the study besides its retrospective design is potentially excluding patients who were less sick (those with bilirubin levels below that used as an inclusion criterion), affecting survival rates. Other limitations might be defining biliary obstruction based on the results of ultrasound. However, we found very good correlation between ultrasound evidence of dilated biliary ducts and those who had evidence of biliary obstruction on MRCP and ERCP (data not shown).

However, one seemingly large difference between the current study and the Danish study14 is in the prognosis of patients with gallstone disease. The overall 1‐year survival was similar in the 2 studies, but whereas in the Danish study the deaths of 9 of 105 patients (8.6%) was attributed to their gallstone disease, the death of only 1 of the 57 patients (1.8%) in the current study could be attributed to gallstone disease. The reason for this difference is not easily explained but might have been a result of better diagnostic instruments and/or more commonly used ERCP procedures than were previously available.

Although jaundice resulting from a malignancy in the hepatobiliary tract is said to be painless,35 in our study approximately one third of patients with a malignancy experienced pain at presentation. However, our study confirmed that abdominal pain was significantly more often associated with benign conditions. The limitation of the current study was its retrospective nature. However, information about the occurrence of abdominal pain was available in medical records of all patients. Although we could not analyze the character, location, or nature of the abdominal pain, the attending doctor always asked a patient about whether he or she was experiencing abdominal pain.

We can conclude that the severe jaundice of one third of patients was a result of obstructive jaundice. Most of these cases were also a result of a malignancy, with high bilirubin levels indicating prolonged biliary obstruction. Obstructive jaundice caused by a malignancy carried a very poor prognosis, with approximately 95% mortality during a 1‐ to 2‐year follow‐up period. In the absence of methods to cure a significant number of these patients, good methods of palliation are important challenges in the near future.

Jaundice is an important clinical entity associated with a wide variety of differential diagnoses for which the prognosis differs depending on etiology. Recently, the etiological spectrum of unselected patients with jaundice has been reported.12 Among patients with cholestatic jaundice, abdominal ultrasound remains the primary investigation in order to distinguish extrahepatic biliary obstruction from intrahepatic disease.

Recent studies of patients with jaundice have included a limited number of patients with jaundice due to biliary obstruction and provided no analysis of the clinical characteristics and prognosis of these patients.12 Moreover, the prognosis of unselected patients with severe obstructive jaundice is unclear nowadays. The most common clinical presentation of malignant obstructive jaundice traditionally has been considered silent jaundice.35 However, the clinical features of malignant versus benign causes of jaundice have not been a focus of interest during the last decades, and it is not clear from the literature what proportion of patients with choledocholithiasis and jaundice present with silent jaundice. Studies on the prognosis of patients with jaundice were published more than 20 years ago, prior to major advances in imaging modalities and endoscopic treatment.614 Thus, we aimed to study the clinical features, etiology, and prognosis of patients presenting with obstructive jaundice in the current era of improved imaging and noninvasive treatment.

MATERIAL AND METHODS

Over a 2‐year period from the beginning of 2003 to the end of 2004, all adult patients with s‐bilirubin of 5.85 mg/dL (100 mol/l; reference value < 25 mol/L) were identified at the clinical laboratory serving the Sahlgrenska University Hospital (Gothenburg, Sweden), which analyzed the serum bilirubin of all patients in Gothenburg. Sahlgrenska University Hospital provides hospital services for all inhabitants of the city and comprises 3 hospitals (Sahlgrenska Hospital, stra Hospital, and Mlndal Hospital) that serve as community hospitals as well as a university hospital. The Gothenburg metropolitan area has 600,000 inhabitants.

The inclusion criteria for the study cohort were s‐bilirubin 100 mol/L at any point during the 2‐year period with evidence of dilated biliary ducts on abdominal ultrasound. A retrospective review of medical records was performed to retrieve information on the presence of abdominal pain associated with jaundice, computerized tomography (CT) and/or magnetic resonance cholangio‐pancreatography (MRCP) testing, and s‐AST, s‐ALT, s‐ALP, and bilirubin levels. The liver tests performed at the time that s‐bilirubin peaked during hospitalization were analyzed. Information about whether abdominal pain was associated with jaundice at the time of admission to the hospital, was obtained from medical records. The etiology of and treatment for the biliary obstruction were noted. Furthermore, the prognosis of the patients was analyzed. If a patient was discharged from the hospital, information about whether the patient was alive at the time of follow‐up was obtained from the Swedish National Registration of Inhabitants; if the patient had died outside the hospital, a death certificate was requested from the Cause of Death Register of the Swedish National Board of Health and Welfare. Patients were followed up in July 2005, providing a follow‐up period ranging from 6 months to 2.5 years.

RESULTS

Causes

The causes of the obstructive jaundice are shown in Table 1. Among the different types of malignancy causing obstructive jaundice, pancreatic cancer and cholangiocarcinoma were the most common, followed by the other malignancies category (Table 1). As shown in Table 2, a wide variety of other malignancies caused cases of biliary obstruction, although most were a result of metastases from gastrointestinal malignancies. Gallstone disease and biliary stricture were the most common benign causes. Less common causes are shown in Table 2. Patients with malignant versus benign obstructive jaundice were similar in age (Table 3). However, only 10 patients (6.5%) with malignant obstructive jaundice (OJ) were less than 50 years old, whereas 23 patients (26%) with benignly caused OJ were under the age of 50. Among the patients with malignancy, patients with pancreatic cancer were significantly older than those with cholangiocarcinoma (P = .04, Table 1). No other major age differences were observed in the etiological groups. Most patients with gallstone disease presenting with jaundice had experienced abdominal pain in association with jaundice, but the jaundice of 9% of the patients was painless (Fig. 1). This was in contrast with patients whose OJ was caused by different types of malignancies, a minority of whom experienced pain at presentation (Fig. 1). Table 3 shows a comparison of patients with a malignant obstruction and those with a benign obstruction. Abdominal pain associated with jaundice was less prevalent at presentation in patients with malignant obstructive jaundice compared with those with nonmalignant obstructive jaundice (34% vs. 71%; P < .0001; Table 3). In 4 patients, the cause of jaundice could not be determined from chart review. Three of these patients presented late in a generally bad condition; ultrasound showed dilated ducts, but these patients died in a few days, before further investigations had been performed (autopsies were not performed), and 1 patient refused further investigations. Thus, an etiological explanation was found for the obstruction of almost all patients.

Table 1.Demographics of Major Diagnostic Groups, Investigations Performed in Each Group, and Treatment and Prognosis

	Pancreatic cancer	Cholangio‐cancer	Other cancers	Papilla cancers	Biliary strictures	Gallstone disease	Other diagnoses	PSC
The results for age and survival in days are shown as medians with interquartile ranges in parentheses. F, female, M, male.
Total number	69	44	36	5	7	57	18	5
Age	73 (6782)	67 (5678)	67 (5975)	79 (7081)	80 (5184)	69 (4983)	72 (5285)	61 (3468)
Sex‐F/M	36/33	27/17	19/17	3/2	4/3	29/28	9/9	2/3
Surgery	10/69	10/44	1/36	3/5	0/7	21/57	4/18	1/5
Alive at follow‐up	3/69 (4.3%)	2/44 (4.5%)	2/36 (5.6%)	1/5 (20%)	6/7 (86%)	46/57 (80.1%)	12/18 (66%)	4/5 (80%)
Survival (days)	142 (58267)	166 (80300)	31 (1873)	257 (130380)	510 (455900)	558 (424665)	412 (103558)	570 (319676)

Table 2.Other Malignancies Causing Both Obstructive Jaundice and Intrahepatic Jaundice Not Classified Elsewhere and Other Causes of Jaundice Not Classified Elsewhere

Type of malignancy	Number of patients	Other cause of OJ not classified elsewhere	Number of patients
Colorectal cancer with liver metastases	9	Cholangitis	4
Liver metastases with unknown primary tumor	9	Papillary adenoma	4
Gastric cancer with liver metastases	5	Unknown cause	4
Small bowel cancer with liver metastases	2	Choledochal injury after cholecystectomy	2
Neuroendocrine tumor with liver metastases	2	Retroperitoneal fibrosis	1
Primary hepatocellular cancer	2	Mirizzis syndrome	1
Esophageal cancer with liver metastases	1	Chronic pancreatitis	1
Renal cancer with liver metastases	1	Duodenal diverticula	1
Lung cancer with liver metastases	1
Tuba uteri cancer with liver metastases	1
Prostate cancer with liver metastases	1
Chronic lymphatic leukemia with liver infiltrates	1
Liver cancer of unknown source	1

Table 3.Demographics, Liver Test Results, Investigations Undertaken, and Treatment of and Prognosis for patients with a Malignant Form of Obstructive Jaundice and a Nonmalignant Cause of Jaundice

	Malignant obstruction	Benign obstruction
The results are shown as medians with interquartile ranges in parentheses. * P < 0.05; P < 0.01; < 0.001. Liver laboratory values are expressed as multiples of the upper limit of normal (medians, with interquartile range in parentheses). The percentage of patients with abdominal pain at presentation is in parentheses. CT, computerized tomography; MRCP, magnetic resonance cholangio‐pancreatography; ERCP, endoscopic retrograde cholangio‐pancreatography; PTC, percutaneous transhepatic cholangiography.
Total number of patients	154	87
Female/male	85/69	44/43
Age	72 (6181)	69 (4983)
Abdominal pain at presentation	53/154 (34%)	62/87 (71%)
AST	3.3 (2.35.1)	3.3 (2.16.4)
ALT	3.1 (26)	4.3 (2.69.1)
ALP	9.9 (4.813.3)	5.9 (3.78.5)
Bilirubin	13.8 (1020)	7.1 (5.79.0)
CT	125/154 (81%)	47/87 (54%)
MRCP	47/154 (30%)	27/87 (31%)
ERCP	108/154 (70%)	67/87 (77%)
PTC	59/154 (38%)	7/87 (8%)
Surgery	24/154 (15.6%)*	26/87 (29.9%)
Alive at follow‐up	8/154 (5.2%)	68/87 (78%)

Figure 1

Prognosis

A total of 165 of the 241 patients (68.5%) died during follow‐up. Mortality was very high among patients with malignant obstructive jaundice, with only 8 of 154 patients (5.2%) alive at the end of follow‐up (Table 3). All these patients had been followed for at least 1 year (mean duration of follow‐up, 535 days). Among those who had survived at least 1 year, 1 patient with cholangiocarcinoma had undergone a liver transplantation, and another 5 patients had been operated on, 3 with pancreatic cancer, 1 with cholangiocarcinoma, 1 with a papilla Vateri cancer, and 1 with carcinoid syndrome with liver metastases. One patient with tuba uteri cancer who had received chemotherapy was also alive. The survival rates of the different etiological groups are shown in Table 1. Of 24 patients undergoing surgery for a malignant condition leading to obstructive jaundice, only 9 (37.5%) survived 1 year. The mortality in the total study group within 3 months of diagnosis was 32% (Table 5). The 3‐month, 6‐month, and 1‐year survival rates for the different etiological groups are given in Table 5. Generally, the patients with benign obstructive jaundice had a good prognosis. A total of 46 of 57 patients (80%) with gallstone disease were alive at the end of follow‐up. Only 3 patients with gallstone disease did not survive for 3 months after jaundice occurred. All these patients were very old, none died while hospitalized for jaundice, and only 1 death could be attributed to gallstone disease (cholangitis and sepsis) 1 month after the initial hospitalization. Figure 2A,B shows the mortality over time among the major etiological groups.

Table 5.Survival for 3, 6, and 12 Months of Patients in the Different Diagnostic Groups

	Pancreatic cancer	Cholangio cancer	Other cancers	Papilla cancer	Biliary strictures	Gallstone disease	Other diagnoses	PSC
Percentages are in parentheses.
3 months' survival	44/69 (63.8%)	32/44 (72.7%)	6/36 (16.7%)	4/5 (80%)	7/7 (100%)	54/57 (95%)	13/16 (81%)	5/5 (100%)
6 months' survival	28/69 (40.6%)	20/44 (45.5%)	5/36 (13.9%)	3/5 (60%)	7/7 (100%)	50/57 (88%)	11/16 (68%)	4/5 (80%)
12 months' survival	10/69 (14.5%)	9/44 (20.5%)	2/36 (5.6%)	2/5 (40%)	7/7 (100%)	47/57 (82%)	14/18 (77%)	4/5 (80%)

Figure 2

DISCUSSION

Our analysis of the causes of jaundice among unselected patients with a bilirubin level 5.85 mg/dL (100 mol/L) revealed that approximately one third of the cases were a result of obstructive jaundice. Studies published more than 20 years ago are available on the etiology and prognosis of these patients, reflecting the diagnostic techniques and hospital practice at that time.69 Furthermore, more recently published studies report the etiological spectrum of patients with obstructive jaundice in Africa and India.1012 In our study population, 154 of 241 patients (64%) had a malignancy, which is remarkably similar to the 61% and 65% of cases of obstructive jaundice due to malignancy reported in studies published more than 25 years ago from Denmark and Spain, respectively.67, 14

The results of the current study demonstrate the poor prognosis of patients with hepatobiliary malignancy that causes obstructive jaundice. The patients whose OJ was caused by a malignancy had a mortality rate of approximately 95% during the study's rather short follow‐up. Previous studies, mostly from the 1980s, found similarly dismal outcomes,1213 suggesting that the prognosis of these patients has not improved during the last 3 decades. Among patients hospitalized for malignant obstructive jaundice in Denmark in the 1970s and the beginning of the 1980s, 1‐year survival was reported to be 11%.14 Thus, unfortunately, the prognosis of patients presenting with jaundice caused by hepatobiliary cancer obstructing the biliary ducts (or due to liver metastases) does not seem to have improved during the last 3 decades. The most common cause of malignant obstructive jaundice in the current study was pancreatic cancer, which is in agreement what was reported in earlier studies.3, 1115 The poor prognosis of patients with pancreatic cancer is well known, but operative mortality is very low nowadays, and some series have reported 5‐year survival rates in the range of 10%30%.1620 The results of the current study suggest that the prognosis for patients with pancreatic cancer presenting with bilirubin 5.85 (100 mL/L) is worse than the 5‐year survival rates reported in recent studies.1620

In the current study patients with cholangiocarcinoma were almost one third of those with malignant obstructive jaundice, which is a higher proportion than that previously reported in series from Australia (9%), India (14%), and Denmark (17%).13, 11, 14 The increased proportion of patients with cholangiocarcinoma might reflect the recent observations of an increased incidence of cholangiocarcinoma in many countries.2122 Similar to the situation of patients with pancreatic cancer, very few patients with cholangiocancer will survive long term,2325 and as in the current study, the prognosis of these patients presenting with severe jaundice seems even worse. Mortality among our patients with malignancies other than pancreatic cancer and cholangiocancer was also very high, with only 5% surviving, mostly because of liver metastases. This is identical to the 1‐year survival of patients with liver metastases presenting with jaundice in Denmark more than 25 years ago.14 Although our patients might not be directly comparable to those seen in Denmark at that time, the results of the current study do suggest that the prognosis of patients with jaundice resulting from liver metastases has not improved over time, despite the considerable advances in diagnostic procedures during the last 2 or 3 decades. One of the limitations of the study besides its retrospective design is potentially excluding patients who were less sick (those with bilirubin levels below that used as an inclusion criterion), affecting survival rates. Other limitations might be defining biliary obstruction based on the results of ultrasound. However, we found very good correlation between ultrasound evidence of dilated biliary ducts and those who had evidence of biliary obstruction on MRCP and ERCP (data not shown).

However, one seemingly large difference between the current study and the Danish study14 is in the prognosis of patients with gallstone disease. The overall 1‐year survival was similar in the 2 studies, but whereas in the Danish study the deaths of 9 of 105 patients (8.6%) was attributed to their gallstone disease, the death of only 1 of the 57 patients (1.8%) in the current study could be attributed to gallstone disease. The reason for this difference is not easily explained but might have been a result of better diagnostic instruments and/or more commonly used ERCP procedures than were previously available.

Although jaundice resulting from a malignancy in the hepatobiliary tract is said to be painless,35 in our study approximately one third of patients with a malignancy experienced pain at presentation. However, our study confirmed that abdominal pain was significantly more often associated with benign conditions. The limitation of the current study was its retrospective nature. However, information about the occurrence of abdominal pain was available in medical records of all patients. Although we could not analyze the character, location, or nature of the abdominal pain, the attending doctor always asked a patient about whether he or she was experiencing abdominal pain.

We can conclude that the severe jaundice of one third of patients was a result of obstructive jaundice. Most of these cases were also a result of a malignancy, with high bilirubin levels indicating prolonged biliary obstruction. Obstructive jaundice caused by a malignancy carried a very poor prognosis, with approximately 95% mortality during a 1‐ to 2‐year follow‐up period. In the absence of methods to cure a significant number of these patients, good methods of palliation are important challenges in the near future.

Jaundice is an important clinical entity associated with a wide variety of differential diagnoses for which the prognosis differs depending on etiology. Recently, the etiological spectrum of unselected patients with jaundice has been reported.12 Among patients with cholestatic jaundice, abdominal ultrasound remains the primary investigation in order to distinguish extrahepatic biliary obstruction from intrahepatic disease.

Recent studies of patients with jaundice have included a limited number of patients with jaundice due to biliary obstruction and provided no analysis of the clinical characteristics and prognosis of these patients.12 Moreover, the prognosis of unselected patients with severe obstructive jaundice is unclear nowadays. The most common clinical presentation of malignant obstructive jaundice traditionally has been considered silent jaundice.35 However, the clinical features of malignant versus benign causes of jaundice have not been a focus of interest during the last decades, and it is not clear from the literature what proportion of patients with choledocholithiasis and jaundice present with silent jaundice. Studies on the prognosis of patients with jaundice were published more than 20 years ago, prior to major advances in imaging modalities and endoscopic treatment.614 Thus, we aimed to study the clinical features, etiology, and prognosis of patients presenting with obstructive jaundice in the current era of improved imaging and noninvasive treatment.

MATERIAL AND METHODS

Over a 2‐year period from the beginning of 2003 to the end of 2004, all adult patients with s‐bilirubin of 5.85 mg/dL (100 mol/l; reference value < 25 mol/L) were identified at the clinical laboratory serving the Sahlgrenska University Hospital (Gothenburg, Sweden), which analyzed the serum bilirubin of all patients in Gothenburg. Sahlgrenska University Hospital provides hospital services for all inhabitants of the city and comprises 3 hospitals (Sahlgrenska Hospital, stra Hospital, and Mlndal Hospital) that serve as community hospitals as well as a university hospital. The Gothenburg metropolitan area has 600,000 inhabitants.

The inclusion criteria for the study cohort were s‐bilirubin 100 mol/L at any point during the 2‐year period with evidence of dilated biliary ducts on abdominal ultrasound. A retrospective review of medical records was performed to retrieve information on the presence of abdominal pain associated with jaundice, computerized tomography (CT) and/or magnetic resonance cholangio‐pancreatography (MRCP) testing, and s‐AST, s‐ALT, s‐ALP, and bilirubin levels. The liver tests performed at the time that s‐bilirubin peaked during hospitalization were analyzed. Information about whether abdominal pain was associated with jaundice at the time of admission to the hospital, was obtained from medical records. The etiology of and treatment for the biliary obstruction were noted. Furthermore, the prognosis of the patients was analyzed. If a patient was discharged from the hospital, information about whether the patient was alive at the time of follow‐up was obtained from the Swedish National Registration of Inhabitants; if the patient had died outside the hospital, a death certificate was requested from the Cause of Death Register of the Swedish National Board of Health and Welfare. Patients were followed up in July 2005, providing a follow‐up period ranging from 6 months to 2.5 years.

RESULTS

Causes

The causes of the obstructive jaundice are shown in Table 1. Among the different types of malignancy causing obstructive jaundice, pancreatic cancer and cholangiocarcinoma were the most common, followed by the other malignancies category (Table 1). As shown in Table 2, a wide variety of other malignancies caused cases of biliary obstruction, although most were a result of metastases from gastrointestinal malignancies. Gallstone disease and biliary stricture were the most common benign causes. Less common causes are shown in Table 2. Patients with malignant versus benign obstructive jaundice were similar in age (Table 3). However, only 10 patients (6.5%) with malignant obstructive jaundice (OJ) were less than 50 years old, whereas 23 patients (26%) with benignly caused OJ were under the age of 50. Among the patients with malignancy, patients with pancreatic cancer were significantly older than those with cholangiocarcinoma (P = .04, Table 1). No other major age differences were observed in the etiological groups. Most patients with gallstone disease presenting with jaundice had experienced abdominal pain in association with jaundice, but the jaundice of 9% of the patients was painless (Fig. 1). This was in contrast with patients whose OJ was caused by different types of malignancies, a minority of whom experienced pain at presentation (Fig. 1). Table 3 shows a comparison of patients with a malignant obstruction and those with a benign obstruction. Abdominal pain associated with jaundice was less prevalent at presentation in patients with malignant obstructive jaundice compared with those with nonmalignant obstructive jaundice (34% vs. 71%; P < .0001; Table 3). In 4 patients, the cause of jaundice could not be determined from chart review. Three of these patients presented late in a generally bad condition; ultrasound showed dilated ducts, but these patients died in a few days, before further investigations had been performed (autopsies were not performed), and 1 patient refused further investigations. Thus, an etiological explanation was found for the obstruction of almost all patients.

Table 1.Demographics of Major Diagnostic Groups, Investigations Performed in Each Group, and Treatment and Prognosis

	Pancreatic cancer	Cholangio‐cancer	Other cancers	Papilla cancers	Biliary strictures	Gallstone disease	Other diagnoses	PSC
The results for age and survival in days are shown as medians with interquartile ranges in parentheses. F, female, M, male.
Total number	69	44	36	5	7	57	18	5
Age	73 (6782)	67 (5678)	67 (5975)	79 (7081)	80 (5184)	69 (4983)	72 (5285)	61 (3468)
Sex‐F/M	36/33	27/17	19/17	3/2	4/3	29/28	9/9	2/3
Surgery	10/69	10/44	1/36	3/5	0/7	21/57	4/18	1/5
Alive at follow‐up	3/69 (4.3%)	2/44 (4.5%)	2/36 (5.6%)	1/5 (20%)	6/7 (86%)	46/57 (80.1%)	12/18 (66%)	4/5 (80%)
Survival (days)	142 (58267)	166 (80300)	31 (1873)	257 (130380)	510 (455900)	558 (424665)	412 (103558)	570 (319676)

Table 2.Other Malignancies Causing Both Obstructive Jaundice and Intrahepatic Jaundice Not Classified Elsewhere and Other Causes of Jaundice Not Classified Elsewhere

Type of malignancy	Number of patients	Other cause of OJ not classified elsewhere	Number of patients
Colorectal cancer with liver metastases	9	Cholangitis	4
Liver metastases with unknown primary tumor	9	Papillary adenoma	4
Gastric cancer with liver metastases	5	Unknown cause	4
Small bowel cancer with liver metastases	2	Choledochal injury after cholecystectomy	2
Neuroendocrine tumor with liver metastases	2	Retroperitoneal fibrosis	1
Primary hepatocellular cancer	2	Mirizzis syndrome	1
Esophageal cancer with liver metastases	1	Chronic pancreatitis	1
Renal cancer with liver metastases	1	Duodenal diverticula	1
Lung cancer with liver metastases	1
Tuba uteri cancer with liver metastases	1
Prostate cancer with liver metastases	1
Chronic lymphatic leukemia with liver infiltrates	1
Liver cancer of unknown source	1

Table 3.Demographics, Liver Test Results, Investigations Undertaken, and Treatment of and Prognosis for patients with a Malignant Form of Obstructive Jaundice and a Nonmalignant Cause of Jaundice

	Malignant obstruction	Benign obstruction
The results are shown as medians with interquartile ranges in parentheses. * P < 0.05; P < 0.01; < 0.001. Liver laboratory values are expressed as multiples of the upper limit of normal (medians, with interquartile range in parentheses). The percentage of patients with abdominal pain at presentation is in parentheses. CT, computerized tomography; MRCP, magnetic resonance cholangio‐pancreatography; ERCP, endoscopic retrograde cholangio‐pancreatography; PTC, percutaneous transhepatic cholangiography.
Total number of patients	154	87
Female/male	85/69	44/43
Age	72 (6181)	69 (4983)
Abdominal pain at presentation	53/154 (34%)	62/87 (71%)
AST	3.3 (2.35.1)	3.3 (2.16.4)
ALT	3.1 (26)	4.3 (2.69.1)
ALP	9.9 (4.813.3)	5.9 (3.78.5)
Bilirubin	13.8 (1020)	7.1 (5.79.0)
CT	125/154 (81%)	47/87 (54%)
MRCP	47/154 (30%)	27/87 (31%)
ERCP	108/154 (70%)	67/87 (77%)
PTC	59/154 (38%)	7/87 (8%)
Surgery	24/154 (15.6%)*	26/87 (29.9%)
Alive at follow‐up	8/154 (5.2%)	68/87 (78%)

Figure 1

Prognosis

A total of 165 of the 241 patients (68.5%) died during follow‐up. Mortality was very high among patients with malignant obstructive jaundice, with only 8 of 154 patients (5.2%) alive at the end of follow‐up (Table 3). All these patients had been followed for at least 1 year (mean duration of follow‐up, 535 days). Among those who had survived at least 1 year, 1 patient with cholangiocarcinoma had undergone a liver transplantation, and another 5 patients had been operated on, 3 with pancreatic cancer, 1 with cholangiocarcinoma, 1 with a papilla Vateri cancer, and 1 with carcinoid syndrome with liver metastases. One patient with tuba uteri cancer who had received chemotherapy was also alive. The survival rates of the different etiological groups are shown in Table 1. Of 24 patients undergoing surgery for a malignant condition leading to obstructive jaundice, only 9 (37.5%) survived 1 year. The mortality in the total study group within 3 months of diagnosis was 32% (Table 5). The 3‐month, 6‐month, and 1‐year survival rates for the different etiological groups are given in Table 5. Generally, the patients with benign obstructive jaundice had a good prognosis. A total of 46 of 57 patients (80%) with gallstone disease were alive at the end of follow‐up. Only 3 patients with gallstone disease did not survive for 3 months after jaundice occurred. All these patients were very old, none died while hospitalized for jaundice, and only 1 death could be attributed to gallstone disease (cholangitis and sepsis) 1 month after the initial hospitalization. Figure 2A,B shows the mortality over time among the major etiological groups.

Table 5.Survival for 3, 6, and 12 Months of Patients in the Different Diagnostic Groups

	Pancreatic cancer	Cholangio cancer	Other cancers	Papilla cancer	Biliary strictures	Gallstone disease	Other diagnoses	PSC
Percentages are in parentheses.
3 months' survival	44/69 (63.8%)	32/44 (72.7%)	6/36 (16.7%)	4/5 (80%)	7/7 (100%)	54/57 (95%)	13/16 (81%)	5/5 (100%)
6 months' survival	28/69 (40.6%)	20/44 (45.5%)	5/36 (13.9%)	3/5 (60%)	7/7 (100%)	50/57 (88%)	11/16 (68%)	4/5 (80%)
12 months' survival	10/69 (14.5%)	9/44 (20.5%)	2/36 (5.6%)	2/5 (40%)	7/7 (100%)	47/57 (82%)	14/18 (77%)	4/5 (80%)

Figure 2

DISCUSSION

Our analysis of the causes of jaundice among unselected patients with a bilirubin level 5.85 mg/dL (100 mol/L) revealed that approximately one third of the cases were a result of obstructive jaundice. Studies published more than 20 years ago are available on the etiology and prognosis of these patients, reflecting the diagnostic techniques and hospital practice at that time.69 Furthermore, more recently published studies report the etiological spectrum of patients with obstructive jaundice in Africa and India.1012 In our study population, 154 of 241 patients (64%) had a malignancy, which is remarkably similar to the 61% and 65% of cases of obstructive jaundice due to malignancy reported in studies published more than 25 years ago from Denmark and Spain, respectively.67, 14

The results of the current study demonstrate the poor prognosis of patients with hepatobiliary malignancy that causes obstructive jaundice. The patients whose OJ was caused by a malignancy had a mortality rate of approximately 95% during the study's rather short follow‐up. Previous studies, mostly from the 1980s, found similarly dismal outcomes,1213 suggesting that the prognosis of these patients has not improved during the last 3 decades. Among patients hospitalized for malignant obstructive jaundice in Denmark in the 1970s and the beginning of the 1980s, 1‐year survival was reported to be 11%.14 Thus, unfortunately, the prognosis of patients presenting with jaundice caused by hepatobiliary cancer obstructing the biliary ducts (or due to liver metastases) does not seem to have improved during the last 3 decades. The most common cause of malignant obstructive jaundice in the current study was pancreatic cancer, which is in agreement what was reported in earlier studies.3, 1115 The poor prognosis of patients with pancreatic cancer is well known, but operative mortality is very low nowadays, and some series have reported 5‐year survival rates in the range of 10%30%.1620 The results of the current study suggest that the prognosis for patients with pancreatic cancer presenting with bilirubin 5.85 (100 mL/L) is worse than the 5‐year survival rates reported in recent studies.1620

In the current study patients with cholangiocarcinoma were almost one third of those with malignant obstructive jaundice, which is a higher proportion than that previously reported in series from Australia (9%), India (14%), and Denmark (17%).13, 11, 14 The increased proportion of patients with cholangiocarcinoma might reflect the recent observations of an increased incidence of cholangiocarcinoma in many countries.2122 Similar to the situation of patients with pancreatic cancer, very few patients with cholangiocancer will survive long term,2325 and as in the current study, the prognosis of these patients presenting with severe jaundice seems even worse. Mortality among our patients with malignancies other than pancreatic cancer and cholangiocancer was also very high, with only 5% surviving, mostly because of liver metastases. This is identical to the 1‐year survival of patients with liver metastases presenting with jaundice in Denmark more than 25 years ago.14 Although our patients might not be directly comparable to those seen in Denmark at that time, the results of the current study do suggest that the prognosis of patients with jaundice resulting from liver metastases has not improved over time, despite the considerable advances in diagnostic procedures during the last 2 or 3 decades. One of the limitations of the study besides its retrospective design is potentially excluding patients who were less sick (those with bilirubin levels below that used as an inclusion criterion), affecting survival rates. Other limitations might be defining biliary obstruction based on the results of ultrasound. However, we found very good correlation between ultrasound evidence of dilated biliary ducts and those who had evidence of biliary obstruction on MRCP and ERCP (data not shown).

However, one seemingly large difference between the current study and the Danish study14 is in the prognosis of patients with gallstone disease. The overall 1‐year survival was similar in the 2 studies, but whereas in the Danish study the deaths of 9 of 105 patients (8.6%) was attributed to their gallstone disease, the death of only 1 of the 57 patients (1.8%) in the current study could be attributed to gallstone disease. The reason for this difference is not easily explained but might have been a result of better diagnostic instruments and/or more commonly used ERCP procedures than were previously available.

Although jaundice resulting from a malignancy in the hepatobiliary tract is said to be painless,35 in our study approximately one third of patients with a malignancy experienced pain at presentation. However, our study confirmed that abdominal pain was significantly more often associated with benign conditions. The limitation of the current study was its retrospective nature. However, information about the occurrence of abdominal pain was available in medical records of all patients. Although we could not analyze the character, location, or nature of the abdominal pain, the attending doctor always asked a patient about whether he or she was experiencing abdominal pain.

We can conclude that the severe jaundice of one third of patients was a result of obstructive jaundice. Most of these cases were also a result of a malignancy, with high bilirubin levels indicating prolonged biliary obstruction. Obstructive jaundice caused by a malignancy carried a very poor prognosis, with approximately 95% mortality during a 1‐ to 2‐year follow‐up period. In the absence of methods to cure a significant number of these patients, good methods of palliation are important challenges in the near future.