Sunday, October 20, 2013

Dare to Fare in Critical Care

Posted by Adam Loyson at Sunday, October 20, 2013

Since writing about my nephrology rotation in the outpatient/inpatient dialysis unit setting, I am now concluding a rotation in critical care at a small private hospital. This new chapter of my APPE experience has been truly amazing, calling upon every bit of my pharmaceutical knowledge to save patient lives.

Detective work
With my new-found confidence growing from just one rotation under my belt, I was up for a new challenge. Enter the critical care arena. Becoming oriented to the intensive care unit (ICU) brought many new opportunities. Starting from day one, I found myself judiciously evaluating the complex clinical status and pharmacotherapy of the patients I was following. I also began participating in multidisciplinary patient rounds for the first time.  Intimidated, yes; but I was determined to make a difference.

Patients arriving to the ICU from the emergency department were often diagnosed with numerous disease states, frequently more than I could count with two hands. These patients required intricate care, with physicians often asking the pharmacist and me for our advice on the direction, agent selection, dosing, and duration of pharmaceutical care. With such inquiries, I quickly found myself becoming a supersluth in researching and recommending solutions from cardiovascular, respiratory, neural, metabolic, infectious disease, and gastrointestinal disease state guidelines. 

Endless opportunities
An exceptionally neat aspect about rotating in the ICU is the sheer number of interventions you can make as a student pharmacist. On a daily basis, I was involved in developing pharmacokinetic and therapeutic plans for patients receiving antibiotics (e.g., aminoglycosides and vancomycin) and anticoagulants (e.g., heparins and warfarin). I often encountered patients that required antibiotics for their recent onset of pneumonia, medications to convert their heart arrhythmia, or electrolyte supplementation. In these situations, I was able to educate the new medical residents about the appropriate agents, medicinal algorithms, and patient monitoring parameters to use.

In contrast to my last rotation in the dialysis unit, many patients in the ICU arrived with multi-organ failure. With elevated levels of acuity, many patients were prescribed complex medication regiments as inpatients.  Thus, I was able to answer many questions from nurses about drug interactions and intravenous line compatibility.

The multidisciplinary team of physicians, dieticians, respiratory therapists, and nurses often consulted pharmacy services and inquired about the evidence behind particular therapies or signs of drug toxicity. My ICU experience  served as an excellent opportunity for gathering drug information, permitting me to evaluate literature sources for strength and relevance for the individual patients I covered.

For example, a patient was referred to the hospital and admitted into the ICU after taking four pills of diphenhydramine instead of one to help her fall asleep. The patient presented to the hospital with abnormal muscular spasms. After performing a quick search of the literature and contacting poison control, I recommended that an antimuscarinic agent be given for treatment.

Another pharmacy service that I participated in was the monitoring of per-protocol medication administration and assuring that standardized procedures were being met on a consistent basis based on patient care quality indicators. Such indicators that pharmacy would oversee include appropriate administration of a thrombolytic agent during a stroke, a benzodiazepine during alcohol withdrawal, or venous thromboembolism/gastrointestinal stress ulcer prophylaxis for patients during their ICU stay. Interventions were made if any practices were not in agreement with Joint Commission criterion or Medicare reimbursement models.

Continuous learning
Rounding out my rotation experience, I am happy that I have been exposed to the continually revolving care of ICU patients and the treatment of their medical conditions. Whether it is sepsis, hypertensive crisis, drug overdose, or acute coronary syndrome, I can assure you that I have learned substantially from the medication management in the critically ill patient population.  I recommend the ICU experience for any student pharmacists that are interested in challenging themselves and participating in a coordinated team to treat the extremes of human disease and ensuing ethical and social dilemmas.

Needless to say, this rotation has been a great opportunity to help me review for the pharmacy licensing exam!

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