Tomorrow's Pharmacist
2007:22-23
January 2007
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A career in critical care |
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Critical care provides a career pathway for pharmacists, with a standard set of skills and competencies and a structured training programme for basic grade to consultant pharmacists in this specialty. Haley Hill discusses the role of a pharmacist dedicated to the care of seriously ill patients |
Critical care concerns the complete process of caring for the critically ill patient. The term also encompasses the needs of those at risk of critical illness and those who are recovering or have recovered from such illnesses. Generally, a critical care pharmacist will predominantly cover the intensive therapy unit (ITU) where patients require advanced respiratory support alone, or basic respiratory support together with the support of at least two organ systems (including patients with multi-organ failure).1 Therefore, the pharmaceutical management of a critically ill patient is a complex task, requiring knowledge of drug therapy in all chronic and acute disease states, often severe in nature. It is generally a role given to an “experienced pharmacist” but most hospital pharmacists will have some involvement in critical care whether it be through on-call queries, covering the workload of a critical care pharmacist or a patient transfer from an ITU to a high dependency unit or a general ward. Oral therapy is often not possible for critically ill patients and alternative routes of drug administration are frequently required. Approximately 95 per cent of prescribed medicines in ITU are administered by injection. Thereby, pharmacists working in an ITU deal almost exclusively with intravenous therapy: bolus injections, intermittent infusions and continuous infusions. Experience in a number of areas are a fundamental requirement to practise as a critical care pharmacist. The alternative routes of administration required in an ITU mean that pharmacists are often required to offer advice on formulations, ie, suitability for administration via a nasogastric tube or a percutaneous endoscopic gastrostomy tube. The critical care pharmacist needs an adequate knowledge of which formulations can be crushed or dissolved and be able to suggest alternative medicines where necessary. Polypharmacy is common in an ITU, often involving high doses or high-risk drugs. Therefore an understanding of drug-drug and drug-disease interactions is vital. ITU patients are frequently prescribed several intravenous therapies for administration via a central line. Pharmacists need to be able to give information and advice on the compatibility of intravenous drugs. Pharmacokinetics and bioavailabilty Critically ill patients will invariably have some degree of renal or hepatic impairment so haemofiltration and dialysis are often required. Knowledge of the distribution, metabolism, clearance and appropriate therapeutic drug monitoring of a medicine is vital to optimise treatment outcomes. Also, critically ill patients often have reduced gastric absorption so knowledge of the bioavailability of drugs will assist decisions on appropriate therapy. An understanding of bioavailability is also necessary to advise on equivalent doses when the route of administration or form of a drug is changed. A text-book approach is not appropriate for critical care pharmacy. Many of the drugs are prescribed for unlicensed indications or at unlicensed doses, and guidelines are generally local and based on the consultant’s personal experience. Although several major trials (multicentre and multinational) have been conducted, information is generally obtained from small group patient studies, focus groups and conference consensuses. Critical care pharmacists have to work together to build consensus and standardisation. The UK Clinical Pharmacy Association Critical Care Group has set up an e-mail network to provide a forum for communication and enable pharmacists to draw on each other’s experience. In critical care, answers are rarely straightforward and queries may receive three or four different responses depending on the experience in each individual situation. The pharmacist then, using his or her judgement, interprets the risks and benefits and applies the information to a particular situation. The scope for pharmaceutical interventions in critical care is broad. Issues such as impaired organ function, dialysis, haemofiltration, impaired circulation and impaired respiration can alter drug handling significantly. Pharmaceutical problems are rarely isolated and critical care pharmacists need to exercise their judgement, make decisions and offer advice, taking all the pharmaceutical and medical issues into account. Critically ill patients are often prescribed many infusions. Together with organ impairment (eg, renal failure or heart failure), this can often lead to fluid overload. Pharmacists frequently offer advice on increasing the concentration of infusions and also provide information on the sodium content of drugs and infusion fluids, suggesting alternatives when necessary, for fluid-restricted patients. Drug therapy in critical care is more high risk than on general wards. If, for example, a critically ill patient is receiving 20 or so intravenous drugs, the probability of something going wrong is quite high, especially with known high-risk drugs such as potassium (intravenous concentrated potassium solutions). This is a potential area for pharmacists to manage. Pharmacy practice within a critical care setting is a challenging yet rewarding experience. It is a specialty in which a pharmacist’s expert knowledge of drugs can make an invaluable contribution to patient care. This career pathway will increase the profile of pharmacists within the multidisciplinary team as well as help to standardise pharmaceutical care provided for critically ill patients. References |
