Role of Clinical

Pharmacist in ICU
Presented By
Mohamed Rawy
Clinical Pharmacist, BSc, BCPS, BCCCP
Intensive Care Unit
Talk Outline
▪ Pharmacist duties in ICU
▪ How to check your patient
▪ Sources of information
▪ Practical Case
Pharmacist duties in ICU
Pharmacist Role in ICU
Medication Reconciliation

Assess the status of the patient's health problems

Evaluate the appropriateness and effectiveness of the patient’s medications

Provide Information about Drugs , DDI , IV Compatibility & drug administration

Identify ADEs & TDM Monitoring

Lectures & Training

Documentation of clinical activities

How to check your patient
Golden Mnemonic is

FAST HUG
MAIDNES
F Feeding
A Analgesia
S Sedation
T DVT Prophylaxis
H Head of bed Elevation
U SUP
G Glycemic Control
M Medication Reconciliation
A Anti microbials
I Indications of medications
D Drug dosing
E Electrolytes , Hematology & other lab values
N No Duplication , No DDI , No Allergies , No S.E
S Stop dates
How to check a medication order
▪ Guideline or Efficacy in place
▪ Indication & Dosing
▪ Contraindications
▪ Renal Adjustment
▪ Hepatic Adjustment
▪ Drug Interactions
▪ Dosage Form
▪ Preparation
▪ Administration
▪ Monitoring
Sources of information
Sources of information
▪ Lexi comp … Application
▪ Up to date … Application
▪ Sanford Guide … Application
▪ Neofax … Application
▪ Clincalc , Globalrph … Website
▪ Handbook of drug administration via EFT … Book
▪ Mims.com … Website
▪ EMC.com … Website
▪ Specific Guidelines for each disease … Booklet
- IDSA for Infectious diseases
- AHA or ESC for Cardiac Problems
- KDIGO for Nephrology issues
Practical Case
Practical case
• A 65-year-old woman , AF on Concor 5mg OD & Eliquis 5mg BID
• Patient with a history of alcohol abuse who presented to the emergency room
with abdominal pain and fatigue progressively worsening over the past 2 days
she endorsed drinking four mixed drinks per day along with taking large amount
of acetaminophen for daily headaches , She complained of subjective fevers but
denied chills, cough, chest pain, emesis, or diarrhea.
• On initial presentation, she was alert and answering questions appropriately ,
She was afebrile with a heart rate of 110 bpm and blood pressure of 98/60
mmHg , Notable findings on physical exam included mild tenderness to palpation
in the epigastric region and right upper quadrant , The remainder of her exam
was unremarkable
• Her labs on presentation were notable for (AST) 1450 Unit/L, (ALT) 680 Unit/L,
alkaline phosphatase 70 Unit/L, total bilirubin 5.1 mg/dL, international
normalized ratio (INR) of 2.1, Albumin 2.2mg/dL and acetaminophen level of 65
mcg/ml

- So … What Do You Think ?

Practical case
• Over the next 24 h, she was noted to have a significant decline in her
mental status with inability to maintain eye contact and answer questions
appropriately
• She was electively intubated and placed on mechanical ventilation

- So … What Do You Think ?

Practical case
• On day 3 of admission, she was noted to be in AKI (S.Cr increased
from 1 to 3mg/dL) & being Anuric with ongoing fulminant liver failure
, She was initiated on CRRT and listed for liver transplantation
• After 5 days , UOP improved after 3 HDX sessions , Now his UOP is
50-100mL/h & last S.cr was 1.1
• Conscious level is improved , his GCS is 12/15 from 7/15
• PAUS shows Cirrhotic Liver with Moderate Ascites , His serum
albumin level=1.9 , K Level=3.9 , Sodium=115 , INR=2
• On day 9 of admission she developed Hematemesis , PPI &
Vasopressin analogue was initiated & planned for UGIE
- So … What Do You Think ?
Practical case
• UGIE is done & shows Esophageal varices , Band ligation is done &
PPI Infusion is stopped & shifted to OD as SUP
• His Na Level now is 130 after 2 days with HTS so it is stopped
• On day 10 His sputum culture shows Acinetobacter XDR shows
sensitivity only to Colistin & Urine C/S shows Candida albicans
patient is feverish (Temp=39°C) , Still intubated & MV for Hypoxia
(Sa02=91% , Fio2=40%)
• He also still DCL , For this he is requested for EEG which shows
epileptic form activity & he is prescribed Tegretol

- So … What Do You Think ?

Define your
problems
 Revision Summary
-Problems to be managed
Atrial Fibrillation 
Acetaminophen Toxicity 
Hepatic Encephalopathy 
Mechanical Ventilation 
Hepato-Renal Syndrome 
Anuria 
Upper GI Bleeding 
Hyponatremia 
MDR Bacteria 
Seizures 
 Practical case
- Patient’s Medications are:
NAC 150mg/kg with 250mL D5W over 1h IV Hypertonic Saline with rate of 30mL/h IV
NAC 50mg/kg with 500mL D5W over 4h IV Albumin 50mL BID IV
NAC 100mg/kg with 1000mL D5W over 16h IV Terlipressin 1mg QID IV
Controloc 80mg+50mL NS with rate of 5mL/h IV Eliquis 5mg BID PO
Sandostatin 200mcg+50mL NS with rate of 12.5mL/h IV Carvid 6.25mg BID PO
Lactulose 30mL TID PO Procrolan 5mg BID PO
Gastrobiotic 550mg BID PO Ondansetron 8mg TID PO
Enema + Lactulose TID PR Tegretol 200mg TID IV
Ursoplus 1 tab TID PO Colistin 9M I.U LD then MD of Colistin 2M I.U IV
Lasilactone 100/20mg OD PO Unictam 3g BID IV
Fentanyl 5 amp +50mL NS with rate of 5mL/h IV Fluconazole 400mg LD then 100mg OD MD IV
Precedex 1 amp +50mL NS with rate of 5ml/h IV Levophed 8mg+50mL D5W with rate of 5mL/h IV
Ceftriaxone 2g OD IV Refresh Tears E.D & Chlorhexidine M.W Topical
Practical case
- My Recommendations are:
1. NAC IV infusion
2. Start Anti Coma measures
3. Analgesia & Sedation (Avoid Acetaminophen & Propofol + BDZ)
4. Controloc + Sandostatin infusion until UGIE findings
5. Ceftriaxone 2g OD for 7 days for SBP Prophylaxis then Stop
6. Carvid (or any non-selective BB) & Hold during shock state period
7. Avoid Anticoagulants till Hematemesis being resolved
8. Dosing adjust based on HDx dosing during HDx & adjust after that according to crCl
9. Hypertonic Saline till Na level of 125 then Stop
10. Avoid Hepatotoxic drugs or drugs with extensive hepatic metabolism
11. Start nutrition through Ryle Feeding
12. Unictam + Colistin for CRAB …. Fluconazole for Cnadida albicans
13. Replace Tegretol with Levetiracetam for Non Convulsive fits (DDI category X with Eliqiuis)
14. Stop Procrolan (Contraindicated in AF & Child Pugh C)
15. Reduce dose of Ondansetron to maximum of 8mg OD not TID in child pugh C
16. Add Refresh tears Eye drops and Orovex Mouth wash as a VAP Bundle
 Ryle feeding
F
Fentanyl Infusion
A
Precedex Infusion
S
Heparin Infusion (Therapeutic Anticoagulant)
T
30-45° Position
H
Controloc Infusion
U
Not DM & his BGL is between 140-180
G
 Done at admission (Concor + Eliquis + Acetaminophen)
M NKDA , No recent hospital admission nor AB user within last 90d
Rocphine … SBP Prophylaxis then Changed to Unasyn + Colistin for
A Acinetobacter & Diflucan … Candida Albicans
All medications were aligned with guidelines
I
Dosing of Medications are calculated & adjusted as per Lexi comp
D
Hyponatremia … HTS infused , Low albumin … Albumin added
E Other lab values to be followed up Especially LFTs , RFTs
INR for anticoagulation monitoring
DDIs were found & managed accordingly
N
Stop dates for Antimicrobials are based on IDSA guidelines & after
S C/S Revision
 So What you think ☺ ??
-Acquired Skills
Lexi comp … Drug Monograph Revision 
Drug-Drug Interactions 
Calculation of rate of infusion of medications 
MD Calc … Medical Scores 
Define Your Problems 
Evidence Based Medicine 
FASTHUG MAIDNES 
Systematic Approach
Confirm Diagnosis

Treatment Plan

Monitoring

Check Daily Labs & Investigations

Check Daily Microbiology & ID

Medications (FASTHUG MAIDNES)

Documentation of clinical activities
 Let’s go for
Questions ??
Answers
Q.A ... 3
Q.B … 2
Q.C … 4
Q.D … 1
Q.E … 4
Q.F … 3
Q.A
- Acetaminophen overdose is treated with ?
1. Glucagon
2. Paracetamol
3. N-Acetyl Cysteine
4. Phentolamine
Q.B
- Hepatic Encephalopathy is treated with ?
1. Ceftriaxone
2. Lactulose + Gastrobiotic
3. Hypertonic Saline
4. Albumin + Glypressin
Q.C
- Hepato Renal Syndrome is?
1. Liver Cirrhosis + Bleeding
2. Liver Cirrhosis + Hyponatremia
3. Liver Cirrhosis + Ascites
4. Liver Cirrhosis + Acute Kidney Injury
Q.D
- DVT Prophylaxis & SUP is done with ?
1. Heparin & PPI
2. Alteplase & Mucosta
3. Plavix & Mucogel
4. Pletaal & Famotidine
Q.E
- DDI Between Phenytoin & Eliquis is Category?
1. B
2. C
3. D
4. X
Q.E
Q.F
- If we decide to give heparin infusion for AF
patient weights 75kg … what is the dosing ?
- How to prepare & administer if you know we
add 1 Amp (5000 i.u + 50mL NS)
1. 6000 I.U LD Followed by 1350 I.U … 60mL Bolus then 13.5mL/h
2. 5000 I.U LD followed by 1350 I.U … 50mL Bolus then 13.5mL/h
3. 5000 I.U LD Followed by 1000 I.U … 50mL Bolus then 10mL/h
4. No LD & Start with 1500 I.U … 15mL/h
Q.F
Any Questions ??
Thank you …