#ICUInsights #ICUXposts
Last year, I supervised multiple residents and interns, and I would like to share some teaching points that might be helpful for those considering a learning experience in the ICU.
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Firstly, the ICU environment depends on a multidisciplinary team, which includes ICU Consultants, Fellows, residents, nurses, Clinical Pharmacists, a Respiratory Team, Dietitians, and Physiotherapists. The team engages in daily discussions and makes decisions based on recommendations from all team members.
Secondly, the ICU is a critical care area that encompasses multiple specialties, such as (Medical ICU, Trauma ICU, Surgical ICU, Neuro Critical Care, Respiratory ICU, ECMO support, Burn ICU, Maternity ICU, and Hematology, Oncology, Transplant ICUs and etc..). The variety of specialties available depends on the institution, with some having all these units and others only two or three.
Thirdly, understanding the role of the Clinical Pharmacist in critical care is important. It's not just limited to reviewing patients and adding recommendations. Other roles include (building protocols/guidelines, participating in educational activities for the team, and engaging in training and research.. etc)
2/12

From my experience, the main points as a Survival Guide to Pharmacy Rounding in the ICU can be summarized as follows:
1) We should ask ourselves two main questions: "Why was the patient admitted to the hospital on a specific date?" and "Why was the patient then admitted to the ICU on a specific date?"
2) We view the patient as a whole system, and there are multiple tools such as "Head to Toe" and FASTHUG-MAIDENS. We will go through these tools one by one to update on a daily basis and understand the problem list.
3) For the "Head to Toe" approach, what's essential? System-wise, we need to approach it with specific questions.
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1️⃣ Central Nervous System (CNS) 🧠: Here, you should list all the drugs related to the system, including the assessment.
For example, when examining a critically ill patient's sedation, pain control, and delirium:
- Pain: We have 3 main assessment tools, with self-reporting being the gold standard. If the patient is on mechanical ventilation, use either the Behavioral Pain Scale (BPS) or the Critical‐Care Pain Observation Tool (CPOT). Then list the medications, either opioid or non-opioid.
- Sedation: We have 2 main tools—the Richmond Agitation and Sedation Scale (RASS) score and the Riker Sedation-Agitation Scale (SAS). Then list the medications, either benzodiazepine or non-benzodiazepine.
- Delirium: For assessment, use the Confusion Assessment Method for the ICU (CAM-ICU). Then list the medications, either benzodiazepine or non-benzodiazepine.
- Antiepileptics, etc ..
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2️⃣ Cardiovascular (CV) 🫀: Determine if the patient is hemodynamically stable or unstable (on inotropes).
- What is the type of shock (obstructive, hemorrhagic, distributive, or cardiogenic)?
- What medications are being used (e.g., norepinephrine, epinephrine, dobutamine, etc.)?
- What is the assessment for dose changes over the last hours—increasing or decreasing?
- What is the goal Mean Arterial Pressure (MAP)? Some types of shock and status require a higher MAP.
- Are steroids and vasopressin being added?
- Is there an updated echocardiogram?
- If the patient is hemodynamically stable, are they known to have hypertension or heart failure, etc., and what drugs are ongoing?
5/12

3️⃣ Respiratory or Pulmonary 🫁:
- Is the patient known to have asthma or COPD, etc.?
- Is the patient on mechanical ventilation (MV)? For how many days, and what are the mode and FiO2%?
- Is the patient ready for extubation? So, is a cough leak test?
- Do all these points lead you to decide to add medications like steroids or to assess the fluid balance for the patient?
- ABG/VBG abnormality?
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4️⃣ Deep Vein Thrombosis (DVT) Prophylaxis/Treatment 🩸:
- Scoring for DVT risk as there are various scales for different contexts (e.g., surgical, maternity, etc.).
- Use mechanical, pharmacological methods, or a combination for prophylaxis?
- Is there a history of or risk for Heparin-Induced Thrombocytopenia (HIT)?
- What is the patient's renal function?
5️⃣ Gastrointestinal (GI) :
- Is the patient tolerating feeding, on trophic feeding (10-20 mL/hr), or requiring Total Parenteral Nutrition (TPN)?
- Has the target for feeding been achieved?
- Is the patient on GI prophylaxis, and is it indicated?
- What is the volume of gastric residuals, and when was the last bowel movement?
- Is there a risk or incidence of refeeding syndrome?
7/12

6️⃣ Endocrine:
- What is the last recorded blood glucose level? Were there any episodes of hyperglycemia or hypoglycemia?
- How much insulin has the patient used in the last 24 hours?
- What type of insulin is being administered? What is the standard for the sliding scale (low, moderate, high)?
- Is there evidence of adrenal insufficiency, hyperthyroidism, or hypothyroidism?
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7️⃣ Renal:
- What is the urine output over the last 6 or 24 hours?
- Is there evidence of acute kidney injury (AKI) or chronic kidney disease (CKD)?
- If the patient is on dialysis, what type is it (CVVH/CVVHD/CVVHDF)?
- Are there any electrolyte imbalances?
- on diuretics? What the indications?
8️⃣ Fluid:
- What type of fluids are being administered, at what rate, and for how many hours?
- Are the fluids indicated?
9/12

9️⃣ Infectious Diseases (ID):
Considerations when reviewing this component:
- Is there a fever present? Could it be central in origin, drug-induced, or infectious?
- Are there elevated inflammatory markers? On steroids?
- Are there deviations in the neutrophil count? How are CSF analyses interpreted, etc.?
- What are the mechanical ventilation settings, and have there been any changes noted on a chest X-ray?
- Is there a response to inotropes?
Cultures:
- List results or pending cultures with corresponding dates and report times.
Antibiotics:
- Are the antibiotics empirical or targeted?
- For how many days have they been administered, and what is the planned stop date?
- Are the doses appropriate with consideration of pharmacokinetics and the patient’s condition?
10/12

🔟 Therapeutic Drug Monitoring (TDM) ⭐️:
- Do any drug levels need to be requested? When should they be sent? Is there a need for repeat testing?
- What are the target levels for the drugs in question (μmol/L or mg/dL)?
📝 Formulating the Final Plan:
1- Each part should involve a review of dosages, routes of administration, potential interactions, preparations and compatibility.
2- Conclude your recommendations with bullet points.
3- Review any medication errors or adverse drug reactions, including their severity.
4- Formulate a further plan depending on the specifics of the case.
5- TDM/TPN plan
11/12

Example for checklist or follow-up sheet as following:
1- dropbox.com
2-dropbox.com
Good luck, and enjoy your ICU rotation 👏🏻✨ #CriticalCare
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