Critical care is one of the oldest clinical pharmacy specialties and it is well established that the presence of a pharmacist on rounds in an intensive care unit pays off for the patient, the medical team and the institution. Few niche clinical pharmacy areas have documented the powerful impact a pharmacist’s presence can have in the way it has been done in critical care. This influential role critical care pharmacists can have is what drew me in.  From there, I was propelled by the challenges I would face and the intensities I would experience.

The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development.

Imagine you are a critical care pharmacist at a large teaching hospital. During the ward round, the intensivist enquires about the appropriate infusion rate of intravenous nutrition for a cachexic patient with burns to 60% of their body, who is currently fluid overloaded. A nurse then approaches you about a septic patient with two central lines but four drugs to administer. Which of the drugs can be mixed? Which can be administered as a bolus and which via a Y-site connection. Being able to handle complex clinical queries such as these in a high-pressure environment makes specialist pharmacists an indispensible part of the critical care multidisciplinary team (MDT).

Limitations in mobility lead to an increased risk of developing deep vein thrombosis (DVT). DVT prophylaxis is an aspect of supportive care where pharmacists play a key role. At our facility, we were able to run a VTE prophylaxis report with the most recent DVT prophylaxis ordered for a patient, including sequential compression devices, enoxaparin, or unfractionated heparin. Pharmacists review the patient’s INR, platelet count, hemoglobin, and hematocrit to assess appropriateness of chemical prophylaxis. The general chief complaint or reason for admission can also indicate whether a patient may be a candidate for chemical prophylaxis. For example, chemical prophylaxis may not be the best choice in a patient who has received a thrombolytic within the past 24 hours. If anticoagulation is suspended for this reason, pharmacists may review follow-up CT scans, and consult with the neurologist on the plan for DVT prophylaxis going forward.

Regards
Rutherford
Managing Editor
Pharmacy Practice and Education.