By Catherine McKenzie, Consultant Pharmacist in Critical Care
Consultant pharmacist in critical care. My job is all about the 3 p’s – pain, patients and publications. My job plan is split between expert professional practice, leadership, education and research.
Why and when is your role important?
The specialist clinical pharmacist (SCP) in critical care is critical. I always joke that apart from intubation there is not much we can’t do. It’s a diverse role, but to deliver effectively one has to be an ‘expert’ in critical care.
So what do we do? I believe most importantly we protect patients when they are most vulnerable. We do that by producing evidence-based guidelines on anti-invectives or anti-convulsants and anti-coagulants. And therapeutic drug monitoring, review of prescribing errors, ASD clinical ward rounds. And much more.
How do you approach your work?
I consider a patient in pain as a failure of my ASD service and I am passionate about trying to ensure that each patent’s journey should be painfree or as near as we can get.
“Less is more in the world of sedation”.
I use the euphenism: Less is more in the world of sedation. We know that early deep sedation is harmful to mortality and morbidity. I try my best to keep the RASS as light as is possible. Although that is challenging, especially with a delirious patient (the perfect type for light sedation).
I find assuring a patient in severe pain very rewarding. Especially when that reassurance is coupled with a change to more effective opioid analgesia. We know that thoracic surgery is exquisitely painful. Therefore pre-emptive techniques are uniquely helpful. Preoperative and postoperative prescription of pregabalin can support the anxiety and pain associated with penumonectomys.
Can you give us a tour of your normal workday?
I start work between 8am and 10am. When I am the hospital, I spend the first hour answering emails and reviewing with my research pharmacist whether there are any patients eligible for SPICE (sedation practice in intensive care evaluation), which is an international study of early goal directed sedation versus standard sedation in ventilated patient.
At about 10am the clinical pharmacists return from handover. We discuss whether there are any patients to review in the analgesia, sedation and delirium (ASD) clinical round or whether there are complex patients that requires a senior clinical pharmacist.
At my hospital we also host a severe respiratory failure (SRF) referral service. We are referred a number of patients where ventilation is challenging. Many of these will go onto extra corporeal membrane oxygenation therapy (ECMO).
“Getting the dose right is critical, and we often discuss this between clinical pharmacists or intensivists and microbiologists”.
Medicinal therapy is often critical. They may have a life threatening infection where anti-bacterials are critical but, at the same time, cause considerable harm to organ function.For example aminoglycosides (in our case gentamicin) where high peaks are required for maximum bactericidal activity and reduction in mortality.
That’s balanced against low troughs (amino glycoside clearance between doses) to reduce risk of nephrotoxicity and vestibular or ototoxicity. There are multi components to the latter including genetic predisposition and peak area. Getting the dose right is critical, and we often discuss this between clinical pharmacists or intensivists and microbiologists.
“I work on the simple premise that pain and severe pain is something we do not desire in critical care”.
I am referred a number of ASD patients and will review those where there is a clinical need and the consultant intensivist is in full agreement with the referral or review.
What are the highs…?
All the p’s! Patients and publishing.
I find meeting patients and families in the corridor who have been in intensive care so rewarding. One day, a lady stopped me and asked if I was an ICU pharmacist. Apparently she has been on ICU with an open sternum, and for some reason her fentanyl was stopped. I had it restarted. She said she had been looking for me to thank me for a long time. I was just so touched.
I also love the reward of publishing. I have over 30 publications (not very much by others standing). For me publishing has been about bringing scientific rigour to clinical practice.
…and the challenges?
There are lots. I have complex regional pain syndrome (CRPS). It helps me understand the patients and their medications. I used to wonder why chronic pain medicines were so critical – I now understand it’s because missing only small number of doses can mean a lot of pain.
“I used to wonder why chronic pain medicines were so critical – I now understand it’s because missing only small number of doses can mean a lot of pain”.
On a normal day, I can spend 30 minutes or more with a junior nurse and an agitated patient. I remind myself that I could be the only professional this nurse might see in 24/7 except for break cover, wardround and handover. These patients can be very sick and their illness very complex. I try and help as much as I can. This might involve the CAMICU, extra reassurance for patient or family or offering to negotiate medicines with clinicians when an interaction becomes apparent.
Anything you would like to change in critical care?
I had the intravenous haloperidol license withdrawn in 2011 for concerns of CV safety and lack of efficacy. It is still widely used in critical care. My mantra is my patients deserve better.
One can get rebound agitation with intravenous lorazepam, but is this better or worse than tornado and sudden death after haloperidol? I ask that where there is an alternative to intravenous haloperidol, then please consider.