What are the key medication management recommendations for critical care pharmacy?

Key Medication Management Recommendations for Critical Care Pharmacy

Critical care pharmacists should be regularly involved in ICU operations, focusing on medication error prevention through standardized labeling systems, programmable infusion devices, and heightened vigilance for high-risk medications like sedatives and vasoactive agents. 1

Core Pharmacy Practice Recommendations

Pharmacist Integration and Involvement

• Regular involvement of a pharmacist in the ICU is essential for optimizing medication safety and therapeutic outcomes 1
• Critical care pharmacists should actively participate in institutional and regional surge capacity planning, particularly for pharmaceutical preparedness 1
• Pharmacists must be involved in developing medication substitution rules, dose reduction protocols, and conversion strategies from parenteral to enteral administration 1

Medication Safety and Error Prevention

High-priority safety measures include:

• Implement international color coding of labels for syringes, administration routes, preparation bags, and medication storage devices 1
• Apply the five-rights rule consistently: right medication, right dose, right time, right route, right patient 1
• Establish protocols for preparing and administering medications with formal documentation and verification processes 1
• Use error-reduction devices and bar-code readers to minimize selection and administration errors 1

High-Risk Medication Management

• Maintain high vigilance for sedative and vasoactive agents, which are involved in most medication errors in the ICU 1
• High-risk medications like potassium chloride should ideally not be stored in patient care areas; if storage is necessary, implement special precautions for shelving, labeling, and delivery 1
• Use programmable power syringes connected to computer systems for continuous infusions 1

Antibiotic Optimization Strategies

Dosing Principles

• Optimize antibiotic dosing through prolonged infusions in ICU populations with altered pharmacokinetics 2
• Apply pharmacokinetic/pharmacodynamic (PK/PD) principles to maximize clinical outcomes and suppress resistance development 3
• Optimal and timely PK/PD target attainment is associated with increased likelihood of clinical and microbiological success in critically ill patients 3

Antimicrobial Stewardship

Implement the following stewardship strategies:

• Initiate active empiric antibiotic therapy based on local susceptibilities with daily evaluation of infection signs and symptoms 2
• Narrow antibiotic therapy when feasible through de-escalation protocols 4, 2
• Reduce total duration of therapy while maintaining efficacy 2
• Collect appropriate specimens and implement molecular diagnostics for targeted therapy 2

Special Populations

• For patients on renal replacement therapy (IHD, PIRRT, CRRT), dosing must account for drug clearance properties, RRT system characteristics, and residual renal function 5
• Consider severity of illness, comorbidities, and patient response when individualizing antibiotic regimens in critically ill patients 5
• Utilize therapeutic drug monitoring when optimizing therapy in patients with extreme shifts in organ function 6

Guideline Quality Considerations

Critical Appraisal of Guidelines

• Only two-thirds of critical care pharmacotherapy guidelines can be recommended for use, with most strong recommendations backed by low-quality evidence 1
• Strongly recommended guidelines include those for severe traumatic brain injury management, ventilator-associated pneumonia prevention, and stress ulcer prophylaxis 1
• Guidelines that cannot be recommended include those addressing penetrating brain injury, SARS, and hemodynamic support of sepsis 1

Implementation Approach

• Critically appraise guidelines before applying recommendations to practice, as poor quality guidelines fail to reduce unnecessary care variations 1
• Scrutinize the scientific evidence supporting recommendations, as only one-third of strong critical care pharmacotherapy recommendations are supported by highest quality evidence 1
• Each ICU should have a monitoring program in place to evaluate antibiotic utilization and effectiveness at the local level 4

Medication Storage and Organization

• Storage systems must be clear, formally defined, and shared across all sites including emergency supplies, crash carts, and anesthesia tables 1
• Only medications that are absolutely necessary and used regularly should be available 1
• Avoid similarities in shape, color, and name among medications stored in the same environment 1
• Medications should not be prepared in advance; extemporaneous preparation minimizes selection errors 1

Documentation and Labeling

Each preparation bag or bottle must be labeled immediately after medication addition with:

• Drug name (international non-proprietary name) 1
• Amount or concentration 1
• Preparation date, time, and preparer's name 1
• Administration initiation date and time 1
• Bar-code identification when applicable 1