Being on the PSICU service has introduced me into a completely new realm of pharmacy. This was my first pediatrics rotation, my first ICU rotation, and my first surgical rotation. As my three weeks on PSICU nears its end, I've had the opportunity to see and learn a lot. In this post, I will attempt to break down what I've learned and specifically tailor it in terms of pharmacy.
The main role of the physicians, pharmacists, nurses, and respiratory therapists is to manage the patients postoperatively. The pharmacist's job is to ensure the appropriate medication management of these patients. Once the patients are stable, they are transferred to the floors and, if all goes well, they are discharged home.
What I have found is that the medications used on this service all come down to the following classes:
2) Inotropic agents
3) Sedation/pain relief
4) Stress Ulcer prophylaxis
AntibioticsThe antimicrobial regimens used on the service are primarily for surgical prophylaxis. With any surgery, there is an increased chance of infection, and the risk is even higher in pediatric patients. For the most part, they followed the Antimicrobial Prophylaxis for Surgery guidelines from The Medical Letter, Inc. However, after listening to discussions on rounds and speaking with my preceptor, I realized that the antibiotic selection largely depends on how the surgeon felt about the surgery ie how long the surgery took, if there were any complications. From a pharmacy standpoint, my pharmacist was not as involved in the antibiotic selection, but more in the dosage adjustment for the individual patients. As the patients clinically improve after surgery, the antibiotics are peeled off gradually. Some of the considerations the physicians take into account to see if patients are improving are the number of lines and drainages remaining, whether an extracorporeal membrane oxygenation (ECMO) is required, and lab values returning to normal limits. There was not official antibiotic algorithm at NTUH, however, the basic progression of antibiotic selection consisted of the following:
no complications in surgery---------->severe complications
cefazolin-->ampicillin/sulbactam-->piperacillin/tazobactam-->vancomycin + ceftazidime-->ADD fluconazole
Every single patient is started on dopamine and milrinone to start. If another agent is indicated, epinephrine is added on. My assessment of these agents is mentioned in a previous post. As the patient clinically improves, the inotropic agents are gradually tapered off, and eventually, discontinued. In general, the epinephrine is tapered off first, followed by the dopamine.
The two mainstays of sedation and pain relief on the service were fentanyl and pancuronium. The fentanyl is an analgesic and pancuronium is on mainly as a muscle relaxant. Most patients are tapered to midazolam,which has both sedative and analgesic effects.
Surgery is putting stress on the body. With high stress, patients are at risk of stress ulcers. Famotidine is the medication used for prophylaxis. If, however, the patient experiences bloody stools, they transition them to a proton pump inhibitor.
Other medications that are commonly seen are antiplatelets such as heparin and aspirin, to prevent shunts from clotting. Coumadin is common for older patients, especially those with shunts and mechanical valves.
Everyday on rounds, I learned something new. I feel that six weeks (ore more) could easily have been devoted to a rotation like this.