Journal of pharmacy practice
-
Most critically ill patients receive a myriad of psychoactive medications during their hospital stay. An understanding of the pharmacology of the more commonly used sedative and analgesic therapies enables the clinician to aptly utilize these medications and limit toxicity. ⋯ Limiting these therapies while optimizing patient comfort has been shown to reduce the duration of mechanical ventilation and reduce intensive care unit (ICU) and hospital length of stay and should be the aim of the multidisciplinary medical team. This review is intended to provide the reader with a fundamental understanding of how to facilitate comfort of the mechanically ventilated critically ill adult patients and how to minimize medication-related toxicities.
-
Nutrition support in the critically ill patient has shifted from adjunctive toward fundamental therapy with the publication of high-grade evidence. Early enteral nutrition (EN) is recommended because it is associated with decreased infectious complications and use of EN is associated with decreased mortality and infections compared with parenteral nutrition (PN). EN is not without risks, such as diarrhea or aspiration, but use of prokinetic agents, head of bed elevation, and use of feeding protocols can maximize benefits and minimize risks. ⋯ In nonobese patients, small studies have demonstrated that providing more than 70% or less than 30% of goal caloric intake may be associated with worse outcomes, but more studies are needed. Additional research is also needed to conclude whether withholding intravenous fat emulsions for the first 7 to 10 days of PN reduces infectious complications. Finally, more high-quality studies are needed to define the role of immune-enhancing nutrients such as arginine, glutamine, omega-3 fatty acids, zinc, and selenium.
-
Review Case Reports
A practical approach to understanding acid-base abnormalities in critical illness.
Acid-base disorders are common in the critically ill. Arterial blood gas (ABG) analysis is frequently used to identify and manage acid-base disturbances. Using a systematic problem-solving approach to acid-base disturbances will facilitate the identification and assess the progression and severity of the metabolic and respiratory abnormality. The intent of this review is to examine acid-base physiology and regulation, provide a method to evaluate a patient's acid-base disorder, and provide therapeutic interventions.
-
Mechanical ventilation is a common therapeutic modality required for the management of patients unable to maintain adequate intrinsic ventilation and oxygenation. Mechanical ventilators can be found within various hospital and nonhospital environments (ie, nursing homes, skilled nursing facilities, and patient's home residence), but these devices generally require the skill of a multidisciplinary health care team to optimize therapeutic outcomes. ⋯ Pharmacists may be intimidated by the introduction of advanced ventilator microprocessor technology, but understanding and integrating ventilator management with the pharmacotherapeutic needs of the patient will ultimately help the pharmacist be a better qualified and respected practitioner. The goal of this article is to assist the pharmacy practitioner with a better understanding of mechanical ventilation and to apply this information to improve delivery of pharmaceutical care.
-
Infection is common in the critically ill and often results due to the severity of the patient's illness. Recent data suggest 51% of intensive care unit (ICU) patients are infected, and 71% receive antimicrobial therapy. Bacterial infection is the primary concern, although some fungal infections are opportunistic. ⋯ Absorption, distribution, metabolism, and excretion may all be affected by the various disease states that define critical illness. Several specific diseases are discussed, including ventilator-associated pneumonia, various fungal infections, gastrointestinal infections due to Clostridium difficile, urinary tract infections, and bloodstream infections. Within each disease section, discussion includes causes and prevention strategies, microbiology, evidence-based guidelines, and important caveats.