Episode 264: How a pharmacist can assess a critical care patient

In this episode, I’ll discuss how a pharmacist can assess a critical care patient.

Making assessments of critically ill patients can be challenging for pharmacists since traditional pharmacy training does not necessarily incorporate much about patient assessment.

The process I have developed for assessing critically ill patients from a pharmacist’s point of view involves:

1. Determining why the patient is in the ICU
2. Determining how sick the patient is
3. Looking at medications last

Why is the patient in the ICU?

There are 3 categories of reasons why a patient might be in an ICU. I want to make sure I identify the reason as early as possible in my assessment.

1. A vital system has failed and we need to support it (respiratory failure, need for vasopressors, etc…)
2. Something has happened that makes it likely a vital system will fail, and we need to recognize and support it when that happens (tPA for stroke within the last 24 hours, an overdose of unknown substances, a high-risk surgical procedure)
3. The patient doesn’t need to be in the ICU any longer.  Sometimes unnecessary ICU stays are rationalized because the patient is a “VIP,” or a consultant physician wants to keep them “one more day,” or there is a bed availability issue in the hospital.

Knowing why a patient is in the ICU is the beginning step in assessing how sick a patient is.

How sick is the patient?

Being able to assess how sick a patient is will help us determine the optimal pharmacotherapy regimen to use to help the patient recover from their critical illness. For many medications, the degree of how sick a patient is will change the risk:benefit ratio of using that medication.

For example, being able to identify whether an infection is moderate or severe is necessary to choose the best antibiotic and dosing regimen for a patient. And being able to identify how critical a patient’s hypotension is helps us decide the best starting dose for vasopressor therapy.

Here are some of the things I look at when deciding how sick an ICU patient is:

1. How does the patient look? Are they discolored? In distress? Unresponsive?
2. How many systems are being supported? Ventilator? Pressors/inotropes? Dialysis?
3. How intense is the support? PEEP/FIO2? Pressor dose? Number of pressors? CRRT? Number of consultants? Number of IV pumps in use?
4. How successful is the support? MAP>65? Tachycardia resolving? O2 sats acceptable? Urine output trending positive? Fever persisting? Following commands?
5. What do the labs say? Are the 2nd set of blood cultures negative? WBC trending down? Creatinine trending down? Lactate normal? Liver enzymes normal?

Look at the medications last

I avoid looking at the medication profile until the last step in my patient assessment. I do this for 2 reasons:

1. I want to develop my own pharmacy problem list and then compare it to the physicians’.
2. Looking at the medication profile first leads to unnecessary guessing about the patient’s disease states.

For example, if you see ceftriaxone/azithromycin on a patient’s profile you might guess they have pneumonia.  If you see furosemide you might guess they have heart failure. But these guesses are often wrong, and if not corrected can lead to missed opportunities to improve a patient’s pharmacotherapy regimen.

This method of guessing the patient’s problems is leftover from a time of paper charting when pharmacists were physically separated from the patient’s medical record.  But now electronic charting and the decentralization of pharmacy services means the patient’s problem list should be readily available to the pharmacist, and guessing is no longer necessary.

I found that my interventions became more meaningful and significant when I began looking at the medication list last – after reviewing notes, flow sheets, laboratory, and home medication records.

Here are some examples of problems that might not be recognized by looking at the meds first but are obvious if you have already reviewed the rest of the patient’s record:

• Propofol alone as sedation might be OK for some patients, but if I know they just underwent a major surgery the absence of fentanyl or another analgesic becomes clear.
• Determining the cause of a patient’s agitation can be very time consuming, but if I know they were on venlafaxine at home and haven’t had it for 3 days it is easier to narrow down the possible causes.
• Seeing oral vancomycin as an order doesn’t necessarily mean anything, but knowing that the cdiff test was negative and the CT did not find colitis makes it immediately clear the vancomycin can be discontinued safely.

Members of my Hospital Pharmacy Academy have access to my ICU Patient Assessment Masterclass where I dive deep into these topics.  To get access click here.

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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