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Madison Schwartz, Pharm.D.
PGY1 Pharmacy Resident
Baptist Health Medical Center – Little Rock
A FASTHUG FOR PHARMACISTS
WORKING IN THE ICU
Objectives
• Describe the components of FASTHUG-MAIDENS
• Utilize the FASTHUG-MAIDENS method to identify and
resolve drug-related problems in patients admitted to
the intensive care unit (ICU)
F
• Feeding
A
• Analgesia
S
• Sedation
T
• Thromboprophylaxis
H
• Head up position
U
• Ulcer prophylaxis
G
• Glycemic control
S
• Spontaneous Breathing
Trial (SBT)
B
• Bowel Care
I
• Indwelling catheter removal
D
• De-escalation of antibiotics
Crit Care Med. 2009 Jul;37(7):2326-7
Images: http://fcmcng.com/services/
F
• Feeding
M
• Medication reconciliation
A
• Analgesia
A
• Antimicrobials
S
• Sedation
I
T
• Thromboprophylaxis
• Indications for medications
D
• Dosing
H
• Hypoactive or
Hyperactive delirium
E
• Electrolytes, hematology,
and other lab tests
U
• Ulcer prophylaxis
N
• No drug interactions, allergies,
duplications, or side effects
G
• Glycemic control
S
• Stop dates
Can J Hosp Pharm 2013;66(3):157-62.
Can J Hosp Pharm. 2011;64(5):366-9.
Crit Care Med. 2009 Jul;37(7):2326-7
Feeding
Macromolecule Requirements
PO>EN>TPN
Dosing Weight = IBW + 0.25 (ABW-IBW)
• Use the gut
• Avoid infection
Start with 8-10 kcal/kg/day
Goal of 25-30 kcal/day after ~ 1 week
Changing routes of administration
Protein (Amino Acids): 4 kcal/g
- Moderate illness: 0.8-1.2 g/kg/day
- Critical illness: 1.2-1.5 g/day
• IV to PO, PO to G-tube, etc.
Feeding tube considerations
• Do not crush list – ER, SR, CR formulations
• Drug interactions with enteral feeding products
JAMA. 2012 Feb;307(8):795-803.
Can J Hosp Pharm. 2011;64(5):366-9.
PO: By mouth
Dextrose: 3.4 kcal/g
- Majority of daily kcals
EN: Enteral Nutrition
Lipids (Fat Emulsion): 2 kcal/mL (20%)
- 30% of daily kcal requirements
- Monitor triglycerides
- Propofol: 1.1 kcal/mL
- Clevidipine (IV fat emulsion): 2 kcal/mL
TPN: Total Parenteral Nutrition
Analgesia BEFORE Sedation
Consequences of Uncontrolled Pain
Acute Stress Response:
- Hypercatabolic state
- Decreased tissue perfusion
- Decreased immune response to infection
- Impaired wound healing
Long-term effects:
- Decreased health-related quality of life
- Post-traumatic stress disorder
- Chronic pain
Analgosedation
IV Opioids First-line
Avoid Continuous Infusions
Neuropathic & Antispasmodic Agents
Pain & Sedation Scoring
Crit Care Med 2013;41:263-306
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://namas.co/clinical-auditing-improvement-cai/
Thromboprophylaxis
Bleeding
Risk
Clotting
Risk
Chest. 2012;141(2_suppl):7S-47S.
Can J Hosp Pharm. 2011;64(5):366-9.
SCDs: Sequential Compression Devices
LMW: Low Molecular Weight
DTIs: Direct Thrombin Inhibitors
Thromboprophylaxis
Clotting
Risk
Bleeding
Risk
Chest. 2012;141(2_suppl):7S-47S.
Can J Hosp Pharm. 2011;64(5):366-9.
SCDs: Sequential Compression Devices
LMW: Low Molecular Weight
DTIs: Direct Thrombin Inhibitors
Thromboprophylaxis
Treatment Options:
- SCDs
- Heparin
- LMW Heparins
- DTIs
- Factor Xa Inhibitors
Patient Factors:
- Age
- Current Diagnoses
- Procedures
- Renal Impairment
- Hepatic Impairment
- Patient Mobility
Bleeding
Risk
Clotting
Risk
Monitoring:
- Signs of bleed/clot
- Platelets
- Anti-Xa levels
Chest. 2012;141(2_suppl):7S-47S.
Can J Hosp Pharm. 2011;64(5):366-9.
SCDs: Sequential Compression Devices
LMW: Low Molecular Weight
DTIs: Direct Thrombin Inhibitors
Hypoactive or Hyperactive Delirium
Assess Every 8-12 Hours
Scoring Tools
CAM-ICU, ICDSC
Consequences of Delirium
Increased patient mortality
Increased duration of mechanical ventilation
Increased likelihood of being discharged to a nursing home
Drug Classes Known to Cause Delirium
Benzodiazepines
Opiates
Anticholinergics
Antipsychotics
Crit Care Med 2013;41:263-306
Can J Hosp Pharm. 2011;64(5):366-9.
Antispasmodics
Anticonvulsants
Corticosteroids
**Withdrawal**
Image: https://newsatjama.files.wordpress.com/2013/10/10-2-13-icu-delirium-istock_000021992120xsmall.jpg
Ulcer Prophylaxis
Stress ulcer prophylaxis for ALL mechanically ventilated patients
Treatment Options:
- Feed the patient
- Proton-pump inhibitors
- Histamine-2 Receptor Blockers
Complications:
- C. difficile
- Pneumonia
Pharmacist’s Role:
- Separation of acid suppressants from interacting medications
- Changing from IV to PO
- Appropriate discontinuation of acid suppressants
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://www.iccueducation.org.uk/evidence-based-practice/routine-stress-ulcer-prophylaxis-why
Glycemic Control
Blood Glucose < 180 mg/dL in ICU patients
Drugs That Can Raise BG Levels
Corticosteroids
Catecholamines
Barbiturates
Antipsychotics
Octreotide
Beta-agonists
Baclofen
Tacrolimus
Cyclosporine
Phenytoin
Drugs That Can Lower BG Levels
Diabetes Medications
Sulfamethoxazole/Trimethoprim
Beta-blockers (non-selective)
Aspirin
NEJM. 2009. 360(13):1283-1297.
Can J Hosp Pharm. 2011;64(5):366-9.
Images: http://www.medscape.com/viewarticle/861746a
Medication Reconciliation
ACCURATE home medication lists
Important Information to Discuss with
Patients During Medication Reconciliation
Allergies and reactions
Past and current medical history
Restarting important home medications
• Avoid withdrawal – antidepressants, benzodiazepines, baclofen
• Opiate use – tolerance, maintenance doses
Recent antibiotic use (last 90 days)
Injectable medications (insulin, steroids)
Inhaler use
Samples
Eye drops
Drug-related causes for hospitalization
• AKI associated with excessive NSAID use
• Bleeding associated with anticoagulants
• Toxicities/Overdoses
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://www.huffingtonpost.com/2013/06/19/prescription-drugs-prevalence-americans_n_3466801.html
Aspirin
Warfarin dosing
Topical medications
Vaccine status
Recent medication changes
OTCs/Herbals
Antimicrobials
C&S
Testing
Antibiotic
De-escalation
Antibiogram
Data
Antibiotic
Stewardship
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://www.slideshare.net/fergua/drugs-against-bugs-antibiotics-in-the-icu
Inducible
Resistance
Antimicrobials
C&S
Testing
Factors Affecting Choice
of Antibiotic Therapy
Antibiotic
De-escalation
Allergies
Renal function
Recent antibiotic use
Antibiogram
Data
Antibiotic
Stewardship
Inducible
Resistance
Recent hospital admission
Drug interactions
Adverse effects
Therapeutic drug monitoring
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://www.slideshare.net/fergua/drugs-against-bugs-antibiotics-in-the-icu
Indications for Medications
Decrease unnecessary medication use to avoid:
•
•
•
•
Adverse effects
Drug interactions
Medication errors
Costs
Assess patients for untreated indications:
• DVT prophylaxis
• Pain medications
• Withdrawal
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://mrnussbaum.com/pioneers/isaac_newton/
For every indication, there should
be an equal and opposite
medication…
Dosing
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://media.gettyimages.com/photos/spilled-capsules-from-prescription-bottle-picture-id182725169
Dosing
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://media.gettyimages.com/photos/spilled-capsules-from-prescription-bottle-picture-id182725169
Electrolytes, Hematology,
and Other Laboratory Tests
Drug-related
Lab
Abnormalities
Therapeutic
Drug
Monitoring
Drug Side
Effects
Volume Status
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://guidelineshealth.com/health-care/send-it-to-the-lab-how-medical-professionals-process-lab-tests/
No Drug-Related Problems
No Interactions
•
•
•
•
Drug-drug
Drug-food
Drug-laboratory
IV compatibility
No Allergies
• Allergy vs. intolerance
No Duplications
No Side Effects
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://www.pepid.com/drug-interactions/
Image: https://janaburson.wordpress.com/2014/03/25/drug-interactions-with-methadone/
Stop Dates
Major Culprits:
• Ketorolac (IV)
• Hypertonic saline
• Antibiotics
• Corticosteroids
• Sedatives
Avoid inappropriate discontinuation of therapy
Can J Hosp Pharm. 2011;64(5):366-9.
Image: http://www.clipartpanda.com/categories/stop-sign-clip-art-microsoft
Take Away Points
A standardized approach to pharmaceutical
management of ICU patients can improve:
• Pharmacists’ ability to identify drug-related problems
• Provision of high-quality therapy
The FASTHUG-MAIDENS pneumonic may be a
useful tool for pharmacists caring for ICU patients
Can J Hosp Pharm. 2011;64(5):366-9.
http://www.keepcalm-o-matic.co.uk/p/keep-calm-and-give-your-patient-a-fast-hug-1/
Question
• Which of the following is known to cause delirium?
A.
B.
C.
D.
Lorazepam
Simvastatin
Amlodipine
All of the above
References
Vincent WR 3rd, Hatton KW. Critically ill patients need “FAST HUGS BID” (an updated mnemonic). Crit Care
Med. 2009 Jul;37(7):2326-7.
Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P. Initial trophic vs
full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012 Feb;307(8):795803.
Mabasa VH, Malyuk DL, Weatherby EM, Chan A. A standardized, structured approach to identifying drugrelated problems in the intensive care unit: FASTHUG-MAIDENS. Can J Hosp Pharm. 2011;64(5):366-9.
Masson SC, Mabasa VH, Malyuk DL, Perrott JL. Validity Evidence for FASTHUG-MAIDENS, a Mnemonic for
Identifying Drug-Related Problems in the Intensive Care Unit. Can J Hosp Pharm 2013;66(3):157-62.
References
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and
delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263-306
Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P. Initial trophic vs
full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012 Feb;307(8):795803.
Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest.
2012;141(2_suppl):7S-47S.
Finfer S, et al. "Intensive versus conventional glucose control in critically ill patients". The New England Journal
of Medicine. 2009. 360(13):1283-1297.
Questions?
Madison Schwartz, Pharm.D.
PGY1 Pharmacy Resident
Baptist Health Medical Center – Little Rock
A FASTHUG FOR PHARMACISTS
WORKING IN THE ICU