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Integración del Farmacéutico en UCI
Dr. Sebastián Ugarte
ICU INDISA Clinic – Andrés Bello University
President FPIMCTI
Council WFSCCM
Envejecimiento de la
población
Aumento de la necesidad
de camas críticas
Crecimiento de las
Expectativas
Aumento de la necesidad
de camas críticas
Crecimiento de las
Expectativas
Envejecimiento de la
población
Aumento de la necesidad
de camas críticas
Ecases de camas UCI



Chile: ocupación es 92%.
Australia: en algunos
hospitales es 90%*
Irlanda: no hay camas de
UCI para el 30% que
requiere.**
*http://www.dhs.vic.gov.au/ahs/archive/icu/servlev.htm
**http://www.icmed.com/archive/publications/Adult%20In
tensive%20Care%20Capacity%20Planning%20and%20D
evelopment%20in%20Ireland.doc
Escasez de los
Profesionales de UCI
Crecimiento de las
Expectativas
Envejecimiento de la
población
Aumento de la necesidad
de camas críticas
Profesionales críticos
¿EL TEMA ES QUIENES ESTARÁN A CARGO DE
LOS PACIENTES CRÍTICOS?
UCI es un trabajo de equipo
TENS
Nutricionistas
Enfermeras
Psicólogos
Kinesiólogos-Terapistas
Médicos
Farmacéuticos – Farmecéuticos clínicos
4 Requerimientos de FARMACIA en Chile
1.
2.
3.
4.
QF 24/7
Farmacólogo clínico 11 horas UCI
Política de calidad de medicamentos
Dispensadores automáticos
SOCHIMI –SOCHINF 2011
Pharmacy evolved
Curricula has changed

To prepare as clinicians:
–
–
–
–
–
–

pharmacotherapeutics,
pharmacokinetics,
pathophysiology,
human anatomy and physiology,
physical assessment,
and pharmacoeconomics
Additional training for graduates (residencies,
fellowships in critical care).
Pharm.D Pharmacotherapy. 2002;22(11)
Critical Care evolved
¿Qué tienen en común?
Alto costo
Full teconolgía
Velocidad
Riesgos
¿Qué más tienen en común?
¿Qué más tienen en común?
Trabajo en equipo
¿Qué más tienen en común?
Trabajo en equipo
Wellcome to the ICU
Drug-Drug Interaction
Drug-Nutrient Interaction
Altered pharmacokinetics
↑ ADE
2013: a global view

Ph have been performing clinical services > 3
decades.
Drug Intell Clin Pharm 1986;20:33-48.

↑ research articles and surveys have identified
areas in which critical care Ph make significant
contributions to patient care.
Am J Hosp Pharm 1993;50:1371-404.
Pharmacotherapy 1994;14:282-304.
Am J Hosp Pharm 2000;57:2171-87.
N Engl J Med 1972;287:151.
Drug Intell Clin Pharm 1973;7:298-308.
Am J Hosp Pharm 1995;52:980-4.
5 areas of contribution: or more?
1.
2.
3.
4.
5.
6.
Assisting physicians in pharmacotherapy decision
making,
Pharmacokinetic consultations
Monitoring drug efficacy and safety,
Drug information, and
Medical education to physicians, nurses, and patients
CPR team
Pharm.D Pharmacotherapy. 2002;22(11)
3 Specific to the CPR team
Provide artificial respiration
 Administer chest compressions
 Relative to drugs:

–
–
–
–
–
–
prepare drugs,
administer drugs,
record drug administration,
provide drug information,
calculate dosages and infusion rates,
set up or operate intravenous pump devices.
Pharm.D Pharmacotherapy. 2002;22(11)
Science of Safety and Patient Health
In the U.S. health care system
– 7 % of patients suffer a medication error
– On average, every patient admitted to an
intensive care unit (ICU) suffers an adverse
event
– 78% of serious medical errors in the ICU
Crit Care Med 2005, 33:1694-1700.
6
On average, every patient admitted to an
intensive care unit (ICU) suffers an adverse
event
6 areas of contribution: or more?
Assisting physicians in pharmacotherapy decision
making,
2. Pharmacokinetic consultations
3. Monitoring drug efficacy and safety,
4. Drug information, and
5. Medical education to physicians, nurses, and patients
6. CPR team
7. Cost containment issues
8. Nutrition support, and
9. Clinical research
Crit Care Med 1999;27:422-6
10. Academic
1.
¿Y esto
cambió los
resultados?
Measurable clinical effects?

↓ Drug errors and adverse drug events

↓ morbidity and mortality rates

↓ $$
On average, every patient admitted to an
intensive care unit (ICU) suffers an adverse
event
↓ Drug errors and adverse drug events


Altered organ function and polypharmacy contribute to
ADEs in ICU patients.
Clinical pharmacists can reduce drug errors and ADEs in a
hospital setting
JAMA 1999;282:267-70.
Prospective Study



2 phases, baseline and intervention
ICU with a pharmacist rounding vs. control coronary care
unit.
Within 9 months:
– ↓ 66% in preventable ADEs (10.4 before to 3.5/1000 patientdays after)
– 99% of recommendations were accepted by physicians.
JAMA 1999;282:267-70.
Can affect clinical end points



↓ Fluid intake in fluid-restricted patients in the ICU
Optimal antimicrobial selection in streptococcal
pneumonia
↓Nephrotoxicity associated with aminoglycosides
– with a ↓ cost > $90,000/100 patients studied.

Identifying appropriate indicators to ensure that drug
therapy leads to a measurable outcome
Drug Intell Clin Pharm 1991;25:208-10.
Presence vs absence of a clinical pharmacist



Shorter hospital stays
Benefit:cost ratio of 6:1
Lower percentage of medical patients required
transfer back into the ICU
Am J Hosp Pharm 1993;50:1875-84.
Reduction in hospital mortality rates

number of pharmacists/average daily census and
combined hospital wide clinical pharmacy
services, were associated with a ↓in mortality
– pharmacists in patient-care areas and participation on
medical rounds,
– availability of therapeutic drug and ADE monitoring
– pharmacokinetic services
– patient drug counseling
– nutrition recommendations
– admission histories
– clinical research, and drug information services.
Pharmacotherapy 1994;14:620-30.
1029 hospitals


Patient mortality rates decrease as pharmacy
staffing/occupied bed increases
specific services having greatest impact:
– participation on medical rounds
– On CPR teams,
– absolute reduction in mortality of 40,000 patients
Pharmacotherapy 1999;19:130-8.
Pharmacotherapy 1999;19:556-64.
Positive economic impact



41% lower drug costs (mean $73.75 vs $43.40,
p<0.001)
$7900 approximate savings (95% CI $900-14,800)
extrapolated to an annual savings of $113,000
(95% CI $13,000-212,000) based on 80,000 patientdays in those areas in 1997.
Crit Care Med 1994;22:1044-8.
Pharmacotherapy 1999;19:1354-62
Am J Hosp Pharm 1986;43:3008-13.
Economic impact
Pharmacotherapy 1999;19:1354-62
Economic impact in the ICU
Am J Hosp Pharm 1986;43:3008-13.
Protocolo de infusión Dex
Ugarte S, Ramirez J, submitted RCHMI 2008
Cambios en la frecuencia cardíaca
del grupo dexmedetomidina

70% mostró < FC con
dexmedetomidina
– 91.8 vs 81.6 durante la
infusión y
– 91.1 a 12 h post

disminución relativa
– - 8.6 durante y
– - 0.8, 12 h post
Ugarte S, Ramirez J, submitted RCHMI 2008
Cambios en la frecuencia cardíaca :
grupo Dex vs.control
Ugarte S, Ramirez J, submitted RCHMI 2008
Mejor frecuencia respiratoria: grupo Dex
vs.control
Ugarte S, Ramirez J, submitted RCHMI 2008
Conclusions



Pharmacy has evolved into a profession that clearly complements
the practice of medicine.
Critical care pharmacists can have a positive impact in the ICU by
decreasing ADEs, improving morbidity and mortality rates, and
decreasing overall health care costs.
The education and training that pharmacists receive prepare these
clinicians to be valuable members of multidisciplinary health care
teams.
Thank you