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KNOWLEDGE COMPETENCIES
Discuss advantages and disadvantages of various routes for medication delivery in critically ill patients.
Identify indications for use, mechanism of action, administration guidelines, side effects, and contraindications for drugs commonly administered in critical illness.
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Critically ill adult patients often receive multiple medications during their admissions to an intensive care unit (ICU). These patients may be at risk for increased adverse effects from their medications because of altered metabolism and elimination that is commonly seen in the critically ill patient. Organ dysfunction or drug interactions may produce increased serum drug or active metabolite concentrations, resulting in enhanced or adverse pharmacologic effects. Therefore, it is important to be familiar with each patient’s medications, including the drug’s metabolic profile, drug interactions, and adverse effect profile. This chapter reviews medications commonly used in ICUs and discusses mechanisms of action, indications for use, common adverse effects, contraindications, and usual doses. A summary of intravenous (IV) medication information is provided in Chapter 23, Pharmacology Tables.
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In the care of the critically ill, the medication-use process (which includes prescribing, preparation, dispensing, administration, and monitoring) is particularly complex. Each step in the process is fraught with the potential for breakdowns in medication safety (ie, adverse drug events [ADEs], medication errors). Improvement in medication safety requires interdisciplinary focus and attention. The Institute for Safe Medication Practices (ISMP) has highlighted the following key elements that must be optimized in order to maintain patient safety in the medication use-process:
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Patient information: Having essential patient information at the time of medication prescribing, dispensing, and administration will result in a significant decrease in preventable ADEs.
Drug information: Providing accurate and usable drug information to all healthcare practitioners involved in the medication-use process reduces the amount of preventable ADEs.
Communication of drug information: Miscommunication between physicians, pharmacists, and nurses is a common cause of medication errors. To minimize medication errors caused by miscommunication, it is important to always verify drug information and eliminate communication barriers.
Drug labeling, packaging, and nomenclature: Drug names that look alike or sound alike, as well as products that have confusing drug labeling and non-distinct drug packaging significantly contribute to medication errors. The incidence of medication errors is reduced with the use of proper labeling and the use of unit dose systems within hospitals.
Drug storage, stock, standardization, and distribution: Standardizing drug administration times, drug concentrations, and limiting the concentration of drugs available in patient care areas will reduce the risk of medication errors or minimize their consequences if an error occurs.
Drug device acquisition, use, and monitoring: Appropriate safety assessment of drug delivery devices is made both prior to their purchase and during their use. Also, a system of independent double checks within the institution helps prevent device-related errors such as selecting the wrong drug or drug concentration, setting the rate improperly, or mixing the infusion line up with another.
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