Tips for Excelling in a Critical Care Rotation from an ICU integrated pharmacist

By Salma, Integrated Clinical Pharmacist, read about her here (hyperlink to other post)

Do you have a critical care rotation coming up?

Although it may feel overwhelming, this could be one of the most rewarding rotations you'll have. Here are 3 tips I recommend to help you get the most out of your critical care rotation.

Develop a Method for Working Up Patients

Every pharmacist will have their own way to work up patients. Some may work up by body system approach (neuro, renal, respiratory, etc.), while others focus on the problem list method (prioritizing the most critical issues first).

Review Common Critical Care Illnesses

Each ICU has its own set of commonly encountered conditions. Brushing up on these ahead of time can make a huge difference in your confidence and performance.

MICU

• Diabetic ketoacidosis (DKA) / Hyperosmolar hyperglycemic state (HHS)

• Acute respiratory distress syndrome (ARDS)

• Septic shock

• Toxicology and overdose management

• Acute kidney injury (AKI), including HD, PD, and CRRT

SICU

• Post-CABG management

• Cardiogenic shock

• Atrial fibrillation

• Post-operative complications

• Surgical antibiotic prophylaxis

Neuro ICU

• Stroke (ischemic and hemorrhagic)

• Seizures

• Meningitis

• Neuromuscular disorders (e.g., Guillain-Barré Syndrome, Myasthenia Gravis)

• Encephalitis

Learn FAST HUG BID

During my PGY-1 residency, I was introduced to FAST HUG BID, which is a comprehensive mnemonic that can be used by the interdisciplinary team to ensure safe and structured patient care.

Feeding: Malnutrition. worsens the outcome for our patients. Route of nutrition is crucial early on (ex: oral nutrition, tube feeding, TPN, PPN)

Analgesia: Adequate pain relief from illnesses or procedures should always be considered.

Sedation: Appropriate sedation goes a long way. Oversedation can lead to complications such as thrombosis, decreased motility, hypotension, and even prolonged ICU stay.

Thromboembolic prophylaxis: blood in stasis will clot. DVT prophylaxis should be considered unless the patient has a contraindication.

Head of bed elevation: A 30-45-degree elevation can reduce the risk of VAP and aspiration.

Ulcer prophylaxis: Stress ulcer prophylaxis can prevent bleeding (especially in patients who are intubated or with coagulation abnormalities).

Glycemic control: Uncontrolled glucose leads to poor wound healing and longer hospital stays. Target range in ICU: 140-180 mg/dL.

Bowel regimen: GI motility, ileus, constipation, and diarrhea are common in critically ill patients. Complications may include bowel obstruction or fecal impaction.

Indwelling catheter removal: removing any unnecessary lines/tubes can decrease the risk of infection for our patients.

De-escalation of antibiotics: antimicrobial stewardship comes into play as we (pharmacists) try to reduce broad-spectrum antibiotic therapy, adverse effects, and costs.

Final Thoughts

Here’s something I wish I fully believed during my own training: it’s okay not to know everything.

You’re there to learn, not to be perfect. Your preceptor’s role is to guide you, challenge you, and help you grow. The ICU is a brand-new environment for most learners, and it takes time to adjust.

Looking back, I spent too much energy stressing about getting every answer right. Growth comes from stepping out of your comfort zone. Good luck!

Reference:

1. FAST HUG BID: Vincent, William R. III PharmD; Hatton, Kevin W. MD. Critically ill patients need “FAST HUGS BID” (an updated mnemonic). Critical Care Medicine 37(7):p 2326-2327, July 2009. | DOI: 10.1097/CCM.0b013e3181aabc29