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Pharmacists in Critical
Care: Acute Liver
Failure
Jane Booth
Senior Medicines Information Pharmacist
Austin Health (Melbourne, Australia)
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Pharmaceutical care for critically-Ill
patients
Presentation:
Rapid decline in liver function
Symptomatic: jaundice, coagulopathy, hepatic encephalopathy
Cerebral oedema
Vasodilatory shock
Sepsis
Coagulopathy
Renal failure
Haemodialysis:
Intermittent (three days per week)
Timing of medicines can be important
Haemofiltration (CVVH):
Continuous
Approximately equivalent to eGFR 30 (depending on the
system used)
Primary literature
Dr Jason Roberts publishes extensively in this area
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Role for the pharmacist #3
Antimicrobial stewardship
appropriate medicine choice
appropriate dose
appropriate duration
drug/disease interactions
therapeutic drug monitoring
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Cardiovascular management
Why?
Comatose patients cannot protect their airway from
aspiration and obstruction
normal reflexes not functioning
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Role for the pharmacist #5 and
#6
What else is wrong with the patient?
take an accurate medication history
consider IF regular medicines should be continued in ICU
appropriate in critical illness, renal/hepatic impairment?
consider HOW regular medicines should be continued in ICU
antidepressants, mood stabilisers, Parkinsons Disease
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Role for the pharmacist #7
Useful resources:
Local guidelines
Australian Injectable Drugs Handbook (SHPA)
Trissel: Handbook on Injectable Drugs (US)
Trissels Tables (US)
Gray et al: Injectable Drugs Guide (UK)
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Parenteral compatibility
Approach:
1. Identify which medicines are continuous infusions or take a
long time to run
2. Identify the medicines that need to be given via a central
line
3. Identify any medicines that should not be mixed with other
medicines or are grouped together
4. Check compatibilities for remaining medicines
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Parenteral compatibilty
1. Identify which medicines are continuous
infusions or take a long time to run
Vancomycin 10 mg/minute (eg 2g over 200 minutes)
Ceftriaxone over 3-5 minutes
Ranitidine over at least 5 minutes
Vitamin K (phytomenadione) over 30 seconds
Methylprednisolone over at least 5 minutes
Mycophenolate over at least 2 hours
Noradrenaline infusion
Alprostadil 0.1-0.6 microg/kg/hour (when inotropes not required)
Dextran 40 10 mL/hour
Insulin infusion
Glucose 5% as drug and flush line
Ganciclovir over 1 hour
Anidulafungin 1.1 mg/minute
TPN
Morphine or fentanyl infusion/patient-controlled analgesia
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Parenteral compatibilty
2. Identify the medicines that need to be given via
a central line
Vancomycin 10 mg/minute (eg 2g over 200 minutes)
Ceftriaxone over 3-5 minutes
Ranitidine over at least 5 minutes
Vitamin K (phytomenadione) over 30 seconds
Methylprednisolone over at least 5 minutes
Mycophenolate over at least 2 hours
Noradrenaline infusion
Alprostadil 0.1-0.6 microg/kg/hour (when inotropes not required)
Dextran 40 10 mL/hour
Insulin infusion
Glucose 5% as drug and flush line
Ganciclovir over 1 hour
Anidulafungin 1.1 mg/minute
TPN
Morphine or fentanyl infusion/patient-controlled analgesia
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Parenteral compatibilty
3. Identify any medicines that should not be mixed
with other medicines or are grouped together
Try to keep similar things together if compatible:
Insulin infusion, Glucose 5% as drug and flush line
Noradrenaline with other vasopressors
Generally keep separate:
TPN
Morphine or fentanyl infusion/patient-controlled analgesia
Blood products
Leaves us with:
Vancomycin 10 mg/minute (eg 2g over 200 minutes)
Ceftriaxone over 3-5 minutes
Ranitidine over at least 5 minutes
Vitamin K (phytomenadione) over 30 seconds
Methylprednisolone over at least 5 minutes
Mycophenolate over at least 2 hours
Dextran 40 10 mL/hour
Ganciclovir over 1 hour
Anidulafungin 1.1 mg/minute (100 200 minutes)
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Parenteral compatibilty
4. Check compatibilities for remaining medicines
Twitter: @MI_JaneBooth
Further reading:
Warrillow SJ, Bellomo R. Preventing cerebral oedema in acute
liver failure: the case for quadruple-H therapy. Anaesthesia
and Intensive Care. 2014;42(1):78-88.