Critically
ill patients require specialized management and
supervised care in the intensive care unit (ICU) setting.
They are generally victims of burns, multiple trauma,
severe infections, multiple or major organ failure, or
shock. Minute to minute changes in the biochemical and
vital organ function status calls for constant and close
monitoring by members of a specially trained intensive
care provider team.
In addition to various non-pharmacologic life support
measures, ranging from the simple to the highly
sophisticated, there is also a legitimate and vital need
to administer multiple drugs simultaneously. The numbers
can reach 7 to 10 or even 15 to 20 drugs at a time. The
risk of adverse drug reactions and interactions is
thereby increased manifold. Therapeutic strategies in the
critical care setting, whether pharmacologic or
non-pharmacologic, is necessarily individualized, and no
'cook-book approach' can be advocated. Nevertheless, drug
use must still be based on rational and basic
pharmacologic principles. Otherwise clinical
deterioration or even death may result from inappropriate
use of drugs.
Drugs that are frequently needed in the management of the
critically ill patients belong to diverse classes -
fluids & electrolytes, blood & blood components,
advanced cardiac life support drugs, analgesics, local
& general anesthetics, antiarrhythmics, antibiotics,
anticoagulants & thrombolytics, anticonvulsants,
antihypertensives, bronchodilators, corticosteroids,
insulin, muscle relaxants, poisoning antidotes,
sedatives, etc. All these drugs are essential and very
often life-saving. Their prompt availability in the ICU
facility requires maintenance of an adequate and closely
verified stock. Quality of the drug preparations must be
assured through good pharmaceutical procurement policy
and appropriate storage and handling measures.
Prescribing drugs is among the primary responsibilities
of ICU doctors. A team, at least a skeletal one, should
be present in the ICU round-the-clock, instead of on call
as is common practice. Prescribing by members of this
team should be the culmination of logical deductive
process based on objective information and clinical
judgment and should not be just a 'knee-jerk reaction'.
The selection of drugs for the ICU basket should take
into consideration the possibility of altered
pharmacokinetic (and sometimes even pharmacodynamic)
behavior of the drugs in the backdrop of the critical and
changing status of the patients. Polypharmacy being the
rule, the doctors must be knowledgeable about and be
alert to the possibility of adverse reactions and
interactions. Once the appropriate drug is selected, each
facet of the dosing regime must be given careful thought.
Many well run ICUs find it convenient to provide
handbooks of critical care therapy, laying down basic
protocols tailored to the local conditions, for quick
reference. This helps not only new entrants to the ICU,
but also experienced members, to streamline operations.
Since drug administration is necessarily highly
supervised, the responsibility of non-adherence to the
prescribed regimes lies almost entirely with the care
givers rather than with the patients. Nursing staff in
the ICU require special training to cope with the
intricacies of different drug delivery techniques usually
required in this setting. All members must make it second
nature to follow guidelines for preventing iatrogenic
infections.
Constant monitoring of treatment outcome is also an
essential component of rational drug use in the ICU
setting and probably the best indicator for the
appropriateness of treatment individulization.
Therapeutic drug monitoring can be done in either of two
ways:
a drug concentration strategy that
relies on estimation of trough (pre-dose)
concentration of the drug in blood.
a drug effect strategy that calls
for an objective assessment of pharmacodynamic
endpoints, planned a priori according to
the demands of the given situation.
The cost of critical care drug therapy
is extremely high and ever escalating. A conscientious
intensivist is always in a dilemma between not
compromising the treatment and containing the costs. The
ethical issues involved are delicate. In India consumers
usually pay for treatment directly from their pockets and
family members stake all to save the lives of their near
and dear ones. Even today, at least in such situations,
they look upon their doctors as next to God, reposing
total faith and confidence, and expecting them to do
their best. While enjoying the privilege, the care giver
is under ethical obligation to consider the
cost-effectiveness of any treatment prescribed. This
obligation must be respected for the greater good of
society.
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