Inpatient Pharmacy Vivian Sinkaset, Pharm.D., BCPS Miramar Science Club Guest Speaker April 28, 2010

Outline Education Terminology Inpatient pharmacist responsibilities All in a day’s work

Education Pre-requisite courses for pharmacy school Bachelor’s degree (B.S., B.A.) – recommended, but optional Doctor of Pharmacy degree (Pharm.D.) Residency – post-doctorate training optional How long does it take to become an inpatient pharmacist? ** 5 – 9 years **

Outpatient/Retail Pharmacist

Inpatient/Clinical Pharmacist

Inpatient Pharmacy at Kaiser Staff pharmacist Intensive care unit (ICU) pharmacist Pediatrics/neonatal ICU pharmacist Infectious diseases pharmacist Operating room pharmacist IV room pharmacist

Responsibilities Verify doctor’s medication orders and monitor medication therapy of hospitalized patients Review medication profiles for dosage accuracy, drug-interactions, and side effects Monitor the distribution, dispensing, and compounding of medications

Responsibilities Perform pharmacokinetic evaluations on anitibiotics and anticoagulants Schedule and order drug levels Collaborate with dietitians to formulate and provide parenteral nutrition to patients who cannot receive oral feedings

Responsibilities Evaluate patient’s kidney function and adjust medication dosage accordingly Supervise pharmacy technicians and interns Educate and counsel patients being discharged on new Coumadin therapy and arrange for follow-up visits Respond to code blue and stroke codes

A Typical Day at Work… 7:00am – 3:30pm Get report from graveyard pharmacist and pick up pager Print “work list” for the day –Pharmacy protocols Prioritize critical patients –Blood thinners, antibiotics, total parenteral nutrition (TPN)

Pharmacy protocols Antibiotics –Vancomycin, Gentamicin, Amikacin, Tobramycin Blood thinners –Heparin, Enoxaparin, Fondaparinux and Warfarin (Coumadin®) Parenteral nutrition Renal dosage adjustment –Adjust medication doses based on kidney function

Patient Case 38 y.o. male complain of swelling and redness on left lower leg x 1 week. Seen in clinic 3 days ago, given oral antibiotics, but symptoms worsened. Now has fever of °F. Admitted for cellulitis. Doctor wants to start IV antibiotics with Zosyn and vancomycin per pharmacy protocol.

Fred Flintstone Obtain patient information -- Age: 38 y.o. Gender: Male Height: 5’9” Weight: 180 lbs (= 81.8 kg) Serum creatinine: 0.9mg/dL Perform pharmacokinetic calculations

Pharmacokinetic formulas Cockcroft and Gault equation : CrCl = [(140 - age) x IBW] / (Scr x 72) Volume of distribution (Vd) = Weight x 0.75 L/Kg T 1/2= / Kel Calculate Maintenance dose (MD):_____mg. MD = [(kel) x (Vd) x (ti) x (Cpeak desired) x (1 - e -kT )] / (1 - e -kti ) Calculate Loading dose (LD):_____mg. LD = 25mg/Kg Vancomycin: Kel = ( x CrCl)

Pharmacist Note Subjective / Objective: –38 y/o caucasian male admitted with cellulitis, start vancomycin per pharmacy –Pertinent labs: SCr: 0.9 mg/dL WBC 18,000 Temp: °F 4/28/10 Wound cultures: pending Assessment / Plan: –Give vancomycin loading dose 2000mg IV x1, then start vancomycin 1750mg IV every 12 hours for target concentration of 10-15mcg/ml. –Check level on 4/30/10 before morning dose

Pharmacy protocols Antibiotics –Vancomycin, Gentamicin, Amikacin, Tobramycin Blood thinners –Heparin, Enoxaparin, Fondaparinux and Warfarin (Coumadin®) Parenteral nutrition Renal dosage adjustment –Adjust medication doses based on kidney function

Throughout the day… Communicate with nurses and doctors –Medication related issues Intravenous compatibility, infusion rate Drug-drug interactions, drug-food interactions Clarify orders Recommend antibiotic regimens

Throughout the day… Respond to code blue –Cardiac / respiratory arrest –Provide emergency medications

Conclusion Communication skills –Explain treatments to patients as well as co- ordinate treatment with other healthcare professionals Organization –Workload can be extremely hectic and stressful. Prioritize and multitask without making mistakes Attention to detail –Dispensing the right medicines and right dosage can be a “life and death” activity. Mistakes really could be fatal!

Questions?