A FASTHUG FOR PHARMACISTS WORKING IN THE ICU

A FASTHUG FOR PHARMACISTS WORKING IN THE ICU
Madison Schwartz, Pharm.D. PGY1 Pharmacy Resident Baptist Health Medical Center – Little Rock A FASTHUG FOR PHARMACISTS WORKING IN THE ICU Good afternoon everyone. My name is Madison Schwartz, I am a PGY1 resident at Baptist Health Medical Center in Little Rock. Today I will be talking to you about the FASTHUG pneumonic, which is can used by pharmacists working in the ICU to enhance the care of these patients.

Objectives Describe the components of FASTHUG-MAIDENS
Utilize the FASTHUG-MAIDENS method to identify and resolve drug-related problems in patients admitted to the intensive care unit (ICU) So by the end of this presentation, you should be able to describe the components of the FASTHUGS-MAIDENS pneumonic as well as be able to utilize this pneumonic in identifying and resolving drug-related problems in patients admitted to the ICU.

B I D F A S T H U G Feeding Bowel Care Analgesia
Sedation S Thromboprophylaxis T Head up position H Ulcer prophylaxis U Glycemic control G Spontaneous Breathing Trial (SBT) Bowel Care B Indwelling catheter removal I De-escalation of antibiotics D Now some of you may be familiar with the FASTHUGS-BID pneumonic, which was proposed in 2005 and validated as a standardized approach to help ICU physicians ensure that all essential aspects of care for critically ill patients are met. However, the FASTHUGS-BID mnemonic was NOT designed to identify drug-related problems commonly seen in the ICU, and so this approach to ICU care is only somewhat applicable to pharmacists, who must ensure that all medication therapies are appropriate for the care and safety of these patients. Crit Care Med Jul;37(7):2326-7 Images:

M F A A S I T H U G E N S D Dosing
Feeding F Analgesia A Sedation S Thromboprophylaxis T Hypoactive or Hyperactive delirium H Ulcer prophylaxis U Glycemic control G Medication reconciliation M Antimicrobials A Indications for medications I Dosing D Electrolytes, hematology, and other lab tests E No drug interactions, allergies, duplications, or side effects N Stop dates S So, in 2011, four Canadian pharmacists created and published the FASTHUG-MAIDENS pneumonic as a possible method or checklist for pharmacists working in the ICU to be able to identify and resolve various medication-related issues that can occur in these sometimes very complicated patients. In a 2013 study, use of the FASTHUG-MAIDENS mnemonic by pharmacy residents allowed them to identify significantly more, 24% more, drug-related problems in ICU patients than pharmacy residents using standard monitoring practices. And so, although this is a lot more letters to get through in one presentation, I believe that because we are at a pharmacy conference that I needed to instead present this more pharmacy-oriented FASTHUG-MAIDENS pneumonic. So lets get started! Can J Hosp Pharm 2013;66(3): Can J Hosp Pharm. 2011;64(5):366-9. Crit Care Med Jul;37(7):2326-7

Feeding PO>EN>TPN Changing routes of administration
Macromolecule Requirements Dosing Weight = IBW (ABW-IBW) Start with 8-10 kcal/kg/day Goal of kcal/day after ~ 1 week Dextrose: 3.4 kcal/g - Majority of daily kcals Protein (Amino Acids): 4 kcal/g - Moderate illness: g/kg/day - Critical illness: g/day Lipids (Fat Emulsion): 2 kcal/mL (20%) - 30% of daily kcal requirements - Monitor triglycerides - Propofol: 1.1 kcal/mL - Clevidipine (IV fat emulsion): 2 kcal/mL PO>EN>TPN Use the gut Avoid infection Changing routes of administration IV to PO, PO to G-tube, etc. Feeding tube considerations Do not crush list – ER, SR, CR formulations Drug interactions with enteral feeding products As we go through each of the components of the FASTHUG-MAIDENS pneumonic, you’ll notice that some of the components of the original FASTHUG pneumonic are still incorporated. Like the original FASTHUGS-BID pneumonic, F still stands for feeding. Pharmacists often are consulted to manage TPN formulations on patients, and recommendations from dieticians can help guide macromolecule and additive requirements as well as monitor patient diets for progression toward the PO route as soon as possible to avoid infections and other complications associated with prolonged TPN use and lack of gut utilization. Pharmacists can also play a role in ensuring that there are no medication-feeding related issues; including changing routes of administration of medications such as IV to PO or to per G-tube. And if medications are being given through an OG or NG tube, pharmacists have the responsibility to ensure that there are no feeding tube or feeding product interactions, such as with phenytoin or extended-release formulations. Direct comparisons of enteral nutrition to parenteral nutrition in critically ill patients indicate that enteral nutrition does not reduce mortality but may be associated with a lower incidence of infection Evidence suggests that early parenteral nutrition in well-nourished critically ill patients, whether given as the sole therapy or supplemental to enteral nutrition, does not reduce mortality and may be associated with an increased risk of nosocomial infections. Early parenteral nutrition may increase the risk of infection and prolong mechanical ventilation, intensive care unit (ICU) stay, and hospital stay – but patients that are malnourished upon arrival to the ICU may require earlier feeding initiation Do not give total calorie requirement for the first week, can lead to worse pt outcomes – start low and go slow Nutritional surrogates, particularly serum proteins (eg, albumin, prealbumin/transthyretin) are similarly susceptible to the effects of systemic inflammatory illness, and are not responsive to nutrient intake Importance of fluids - Guidelines discourage early enteral nutrition in critically ill patients who are both hemodynamically unstable and have not had their intravascular volume fully resuscitated, since such patients may be predisposed to bowel ischemia Other contraindications to enteral nutrition include bowel obstruction, severe and protracted ileus, major upper gastrointestinal bleeding, intractable vomiting or diarrhea, severe hemodynamic instability, gastrointestinal ischemia, and a high output fistula. Contraindications to parenteral nutrition include hyperosmolality, severe hyperglycemia, severe electrolyte abnormalities, volume overload, inadequate IV access, and inadequate attempts to feed enterally. Patients with chronic undernourishment should receive supplemental thiamine prior to initiation of artificial nourishment to prevent Wernicke syndrome. Zinc deficiency in patients getting prolonged propofol infusions JAMA Feb;307(8): Can J Hosp Pharm. 2011;64(5):366-9. PO: By mouth EN: Enteral Nutrition TPN: Total Parenteral Nutrition

Consequences of Uncontrolled Pain
Analgesia BEFORE Sedation Analgosedation IV Opioids First-line Avoid Continuous Infusions Neuropathic & Antispasmodic Agents Pain & Sedation Scoring Consequences of Uncontrolled Pain Acute Stress Response: - Hypercatabolic state - Decreased tissue perfusion - Decreased immune response to infection - Impaired wound healing Long-term effects: - Decreased health-related quality of life - Post-traumatic stress disorder - Chronic pain When I was first taught about the FASTHUGS pneumonic, I learned that A comes before S for a reason. The 2013 Pain, Agitation, and Delirium Guidelines describe the utilization of Analgosedation, a method that involves managing a patients pain first with IV opioids in order to take advantage of their additional sedating properties and potentially decrease sedative requirements. Treating pain first is crucial, as uncontrolled pain in ICU patients can lead to acute stress response that leads to a hypercatabolic state and decreases patients immune function. In addition, uncontrolled pain has been a major cause of PTSD and decreased quality of life in ICU survivors. As pharmacists, we can play a role in ensuring patients have adequate pain control, and appropriate sedation levels. In addition, pharmacists can make recommendations to help prevent accumulation of IV analgesics and sedatives by monitoring renal and hepatic function as well as promoting the use of boluses over continuous infusions whenever possible. Crit Care Med 2013;41: Can J Hosp Pharm. 2011;64(5): Image:

Thromboprophylaxis Bleeding Risk Clotting Risk
Next in the pneumonic is T, which stands for Thromboprophylaxis, which is typically covered with sequential compression devices, aka SCDs, with or without pharmacological agents such as heparin. Pharmacists can make recommendations for initiating thromboprophylaxis, make renal dose adjustments when appropriate, and help monitor patients for signs of bleeding and clotting risk by assessing patient factors such as age and diagnosis as well as laboratory factors such as anti-Xa levels and trends in platelets. Chest. 2012;141(2_suppl):7S-47S. Can J Hosp Pharm. 2011;64(5):366-9. SCDs: Sequential Compression Devices LMW: Low Molecular Weight DTIs: Direct Thrombin Inhibitors

Thromboprophylaxis Clotting Risk Bleeding Risk
Next in the pneumonic is T, which stands for Thromboprophylaxis, which is typically covered with sequential compression devices, aka SCDs, with or without pharmacological agents such as heparin. Pharmacists can make recommendations for initiating thromboprophylaxis, make renal dose adjustments when appropriate, and help monitor patients for signs of bleeding and clotting risk by assessing patient factors such as age and diagnosis as well as laboratory factors such as anti-Xa levels and trends in platelets. Chest. 2012;141(2_suppl):7S-47S. Can J Hosp Pharm. 2011;64(5):366-9. SCDs: Sequential Compression Devices LMW: Low Molecular Weight DTIs: Direct Thrombin Inhibitors

Thromboprophylaxis Patient Factors: Treatment Options: - Age - SCDs
- Current Diagnoses - Procedures - Renal Impairment - Hepatic Impairment - Patient Mobility Treatment Options: - SCDs - Heparin - LMW Heparins - DTIs - Factor Xa Inhibitors Bleeding Risk Clotting Risk Next in the pneumonic is T, which stands for Thromboprophylaxis, which is typically covered with sequential compression devices, aka SCDs, with or without pharmacological agents such as heparin. Pharmacists can make recommendations for initiating thromboprophylaxis, make renal dose adjustments when appropriate, and help monitor patients for signs of bleeding and clotting risk by assessing patient factors such as age and diagnosis as well as laboratory factors such as anti-Xa levels and trends in platelets. Monitoring: - Signs of bleed/clot - Platelets - Anti-Xa levels Chest. 2012;141(2_suppl):7S-47S. Can J Hosp Pharm. 2011;64(5):366-9. SCDs: Sequential Compression Devices LMW: Low Molecular Weight DTIs: Direct Thrombin Inhibitors

Hypoactive or Hyperactive Delirium
Assess Every 8-12 Hours Consequences of Delirium Increased patient mortality Increased duration of mechanical ventilation Increased likelihood of being discharged to a nursing home Scoring Tools CAM-ICU, ICDSC Drug Classes Known to Cause Delirium Benzodiazepines Opiates Anticholinergics Antipsychotics Antispasmodics Anticonvulsants Corticosteroids **Withdrawal** Moving on to H, you may notice that the FASTHUG-MAIDENS pneumonic replaced the H for “Head up position” and changed it to “Hypo- or Hyper-active delirium.” Head-up position is still important to remember for your patients, but from a pharmacy perspective, there are far more medication-related issues associated with delirium. Delirium is a serious complication in ICU patients which has been associated with a 3-fold increase in patient mortality, time on mechanical ventilation, as well as increased likelihood of being discharged to a nursing home. Early detection of delirium is vital, and patients should be assessed at least every 12 hours using tools such as the CAM-ICU score. When delirium is suspected, pharmacists can help by reviewing patient medications to assess for possible causes of drug-induced delirium and help determine ways to wean or discontinue these medications. Unfortunately, as you can see in the table, almost all of these medication classes are commonly used in ICU patients. In addition, pharmacists can review patient home medications to evaluate for delirium caused by drug withdrawal. For the treatment of delirium, pharmacists can also help with antipsychotic medication management by ensuring that dosing is appropriate and monitoring for various adverse effects associated with antipsychotics, such as extrapyramidal symptoms, QT prolongation, or hyperglycemia. Crit Care Med 2013;41: Can J Hosp Pharm. 2011;64(5): Image:

Stress ulcer prophylaxis for ALL mechanically ventilated patients
Treatment Options: - Feed the patient - Proton-pump inhibitors - Histamine-2 Receptor Blockers Complications: - C. difficile - Pneumonia Pharmacist’s Role: - Separation of acid suppressants from interacting medications - Changing from IV to PO - Appropriate discontinuation of acid suppressants U stands for Ulcer prophylaxis, or Stress Ulcer prophylaxis, which is typically managed with proton-pump inhibitors or histamine-2 receptor blockers. Pharmacists can play a major role in ulcer prophylaxis by assuring that interacting medications are not being administered with acid suppressants and changing administration times if necessary, changing agents from IV to PO when possible, and recommending discontinuation of acid suppressants when appropriate to avoid complications such as C. diff diarrhea and pneumonia. Can J Hosp Pharm. 2011;64(5):366-9. Image:

Blood Glucose < 180 mg/dL in ICU patients
Glycemic Control Blood Glucose < 180 mg/dL in ICU patients Drugs That Can Raise BG Levels Corticosteroids Catecholamines Barbiturates Antipsychotics Octreotide Beta-agonists Baclofen Tacrolimus Cyclosporine Phenytoin The next letter in the pneumonic, G, stands for Glycemic control. The NICE SUGAR trial in 2009 found that intense glucose control in ICU patients has been associated with increased mortality, and so blood glucose goals in ICU patients are slightly more lenient, typically with an acceptable max blood glucose of 180 mg/dL. That being said, it is important that pharmacists monitor patient glucose levels, which are typically managed with insulin. In addition, pharmacists can help review patient medications that may be associated with hyperglycemia, such as corticosteroids; or hypoglycemia, such as aspirin, although this typically occurs with excessive amounts of aspirin. Drugs That Can Lower BG Levels Diabetes Medications Sulfamethoxazole/Trimethoprim Beta-blockers (non-selective) Aspirin NEJM (13): Can J Hosp Pharm. 2011;64(5): Images:

Medication Reconciliation
ACCURATE home medication lists Restarting important home medications Avoid withdrawal – antidepressants, benzodiazepines, baclofen Opiate use – tolerance, maintenance doses Drug-related causes for hospitalization AKI associated with excessive NSAID use Bleeding associated with anticoagulants Toxicities/Overdoses Important Information to Discuss with Patients During Medication Reconciliation Allergies and reactions Past and current medical history Recent antibiotic use (last 90 days) Injectable medications (insulin, steroids) Inhaler use Samples Eye drops Aspirin Warfarin dosing Topical medications Vaccine status Recent medication changes OTCs/Herbals Now as we move onto the new MAIDENS addition of the pharmaceutical FASTHUG pneumonic, we start with M for Medication Reconciliation. It is not only important that medication histories are being conducted for all patients, but that dosages and frequencies are recorded accurately. Important questions that are sometimes missed during medication reconciliation include asking about injectable medications like insulin (because sometimes patients only associate medications with pills), recent antibiotic use, or vaccine status. Pharmacists should be reviewing patient medication histories not only for accuracy, but also for need of reinitiating vital maintenance medications, such as chemotherapy or HIV medications, and medications that may cause withdrawal, such as benzodiazepines or baclofen. In addition, a medication history can provide clues to current patient problems, such as AKI that could associated with excessive NSAID use, or in toxicity or overdose situations. With many patients, a high-quality med rec can be incredibly valuable. Can J Hosp Pharm. 2011;64(5):366-9. Image:

Antibiotic Stewardship Antibiotic De-escalation
Antimicrobials Antibiotic Stewardship Antibiogram Data C&S Testing Antibiotic De-escalation Inducible Resistance In MAIDENS, A stands for Antimicrobials. Along with adjusting doses and frequencies of antimicrobials, pharmacists can play a major role in promoting antibiotic stewardship by comparing agents with local antibiogram data, regularly reviewing culture and sensitivity analyses and recommending narrower-spectrum agents for antibiotic de-escalation and alerting physicians of possible inducible antibiotic resistance. In addition, pharmacists should look out for factors that can influence antibiotic choice, including drug allergies, previous antibiotic use, and drug interactions, as well as monitor levels of narrow therapeutic index agents like aminoglycosides or vancomycin. Can J Hosp Pharm. 2011;64(5):366-9. Image:

Factors Affecting Choice
Antimicrobials Factors Affecting Choice of Antibiotic Therapy Allergies Renal function Recent antibiotic use Recent hospital admission Drug interactions Adverse effects Therapeutic drug monitoring Antibiotic Stewardship Antibiogram Data C&S Testing Antibiotic De-escalation Inducible Resistance In MAIDENS, A stands for Antimicrobials. Along with adjusting doses and frequencies of antimicrobials, pharmacists can play a major role in promoting antibiotic stewardship by comparing agents with local antibiogram data, regularly reviewing culture and sensitivity analyses and recommending narrower-spectrum agents for antibiotic de-escalation and alerting physicians of possible inducible antibiotic resistance. In addition, pharmacists should look out for factors that can influence antibiotic choice, including drug allergies, previous antibiotic use, and drug interactions, as well as monitor levels of narrow therapeutic index agents like aminoglycosides or vancomycin. Can J Hosp Pharm. 2011;64(5):366-9. Image:

Indications for Medications
Adverse effects Drug interactions Medication errors Costs Decrease unnecessary medication use to avoid: DVT prophylaxis Pain medications Withdrawal Assess patients for untreated indications: For every indication, there should be an equal and opposite medication… Next down the list is I for Indications for Medications, and if Issaac Newton was a pharmacist, I bet he would say something along the lines of “for every indication, there should be an equal and opposite medication. “ When reviewing patient medications, pharmacists should be confirming that every medication being given is still required. In addition, it is important that pharmacists review patient charts and address indications that may require pharmacologic therapy. Can J Hosp Pharm. 2011;64(5):366-9. Image:

Correct Dose for Indication Narrow Therapeutic Index Drugs
Dosing Renal Dosing Hepatic Dosing Drug Interactions Correct Dose for Indication Narrow Therapeutic Index Drugs Next in the pneumonic is D for Dosing, and as I have stated throughout this presentation, pharmacists play a significant part in evaluating dosing of medications based on patient’s renal or hepatic function, assessing all medications for drug interactions for need to increase or decrease doses of interacting drugs like warfarin and amiodarone, monitoring levels of narrow therapeutic index drugs, and ensuring that medication doses are appropriate for the indication being treated, like how dosing varies for antibiotics when treating meningitis versus cellulitis. Can J Hosp Pharm. 2011;64(5):366-9. Image:

Drug-related Lab Abnormalities Therapeutic Drug Monitoring
Electrolytes, Hematology, and Other Laboratory Tests Drug-related Lab Abnormalities Therapeutic Drug Monitoring Drug Side Effects Volume Status Monitoring for drug-related laboratory abnormalities Thrombocytopenia – heparin, antibiotics Elevated CPK – dapto Therapeutic Drug Monitoring: digoxin, phenytoin, aminoglycosides, vanco IV Fluids: Assess volume status – Depletion? Overload? Ab-Normal saline – 154 mEq/L, slightly acidic Can J Hosp Pharm. 2011;64(5):366-9. Image:

No Drug-Related Problems
No Interactions Drug-drug Drug-food Drug-laboratory IV compatibility No Allergies Allergy vs. intolerance No Duplications No Side Effects Can J Hosp Pharm. 2011;64(5):366-9. Image: Image:

Stop Dates Major Culprits: Ketorolac max 5 days duration
Ketorolac (IV) Hypertonic saline Antibiotics Corticosteroids Sedatives Avoid inappropriate discontinuation of therapy Image: Major Culprits: Ketorolac max 5 days duration Hypertonic saline Antibiotics Corticosteroids Sedatives Avoid inappropriate discontinuation of therapy Can J Hosp Pharm. 2011;64(5):366-9. Image:

Take Away Points A standardized approach to pharmaceutical management of ICU patients can improve: Pharmacists’ ability to identify drug-related problems Provision of high-quality therapy The FASTHUG-MAIDENS pneumonic may be a useful tool for pharmacists caring for ICU patients Can J Hosp Pharm. 2011;64(5):366-9.

Question Which of the following is known to cause delirium? Lorazepam
Simvastatin Amlodipine All of the above

References Vincent WR 3rd, Hatton KW. Critically ill patients need “FAST HUGS BID” (an updated mnemonic). Crit Care Med Jul;37(7): Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA Feb;307(8): Mabasa VH, Malyuk DL, Weatherby EM, Chan A. A standardized, structured approach to identifying drug-related problems in the intensive care unit: FASTHUG-MAIDENS. Can J Hosp Pharm. 2011;64(5):366-9. Masson SC, Mabasa VH, Malyuk DL, Perrott JL. Validity Evidence for FASTHUG-MAIDENS, a Mnemonic for Identifying Drug-Related Problems in the Intensive Care Unit. Can J Hosp Pharm 2013;66(3):

References Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41: Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA Feb;307(8): Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2_suppl):7S-47S. Finfer S, et al. "Intensive versus conventional glucose control in critically ill patients". The New England Journal of Medicine (13):

A FASTHUG FOR PHARMACISTS WORKING IN THE ICU
Questions? Madison Schwartz, Pharm.D. PGY1 Pharmacy Resident Baptist Health Medical Center – Little Rock A FASTHUG FOR PHARMACISTS WORKING IN THE ICU

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