Renal excretion is an important pharmacokinetic parameter for many drugs. Clinical pharmacists carefully monitor patient’s renal function to assess if changes in drug dosing are required to avoid toxicity or maximum efficacy. The kidney do a lot more than excrete drugs, they participate in maintaining fluid and electrolyte balance, acid/base homeostasis, red blood cell production, vitamin production and waste excretion. As kidney function declines into chronic kidney disease (CKD), pharmacotherapy may be employed to partially regulate these homeostatic functions. However, now a patient less able to renally excrete drugs requires a greater number of medications. This is one of the dilemmas that will be addressed during my nephrology rotation. Hemodialysis (HD) may be employed when kidney function declines to a point where medications and life style alone cannot compensate for the loss in filtration. HD also has its limitations and an in-depth understanding of these is required when optimizing drug therapy in these individuals. Something tells me there will be a lot to learn on this rotation.
These are my personal rotation specific goals in addition to those presented on the ROAD document.
- To gain a thorough understanding of common co-morbidities and treatment options in CKD and dialysis patients including but not limited to heart failure, hepatic disease, atrial fibrillation and infection.
- To conduct pharmacokinetic assessment in patients with CKD or on dialysis including vancomycin, aminoglycosides and phenytoin if the opportunity presents.
- To evaluate and form a treatment plan for acid-base disturbances in patients with CKD and on dialysis.
- To evaluate and form a treatment plan for electrolyte disturbances in patients with CKD and on dialysis.
I was involved in the care of a pleasant, elderly patient with a high number of comorbidities, admitted post-fall with CHF, liver disease with abdominal ascites and hepatic encephalopathy, Afib, leg chronic leg ulcers secondary to venous insufficiency with a historical ADR to furosemide (list incomplete!). She was being treated with an increased dose of metolazone and spironolactone in hospital for ++ abdominal ascites that would not drain mechanically. Her renal function declined below CrClIBW of 30mL/min and spironolactone use was no longer safe in this patient.
Rather that presenting the problem alone (spironolactone was unsafe at CrClIBW < 30mL/min). I was able to investigate the ADR to furosemide in more detail to determine if it was “off the table” as an option for symptom management. The family had expressed the wish to avoid furosemide if alternatives are available but what if there were not? The reported ADR was hearing loss. By talking with the family I discovered she had previously been stabilized on furosemide for 10 years with no adverse reaction. Following an incident of ++ edema three years previously, she was reportedly instructed to increase the dose of furosemide to 4 times her regular amount. In the days following the dose increase, she experienced reversible hearing loss in her left ear. She was admitted to hospital and treated with corticosteroids. Reversible and non-reversible hearing loss/deafness is a side effect of furosemide when administered by IV push or IM. Her husband believes she was taking furosemide 40mg PO daily and her dose increase would have been 160mg (unverified by pharmanet).
Conclusion? It appears that the sudden furosemide dose increase was responsible for the ADR rather than the medication alone. Given that spironolactone is not a safe medication to use with her current renal function, low dose furosemide could be a suitable alternative given it was titrated very slowly with close monitoring of her hearing (in addition to other monitoring parameters). In the end, the acute on chronic kidney injury which related temporally with increased diuretic use improved by decreasing the diuretics to pre-hospital doses. Her journey is not over and there may be a time in the future that furosemide use could be considered.
Take home for my learning: Diagnosis and treatment is often a moving target with co-morbidities complicating drug treatment. This sometimes requires re-evaluation of past therapies.
During my 2 weeks on an acute medicine ward at VGH, I had the opportunity to work with patients with a variety of clinically interesting conditions and pharmaceutical care needs. These included infectious diseases such as an abdominal abscess, urosepsis in patient with hypopituitarism and another with complicated cellulitis of the legs. Multi-organ damage was common in this patient group. One who stood out was admitted post-fall with hepatic encephalopathy, liver disease with abdominal ascites, CHF, atrial fibrillation, leg chronic ulcers secondary to venous insufficiency with a historical ADR to furosemide (yes, this was one patient and I will talk about the ADR in more detail in another post).
Throughout these busy weeks (snow and all!) I was able to meet my rotation specific goals with the assistance of my preceptor. The last week included a mock oral exam which I was able to complete in the 2h time period. More than this, I am excited to be back in the residency. I am thrilled to be involved with the interdisciplinary team again with the patient right where the patient belongs, in the center!
Speaking of organ systems and comorbidities, on to nephrology…
Following an eight-month leave of absence to focus on my health, the Island Health Residency program is accommodating my return. A two-week re-orientation to clinical pharmacy has been planned prior to my final two rotations. I am excited to re-orientate to residency life and I am grateful for the opportunities provided. Since re-orientation to the hospital environment and patient care is the goal, I will be focusing on my midpoint learning goals and objectives relating to the patient work up process. Following an absentee, I will be responsible for successfully completing an oral exam, as I was earlier in my residency. Working towards this and my career as a clinical pharmacist I will focus on my foundation and the following mid-point learning objectives in this re-orientation rotation:
I will consistently develop a thorough, patient specific, pharmaceutical care plan (e.g. within two hours) and be able to effectively communicate this plan both verbally and in writing.
- Efficiently collect and interpret relevant clinical and laboratory information.
- Conduct patient interview times (less than 20mins) through the use of efficient, targeted questioning.
- Create a medical problems list in order of priority.
- Identify all DTPs and provide recommendations and alternatives for each.
- Communicate patient clinical status and drug therapy recommendations efficiently to my preceptor and other healthcare professionals.
- Prioritize patients who would most benefit from a comprehensive work-up.
- Manage “problem orders” on an acute medical ward.
- Conduct PK antibiotic assessments on an acute medical ward.
- Use resources effectively to answer DRPs.
- Create timed scenarios by week 2 to prepare for the oral assessment.
I will be able to write effective chart notes containing all relevant lab values and pertaining information at an appropriate length.
- Demonstrate the ability to write concise, descriptive chart notes by the end of this rotation.
- Communicate comprehensive medication assessments in patient charts.
I cannot predict more than anyone the learning curve ahead of me. I can commit to giving it 110%.
Back on the bike and heading to the ROADs!
I have just completed my ICU rotation and it was a different world altogether! I could write pages about inotropes and vasopressors or the different agents for sedation. I gained a wealth of knowledge and experience in this rotation including interpreting ABGs, including detecting superimposed metabolic acidosis,’ the different mechanisms of shock, cardiogenic, distributive and hypovolemic and assessment of pain and delirium in a critically ill population.
Something else happened that I will not likely forget anytime soon. This is not insignificant considering the fluctuating and dynamic environment of the ICU.
My oral exam was scheduled during this rotation and so, as you can imagine, my mind was also focused on completing a full patient work-up in 2 hours in order to successfully complete my exam and meet this CHPRB standard. Time management and prioritization has been one of my primary goals throughout this year. The residency program and my exceptional preceptors have been reinforcing this and providing me the opportunity to gain the necessary skills and training to meet the challenges.
Back to the point, a patient whose care I had become involved in had extensive coronary disease and renal failure among many things but was smiling while I reviewed his home medications and held my hand with a strong grip before I left. I needed to leave briefly for a Leadership and Management session and could not find the chart to order his home eye drops.
Two hours later, I ran up the stairs to grab the chart before heading home to do some reading. Again the chart was not by the bed. The intensivists was documenting as the patient passed. I acted professionally but my shock was tangible as he was still in his room.
I completely understand the necessity to provide excellent pharmaceutical care in an efficient, step wise approach. This was however, a crystalizing moment for me. I had only been out of ICU 2 hours. The eye drops would not have prevented ventricular fibrillation, he was critically ill and there was nothing that could have been done in this case. However, time is finite and suddenly refining my process for the sake of an exam seemed somewhat trivial. It had to be for the patients. The exam was simply a demonstration of this ability and the process to ensure completeness and competency.
With the rotation and exam complete!
Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients with Agitated Delirium (DahLIa): A Randomized Clinical Trial. (Reade MC, et al. JAMA. 2016;315(14):1460-1468.)
Beginning my adult ICU rotation, I have outlined the following goals and objectives that I have identified for the next 4 weeks:
1) Goal: Demonstrate necessary skill to provide direct patient care
a) Consistently, identify, justify and prioritize patient-
specific drug therapy problems.
b) Complete patient work up in 2 hrs including interview and
resolution of top DTP.
c) Increase efficiency of care through increasing patient care
These are quite fundamental and areas where I will continue to strive to improve to increase my proficiency in providing effective, timely and safe patient care and recommendations.
Specific to ICU, my learning objectives are to:
1) Understand the different types of shock and various shock treatments depending on etiology.
2) Improve ability in interpreting ABGs.
3) Electrolyte replacement, including magnesium and phosphate, to achieve normal