Intensive Care Unit – St. Paul’s Hospital

First clinical rotation completed and it definitely set the bar high for subsequent rotations! This rotation provided the exact type of high-level learning experience I was hoping to have as a year 2 pharmacy resident. I was able to have many higher-level discussions with my fantastic preceptor (pathophysiology, pharmacology, therapeutics), teach pharmacist colleagues, medical residents, and medical students, and provide patient-care to complex patients.

 

Learning Goals and Objectives:

1. Enhance my knowledge of sedatives used in the ICU.

I achieved this learning objective by developing and delivering a teaching session to the ICU medical staff on sedatives. I also developed an algorithm that they could use to help guide decision making when selecting a sedative agent.

presentation on sedation for icu staff – final

2. Develop a deeper understanding of the place in therapy for steroids in septic shock.

Steroids for septic shock remains a controversial subject despite years of research and multiple clinical trials. Upon critical appraisal, it is my opinion that the extant literature has failed to show that corticosteroids confer a mortality benefit in any septic patient population. There is a pathophysiological rationale for steroids to increase the response to vasopressors and reduce the time of vasopressor dependance, which has been demonstrated in the literature. Whether the observed benefits are clinically significant is debatable. Based on the literature, it appears that the main harm from steroids is hyperglycemia, with no observed increases in bacterial superinfection or new sepsis. In my opinion the addition of fludrocortisone to hydrocortisone has no place in therapy. Steroids remain a reasonable addition in patients with septic shock not responsive to fluid resuscitation and vasopressors.

Update: see my analysis of the latest steroid trial below

APROCCHSS Journal Club – Handout v 1.2

3. Become proficient at interpreting blood gases and treating acid/base abnormalities.

By developing a systematic approach to assessing blood gases and practicing daily I was able to attain this learning goal. First determine the pH status (the -emia), then determine the primary process (the -osis; metabolic acidosis/alkalosis vs. respiratory acidosis/alkalosis), then check the degree of compensation, then calculate the serum anion gap, then if there is an anion gap calculate the “excess” anion gap to determine if there is concurrent non-SAG metabolic acidosis or metabolic alkalosis.

 

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