1. Jones, G. Morgan PharmD, BCPS, BCCCP
  2. Issue Editor

Article Content

Complex Medication Use in the Intensive Care Unit

In this issue of Critical Care Nursing Quarterly, our readership is presented with a series of review articles that emphasize the role that complex medication therapies play in the intensive care unit (ICU). Recent research has provided varying perspectives on the safety of therapies once considered the standard of care while also bringing forward new potential treatments for specialized disorders. As ICU patients continue to be impacted by the growing number of medication shortages, clinicians also continue to be challenged to maintain familiarity with treatment alternatives that may be used. The articles in this issue are all aimed at increasing familiarity with complex medication use across a variety of specialty areas, including solid organ transplant, toxicology, medical critical care, and cardiac critical care.


Adequate fluid resuscitation in sepsis has been the cornerstone of treatment for nearly a decade. Recent research, however, has demonstrated that the overuse of sodium chloride products may have detrimental effects on outcomes. Gross, Samarin, and Kimmons detail this literature and tackle the controversy of fluid choice in patients with sepsis. Their article describes the properties, adverse effects, and monitoring parameters of commonly used colloid and crystalloid fluids, providing information to aid in proper fluid selection in patients with sepsis. The authors also summarize concepts that will increase provider knowledge when caring for patients both in and out of the ICU.


Furthermore, the septic population is at high risk of developing complications such as acute respiratory distress syndrome. Recent literature has validated the use of continuous infusion neuromuscular blocking agents (NMBAs) in this population, while prescribing for other indications is also expanding. Overall, the clinical benefit of these medications is balanced with concerns of propagating ICU-acquired weakness, which may prolong mechanical ventilation and impair the ability to assess neurologic function. Smetana, Roe, Doepker, and Jones aim to educate critical care clinicians on many of the pharmacologic nuances of these agents in their review of continuous infusion NMBAs. They also summarize the literature on each of the available agents as a means to educate providers on how to properly select and monitor therapy while employing ancillary therapies to reduce associated complications.


Along with management of sepsis, agitation is one of the most commonly encountered acute issues in the critically ill. While treatment often necessitates the use of intravenous or intramuscular medications, recent changes in drug manufacturing have resulted in several of these agents being unavailable, forcing clinicians to seek out possible alternatives. Yeo, Wiley, Smith, and Hammond present a summary of possible oral agents that may be used as treatment options for the management of acute agitation in the ICU. They encourage health care providers to become more familiar with these alternate choices due to possible shortage issues with first-line therapies, ensuring that clinicians maintain competency with a variety of treatment options.


Among the first of our specialty ICU topics in this issue, Reed and Devabhakthuni describe the challenging clinical conundrum of diuretic resistance in acute decompensated heart failure (ADHF). The lack of standard definition for this clinical situation has resulted in limited recommendations for standard treatment. The review provides a detailed description of the phenomenon and its underlying mechanisms, as well as a very useful stepwise approach for managing volume overload in patients with ADHF. The information presented will again aid clinicians in the treatment of ICU patients, while also being useful for those patients who are not critically ill.


The rising use of novel psychoactive substances has resulted from many patients searching for "legal highs" that are more readily accessible. Abuse of these substances has resulted in an increase in hospitalizations and presents a unique challenge for health care professionals, given the limited ability to detect the presence of these products. Rivera, Vance, Rushton, and Arnold review the most common substances in this growing class of psychoactive agents. The goal of this article is to increase familiarity with and to understand trends of abuse associated with these agents in order to grow our ability to identify and manage intoxication. With many patients overdosing on these products may present with a variety of symptoms, they could ultimately be treated in many specialty ICU settings due to conditions such as myocardial infarction, stroke, or multiorgan failure. The information provided in this review may be invaluable for a wide range of providers in identifying patients who present with a complication due to overdose of the new substances, even if they may not initially realize it.


Patients who have undergone solid organ transplantation may represent some of the most complex patients admitted to our ICUs. Management of these patients presents added challenges, given the number of drug interactions and special medication use parameters associated with many of these medications. Immunosuppressive agents that are required to prevent allograft rejection may lead to a plethora of infectious complications that may require even more unique and complex treatment regimens. In the first of a 2-part article series, Personett and Laub present a review of risk factors for common infectious pathogens, as well as important considerations regarding prophylactic medications in solid organ transplant recipients. The article highlights the time periods associated with various opportunistic infections, as well as the common medications used to prevent them.


Next Goetz, Evans, and Rendulic describe a focused approach to treatment of active pulmonary infections in an immunocompromised host. Their review summarizes not only the most common opportunistic pulmonary infections but also their complex treatment regimens. Given that the medications used to treat these infections are frequently classified as high risk and require specialized administration methods, the medication use parameters discussed may aid any clinician challenged with treating active pulmonary infections in this unique patient population.


Finally, medication use in the ICU is also associated with significant financial implications. Pannell, Murphy, Byrd, and Tubbs outline a number of measures described in the medical literature that are aimed at containing costs in the modern era of critical care medicine. This article provides a thorough summary of factors associated with rising pharmaceutical costs, as well as practical examples employed by a major medical center to curtail these costs.


-G. Morgan Jones, PharmD, BCPS, BCCCP


Issue Editor


Department of Pharmacy


Methodist University Hospital


Memphis, Tennessee


Department of Clinical Pharmacy,


Neurology, and Neurosurgery,


University of Tennessee Health


Science Center


Memphis, Tennessee