Transcript Inpatient Pharmacy

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 101.7
°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
Vancomycin: Kel = (0.00083 x CrCl) + 0.0044
T 1/2= 0.693 / Kel
Calculate Loading dose (LD):_____mg.
LD = 25mg/Kg
Calculate Maintenance dose (MD):_____mg.
MD = [(kel) x (Vd) x (ti) x (Cpeak desired) x (1 - e-kT)] / (1 - e-kti)
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: 101.7 °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 coordinate 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?