Advertisement

International Journal of Clinical Pharmacy

, Volume 39, Issue 3, pp 573–581 | Cite as

Impact of pharmaceutical care on pain and agitation in a medical intensive care unit in Thailand

  • Pitchaya Dilokpattanamongkol
  • Viratch Tangsujaritvijit
  • Thanarat Suansanae
  • Chuthamanee SuthisisangEmail author
Research Article

Abstract

Background Currently, a lack of pharmaceutical care exists concerning pain and agitation in medical intensive care units (MICU) in Thailand. Pharmaceutical care focusing on analgesics/sedatives would improve clinical outcomes. Objective To investigate the impact of pharmaceutical care of pain and agitation on ICU length of stay (LOS), hospital LOS, ventilator days and mortality. Setting The MICU of a university hospital. Method A before/after study was conducted on mechanically ventilated patients receiving analgesics/sedatives. Medical chart reviews and data collection were conducted in the retrospective group (no pharmacists involved). In the prospective group, pharmacists involved with the critical care team helped select analgesics/sedatives for individual patients. Main outcome measure ICU LOS Results In total, 90 and 66 patients were enrolled in retrospective and prospective groups, respectively. The median duration of ICU LOS was reduced from 10.00 (2.00–72.00) in the retrospective group to 6.50 days (2.00–30.00) in the prospective group (p = 0.002). The median hospital stay was reduced from 30.50 days (2.00–119.00) in the retrospective group to 17.50 days (2.00–110.00) in the prospective group (p < 0.001). Also, the median ventilator days was reduced from 14.00 days (2.00–90.00) to 8.50 days (1.00–45.00), p = 0.008. Mortality was 53.03% in the prospective group and 46.67% in the retrospective group (p = 0.432). Conclusion Pharmacist participation in a critical care team resulted in a significant reduction in the duration of ICU LOS, hospital LOS and ventilator days, but not mortality.

Keywords

Agitation Analgesics Critically ill patients Medical intensive care unit Pain Pharmaceutical care Sedatives Thailand 

Notes

Acknowledgements

We give special thanks to: the Critical Care Department, nurses and staff at the MICU, Faculty of Medicine, Ramathibodi Hospital, Mahidol University; the Pharmacy Department at Ramathibodi Hospital; the Dilokpattanamongkol and Sornsunthorn family; Jiradej Vatanutanon, Amaraporn Wongrakpanich and all of the critical care residents for their support. Special thanks go to Christopher C. Salisbury and Thomas MC Manamon for English editing. We also wish to thank Dr. Sunthiti Morakul and Dr. Cherdkiat Karnjanarachata for their advices throughout the study.

Funding

This study was funded by the Research Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok.

Conflicts of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Gutsche JT, Kohl BA. Who should care for intensive care unit patients? Crit Care Med. 2007;35(2 Suppl):S18–23.CrossRefPubMedGoogle Scholar
  2. 2.
    Kane-Gill SL, Kirisci L, Verrico MM, Rothschild JM. Analysis of risk factors for adverse drug events in critically ill patients. Crit Care Med. 2012;40(3):823–8.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Yoo EJ, Edwards JD, Dean ML, Dudley RA. Multidisciplinary critical care and intensivist staffing: results of a statewide survey and association with mortality. J Intensive Care Med. 2016;31(5):325–32.CrossRefPubMedGoogle Scholar
  4. 4.
    Payen JF, Chanques G, Mantz J, Hercule C, Auriant I, Leguillou JL, et al. Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology. 2007;106(4):687–95.CrossRefPubMedGoogle Scholar
  5. 5.
    Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S. A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology. 2007;107(5):858–60.CrossRefPubMedGoogle Scholar
  6. 6.
    Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, 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(1):263–306.CrossRefPubMedGoogle Scholar
  7. 7.
    Horn E, Nesbit SA. Pharmacology and pharmacokinetics of sedatives and analgesics. Gastrointest Endosc Clin N Am. 2004;14(2):247–68.CrossRefPubMedGoogle Scholar
  8. 8.
    Dahan A, Yassen A, Bijl H, Romberg R, Sarton E, Teppema L, et al. Comparison of the respiratory effects of intravenous buprenorphine and fentanyl in humans and rats. Br J Anaesth. 2005;94(6):825–34.CrossRefPubMedGoogle Scholar
  9. 9.
    Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med. 2013;125(4):115–30.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Saari TI, Uusi-Oukari M, Ahonen J, Olkkola KT. Enhancement of GABAergic activity: neuropharmacological effects of benzodiazepines and therapeutic use in anesthesiology. Pharmacol Rev. 2011;63(1):243–67.CrossRefPubMedGoogle Scholar
  11. 11.
    Becker DE. Pharmacodynamic considerations for moderate and deep sedation. Anesth Prog. 2012;59(1):28–42.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Bucknall TK, Manias E, Presneill JJ. A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit. Crit Care Med. 2008;36(5):1444–50.CrossRefPubMedGoogle Scholar
  13. 13.
    Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi DK, Kavanagh BP. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg. 2010;111(2):451–63.CrossRefPubMedGoogle Scholar
  14. 14.
    De Jonghe B, Bastuji-Garin S, Fangio P, Lacherade JC, Jabot J, Appere-De-Vecchi C, et al. Sedation algorithm in critically ill patients without acute brain injury. Crit Care Med. 2005;33(1):120–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault PF, et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med. 2006;34(6):1691–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282(3):267–70.CrossRefPubMedGoogle Scholar
  17. 17.
    Ng TM, Bell AM, Hong C, Hara JM, Touchette DR, Danskey KN, et al. Pharmacist monitoring of QTc interval-prolonging medications in critically ill medical patients: a pilot study. Ann Pharmacother. 2008;42(4):475–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Montazeri M, Cook DJ. Impact of a clinical pharmacist in a multidisciplinary intensive care unit. Crit Care Med. 1994;22(6):1044–8.CrossRefPubMedGoogle Scholar
  19. 19.
    MacLaren R, Bond CA. Effects of pharmacist participation in intensive care units on clinical and economic outcomes of critically ill patients with thromboembolic or infarction-related events. Pharmacotherapy. 2009;29(7):761–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Marshall J, Finn CA, Theodore AC. Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Crit Care Med. 2008;36(2):427–33.CrossRefPubMedGoogle Scholar
  21. 21.
    Kotani Y, Shimazawa M, Yoshimura S, Iwama T, Hara H. The experimental and clinical pharmacology of propofol, an anesthetic agent with neuroprotective properties. CNS Neurosci Ther. 2008;14(2):95–106.CrossRefPubMedGoogle Scholar
  22. 22.
    Olkkola KT, Ahonen J. Midazolam and other benzodiazepines. Handb Exp Pharmacol. 2008;182:335–60.CrossRefGoogle Scholar
  23. 23.
    Page VJ, Casarin A. Use of antipsychotics for the treatment of intensive care unit delirium. Rev Bras Ter Intensiva. 2014;26(2):86–8.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Wagner J, Wagner ML, Hening WA. Beyond benzodiazepines: alternative pharmacologic agents for the treatment of insomnia. Ann Pharmacother. 1998;32(6):680–91.CrossRefPubMedGoogle Scholar
  25. 25.
    Makii JM, Mirski MA, Lewin JJ 3rd. Sedation and analgesia in critically ill neurologic patients. J Pharm Pract. 2010;23(5):455–69.CrossRefPubMedGoogle Scholar
  26. 26.
    Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983–91.CrossRefPubMedGoogle Scholar
  27. 27.
    Ely EW. Confusion Assessment Method for the ICU (CAM-ICU): the complete training manual. http://www.icudelirium.org/docs/CAM_ICU_training.pdf. Accessed Apr 7 2014.
  28. 28.
    Pipanmekaporn T, Wongpakaran N, Mueankwan S, Dendumrongkul P, Chittawatanarat K, Khongpheng N, et al. Validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Clin Interv Aging. 2014;9:879–85.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Pereira J, Lawlor P, Vigano A, Dorgan M, Bruera E. Equianalgesic dose ratios for opioids. a critical review and proposals for long-term dosing. J Pain Symptom Manag. 2001;22(2):672–87.CrossRefGoogle Scholar
  30. 30.
    Labbate LA. Handbook of psychiatric drug therapy. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.Google Scholar
  31. 31.
    MacLaren R, Bond CA, Martin SJ, Fike D. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. Crit Care Med. 2008;36(12):3184–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Louzon P, Jennings H, Ali M, Kraisinger M. Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle rounds. Am J Health Syst Pharm. 2017;74(4):253–62.CrossRefPubMedGoogle Scholar
  33. 33.
    Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Ekstrom MP, Bornefalk-Hermansson A, Abernethy AP, Currow DC. Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study. BMJ. 2014;348:g445.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Murray MJ, DeBlock H, Erstad B, Gray A, Jacobi J, Jordan C, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016;44(11):2079–103.CrossRefPubMedGoogle Scholar
  36. 36.
    Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170(4):369–76.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Bickenbach J, Fries M, Rex S, Stitz C, Heussen N, Rossaint R, et al. Outcome and mortality risk factors in long-term treated ICU patients: a retrospective analysis. Minerva Anestesiol. 2011;77(4):427–38.PubMedGoogle Scholar
  38. 38.
    Visser P, Harriss LR, Hart GK, Bohensky M, Sundaresan L, Kennedy M. Factors involved in intensive care unit mortality following medical retrieval: identifying differences between intensive care unit survivors and non-survivors. Emerg Med Australas. 2013;25(3):260–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing 2017

Authors and Affiliations

  • Pitchaya Dilokpattanamongkol
    • 1
  • Viratch Tangsujaritvijit
    • 2
  • Thanarat Suansanae
    • 1
  • Chuthamanee Suthisisang
    • 3
    Email author
  1. 1.Division of Clinical Pharmacy, Department of Pharmacy, Faculty of PharmacyMahidol UniversityRatchathewi, BangkokThailand
  2. 2.Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi HospitalMahidol UniversityRatchathewi, BangkokThailand
  3. 3.Department of Pharmacology, Faculty of PharmacyMahidol UniversityRatchathewi, BangkokThailand

Personalised recommendations