By Satoshi Egawa1, Nobuhiro Narabu2, Satomi Yamagata2, Ryosuke Okada2, Minoru Fukuda2, Hidetoshi Nakamoto3 and Yuichi Kubota3 (from left)1. Neurointensive Care Unit, TMG Asaka Medical Center2. Pharmacy, TMG Asaka Medical Center3. Stroke and Epilepsy Center, TMG Asaka Medical Center
Excellent activity of any hospital demands effective teamwork of its medical staff, especially in the intensive care unit (ICU). Since Jan. 1, 2018, TMG Asaka Medical Center has been operating the neuro ICU in complete collaboration with pharmacists. Every day, one pharmacist works as a team member managing the operation of the neuro ICU. This article aims to report the role of pharmacists in our neuro ICU at the TMG Asaka Medical Center.
Typically, neuro ICUs host patients whose diseases and prescribed drugs are often uncommon for general intensivists. Thus, the safe, timely and evidence-based appropriate administration of medications warrants advice and supervision of pharmacists.
Because of its proximity to the Epilepsy Center, the neuro ICU at TMG Asaka Medical Center receives many status epilepticus (SE) patients. The adherence of AEDs and drug interactions presents several pitfalls. Physicians might find it hard to understand all drugs completely in the early stage of their hospitalization. In such scenarios, the pharmacists obtain relevant information of patients, starting from their history to medical conditions such as allergy and adherence. In addition, in the neuro ICU, there are not only SE but also a lot of refractory and superrefractory SE patients who must be monitored by continuous EEG monitoring. In those cases, they monitor drug interactions and side effects, especially skin rashes, every day. Using the expertise of pharmacists in the neuro ICU enhances and facilitates determining the effective drug combination promptly.
In addition, pharmacists help in the compliance of safety guidelines of DOAC (direct oral anticoagulants) usage, which warrants extraordinary attention because of its dosage dependence on patients’ body weight and age. Hence, pharmacists’ support might decrease hemorrhagic complications. For other drugs, they monitor the renal function and suggest alternate drug regimen as applicable. On morning neuro ICU rounds, a pharmacist shares those findings with the medical team to assess whether any change in management is required. In addition, during these rounds, pharmacists routinely deliver a short lecture about the patients’ drugs to educate the neurocritical care team. Routine lectures are planned, too. For instance, sedation and analgesia for patients in the neuro ICU, shivering management during targeted temperature management and proper use of AEDs and hyperosmotic agents. The information provided by pharmacists is beneficial for residents, neurosurgeons and nurses.
Pharmacists have a lot of opportunity to learn clinical knowledge, which is imperative to clinical works in the neuro ICU. Both intensivists and neurointensivists teach them the pathophysiology of patients to acquire an understanding of clinical medicine, thus enabling them to discuss the drug dosage depending on patients’ condition. Furthermore, every pharmacist is advised to undertake an ENLS course. In Japan, reportedly, half of the ICUs have at least one full-time pharmacist; however, the neuro ICU itself is rarely established. In Japan, establishing the position of pharmacists with an expertise in neurocritical care is important too for the smooth functioning of the neuro ICU.
TMG Asaka Medical Center is a general hospital comprising 446 beds and located in the environs of Tokyo. The hospital is characterized by its neurocritical care and epilepsy center. While the neuro ICU has six beds, the stroke care unit has nine beds; a neurointensivist manages these 15 beds. Our ability to conduct multi-modality monitoring in the neuro ICU, especially continuous EEG, is the highlight of our neuro ICU. We can perform EEG monitoring in every bed if necessary. In addition, neurophysiologists can monitor each bed in the neuro ICU from the EEG monitoring room. We are planning to use this room as a tele neuro ICU, too.
Left: A short lecture during the morning round focused on the renal toxicity of representative drugs.
Left: Discussing drug information about AEDs with neurosurgeons. Right: The neuro ICU at the TMG Asaka Medical Center.
Left: An ENLS-certified pharmacist. Right: The EEG monitoring room at the TMG Asaka Medical Center. #NCSRoundup #International #AsianCorner