TY  - CHAP
M1  - Book, Section
TI  - Pharmacology in Critical Illness
A1  - Chen, Julie
A2  - Oropello, John M.
A2  - Pastores, Stephen M.
A2  - Kvetan, Vladimir
PY  - 1
T2  - Critical Care
AB  - KEY  POINTSComplex  pharmacokinetic  and  pharmacodynamic  variations  occur  in  critically  ill  patients  secondary  to  underlying  illness  and  acute  organ  failures  as  well  as  the  multiple  supportive  modalities  employed.Failure  to  appreciate  variabilities  in  pharmacokinetic  and  pharmacodynamic  characteristics  may  contribute  to  suboptimal  dosing,  adverse  outcome,  increased  risk  of  medication  errors  and  adverse  drug  reactions.Altered  drug  absorption,  plasma  protein  binding,  volume  of  distribution,  renal  and  hepatic  clearance,  and  affinity  of  binding  to  target  receptors  in  critically-ill  patients  can  all  affect  the  therapeutic  response  and  clinical  outcome.For  medications  with  monitoring  parameters  available  and  a  fairly  rapid  onset  of  action,  careful  dose  titration  based  on  clinical  observation  is  appropriate;  many  of  the  cardiovascular  active  agents  fall  into  this  category.For  medications  with  slower  onset  of  action  and  dose-dependent  pharmacology,  proper  loading  and  maintenance  doses  should  be  determined;  changes  in  drug  volume  of  distribution  and  clearance  observed  or  measured  in  individual  patients  should  be  taken  into  consideration.Therapeutic  drug  monitoring  (TDM)  is  recommended  for  certain  medications,  including  some  antimicrobials,  antiepileptics  and  cardiovascular  agents.  These  tests  are  widely  available  with  quick  turnaround  time  for  the  results  to  assist  in  dose  adjustment.Different  renal  replacement  regimens  may  have  different  impacts  on  the  volume  of  distribution  and  clearance  of  each  medication.  Dosing  need  to  be  tailored  to  the  dialysis  modality  utilized  and  delivered.  In  general,  higher  doses  and  more  frequent  dosing  are  necessary  with  continuous  renal  replacement  therapy  as  compared  to  intermittent  HD.Other  supportive  modaltites,  such  as  ECMO  and  plasmaphoresis,  can  also  affect  the  pharmacology  of  some  medications.Polypharmacy  is  inevitable  in  critically  ill  and  may  contribute  to  adverse  outcome  secondary  to  drug  interactions  or  toxicity;  careful  monitoring  and  patient  assessment  remains  the  key  for  optimal  therapeutic  outcome.  
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/18
UR  - accessanesthesiology.mhmedical.com/content.aspx?aid=1136413503
ER  -