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I pause, think... then stop the drug (Emma Graham-Clarke)

Another day, another ward round, but many of the patients remain thesame. Critical care is a mixture of fast turnover patients, in and outin about 24 hours, and long-stay patients, some of whom remain on theunit for several weeks. However, the medicines all need reviewingregardless of the patient

Emma Graham-ClarkeAnother day, another ward round, but many of the patients remain the same. Critical care is a mixture of fast turnover patients, in and out in about 24 hours, and long-stay patients, some of whom remain on the unit for several weeks. However, the medicines all need reviewing regardless of the patient.

First bed, a patient gradually getting better and now absorbing his nasogastric feed. I pause, think and then stop the IV ranitidine he’s been getting for stress ulcer prevention; I know that it’s important to prevent stress ulcers but I also know that acid suppression is associated with gastric bacterial overgrowth and an increased risk of ventilator-associated pneumonia if aspiration of stomach contents occurs.

Prescribing for this patient as in so many cases is an act of balancing risk and benefit.

I move on to the next bed. This patient has been on laxatives and prokinetics for a few days, but I note she hasn’t had the previous couple of doses of laxatives. A chat with the nurse reveals that the patient is now absorbing her feed and that her bowels have opened — several times. Needless to say, I can’t consult the patient since she’s sedated and ventilated. I cross both prokinetics and laxatives off. The patient may not be aware of what’s happening but the nurse is grateful that there may be less cleaning up to do.

We then get a phone call from microbiology with a vancomycin level for another patient. She’d needed vancomycin for an infection, which had been started at an appropriate dose. However, the first level had come back a little high, so the next dose was omitted, and then the dose reduced. Unfortunately the next level is even higher so I cross the vancomycin off completely — we’ll wait for the levels to drop before we give her anything else. And so my morning continues, crossing off sundry unneeded medicines.

I attended a recent Intensive Care Society meeting and was struck by the first session themed “less is more”. The gist of that part of the programme was that just because we could do an intervention, or give a medicine, didn’t mean we should.

I have noticed that prescribers tend to be very good at starting medicines, but less good at stopping the ones that aren’t needed. As I thought about this session and how it related to my practice I reflected that since I completed the prescribing course I’ve probably stopped more medicines than I’ve started.

Less is more is a good mantra, and one that I fully intend to continue following. Will my patients know? I doubt it. But with luck there’ll be fewer complications and side effects.


Emma Graham-Clarke is consultant pharmacist for critical care at Sandwell and West Birmingham Hospitals NHS Trust

Citation: Clinical Pharmacist URI: 11004627

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