PGY2 Critical Care Pharmacy Residency
Cardiac Intensive Care Unit (CICU) Rotation
Primary Preceptor: Bethany Kalich, Pharm.D., BCPS, Clinical Pharmacy Specialist, Cardiology
Office: 9th floor Cardiology Workroom 9-168 I Cell Phone: 210.844.4330 I Email: kalich@uiwtx.edu
1. General Description
The purpose of the CICU rotation is to familiarize the resident with the functions of clinical pharmacists in a cardiac ICU and to enhance the
resident’s knowledge of therapeutics and the skills necessary to provide optimal pharmaceutical care.
The resident shall be an active member of a multidisciplinary team and follow patients from the time of admission, hospital progression and
discharge counseling. The pharmacy resident will round with the cardiology team during the duration of the rotation and will meet daily with the
preceptor to discuss findings and recommendations.
2. Communication
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Residents are expected to maintain ongoing communication with the preceptor throughout the day
Office extension, cell phone number, or pager: all appropriate for urgent questions pertaining to patient care
Cell phone number: appropriate for emergency issues
E-mail: residents should read e-mails at the beginning and end of each day. E-mail is appropriate for routine, non-urgent communication with the
preceptor
3. Daily Schedule and Preceptor Interaction
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0800-1200 - Daily patient care rounds with cardiology team
1300-1630 – Work in cardiology team room to follow-up on changes and provide drug information, discuss changes with preceptor, topic
discussions with preceptor
Tuesdays 1200-1300, Weekly PGY2 critical care topic discussion
Fridays 1300-1500, Pharmacotherapy Seminar, UTHSCSA McDermott Building
Fridays 1500-1600, Pharmacotherapy Conference, UTHSCSA McDermott Building
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4. Expected Progression of Resident Responsibility
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Day 1 orientation:
o Preceptor to review learning activities, expectations, schedule, and required readings with resident
o Preceptor to orient resident to unit, including introductions to the team and tour of patient care areas
o Preceptor to assign patients to resident
Weeks 1-2:
o Resident to work up all patients on cardiology service and prioritize most critically ill
o Resident to discuss questions and recommendations with preceptor daily
o Resident to round with cardiology team and update preceptor post-rounds
Weeks 3-4:
o Resident will continue to work up all patients and round independently with the team, gaining experience and confidence with cardiology
patient population
o Resident to attend and participate in rounds as the primary pharmacist, with the preceptor observing periodically to facilitate the
transition to independence
5. Evaluation Strategy
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Formative
o The preceptor will provide opportunities for formative resident self-evaluation and preceptor feedback throughout the rotation
Summative
o A summative evaluation by the preceptor and summative self-evaluation, learning experience evaluation, and preceptor evaluation by the
resident will be completed at the end of the rotation
o Resitrak will be used for documentation of scheduled evaluations
o The resident and preceptor will independently complete the assigned evaluations in Resitrak, then meet to discuss them
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6. Goals & Objectives
Goals and Objectives to be Taught and Formally Evaluated
Goals and Objectives
Activities to Facilitate Achievement of Goals
Outcome R2
Optimize the outcomes of critically ill patients by providing
evidence-based medication therapy as an integral part of an
interdisciplinary team.
Goal R2.2
Prioritize the delivery of care to critically ill patients.
OBJ R2.2.1
Goal R2.3
(Synthesis) Devise a plan for deciding which critical care patients to focus on if
given limited time and multiple patient care responsibilities
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Organize daily activities around patient care
issues
Prioritize and manage patient care issues in a
timely and appropriate fashion
Act in accordance with a covenantal relationship with the patient.
OBJ R2.3.1
(Synthesis) Formulate a strategy to guide care for a critically ill patient and
interaction with the patient’s family that reflects the acceptance of a covenant
with the patient for that patient’s care.
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Goal R2.4
Interact directly with patients and their
caregivers, both individually and with the
cardiology team as applicable
Discuss medication-related patient care issues
with patient and caregivers
Collect and analyze pertinent patient information.
OBJ R2.4.1
(Analysis) Collect and organize all patient-specific information needed to identify,
prevent, and resolve medication and specialized nutrition support-related
problems in order to provide appropriate evidence-based recommendations in
critically ill patients with complex conditions
(Evaluation) Assess the information base created for a critically ill patient for
adequacy to identify problems and design a therapeutic regimen
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OBJ R2.4.2
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Collect and organize pertinent patient
information for all patients on the cardiology
service using Sunrise and personal
communication
Review each patient’s medication profile daily to
determine presence of any medication therapy
problems and make recommendations for
resolving problems
Construct and prioritize a problem list for each
patient
Explain the mechanism of action,
pharmacokinetics, pharmacodynamics,
pharmacoeconomics, indications,
contraindications, interactions, ADRs and
therapeutics of medications in the treatment of
diseases commonly encountered in cardiology
patients
OBJ R2.4.3
(Analysis) Determine the presence of any of the following problems in a critically ill
patient’s current medication or specialized nutrition support therapy:
1. Medication or specialized nutrition support used with no medical indication
2. Patient has acute or chronic (e.g., steroid dependence) medical conditions for
which there is no medication or specialized nutrition support prescribed
3. Medication or specialized nutrition support prescribed inappropriately for a
particular medical condition
4. Current medication therapy or specialized nutrition support regimen contains
something inappropriate (dose, dosage form, duration, schedule, route of
administration, method of administration)
5. There is therapeutic duplication
6. Medication to which the patient is allergic has been prescribed
7. There are adverse drug or device-related events or potential for such events
8. There are clinically significant drug-drug, drug-disease, drug-nutrient, or druglaboratory test interactions or potential for such interactions
9. Medical condition is complicated by social, recreational, nonprescription, or
nontraditional (e.g., herbal) drug use by the patient
10. Patient not receiving full benefit of prescribed medication therapy or
specialized nutrition support (e.g., system error)
(Analysis) Prioritize a critically ill patient’s health care needs
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Assure adherence to the Adult Immunization
schedule
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Examine patients’ profiles and new medication
orders prospectively to determine the
appropriateness of the order in regards to
indication, route, frequency, drug interactions,
etc
Investigate potential adverse drug reactions
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Construct and prioritize a problem list for each
patient focusing first on the hemodynamically or
neurologically unstable, intubated, and high acuity
patients
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Discuss commonly encountered disease states in
cardiac ICU patients
Use evidence-based consensus guidelines to
specify and design therapeutic goals for each
patient when applicable
Recognize factors that may influence therapeutic
goals such as cultural, ethical, financial, and agerelated barriers
OBJ R2.4.4
Goal R2.5
Design evidence-based therapeutic regimens for critically ill patients.
(Synthesis) Specify therapeutic goals for a critically ill patient incorporating the
principles of evidence-based medicine that integrate patient-specific data, disease
and medication-specific information, ethics, and, when possible, quality-of-life
considerations.
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OBJ R2.5.1
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OBJ R2.5.2
(Synthesis) Design a regimen that meets the evidence-based therapeutic goals
established for a critically ill patient; integrates patient-specific information,
disease and drug information, ethical issues and, when possible, quality-of-life
issues; and considers pharmacoeconomic principles.
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Design a therapeutic plan that incorporates
consensus guidelines, primary literature and
patient preferences
Goal R2.6
Design evidence-based monitoring plans for critically ill patients.
(Synthesis) Design an evidenced-based monitoring plan for a critically ill patient’s
therapeutic regimen that effectively evaluates achievement of the patient-specific
goals.
OBJ R2.6.1
Outcome R5
Goal R5.1
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Participate in the management of medical emergencies
Participate in the management of medical emergencies.
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Maintain active BLS and ACLS certifications
Respond to “code blue” emergencies as feasible
during scheduled work hours
 Prepare required medications
 Provide drug information and pharmacologic
treatment recommendations
 Calculate doses and administration rates
(Evaluation) Interpret the appropriateness of a critically ill patient’s medication
order following existing standards of practice and the organization’s policies and
procedures
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(Evaluation) Assess a critically ill patient’s medication profile for appropriateness
following existing standards of practice and the organization’s policies and
procedures
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Review and verify patients’ medication orders in
Sunrise
Intervene with physicians as required for
clarification of medication orders
Review each patient’s medication profile to
determine presence of any patient medication
therapy problems
(Application) Exercise skill as a team member in the management of medical
emergencies as exhibited by certification in the American Heart Association
Advanced Cardiac Life Support and, if applicable, Pediatric Advanced Life Support
OBJ R5.1.1
Outcome E1
Goal E1.3
OBJ E1.3.1
OBJ E1.3.2
Construct a medication monitoring plan for each
patient on the cardiology service based on
individual patient data, age, race, gender, organ
function, and disease state
Devise specific monitoring plans for patients
receiving drugs that require therapeutic drug
monitoring
Perform quality improvement activities aimed at enhancing the
safety and effectiveness of medication-use processes in the critical
care area.
Evaluate critically ill patients’ medication orders and/or profiles.
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Goals and Objectives to be Taught (not formally evaluated)
Goals and Objectives
Activities to Facilitate Achievement of Goals
Outcome R2
Optimize the outcomes of critically ill patients by providing
evidence-based medication therapy as an integral part of an
interdisciplinary team.
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Goal R2.1
Establish collaborative professional relationships with other
members of the interdisciplinary critical care team.
OBJ R2.1.1
Goal R2.7
(Synthesis) Implement a strategy that establishes cooperative, collaborative,
communicative, and effective working relationships with other members of the
interdisciplinary critical care team.
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Introduce resident to cardiology team on first
day
Participate in daily cardiology rounds and team
conferences as scheduled
Recommend regimens and monitoring plans for critically ill patients.
OBJ R2.7.1
(Application) Recommend an evidence-based therapeutic regimen and
corresponding monitoring plan in a way that is systematic, logical, accurate, timely,
and secures consensus from the critical care interdisciplinary team
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Communicate recommendations for therapeutic
regimens and monitoring plans to team
members during daily rounds and as required
Schedule follow-ups for anticipated laboratory
monitoring of therapeutic changes
When appropriate, implement selected aspects of critical care
patients’ regimens and/or monitoring plans.
Goal R2.8
(Application) When appropriate, order a therapeutic regimen for a critically ill
patient according to the health systems’ procedures
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OBJ R2.8.1
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OBJ R2.8.2
(Application) When appropriate, follow organizational procedures to implement
(e.g.,order tests) the monitoring plan
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Follow up daily after rounds to ensure that
recommendations for medication regimens and
monitoring are implemented
Ensure medication regimens ordered are in
accordance with the hospital’s formulary
Counsel patients on anticoagulants or designated
medications as requested by team
Contact prescriber directly when required and
help facilitate orders in patient’s chart as a verbal
or telephone order if needed
Evaluate critically ill patients’ progress and redesign regimens and
monitoring plans
Goal R2.9
(Evaluation) Accurately assess the critically ill patient’s progress toward the
therapeutic goal(s) and the absence of adverse drug events
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Evaluate patient’s improvement through use of
objective clinical information found in Sunrise
along with subjective information gathered from
patient and care providers
(Synthesis) Redesign an evidence-based therapeutic plan for a critically ill patient as
necessary based on evaluation of monitoring data and therapeutic outcomes
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(Application) Collect outcomes data based on the patient’s response to therapy
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Make recommendations for redesign of each
patient’s medication regimen and monitoring
plan as necessary
Collect, interpret, and evaluate results of
monitoring parameters, including labs, drug
levels, clinical response, etc.
OBJ R2.9.1
OBJ R2.9.2
OBJ R2.9.3
Goal R2.10
Communicate ongoing patient information.
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OBJ R2.10.1:
Goal R2.11
(Application) When given a patient who is transitioning out of the critical care
setting, communicate pertinent pharmacotherapeutic information to the receiving
health care professionals.
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Communicate pharmacotherapeutic information
to receiving providers when a patient is
transferred to medicine floor
Determine urgency of patient-specific
medication information, and prioritize and
communicate accordingly (e.g., lab or micro
results, drug information questions, etc.)
Document direct patient care activities appropriately.
(Analysis) Appropriately select direct patient-care activities for documentation
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OBJ R2.11.1
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Document all significant patient-care
interventions in the pharmacy intervention
database
Investigate and report adverse drug reactions
7. Learning Topics
During this rotation, the resident is expected to develop a working knowledge of the following topics through literature review, topic discussions,
didactic lectures, and/or direct patient care:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Cardiac anatomy and physiology
Arrhythmias
Acute coronary syndromes
Heart failure
Cardiogenic shock
Stable Ischemic Heart Disease
Isolated systolic hypertension
Atherosclerotic cardiovascular disease
Hypertrophic cardiomyopathy
8. Required Reading
Arrhythmias
 Anderson JL, Halperin JL, Albert NM, et al. Management of patients with atrial fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS
Recommendation): A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:19161926.
 Beck H, See VY. Acute management of atrial fibrillation: from emergency department to cardiac care unit. Cardiology Clinics.2012;30:567-589
 Danelich HM, Reed BN, Hollis IB, et al. Clinical update on the management of atrial fibrillation. Pharmacotherapy 2013;33:422-446.
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Zimetbaum P. Antiarrhythmic drug therapy for atrial fibrillation. Circulation 2012;125:381-389.
Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med.
2002;347(23):1825-1833. (AFFIRM)
Roy D, Talajic M, Nattel S, et al. Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure. New England Journal of Medicine.
2008;358(25):2667-2677. (AF-CHF)
Van Gelder IC, Groenveld HF, Crijns HJ, et al. Lenient versus strict rate control in patients with atrial fibrillation. New England Journal of Medicine.
2010;362(15):1363–1373. (RACE II)
ACTIVE Writing Group of the ACTIVE Investigators, Connolly S, Pogue J, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial
fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial.
Lancet. 2006;367(9526):1903-1912.
Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. New England Journal of Medicine.
2009;361(12):1139–1151. (RE-LY)
Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. New England Journal of Medicine.
2011;365(10):883–891. (ROCKET-AF)
Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. New England Journal of Medicine.
2011;365(11):981–992. (ARISTOTLE)
Acute coronary syndromes
 O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guidelines for the management of ST-elevation myocardial infarction: a report of the American
College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362-e425.
 Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guidelines for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: A
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014
 Trost JC, Lange RA. Treatment of acute coronary syndrome: Part 1: Non-ST-segment acute coronary syndrome. Crit Care Med 2011;39:2346-2353.
 Trost JC, Lange RA. Treatment of acute coronary syndrome: Part 2: ST-segment elevation myocardial infarction. Crit Care Med 2012;40:1939-1945.
 Libby P. Mechanisms of Acute Coronary Syndromes and Their Implications for Therapy. New England Journal of Medicine.
2013;368(21):2004–2013.
 Yusuf S, Bijsterveld NR, Moons AHM. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment
elevation: the Clopidogrel in Unstable Angina to Prevent recurrent Events Trial Investigators. The New England journal of medicine.
2001;345(7):494–502.(CURE)
 Mehta SR, Tanguay J-F, Eikelboom JW, et al. Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals
undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial. Lancet.
2010;376(9748):1233–1243.
 Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. New England Journal of
Medicine. 2009;361(11):1045–1057. (PLATO)
 Pfeffer M, Braunwalk E, Moye LA, Basta L, Brown Jr E, Cuddy TF. Effect of captopril on mortality and morbidity in patients with left ventricular
dysfunction after myocardial infarction: SAVE. New England Journal of Medicine. 1992;327(10):669–77.
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Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised
placebo-controlled trial. Lancet. 2005;366(9497):1622–1632. (COMMIT)
Cannon C, Braunwald E, McCabe C, et al. Intensive versus Moderate Lipid Lowering with Statins after Acute Coronary Syndromes. New.
2004;350(15):1495-1504.(PROVE-IT)
Heart Failure
 Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guidelines for the Management of Heart Failure: A report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 128:000-000.
 Kemp CD, Conte JV. The pathophysiology of heart failure. Cardiovascular Pathology. 2012;21(5):365-371. The CONSENSUS Trial Study Group.
Effects of enalapril on mortality in severe congestive heart failure: Results of the Cooperative North Scandinavian Enalapril Survival Study
(CONSENSUS). N Eng J Med. 1987;316(23):1429-35.
 Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF).
Lancet. 1999;353(9169):2001-2007
 Bristow MR, Gilbert EM, Abraham WT, et al. Carvedilol produces dose-related improvements in left ventricular function and survival in subjects
with chronic heart failure. MOCHA Investigators. Circulation. 1996;94(11):2807-2816.
 Pfeffer MA, Swedberg K, Granger CB, et al. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARMOverall programme. Lancet. 2003;362(9386):759-766.
 Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. New England Journal of Medicine.
2011;364(1):11–21. 2. (EMPHASIS)
 Channer K, McLean K, Lawson-Matthew P, Richardson M. Combination diuretic treatment in severe heart failure: a randomised controlled trial. Br
heart J. 1994;71:146-150.
 Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. New England Journal of Medicine.
2011;364(9):797–805.(DOSE study)
 Fonarow GC, Abraham WT, Albert NM. Influence of beta-blocker continuation or withdrawal on outcomes in patients hospitalized with heart failure.
Findings from the OPTIMIZE-HF Program. J Am Coll Cardiol. 2008;52:190-99
 Jondeau G, Neuder Y, Eicher J-C, et al. B-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with Congestive heart failure
hospitalizED for a decompensation episode. European Heart Journal. 2009;30(18):2186-2192.
 Chen HH, Anstrom KJ, Givertz MM, et al. Low-Dose Dopamine or Low-Dose Nesiritide in Acute Heart Failure With Renal Dysfunction: The ROSE
Acute Heart Failure Randomized Trial. JAMA. 2013;310(23):2533–2543.
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Cardiogenic shock
 Vincent JL, DeBacker D. Circulatory shock. N Engl J Med 2013;369:1726-34.
 Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation 2008;118:1047-1056.
 Reynolds HR, Hochman JS. Cardiogenic Shock: Current Concepts and Improving Outcomes. Circulation 2008;117(5):686-697.
 Klein T, Ramani GV. Assessment and Management of Cardiogenic Shock in the Emergency Department. Cardiology Clinics 2012;30(4):651-664.
 Trost JC, Hillis LD. Intra-Aortic Balloon Counterpulsation. The American Journal of Cardiology 2006;97(9):1391-1398.
 Ouweneel DM, Henriques JPS. Percutaneous cardiac support devices for cardiogenic shock: current indications and recommendations. Heart
2012;98(16):1246-1254. doi:10.1136/heartjnl-2012-301963.
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Hypertension
 James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guidelines for the management of high blood pressure in adults. Report from the panel members
appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013;E1-E14.
Atherosclerotic Disease
 Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guidelines on the Treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in
adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013.
 Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guidelines on the assessment of cardiovascular risk: A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013.
Hypertrophic Cardiomyopathy
 Fifer MA, Vlahakes GJ. Management of symptoms in hypertrophic cardiomyopathy. Circulation 2008;117:429-439.
 Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: A Report of the American
College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Cirulation 2011;124:e783-e831
Additional handouts and articles will be given as topics are assigned by preceptor: http://cicurotation.weebly.com/
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