List potential adverse drug reactions, and outline how they may impact on your management of the critically ill patient.
This question was best answered using a systematic approach. Many candidates did not address the impact of adverse reactions on management, in particular how to prevent or minimise their occurrence. Reasonable list should include effects of drug alone and drug on drug.
Expected reactions (ie extensions of known pharmacologic effects) are many and should include pharmaceutic (eg. compatibility issues), pharmacokinetic (eg. absorption, enzyme induction), pharmacodynamic (eg. innocent bystander organs, competition). Unexpected reactions include idiosyncratic (haematological, hepatic, dermatological), and allergic (mild through to anaphylaxis and anaphylactoid). Management requires detailed drug history: drugs administered (over the counter as well as prescription drugs), alcohol intake, previous drug reactions, conditions that make adverse effects more likely (eg. respiratory depression and sleep apnoea, or severe airways disease). Examination: to look for conditions that may make reactions more likely. Careful prescribing (ie only using drugs when indicated) with attention to potential interactions (including physical incompatibilities etc), and appropriate monitoring (eg. drug levels, organ function).
Twenty-three out of forty-one candidates passed this question.
This is a question which would benefit from a systematic approach. An alternative to the college system is the one offered in Table 1 from the Lancet article by Edwards et al (2000). Apparently, that is the official classification used in "the industry".
Dose and time related reactions
Time related reactions
Unexpected failure of therapy
Leape, Lucian L., et al. "Pharmacist participation on physician rounds and adverse drug events in the intensive care unit." Jama 282.3 (1999): 267-270.
Edwards, I. Ralph, and Jeffrey K. Aronson. "Adverse drug reactions: definitions, diagnosis, and management." The Lancet 356.9237 (2000): 1255-1259.
Cullen, David J., et al. "Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units." Critical care medicine25.8 (1997): 1289-1297.
Bates, David W., et al. "Incidence of adverse drug events and potential adverse drug events: implications for prevention." Jama 274.1 (1995): 29-34.