Published 07/07/2022
Claire Hannah
Lead Pharmacist

When she is not working at the Royal Infirmary of Edinburgh, Claire enjoys running, playing tennis and going to watch live bands.

    Grainne Smyth
    Lead Pharmacist

    Grainne works at the Western General Hospital in Edinburgh and has very little free time at the moment as she experiences the joys of being mum to a young family.

    Anne Neally
    Lead Pharmacist

    Anne works at St John’s Hospital in Livingston and away from work enjoys gardening, dog walks and planning her next holiday destination.

    FAST HUGS is a widely used mnemonic within critical care but what do FAST HUGS mean to a pharmacist? Highlighted below is our pharmacist take on how we work within critical care. Under the current Covid climate is seemed only appropriate to add an extra letter so that we could represent our journey on the NHS steam train that relentlessly continues to ‘chug’ along the track life.


    • Feed – Route, total parenteral nutrition (consider pabrinex for re-feeding), target rate, aspirates (prokinetics and route of administration of drugs), feed breaks for some drugs.
    • Filter/Acute Kidney Injury (AKI) – review medication doses & frequencies, anticoagulation.
    • Fluids – maintenance & fluid balance, urine output (<0.5 ml/kg/hr = AKI), reviewing IV infusions in fluid restricted patients (advising on minimum volumes that can be given or appropriate concentrations for peripheral versus central administration).



    • Lines – peripheral or central – consider drug compatibility & concentration of infusion.
    • Laboratory tests, electrolytes and haematology – drug related causes of abnormalities.
    • Laxatives – ensure bowels moving in patients being fed, as per local protocol.



    • Allergies.
    • Antibiotics or Anti-infectives – indications and review dates documented.
    • Appropriate indications – all prescribed medications are necessary.
    • Adjustments of dosing – based on renal/hepatic function/drug. interactions/age/weight/ clinical condition.
    • Analgesia – monitor pain control and form of analgesia; epidural blocks, regional anaesthesia, infusions, modified release or regular short acting, patient-controlled analgesia.



    • Thromboprophylaxis – Low Molecular Weight Heparin (adjusting dose based on weight & renal function) and unfractionated heparin if appropriate, all based on local protocol.
    • Therapeutic Drug Monitoring – e.g. phenytoin, gentamicin, amikacin, vancomycin.



    • Covid-19 Management:
      • Ensuring patient is receiving most appropriate treatment for Covid-19 pneumonitis based on local protocol.
      • Adjusting Thromboprophylaxis if appropriate.
      • Maintaining stock surveillance for treatments, particularly those in short supply.
      • Ensuring treatment as part of clinical trials is prescribed appropriately.



    • Hypoactive or Hyperactive Delirium – for non-pharmaceutical and pharmaceutical management as per local protocols.
    • Hydrocortisone - 50mg QDS when >0.2mcg/kg/min IV noradrenaline, despite optimal fluid resuscitation (low evidence).
    • Hepatic Function – review impact on prescribed medication.
    • High cost medicines – highlight to team, monitor use, review expenditure reports.



    • Ulcer prophylaxis – pantoprazole 40mg IV OD, stepping down to lansoprazole when route available if appropriate, stopping if no risk factors and on full feed.
    • Usual Medication- undertake full medication history including OTC/illicit/herbal, and ensure necessary medications continued where appropriate. Consider risk of withdrawal e.g. SSRIs, benzodiazepines, alcohol, nicotine, illicit drugs.
    • Unlicensed Medication – ensure it is indicated / no licensed alternative available. Consider how it can be sourced and governance requirements when obtaining supply.
    • Updating Unit Documentation – ensuring protocols and monographs in use are regularly reviewed and evidence-based.



    • Glycaemic control – aim <10mmol/L.  Identify causes in fluctuations; consider steroids, propofol, atypical antipsychotics.
    • GPICS standards – endeavour to meet standards for pharmacy.



    • Sedation, Agitation, Hypoactive/Hyperactive Delirium – consider daily sedation holds, contributing factors (sleep hygiene, noise etc.), consider Confusion Assessment method for the ICU (CAM-ICU), pharmaceutical management where appropriate as per local protocol.
    • Supply – is drug stock? If non-stock, consider ordering adequate supply or alternatives if possible.
    • Side effects, interactions and duplications – consider adverse effects from medications, consider drug-drug, drug-patient and drug-laboratory interactions, stop unnecessary duplications.
    • Standard Drug Infusions – ensure infusions prescribed appropriately, documenting diluents, final volume, rate and route.
    • Stop dates – e.g. anti-infective agents, steroids.


    ...Just for the record, none of our authors are particular train enthusiasts.



    Adapted from King’s Hospital Critical Care Units FLAT HUGS for pharmacists, written by Critical Care Pharmacists at King’s College Hospital, July 2019.