Acute Care Flashcards
Absorption
Oral absorption is ___ / ___ in critically ill patients
- alterations in gastric emptying, gastric motility
- interactions with enteral feeding / GI tubes
- GI injury/disease
impaired/unpredictable
Distribution
Alterations vary between different critically ill patient populations
- relates in part to ___ status
- hydrophilic drugs (e.g., aminoglycosides) have ___ Vd in critically ill
surgical/trauma patients (~ __ - __ L/kg) than in medical patients (~ ___ L/kg)
- fluid
- higher
- 0.3-0.35, 0.25
Distribution
Alterations in plasma protein binding
* ___ albumin
* ___protein binding of many drugs
* ___ acute phase proteins (e.g., α1-acid glycoprotein)
* ___ protein binding of drugs that bind α1-acid glycoprotein
- decreased
- decreased
- increased
- increased
Metabolism
Hepatic metabolism
* hepatic blood flow
* enzyme expression and activity
* protein binding
In general: hepatic enzyme expression and activity may be ___ in some critically ill patients
* limited data
decreased
Renal Elimination
Renal dysfunction is a common complication during critical illness
* shock, sepsis-related organ failure
* nephrotoxic drugs
* HD or continuous renal replacement therapy (e.g., CVVH, etc) is common in
ICU
* Some disease states may be associated with ___ renal elimination
* burns
* trauma
increased
Sepsis
life threatening ___ dysfunction caused by dysregulated response to
infection
* immune ___
* coagulation and thrombosis leading to endothelial injury
* high mortality rates (~30%)
* can occur in response to any ___ (bacterial most common) and any site of infection (common: lungs, bloodstream, urinary tract)
* no specific drug therapy, early detection and supportive therapy is critical
* antibiotic therapy (broad spectrum IV antibiotics) and source control
- organ
- dysregulated
- pathogen
Septic shock
sepsis associated with ___ collapse
- ___ related to decreased vascular tone
treatment
* ___ (crystalloids, colloids)
* ___ (increase vascular tone, potentially cardiac output)
* target MAP ≥ 65 mm Hg
* ___ preferred, also phenylephrine, epinephrine, dopamine
* ___ (add-on)
* ___ (inotrope, not a vasopressor)
* corticosteroids (IV ___ ) if refractory
- CV
- hypotension
- fluids
- vasopressors
- norepinephrine
- vasopressin
- dobutamine
- hydrocortisone
Respiratory Failure
- respiratory failure/mechanical ___ is a common reason for ICU admission
- causes: airway compromise, hypoventilation, hypoxic failure (poor air exchange), inability to
protect airway, etc
Acute Respiratory Distress Syndrome (ARDS)
* life threatening respiratory failure characterized by acute, diffuse ___ lung injury
* 25-40% mortality
* risks include pneumonia, sepsis, trauma, aspiration, others
* often requires mechanical ventilation with ___ , potentially ___ blockade
* ___ may decrease mortality in severe ARDS
- ventilation
- inflammatory
- sedation, neuromuscular
- corticosteroids
General Supportive Care
“FAST HUGS BID”
F: feeding/fluids
A: analgesia
S: sedation
T: thromboprophylaxis
H: HOB elevation
U: Ulcer (stress ulcer) prophylaxis
G: glycemic control
S: spontateous awakening trial, spontaneeous breathing trial
B: bowel regimen
I: indewelling catherters
D: de-escalation of antibiotics/delirium assessment
General Supportive Care
Feeding
* many ICU patients unable to take adequate oral intake
may have specialized nutritional requirements
* liver, renal failure
* ___ caloric, nutrient needs (trauma, surgery, burn)
enteral nutrition (“tube feeds”) and parenteral nutrition (“TPN”) common
* ___ preferred (”if the gut works, use it”)
* can be complicated by decreased GI motility, underlying disease states
increased
enteral
General Supportive Care
Fluids
* goal is adequate ___ and meeting ___ requirements without causing fluid overload
* carefully monitor “IN’s” and “OUT’s”
- resuscitation
- maintenance
General Supportive Care
Thromboprophylaxis
most critically patients have risk factors for venous thromboembolism (VTE)
- ___
- trauma, surgery, use of vascular catheters, sepsis, hypercoagulable states
- cancer, obesity, prior history of VTE
can be complicated by underlying bleeding risks, active bleeding, need for
invasive procedures, neuraxial anesthesia
the majority of ICU patients should receive pharmacological VTE ___ unless sufficiently mobile and very low risk OR contraindications to pharmacological prophylaxis
- immobility
- prophylaxis
General Supportive Care
Thromboprophylaxis
* ___ generally preferred over UFH
* others: fondaparinux, bivalrudin, argatroban, warfarin, dabigatran, rivaroxaban, apixaban
___ prophylaxis in patients with contraindications to pharmacologic prophylaxix
LMWH
mechanical
General Supportive Care - Thromboprophylaxis
UFH dosing and monitoring
* ___ U SC q __ h or q12h (possibly 7500 U SC q12h)
* monitoring: s/s of ___, CBC (platelets for ___ )
* no adjustment for ___ dysfunction
enoxaparin
* __ mg SC q12h, __ mg SC q __ h (may dose base on anti-Xa activity in selected patients)
* monitoring: s/s of ___ , CBC (platelets for ___ )
* CrCl < ___ ml/min: __ mg SC q __ h
dalteparin
* ___ USC q24h
* monitoring: s/s of bleeding, CBC (platelets for HIT)
* CrCl < 30 ml/min: no adjustment necessary
- 5000, 8
- bleeding, HIT
- renal
- 30, 40, 24
- bleeding, HIT
- 30, 30, 24
- 5000
General Supportive Care
Head of Bed Elevation
- to reduce ___ risk
aspiration
General Supportive Care
Stress Ulcer Prophylaxis
stress related mucosal damage
* superficial lesions commonly involving the mucosal layer of the ___ following major stressful events
* clinically important bleeding likely uncommon (1.5%-5%), but associated with high morbidity and mortality (12.5%-20%)
risk factors
* shock, coagulopathy, chronic liver disease
* mechanical ___ /respiratory failure (?)
* others: neurotrauma, burn injury, extracorporeal life support
* drugs: antiplatelet agents, anticoagulants, ___
- stomach
- ventilation
- NSAIDs
General Supportive Care
Stress Ulcer Prophylaxis
prophylaxis (“SUP”)
* H2RAs
* PPIs
* ___ feeding - should not be used as sole prophylaxis in high-risk patients (add SUP)
PPIs vs H2RA is controversial
* guidelines do not recommend one vs the other
* some suggestion that PPIs may be more effective in preventing clinically important ___
* ___ SUP when risk factors no longer present
- enteral
- bleeding
- d/c
Stress Ulcer Prophylaxis
H2RAs (2)
* enteral or parenteral
* ADRs: potential ___ (rare)
- thrombocytopenia
Stress Ulcer Prophylaxis
PPIs (5)
- enteral or parenteral
- potential for risk ___ colitis, nosocomial pneumonia
- effect on mortality controversial
- C. diff
SUP Summary
Prophylaxis generally considered to be warranted in critically ill patients
considered to be at high risk:
- mechanical ___
- chronic ___ disease
- shock
- coagulopathy
PPI vs H2RA controvercial
- PPIs have less ___ but more ___
d/c prophylaxis when risk factors no longer present
- ventilation
- liver
- bleeding, infection
General Supportive Care
Glycemic Control
- ___ is associated with increased ICU mortality
multifactorial causes (not limited to patients with underlying diabetes)
- underlying stress, TPN
in general target BG ___ - ___ mg/dl
initiate insulin if BG > ___ mg/dl
* sliding scale
* ___ infusion
* electronic glucose management systems
* avoid ___ insulin formulations in unstable patients
- hyperglycemia
- 144-180
- 180
- continuous
- long-acting
General Supportive Care
Spontaneous Awakening trial, Spontaneous Breathing Trial
- helps prevent ___ and promotes weaning from mechanical ___
- oversedation
- ventilation
General Supportive Care
Bowel Regimen
hypomotility is common in critical illness
- particularly in patients on high dose/prolonged opioids
constipation
* stool softeners (e.g., ___ )
* laxatives ( ___, docusate sodium, lactulose)
gastroparesis
* promotility agents ( ___, ___)
D/C if patient is having diarrhea/frequent stools
- senna
- polyethylene glycol
- metoclopramide, erythromycin
General Supportive Care
Indwelling Catheters
- assess need, ___ regularly, remove if infected
De-escalation of Antibiotics
- often start with ___ coverage, refine and de-escalate based on culture results and clinical response
Delerium Assessment
- replace
- broad spectrum
Neuromuscular Blocking Agents (NMBA’s, “paralytics”)
two types
depolarizing
nondepolarizing
Succinylcholine
Physically resembles acetylcholine (Ach)
- activates Ach receptors
- sustained ___ of neuromuscular junction = muscle
contraction canʼt occur
- hydrolyzed much more ___ than Ach
- May cause initial muscle ___
- Dose: 1.5 mg/kg IV
- Onset: ~1 minute
- Duration ~3-5 minutes
- Elimination: rapidly hydrolyzed in serum by the enzyme pseudocholinesterase
- depolarization
- slowly
- contractions
Succinylcholine
Used for ___ ___ ___ (RSI)
* placement of an endotracheal tube
* permits complete airway control and simplifies visualization of vocal cords
can cause initial muscle contractions
* may pre-administer defasciculating dose of ___ NMBA
immediately prior to succinylcholine
NOT used for ___ neuromuscular blockade
- rapid sequence intubation
- nondepolarizing
- sustained
Succinylcholine: ADRs
___ -> need to be ready to intubate
Muscle ___ -> deep aching muscle pain, may persist for days
Hyper ___ : precise mechanism unknown
- asynchronous ___ of muscle cells
- alterations in receptor sensitivity
contraindicated in major ___ , __ injury, and upper motor ___ disease
- potential life threatening ___
- unclear the precise duration that these contraindications should
persist
- apnea
- fasciculations
- hyperkalemia
- depolarization
- burns, crush, neuron
- hyperkalemia
Succinylcholine: ADRs
Prolonged ___
* result of impaired ___ activity or decreased levels
* Intracranial pressure (ICP) ___ (controversial in TBI)
* Increased intraocular pressure (? clinically significant)
apnea
- pseudocholinesterase
- elevation
Nondepolarizing NMBA’s
Competitively block the action of Ach (i.e., do NOT ___ receptors)
* do not cause initial ___
* competitive
2 general classes: ___ and ___
reversal possible, but generally not used in ICU
* acetylcholinesterase inhibitors ( ___ and ___)
* ___ - modified A-cyclodextrin for reversal of rocuonium/vecuronium
- activate
- fasciculations
- aminosteroidal, benzylisoquinolinium
- pyridostigmine, neostigmine
- sugammadex
Aminosteroidal NMBA’s
3 drugs
- pancuronium
- vecuronium
- rocuronium
Benzylisoquinolinium NMBA’s
2 drugs
- atracurium
- cisatracurium
NDNMBA’s: Clinical Indications
May use for both ___ / ___ paralysis
Mechanical Ventilation
* generally in patients with acute lung injury or ___
* 25-50% of ARDS patients, recommended to administer as a ___ infusion
prevents ___ with ventilator, stops spontaneous respiratory effort
* improves gas exchange
* facilitates “nontraditional” methods of ventilation
* ___ required in all mechanically ventilated patients!
- immediate/sustained
- ARDS
- continuous
- NOT
NDNMBA’s: Clinical Indications
Operative Settings
* muscle relaxation
RSI
* if contraindications to ___ (e.g., ___ , etc.)
* fast-acting agent
Manage Increased ___
* typically reserve for patients with severe posturing, difficulties in
mechanical ventilation, refractory increased ICP
Therapeutic ___
* body temp 32-34 C post cardiac arrest
* prevent/treat ___
___ Oxygen Consumption
* controversial -> severe ___ may be associated with high oxygen demands,
may improve “supply-demand” relationship
- succinylcholine, burns
- ICP
- hypothermia
- shivering
- decrease
NDNMBA’s: ADR’s
Paralysis of ___ muscles/ ___
* safeguards to prevent unplanned extubation
Inadequate ___ and ___
* NMBAʼs do NOT provide analgesic, sedative, or anxiolytic effect
* patients still feel pain and anxiety, however are unable to communicate
* no longer able to assess typical symptoms of pain and anxiety
* patients must be optimized on ___ and ___ drugs (ideally ___ to initiation of NMBA)
- respiratory, apnea
- pain, sedation
- sedative, analgesic, prior
NDNMBA’s: ADR’s
Prolonged Paralysis/Muscle Weakness
- ICU-acquired skeletal muscle weakness (ICUAW)
- acute quadriplegic myopathy syndrome (AQMS)
- critical illness myopathy (CIM)
- critical illness polyneuropathy (CIP)
multifactorial:
* pharmacokinetic effected ( ___ ) possible pharmacodynamic effects
* risk increased with ___ NMBA administration, possibly
increased with ___ , ___ , or ___ shock
* drug holidays may decrease the incidence of AQMS
all those are the same thing
- accumuation
- polonged
- corticosteroids, sepsis, septic
corticosteroid thing controversial
NDNMBA’s: ADR’s
Msc ADRʼs
related to immobility
* ___ prophylaxis
* ocular ___
agent specific ADRʼs
* Drug Interactions - ___ and NMBAʼs (note that contribution is controversial)
- DVT
- lubricants
- corticosteroids
Monitoring Sustained NMB
Challenging (and often misunderstood)
* Associated with significant ___ in response
* Goal: ___ dose possible, minimization of ADRʼs
* efficacy endpoint -> based on clinical indication
* difficult to assess
- variability
- lowest
Monitoring Sustained NMB
___ endpoint -> Peripheral nerve stimulation (“twitch monitoring”, train-of-four [TOF] assessment):
- nerve stimulated 4 times
- 4/4 = < 75% suppression
- 3/4 = 75% suppression
- 2/4 = 80% suppression
- 1/4 = 90% suppression
- 0/4 = 100% suppression
titrating to ___ should be avoided
- adjust dose to 1-2 twitches of train
- toxicity
- 0/4
PADIS
pain, agitation/sedation, delirium, immobility, sleep
Pain and Analgesia
poorly treated in hospitalized patients
- most (≥50%) ICU patients experience pain
- many unable to self report
pain related stress response
* increases ___ nervous system activation, raises ___ levels
* vaso ___ , impaired tissue perfusion
* catabolism/ ___
* impaired wound healing/increased wound infection
* ___ suppression
* can alter ___ patterns and mechanics
- sympathetic, catecholamine
- vasoconstriction
- hypermetabolism
- immunosuppression
- breathing
Pain Assessment
if unable to self report
* ___ : facial expression, upper limb movements, compliance with
mechanical ventilation (each rated on scale of 1-4, total score 3-12)
* ___ : facial expression; body movements; muscle tension; compliance with mechanical ventilation OR vocalization (each rated on scale of 0-2, total score 0-8
- BPS: Behavioral Pain Scale
- CPOT: Critical Care Pain Obseravtion Tool
in general, IV ___ preferred for non-neuropathic pain in critically ill
patients
- equally effective when titrated to similar endpoints
- note that opioids may have ___ effects
non-opioid analgesics may be used to ___ opioid requirements (mulit-
modal approach)
- acetaminophen
- ___ pain medications (gabapentin, pregabalin, carbamazepine)
- NSAIDs (don’t routinely use)
- ketamine (post surgery)
- opioids
- sedative
- decrease
- neuropathic
Agitation/Sedation
agitation = state of anxiety accompanied by motor restlessness
frequent in critically ill patients, associated with adverse clinical outcomes
* ventilator ___
* inappropriate verbal behavior
* physical ___
* increased motor activity
* increases in oxygen consumption
* inadvertent removal of devices and indwelling lines and catheters
- dysynchrony
- aggression
Agitation/Sedation
underlying causes of agitation
- pain
- mechanical ventilation
- delirium
- hypoxia
- hypotension
- withdrawal (EtOH, drugs)
Treatment of Agitation
nonpharmacologic efforts
* maintenance of patient comfort
* provision of adequate ___
* frequent reorientation
* optimization of environment to maintain normal ___ pattern
* many (this used to say most) patients requiring mechanical ___ will
require some pharmacological ___
- analgesia
- sleep
- ventilation
- sedation
Treatment of Agitation-Sedation
pharmacologic sedation should be started after providing adequate ___ and treating reversible physiological causes
should not be used as a method of restraint, coercion, discipline, convenience,
or retaliation
analgesia
Treatment of Agitation-Sedation
degree of sedation in part depends on patient’s need/ability to protect ___
* over sedation is problematic
* increase time on mechanical ___
* ___ ICU and hospital length of stay
* obscure neurological function testing
airway
- ventilation
- increase
Treatment of Agitation-Sedation
Goal: adequate sedation, but not over sedation
* LESS IS BEST
* calm ___ patient, able to purposefully follow simple commands
Benefits
- decreased duration of mechanical ventilation
- decrease in ICU LOS
- possible decrease in mortality (controversial)
efforts to achieve light sedation should be empoyed
- daily sedation ___
- nursing-protocolized target sedation
- arousable
- interruption
Assessment of Sedation
assessment facilitates titration of sedatives to pre-determined endpoints
- subjective assessment is difficult in patients with altered level of mentation or inability to outwardly express anxiety
2 sedation scales: ___ and ___
- Richmond-Agitation-Sedation Scale (RASS)
- Sedation-Agitation Scale (SAS)
Assessment of Sedation
____ ___ ___ Scale ( ___ ):
* 10-point scale
* four levels of anxiety or agitation (1 to 4)
* one level to denote a calm and alert state (0)
* 5 levels of sedation (-1 to -5)
___ :
* consciousness and agitation from a 7-item list
* 1=unarousable
* 7=dangerously agitated
- Richmond Sedation Agitation Scale (RASS)
- SAS
Assessment of Sedation
objective assessment
___ ___ ( ___ ):
* digital scale from 100 (completely awake) to 0 (isoelectric EEG)
guidelines suggest using in patients in whom other measures are not feasible (e.g., deep sedation, neuromuscular blockade)
- currently do not recommend BIS monitoring (or other objective measures of brain function) in all sedated ICU patients
- recommend EEG monitoring for non-convulsive seizure activity in ICU patients with known/suspected seizures or to titrate medications to achieve burst suppression
- Bispectral Index (BIS)
