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
Aminosteroidal NMBA’s
3 drugs
- pancuronium
- vecuronium
- rocuronium
Benzylisoquinolinium NMBA’s
2 drugs
- atracurium
- cisatracurium
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
