Acute Care Therapeutics Flashcards
How is absorption of drugs altered in critical care
impaired/unpredictable due to:
-gastric emptying/motility
-interactions w/ tube feeds
How is distribution of drugs altered in critical care?
Fluid and hydration status is altered
Alterations in plasma protein binding
How is metabolism of drugs altered in critical care?
Hepatic enzyme expression may be decreased
How is renal elimination altered in critical care patients
Kidney may not work so drugs will build up in system
what is sepsis
life threatening organ dysfunction caused by dysregulated response to infection
how to treat sepsis
no specific drug therapy
antibiotics and source control
what is septic shock?
sepsis associated with CV collapse/hypotension
how do you treat septic shock?
fluids (LR)
vasopressors (norepi)
steroids (hydrocortisone)
What is Acute Respiratory Distress Syndrome (ARDS)
Life threatening respiratory failure that is acute with lung injury
often requires ventilation and sedation
what is FASTHUGSBID
Feeding/fluids
Analgesia
Sedation
Thromboprophylaxis
HOB elevation
Ulcer prophylaxis
Glycemic control
Spontaneous waking
Bowel regimen
Indwelling catheters
Delirium assessment
who in the ICU should receive thromboprophylaxis
majority of ICU patients should unless sufficiently mobile and very low risk or a contraindication
what are the factors that ICU patients have that make them candidates for thromboprophylaxis
immobility
trauma, hypercoagulable states
cancer/obesity/prior VTE
what are the preferred agents for thromboprophylaxis
LMWH (enoxaparin, dalteparin) over UFH
what is the dosing of UFH for thromboprophylaxis
5000 U SC q8h or q12h
what is the dose of enoxaparin for thromboprophylaxis
30mg SC q12h, 40mg SC q24h
what is the dose of dalteparin for thromboprophylaxis
5000 U SC q24h
what is the monitoring for all thromboprophylaxis agents
s/s bleeding, CBC for HIT
what thromboprophylactic agents need renal adjustments
Enoxaparin
what are risk factors for stress ulcers
shock, coagulopathy
mechanical ventilation
neurotrauma
burns
life support
drugs: antiplatelets, anticoag, NSAIDs
what should you do for stress ulcer prophylaxis
H2RAs or PPIs and encourage enteral feeding
which is better for stress ulcer prophylaxis
H2RA and PPI are same
when to d/c SUP
when risk factors no longer present
what are ADRs of H2RAs
potential thrombocytopenia
adjust for renal dysfunction
what are the ADRs of PPIs
increased risk for C. diff and pneumonia
why do we care about glycemic control in the ICU?
hyperglycemia is associated with increased ICU mortality
what is the BG target in the ICU
144-180
when to initiate insulin in ICU and with what formulations
initiate insulin if BG > 180
avoid long acting insulin in unstable patients
MOA of succinylcholine
binds and activates Ach receptors to induce sustained depolarization of neuromuscular junctions (muscle cant contract)
what are ADRs of succinylcholine
may cause initial muscle contractions
APNEA
Hyperkalemia
increased intracranial pressure (ICP)
when to use succinylcholine
Rapid sequence intubation
NOT for sustained NMB
when is succinylcholine contraindicated
major burns
crash injury
upper motor neuron disease
what is the MOA of nondepolarizing NMBAs
competitively block the action of Ach
what are the 2 general classes of nondepolarizing NMBAs
aminosteroidal
benzylisoquinolinium
when are NDNMBAs indicated
immediate and sustained paralysis
mechanical ventilation (ARDS)
manage increased ICP
what are ADRs of NDNMBAa
paralysis of respiratory muscles/apnea
Inadequate pain and sedation (must be optimized prior to sedation)
prolonged paralysis/muscle weakness
how to monitor sustained NMB
can’t really monitor
goal is lowest dose possible and minimize ADRs
what is a toxicity endpoint for NMB
peripheral nerve stimulation
what is peripheral nerve stimulation
test 4 muscles to determine how deeply someone is suppressed. adjust to 1-2 twitches
what is PADIS
Pain
Agitation
Delirium
Immobility
Sleep
how is agitation characterized
increased motor activity and autonomic arousal
agitation!!!
How is delirium characterized
fluctuation or change in baseline mental status
disturbed consciousness
what are the two major pain scales
BPS or CPOT
what pain meds are preferred in the ICU
IV opioids
what IV opioids are most common
fentanyl
morphine
when should sedatives be introduced
when adequate analgesia is not enough to keep patient calm and resting
why is oversedation bad
increased time on ventilator
increased ICU stay
obscure neuro testing
what is the goal of sedatives
LESS IS BEST!
keep sedation light for spontaneous awakening to improve outcomes
what are the 2 sedation assessments called
RASS and SAS
is the bispectral index indicated?
not recommended in sedated ICU patients
what are the common sedative drugs used in the ICU
benzos (lorazepam, midazolam)
propofol
dexmedetomidine
what are ADRs of benzos
respiratory depression
CV effects
withdrawal could lead to seizures
delayed emergence from sedation
delirium
what are the cons of using lorazepam
delayed onset, prolonged duration of effect
less titratable
what is an advantage of lorazepam
metabolite does not linger in elderly
less prone to DDIs
what do some IV lorazepam agents contain that is toxic
propylene glycol solvent
how to track propylene glycol toxicity
calculate osmol gap
what is the onset of midazolam
rapid onset and short half life
titratable
what is the onset of propofol
rapid onset
rapid offset
what should be checked before starting propofol
egg or soybean allergy
how long can you hand propofol
no more than 12hrs risk of infection
what are the ADRs of propofol
apnea
Hypotension, bradycardia
pain
inc TGs
seizures neuroexcitory system
what limits high doses of propofol
CV effect/propofol infusion system
how to dc propofol
gradual tapering of dose especially if greater than 7 days of therapy
what is the MOA of dexmedetomidine
selective alpha-2 agonist
how is dexmed different than other sedatives
patients readily arousable with gentle stimulation
no respiratory depression
no anticonvulsant activity
less delirium than BZDs
PK of dexmed
short half life
hepatically metabolized
what is the dose of dexmed
maintenance infusion: 0.2-0.7 ug/kg/h
AVOID LOADING DOSE
what are LDs of dexmed associated with
increased CV effects
how long can dexmed be used
only approved for short term, but can go longer if other options too risky
what are the ADRs of dexmed
increased CV effects such as bradycardia, hypotension
when should dexmed be used over benzos
for critically ill mechanically ventilated adults
what are non pharm treatments/prevention of delirium
early mobilization
improving cognition
optimizing sleep, hearing, and vision
what are pharm treatments/prevention of delirium
NO DRUGS
antipsychotics may be used for short term but associated w/ significant stress
dexmed may be option
when can haloperidol be used
in acute delirium situations
what are ADRs of haloperidol
prolongation of QT interval on ECG
decreases seizure threshold
when to dc haloperidol
if QTc exceeds 450msec or increases >25 % from baseline?
what are the PAD guidelines
best way to avoid over sedation
encourage regular assessment of ICU patient
