Ch 4-7 Flashcards
What is the pathogenesis of stress-related mucosal injury?
Inadequate nutrient blood flow, aggravated by gastric acid
What are the two independent risk factors for significant GI bleeding?
Mechanical ventilation >48 hours and coagulopathy
What is the best method of GI bleeding prophylaxis?
Enteral tube feeding
How is the pH of the stomach contents affected by sucralfate?
Stomach pH is not altered by sucralfate
How does sucralfate significantly impact the administration of other medications?
It binds to certain medications in the GI tract decreasing their absorption
What common medications are bound and partially neutralized by sucralfate?
Warfarin, Digoxin, FQs, Phenytoin, Tetracycline
What is the mechanism of action, dosing, administration, elimination for Famotidine?
H2 blocker, 20mg IV every 10-12 hours, renal elimination - reduce in renal failure or risk neurotoxicity
What is the mechanism of action, dosing, administration for Ranitidine?
H2 blocker, 50mg IV every 6-8 hours, renal elimination - reduce in renal failure or risk neurotoxicity
What is the major disadvantage of continuous H2 blockade?
tolerance
Which is preferred for GI prophylaxis: sucralfate or H2 blocker, why?
Sucralfate because NNT is lower for pneumonia prevention
Why might a PPI be preferred over an H2 blocker for GI prophylaxis?
No tolerance to prolonged use.
What is the preferred test for occult blood in gastric aspirates, why?
Gastroccult because it is not influenced by pH
What is the strategy for prophylaxis against harmful GI contamination in an intubated patient?
Oral decontamination: 2% gentamicin, 2% colistin, 2% vancomycin paste applied to buccal mucosa by a gloved finger Q6H until extubated
What is the efficacy of oral decontamination?
Aerobic bacteria and candida after 1 week of continuous treatment
What patients are candidates for oral decontamination (4)?
>1 week ventilation, severe lung impairment, pulmonary aspiration risk, recurrent pneumonia
What is the protocol for selective digestive decontamination (3 components)?
Standard oral decontamination; oral meds: (non-absorbable meds) Polymyxin E, tobramycin, amphotericin every 6 hours; systemic preloading: IV cefuroxime Q8H for first 4 days
What patients are candidates for selective digestive decontamination (5)?
Liver transplant recipient, severe burns, recurrent septicemia of unknown origin, >1 week of neutropenia, long ICU stay postgastrectomy
What is the advantage of selective digestive decontamination?
35% reduction in mortality when guidelines are followed
What do you do if you suspect an air embolism during your procedure?
Aspirate, place patient left side down keep air in the right side of the heart. Air can be aspirated with a needle through the 4th intercostal space at a 45 degree angle into the right atrium.
How do you best see a small pneumothorax on cxr?
Obtain films during expiration
Where does pleural air collect in supine patients?
Subpulmonic recesses and ateromedial border of the mediastinum
How long after a line insertion should you be worried about a pneumo?
24-48 hours
Your patient had a line place 2 days ago, cxr was normal and was doing well but just developed dyspnea, hypoxia. What’s your first test order? Why?
Cxr for pneumo
What is the proper placement on cxr of an ij or subclavian central line?
It should follow the svc and the tip should be at or slightly above the third anterior intercostal space
