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The ICU Book by Paul Marino > Ch 4-7 > Flashcards

Ch 4-7 Flashcards

1
Q

What is the pathogenesis of stress-related mucosal injury?

A

Inadequate nutrient blood flow, aggravated by gastric acid

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1
Q

What are the two independent risk factors for significant GI bleeding?

A

Mechanical ventilation >48 hours and coagulopathy

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2
Q

What is the best method of GI bleeding prophylaxis?

A

Enteral tube feeding

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3
Q

How is the pH of the stomach contents affected by sucralfate?

A

Stomach pH is not altered by sucralfate

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4
Q

How does sucralfate significantly impact the administration of other medications?

A

It binds to certain medications in the GI tract decreasing their absorption

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5
Q

What common medications are bound and partially neutralized by sucralfate?

A

Warfarin, Digoxin, FQs, Phenytoin, Tetracycline

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6
Q

What is the mechanism of action, dosing, administration, elimination for Famotidine?

A

H2 blocker, 20mg IV every 10-12 hours, renal elimination - reduce in renal failure or risk neurotoxicity

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7
Q

What is the mechanism of action, dosing, administration for Ranitidine?

A

H2 blocker, 50mg IV every 6-8 hours, renal elimination - reduce in renal failure or risk neurotoxicity

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8
Q

What is the major disadvantage of continuous H2 blockade?

A

tolerance

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9
Q

Which is preferred for GI prophylaxis: sucralfate or H2 blocker, why?

A

Sucralfate because NNT is lower for pneumonia prevention

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10
Q

Why might a PPI be preferred over an H2 blocker for GI prophylaxis?

A

No tolerance to prolonged use.

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11
Q

What is the preferred test for occult blood in gastric aspirates, why?

A

Gastroccult because it is not influenced by pH

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12
Q

What is the strategy for prophylaxis against harmful GI contamination in an intubated patient?

A

Oral decontamination: 2% gentamicin, 2% colistin, 2% vancomycin paste applied to buccal mucosa by a gloved finger Q6H until extubated

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13
Q

What is the efficacy of oral decontamination?

A

Aerobic bacteria and candida after 1 week of continuous treatment

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14
Q

What patients are candidates for oral decontamination (4)?

A

>1 week ventilation, severe lung impairment, pulmonary aspiration risk, recurrent pneumonia

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15
Q

What is the protocol for selective digestive decontamination (3 components)?

A

Standard oral decontamination; oral meds: (non-absorbable meds) Polymyxin E, tobramycin, amphotericin every 6 hours; systemic preloading: IV cefuroxime Q8H for first 4 days

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16
Q

What patients are candidates for selective digestive decontamination (5)?

A

Liver transplant recipient, severe burns, recurrent septicemia of unknown origin, >1 week of neutropenia, long ICU stay postgastrectomy

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17
Q

What is the advantage of selective digestive decontamination?

A

35% reduction in mortality when guidelines are followed

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18
Q

What do you do if you suspect an air embolism during your procedure?

A

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.

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19
Q

How do you best see a small pneumothorax on cxr?

A

Obtain films during expiration

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20
Q

Where does pleural air collect in supine patients?

A

Subpulmonic recesses and ateromedial border of the mediastinum

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21
Q

How long after a line insertion should you be worried about a pneumo?

A

24-48 hours

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22
Q

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?

A

Cxr for pneumo

23
Q

What is the proper placement on cxr of an ij or subclavian central line?

A

It should follow the svc and the tip should be at or slightly above the third anterior intercostal space

24
Q

PictureWhat should be done with this catheter?

A

Either withdraw to innominate vein or advanced further down the svc

25
Q

What is the preferred dressing for catheter insertion sites?

A

Sterile gauze

26
Q

What kind of antimicrobial protection should there be around a catheter?

A

None, no ointments in particular

27
Q

How often should peripheral athletes be changed?

A

Every 72-96 hours

28
Q

What are the indications (4) for central catheter replacement?

A

Purulent drainageSepsisEmergent placement without aseptic technique Femoral catheters after 48 hours

29
Q

How is a venous catheter maintained?

A

Daily heparin flush

30
Q

How is an arterial catheter maintained?

A

Normal saline flush

31
Q

What is the most common cause o catheter obstruction?

A

Thrombosis

32
Q

What are the signs of catheter thrombosis?

A

Limited flow, cessation of infusate but able to withdraw blood or total cessation of flow

33
Q

How do you combat thrombotic occlusions without removing the catheter?

A

Altplase mg maximum

34
Q

How do you combat non-thrombotic occlusion?

A

Dilute acid - for calcium depositsHcl70% ethanol - lipid infusion

35
Q

What is the gold standard for the diagnosis of upper extremity thrombosis?

A

Contrast venography

36
Q

Your patient had a central line placed 6 weeks ago and now presents with chest pain, cough and dyspnea. What tests do you order?

A

Cxr shows mediastinal widening and pleural effusion

37
Q

How do you diagnose svc perforation?

A

Thorocentesis shows similar glucose levels in pleural fluid to infusion fluid. Confirmed by injecting radio contrast

38
Q

What is the relationship between insertion site inflammation and complications of a catheter?

A

No relationship to systemic infection, only for surface infections

39
Q

How do you diagnose catheter related septicemia?

A

Culturing a 2 inch segment of the catheter

40
Q

How common is a catheter infected?

A

About 50% of suspected catheters are infected.

41
Q

What is the difference between a semiquantitative and a quantitative catheter tip culture?

A

Semi: rolled on a plateQuant: agitated in broth which is plated

42
Q

What are the 5 most common bugs for catheter tip septicemia?

A

Staph epidermidis (36)Entercocci (16)Gram (-) aerobic bacilli (16) - pseudomonas/klebsiellaS aureus (13)Candida (11)

43
Q

What is the initial management in a patient with a central line and isolated fever?

A

Cultures and vanc

44
Q

Treatment of catheter patient with severe sepsis or shock

A

Remove catheter and treat with vanc and ceftaz

45
Q

Treatment of catheter patient with neutropenia

A

Remove catheter for culture and start vanc an imipenem

46
Q

Treatment of catheter patient with a prosthetic valve and suspected infection

A

Remove athletes and start vanc and aminoglycoside

47
Q

What is antibiotic lock therapy?

A

Concentrated abx in suspected in dwelling catheter. For use only in catheters in place > 2 weeks for 2 weeks

48
Q

With continued sepsis, what 3 conditions should you think of?

A

Suppurative thrombosis (thrombus infection from a catheter)EndocarditisDisseminated candidiasis

49
Q

In a patient with s. aureus bacteremia, what other condition should you think of? testing?

A

endocarditis, TEE

50
Q

What is the most common etiology of nosocomial endocarditis?

A

s. aureus

51
Q

What is the standard duration of treatment for nosocomial endocarditis?

A

4-6 weeks of antibiotis

52
Q

sepsis picture with negative culture, what is your first suspicion?

A

disseminated andidiasis

53
Q

What complication occurs in 1/3 of patients with disseminated candidiasis?

A

endophthalmitis causing permanent blindness

54
Q

What consult should be ordered on a patient with disseminated candidiasis?

A

ophtho

55
Q

What are the treatment options (2) and outcome for invasive candidiasis patients?

A

satisfactory outcomes in 60-70% with either amphotericin B (1st choice) or capsofungin treatment

The ICU Book by Paul Marino (3 decks)

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