Critical Care Flashcards
absorption problems in ICU
- gastric emptying / motility
- enteral tube interactions (drugs)
- GI injury / disease
criticially ill patients Vd of hydrophillic drugs
high because theyre pumped with fluids
hydrophillic drugs that are better absorbed with larger Vd
aminoglycosides
album and protein binding in critically ill patients is
decreased due to underlying stress
protein binding of what drugs is increased in critical illness
drugs binding alpha 1 acid glycoprotein
how is hepatic metabolism in critically ill pts
decreased
disease states associated with decreased renal elimination
shock
sepsis
organ failure
nephrotoxic drugs
disease states that may have increased renal elimination
burns
trauma
how do we detect changes in renal function
urine output
what is sepsis
life threatening organ dysfunction caused by response to infection
what can happen in sepsis
immune dysregulation
coagulation and thrombosis
what is most common pathogen that sepsis happens from
bacterial
most common sites of sepsis infection
blood, lungs, urinary tract
treatment of sepsis
supportive therapy
broad spectrum IV antibiotics
symptoms of septic shock
cardiovascular collpase
hypotension
drug classes given in septic shock
fluids
vasopressors
corticosteroids
fluids given in septic shock
crystalloids / colloids
vasopressors used in septic shock
norepinephrine preferred
can add vasopressin
goal mean arterial pressure in septic shock (MAP)
> 65 mm Hg
corticosteroid used in septic shock
IV hydrocortisone
what is acute respiratory distress syndrome (ARDS)
life threatening respiratory failure categorized by lung injury
25-40% mortality
risks for ARDS
sepsis, pnemonia, trauma, aspiration
treatment for ARDS
mechanical vent
corticosteroids dec mortality
FAST HUGS BID
F - feeding/fluids
A - analgesia
S - sedation
T - thrombophrophylaxis
H - HOB elevation
U - ulcer prophylaxis
G - glycemic control
S - spontaneous awakening trial
B - bowel regimen
I - indwelling catheters
D - de-escalation antiobiotics / delirium
risk factors for VTE
immobility
trauma, surgery, sepsis
cancer, obesity, VTE hx
who should receive VTE prophylaxis
everyone except:
- mobile
- very low risk
- contraindications
what do we use for thromboprophylaxis
UFH or LMWH
LMWH preferred
what if patient has contraindication to pharmacologic thromboprophylaxis
mechanical prophylaxis
UFH dose prophylaxis
5000 units SC q8h or q12h
no renal adjustments
enoxaparin dose prophylaxis
30 mg SC q12h
40 mg SC q24h
CrCl < 30: 30 mg SC q24h
monitoring for UFH and enoxaparin
bleeding
CBC (platelets for HIT)
stress ulcer happens how
lesions on mucosal layer of the GI caused by stress
are stress ulcers clinically importnat
not always, if bleeding important its deadly
risk factors for stress ulcers
shock
coagulopathy
liver disease
neurotrauma
burn
MECHANICAL VENTILATION
drugs
drugs with high risk for ulcer
NSAIDS, antiplatelets, anticoagulants
what do we use for stress ulcer prophylaxis (class)
PPI or H2RA
PPI may be better
H2RA drugs used for stress ulcer prophylaxis
famotidine
ranitidine
adverse reactions of H2RAs
potential thrombocytopenia
when do we d/c stress ulcer prophylaxis
once risk factor gone
side effect of PPI
increase risk c diff
nosocomial pnemonia
dosing consideration for H2RAs
renal adjustment
why do we keep glycemic control in ICU
hyperglycemia increased mortality
pts with stress / TPN can get even w/o diabetes
BG target in ICU
144-180
what kind of insulin should we not use in ICU
long acting
what does spontaneous awakening trial help prevent
oversedation
promotes weaning from mechanical vent
what is succinylcholine and how does it work
depolarizing NMBA
binds ACh receptor and prevents ACh from binding so muscle contraction can’t occur
- may cause initial muscle contraction
dose onset and duration of succinylcholine
1.5 mg/kg
onset: 1 min
duration: 3-5 min
how is succinylcholine eliminated
neither renal or hepatic
what is succinylcholine used for
rapid intubation
NOT sustained neuromuscular blockade
what can we preadminister before succinylcholine so we don’t have initial contractions
non-depolarizing NMBA imediatley prior
succinylcholine ADRs
apnea
hyperkalemia
muscle contractions
incr intracranial pressure
incr intraocular pressure
succinylcholine contraindications
burn
crush victim
upper neuron disease (ALS)
what are non-depolarizing NMBAs
competitively block ACh receptors
do not cause muscle contractions
classes of non-depolarizing agents
aminosteroidal
benzylisoquinolinium
reversal agents for non-depolarizing NMBAs
ACh esterase inhibs (stigmines)
suggamedex
non-depolarizing NMBA ending
-oniums
who gets non-depolarizing NMBAs in mechanical vent
not everyone
often in ARDS - continuous administration
indications for NDNMBAs
mechanical vent ARDS common
contraindication to succ: burn, crunch, neuron dx
operative
increased intracranial pressure
hypothermia
adverse effects of NDNMBAs
apnea
inadequate pain and sedation
prolonged paralysis
DVT
ocular dryness
what must patients be on before sedative given
optimized on analgesia and sedative
drug interaction with NMBAs
corticosteroids
whats the efficacy endpoint in NMB
are we seeing improvement
how do we monitor the toxicity endpoint in NMBAs
peripheral nerve stimulation, twitch monitor
more twiches = less suppression
4/4 < 75%
3/4 75%
2/4 80%
1/4 90%
0/4 100%
how many twitches do we want to dose adjust to
1-2 twitches
what is delirium
acute onset of cerebral dysfunction with
change in baseline mental status
inattention
disorganized thinking
altered level of consciousness
cardinal feautre of delirium
disturbed level of consciousness/attention
and
change in cognition or development hallucinations /delusions
gold standard for pain if pt can communicate
what the pt says
pain scale if pt cant commuicate
behavioral pain scale (BPS)
critical care pain oversavation tool (CPOT)
proxy - caretaker suggestion
what pain meds preferred for non-neuropathic pain
IV opioids, can cause sedation
non-opioids used to decrease opioid requirement
tylenol
ketamine (post surgery)
gapapentin/pregabalin
NSAID - bleed risk tho
how do we give opioids IV
bolus or continuous
causes of agitation in ICU
pain
mechanical vent
hypoxia
hypotension
withdrawal EtOH, drugs
delirium
nonpharm treatment of agitation
patient comfort
analgesia
reorientation
optimization of sleep environment
who gets sedatives in agitation
adjunct for anxiety/agitation
non-pharm supplement
many on mechanical vent, not all
what should we not use sedative for
restraint
coercion
discipline
convenience
retaliation
“you dont like them”
pharm treatment of agitation can be given after what
analgesia and reversible physiollogic causes treated
why is over sedation dangerous
longer time on vent
longer time in ICU
no neruological testing
sedation goal
calm but arousable so can follow simple commands
how do we assess sedation and titrate subjectively
richmond agitation sedation scale (RASS)
sedation agitation scale (SAS)
how do we assess sedation for patients on a NMBA or if we cant use typical scales
bispectral index (BIS): EEG
benzos used in ICU
lorazepam
midazolam
benzos adverse effects
respiratory depression
withdrawal
prolonged sedation/duration
delirium association
onset and duration of lorazepam
long duration
delayed onset
less titratable
lorazepam elimination
not renally or hepatially eliminated
no dose accumulation
IV formulation of lorazepam has what solvent
propylene glycol
how can we detect prpylene glycol toxicity
calculate osm gap
high dose lorazepam
lorazepam not a good choice if what
want to wake quickly
midazolam metabolized how
CYP3A
midazolam halflife and duration
short halflife
unpredicitible duration
midazolam reccommended over loraZepam for what
quick sedation
short term use
propofol onset and offset
quick onset
quick offset
propofol given as what
infusion
propofol popular in wht
surgery
general anesthesia
neurosurgery dec ICP
propofol dosage form
emulsion
lipid vehicle
watch for hypertriglyceridemia
safe in egg/soy allergy
adverse effects of propofol
apnea
hypotension
bradycardia
pain upon infusion
hypertriglyceridemia
propofol infusion syndrome
allergic reactions
what is propoofol infusion syndrome
acidosis
bradycardia
lipidemia
- associated with high mortality
propofol not reccoemmended for who
high doses in peds
what should we monitor in propofol
triglyerides after 48 hours
caloric intake - 1.1 kcal/mL
propofol infusion syndrome
propofol affect on body
CNS depression
dexmedetomidine class
alpha 2 agonist
decrease NE release in CNS
dexmed level of sedation
light sedation, can wake pts up
dexmed differences
some analgesia and dec opioid requirement
light sedation
anxiolysis like Benzos
no respiratory depression
dexmed halflife
short, titratable
dexmed elimination
hepatic, might have to dose reduce
how do we administer dexmed
NO loading dose
just do infusion
adverse effects with dexmed
bradycardia
hypotension
increase BP with rapid admin
who should we not use dexmed in
hypovolemic
shock
hemodynamically unstable
which sedative has least delirium
dexmed
types of delirium
hyperactive - agitated
hypoactive - calm, sedated
who gets delirium
80% of mechanical vent patients
delirium can cause what after ICU
cognitive impairment
mortality maybe
delirium risk factors
benzos use
blood transfusions
older age
dementia
severity of illness
assessmnet scales used for delirium
ICDSC
CAM-ICU
nonpharm way to decrease delirium
early mobilization
optimization of sleep
optimization of hearing/vision
when do we use drugs in delirium
no prophylaxis
no routine treatment
short term with significant stress
what drugs used in delirium
dexmed
haloperidol
atypical antipsychotics
what drug can we used in delirium if we cant get them off the vent
dexmed
haloperidol usea
mild sedation for agitation/delirium
haloperidol dosing
NO continuous infusion
every 1 hour boluses
haloperidol risk
QT prolongation - torsades
high dose IV
seizure
EPS
NMS
atypical antipsychotics benefit in delirium
safety benefit
decreased risk of torsades but still could cause torasad and QT
atypical antipsychotics used
risperidone
olanzapine
quetiapine
adverse effects antipsychotics
Qt prolong
torasad
which med used for stress with delirium
antipsychotics
which med for acute agitaiton with delirium
haloperidol
