Critical Care Flashcards
1
Q
common causes of pain for ICU patients
A
surgery trauma burns cancer procedural etc.
2
Q
Consequences of untreated pain
A
insufficient sleep psychiatric problems PTSD higher risk of chronic pain lower QOL possible
3
Q
IV fentanyl onset
A
1-2 minutes
4
Q
IV Fentanyl metabolite
A
no metabolite
5
Q
IV fentanyl accumulation
A
accumulates with hepatic impairment
6
Q
IV Fentanyl other information
A
less hypotension than morphine
-infuse at 0.7-10 ug/kg/hr
7
Q
IV Hydromorphone onset
A
5-15 minutes
8
Q
IV hydromorphone metabolite
A
no active metabolite
9
Q
IV hydromorphone accumulation
A
accumulates with hepatic and renal failure
10
Q
IV hydromorphone other information
A
therapeutic option in patients tolerant to morphine and fentanyl
11
Q
IV morphine onset
A
5-10 minutes
12
Q
IV morphine metabolite
A
6- and 3- glucuronide
13
Q
IV morphine accumulation
A
accumulates with hepatic and renal failure
14
Q
IV morphine other information
A
causes histamine release!! pts will experience itching
15
Q
role of APAP and NSAIDS in ICU
A
adjunctive pain therapy to reduce opioid need
16
Q
how is neuropathic pain treated?
A
enterally administered gabapenten and carbamazepine in patients with sufficient GI absorption and motility
17
Q
Underlying causes of agitation
A
pain delirium hypoxemia hypoglycemia hypotension withdrawal
18
Q
what should be done to minimize agitation prior to administering sedatives
A
maintenance of patient comfort
provision of adequate analgesia
frequent reorientation
optimization of environment to maintain normal sleep patterns
19
Q
Midazolam onset
metabolite accumulation
duration
A
O: 2-5 minutes
M: yes, in renal failure
D: 2h
20
Q
Midazolam ADRs and monitoring
A
Respiratory depression
Hypotension
21
Q
Midazolam DOC situation
A
when rapid onset is needed
22
Q
Lorazepam Onset
Metabolite accumulation
duration
A
O: 15-20 minutes
M: none
D: 6-8 hours
23
Q
Lorazepam ADRs and monitoring
A
respiratory depression
hypotension
propylene-glycol-related acidosis
nephrotoxicity
24
Q
Lorazepam DOC situation
A
patients with hepatic impairment
25
Propofol onset
metabolite accumulation
duration
O: 1-2 minutes
M: none
D: 3-10 minutes
26
Propofol ADRs and monitoring
```
pain on injection
hypotension
respiratory depression
hypertriglyceridemia
pancreatitis
allergic reaction
propofol-related infusion syndrome (deep sedation with propofol associated with significantly longer emergence times than with light sedation)
```
27
Propofol DOC situation
when rapid awakening is needed
| to lower intracranial pressure
28
Dexmedetomidine onset
metabolite accumulation
duration
O: 5-10 minutes
M: none
D: 1-2 hours
29
Dexmedetomidine ADRs and monitoring
bradycardia
hypotension
hypertension with loading dose
loss of airway reflexes
30
Dexmedetomidine DOC situation
when minimal respiratory depression is desired
| or pt needs to be easily arousable
31
all anti-agitation medication ADRs
respiratory depression
| may build up in hepatic insufficiency
32
all opioid analgesic ADRs
respiratory depression
GI
CNS
hemodynamic effects
33
cardinal features of delirium
disturbed level of consciousness with reduced ability to focus, sustain, or shift attention
either a change in cognition or the development of a perceptual disturbance
other symptoms such as sleep disturbances, abnormal psychomotor activity, or emotional disturbances
34
risk factors of delirium
age
genetics
exposure to opioids or sedatives (iatrogenic factors)
prolonged physical restraint or immobilization (environmental factors)
Base line risk factors (pre-existing dementia, history of hypertension, history of alcoholism, or high severity of illness at administration)
35
outcomes associated with delirium
increased mortality
increased hospital LOS
increased cost of care
increased long-term cognitive impairment consistent with dementia-like state
36
appropriate treatment for delirium
atypical antipsychotics may reduce duration
| no proof that haloperidol will do the same
37
neuromuscular blocker MOA
block ACh from bonding to receptors, blocking motor function
38
indications for NMB therapy
adult ICU patients to manage ventilation
treat muscle spasms
manage increased ICP
decrease O2 consumption
ONLY use when all other means have been tried with no success. for LIFE SAVING MEASURES or to PREVENT NEGATIVE PERMANENT CONSEQUENCES
**optimize sedatives and analgesics before therapy initiation
39
Pancuronium duration
long - 90 minutes
40
pancuronium elimination
mainly Renal
| some hepatic
41
Pancuronium ADRs and monitoring
Vagolytic (increases HR)
| caution in renal failure and cirrhosis, can decrease clearance and increase half life
42
vecuronium duration
intermediate - 25-30 minutes
43
vecuronium elimination
mainly hepatic
| some renal
44
vecuronium ADRs and monitoring
more commonly produces prolonged blockade upon discontinuation
may be more likely if given with corticosteroids
45
Cisatracurium duration
intermediate
46
Cisatracurium elimination
hoffman and hydrolysis (not renal/hepatic)
47
Cisatracurium ADRs and monitoring
lower risk of cardio effects
lower risk of mast cell degranulation
duration should not be effected by renal/hepatic dysfunction
48
Preload
what is coming into the heart
| measured by PAOP or PCWP. Also SV
49
Contractility
How effectively the heart pumps
| Measured by CI or CO
50
Afterload
what pressure the heart pumps blood out against
| Measured by SVR
51
example causes of Hypovolemic shock
```
severe external or internal bleeding
profound fluid loses from GI sources
urinary losses
burns
capillary leak
trauma
AAA
vomiting
diarrhea
third-spacing
```
52
changes that happen in Hypovolemic shock
low volume in body, decreased SV
| body compensates by tachycardia and reflex increases in SVR and CO
53
example causes of cardiogenic shock
Massive MI
| Severe CHF
54
changes that happen in cardiogenic shock
low contractility, CO, the heart has trouble pumping
| get overload of blood in heart and cardio system backs up
55
example causes of distributive shock
sepsis
anaphylactic shock
spinal cord injury
56
changes that happen in distributive shock
every vessel is dilated, blood doesn't get through well, it pools up instead of being pushed through. SVR is low
57
goals of treating hypovolemic shock
restore effective circulating blood volume
| manage underlying cause
58
Examples of crystalloids
lactated ringer's
| NS
59
advantages of crystalloids
relatively low volume expansion
widely available
low cost
rapid delivery
60
disadvantages of crystalloids
possible fluid overload, more fluid required than colloids
| may lead to leakage, edema, electrolyte disturbances, and dilution of anticoagulation factors
61
amount of crystalloid to be given
1-2 L in the first hour
| 2-4 L or more total
62
examples of colloids
albumin
dextran
netastarch
63
advantages of colloids
recommended when patients require substantial amounts of crystalloids because not as much volume is needed with colloids
better at keeping volume in veins, less third-spacing
64
disadvantages of colloids
expensive
takes longer to administer
hetastarch and dextran are not recommended for sepsis
65
hetastarch and dextran ADRs
increased risk of bleeding and anaphylactoid reactions
66
amount of colloids to be given
500-1000 ml
67
norepinephrine
first line therapy
| primary effect through vasoconstriction
68
norepinephrine ADRs
tissue necrosis
arrhythmias
potentially lower mortality
69
Dopamine
only consider for use if pt has low risk of tachyarrhythmias or bradycardia
effect is dose dependent, mostly increases SV and HR
70
Dopamine and Renal Protection
low-dose dopamine (<3 mcg/kg/min) can improve renal function in patients with inadequate urine output despite high filling pressures and volume overload
controversial
71
Dopamine ADRs
tissue necrosis with extravasation
arrhythmias
tachycardia
72
vasopressin
direct vasoconstrictor without inotropic or chronotropic effects
acts at alpha-receptors
may add to NE therapy to maintain BP or decrease NE dose
73
vasopressin ADRs
```
arrhythmias
tachycardia
increased CO
chest pain
MI
vasoconstriction
venous thrombosis
```
74
epinephrine
alpha and beta agonist
increases cardiac index and peripheral vasoconstriction (increased SVR)
may be added to NE if needed to maintain BP
75
epinephrine ADRs
```
angina
arrhythmia
chest pain
flushing
HTN
palpitation
tachycardia
vasoconstriction
ventricular ectopy
v-fib
```
76
dobutamine
```
inotrope
increases CO (HR and contractility)
vasodilation
B1 and B2 agonists
minimally works at a1
reserved for pts with systolic BP >90, severe HF, MI, or cardio shock
decreased preload
```
77
dobutamine ADRs
tachycardia
| arrhythmia
78
dobutamine use with milrinone
may be used, but as last line!!
| milrinone causes severe hypotension, arrhythmias, and thrombocytopenia
79
define SIRS
```
patient has two of the following
temp 38*C
HR > 90
Resp > 20
WBC > 12,000 or < 4,000 or > 10% bands
```
80
define sepsis
SIRS + infection
81
define severe sepsis
sepsis + organ dysfunction in 1 or more organs
82
septic shock
sepsis + hypotension unresponsive to fluids
83
what causes sepsis
```
pulmonary causes
GI causes
GU causes
blood stream infections
all count for majority of sepsis cases
```
84
risk factors for sepsis
```
age
cancer
immunodeficiency
chronic organ failure
genetic factors
bacteremic patients
polymorphisms in genes that regulate immunity
```
85
general approach to treatment of sepsis
early goal-directed resuscitation of septic patients during the first 6 hours after recognition
early administration of broad-spec anti-infective therapy
hydrocortisone for septic shock patients refractory to resuscitation and vasopressors
glycemic control via insulin infusion ith BG goal of 140-180
adjunctive therapies (nutrition, DVT ppx, stress ulcer ppx, sedation for mechanically ventilated patients
86
monitoring parameters and goals for initial resuscitation monitoring
central venous pressure: 8-12 mmHg, 12-15 for intubated patients
Mean arterial pressure 65 or greater
urine output 0.5 ml/kg/h or more
central venous 70% or mixed venous oxygen saturation 65% or greater
87
risk factos for VTE
```
age > 50
prior history of VTE
venous stasis
vascular injury
hypercoagulable states
drug therapy (estrogen, chemo, etc)
```
88
unfractionated heparin dose, frequency, and route (for ppx)
5000 units 2-3 times daily subQ
89
does unfractionated heparin require renal adjustment?
no
90
Enoxaparin dose, frequency, and route (for ppx)
40mg daily subQ
91
does enoxaparin require renal adjustment?
yes - 30mg daily subQ
92
Fragmin (dalteparin) dose, frequency, and route
5000 units daily subQ
93
does Fragmin require renal adjustment?
yes - monitor anti-Xa levels at CrCl <30 ml/min
94
Arixtra (fondaparinux) dose, frequency, and route
2.5mg daily subQ
95
does Arixtra require renal adjustment?
yes - use caution in patients with CrCl 30-50, do not use in pts with CrCl <30
96
Monitoring parameters for all VTE ppx agents
PT, aPTT, thrombocytopenia, excessive bleeding, CBC, SCr
Heparin - monitor hemoglobin and hematocrig
Enoxaparin - monitor anti-Xa levels (PT and aPTT not necessary)
97
Stress-related mucosal disease (SRMD) risk factors
Coagulopathy
mechanical ventilation for > 48 hours
Hypotension
98
Agents used for SRMD ppx
PPI - hard to give to NG tube patients. Risk of C. diff infection may be enhanced
H2RA - limited with low CrCl, confusion, or thrombocytopenia
99
how to measure Mean Arterial Pressure (MAP)
((2*diastolic) + systolic)/3
100
Can epidurals be used in anticoag patients?
NO!!! can cause paralysis if the patient bleeds into spinal space
