Critical Care Flashcards
Definition of Sepsis
Temperature >38.3°C or <36°Ca Heart rate >90 beats/minutea Respiratory rate >20 breaths/minute or Paco2 <32 mm Hga WBC >12 × 103 cells/m3 or <4 × 103 cells/mm3a Altered mental status Hyperglycemia (BG >120 mg/dL without diabetes) Immature leukocytes (bands) >10% Significant edema or positive fluid balance (>20 mL/kg over 24 hours)
Definition of Severe Sepsis
SBP <90 mm Hg (or a >40–mm Hg drop) or MAP <70 mm Hg
Venous saturation (Svo2
) <70%
Need for mechanical ventilation
Hypoxemia (Pao2
/Fio2
<300)
CI >3.5
Lactate >1 mmol/L
Decreased capillary refill (press finger until turns white; time for
color to return is refill time and normally <2 seconds)
Mottling
Creatinine increase >0.5 mg/dL
Urine output <0.5 mL/kg/hour for ≥2 hours
Coagulopathy (INR >1.5 or aPTT >60 seconds)
Thrombocytopenia (platelet count <100,000/mm3
)
Ileus
Hyperbilirubinemia (total bilirubin >4 mg/dL)
Definition of Septic Shock
Persistent hypotension or a requirement for vasopressors after the
administration of an intravenous fluid bolus
SSC bundles (3 hours)
To be completed within 3 hours:
- Measure lactate
- Obtain blood cultures
- Administer broad spectrum antibiotics
- Administer 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L or greater
SSC bundles (6 hours)
To be completed within 6 hours:
- Apply vasopressors to maintain MAP 65 mm Hg (that does not respond to initial fluid resuscitation)
- NE is the vasopressor of choice
- Epinephrine can be added or substituted for NE
- Vasopressin (0.03 unit/minute) can be added to NE
- Phenylephrine can be considered in patients with vasopressor induced serious tacharrhythmias or persistent hypotension
Risk factors for candidemia
- Recent abdominal surgery
- Chronic TPN
- Indwelling central venous catheters
- Recent tx w/ broad spectrum antibiotics
- Immunosuppressed
Preferred antifungal agents for Candida glabrata or krusei
Echinocandin
Calculate Anion Gap
[Na+] − [Cl− \+ HCO3 − ] Hypoalbuminemia decreases the AG by 2.5–3 mEq/L for every 1-g/dL decrease in serum albumin less than 4 g/dL.
Etiology of Metabolic Acidosis (Anion Gap)
MUDPILES Methanol Uremia DKA Propylene glycol Infection Lactic acidosis Ethylene glycol Salicylate
Drug able to administer through endotracheal tube during cardiac arrest
NAVEL Naloxone Atropine Vasopressin Epinephrine Lidocaine
When pursuing therapeutic hypothermia, what medications can combat complications such as shivering?
Sedatives (dexmetomidine, ketamine), anesthetics, analgesics (e.g. mepteridine, fentanyl, tramadol), dexamethasone, cloniddine, magnesium, ondansetron, buspirone, paralytics (avoided if possible)
What is the starting continuous infusion rate for lorazepam and a potential complication for prolonged infusion?
1 mg/hr, propylene glycol toxicity
What is the starting dose of continuous infusion for midazolam and a potential complication of prolonged infusion?
1 mg/hour and titrate to RASS goal
Midazolam may accumulate because of greater lipophilicity, especially in renal dysfunction
Titration dose for propofol?
Would you want to provide loading doses?
Monitoring parameters?
5 mcg/kg/min and titrate to RASS by 5 mcg/kg/min every 5 min, avoid loading doses due to hypotension and provides no analgesic properties
Prolonged infusions greater than 50 mcg/k/min may lead to PRIS
Monitoring:
BP, TG and calories provided from propofol (1 kcal/mL)
Titration schedule for dexmedetomidine?
Loading dose?
Monitoring parameters?
Maintenance dose of 0.2-0.7 mcg/kg/hour but evidence has shown up to 1.5 mcg/kg/hour. Loading doses are suggested for surgery but otherwise not due to bradycardia and hypotension
Monitoring:
Dose related bradycardia and hypotension
Which medications traditionally used for delirium can cause EPS?
Haloperidol (lower doses 1-2.5 mg for older adults) and risperidone (>6 mg/day)
What medications can antagonize blocking of neuromuscular blockers?
Aminophylline, theophylline, CBC, phenytoin (chronic)
What medications can potentiate neuromuscular blockers?
Corticosteroids, AMG, clindamycin, tetracyclines, polymyxins, CCBs, type Ia antiarrhythmics, furosemide, lithium
What electrolyte disorders can potentiate neuromuscular blockers?
Hypermag, hypocalcemia, hypokalemia
The 2012 SCCM guidelines for insulin infusion state insulin infusion should be started at what BG for critically ill patients?
150 mg/dL and targeting <180 mg/dL
What are the major risk factors for stress ulcer prophylaxis?
- Mechanical ventilation > 48 hours
- Coagulopathy, plt < 50k, INR > 1.5 or aPTT 2x than control
What risk factors do you need 2 or more of to recommend stress ulcer prophylaxis?
1) Head/spinal injury
2) Severe burn >35% BSA
3) Hypoperfusion
4) Acute organ dysfunction
5) High dose of corticosteroids (>250 mg/day hydrocortisone)
6) Liver failure with associated coagulopathy
7) Transplantation
8) AKI
9) Major surgery
10) Multiple trauma
For overweight adults, how would you dose adjust LMWF and heparin for DVT ppx?
Increase heparin 7500 units and LMWH by 30-100% if BMI > 40 kg/m2; an anti-Xa 0.2-0.4 IU/mL
How much time should you wait before spinal needle placement after the last LMWH dose?
10-12 hours
What does AHA state about the systolic BP goal for SAH patients?
Less than 160 mm Hg
What is an indication for the use of TXA or aminocaproic acid in the setting of SAH?
Delay in surgical intervention (<72 hours)
What is the treatment of vasospams due to aneurysmal SAH?
Oral nimodipine 60 mg Q4H x 21 days
What are methods to prevent VAP in the ICU?
1) Elevate head 30-45 degrees
2) Stress ulcer prophylaxis
3) Anticoag prophylaxis
4) Daily sedation interruptions
5) Daily oral care with chlorhexidine
