critical care medicine Flashcards
What are the 6 aspects of high quality care in the ICU
- adherence to hand hygiene and infectious precautions
- good interdisciplinary communication
- good pt and family communication
- interuption of sedation to assess readiness to extubate
- frequent monitering for delerium
- early mobilization of pts
pain, agitation and delerium are all risks for….. and therefore it is critical to manage these aspects
Post ICU syndrome
What is post ICU syndrome
characterized by weakness, cog dysfunction, and PTSD
What goal should be assessed first
analgesic goals
once this is done, target sedation to pt needs
what is the 1st line tx of nonneuropathic pain in ICU patients
IV opioids with nonopioid analgesics (tylenol and NSAIDs) as adjuncts
what are the IV opioid agents MC used in the ICU
- fentanyl
- hydromorphone
- morphine
- methadone
what should you give an ICU patient who has delerium with a normal QTc
PO Quetapine
IV or PO Haldol
what should you give a pt in the ICU who has delerium and QTc prolongation
- PO zyprexa
- SC Zyprexa
what should you give an ICU patient who is agitated and in need of prolonged sedation but does NOT have delerium
Dexmedetomidine
- If this doesnt work add propofol
- If they become hypotensive at any time during this consider BZD
Im not learningh this but yall are welcome to
In the ICU (bolus/continuous) dosing of medication is preferred
Bolus
What must you monitor for when treating patients in the ICU for pain
- hypotension
- depressed respiratory drive
- constipation
- urinary retention
what are the SE of opioid analgesics on the GI
- reduced gut transit
- ileus
- urinary retention
How do you taper opioids? why is this important
- infusions should not be decreased more than 25% daily
- rapid tapering leads to withdrawal in pts who have been on high doses of opioids for more than 1 week
What is the first thing to do in management of a patient with agitation and anxiety in the ICU
mitigation attempts without the use of sedatives by attempting to address reversible causes
what are reversible causes of agitation/anxiety in the ICU
- pain
- hypoxemia
- hypotension
- disruption of sleep/wake cycle
- substance withdrawal
research shows (light/deep) sedation has better outcomes and leads to shorter hospital stays
in pts who are agitated/anxious
light
what are the MC sedatives used in the ICU
- BZDs
- propofol
- Dexmedetomidine
what is the agent of choice for brief procedural sedation or short term mechanical ventilation (<1-3 days)
Propofol!
what is the more cost effective way to do sedation that is expected to last longer than a few days
BZDs
() is a water soluble primarily a-2 receptor agonist.
These are especially useful for (short/long) term sedation
Dexmedetomidine
short
What are the pros of Dexmedetomidine
- very little depressent effect
- some analgesic properties
- permit ventilator weaning w/o full discontinuation of drug!
What is the timeline for ventilator acquired pneumonia
developes in patients more than 48-72 hours after endotracheal intubation
what s/s would you see that could indicate ventilator assocaited pneumoani
- fever
- change in resp secretions
- leukocytosis
- change in O2 requirement
- new/persisiten infiltrate on CXR
T/F you should start ABX immediatly once VAP is suspected
FALSE! got ya
a lower respiratory tract sample should be obtained for culture PRIOR TO initiation of ABX
obtained via bronchoscopy or lavage/suction
what are strategies used to prevent VAP
- elevate bed 30-45 deg to prevent aspiration
- continuous aspiration of subglottic secretions
- silver coated endotracheal tubes (reduces bacteria and niofilm formation)
- decontamination of oropharynx w chorhexidine wash may decease the burden of microbes
what are postulated mechanisms for stress ulcer bleeding
- excessive acid secretion
- mucosal ischemia
- impaired mucus production
What can we give to reduce the risk of GI bleeding in stress ulcers
- H2 blockers
- PPIs
increase gastric pH
what patients are at high risk of overt GI bleeding and should undergo prophylaxis for stress ulcer bleeds?
- respiratory failure (mech ventilation >48hrs)
- coagulopathy (INR >1.5 or platelet count <50k)
- 2+ of the following:
stop prophylaxis once risks resolve
Therapeutic hypothermia is MC used in…
- post out-of-hospital cardiac arrest patients who remain comatose after return of spontaneous circultion
- used in infants who have suffered asphyxia/anoxia
what is the goal of therapeutic hypothermia
prevent or diminish hypoxic ischemic encephalopathy and other organ dysfunction
what is HIE (hepatic ischemic encephalopathy)
acute global brain injury 2/2 critical reduction of blood flow and therefore oxygen/nutrients
what are the 3 phases of therapeutic hypothermai
- induction
- maintenance
- rewarming
what is the process of therapeutic hypothermia induction
- internal thermometer probe is inserted usualy w foley
- internal cooling w infusion of cooled NS
- external cooling w blanket/ice packs
A RAPID induction!!!
what must you watch for during the maintenance phase of therapeutic hypothermia
- hypotension
- hypokalemia
- shivering
what is the process of rewarming in therapeutic hypothermia
- done over 8-24 hrs w cooling device and/or infusion of warmed saline
is this supposed to be “warming” device? idk
what is the temperature goal for therapeutic hypothermia
32-34
provides most benefit while avoiding adverse effects
how long does therapeutic hypothermia last
should be initiated ASAP and lasts 12-24 hrs at least.
time starts AFTER reaching goal temp.
