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Critical Care Week 1 Flashcards

1
Q

What does FAST HUGS BID stand for?

A

Feeding
Analgesia
Sedation
Thromboprophylaxis

Head of bed (VAP)
Ulcer prophylaxis
Glycemic control
Spontaneous breathing trial

Bowl regimen
Indwelling catheters
De-escalation of antibiotics

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2
Q

(Enteral/parenteral) feeding is preferred when applicable.

A

Enteral

If the gut works, use it

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3
Q

What things need to be considered for analgesia therapy?

A
  • Nociceptive vs. neuropathic
  • Duration of pain (selection of short vs. long-term agents)
  • Home medications (may lead to underdosing inpatient)
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4
Q

What RASS scale levels are usually targeted in sedation?

A

-2 to 0

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5
Q

What medications can be considered when sedation AND pain relief are goals?

A

Fentanyl or dilaudid drip

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6
Q

Why are benzodiazepines not preferred for sedation?

A

More delirium and neurocognitive implications

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7
Q

What are the preferred sedative agents?

A

Propofol and dexmedetomidine

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8
Q

What is a normal enoxaparin dose for VTE prophylaxis?

A

Enoxaparin 40 mg SQ QD or 30 mg SQ BID

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9
Q

What VTE prophylaxis should be used for patients with renal dysfunction?

A

Unfractionated heparin 5000 units SQ Q8H

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10
Q

What VTE prophylaxis should be used for patients with high bleed risk?

A

Non-pharm: Compression stockings or intermittent pneumatic compression

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11
Q

What is done for VAP prophylaxis?

A
  • 30-45 bed-head angle to reduce reflux
  • Chlorhexidine mouthwash TID
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12
Q

Who needs VAP prophylaxis?

A

Those who are mechanically ventilated

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13
Q

What are the major risk factors for GI bleeding?

A
  • Mechanically ventilated >48 hours
  • INR >1.5, PTT > 2x ULN, or platelets <50k
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14
Q

What are minor risk factors for GI bleeding?

A
  • Drugs with bleed risk
  • Shock/sepsis/hypotension
  • Hepatic/renal failure
  • Multiple trauma
  • Burns >35%
  • Transplant
  • Head/spine trauma
  • Hx of upper GI bleed or PUD
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15
Q

What are options for stress ulcer prophylaxis?

A

PPIs (pantoprazole 40mg)
H2RAs (famotidine 20mg BID)
-> continue until risk factors resolve

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16
Q

What did the NICE-SUGAR trial show?

A

Tighter glycemic control (80-100 mg/dL) showed worse outcomes compared to 140-180 mg/dL goals.

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17
Q

What is the point of the spontaneous breathing trial (SBT)?

A

To get patients off mechanical ventilation ASAP (complications)

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18
Q

How often should SBT be done for mechanically ventilated patients?

A

Daily

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19
Q

How often should we monitor patients’ bowel movements?

A

Daily

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20
Q

When would you use a CVC over a peripheral venous catheter?

A

More aggressive meds, longer duration of catheterization

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21
Q

What signifies shock?

A

Hypotension
- SBP <90 mmHg
- Decrease by 40 mmHg

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22
Q

What is the formula for MAP?

A

1/3 SBP + 2/3 DBP

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23
Q

What is MAP dependent on?

A

Cardiac output and vascular resistance

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24
Q

What are goals for MAP and lactate in shock?

A

MAP >65 mmHg
Lactate <2 mmol/L

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25
Q

T/F: Pulmonary artery catheters are standard of care in shock?

A

FALSE: Many complications

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26
Q

What is the goal Svo2 using a PAC?

A

60%

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27
Q

What is the goal Scvo2 using a CVC?

28
Q

What is the #1 cause of death in those under 45?

A

Hypovolemic shock

29
Q

How should hypovolemic shock be treated?

A

Identify source of loss!
Hemorrhage - give PRBCs
GI losses, burns, third spacing - give fluids

30
Q

What is cardiogenic shock?

A

Failure of LV to deliver blood (associated with CV disease)

31
Q

What are the main causes of cardiogenic shock?

A
  • Acute MI***
  • Arrhythmias
  • Other heart issues
32
Q

How do you treat cardiogenic shock?

A

Treat the source - restore cardiac function
MI - cardiac catheter or CABG
Arrhythmias - achieve sinus rhythm
LVADs
ECMO

33
Q

What is distributive shock?

A

Lowered SVR causes lowered perfusion
Example: anaphylaxis, sepsis

34
Q

What are common causes of obstructive shock?

A
  • PE (treat with thrombolytics)
  • Severe pulmonary HTN
  • Tension pneumothorax
  • Pericardial tamponade
35
Q

What fluids should you give for shock?

A

Crystalloid 30 mL/kg over 15-30 min (then 10 mL/kg boluses)
[Cardiogenic shock: 100-200mL boluses]

36
Q

MAP remains <65 despite fluid administration in shock. What should we do next?

A
  • Arterial line should be placed for monitoring and admin (CVC)
  • Vasopressors (NE)
  • Inotropes
37
Q

What is the MOA of NE?

A

Potent alpha adrenergic agonist
Increases MAP via peripheral vasoconstriction

38
Q

What is the vasopressor preferred for anaphylactic shock?

A

Epinephrine
- May increase aerobic lactate production

39
Q

T/F: Pharmacology for dopamine use is dose-dependent

A

TRUE
B1 at low doses, A1 at high doses

40
Q

When can dopamine be considered in shock?

A

Hypotensive patients with depressed cardiac function

41
Q

What are major ADEs of dopamine?

A
  • Tachycardia
  • Arrhythmogenesis
42
Q

Which A1 agonist causes reflex bradycardia?

A

Phenylephrine

43
Q

When can phenylephrine be considered in septic shock?

A

CO is high and BP is persistently low
Last line

44
Q

When should dobutamine be added to shock treatment?

A

CO or SvO2/ScvO2 goals not achieved
(B1 inotrope)

45
Q

What is the idea behind vasopressin use?

A

To reduce concurrent vasopressor doses

46
Q

What is the risk with Giapreza (angiotensin II)?

A

Thromboembolism

47
Q

When is Giapreza used in shock?

A

Add-on to standard therapy, reduce utilization of catecholamine vasopressors

48
Q

What are common causes of DKA?

A
  • Infection*** (#1 cause)
  • Initial DM presentation
  • Insufficient insulin therapy
  • Pancreatitis
  • Acute CV events
  • Medications (steroids, atypical antipsychotics, BBs, thiazides, sympathomimetics)
49
Q

What are the cardinal signs of DKA (as opposed to HHS)?

A
  • Kussmaul breathing
  • Acetone breath
50
Q

T/F: HHS presents from hours-days while DKA lasts days-weeks

A

FALSE: other way around

51
Q

What are diagnostic findings in DKA?

A
  • BG >250 mg/dL
  • Acidosis pH < 7.3
  • Serum bicarb <18
  • Urine ketones positive
  • Anion gap >12
  • Variable mental status, osmolality
52
Q

What are diagnostic findings in HHS?

A
  • BG >600 mg/dL
  • Normal pH, serum bicarb, ketones
  • Serum osmolality >320 mOsm/kg
  • Altered mental status
  • Variable anion gap
53
Q

How do you calculate anion gap?

A

Na+ - (Cl- + HCO3)

54
Q

How do you correct sodium?

A

Add 1.6 mEq sodium for every 100 mg/dL of glucose over 100

55
Q

How do you calculate osmolality?

A

2Na + (glucose/18) + (BUN/2.8)

56
Q

What IV fluids should be given in DKA and HHS?

A

500-1000 mL/hr of NS or LR during first 2-4 hours

57
Q

How should insulin be given in DKA and HHS?

A
  1. 0.1 U/kg bolus, 0.1 U/kg/hr IV infusion
  2. Increase IV rate every hour if glucose does not decrease 50-75 mg/dL
  3. Give dextrose-containing fluids and decrease insulin to 0.02-0.05 U/kg/hr once glucose reaches 200-250 (DKA) or 250-300 (HHS)
58
Q

What should you do if K <3.3?

A

Hold insulin, give 10-20 mEq/hr K until K>3.3

59
Q

What should you do if K 3.3-5.2?

A

Give 20-30 mEq K+ in each L of IV fluid to maintain

60
Q

When should we give bicarb in DKA?

A

pH <6.9, stop once pH >7

61
Q

What constitutes resolution of DKA?

A

BG <200 PLUS 2 criteria:
- Bicarb >15
- pH > 7.3
- Anion gap <12

62
Q

What constitutes resolution of HHS?

A

Serum osmolality <320 and
resolved mental status

63
Q

What are complications of DKA/HHS treatment?

A
  • Hypoglycemia
  • Hypokalemia
  • Cerebral edema
64
Q

What causes euglycemia DKA?

A
  • SGLT2s
  • Fasting
  • Surgery
  • Pregnancy
65
Q

What is criteria for euglycemic DKA?

A
  • Glucose normal <250
  • pH <7.3
  • Bicarb <18

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