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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
T/F: Pulmonary artery catheters are standard of care in shock?
FALSE: Many complications
26
What is the goal Svo2 using a PAC?
60%
27
What is the goal Scvo2 using a CVC?
65%
28
What is the #1 cause of death in those under 45?
Hypovolemic shock
29
How should hypovolemic shock be treated?
Identify source of loss! Hemorrhage - give PRBCs GI losses, burns, third spacing - give fluids
30
What is cardiogenic shock?
Failure of LV to deliver blood (associated with CV disease)
31
What are the main causes of cardiogenic shock?
- Acute MI*** - Arrhythmias - Other heart issues
32
How do you treat cardiogenic shock?
Treat the source - restore cardiac function MI - cardiac catheter or CABG Arrhythmias - achieve sinus rhythm LVADs ECMO
33
What is distributive shock?
Lowered SVR causes lowered perfusion Example: anaphylaxis, sepsis
34
What are common causes of obstructive shock?
- PE (treat with thrombolytics) - Severe pulmonary HTN - Tension pneumothorax - Pericardial tamponade
35
What fluids should you give for shock?
Crystalloid 30 mL/kg over 15-30 min (then 10 mL/kg boluses) [Cardiogenic shock: 100-200mL boluses]
36
MAP remains <65 despite fluid administration in shock. What should we do next?
- Arterial line should be placed for monitoring and admin (CVC) - Vasopressors (NE) - Inotropes
37
What is the MOA of NE?
Potent alpha adrenergic agonist Increases MAP via peripheral vasoconstriction
38
What is the vasopressor preferred for anaphylactic shock?
Epinephrine - May increase aerobic lactate production
39
T/F: Pharmacology for dopamine use is dose-dependent
TRUE B1 at low doses, A1 at high doses
40
When can dopamine be considered in shock?
Hypotensive patients with depressed cardiac function
41
What are major ADEs of dopamine?
- Tachycardia - Arrhythmogenesis
42
Which A1 agonist causes reflex bradycardia?
Phenylephrine
43
When can phenylephrine be considered in septic shock?
CO is high and BP is persistently low Last line
44
When should dobutamine be added to shock treatment?
CO or SvO2/ScvO2 goals not achieved (B1 inotrope)
45
What is the idea behind vasopressin use?
To reduce concurrent vasopressor doses
46
What is the risk with Giapreza (angiotensin II)?
Thromboembolism
47
When is Giapreza used in shock?
Add-on to standard therapy, reduce utilization of catecholamine vasopressors
48
What are common causes of DKA?
- Infection*** (#1 cause) - Initial DM presentation - Insufficient insulin therapy - Pancreatitis - Acute CV events - Medications (steroids, atypical antipsychotics, BBs, thiazides, sympathomimetics)
49
What are the cardinal signs of DKA (as opposed to HHS)?
- Kussmaul breathing - Acetone breath
50
T/F: HHS presents from hours-days while DKA lasts days-weeks
FALSE: other way around
51
What are diagnostic findings in DKA?
- BG >250 mg/dL - Acidosis pH < 7.3 - Serum bicarb <18 - Urine ketones positive - Anion gap >12 - Variable mental status, osmolality
52
What are diagnostic findings in HHS?
- BG >600 mg/dL - Normal pH, serum bicarb, ketones - Serum osmolality >320 mOsm/kg - Altered mental status - Variable anion gap
53
How do you calculate anion gap?
Na+ - (Cl- + HCO3)
54
How do you correct sodium?
Add 1.6 mEq sodium for every 100 mg/dL of glucose over 100
55
How do you calculate osmolality?
2Na + (glucose/18) + (BUN/2.8)
56
What IV fluids should be given in DKA and HHS?
500-1000 mL/hr of NS or LR during first 2-4 hours
57
How should insulin be given in DKA and HHS?
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
What should you do if K <3.3?
Hold insulin, give 10-20 mEq/hr K until K>3.3
59
What should you do if K 3.3-5.2?
Give 20-30 mEq K+ in each L of IV fluid to maintain
60
When should we give bicarb in DKA?
pH <6.9, stop once pH >7
61
What constitutes resolution of DKA?
BG <200 PLUS 2 criteria: - Bicarb >15 - pH > 7.3 - Anion gap <12
62
What constitutes resolution of HHS?
Serum osmolality <320 and resolved mental status
63
What are complications of DKA/HHS treatment?
- Hypoglycemia - Hypokalemia - Cerebral edema
64
What causes euglycemia DKA?
- SGLT2s - Fasting - Surgery - Pregnancy
65
What is criteria for euglycemic DKA?
- Glucose normal <250 - pH <7.3 - Bicarb <18

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