Exam 3 - Foster Flashcards
how is oral absorption affected in critically ill patients?
impaired/unpredictable due to alterations in gastric emptying and gastric motility
how is distribution affected in critically ill patients?
-alterations vary, relates to fluid/hydration status
-decreased albumin = decreased protein binding of many drugs
-increased protein binding of drugs that bind to a1-acid glycoprotein
how is metabolism affected in critically ill patients?
hepatic enzyme expression and activity may be decreased - some degree of hepatic impairment in critically ill patients
how is renal elimination affected in critically ill patients?
-renal dysfunction common in critical illness
-we detect changes in renal function through urine output
-dialysis of continuous renal replacement therapy is common in ICU
What is sepsis? Where does it occur?
-life threatening organ dysfunction caused by dysregulated response to infection
-can occur in response to any pathogen
-most common sites of infection are lungs, bloodstream, and urinary tract
Sepsis treatment options
-no specific drug therapy - broad spectrum IV antibiotics + source control
-early detection and supportive care is critical
Septic shock treatment options
- fluids - crystalloids, colloids
- vasopressors - norepinephrine
- Corticosteroids if refractory
What is the MAP goal in septic shock?
> 65mmHg
What is the preferred treatment for thromboprophylaxis in ICU patients?
LMWH - enoxaparin, dalteparin
UFH dosing
5000 U SC q8h
Enoxaparin dosing (+ renal dosing)
30mg SC q12h or 40mg SC once daily
CrCl < 30: 30mg SC once daily
Blood glucose target in ICU patients
144-180 mg/dL
stress ulcer risk factors
shock
coagulopathy
chronic liver disease
mechanical ventilation
neurotrauma
drugs: NSAIDS, anticoags
When should you d/c stress ulcer prophylaxis?
when risk factors are no longer present
What type of insulin should you avoid in unstable patients? Why?
long-acting insulin, because they might be on and off tube feeds
What type of NMBA is depolarizing?
Succinylcholine
What is the only indication for succinylcholine?
Rapid sequence intubation (RSI) - placement of endotracheal tube
Succinylcholine ADRs
- Apnea (must be ready to intubate)
- Muscle fasciculations - deep aching muscle pain
- Hyperkalemia
- intracranial pressure elevation
- Increased intraocular pressure
Which NMBAs do NOT activate Ach receptors?
Non-depolarizing NMBAs:
(aminosteroidal: vecuronium, rocuronium, pancuronium)
(benzylisoquinolinium: cisatracurium, atracurium)
In patients with acute respiratory distress syndrome (ARDS), how should NMBA be administered?
as a continuous infusion
Are NMBAs required in all mechanically ventilated patients?
No
NMBAs do NOT provide ___________, ___________, or ____________ effects
analgesic, sedative, or anxiolytic
What must be done prior to initiation of NMBA?
optimize sedative and analgesic drugs
NDNMBAs ADRs
prolonged paralysis/muscle weakness or ICU-acquired muscle weakness
What is the toxicity endpoint of NMBAs?
peripheral nerve stimulation - avoid 0/4 twitches!
(adjust dose to 1-2 twitches)
What is the gold standard for pain assessment?
Patient self-reported pain
What does the Behavioral Pain Scale (BPS) look for?
- facial expression
- upper limb movements
- compliance with mechanical ventilation
What does the Critical Care Pain Observation Tool look for?
- facial expressions
- body movements
- muscle tension
- compliance with mechanical ventilation
- vocalization
What is generally preferred for non-neuropathic pain in critically ill patients?
IV opioids
In what patients might the Bispectral Index (BIS) be used?
In patients in whom other measures are not feasible - deep sedation and neuromuscular blockade
Benzodiazepines adverse effects
- respiratory depression
- CV effects
- withdrawal/risk of seizures - TAPERING REQUIRED
- delayed emergence from sedation
- association with delirium
Which BZD has delayed onset and prolonged duration of action?
Lorazepam
Which one is more titratable: midazolam or lorazepam?
Midazolam
What toxic component do IV formulations of lorazepam contain? What should you monitor for this?
Propylene glycol - monitor Osm gap
Osm gap > ________ may indicate PG toxicity
10
Lorazepam is the least _______ _______ of the commonly used BZDs, but it is also the least prone to _______ ________
lipid soluble
drug interactions
Midazolam has high _______ _______ so it has _______ onset of action
lipid solubility
rapid
Midazolam is __________ metabolized, so t1/2 is increased in hepatic disease
hepatically
Which is more likely to accumulate in elderly patients: midazolam or lorazepam?
Midazolam
Midazolam may be a good option for what situations?
- rapid sedation of acutely agitated patients
- short-term use
- procedural sedation
NOT LONG TERM
Does propofol have analgesic properties?
NO
Propofol has _______ onset and _______ offset
RAPID
Propofol is ____________ metabolized
hepatically
Propofol is __________ protein bound and has a ________ Vd
highly
large
Propofol adverse effects (7)
- apnea
- hypotension + bradycardia
- pain upon infusion
- hypertriglyceridemia
- elevated pancreatic enzymes
- Electrolyte abnormalities with preservative EDTA (Diprivan)
- Withdrawal possible - tapering required
How does propofol infusion syndrome present?
metabolic acidosis, bradycardia, lipidemia
Why might propofol be preferred in neurosurgical/neurotrauma patients?
It may aid in decreasing intracranial pressure
When should triglycerides be checked after starting propofol?
after 48h
What type of drug is dexmedetomidine?
selective a2 agonist
Precedex should not be used for _______ sedation
deep
T/F: Precedex can cause respiratory depression
FALSE
Precedex pharmacokinetics:
1. ________ protein-bound
2. _________ t1/2
3. __________ metabolized
- highly
- short
- hepatically
Why should you avoid a loading dose of Precedex?
associated with more severe side effects - mostly CV effects like transient increased BP followed by bradycardia and hypotension
What are the two subtypes of delirium?
- hyperactive (agitated, delusions)
- hypoactive (calm, confusion)
patients can go between the two
Is pharmacological treatment recommended for prevention of delirium?
NO
When is dexmed recommended for delirium?
when agitation is preventing extubation
Haloperidol adverse effects
- QTc prolongation - potential torsades de pointes
- decreased seizure threshold
- EPS
Of the typical antipsychotics used for delirium, which one causes the highest rate of QTc prolongation?
Ziprasidone
What other properties does dexmed have besides sedating?
- anxiolysis similar to BZDs
- analgesic-sparing effects
