Exam 3 lecture 7

Question 1

What are PAD guidelines for analgesia?

Answer 1

provide analgesia and treat reversible physiological causes
- active and preemptive analgesia
- sleep promotion
- mobility

Question 2

What are PAD guidelines on sedation

Answer 2

Less is more. Light sedation preferred vs deep sedation
sedation strategies that encourage deep sedation may lead to worse outcomes

Question 3

define the sedation algorithim

Answer 3

protocol based on analgesia-first sedation.
this is because pain is often primary source of agitation

Question 4

WHat role do benzodiazepines play in PAD guidelines?
Use of midazolam? Lorazepam? Monitoring with lorazepam?

Answer 4

Treating anxiety
patient with seizures
withdrawal

Midazolam- may be used for very rapid sedation. Only for short term use. Becomes less predictable as time progresses.

Lorazepam- prolonged sedation. Gradual onset and long duration. Does not have changes in metabolism and elimination because it is glucuronidated.

We also have to monitor propylene glycol toxicity if we use high doses. We monitor Osmol gap if we are worried about patient receiving high doses.

Question 5

What is the preferred sedative when rapid awakening is desired? BZDs vs propofol for carduac surgery?

Answer 5

Propofol may be preferred sedative when rapid awakening is desired

Propodol over BZDs for cardiac surgery.

Question 6

What is the drug of choice in a patient with delirium and agitation?

Answer 6

Dexmed

Question 7

What drug is associated with less delirium and decreased duration of mechanical ventilation

Answer 7

Dexmed

Question 8

How should we stop the sedation drugs?

Answer 8

There is a risk for withdrawal-> Dose should be tapered gradually. ESPECIALLY with patients at risk for seizures.

Question 9

WHat tools to use to assess patients for delirium regularly? DO we prophylax pharmacologcally for delirium

Answer 9

CAM ICU
ICDSC

We do not use pharmacologic measures for prevention

Question 10

propofol is frequently used in neurosurgical patients because

Answer 10

It has a short duration which helps facilitate neurological checks and Decreases ICP

Question 11

Which sedative may have analgesic sparing effects

Answer 11

Dexmed (allows reduced dose of analgesic)

Question 12

why would we not use BZDs in patients on mechanical ventilation that are in ICU. Compare lorazepam and midazolam

Answer 12

BZDs associated with delirium
lorazepam takes a while to work, doe not get past BBB quickly and has intermediate half life

Midazolam is more titrateable than lorazepam. quicker onset and offset. Goes through BBB quickly. DOes cause delirium too.

If a patient needs sedation for a longer period of time (more than 48 hrs), we do not use BZDs.

Question 13

when would we pick propofol over dexmed?

Answer 13

propofol helps with ICU and is titrateable.
Dexmed is also titrateable, but does not give us the depth of sedation we may need in really sick patients.

Question 14

If a patient is not responding well to propofol and is still agitated, what drug do we use

Answer 14

optimize patient on opioid to attack source of agitation (pain)

Question 15

What are some risk factors for stress ulcers

Answer 15

-anticoag/ antiplatelety/ NSAIDs/ antithrombotic drugs
- intubation (mechanical ventilation)
shock
-coagulopathy
-chronic liver failure

Question 16

Can we use EN as SUP alone?

Answer 16

No, it does offer protective effects, however, it should not be used alone.

Question 17

When can we dx SUP

Answer 17

When risk factors are gone

Question 18

Do we have to check PTT for prophylactic dose of UFH?

Answer 18

no

Question 19

What do we monitor on prophylactic dose of UFH

Answer 19

CBC for s/s of bleeding and thrombocytopenia

Question 20

What is the biggest side effect we look at with dex med?

Answer 20

hypotension

Question 21

What do we use for septic shock

Answer 21

Norepinephrine infusion is drug of choice

Hydrocortisone for refractory septic shock

Dobutamine (it is an ionotrope), not 1st choice

vasopressin (as adjunct)

Dopamine is also an option but is not common at all

Question 22

what is succinylcholine used for

Answer 22

RSI (for intubation)

not used if patient is already mechanicLly ventilated

Question 23

should sedation come first or analgesia with opioid?

Answer 23

Sedation should be done after analgesic.

Question 24

What is a BIS monitor used for?

Answer 24

Used to assess EEG (computerized) used when RASS or SAS can not be used for patient to assess sedation on neuromuscular blocker

Question 25

is train of four an efficacy endpoint or toxicity end point

Answer 25

Toxicity end point that stops us from giving too much sedative.

Question 26

What drug should we monitor QT for

Answer 26

Haloperidol

Question 27

Do we have to monitor aPTT on Enoxaparin (prophylactic)? What do we monitor

Answer 27

No aPTT

monitor CBC

Question 28

calories of propofol we take into consideration

Answer 28

1.1 kcal/ml

Question 29

what drug affects triglycerides

Answer 29

Propofol (monitor)

Question 30

What drug affects Osmol gap?

Answer 30

lorazepam

Question 31

What drugs do we use train-of-four on?

Answer 31

neuromuscular blocker

Question 32

define FAST HUGS BID

Answer 32

F- feeding/fluids
A- Analgesia
S- Sedation
T- Thromboprophylaxis

H-HOB elevation
U- Ulcer (stress ulcer) Prophylaxis
G- Glycemic control
S- Spontaneous awakening trial

B- bowel regimen
I- Indwelling catheters
D- De-escalation of antibiotics and delirium assessment

Question 33

target for glycemic control

Answer 33

140-180

Question 34

When do we start insulin in ICU ppts

Answer 34

> 180

Question 35

consequences of high BG

Answer 35

Slow wound healing

Question 36

What is the role of PPI for stress related mucosal disease prophylaxis? Adverse effect?

Answer 36

PPI are effective and provide adequate acid suppression, however, it is unclear whether they are associated with an increase in incidence of pneumonia.

Question 37

can we use enteral PPI

Answer 37

Yes sometimes