FASTHUGS BID

Question 1

F in FASTHUGS BID

Answer 1

Feeding

Question 2

A in FASTHUGS BID

Answer 2

Analgesia

Question 3

S in FASTHUGS BID (the first S)

Answer 3

Sedation

Question 4

T in FASTHUGS BID

Answer 4

Thromboembolism prophylaxis

Question 5

H in FASTHUGS BID

Answer 5

Head of bed

Question 6

U in FASTHUGS BID

Answer 6

Ulcer prophylaxis

Question 7

G in FASTHUGS BID

Answer 7

Glycemic control

Question 8

S in FASTHUGS BID (the second S)

Answer 8

Spontaneous breathing trial

Question 9

B in FASTHUGS BID

Answer 9

Bowel regimen

Question 10

I in FASTHUGS BID

Answer 10

Indwelling catheters

Question 11

D in FASTHUGS BID

Answer 11

De-escalation of ABX

Question 12

Importance of feeding

Answer 12

malnutrition can lead to impaired immune function → increased susceptibility to infection, impaired wound healing, bacterial overgrowth in the GI tract and an increased risk for development of decubitus ulcers → feeding should be considered as soon as the patient is clinically stable

Question 13

Considerations for feeding

Answer 13

Enteral > parenteral: if the gut works, use it, but parenteral nutrition may become necessary if gut isn’t working or enteral feeds aren’t tolerated

What feeds/diet is the patient receiving and can it be optimized?
Does the patient need to be NPO? If the patient is going to remain NPO for a longer period of time, should TPN be considered? (≥7 days NPO)

Question 14

Importance of analgesia

Answer 14

providing adequate analgesia optimizes patient comfort and minimizes the acute stress response, hypermetabolism, increased oxygen consumption, hypercoagulability, and alterations in immune function. In addition, can reduce the risk of developing agitation

Question 15

Considerations for analgesia

Answer 15

Type of pain- nociceptive vs. neuropathic: helps to choose best agent to relieve pain
Duration of pain- helps us determine whether we need long-acting agents or PRN boluses for situational pain
Account for home pain regimens: make sure underdosing isn’t occurring in patients that receive high doses at home

Question 16

Common pain meds used in the ICU

Answer 16

Fentanyl, hydromorphone, morphine, oxycodone

Question 17

Sedation considerations

Answer 17

RASS goals should be determined by the healthcare team and communicated to each member to ensure optimal use of sedative agents (to prevent under or oversedation)

Goal of 0 to -2 for most situations

Question 18

Preferred sedative agents

Answer 18

Propofol, Precedex

Question 19

Considerations for thromboembolism prophylaxis

Answer 19

VTE prophy should be given to ALL PATIENTS IN THE ICU
Initiation of appropriate prophy should be dependent on both VTE and bleed risk

Question 20

Options for thromboembolism prophy

Answer 20

LMWH (enoxaparin 40mg SQ QD, 30mg SQ BID)
Unfractionated heparin in patients with renal dysfunction (5000 units SQ q8h)
High bleed risk: mechanical (nonpharm) prophy with graduated compression stockings or intermittent compression devices should be initiated
Combination of mechanical and pharmacological prophy can be initiated in high risk VTE patients

Question 21

Importance of VAP prophy (head of bed)

Answer 21

Elevating the head and thorax above the bed to a 30-45 degree angle reduces occurrence of GI reflux and nosocomial pneumonia in patients who are receiving mechanical ventilation

Question 22

VAP prophylaxis treatment

Answer 22

Maintain head of bed elevated at 30-45 degrees
Apply antiseptic mouthwash (chlorhexidine 0.12%) topically to the oral cavity TID to maintain patients’ oral hygiene to prevent bacterial growth with the endotracheal tube

Question 23

Importance of ulcer prophylaxis

Answer 23

critically ill patients develop stress-related mucosal damage (SRMD), potentially leading to clinically significant bleeding

Question 24

Major risk factors for GI bleeding

Answer 24

Need one of the following to require prophy:

Mechanical ventilation >48 hours OR
Coagulopathy: INR >1.5, PTT >2x ULN, platelets <50K/mm^3

Question 25

Minor risk factors for GI bleeding

Answer 25

Need at least 2 of the following to require prophy:

Drugs that increase the risk of bleed: steroids, warfarin, heparin
Shock/sepsis/hypotension/vasopressors
Hepatic/renal failure
Multiple trauma
Burns >35% total BSA
Organ transplant
Head or spinal trauma
Hx of upper GI bleeding or PUD

Question 26

Stress ulcer prophy treatment

Answer 26

PPIs (ex: Protonix 40mg QD), H2RAs (famotidine)
Continue until risk factors have resolved

Question 27

Importance of glycemic control

Answer 27

Hyperglycemia is common in critically ill patients (even without a history of DM) due to multiple factors such as stress and medications (steroids, beta-blockers, vasopressors), exogenous glucose (TPN)

Proper glycemic control is necessary in critically ill patients to decrease the incidence of complications such as decreased wound healing and increased infection risk

Question 28

BG level goal in ICU patients

Answer 28

140-180mg/dl

Question 29

What is the purpose of a SBT?

Answer 29

SBT is performed on patients on mechanical ventilation and assesses the patient’s ability to breathe on minimal or no ventilatory support and is designed to assess whether the patient’s respiratory mechanics are favorable enough to consider liberation from mechanical ventilation

Question 30

How often should a SBT be done?

Answer 30

Daily

Question 31

Considerations for a bowel regimen

Answer 31

Important to monitor a patient’s bowel movements at least QD and if constipation occurs, provide them with a bowel regimen

In addition, patients receiving a lot of opioid medications, one should consider preemptively placing them on a bowel regimen

Diarrhea can occur in the ICU for various reasons and should also be paid attention to: infection, feeds, aggressive bowel regimen

Question 32

Agents for bowel regimens

Answer 32

Options: docusate, sennosides, PEG for standing orders; bisacodyl suppositories, enemas, mag citrate for rescue options

Question 33

Indwelling catheters: peripheral venous catheter

Answer 33

placed into a peripheral vein for venous access to administer IV therapy

Question 34

Indwelling catheters: central venous catheter

Answer 34

lines that terminate in the superior vena cava, just above the right atrium

Question 35

Indwelling catheters: arterial lines

Answer 35

placed into the lumen of an artery to provide a continuous display or accurate BP and access frequent arterial blood sampling

Question 36

Indwelling catheters: Foley catheters

Answer 36

flexible tube that passes through the urethra and into the bladder to drain urine

Question 37

Indwelling catheters: rectal tubes

Answer 37

soft catheter inserted into the rectum for fecal management to contain and divert fecal waste

Question 38

How often should lines be assessed?

Answer 38

At least daily to assess for signs of infection/can be removed

Question 39

Considerations for ABX de-escalation

Answer 39

De-escalating ABX as appropriate based on culture results
Setting appropriate ABX duration to avoid under or overuse of ABX
Providing necessary dose adjustments based on PK changes