ICU 101

Question 1

Approach to ICU Rounding

Answer 1

“FAST HUGS BID”: feeding (NPO, diet, feeds, TPN), Analgesia (pain control), Sedation (minimization, non-benzo), Thrombo (VTE prophylaxis), Head of bed elevated (at least 30 degrees, Ulcer prophylaxis (strses ulcer), glycemic control ( 6 - 10 ), Spontaneous breathing trial, Bowel regimen, indwelling lines and catheters, De-escalate antibiotics

Question 2

definition of fever in the ICU

Answer 2

38.3 degrees or higher unless immunocompromised

Question 3

DDx for fever, infectious sources

Answer 3

bacteremia, central-line infections, c.diff, intra-abdominal abscess, sinusitis, UTI, ventilator associated PNA, wound or surgical site infection

Question 4

DDx for non-infectious causes of fever

Answer 4

acalculous cholecystitis, central fever (TBI, stroke, ICH), drug fever, endocrine, NMS or SS, pancreatitis, post-op SIRS, VTE, withdrawal or OD

Question 5

Inv for fevers in the ICU

Answer 5

blood cx, central line and peripheral cultures, endotracheal aspirate or sputum sample, surgical site, wounds, drains, urine Cx, CXR, stool sample; can consider lipase, liver panel TSH, cortisol if no clear infectious cause

Question 6

indication to start antibiotics

Answer 6

empiric treatment is warranted if clear infectious source or signs of evolving sepsis (hemodynamic instability, organ failure, elevated lactate)

Question 7

early MGMT for fevers with ICU

Answer 7

r/o DVT, abdo u/s to r/o acalculous cholecystitis, remove old central lines > 1 week if culture is negative, r/o occult infection: if concern for infection, can consider ID consult, additional imaging

Question 8

approach to transfusions in the ICU consent

Answer 8

description of treatment, benefits, risks, alternative; transfusion risks: fever, hives fluid overload, rare < 1 /1million ofr infections, serious reactions (bacteria, lung injury, allergy, incompatbility)

Question 9

Hgb cut off

Answer 9

non-bleeding: < 70; post cardiac < 754, cardiac ischemia < 80; 1U over 2 hours, if > 65yo or with CHF/renal disease, use slower rate with furosemide IV pre-transfusion, assess clinical status and Hgb before transfusing further; 1 U pRBC to elevated 10 g/L in non-bleeding

Question 10

Plt transfusion indication

Answer 10

spontaneous bleeding if plt < 10, treat major bleeding or bleeding with major procedure < 50, treat or prevent CNS bleeding < 100; transfuse over 1 - 2 hours, if elderly, CHF or renal dysfunction, use slower rate with furosemide IV pre-transfusion; eat dose increasing plt count by 15 - 50

Question 11

FFP transfusion indication

Answer 11

multiple clotting factor deficiences AND major bleeding with INR > 1.8 or microvascular bleeding, massive transfusion and cannot wait for labs; half life is only 6 - 9 hours, dose of 15 mL/kg (3 - 4 U)

Question 12

PCC transfusion indication

Answer 12

indicated for urgent or emergent reversal of warfarin or vitamin K deficiency, or off label for urgent or emergent reversal of oral factor Xa inhibitors; typical dose is 1000U but depends on INR, lasts only 6 hours need to give IV vitamin K as well, if on FXa inhibitor reversal is 2000U

Question 13

fibrinogen concentrate transfusion indications

Answer 13

indications life-threatening hemorrhage fibrinogen < 1.5 - 2 g/L, microvascular bleeding fibrinogen < 1 g/L; dose 4 g IV push 1 g over 5 mins or minibag over 30 mins