ICU evaluation and preventative measures Flashcards
What is the safest way medication can be administered?
oral/enteral route
What eternal access devices are used for short-term use?
- nasogastric tube
- orogastric tube
- nasoenteric tube
- oroenteric tube
What eternal access devices are used for long-term use?
- gastrostomy tube
- jejunostomy tube
What are the inclusion criteria for IV to PO switching?
- tolerate enteral nutrition
- tolerate scheduled oral meds
- s/s of infection improving
- functioning GI tract
- absorption and bioavailability of PO med comparable to IV
How can we tell an infection is improving when considering IV to PO?
- WBC decrease to normal
- improved chest x-ray
- temp <100 for 24-48h
- respitory rate <20 breaths/min
How can we tell if a patient has a functioning GI tract when converting from IV to PO?
- tolerating 1L/day of fluids
- tolerating 40mL/h of enteral nutrition
What are the exclusion criteria for IV to PO switching?
- unreliable response to oral meds (N/V)
- unable to swallow/unconscious
- NPO for procedure
- GI obstruction, malabsorption, GI bleed, paralytic ileus, severe diarrhea
- unresponsive to previous PO tx
- 3/4 mucositis
- The disease state does not support PO
- Pseudomonas infection/ IV abx <1day
- candida tx < 7days
- seizure/ aspiration risk
- refuses PO
- immunocompromised patients
How can we tell is someone has a disease that does not support PO?
- meningitis
- infective endocarditis
- infection of prosthetic device
- osteomyelitis
- sepsis
- severe cellulitis
- bronchiectasis
- pneumonia with AIDS
How can we tell if the patient is immunocompromised?
- febrile neutropenia
- cancer chemotherapy
- post-transplant
- functional asplenia
What is sequential therapy?
refers to the act of replacing a parenteral version with its oral counterpart of the same compound
What is switch therapy?
conversion of IV to PO equivalent within the same class
What is step-down therapy?
conversion from injection med to oral agent in another class or to a different med in the same class with a different dose, frequency, and spectrum of activity may not be the same
All ICU patients have Virchow’s triad, what are the 3 parts?
- stasis
- vascular injury
- hypercoagulable state
What are the major risk factors for VTE?
- cancer
- previous DVT
- obesity
- trauma
- surgery
When should LMWH or LDUH (low-dose unfractionated heparin) be started for DVT prophylaxis in critical care patients?
ASAP
What should be used for DVT prophylaxis in critical care patients at high risk for major bleeding?
mechanical thromboprophylaxis as monotherapy
When would a patient be considered high risk for major bleeding?
platelets <50,000
What are CIs for mechanical thromboprophylaxis?
- open wounds
- active DVT
What is the dose of heparin (LDUH) for DVT prophylaxis?
- 5000 units SQ Q12H
OR - 5000 units SQ Q8H
What is the renal dosing adjustment for LDUH?
No dosing adjustment required
What is the dose of LMWH (Enoxeparin, LOVENOX) for DVT prophylaxis?
- 40mg SQ Q24H
OR - 30mg SQ Q12H
What is the renal dosing adjustment for Enoxiparin?
CrCl <30: 30mg SQ Q24H
What role does Fondaparinux (ARIXTRA) have in DVT prophylaxis?
can be used in patients with moderate, high, or very high risk of DVT if CrCl>30
What role do DOACs have in DVT prophylaxis?
No role in ICU patients
What is a serious immune-mediated adverse reaction with heparin products and what is the outcome?
Heparin-induced thrombocytopenia: presents as low platelets in the presence of UFH or LWMH and leads to thrombosis (stroke, MI, VTE)
When should DVT prophylaxis be held?
- 48-72 hours after serious surgery
- 24 hours after minor surgery
When should VTE prophylaxis be D/C?
- at discharge
- after discharge if at high risk of DVT
What are major independent risk factors for stress ulcers?
- coagulopathy (platelets <50,000)
and/or - mechanical ventilation >48h
What 2 drug classes are recommended for stress ulcer prophylaxis?
- H2RAs
- PPIs
What are SEs with H2RAs?
- thrombocytopenia
- mental status changes/ CNS toxicity
- nosocomial pneumonia
- tachyphylaxis
What is the dose of famotidine (PEPCID) for stress ulcer prophylaxis?
20mg Q12H
What is the renal dose adjustment of famotidine (PEPCID) for stress ulcer prophylaxis?
CrCl<50: 20mg Q24H
What are SEs with PPIs?
- GI disturbance
- nosicomial pneumonia
- c.diff super infection/ colitis
- long-term (fractures, electrolyte disturbances)
What is the dose of Pantoprazole (PROTONIX) for stress ulcer prophylaxis?
40mg Q24H
What is the dose of Esomeprazole (NEXIUM) for stress ulcer prophylaxis?
40mg Q24H
What is the renal dosage adjustment for PPIs?
not required
Which agents for stress ulcer prophylaxis can be administered IV or enteral?
- famotidine
- pantoprazole
- esomeprazole
What is the target glucose range for ICU patients?
140-180 mg/dl
What should be done if a patient becomes hypoglycemic BG</=70?
- stop insulin
- administer dextrose (25g IV or 50mL of 50% dextrose)
- re-evaluate insulin/ glucose control
What are not routine methods of glucose control in ICU patients?
- oral/outpatient antidiabetic agents
- basal/bolus regimens
What is the preferred method of glucose control in ICU patients?
range of short/rapid-acting insulin units given as SQ dose based on current reading
When would insulin infusions be given in ICU?
- not responding to the correctional scale
- conditions affecting SQ absorption
- DKA
- HHS
What are other risk factors for stress ulcers?
- sepsis/shock
- glucocorticoids
- NSAIDs
- hx of ulcers/bleeds within a year
- burns >20% BSA
- head/spinal trauma
- organ transplant
- AKI
- acute liver failure
