Intro Flashcards
What are ways to avoid the incompatibilities between different drugs or fluids when given simultaneously?
-timing: don’t administer at the same time
-ckeck if there are incompatibilities before administering (use Trissel’s on Lexicomp)
Know the lines
-Peripheral IV (INT)
-Peripherally Inserted Central Catheter (PICC)
-Central Venous Catheter (CVC)
tunneled, non-tunneled
-Ports
GI access
-Nasogastric Tube
-Dobhoff/CorPak Tubes
How does PK and PD changes in patients in critical care?
the body metabolizes drugs faster (hypermetabolic, the body is trying to heal)
example: may give vancomycin more frequently if kidneys are fine (q6h instead of q12h)
What are peripheral IV lines (INT)? What are the possible limitations of use?
-lines on peripheral veins
-small diameter
-not all drugs can be used for peripheral IVs bc these are small ports
Name examples of what is not appropriate to use in a peripheral IV.
-vasopressor would cause ischemia due to vasoconstriction but can use the single strength for short-term until central line is ready
-high osmotic load IVs like parenteral nutrition
-dextrose >12% solution
-No TPN or chemotherapy
-watch pH (5-9)
-osmolarity < 600
-watch the concentration with piggybags! (ex Zosyn and Vancomycin)
Explain PICC lines. What is the benefit?
Peripherally inserted central catheter (PICC)
-starts peripheral (antecubital area (arm)) and goes through the arm and subclavian and ends in the heart
-must be confirmed with X-ray
-has multiple tubes inside of the line which are separated, so we can use drugs that are not compatible
-for patients with poor access points
Which catheter might be used in patients who need a quick access point?
Central Venous Catheter (CVC)
inserted into the central lines: non-tunneled
-internal jugular vein (IJ)
-subclavian
tunneled lines are used for patients at home (not used so often, replaced by PICC lines)
Tunneled VS Non-tunneled
Non-Tunneled: inserted directly into the central vein (port is at the neck)
Tunneled: subcutaneously through the skin then pushed into the vein (port is on the chest)
How does concentration change infusion time?
higher concentration extends infusion time
????
-nurses won’t need to change the bag as often
Port line
access point to the vein for long-term drug administration, also used for chemotherapy
What are PICC lines used for?
-used for long-term infusions (antibiotics, nutrition)
-can be used to check the CVP (central venous pressure)
-no dialysis
What kind of pressure is monitored to assess the fluid status of a patient?
CVP: central venous pressure when worried about their fluid status
-gives information about the preload: what is the pressure in the vein right before it enters the heart
What are the access points for the central vein?
-IJ (internal jugular vein)
-subclavian vein
(also femoral vein)
Tunneled VS Non-tunneled
Benefit of a tunneled access point
Non-Tunneled: inserted directly into the central vein (port is at the neck)
Tunneled: the line starts subcutaneously and is pushed into the central vein (port is on the chest)
-more space between the central vein and the access point, reducing the risk for infection
What are the different ways to get GI access?
Where do these tubes end?
Nasogastric tubes: nose to stomach
Dohoff/CorPak tubes: nose to duodenum (passes the stomach, less risk for aspiration)
Orogastric tubes: mouth to stomach
What is the difference between a Nasogastric tube and a Dohoff/CorPak tube?
-Dohoff/CorPak tubes bypass the stomach and enter the duodenum, less risk for aspiration)
-the nasogastric tube has a larger diameter and is sturdier (less flexible)
-the nasogastric can also be used for GI decompression (pull food out of the GI to allow for better flow when the GI is obstructed or in case of ileus)
-nasogastric tubes can be used for GI suction
both can be used for enteral nutrition and medical administration
What needs to be confirmed after setting a GI access point?
confirm that the tube actually entered the esophagus and not the larynx and the lungs
with an X-ray
What are the 3 tools used commonly to assess sedation in patients?
-Ramsey Scale
-SAS (Sedation-Agitation Scale)
-RASS (Richmond Agitation Sedation Scale) !!!
What are the two conditions that are assessed with the RASS tool?
-Sedation
-Delirium
the more positive, the more agitated
the more negative, the more drowsy
What is the goal score of the RASS tool for most patients in critical care?
between 0 and -2
at ventilator: -2 to -3
CAM-ICU: 0
How does Pain affect sedation?
Sedation and neuromuscular blockers do not control pain!!
the patient may be in pain but unable to express it due to sedation
or the pain can make it harder to sedate them
What are the two hallmarks of delirium that differentiates it from dementia?
Delirium:
-fast onset
-fluctuations (they are fine, but then become delirious thereafter)
What are the 4 features of the CAM-ICU worksheet to assess delirium?
- Acute Onset or Fluctuations
- Inattention (letter attention test)
- Altered level of consciousness (RASS score)
- Disorganized thinking
What is the Glasgow Coma Scale (GCS) used for?
assess brain function in brain injuries
the higher the score the better
score from 3 (worst) to 15 (best)
-Eye response
-motor response
-verbal response
What is the purpose of the Neuromuscular Blockade Assessment tool?
What needs to be done before starting an NMB?
How can you tell if the dose of an NMB is too high?
-it assesses neuromuscular blockade in critical patients (not responsive)
-> they administer an electrical stimulation unit to see if they respond (twitch)
-titrated to train of 2/4
-need baseline before starting NMB
-no twitch means too much NMB (may cause muscle atrophy and weakening)
In which patients would you consider the maintenance fluid rate? How would you tell if the rate is high enough?
Maintenance fluid rate
-NPO for a procedure
-check if it is enough -> is the mucous membrane moist? is the urine output and BP high enough?
In which patients would you use the replacement fluid rate?
-in patients who lost a lot of fluids and need a clinical response (BP, HR, UOP)
-give as much as they can tolerate, higher rates if more severe condition
-use isotonic fluids
for example:
DKA patients have severe dehydration,
dehydration from norovirus infections are often less severe
Which fluids are commonly used for Maintenance?
-D5/0.45 NS
-free water to keep cells hydrated and sugar for energy and to prevent muscle breakdown
Which fluids are commonly used for Replacement?
-NS is the most common or lactated ringer
-must be isotonic (we want to replace the fluids in the vessels)
What is the most concerning issue in patients with severe burns?
Fluid shifts or Fluid loss
What is the Parkland Formula?
4ml/kg * %BSA (body surface area) in the first 24 hours (time of the burn, not when we see the patient)
example: 80 kg patient with 20% BSA burn
4*80 * 20 = give 6400 ml within the 1st 24h
3200 ml within 8h
3200 ml within the next 16h
What are the different types of IV fluids?
Crystalloids
Colloids
What are the Crystalloids in IV fluids?
sterile water with solute (electrolytes, sugar, salts)
What are Colloids?
content that affects oncotic pressure and so large that it can’t diffuse freely across a semipermeable membrane (for example proteins)
-Albumin (albumin 5%, 25%)
-Amino acids
-blood products (PRBC, platelets)
-also contains Crystalloids (electrolytes)
How much % of body weight is contributed to Total Body water?
60%
of that 20% is extracellular and 40% is intracellular
intracellular: inside of the cell
extracellular: Plasma or interstitial fluid
Crystalloid maintenance fluids go to which parts of body fluid?
-extracellular and intracellular
To all parts because it is small enough to diffuse freely
-contains electrolytes, sugar
-example 5% dextrose
Crystalloid replacement fluids go to which parts of body fluid?
only extracellular because it is isotonic
-increases Plasma volume and interstitial fluid
-example Lactated Ringer
-for patients who are hypotensive
Colloid solutions go to which parts of body fluid?
only into the plasma
-it contains proteins that can’t pass the membrane
Which type of Dialysis is used for patients in the ICU?
Continuous Renal Replacement Therapy (CRRT)
-slow form of Dialysis bc patients in the ICU are hypotensive and already having issues with their fluids
-requires 1:1 nursing care
What are the indications for Dialysis?
AEIOU
Acidosis
Electrolytes imbalance
Intoxications
Overload
Uremia in the blood
What CrCl should be assumed for a patient on CRRT?
30-40 ml/min -> dose drugs based on it
Which supplement should be given to patients receiving Citrate anticoagulants during CRRT?
Calcium
because the Citrate anticoagulant that runs during CRRT chelates with calcium
