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PTX 3 Exam 1 > Intro to Crit Care > Flashcards

Intro to Crit Care Flashcards

1
Q

Define FASTHUG

A 
Feeding
Analgesia
Sedation
Thromboembolism prevention
Head of bed elevation
Ulcer prevention (stress ulcer prophylaxis)
Glucose control
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2
Q

What are options for Feeding?

A

Examples of enteral access include feeding through the NOSE (Nasogastric, nasoduodenal, or nasojejunal)

Can also perform gastronomy (inject into abdominal cavity)

or Jejunostomy (inject directly into the jejunem - intestines)

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3
Q

What are advantages of Nasal/oral tubes?

Disadvantages?

A

Advantages: It’s easy to place and easy to remove
Disadvantage: Long-term use can cause erosions, and worry about small bore complications and clogging. Also require Xray imaging to confirm placement.

TROUBLE WITH MED ADMINISTRATION/BOLUS FEEDS.

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4
Q

How does risk of aspiration compare among the feeding options?

A

No difference in the risk of aspiration with gastric versus duodenal feedings.

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5
Q

What are advantages/disadvantages of percutaneous tubes?

A

Advantages: Convenient for long-term use
Disadvantage: Requires surgical placement, difficult to remove, associated with MORE INFECTIONS!!

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6
Q

How should Extended Release tabs/capsules be administered? Why?

A

They should NOT be crushed bc this results in increased bioavailability/drug peaks, and the coating can clog tubes.

They should be converted to an IR formulation
Morphine ER 100 mg –> 50 mg IR q6h!
or Suggest a different drug!

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7
Q

Which drugs should not be crushed bc of teratogenicity?

A

Finasteride
Dutasteride
Bosentan
Lenalidomide

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8
Q

Which drugs should not be crushed bc of direct toxicity to skin, mucus membranes, etc?

A

Hydroxurea
Temzolomide
Atomoxetine
Everolimus

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9
Q

What drugs are placed post-pyloric? Why?

A

Bypass site of absorption (acid medium of the stomach)

Iron supplements are best absorbed as Fe2+

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10
Q

Where do J-tubes go?

A

They bypass large portions of the GI system

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11
Q

Which product for feeding is targeted to Diabetics?

A

Glucerna

They have reduced carbohydrate and dextrose contents

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12
Q

Which product for feeding is targeted to General; surgical patients?

A

Impact

Contains more L-arginine to improve immune defense

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13
Q

Which product for feeding is targeted to CKD, ESRD patients?

A

Nepro

Limited potassium and electrolyte content

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14
Q

Which product for feeding is targeted to Pancratitis patients?

A

Vital

Peptide-based; elemental formulation

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15
Q

Which product for feeding is targeted to Diarrhea patients?

A

Osmolite

Low osmolality formulation

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16
Q

What are some reasons ICU pts cannot be fed?

A

Continuous vasopressor requirements (we want their blood shunted to the brain or heart, not GI)

Delayed gastric emptying, ileus obstructions, large resections, and discontinuity

Enteric fistula formation

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17
Q

When should TPN be administered? Why the wait?

A

After 7 days of ICU admission

Bc TPN results in increased risk of infection, electrolyte disturbances, and increased mechanical ventilation duration

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18
Q

Oversedation is associated with…

A

Increased VTE, decreased intestinal motility, hypotension, delirium, increased length of mechanical ventilation, and increased ICU stay

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19
Q

Which comes first, analgesia or sedation?

A

Analgesia!!
Sedation required for agitation/anxiety
Treating pain may help reduce amount of sedation needed

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20
Q

Which scales are used to assess ICU pain?

What about vital signs?

A

Behavioral Pain Scale (BPS)

Critical-Care Pain Observation Tool (CPOT)

Vital signs should NOT BE USED IN ISOLATION when assessing pain in ICU patients

21
Q

What meds are first line for treatment of non-neuropathic pain?

A

IV Opiates

22
Q

What meds do we use for neuropathic pain in ICU pts?

A

Gabapentin or carbamazepine in addition to IV opioids

23
Q

What if a pt has a lot of side effects from IV opioids?

A

We can use non-opioids to reduce the amount necessary and related side effects

24
Q

What level of sedation should we keep ICU patients?

A

LIGHT levels associated with better outcomes

Some indications require deep sedation, ie status epilepticus and traumatic brain injuries

25
Q

What is the best assessment for measuring quality and depth of sedation?

A

RASS (Richmond Agitation-Sedation Score)

26
Q

What sedatives are preferred in mechanically ventilated ICU patients?

A

Non-BDZ sedatives like propofol or dexmedetomidine

27
Q

What does a negative RASS mean? Positive?

A

Negative: Sedated
Positive: Awake (high positive = agitated)

28
Q

What are risk factors for thromboembolism?

A 
Surgery/Trauma
Cancer
Immobility
Central venous catheters
Obesity
Genetic predisposition/previous VTE

Less common in ICU: Estrogens, smoking

29
Q

What are the pharmacological suggestions for VTE prophylaxis in pts with minor surgeries that are fully mobile?

A

LOW risk (less than 10% risk for VTE) - no pharmacologic agents; just early and aggressive ambulation if VTE occurs

30
Q

What are the pharmacological suggestions for VTE prophylaxis in pts who are on bed rest?

A

10-40% risk of VTE means moderate risk; suggests LMWH, LDUH, or fondaparinux

31
Q

What are the pharmacological suggestions for VTE in pts with hip/knee arthroplasty, major trauma, spinal cord injuries?

A

40-80% risk of VTE means high risk; suggest LMWH, fondaparinux, or warfarin to goal INR of 2-3

32
Q

Which VTE prophylactic agent requires no renal adjustment?

A

Heparin

33
Q

Which VTE prophylactic agent is contraindicated in CrCL less than 30 mL/min?

A

Fondaparinux

34
Q

When do we use fondaparinux?

A

In pts with history of HIT

35
Q

How is Enoxaparin dosed?

A

40 mg daily for moderate risk

30 mg BID for high risk

36
Q

How is Enoxaparin monitored?

A

Anti-Xa levels

37
Q

How is Heparin monitored?

A

aPTT

38
Q

How is Fondaparinux monitored?

A

Anti-Xa levels

39
Q

Why do we elevate the head of the bed for mechanically ventilated patients?

A

Reduces GERD and aspiration (reduces rates of nosocomial pneumonia)

May not be appropriate for some patients! ie Unstable traumas, spinal cord injuries

40
Q

Whats the difference between Stress-related injury and Stress ulcers in the context of Stress-related mucosal disease (SRMD)?

A

Stress related injury: Diffuse, superficial, small erosions that do NOT reach the submucosal blood vessels

Stress ulcers: Discrete, deep, focal lesions that reach the submucosal blood vessels and can cause bleeding

41
Q

True or False: Acid production is the primary cause of stress ulcers

A

F A L S E

42
Q

What are well-established risk factors for stress ulcers?

A

Mechanical ventilation for more than 48 hours
Coagulopathy, or platelets less than 50,000, INR over 1.5, or PTT over 2x control (all of which are not medication induced)

43
Q

What are our options for protecting gastric mucosa from stress ulcers?

A 
Enteral nutrition
Sucralfate
Antacids
H2 antagonists
Proton pump inhibitors
44
Q

What are the CrCL cutoffs for renal adjustment of H2 antagonists?

A

Cimetidine: 30 mL/min use 300 mg PO/IV BID instead of QID or 25mg/hr infusion instead of 05

Famotidine: CrCL less than 50 mL a min use 20 mg daily instead of BID

Ranitidine: CrCL less than 50 mL use 150 mg daily instead of BID and 50 mg q12-24 hr instead of q6-8h

45
Q

How long should stress ulcer prophylaxis continue?

A

Until risk factors are no longer present

46
Q

What is the goal for glucose control in ICU?

A

Less than 180 (more intensive goal resulted in increased hypoglycemia and mortality)

47
Q

Which insulin method is used to “chase” insulin?

A

Sliding scale insulin

48
Q

How often do you check blood glucose with sliding scale insulin?

A

Every 4-6 hours

49
Q

How often do you check blood glucose with insulin infusions?

A

Every 1-2 hours

PTX 3 Exam 1 (5 decks)

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