Intro to Crit Care Flashcards
Define FASTHUG
Feeding Analgesia Sedation Thromboembolism prevention Head of bed elevation Ulcer prevention (stress ulcer prophylaxis) Glucose control
What are options for Feeding?
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)
What are advantages of Nasal/oral tubes?
Disadvantages?
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.
How does risk of aspiration compare among the feeding options?
No difference in the risk of aspiration with gastric versus duodenal feedings.
What are advantages/disadvantages of percutaneous tubes?
Advantages: Convenient for long-term use
Disadvantage: Requires surgical placement, difficult to remove, associated with MORE INFECTIONS!!
How should Extended Release tabs/capsules be administered? Why?
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!
Which drugs should not be crushed bc of teratogenicity?
Finasteride
Dutasteride
Bosentan
Lenalidomide
Which drugs should not be crushed bc of direct toxicity to skin, mucus membranes, etc?
Hydroxurea
Temzolomide
Atomoxetine
Everolimus
What drugs are placed post-pyloric? Why?
Bypass site of absorption (acid medium of the stomach)
Iron supplements are best absorbed as Fe2+
Where do J-tubes go?
They bypass large portions of the GI system
Which product for feeding is targeted to Diabetics?
Glucerna
They have reduced carbohydrate and dextrose contents
Which product for feeding is targeted to General; surgical patients?
Impact
Contains more L-arginine to improve immune defense
Which product for feeding is targeted to CKD, ESRD patients?
Nepro
Limited potassium and electrolyte content
Which product for feeding is targeted to Pancratitis patients?
Vital
Peptide-based; elemental formulation
Which product for feeding is targeted to Diarrhea patients?
Osmolite
Low osmolality formulation
What are some reasons ICU pts cannot be fed?
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
When should TPN be administered? Why the wait?
After 7 days of ICU admission
Bc TPN results in increased risk of infection, electrolyte disturbances, and increased mechanical ventilation duration
Oversedation is associated with…
Increased VTE, decreased intestinal motility, hypotension, delirium, increased length of mechanical ventilation, and increased ICU stay
Which comes first, analgesia or sedation?
Analgesia!!
Sedation required for agitation/anxiety
Treating pain may help reduce amount of sedation needed
Which scales are used to assess ICU pain?
What about vital signs?
Behavioral Pain Scale (BPS)
Critical-Care Pain Observation Tool (CPOT)
Vital signs should NOT BE USED IN ISOLATION when assessing pain in ICU patients
What meds are first line for treatment of non-neuropathic pain?
IV Opiates
What meds do we use for neuropathic pain in ICU pts?
Gabapentin or carbamazepine in addition to IV opioids
What if a pt has a lot of side effects from IV opioids?
We can use non-opioids to reduce the amount necessary and related side effects
What level of sedation should we keep ICU patients?
LIGHT levels associated with better outcomes
Some indications require deep sedation, ie status epilepticus and traumatic brain injuries
What is the best assessment for measuring quality and depth of sedation?
RASS (Richmond Agitation-Sedation Score)
What sedatives are preferred in mechanically ventilated ICU patients?
Non-BDZ sedatives like propofol or dexmedetomidine
What does a negative RASS mean? Positive?
Negative: Sedated
Positive: Awake (high positive = agitated)
What are risk factors for thromboembolism?
Surgery/Trauma Cancer Immobility Central venous catheters Obesity Genetic predisposition/previous VTE
Less common in ICU: Estrogens, smoking
What are the pharmacological suggestions for VTE prophylaxis in pts with minor surgeries that are fully mobile?
LOW risk (less than 10% risk for VTE) - no pharmacologic agents; just early and aggressive ambulation if VTE occurs
What are the pharmacological suggestions for VTE prophylaxis in pts who are on bed rest?
10-40% risk of VTE means moderate risk; suggests LMWH, LDUH, or fondaparinux
What are the pharmacological suggestions for VTE in pts with hip/knee arthroplasty, major trauma, spinal cord injuries?
40-80% risk of VTE means high risk; suggest LMWH, fondaparinux, or warfarin to goal INR of 2-3
Which VTE prophylactic agent requires no renal adjustment?
Heparin
Which VTE prophylactic agent is contraindicated in CrCL less than 30 mL/min?
Fondaparinux
When do we use fondaparinux?
In pts with history of HIT
How is Enoxaparin dosed?
40 mg daily for moderate risk
30 mg BID for high risk
How is Enoxaparin monitored?
Anti-Xa levels
How is Heparin monitored?
aPTT
How is Fondaparinux monitored?
Anti-Xa levels
Why do we elevate the head of the bed for mechanically ventilated patients?
Reduces GERD and aspiration (reduces rates of nosocomial pneumonia)
May not be appropriate for some patients! ie Unstable traumas, spinal cord injuries
Whats the difference between Stress-related injury and Stress ulcers in the context of Stress-related mucosal disease (SRMD)?
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
True or False: Acid production is the primary cause of stress ulcers
F A L S E
What are well-established risk factors for stress ulcers?
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)
What are our options for protecting gastric mucosa from stress ulcers?
Enteral nutrition Sucralfate Antacids H2 antagonists Proton pump inhibitors
What are the CrCL cutoffs for renal adjustment of H2 antagonists?
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
How long should stress ulcer prophylaxis continue?
Until risk factors are no longer present
What is the goal for glucose control in ICU?
Less than 180 (more intensive goal resulted in increased hypoglycemia and mortality)
Which insulin method is used to “chase” insulin?
Sliding scale insulin
How often do you check blood glucose with sliding scale insulin?
Every 4-6 hours
How often do you check blood glucose with insulin infusions?
Every 1-2 hours
