Intro to Critical Care

Question 1

Situations requiring prophylaxis in ICU patients

Answer 1

Ventilator associated pneumonia
stress ulcer prophylaxis
VTE prophylaxis

Question 2

PKPD changes in ICU patients

Answer 2

fluid shifts
renal dysfunction
hepatic dysfunction

Question 3

FAST HUGS BID

Answer 3

feeding
analgesia
sedation
thromboprophylaxis

head of bed (VAP prophylaxis)
ulcer prophylaxis
glycemic control
spontaneous breathing trial

bowel regimen
indwelling catheters
de-escalation of abx

Question 4

Feeding

Answer 4

• malnutrition -> impaired immune function
• enteral feeding preferred to parenteral where possible
• does the patient need NPO?
• does the patient need TPN

Question 5

Analgesia

Answer 5

• pain assessment using ICU validated pain scales
• nociceptive vs neuropathic pain management
• duration of pain, long or short term agents
• account for home pain regs (don’t underdose compared to home reg)

Common agents:
fentanyl
hydromorphone
morphine
oxycodone

Question 6

Sedation

Answer 6

• management of agitation
• minimizes acute stress response
• Assess using RASS or SAS
• light sedation RASS 0 to -2

preferred agents:
- propofol
- dexmedetomidine

Question 7

Thromboembolism prophylaxis

Answer 7

• give to all ICU patients
• individualize based on bleed risk vs VTE risk
  LMWH 40mg SQ daily or 30mg SQ BID
  UFH 5000 U SQ Q8H (for renal dysfunction)
  Mechanical prophylaxis (for high bleed risk)

Question 8

Head of Bed

Answer 8

Ventilator Associated Pneumonia Prophylaxis
Elevate head and thorax above bed at a 30-45 degree angle
- reduces occurrence of GI reflux and nosocomial pneumonia
antiseptic mouthwash topically to oral cavity TID
- chlorhexidine 0.12%

Question 9

Ulcer prophylaxis

Answer 9

can develop stress related mucosal damage -> GI bleed

Agents:
- PPI
- H2RA
continue until risk factors resolved

Question 10

Major risk factors for SRMD

Answer 10

1.) Mechanical ventilation > 48 hrs
2.) Coagulopathy
- INR > 1.5
- PTT 2x ULN
- platelets < 50,000/mL

1 of the above -> prophylaxis required

Question 11

Minor risk factors for SRMD

Answer 11

• drugs that increase bleed risk (steroids/ warfarin/ heparin)
• shock/sepsis/hypotension/vasopressors
• hepatic/renal failure
• multiple trauma
• burns > 35% BSA
• organ transplant
• head or spinal trauma
• Hx of upper GI bleed or PUD

Question 12

Glycemic control

Answer 12

Consequences of hyperglycemia:
- decreased wound healing
- infection risk

hypoglycemia may be harder to detect in ICU pts

Goal: 140-180mg/dL

Question 13

Spontaneous breathing trial

Answer 13

mechanical ventilation is associated with a lot of complications -> DC at earliest opportunity

SBTs assess patients ability to breathe on minimal or no ventilatory support

should be performed daily

Question 14

Bowel regimen

Answer 14

monitor bowel movements daily

Question 15

Indwelling catheters

Answer 15

assess daily for:
- signs of infection
- readiness to be removed

Question 16

De-escalation of abx

Answer 16

antimicrobial stewardship should be assessed at least daily
- choose de-escalation according to culture results
- set appropriate abx duration
- provide necessary dose adjustments based on P changes