Intro to critical care Flashcards
ICU role
A specialized section of a hospital that provides comprehensive care for persons who are critically ill
What makes ICU different from medical floor?
ATC monitoring and treatment
Staffed with specially trained healthcare professionals
Makes sure staffing ratio smaller
1:2 ratio vs 1:5
Contains sophisticated monitoring equipment
Role of clinical pharmacist in ICU - direct patient care
Interdisciplinary patient care rounds
Code blue/code stroke response
Perform medication histories
prevent/manage ADR and med errors
PK PD monitoring
Patient and caregiver education
Role of clinical pharmacist in ICU - INdirect patient care
Policy and protocol development
Formulary management
Research
Participation in committees
Therapeutic considerations in the critically ill
- PKPD changes (fluid, renal, hepatic)
- Specific prophylaxes (FASTHUGS BID)
- Nutrition considerations
FASTHUGS BID
Feeding
Analgesia
Sedation
Thromboembolism
Head of Bed (intubated)
Ulcer
Glycemic control
Spontaneous breathing trial (intubated)
Bowel regimen
Indwelling catheter
De-escalate abx
Feeding Importance
Malnutrition = impaired immunity
* infection
* impaired wound healing
* bacterial overgrowth GI
* risk for decubitus ulcer development
Feeding considerations
ASAP clinically stable
Enteral > Parenteral
- physiologic, fewer complications, less GI bleeding
TPN if gut not working or not tolerated
Analgesia Importance
Pain d/t trauma, surgery, standard ICU care (lines, tubes, repositioning, PT)
Adequate pain relief optimizes comfort + reduces risk of developing agitation
Minimizes:
- acute stress response, hypermetabolism
- O2 consumption
- hypercoagulability
- immune fnc alteration
Analgesia considerations
Assess pain using ICU validated pain scales
- CPOT (critical care pain obs tool)
- BPS (behavioral pain scale)
Treat based on type of pain: nociceptive (opioids, APAP) vs neuropathic (gaba)
Duration: bolus vs long acting agents
Account for home pain regimen: make sure not underdosing
Sedation importance
anxiety, pain, no homeostasis, withdrawal, BZD use, sleep wake cycle disruption
Appropriate sedation = comfort, reduce acute stress response, patient safety
Sedation considerations
Assess + re-assess using validated tool
- RASS (Richmond agitation-sedation scale)
- SAS (sedation agitation scale)
Light sedation RASS 0 to -2 for most situations
Drugs: Propofol, Dexmedetomidine > > BZD
Analgosedation
Manage pain first – many ICU patients were over sedated and undertreated for their pain
fentanyl or hydromorphone provides analgesia + light sedation
Benzodiazepines - why bad for sedation
Associated with delirium, agitation, and neurocognitive implications
Thromboembolism PPX considerations
ALL ICU patients receive VTE PPX
initiation of ppx dependent on VTE risk + bleed risk
ICU patient additional risk factors for VTE
CVC - catheter
Immobility
Trauma/burns
Critical illness (sepsis)
= hypercoagulable state
VTE PPX common treatment
LMWH - enoxaparin 40mg SQ QD or 30mg SQ BID
Renal dysfuncion: unfractionated heparin 5000 IU SQ Q8H
VTE PPX if high bleed risk
Nonpharm prophyaxis
- compression stockings
- intermittent pneumatic compression devices
VTE PPX if high VTE risk
combo mechanical (nonpharm) + pharm
generally not recommended ….
Head of bed importance
Only considered for patients on mechanically ventilation (VAP prophylaxis)
Reduces occurrence of GI reflux nosocomial pneumonia
Head of bed tx
Elevate head/thorax above the bed at 30-45 degree angle
Apply antiseptic mouthwash to oral cavity TID to maintain hygiene, prevent bacterial growth with endotracheal tube
Ulcer PPX importance
Stress related mucosal damage (SMRD) causes clinically significant bleeding
SMRD mortality is 50-70% in critically ill
Ulcer PPX major risk factor (1 req)
Mechanical ventilation > 48 hours
OR
Coagulopathy
* INR>1.5
* PTT > 2x ULN
* PLT < 50,000
Ulcer PPX minor risk factors (2+ req)
Drugs : warfarin, steroids, heparin
shock/sepsis/hypotension/vasopressors
hepatic/renal failure
Multiple trauma
Burns >35% total SA
Organ transplant
head/spinal trauma
Hx upper GI bleed or PUD
Ulcer PPX drug options
PPI 40mg QD
H2RA 20mg BID
Glycemic control importance
Hyperglycemia common d/t stress, medications (steroids, BB, vasopressors), exogenous glucose (TPN)
Proper glycemic control decrease incidence of complications
* Decreased wound healing
* Increased infection risk
* Variable glucose = worse morbidity/mortality
* May not tolerate hypoglycemia, delayed detection
Glycemic control goal ICU
maintain BG 140-180 mg/dL
give as sliding scale insulin
If substantial amount - also give long acting
Cont long acting if patient eating
Spontaneous breathing trial importance
See if patient can breathe on minimal or no ventilatory support
Assess if respiratory mechanics are enough to consider liberation from ventilator
Switch to mode where patient needs to work to breathe
Bowel regimen
fundamental for QOL
Monitoring BM at least daily
CONSTIPATION: Provide bowel regimen
- If lots of opioids / constipation
Diarrhea:
CONSIDER; Infection, feeds, TOO aggressive bowel regimen
Indwelling catheters importance
Lines are assessed at least daily for signs of infection
Assessing the need for these lines or if they can be removed
De-escalating abx
Broad spectrum common in critical care
Apply standard antimicrobial stewardship principles should be standard of care in the critical care setting
De-escalate abx based on culture
Select appropriate abx duration per setting
Provide necessary dose adjustment based on
* PK changes
* renal/hepatic
