Supportive Care in the ICU: FASTHUG Flashcards
What are the 7 components of FASTHUG-BID?
OBJECTIVE !!!
Feeding
Analgesia
Sedation
Thromboprophylaxis
Hyperactive or hypoactive delirium
(Stress) Ulcer prophylaxis
Glucose control
Bowel Regimen
Invasive lines
De-escalation of therapies
What are the complications of not feeding (malnutrition) patients in the ICU?
OBJECTIVE !!
-Muscle wasting and weakness
-Impaired wound healing
-increased risk of infection
-catabolic state
What is the caloric requirement in patients in the ICU?
How many g of Protein per day are required?
!!!
NAPLEX
Calories: 25-30 kcal/kg/day
Protein: 1.5-2 g/kg day (less aggressive with renal impairment)
What is the preferred route of feeding?
When do we pick enteral feeding?
What are possible complications?
Enteral feeding
-24-48h -> fewer infections and shorter length of stay if started early
Complications:
-aspiration
-clogged tubes
-diarrhea
-dehydration
At what time point should patients begin receiving parenteral feeding?
after 5-10 days
Complications:
-infections
-hyperglycemia
-refeeding syndrome (electrolyte disturbance after starving for a long time)
What are the Macronutrients?
EXAM !!
NAPLEX
-Protein
4 kcal/gram
1.5 – 2 grams/kg/day
-Lipids
9 kcal/gram
20 – 30 % of daily non-protein calories
-Dextrose
3.4 kcal/gram– Total Daily Need – (Protein + Lipid) = Dextrose Calories
What are the complications of uncontrolled pain?
-Vital sign changes
-Stress response (catecholamine release)
-Catabolic metabolism and impaired immunity
-Delirium
-PTSD
Which analgesic drug would you use for pain control in a patient who needs frequent awakening?
opioids like Fentanyl (need fast on, fast offset; reduces sedation and allows neurologic assessment)
-might be a patient with a head injury
-this patient needs neurologic assessment every 2 hours (Glasgow coma score GCS)
Which analgesic drug would you avoid in a patient with impaired renal function?
Morphine
active metabolite accumulates with renal dysfunction
Which analgesic drug would you use in a patient with a morphine allergy
synthetic opioid
-Oxycodone
-Hydromorphone
What analgesic drug would you use to transition someone from IV to PO/PT analgesia?
Oxycodone
-it has multiple formulations (liquid, crushable forms, formulations without Tylenol component)
Which opioid has the lowest risk for histamine-induced hypotension?
Fentanyl
-risk higher with Morphine
the more potent the opioid the lower the risk for histamine release (and vasodilation)
Which analgesic with non-sedating properties is commonly used in the IUC?
What are the precautions of this drug?
NAPLEX
Ketorolac
no respiratory depression
VERY high risk of GI bleeding, 5day max therapy
Which tool is used to assess sedation in patients in the ICU?
REMINDER
-Ramsey Scale
-SAS (Sedation-Agitation Scale)
-RASS (Richmond Agitation Sedation Scale) !!!
What are the benefits of Propofol as a sedative drug?
What are the precautions of this drug?
Fast on and Fast offset
-ideal for frequent neurologic assessments
-check triglycerides, it is a lipid emulsion and can cause hypertriglyceridemia, and pancreatitis
-avoid bolus: can cause hypotension, respiratory depression (need intubation), or burning
-it accumulates in adipose tissue (may take longer to eliminate in obese patients)
What is the Propofol Infusion Syndrome?
complex of symptoms due to high doses of propofol
-Arrhythmias
-Hyperkalemia
-Hypertriglyceridemia
-Metabolic acidosis
-Rhabdomyolysis -> AKI
What dose of Propofol is associated with Propofol Infusion Syndrome?
> 80 mcg/kg/min for > 48 hours
Which lab may be monitored and is the first sign of Propofol Infusion Syndrome?
high levels of Triglycerides
Which sedative drug might be used if you need deep levels of sedation and have ante retrograde amnesia?
Benzos
Potency:
Lorazepam > Midazolam > Diazepam
Downside of benzos
Changes in sleep pattern – poor quality sleep
Which short-acting sedative provides minimal sedation and strong amnesic effects, making it suitable for patients with bone dislocations?
Midazolam
-3A4 metabolism
-accumulation in renal impairment
Which benzo does not accumulate in patients with renal impairment?
FYI
Lorazepam
Which α-2 agonist is used as a sedative and helps weaning patients from ventilators?
Dexmedetomidine (Precedex)
-bridging sedative
-it provides sedation without reducing respiratory drive in patients discontinuing benzos (they panic as they come off the benzos bc feeling uncomfy breathing through the ventilator)
(Clonidine (α-2 agonist) has abuse potential)
How should Dexmedetomidine be initiated and stopped?
slowly titrate up to avoid: hypotension and bradycardia
slowly titrate down to avoid: rebound hypertension and tachycardia
What is the brand name of Dexmedetomidine?
Precedex
What are the effects of ketamine in critically ill patients?
-rapid analgesia
-sedation
-amnesia
-doesn’t reduce respiratory drive (similar to Dexmedetomidine)
(effective in depression)
What are the precautions of Ketamine?
Ketamine Emergence Reactions !!
-Less common in children and elderly (>65), more in adults
-More common at high doses
-causes vivid dreams, hallucinations, delirium (as it wears off)
- “Falling into a K-hole”
What are things that can be done to avoid oversedation?
-use intermittent dosing
-lowest level of sedation (decreases stay in the ICU)
-sedation vacation (wake them up once daily, decreases total days on the ventilator)
-taper sedation when d/c
-use RASS or SAS for assessment
-Propofol and Dexmedetomidine (less delirium) are preferred over benzos
What factors increase the risk of VTE in the ICU?
-Immobility
-NMB
-IV lines
-Mechanical ventilation
-Surgery
-Trauma
Which anticoagulant needs renal dose adjustment?
Which one is not?
renal dose adjustment: Enoxaparin
no renal adjustment: UFH, heparin
What is the dose of UFH in ICU patients who are not morbidly obese?
5000 units SQ Q8H
What is the dose of Enoxaparin in ICU patients who are not morbidly obese?
40 mg SQ daily
30 mg SQ daily if CrCl <30 ml/min
What are alternative ways to achieve Thromboembolism prophylaxis?
When would you avoid drugs for anticoagulation?
mechanical devices
-IPC (intermittent pneumatic compression) like SCD boots
-GCS (graduated compression stockings)
Mechanical devices should be used together with drugs
-solely use devices and avoid drugs if patients are bleeding !!
What are the interventions to prevent VAP (ventilator-associated pneumonia)?
-Stress-ulcer prophylaxis
-Head of bed elevation 30 – 45° (makes aspiration unlikely)
-DVT prophylaxis
-Daily sedation vacations
-Oral care (chlorhexidine mouth rinse BID)
Hyperactive VS Hypoactive Delirium
-Hyperactive: agitated, restless
-Hypoactive: sedated, lethargic
for delirium it has to have a fast onset (in contrast to dementia) and waxing and waning confusion and DSM-5 criteria: disturbed attention/focus, change in cognition, delirious
What are the factors that contribute to delirium in the ICU?
-Environment: bells, whistles, tubes, lines, drains
-metabolic: electrolytes are off, acidosis, uremia (AKI)
-they have a pre-existing psychiatric illness
-meds: Benzos, Opioids, Sedatives, steroids
How to manage Delirium in the ICU?
-remove contributing factor
-sedation vacation
-frequent reorientation
-sleep hygiene
-drug therapy (not approved)
Which drugs may be used for delirium?
Haloperidol (Qtc prolongation)
Quetiapine
Risperidone
-not FDA approved !!!
-only for patients at risk of hurting others or themselves !!!
When is stress ulcer prophylaxis indicated in ICU patients?
- Coagulopathy (thrombocytopenia !!!
low platelet (<50k)
INR >1.5
aPTT > 2xULN - chronic liver disease !!!
- Shock states !!!
- +/-neurocrit population (neuro ICU, head injury)
- mechanical ventilation >48 hours
(newest guidelines say mechanical ventilation alone is not enough to start prophylaxis)
What is used to treat patients prophylactically for Stress Ulcers?
1st line: enteral feeding
add drugs if they have one of the indications (coagulopathy, liver disease, shock)
Famotidine (Pepcid) - renal adjustment
PPI
Sucralfate
When does Famotidine require renal dose adjustment?
What are the side effects if it accumulates?
CrCl <50 ml/min
can cause neurologic symptoms
-AMS, confusion
What are the side effects of PPIs?
Thrombocytopenia (acutely)
associated with
-Nosocomial pneumonia
-C. diff
-Osteoporosis (long-term)
What is the target glucose level for ICU patients?
140-180 mg/dl unless instructed otherwise in those with hyperglycemia
Which type of insulin provides the best glucose control in ICU patients?
IV continuous infusion of regular insulin
-can be titrated on and off quickly
avoid long-acting insulin in the ICU
-for example Insulin glargine lasts 24 hours and is difficult to adjust in emergency situations
sliding scale insulin is used to see how much insulin they need
Which type of drugs are used for RSI (rapid sequence of events leading to intubation)?
IPA (induction - paralysis - analgesics)
- Sedatives (Induction)
- NMB (Paralysis)
- Analgesics
RSI: sequences of events to get quick access to the respiratory system (cardiac arrest) and intubation
Which drugs are used for induction before intubation?
Sedatives
-Benzos
-Etomidate (Amidate)
What is the benefit of using Etomidate for sedation?
Etomidate does not immediately cause a decrease in BP or cause bradycardia, benzos or propofol do
-rapid onset (15-50 sec) of unconsciousness and apnea (temporarily stop breathing during sleep)
-their BP might be low already in an emergency situation
Downside of Etomidate
it inhibits adrenal cortisol production
-that’s why it is given only once to induce sedation in intubation, not for long-term use
What is the purpose of sedation during the RSI process (intubation)?
-to visualize vocal cords, and see if the muscles are relaxed
-to suppress the sympathetic response that would occur if we intubate
-make the patient unaware of events
Patients need to be ____ before using NMB
sedated
-may not use sedation if they are unconscious
What is the purpose of NMB in RSI?
What are other uses of NMB in practice?
purpose in RSI: relaxes muscles in the neck during intubation
other uses in practice:
-manage ventilation
-reduces intracranial pressure
-prevents shivering in hypothermia
-paralyzing patients who need not move
-decrease oxygen consumption when other options have failed
What supportive care must be provided for patients treated with an NMB?
-eye care (can’t close their eyes, dry eyes)
-DVT prophylaxis (no movement)
-physical therapy (prevent atrophy)
-TOF assessment (train of 4, to assess how much NMB they have in the system)
What is the Depolarizing NMB?
Succinylcholine
-most often used NMB in RSI
-fast ON and OFF (can be used just to intubate, then it wears OFF)
-depolarization causes fasciculations (involuntary twitching)
When should Succinylcholine be avoided due to severe Hyperkalemia?
-Burns
-strokes
-muscle trauma
-Neuromuscular or nerve function disorders
What are the Non-Depolarizing NMBs?
-Cisatracurium (Nimbex)
Eliminated via Hofmann degradation
continuous infusion
-Rocuronium (Zemuron) - last longer, for surgery
renal elimination
-Vecuronium (Norcuron) - last longer
renal elimination
