week 1 ICU, SHOCK, DKA/HHS Flashcards
Fast hugs bid
Feeds
- enteral> parenteral
- parenteral ae: thrombosis, fungal inf
(6) Consequences of malnutrition
- dec immune function
- inc susceptibility to inf
- impaired wound healing
- bacterial overgrowth
- ulcers
fAst hugs bid
Analgesia
- nociceptive: Tylenol, opioids (Fentanyl, hydromorphone, morphine, oxy)
- neuropathy: gaba
- do not underdose compared to at home dose
- scales: CPOT, BPS
faSt hugs bid
Sedation
- propofol + presadex > benzos
- benzos cause delirium and cog impairment
- RASS light sedation -2
- optimize control and minimize acute stress response
fasT hugs bid
thrombolytic prophylaxis
- EVERYONE in ICU gets it unless high risk bleed
- LMWH 40 mg SQ QD or 30 BID
- renal impairment use Heparin 5000 units SQ Q8H
- high risk bleed pts use mechanical (non pharm treatment): graded compression stocks or other device
fast Hugs bid
head of the bed
- elevate bed to 30-45 deg in pts with tube
-chlorhexidine .12% mouth rinse TID to prevent bacteria/inf
fast hUgs bid
ulcer prophylaxis
- PPIs or H2RA (famotidine)
- high risk (1 or more): mech vent >48hrs, coagulopathy
- minor risk (2 or more) meds, shock/sepsis/hypotension, hepatic or renal failure, multiple trauma, burns, organ transplant
fast huGs bid
glycemic control
- monitor often; goal 140-180
fast hugS bid
spontaneous breathing trial
- test daily, d/c mech vent at earliest opportune time
fast hugs Bid
bowel regimen
- if pt on opioids add on regimen
- docustae, sennosides, peg
- for emergency release: bisacodyl, enemas, mag citrate
fast hugs bId
indwelling catheters
- peripheral/ venous- iv meds
- central venous- into superior vena cava, long term
- arterial- continous bp, sampling
- foley- urine
** assess need for lines daily and assess site for infection
fast hugs biD
De-escalation of abx
- source control, narrow spectrum when species identified
- dose adj for pk changes
Shock Goals (vitals/labs)
- MAP>65, HR<100
- Hgb 7-9, o2 sat 88-92, svo2>65
- lactate <2
- urine output >.5 ml/kg/hr
- mental status
preload
left ventricle volume
- give too much fluids too fast can cause overload
- pcwr
invasive monitoring options
1. central venous
measures scvo2s from blood pH
- tells how well heart is contracting
- admin flusids, vasopressors, antimicrobals, parenteral nutrition, sample
invasive monitoring options
2. Pulmonary artery catheter
measures svo2 and svr (venous resistance) as well as preload, cardiac outpt
- ae: rupture, inf
invasive monitoring options
3. Arterial line
meausres BP, MAP, Arterial blood gas (pH) **continuously
what is the calc for MAP
1/3 sbp + 2/3 dbp
what is hypovolemic shock, causes, vitals, treatment options
low and sudden loss of intravascular volume
- caused by: hemorrhage, GI losses, severe dehydration, third spacing, burns
- dec PCWP, dec pump function, inc svr, dec svo2
- packed RBCs for hemorrhage, crystalloid fluids
what is cardiogenic shock, causes, vitals, treatment options
failure of left ventricle to deliver blood due to impaired SV or HR
- causes: acute MI, arrhythmias, end stage HF, valve disease
- inc PCWP, dec pump function, inc svr, dec svo2
- revascularization, LV assist devices
what is distributive shock, causes, vitals, treatment options
pronounced vasodilation, intravascular volume dep
- septic shock #1 cause
- dec PCWP, variable pump function, dec svr, variable svo2
what is obstructive shock, causes, vitals, treatment options
critical dec in LV stroke volume or inc LV outflow obstruction
- causes: PE, severe pulmonary hypertension, tension pneumpthorax, pericardial tamponade
-inc PCWP, dec pump function, inc svr, dec svo2
- thrombolytics, needle decompression, needle drain
fluid management in shock
crystalloids 30ml/kg over 15-30, then followed by 10ml/kg boluses
- specifically cardiogenic shock 100-200 ml boluses
central line for fastest delivery
when, how to give vasopressors in shock. different receptors
- start when MAP <65 despite fluids
- arterial lines
- beta1 inc CO
- alpha1 inc CO, contractility, inotropy
vasopressor options
NE (1st line) a1
dobutamine b1
epi - anaphylactic shock, inc lactate
dopamine - hypotensive pts w/ dec cardiac function. AE- tachycardia, arrhythmogensis
angiotensin II role in shock
- used in septic and distributive shock
- ae: risk of thromboembolism
precipitating factors for DKA & HHS
- infection
- initial pres of Diabetes
- insufficient insulin therapy
- pancreatitis
- acute CV events
- meds: glucose, atypicals pyschs, BB, thiazides, stimulants
clinical pres dka vs hhs
DKA: kussmaul breathing, acetone breathe, hours to days
HHS: days to weeks
1 cause of DKA and HHS
insulin deficiency
labs DKA vs HHS
DKA: bg>250, ph<7.3, urine ketones, anion gap 12 and up, +/- AMS
HHS: bg>600, osm>320, AMS
How to cal anion gap
na - (cl + hco3)
how to calc sodium correction
add 1.6 meq for every 100 mg over 100mg/dl to measured serum na
how to calc serum osm
2(na) + (glu/18) + (bun/2.5)
goals of treatment for DKA and HHS
- hydrate
- correct hyperglycemia + ketosis
- correct electrolyte imbalance
hydration in DKA and HHS
- iv fluids 500-1000ml/hr of norm saline or lactated ringers
- potassium
- bicarb 100 meq in 400ml of sterile water w/ 20meq KCl @200 ml/hr over several hrs (risk of hypokalemia + cerebral edema)
when to give or hold potassium
Goal K 4-5 meq
- if K<3.3 hold insulin, give 10-20 meq until K>3.3
- if K 3.3-5.2 give 20-30 meq in each liter of fluid
- if K>5.2 do not give K
Check q2hrs
how to transition to subq insulin
- new regimen : 0.4-0.5 units/kg/day. 40-50% of TDD as basal, the rest prandial
- continue IV in sulin for 2 hrs after basal insulin is admin
- assume home regimen when appropriate, avoid hyperglycemia
euglycemic DKA risk factors
- risk: fasting, surgery, pregnancy and SGLT2i (ozempic)
euglycemic DKA labs
norm BG (<250), acidosis (ph<7.3) dec serum bicarb (<18), ketons
euglycemic DKA treatements
- insulin to correct acidosis + anion gap
- dextrose
- fluids
end points of DKA
BG< 200 with 1 of the following
- serum bicard >=15
- ph >7.3
- anion gap <= 12
end points of HHS
osm <320
recovery to mental alterness
