Critical Care RW Exam 3

How is a fishbone diagram read?

Top: Na -> Cl -> Bun

Bottom: K -> HCO3 -> SrCr

Far right: Glucose

How is IBW calculated?

Males 50 kg + (2.3 kg/in x [ht in inches - 60])

Females 45.5 kg + (2.3 kg/in x [ht in inches - 60])

How is CrCl calculated?

Males [(140 - age) x IBW] / (72 x serum creatinine)

Females [(140 - age) x IBW] / (72 x serum creatinine) x 0.85

Should pain or agitation be treated first?

Pain should always be treated first with analgesia

If agitation is still occuring can then treat that with sedatives

Practice of analgosedation (analgesia-first sedation)

Which opioids are the cornerstone of treatment for pain for patients in the ICU?

Fentanyl, Morphine, and Hydromorphone

Which opioid is used most commonly, and is preferred, in the ICU setting?

Fentanyl

If a patient has renal failure, what medications should be used for pain management?

Fentanyl preferred

Avoid morphine due to metabolites (C/I in renal failure)

If a patient is hemodynamically unstable, what medications should be used for pain management?

Fentanyl preferred

(very well tolerated, minimal effect on BP)

If a patient claims a morphine allergy, how should their pain be managed?

Clarify allergy - morphine can cause allergy like symptoms even without a true allergy

If true morphine allergy - may use Hydromorphone

What PK properties are desired for pain management medications in the ICU?

Rapid onset and offset preferred

Titratable

What therapies should be used as adjuncts to opioid therapy?

Bowel regimen scheduled (stimulant laxatives needed)

Naloxone prn

Antiemetics prn

What agents can be used as part of multimodal pain management therapy?

NSAIDs

APAP

Gabapentin/Pregabalin

Ketamine

When are NSAIDs used for pain management?

Mild pain

How are NSAIDs administered for pain management?

IV or PO

Ketorolac for max of 5 days

When is APAP used for pain management?

Mild pain, and antipyretic

How is APAP administered for pain management?

IV, PO, or rectal (PR)

When are Gabapentin/Pregabalin used for pain management?

Neuropathic pain

How is ketamine used for pain management?

Low doses (1-2 mcg/kg/hr) post-surgical

For opioid sparing

Do sedatives have analgesic properties?

Sedatives have NO analgesic properties

(Except dexmedetomidine - but effect is still minimal)

Need to address analgesia before using sedatives

What are strategies to improve outcomes for patients on sedatives?

Daily interruption of sedation

RASS -2 to +1 is general goal

Balance minimal sedation and patient comfort

Continually assess need for sedation

Utilize non-pharmacologic therapy

What is the Richmond Agitation Sedation Scale (RASS)?

Sedation assessment

General goal is -2 to +1, ideally pt. would be at 0

Positive numbers = less sedated (combative/agitated)

Negative numbers = more sedated (unarousable)

0 = alert and calm, spontaneously pays attention to caregiver

What are agents used for sedation in the ICU?

Benzodiazepines (Lorazepam)

Propofol

Dexmedetomidine

Which sedatives maintain light sedation, to minimize delirium?

Propofol or Dexmedetomidine

(non-benzodiazepines)

What are risks of using sedation?

Harm from oversedation

Delirium

Prolonged sedation without break worsens outcomes

Harm to self (pulling lines, tachycardia, etc) - if under-sedated

Adverse drug reaction

What are the benefits of using benzodiazepines (Lorazepam) for sedation?

Inexpensive, long history of use

May be useful if risk of alcohol withdrawal or seizures

What are the risks of using benzodiazepines (Lorazepam) for sedation?

Accumulation/prolonged sedation & liver dysfunction may limit use

May cause prolonged dependence on mechanical ventilation, increased risk of delirium, and increased ICU stay

What are the PK's of Lorazepam?

Onset: 15-20 mins if IV, 20-30 mins if PO

Dur: about 6-8 hours if IV/IM

How should benzodiazepines (Lorazepam) be administered for sedation?

Intermittent dosing preferred (over continuous infusion)

When are benzodiazepines (Lorazepam) used for sedation?

Often last line

Unless pt has alcohol withdrawal or specific indication for benzo's (ex. seizures)

What are the PK's of Propofol?

Rapid onset and short duration—ease of use

Onset: 9-51 secs

Duration: 3-10 mins

In what situations is propofol beneficial?

Beneficial for head injury or elevated intracranial pressures

(decreases intracranial pressure, and rapid offset for exams)

What is a concern with Propofol formulation?

Formulated in a lipid emulsion

May increase triglycerides or induce pancreatitis

Account for lipid in total nutrition for patient (1.1kCal/mL)

Not for use in egg- or soy- intolerant patients

What are ADRs of Propofol?

Hypotension

Hypertriglyceridemia

Infection

Propofol-related Infusion Syndrome (PRIS)

What is Propofol-related Infusion Syndrome (PRIS)?

Rare ADR of Propofol, with high mortality

Causes dysrhythmia, heart failure, metabolic acidosis, renal failure

When is Propofol used for sedation?

Often 2nd line (after Dexmedetomidine)

Beneficial for head injury or elevated intracranial pressures

What are advantages of using Dexmedetomidine for sedation?

May be useful in delirium or for extubation

(least risk of delirium, and no resp. depression)

Lighter level of sedation (dec. risk of delirium)

What are disadvantages of using Dexmedetomidine for sedation?

HYPOTENSION or hypertension (esp. if using bolus dose)

May require adjunct benzodiazepines (not being adequately sedated)

Most expensive

What are the PK's of Dexmedetomidine?

Onset: 5-10 min

Duration: 1-2 hours

When is Dexmedetomidine used for sedation?

First-line agent (due to lowest risk of delirium)

Useful in pt.'s w/ delirium or for extubation

Approved for short-term (≤24 hours) use, but used longer in practice

What must be done before starting therapeutic paralysis

MUST adequately treat with sedatives and analgesics first

Sensory neurons NOT affected

Pt. can still hear, smell, feel (pain), etc.; but cannot EXPRESS self

When is therapeutics paralysis used?

Acute respiratory distress syndrome (ARDS)

REFRACTORY agitation/ combativeness

"fighting the vent"

Increased intracranial pressure

Therapeutic hypothermia

What are agents used for therapeutic paralysis?

Non-depolarizing agents: Cisatracurium, Pancuronium, Atracurium

How long should therapeutic paralysis be used for?

Use for shortest duration possible

(due to risk of complications)

What are possible complications of therapeutic paralysis?

Corneal ulcers

Prolonged weakness/atrophy

Pneumonia

Deep vein thrombosis (DVT)

What are non-modifiable risk factors for VTE?

Factor V Leiden or hematological disorders

Age >40 years

Familial history of thrombosis

Oncological disorders

Male sex

What are modifiable risk factors for VTE?

Immobility

Medications

Obesity

Transfusion related

Surgery or trauma

Is pharmacological or non-pharmacologic therapy preffered for VTE prophylaxis?

Pharmacologic has superior efficacy

Only use non-pharm when it is C/I

What are contraindications to VTE prophylaxis?

Thrombocytopenia (

What are pharmacologic options for VTE prophylaxis?

Unfractionated heparin

Enoxaparin

Fondaparinux

What are advantages of UFH for VTE prophylaxis?

May be used in renal failure

What are disadvantages of UFH for VTE prophylaxis?

Multiple daily doses

Risk of HIT

How is UFH dosed for VTE prevention?

5000 units SubQ 2-3x/day

What are advantages of Enoxaparin for VTE prophylaxis?

Single daily dose

Less risk of HIT than UFH (still some risk)

What are disadvantages of Enoxaparin for VTE prophylaxis?

Adjust/monitor in renal dysfunction

How is Enoxaparin dosed for VTE prevention?

40mg SubQ daily

If CrCl 30-15 : 30mg Sub-Q daily

At what CrCl is Enoxaparin dose decreased?

CrCl

At what CrCl is Enoxaparin contraindicated?

CrCl < 15 mL/min

What are advantages of Fondaparinux for VTE prophylaxis?

Single daily dose

No HIT (but STILL thrombocytopenia risk)

What are disadvantages of Fondaparinux for VTE prophylaxis?

Significant adjustment for renal dysfunction

How is Fondaparinux dosed for VTE prevention?

2.5mg SubQ daily

At what CrCl is Fondaparinux contraindicated?

C/I

What are options for non-pharm VTE prophylaxis?

Sequential Compression Devices (SCDs)

What are signs/symptoms of Stress-Related Mucosal Disease (SRMD)/ Stress ulcers?

Vomiting blood (hematemesis)

Blood in stool (occult blood or frank melena)

Decrease in hemoglobin ≥2 grams or require transfusion

Decrease in SBP >20mmHg

HR increase >20 bpm

What are risk factors for stress ulcers (indications for prophylaxis)?

Most ICU patients, rarely acute care

Coagulopathy

Shock

Chronic liver disease

Neurocritical care

What agents are used for stress ulcer prophylaxis?

PPI (preferred) or H2RA

Also utilize enteral nutrition

What are risks of H2RA use?

CrCl (use caution and lowest dosse)

Confusion

Thrombocytopenia

What are risks of PPI use?

Risk of Clostridium difficile infection may be enhanced

When should stress ulcer prophylaxis be stopped?

Stop as soon as risk decreases

What is CAM-ICU?

Tool to identify patients with delirium,

Assess every shift, or at least daily

What are risk factors for ICU delirium?

Greater age

Dementia, prior coma

Emergency surgery/trauma

Higher Acute Physiology and Chronic Health Evaluation (APACHE) score

Benzodiazepines

Blood transfusion

How should ICU delirium be prevented?

Limit risks

Nonpharmacologic: reorientation, sleep hygiene, early mobilization, light sedation

How should ICU delirium be managed?

No medicine proven to treat

Medications may help manage symptoms

(Atypical antipsychotics, Haloperidol, Dexmedetomidine when agitation is preventing extubation; Minimize duration, Maximize safety)

What are the 4 types of shock?

Cardiogenic

Hypovolemic

Septic and Anaphylactic (Distributive shock)

What are common causes of cardiogenic shock?

Massive MI

Severe CHF

What is the major hemodynamic problem in cardiogenic shock?

Low contractility

What is the effect of cardiogenic shock on hemodynamic variables (preload, contractility, afterload)?

Preload: High

Contractility: Low

Afterload: Normal/High

Heart contractility problem (not able to pump enough)

Leads to "backup" of fluid, increasing perload (not moving fluid through fast enough)

What are common causes of hypovolemic shock?

Blood loss

Dehydration

What is the major hemodynamic problem in hypovolemic shock?

Low preload

What is the effect of hypovolemic shock on hemodynamic variables (preload, contractility, afterload)?

Preload: Low

Contractility: Low/Normal

Afterload: High

Not enough volume due to loss - causes low preload

Not enough volume - causes low contractility

Arteries constrict to make up for lack of volume - causes high afterload

What are common causes of septic (distributive) shock?

Blood infection

What is the major hemodynamic problem in septic (distributive) shock?

Low afterload

What is the effect of septic (distributive) shock on hemodynamic variables (preload, contractility, afterload)?

Preload: Low/Normal

Contractility: High

Afterload: Low

Heart works harder to compensate for low afterload - causes high contractility

What are common causes of anaphylactic (distributive) shock?

Type I allergic rxn.

What is the major hemodynamic problem in anaphylactic (distributive) shock?

Low afterload

What is the effect of anaphylactic (distributive) shock on hemodynamic variables (preload, contractility, afterload)?

Preload: Normal

Contractility: High

Afterload: Low

Heart works harder to compensate for low afterload - causes high contractility

How is high preload treated?

Diuretics and NTG

Inotropes

How is low preload (Hypovolemic shock) treated?

FLUIDS

How is low contractility (cardiogenic shock) treated?

Inotropes

How is high afterload treated?

Anti-hypertensive

How is low afterload (septic/anaphylactic shock) treated?

Fluids

Pressors

What is sepsis defined as?

Response to infection

Life-threatening organ dysfunction caused by dysregulated host response

What is septic shock defined as?

Sepsis with hypotension unresponsive to fluids

What is Systemic Inflammatory Response Syndrome (SIRS)?

2 of following 4:

-Temp

-HR >90 BPM

-Resp >20 per min

-WBC >12,000/mm3 or

What are monitoring parameters for sepsis?

Mean Arterial Pressure (MAP)

Urine output

What is the goal MAP?

≥ 65

What is the goal urine output?

>0.5 mL/kg/hour

How is urine output calculated?

Output = amount of output / weight / time for output

What are the steps for management of sepsis?

1.Prompt recognition of the septic patient and early implementation of therapies

2.Fluid therapy, using crystalloids initially

3.Early administration of broad-spectrum antibiotics

4.Vasopressor therapy to maintain MAP of 65 mmHg

5.Hydrocortisone if still hemodynamically unstable

6.Glycemic control to goal of 140-180 mg/dL

7.Adjunctive therapy (nutrition, DVT ppx, SRMD ppx, and sedation for mechanically ventilated patients)

What are the first treatments used in sepsis?

Fluid therapy, using crystalloids initially (within 1 hr)

Early administration of broad-spectrum antibiotics (within 1 hr)

In sepsis, if fluid therapy does not adequately maintain MAP≥65 what therapy should be added?

Vasopressor therapy