Introduction to Critical Care Medicine – Key Concepts

These flashcards cover the pharmacist’s role, ICU scoring systems, stress-ulcer and glycemic management, traumatic brain injury interventions, pharmacokinetic alterations, and ventilator-associated pneumonia prevention, reflecting the breadth of the lecture material.

What are the primary responsibilities of a critical care pharmacist?

Ensure safe and effective medication use through patient review, participation in rounds, order verification, protocol development, consultation, and response to emergencies.

List three patient outcomes shown to improve with critical care pharmacist involvement.

Reduced medication errors, shorter time to antibiotic delivery, and fewer ventilator-associated pneumonias (VAP).

Name the bedside checklist represented by the acronym FASTHUG.

Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Hypo/Hyper-active delirium, Ulcer prophylaxis, Glucose control.

What does the MAIDENS extension of FASTHUG add?

Medication reconciliation, Anti-infectives, Indication, Dose, Electrolytes/Labs, No duplication/Interactions/ADR, Stop dates.

Give four different types of Intensive Care Units (ICUs).

Medical, Surgical, Trauma, Neuro (others include Burn, Cardio, Cardiothoracic, Pediatric, Neonatal).

Why are acuity scoring systems used in critical care?

To predict outcomes and mortality, compare quality of care, and stratify patients for clinical trials.

When should APACHE II or SAPS II be applied?

Within the first 24 hours of ICU admission to estimate disease severity and mortality risk in adult general ICU patients.

Which scoring tool assesses progressive organ failure over time rather than an admission snapshot?

The Sequential Organ Failure Assessment (SOFA) score.

What Glasgow Coma Score (GCS) range indicates severe brain injury?

A GCS of 8 or less.

List two disease-specific scoring systems mentioned in the lecture.

CHA2DS2-VASc and RIFLE criteria (others include MELD, NIH Stroke Scale, qSOFA, etc.).

According to 2024 SCCM guidelines, name one absolute risk factor that warrants stress-ulcer prophylaxis (SUP).

Coagulopathy defined as platelets < 50,000 / µL or INR > 1.5.

Which two drug classes are routinely used for stress-ulcer prophylaxis?

H2 receptor antagonists (H2RAs) and proton-pump inhibitors (PPIs).

State one potential harm associated with acid-suppressive therapy in the ICU.

Increased risk of Clostridioides difficile infection or nosocomial pneumonia.

What advantage do H2RAs have over PPIs for SUP?

Longer safety record with intravenous formulations and lower cost; less association with C. difficile than PPIs.

Give one disadvantage of cimetidine compared with other H2RAs.

More CYP-450 drug interactions and higher rate of CNS side-effects.

Which 2018 New England Journal study showed a 1.7 % absolute risk reduction in clinically important GI bleeding with pantoprazole?

Krag et al., "Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU."

What serum glucose level triggers initiation of glycemic management protocols per 2024 SCCM guidelines?

Persistent blood glucose ≥ 180 mg/dL (10 mmol/L).

What is the recommended target glucose range for most critically ill adults?

140–200 mg/dL; avoid titrating below 140 mg/dL to minimize hypoglycemia risk.

Why is IV insulin preferred over subcutaneous insulin in the acute ICU setting?

It is rapidly titratable, potent, and has no absorption variability in critically ill patients.

Describe the Yale Insulin Infusion Protocol’s initial infusion rate calculation.

Divide the initial BG by 100; the quotient (rounded to nearest 0.5 U) is given as both IV bolus and starting infusion rate in units/hour.

When transitioning from IV to subcutaneous insulin, how is the total daily dose (TDD) estimated?

Average IV insulin rate (units/hr) over the past 6 h × 24, then × 0.75.

What percentage of the calculated TDD should be given as basal insulin during transition?

50 % as basal, 50 % divided as nutritional bolus doses.

Define Level 2 hypoglycemia in the ICU.

Blood glucose < 54 mg/dL.

List three common contributors to ICU hyperglycemia besides diabetes.

Stress response, vasopressors, and corticosteroid therapy (others: TPN, enteral feeds, critical illness).

State the systolic blood pressure goals for adult TBI patients aged 18–49 according to Brain Trauma Foundation.

Maintain SBP > 110 mm Hg.

Name two clinical or radiographic signs that warrant hyperosmolar therapy for intracranial pressure (ICP).

ICP > 22 mm Hg on monitor or evidence of midline shift / impending herniation on CT.

How does mannitol lower ICP?

Creates an osmotic gradient pulling water from brain tissue to the intravascular space and reduces blood viscosity, causing cerebral vasoconstriction.

Give the typical bolus dose range of mannitol in traumatic brain injury.

0.5–1.5 g/kg of 20 % mannitol IV over 20–30 min.

What is the recommended monitoring parameter to avoid mannitol-induced renal toxicity?

Keep serum osmolar gap < 20 mOsm/L and serum osmolality < 320 mOsm/L.

List one situation in which hypertonic saline (HTS) is preferred over mannitol.

Hypotensive or hypovolemic TBI patient because HTS does not cause diuresis and hypotension.

What serum sodium target is used when infusing 3 % hypertonic saline for ICP control?

Maintain serum Na⁺ 145–155 mEq/L.

Why must 23.4 % sodium chloride be given via a central line?

High osmolarity can cause severe tissue injury if extravasation occurs.

For seizure prophylaxis after moderate-severe TBI, which medication is preferred and for how long?

Levetiracetam for 7 days, longer if EEG abnormalities or seizures occur.

State two major pharmacokinetic changes in critically ill patients that increase drug volume of distribution.

Capillary leak/edema (third spacing) and decreased plasma protein (albumin) binding.

Give one bedside implication of altered distribution for hydrophilic antibiotics.

Higher loading doses or therapeutic drug monitoring may be required to achieve target concentrations.

Define Augmented Renal Clearance (ARC).

Creatinine clearance > 130 mL/min often seen in young trauma or burn patients, leading to faster drug elimination.

How should drug dosing references be used for ICU patients?

Prioritize primary literature and institution-specific protocols over standard package inserts due to altered PK/PD.

Provide three key elements in VAP surveillance that suggest infection.

Rising ventilator settings (higher PEEP/FiO₂), new leukocytosis or leukopenia, and purulent secretions with positive culture after ≥4 days of mechanical ventilation.

Name two evidence-based strategies to prevent VAP in adults.

Daily sedation interruption with spontaneous breathing trials and elevating the head of bed 30–45 degrees.

Which common ICU intervention is NOT recommended solely for VAP prevention?

Routine stress-ulcer prophylaxis in all patients (may increase VAP risk).