Supp Care, Pain/Agitation/Delirium, Shock

FASTHUG acronym →

1. feeding

2. analgesia

3. sedation

4. thromboembolism prophylaxis

5. head of bed elevation

6. stress (ulcer prophylaxis)

7. glucose control

STRESS-RELATED MUCOSAL DISEASE Clinical Presentation

1. Occult

2. Overt

3. Clinically significant

1. no visible blood loss, +fecal blood test, iron def anemia

2. frank hemorrhage

3. HD changes, transfusion required

STRESS ULCER PROPHYLAXIS

Independent risk factors

1. →

2. Coagulopathy →

1. mech vent >48h

2. plt count <50k, INR >1.5, PTT >2x normal

What acid suppressants are used for stress ulcer prophylaxis in the ICU?

H2RAs, PPIs

GOALS OF THERAPY

1. Target pH for prevention of SRMD (stress-related mucosal disease)

2. Target pH for prevention of peptic ulcers

1. 4

2. 6

H2RAs may be associated with _________ but _________ compared to PPIs

+risk GI bleeding, -incidence of infectious complications

H2RA WARNING/PRECAUTIONS

1. →

2. →

3. →

4. →

1. DDIs (CYP450)

2. tachyphylaxis

3. CNS ADEs

4. TC

PPI WARNING/PRECAUTIONS

1. →

2. →

3. →

4. →

1. +risk pneumonia and C diff

2. DDIs

3. osteo-related bone fractures

4. hypoMg

VIRCHOW’S TRIAD (contributors to thrombosis)

1. Hypercoagulability → 5

2. Vascular injury → 4

3. Venous stasis → 3

1. hx VTE, malignancy, obesity, preg, estrogen

2. trauma, recent surg, IV catheter, atherosclerosis

3. immobilization, AFib, obstruction

NONPHARM VTE PROPHYLAXIS → 2

1. compression stockings

2. intermittent pneumatic compression

UNFRACTIONATED HEPARIN

1. Potentiates the action of _________ to inactivate thrombin & prevent conversion of fibrinogen → fibrin

2. Dosing:

3. Monitoring: 3

1. antithrombin III

2. <50 kg = 5000U SQ q12h, >100kg = 7500U SQ q8h

3. Hgb/Hct, plt, aPTT

LOW MOLECULAR WEIGHT HEPARIN

Enoxaparin (Lovenox)

1. Potentiates the action of _________ to inactivate thrombin & prevent conversion of fibrinogen to fibrin; stronger inhibition of ______ than thrombin

2. Dosing:

3. NOT approved for use in _______

4. Monitoring → 4

1. antithrombin III, Factor Xa

2. 40 mg SQ daily; CrCL <30 use 30 mg SQ

3. hemodialysis

4. Hgb/Hct, plt, peak anti-Xa, renal fx

FONDAPARINUX

1. _______

2. Dosing

3. Contraindications → 2

4. NOT recommended for critically ill patients → why? (3)

5. Monitoring → 3

1. Factor Xa inhib

2. 2.5 mg SQ once daily, CrCL 30-50 reduce dose by 50%

3. <50 kg, CrCL<30

4. high renal CL, long t1/2, no reversal agent

5. Hgb/Hct, plt, renal fx

__________ may be as effective as pharmacologic stress ulcer prophylaxis with fewer infectious complications

enteral feeding

Gold standard of assessing pain =

Self report

________ are NOT valid indicators of pain

vital signs

Behavioral Pain Scale (BPS)

A score _____ indicates significant pain

>5

Critical Care Pain Observation Tool (CPOT)

A score _____ indicates significant pain

>2

TREATMENT OF PAIN IN THE ICU

1. *Mainstay:

2. _________ as adjunct to -pain and opioid use

3. _________ as adjunct to -opioid use in postsurgical patients

4. _________ for neuropathic pain

5. Preemptive analgesia prior to painful procedures → 2

1. opioids

2. APAP

3. low dose ketamine

4. gabapentin, carbamazepine, pregabalin

5. opioids (lowest effective dose), NSAIDs

TREATMENT OF PAIN IN THE ICU → ______ ARE NOT ROUTINELY RECOMMENDED

NSAIDs

IV OPIOIDS

Onset → metabolism

1. Fentanyl

2. Morphine

3. Hydromorphone

4. Remifentanil

1. 1-2min → hepatic

2. 5-10min → glucuron; accumulates in renal fail

3. 5-15min → glucuron

4. 1-3min → hydrolysis by esterases

OTHER OPIOIDS

1. _________ → not routinely recommended, neurologic toxicity

2. _________ → LONG half life, DDIs, +QTc

1. meperidine

2. methadone

OPIOIDS ADES

1. _______

2. GI intolerance →

3. _______ → most common w morphine

4. _______

5. _______

1. resp depress

2. constipation → prophylactic stimulant + stool softener

3. HD instability

4. altered mental status

5. withdrawal

BB is a 75-year-old male admitted to the ICU after a motor vehicle crash in which he sustained multiple rib fractures. His PMH is significant for HTN and CKD. After intubation, he is agitated and grimacing. Which initial treatment is most appropriate?

a. Fentanyl

b. Midazolam

c. Morphine

d. Propofol

A

SEDATION CHOICE OF AGENT → 2 recommended over benzos

propofol, dexmedetomidine

TARGETING “LIGHT” SEDATION

Patients should receive sedation only if required

1. Assess sedation status and goals ________

2. ______ to allow responsiveness and awareness

3. Spontaneous awakening trial ________

1. atleast daily

2. titrate

3. daily

BENZODIAZEPINES

1. Indications → 3

2. Lorazepam →

3. Midazolam →

1. status epilepticus, alc/benzo withdrawal, DEEP sedation and/or neuromusc blockade

2. intermed acting, hepatic glucuron, DC if osmolar gap 10+ (propylene glycol diluent toxicity)

3. short acting, CYP3A4, caution renal/hepatic dysfx

PROPOFOL 1% (10 mg/mL)

1. MOA

2. Effects

3. PK/PD

4. Dosing

5. ADEs → 5

1. GABA-A agonist, NMDA antag

2. sedative, anesthetic, anti convuls at higher doses

3. lipophilic, large Vd

4. 5-50 mcg/kg/min

5. hypotension, bradycardia, resp depress, hyperTG, pancreatitis

PROPOFOL RELATED INFUSION SYNDROME (PRIS)

1. Over ____ mortality

2. Mechanism of injury: disruption of __________ production

3. Clinical effects → 5

4. Monitoring → 6

5. INCREASED risk with doses ____ mcg/kg/min and duration _____

1. 50%

2. mitochondrial energy

3. bradycardia, lactic acidosis, renal/liver fail, rhabdo, hyperTG

4. CK, lactate, TG, LFTs, SCr, lipase

5. >50, >48h

DEXMEDETOMIDINE

1. MOA

2. Effects

3. Dosing

4. ADEs → 2

1. central alpha agonist

2. sedative, analgesic, anxiolytic

3. 0.2-0.7 (max 1.5) mcg/kg/h

4. hypotension, bradycardia

Which does NOT affect respiratory drive?

A. propofol

B. dexmedetomidine

B

MEDICATION-ASSOCIATED DELIRIUM → 6

1. benzos

2. opioids

3. antichol (diphenhydramine, metoclopramide, tricyclics)

4. anticonvuls

5. steroids

6. DA agonists (ropinirole, pramipexole)

NON-PHARM THERAPY FOR DELIRIUM

1. Reduce modifiable _____

2. Optimize ______

3. Increase ______

4. Optimize _______ and ________

5. Frequent ________

1. risk factors

2. sleep

3. mobility

4. hearing, vision

5. reorientation

DELIRIUM ICU TX

1. Prevention:

2. Consider _______ or ________ in patients with significant distress or agitation leading to physical harm

3. _______ suggested in mechanically ventilated adults where agitation is precluding weaning/extubation

1. not rec

2. haloperidol, atypical antipsychotics (SGAs)

3. dexmedetomidine

ANTIPSYCHOTICS

1. 1st generation: haloperidol dosing → ADEs

2. 2nd generation: agents → ADEs

1. 1-2 mg q 4-6h PRN → sedation, EPS, +QTc

2. quetiapine, olanzapine, risperidone, ziprasidone → low and slow → sedation, +QTc, NMS

ANTIPSYCHOTIC PLAN

1. Consider low starting dose, especially in the _____

2. Normalize ______ and monitor _____

3. Monitor daily for ADEs (especially _______)

4. Ideally, ____________; otherwise clearly communicate plan to floor team or outpatient provider

1. elderly

2. ELs, QTc

3. sedation

4. taper off before ICU discharge

MARKERS OF ORGAN DYSFUNCTION

Brain

altered mental status

MARKERS OF ORGAN DYSFUNCTION

Lungs

1. mech vent

2. hypoxemia (PaO2/FiO2<200-250)

MARKERS OF ORGAN DYSFUNCTION

Heart

1. SBP<90

2. MAP<65

MARKERS OF ORGAN DYSFUNCTION

Liver

1. Tbili <2

2. Plt <100k

3. INR >1.5, aPTT >60s

MARKERS OF ORGAN DYSFUNCTION

Kidneys

1. acute oliguria

2. +Cr

MARKERS OF ORGAN DYSFUNCTION

Gut

1. ileus (absent bowel sounds)

2. abd pain

MARKERS OF ORGAN DYSFUNCTION

Skin

1. mottled

2. dusky

MARKERS OF ORGAN DYSFUNCTION

Lactate _____ mmol/L

>2

TYPES OF SHOCK → 4

1. hypovolemic

2. cardiogenic

3. obstructive

4. distributive

What type of shock does CM most likely have?

a. Cardiogenic

b. Distributive

c. Hypovolemic

d. Obstructive

C

PHASES OF SHOCK TREATMENT → 4

1. Salvage → min acceptable BP, MAP >65

2. Optimization → O2, cardiac output, tissue perfusion

3. Stabilization → organ supp, minimize complications

4. De-escalation → wean vasoactive agents, achieve -fluid balance

SEPSIS

1. Sepsis criteria

2. SIRS criteria → 4

1. infxn (suspected or documented) + >/=2 SIRS criteria

2. temp >38C or <36C, HR>90, RR>20 or PaCO2<32, WBC>12×10^9

Yes

(T 39.9C, HR 121, RR 30 = ¾ SIRS

suspected infxn = green sputum)

SEVERE SEPSIS = sepsis + _______

organ dysfx

yes
(+SCr, lactate>2, MAP 64)

SEPTIC SHOCK =

sev sepsis + hypotension

SEPSIS ANTIMICROBIAL THERAPY INITIATION

1. Stat =

2. Initiate antimicrobial therapy within ______

3. _____________ as rapidly as possible

1. obtain cultures

2. 1h

3. obtain source control

EMPIRIC ANTIMICROBIAL THERAPY 4 important factors →

1. right agent

2. right dose

3. right site

4. right time

SEPSIS IV FLUID RESUSCITATION

1. ________ IVF to be given within the first _____

2. Type =

3. Goals =

1. 30 mL/kg, 3h

2. balanced crystalloids (LR, plasmalyte)

3. MAP 65+, lactate <1 (in elevated lactate)

Which is the most appropriate fluid to administer to DS? (weight = 70 kg)

a. 1000 mL Albumin

b. 1000 mL Lactated Ringer’s

c. 2000 mL Normal saline

d. 2000 mL Plasmalyte

D

1. When to initiate vasopressors?

2. When to initiate inotropes?

1. fluid resus fails

2. myocardial dysfx, ongoing signs of hypoperfusion

Adrenergic receptors

1. alpha 1

2. beta 1

3. beta 2

1. +SVR

2. +SV and CO

3. opposes a1

VASOPRESSOR MOA

1. Epinephrine

2. Norepinephrine

3. Phenylephrine

4. Dopamine

5. Vasopressin (2nd line)

6. Dobutamine

1. ALL

2. a1 + a2 > b1

3. a1**

4. a1 + b1 + b2

5. peripheral V1

6. b1 + b2 > alpha

DOPAMINE DOSING EFFECTS

1. _____ mcg/kg/min = renal artery vasodilation

2. _____ mcg/kg/min = cardiac + vasoconstriction =

3. _____ mcg/kg/min = cardiac + marked vasoconstriction =

1. <2.5

2. 2.5-10 = b1 + b2

3. >10 = a1

ADRENERGIC RECEPTORS ADES

1. a1, V1 →

2. b1 →

3. b2 →

1. tissue ischemia, AKI

2. tachycardia/arrhythmias, +myocardial O2 demand, impairs insulin sens (hyperglycemia)

3. impairs insulin sens, +serum lactate

WHICH VASOPRESSOR FOR SEPSIS?

1. Vasopressor therapy should initially target a MAP of ____ mmHg

2. 1st line vasopressor =

3. ______ or _____ may be added if additional agent is needed

4. May use ________________ with persistent hypoperfusion despite adequate fluids & MAP

1. 65

2. NE

3. EP, vasopressin

4. dobutamine + NE or EP alone

THERAPEUTIC GOALS & MONITORING

1. BP/MAP

2. Urine output

3. Lactate

1. MAP >65

2. 0.5 mL/kg/h

3. -20% in 2h period

After receiving 2L of Plasmalyte, DS’s blood pressure is 94/48 (MAP: 56 mm Hg). What vasoactive agent is most appropriate to start to increase her blood pressure?

a. Dobutamine

b. Dopamine

c. Epinephrine

d. Norepinephrine

D

CORTICOSTEROIDS

1. Who should receive steroids? patients with shock in which ______ and ______ do not restore HD stability

2. How should it be given?

3. Taper when …

1. fluid resus, vasopressors

2. IV 200 mg/day

3. vasopressors no longer req