Critical Care HL Exam 3

Which opioids are used for treatment of pain in the ICU?

fentanyl, morphine, hydromorphone

Which of the following is used most often in the ICU?

A. Fentanyl

B. Morphine

C. Hydromorphone

A. Fentanyl

What are common ADRs of opioids?

Oversedation

Respiratory depression delirium

Hypotension

Decreased GI motility

What are concurrent medication options for treatment of pain in the ICU?

Acetaminophen

NSAIDs

Lidocaine

Ketamine

What are concurrent medication options for treatment of NEUROPATHIC pain in the ICU?

gabapentin and pregabalin

What are non-pharm options for pain?

music

pet

massage

temp control

relaxation techniques

What meds are used for anxiety and agitation?

benzos, propofol, dexmedetomidine

these are only used if not relieved by analgosedation for mechanically ventilated patients

What do the PADIS guidelines recommend for anti anxiety or anti agitation?

propofol or dexmedetomidine

nonbenzos to maintain a light goal of sedation and to minimize delirium

What is the onset of lorazepam via IV?

10 min

What is the onset of lorazepam via IM?

20-30 min

What is the onset of lorazepam via PO?

20-30 min

What are ADRs of lorazepam?

Anterograde amnesia

CNS effects

Neurodevelopmental (kids)

Paradoxical rxns

Propylene glycol toxicity

Withdrawal syndromes

Pain at injection site

What are clinical pearls of lorazepam?

Intermittent dosing >>> continuous infusion

Long term sedation

C/I in patients with alcohol withdrawal or risk of seizures

What is the onset of propofol bolus?

9-51 sec (averages 30 sec)

What is the duration of lorazepam?

6-8 hours

What is the duration of propofol?

3-10 min

What are ADRs of propofol?

Pain at injection site

Hypertriglyceridemia

Pancreatitis

Propofol-related infusion syndrome (PRIS)

Hypotension

Hypersensitivity (soy, egg, peanut allergies)

CV (MI, afib, etc)

What are clinical pearls of propofol?

Patient needs to be awakened rapidly for neurological evaluation

Good option for head injury with elevated intracranial pressures

Causes light sedation

What is the onset of dexmedetomidine (precedex) via IV loading dose?

5-10 min

What is the onset of dexmedetomidine (precedex) via instranasal?

10-20 min

What is the duration of dexmedetomidine (precedex)?

1-2 hours (60-240 min)

What are ADRs of precedex?

CV (hypotension, bradycardia, HTN)

Tolerance

Tachyphlaxis

Withdrawal

Constipation

NA

Agitation

Drowsiness

What are clinical pearls of precedex?

Only drug approved for sedation of non-intubated ICU patients you can extubate and continue giving this medication it does not cause respiratory depression

May require an adjunct benzo

Used for light sedation (

What are FDA approved treatments for delirium?

none, but there are ppx options

What are management strategies for delirium ppx?

Reducing benzodiazepine utilization

Patient reorientation

Improving sleep hygiene

Early mobilization

Lighter sedation strategies

What are 2 things that can be done to improve sleep for patients in the ICU?

minimize noise and light disturbances

What is the blood glucose target for patients in the ICU?

IF 2+ consecutive BG readings above 180mg/dL

→ initiate insulin continuous infusion

→ check glucose Q1-2H to reach goal < 180mg/dL

What patients are at risk for clinically upper gastrointestinal bleeding (UGIB)?

Critically ill adults with... *Coagulapathy, Shock, Chronic liver disease (CLD)

and neurocritical care adults

What are independent RF for stress-related mucosal changes?

coagulopathy and respiratory failure

What does coagulopathy mean?

platelet counts < 50,000/mm3 (INR > 1.5 or PTT >2x NL)

What does respiratory failure mean?

requiring mechanical ventilation for 48+ hours

What are relative RF of stress-related mucosal changes?

spinal cord injury, multiple trauma, hepatic failure

thermal injury (35% or more BSA), partial hepatectomy, head injury (glasgow coma score < 11), hx of ulcer/bleeds within 1 year, sepsis or septic shock, ICU stay for 1+ week, bleeding for 1+ week, and steroids

What are agents for stress-related UGIB?

PPIs > H2 receptor antagonists

Who qualifies for pharm therapy with stress-related UGIB?

patients with independent RF or 2 other RF within the ICU

When should stress ulcer ppx (SUP) be discontinued?

when RF are no longer present

What are RF of VTE?

non-modifiable: factor V leiden or hematological disorders, age 40+, family hx of thrombosis, oncological disorders, males

modifiable: immobility, meds, obesity, transfusion related, surgery or trauma

What is the dose of UFH for ppx?

5000 units 2-3x QD

What is the route of UFH, lovenox, and fondaparinux for ppx?

SQ

What is the CrCl adjustment for UFH ppx?

none

What are monitoring parameters of UFH for ppx?

Hemoglobin,

hematocrit,

platelet count,

PT,

aPTT,

S/S of bleeding,

RF for bleeding,

fecal occult blood test (if clinically indicated);

potassium.

What route is preferred for UGIB agents?

IV or enternal

What is the dose of lovenox for ppx?

40mg QD

What is the CrCl adjustment of enoxaparin (lovenox) for ppx?

decrease to 30mg QD

What are monitoring parameters for enoxaparin?

At baseline and during therapy:

Platelet count,

hemoglobin,

hematocrit,

fecal occult blood,

S/S of bleeding,

anti-factor Xa levels (as appropriate),

and serum creatinine

Monitoring of PT and/or aPTT is not necessary. Routine monitoring of anti-factor Xa activity is not required but has been utilized in patients with obesity and/or kidney insufficiency.

What is the dose of fondaparinux (arixtra) for ppx?

2.5mg QD

What are the CrCl adjustments for fondaparinux for ppx?

30-50mL/min use with caution

C/I if < 30mL/min

What are monitoring parameters of fondaparinux for ppx?

Periodically monitor CBC, platelet count, serum creatinine, occult blood testing of stools, S/S of bleeding.

Anti-Xa activity can be measured if the assay is specifically calibrated.

In patients undergoing neuraxial procedures, monitor for S/S of neurologic impairment.

What agents are used to treat constipation in the ICU?

laxatives: PEG, bisacodyl, senna

prokinetic agents: metoclopramide SOMETIMES

What agents are used to treat opioid induced constipation in the ICU?

bulk forming or osmotic laxatives: psyllium or PEG + docusate (stool softener)

What is the last line agent for opioid induced constipation (OID) in the ICU?

senna (stimulants)

What is preload?

volume in the left ventricle at the end of diastole

What is contractility?

force of the heart

What is afterload?

overall resistance to blood flow leaving the heart

What is mean arterial pressure (MAP)?

important monitoring parameters in shock with a goal of MAP > 65

How do you calculate MAP?

(SBP + 2xDBP) / 3

What are the types of shock?

hypovolemic, cardiogenic, distributive

What are causes of hypovolemic shock?

Bleeding, diarrhea, vomiting, diuretic use, diabetic ketoacidosis, diabetes insipidus, damaged skin

What main change happens in blood flow or circulation when someone has hypovolemic shock?

decreased preload

What main change happens in blood flow or circulation when someone has cardiogenic shock?

decreased myocardial contractility

What main change happens in blood flow or circulation when someone has distributive shock?

decreased afterload (and increased contractility)

What are causes of cardiogenic shock?

MI, CHF, arrhythmias, septal wall rupture

What are causes of distributive shock?

Sepsis, anaphylaxis, neurogenic

What is sepsis?

Life-threatening organ dysfunction caused by a dysregulated host response to infection (which manifests as systemic inflammation, coagulation, and tissue hypo-perfusion, potentially leading to organ dysfunction)

What is septic shock?

subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality

What is the primary desired outcome of sepsis?

prevent morbidity/mortality via rapid recognition and interventions

What are examples of early implementation of sepsis therapies?

fluid resuscitation and antibiotics

What are treatment goals of sepsis?

Reduce or eliminate organ dysfunction

Eliminate source of infection

Avoid ADRs of treatment

Cost-effective therapy

Focus on infection, inflammation, hypoperfusion, and widespread tissue injury

Septic patients may require multiple simultaneous treatment regimens to achieve desired outcomes of decreased morbidity and mortality

What is the general approach to treatment of sepsis?

1. prompt recognition

2. fluids

3. broad spectrum antibiotics

4. vasopressor therapy (NE)

5. IV hydrocortisone

6. glycemic control

7. adjunctive therapies

What is the purpose of NE in sepsis?

maintain hemodynamic stability in patients with shock refractory to fluid resuscitation

What is the purpose of IV hydrocortisone in sepsis?

patients who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor support

What is the goal of glycemic control during sepsis?

140-180mg/dL

What are adjunctive therapy options for sepsis?

Blood product administration

Analgesia

Sedation

Neuromuscular blockade

Renal replacement therapy

Na bicarbonate therapy

VTE ppx

Stress ulcer ppx

Nutrition

What are examples of fluids?

crystalloid vs colloid

What are examples of crystalloids?

lactated ringers (LR) and 0.9% NaCl (NS)

What are advantages of crystalloids?

preferred for initial fluid resuscitations and $

What are disadvantages of crystalloids?

Require more fluid volume, may lead to edema

Large volume of isotonic saline may increase incidence of AKI and renal replacement therapy

Precautions: risk of fluid overload, HF, renal failure, ARDS)

C/I: if large amounts are needed or hypervolumia may be harmful to patient, then avoid crystalloids

What qty is given of crystalloids?

1-2 L in the first hour and then 2-4+ L total

What are examples of colloids?

albumin 5% and 25%

What are advantages of colloids?

Can be used in which large amounts are needed and hypervolemia may be harmful to patient

Use when crystalloids are C/I

What are disadvantages of colloids?

$$$

C/I: Hydroxyethyl starch (HES) increase morbidity and mortality

What qty is given of colloids?

500-1000mL

What is the function of alpha receptors?

vasoconstriction in the periphery

What is the function of beta 1 receptors?

chronotropic (cardiac rate) and inotropic (myocardial contractility)

What is the function of dopaminergic receptors?

increase renal blood flow

What receptors are involved in NE (levophed)?

alpha adrenergic agent with less pronounced beta adrenergic activity

What is the effect of NE (levophed)?

increases BP through vasoconstriction with small changes in HR or cardiac index

Dose: 0.01-0.3mcg/kg/min

What is the first line vasopressor in sepsis?

NE (levophed)

What are ADRs of NE?

extravasation (tissue necrosis)

bradycardia

arrhythmia (but less than DA)

Which is more potent, NE or DA?

NE

What are the receptors and effect of DA?

1-5 mcg/kg/min: improve renal blood flow (not appropriate)

5-10 mcg/kg/min: Beta1 & mild Beta2 & Dopaminergic

10-20 mcg/kg/min: Alpha effects

*Note: receptors and effect are dose-dependent

What are ADRs of DA?

Tachycardia → leading to Arrhythmias (more than NE)

NOT used routinely in the management of septic shock.

NOT used for renal protection as part of the treatment of septic shock.

Low doses should NOT be used for renal protection as part of sepsis treatment

Can cause tissue necrosis w/ extravasation

What receptors are involved with epinephrine?

Nonspecific α- & β- adrenergic agonist

What is the effect of epinephrine?

can increase cardiac index and produce significant peripheral vasoconstriction

What are ADRs of epinephrine?

Angina, arrhythmias, cardiomyopathy, CVA, anxiety, dizziness/drowsiness

What can epinephrine be added to?

NE in patients with persistent hypotension

What receptors are involved with phenylephrine?

Fast-acting, short-acting pure α1- agonist

What are the ADRs of phenylephrine?

Least likely to cause tachycardia but may decrease stroke volume

Should be reserved for use in patients with high cardiac output in whom tachycardia or ischemia limits the use of other vasopressors

What is the effect of vasopressin?

Direct vasoconstrictor without inotropic or chronotropic effects and may result in decreased cardiac output and hepatosplanchnic flow

What are the ADRs of vasopressin?

decreased cardiac output and hepatosplanchnic flow

When do we consider vasopressin?

refractory shock