Critical Care ES

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

fentanyl and hydromorphone

Which opioid is most commonly used for pain in the ICU?

fentanyl

A/E for opioids

- oversedation

- respiratory depression

- delirium

- hypotension

- decreased GI motility

Potential components of multimodal approach to pain treatment

- APAP

- NSAIDs

- lidocaine

- ketamine

- neuropathic pain medications (pregabalin, gabapentin)

Non-pharmacist therapy for pain in the ICU

- music

- pet therapy

- massage

- temperature control

- relaxation techniques

What is used for sedation if anxiety/agitation is not relieved by analgosedation in mechanically ventilated patients?

- benzodiazepines

- propofol

- dexmedetomidine

Which agents do the PADIS guidelines recommend to maintain a light goal of sedation and to minimize delirium?

propofol and dexmedetomidine

Lorazepam onset

15-20 minutes

Lorazepam duration

6-8 hours

ADRs: lorazepam

- anterograde amnesia

- CNS effects (drowsiness, sedation)

- paradoxical reactions

- withdrawal syndrome

Monitoring: lorazepam

- respiratory and CV status

- BP, HR

- symptoms of anxiety

- mental alertness

Pearls: lorazepam

intermittent dosing preferred to continuous infusion

Propofol onset

30 seconds

Propofol duration

3-10 minutes

ADRs: propofol

- hypertriglyceridemia

- pancreatitis

- propofol-related infusion syndrome

- hyperkalemia

- hepatomegaly

Monitoring: propofol

- BP

- oxygen saturation

- S/sx of propofol related infusion syndrome

- CNS function

Dexmedetomidine onset

5-10 minutes

Dexmedetomidine duration

1-2 hours

ADRs: dexmedetomidine

- hypotension

- bradycardia

- tachyphylaxis

Monitoring: dexmedetomidine

- level of sedation

- HR

- RR

- heart rhythm

- BP

MOA: dexmedetomidine

alpha 2 agonist with anesthetic and sedative properties

Delirium

- disturbed level of consciousness

- reduced ability to focus, sustain, or shift attention

- change in cognition

- development of perceptual disturbances

True or false: there are several FDA approved treatments for delirium

False

Management strategies for preventing delirium

- reducing BZD utilization

- patient reorientation

- improving sleep hygiene

- early mobilization

- lighter sedation strategies

What can be done to improve sleep for patients in the ICU?

minimize noise and light disturbances

Blood glucose target for patients in ICU

Guideline recommendation for insulin therapy in ICU

initiate insulin therapy after two consecutive blood glucose values greater than 180 mg/dL to reach a goal of less than 180 mg/dL

How often should glucose be checked in an ICU setting when patient is given insulin?

every 1-2 hours

What patients are considered high risk for clinically important upper GI bleeds?

- coagulopathy (platelets

- shock

- chronic liver disease

- neurocritical care adults

Prophylaxis for stress-induced UGIB

H2RAs and PPIs (PPIs preferred), oral route

When should stress ulcer prophylaxis (SUP) be discontinued?

once the risk factor is resolved

Nonmodifiable risk factors for VTE

- factor V Leiden or hematological disorders

- age >40 years

- familial hx of thrombosis

- oncological disorders

- male sex

Modifiable risk factors for VTE

- immobility

- medications

- obesity

- transfusion related

- surgery or trauma

- PICC lines

What risk assessment is used to evaluate risk of VTE in hospitalized patients?

Padua score

UFH dose/route/frequency for VTE prevention

5000 units subQ 2-3x/day

CrCl adjustment for UFH

none

Monitoring: UFH

- prothrombin time (PT)

- activation partial thromboplastin time (aPTT)

- s/sx of bleeding

- hematocrit

- hemoglobin

- platelet count (for HIT)

LMWH dose/route/frequency for VTE prevention

40 mg subQ daily

CrCl adjustment for LMWH

30 mg subQ daily

Monitoring: LMWH

- platelet count

- hemoglobin

- hematocrit

- s/sx of bleeding

- serum creatinine

Fondaparinux dose/route/frequency for VTE prevention

2.5 mg subQ daily

CrCl adjustment for fondaparinux

- Caution 30-50 mL/min

- C/I

Monitoring: fondaparinux

- CBC

- platelet count

- serum creatinine

- s/sx bleeding

What agents are recommended for critically ill patients to treat or prevent constipation?

PEG, bisacodyl, senna, metoclopramide

Preload

volume in the left ventricle at the end of diastole

Contractility

force of the heart

Afterload

overall resistance to blood flow leaving the heart

Mean arterial pressure (MAP)

monitoring parameter in shock

Goal MAP in shock

>/= 65

MAP equation

MAP = (SBP + 2*DBP)/3

Hypovolemic shock causes

- bleeding

- diarrhea

- vomiting

- diuretic use

- diabetic ketoacidosis

- diabetes insipidus

- damaged skin

Hypovolemic shock alteration in hemodynamic variables

decreased preload

Cardiogenic shock causes

- MI

- CHF

- arrhythmias

- septal wall rupture

Cardiogenic shock alteration in hemodynamic variables

decreased myocardial contractility

Distributive shock causes

- sepsis

- anaphylaxis

- neurogenic

Distributive shock alteration in hemodynamic variables

decreased after load (and increase in contractility)

Sepsis

- life-threatening organ dysfunction caused by a dysregulated host response to infection

- response to infection which manifests as systemic inflammation, coagulation, and tissue hypo perfusion, potentially leading to organ dysfunction

Septic shock

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

General approach to treatment of sepsis

1. prompt recognition of septic patient and early implementation of therapies

2. fluid therapy, using crystalloids, to restore intravascular volume depletion

3. early administration of broad-spectrum anti-microbial therapy

4. vasopressor therapy, using NE initially, to maintain hemodynamic stability in patients with septic shock refractory to fluid resuscitation

5. IV hydrocortisone may be considered for patients who remain hemodynamically unstable despite adequate fluid and vasopressor support

6. glycemic control via infusion of regular insulin to maintain glucose levels between 140 and 180 mg/dL

Adjunctive therapies for sepsis

- blood product administration

- analgesia

- sedation

- neuromuscular blockade

- renal replacement therapy

- sodium bicarbonate therapy

- VTE prophylaxis

- stress ulcer prophylaxis

- nutrition

Examples of crystalloid solutions

- 0.9% sodium chloride

- lactated ringer solution

Examples of colloid solutions

- albumin 5%

- albumin 25%

Which type of fluid is preferred in septic shock?

crystalloids

ADRs: crystalloid fluids

- fluid overload

- edema

- electrolyte imbalances

- dilution of coagulation factors

Initial resuscitation: crystalloids

30 mL/kg over first 3 hours

Initial resuscitation: colloids

500-1000 mL

Alpha receptor action

vasoconstriction in periphery

B1 receptor action

Chronotropic (cardiac rate) and inotropic (myocardial contractility)

Dopaminergic receptor action

increase renal blood flow

Norepinephrine receptors/effects

alpha adrenergic agonist (vasoconstriction in periphery)

What is the first line pressor in septic shock?

NE

ADRs: NE

- extravasation --> tissue necrosis

- bradycardia

- arrhythmias (less than DA)

Normal vasopressin action

normally increased during hypotension to maintain blood pressure by vasoconstriction

Vasopressin in septic shock

shock causes depletion of vasopressin

Vasopressin receptors/effects

direct vasoconstrictor without inotropic or chronotropic effects

ADRs: vasopressin

- Afib

- bradycardia

- decreased cardiac output

- ischemic skin lesions

- hyponatremia

Note about DA as a pressor

receptors and effect are dose-dependent

Generally, what does DA do in shock

increases stroke volume and HR

1-5 mcg/kg/min of DA in shock

improve renal blood flow (not appropriate)

5-10 mcg/kg/min of DA in shock

B1 and mild B2 and DA effects

10-20 mcg/kg/min of DA in shock

alpha effects

ADRs: DA

- tachycardia

- arrhythmias

- N/V

- anxiety

- HA

Epinephrine receptors/effects

nonspecific alpha and beta adrenergic agonist that can increase cardiac index and produce significant peripheral vasoconstriction

ADRs: epinephrine

- arrhythmias

- chest pain

- HTN

- tachycardia

- hyperglycemia

- insulin resistance

- N/V

- anxiety

Phenylephrine receptors/effects

- fast-acting and short-acting pure alpha 1 agonist

- least likely to cause tachycardia, but may decrease stroke volume

When do we use phenylephrine in shock?

only in patients with high cardiac output in whom tachycardia or ischemia limits use of other vasopressors

ADRs: phenylephrine

- arrhythmias

- HTN

- ischemia

- low cardiac output

- diaphoresis

- N/V

- blurred vision

Dobutamine receptors/effects

beta-adrenergic inotropic agent that is used for improvement of cardiac output and oxygen delivery

When do we use dobutamine?

- septic pts with adequate filling pressure and BP, but low cardiac index

- if used in hypotensive pt, combine with vasopressor therapy

ADRs: dobutamine

- chest pain

- tachycardia

- HTN

- palpitations

Angiotensin II receptors/effects

hormone in renin-angiotensin-aldosterone system --> causes vasoconstriction and increases release of aldosterone (increases BP)

ADRs: angiotensin II

- DVT

- tachycardia

- peripheral ischemia

- thrombocytopenia

- metabolic acidosis

- fungal infection

- delirium

When are pressors recommended in septic shock?

pts with systolic BP