Critical Care Summary Slides HL

What are the types of IV lines?

peripheral, central, PICC

What is a risk of IV lines and urinary catheters?

infection

True or False: medications may vary the type of IV line that can be used

True

What are the types of urinary catheters?

foley, suprapubic, external (i.e., condom, purewick)

What are benefits of urinary catheters?

monitor urine output

What are types of feeding tubes?

nasogastric (NG), orogastric (OG), gastrostomy (G)

True or False: the size of NG tubes can vary in diameter, but not flexibility

False: they vary in both diameter and flexibility

What can be administered in an NG or OG tube?

liquid or crushable meds

What can be administered in a G tube?

liquid medications

Which feeding tube must be placed surgically?

G tube

Which feeding tube should avoid medication administration?

G tube

What are the labs in a fishbone?

What are the pharmacokinetics of an ideal pain medication for crit care?

rapid onset + rapid offset + titratable

Should we clarify pain medication allergies?

yes

What are S/S of morphine allergy?

itching bc H2 release

What is the alternative medication when there is a morphine allergy?

hydromorphone

What adjunct therapies should be used with pain medications?

bowel regimen (laxatives) + naloxone prn + antiemetics prn

Which can cause withdrawal

A. Laxatives

B. Naloxone

C. Antiemetics

B

What are examples of antiemetics used with pain management?

Prochlorperazine (Compazine)

Ondansetron (Zofran)

Promethazine (Phenergan)

PRO POPers

Which medications should we consider for mild pain or as antipyretics?

NSAIDs + APAP

What dosage forms are used for NSAIDs in crit care?

IV or PO

What are pros of NSAIDs and APAP?

limits opioid use

What are ADRs of NSAIDs?

GI bleed and renal risk

Which NSAID can only be used for 5 days?

ketorolac

What dosage forms of APAP are used in crit care?

IV, PO, PR

True or False: APAP has a max daily dose

True

What medications are used to treat neuropathic pain in crit care?

gabapentin or pregabalin

What is the MOA of ketamine?

NMDA receptor antagonist

When is ketamine used?

after surgery for opioid sparing

What dose of ketamine should be used?

LOW

What are the opioids often used in crit care pain management?

fentanyl, morphine, hydromorphone

When is fentanyl indicated?

hemodynamic instability or renal failure

What is a precaution of morphine?

renal failure due to metabolites

Things to consider with sedation in ICU:

metabolism (hepatic, renal)

PK

hemodynamics (HR, RR, BP)

Risks

$

What are risks of sedation?

harm from over-sedation

delirium

worsens outcomes when there are no sedation holidays

potential for harm to self (i.e., pulling lines, tachycardia)

ADRs

True or False: sedatives have no analgesic properties

True except precedex

What are sedation holidays?

daily interruptions

What are benefits to sedation holidays?

decreases time on ventilator and length of stay (LOS) in ICU

True or False: sedation does not need to be tapered

False taper when sedation is used for many days

What should we balance when it comes to sedation?

minimal sedation + patient comfort

continuously assess need for sedation and use non-pharm therapy when possible

What RASS score is goal?

-2 to +1

What is the benefit of maintaining a RASS score within goal range?

decreases time on vent, decreases delirium, and decreases long-term cognitive dysfunction

What medications can be used for sedation in the ICU?

benzos (i.e., lorazepam), propofol, dexmedetomidine (precedex)

When is lorazepam indicated for sedation?

useful if risk of alcohol withdrawal or seizures, but LAST choice

What are precautions of lorazepam for sedation?

Accumulation/prolonged sedation and liver dysfunction may limit use

Prolonged dependence on mechanical ventilation

Increased risk of delirium

Increased ICU stay?

What are benefits of lorazepam for sedation?

cheap and long hx of use

What is the onset and duration of propofol?

rapid + short

When is propofol indicated for sedation?

Beneficial for head injury (rapid and frequent monitoring)

Evaluated intracranial pressures

Which sedative is made in lipid emulsion and must be accounted for in total nutrition for patient?

propofol

What are precautions of propofol?

increase TGs or induce pancreatitis

What are ADRs of propofol?

PRIS (rare)

hypotension (add vasopressors)

hyperTGs

infection

What are S/S of PRIS?

high mortality

dysrhythmia

HF

metabolic acidosis

renal failure

What is the most expensive sedative?

precedex

When is precedex indicated?

short term (< 24 hour) use

delirium

extubation

What are ADRs of precedex?

hypotension or HTN (esp if bolus dose)

Which sedatives may be used together as adjunct therapy?

precedex + benzos

When is therapeutic paralysis indicated?

Certain cases of acute respiratory distress syndrome (ARDS)

REFRACTORY agitation/combativeness

"Fighting the vent"

Increased intracranial pressure

Therapeutic hypothermia

What agents are used for therapeutic paralysis?

nondepolarizing agents: cisatracurium (Nimbex) >>>> or pancuronium or atracurium

True or False: sensory neurons are not affected during therapeutics paralysis

True can still hear, smell, feel pain, but CANNOT express themselves

What must be used prior to paralytics?

sedatives + analgesics

What are possible complications of paralytics?

corneal ulcers (unable to blink, treat with artificial tears or close eyes)

prolonged weakness/atrophy

pneumonia

DVT

How long can we use paralytics for?

idk but shortest duration as possible

Who is at risk for VTE?

most ICU patients

Would you want to use non pharm or pharm therapy for VTE PPX?

pharm therapy is preferred

What should we adjust for with VTE PPX?

renal dysfunction

What are C/Is of VTE PPX?

thrombocytopenia (< 100K) or an active bleed

What can we use for VTE PPX?

UFH, lovenox, fondaparinux

When do we use UFH?

renal failure

What is the dose of UFH?

2-3x QD

What is the ADR of UFH?

risk of HIT

What is the precaution of lovenox and fondaparinux?

adjust/monitor in renal dysfxn

What is the dose of lovenox and fondaparinux?

QD

What is the ADR of fondaparinux?

thrombocytopenia (NOT HIT)

When do we use non pharm VTE PPX?

use SCDs when C/I to other therapies

How long are SCDs worn daily?

20+ hours

What are precautions of SCDs?

poor adherence and fall risk

What causes stress ulcers?

physiological stress

→ mucosal ischemia

→ lack of homeostasis in gastric mucous

→ SRMD

→ bleeding

What are S/S of stress ulcers?

Vomiting blood (hematemesis)

Blood in stool (occult blood, frank melena)

Decrease in hemoglobin > 2 g Or require transfusion

Decrease in SBP > 20 mmHg

HR increase > 20 bpm

What are RF of stress ulcers?

coagulapthy

shock

CLD

neuro-critical care (i.e., head injury)

True or False: stress ulcers are rarely in the ICU, mostly in acute care

False other way around

When do we stop stress ulcer PPX?

when risk decreases

What medications are used for stress ulcer PPX?

PPIs and H2RAs

Which stress ulcer PPX medication increases risk of c. diff?

PPIs

What are limitations of H2RAs?

CrCl, confusion, thrombocytopenia

What is delirium?

disturbed level of consciousness and cognition or perception, reduced focus/attention

Is delirium considered hypo or hyperactive?

it can be either

What are RF for delirium?

Elderly

Dementia

Prior coma

Emergency surgery/trauma

Higher Acute Physiology and Chronic Health Evaluation (APACHE) score

Benzos

Blood transfusion

How can we prevent delirium?

Reorientation

Sleep hygiene

Early mobilization

Light sedation

How can we treat delirium?

there is only symptom management, NO treatment

What medications treat delirium symptoms?

Atypical Antipsychotics

Haloperidol

Dexmedetomidine

When do we use precedex for delirium?

when agitation is preventing extubation

How long should medications be used for delirium symptom management?

minimal duration + maximize safety

What are pathophys components of hemodynamics?

preload, cardiac contractility (CI), and afterload

What is preload?

amount of fluid entering the heart

What is CI?

heart strength

What is afterload?

pressure the heart must pump against to force fluid through the system

What measures hemodynamics in ICU?

pulmonary artery catheter

What are the types of shock?

cardiogenic, hypovolemic, septic, and anaphylactic

What causes cardiogenic shock?

massive MI or severe CHF

What are the hemodynamic characteristics of cardiogenic shock?

LOW CI

high preload + normal or high afterload