Acute Care Flashcards by Reagan Smith

Absorption

Oral absorption is ___ / ___ in critically ill patients
- alterations in gastric emptying, gastric motility
- interactions with enteral feeding / GI tubes
- GI injury/disease

impaired/unpredictable

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Distribution

Alterations vary between different critically ill patient populations
- relates in part to ___ status
- hydrophilic drugs (e.g., aminoglycosides) have ___ Vd in critically ill
surgical/trauma patients (~ __ - __ L/kg) than in medical patients (~ ___ L/kg)

fluid
higher
0.3-0.35, 0.25

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Distribution

Alterations in plasma protein binding
* ___ albumin
* ___protein binding of many drugs
* ___ acute phase proteins (e.g., α1-acid glycoprotein)
* ___ protein binding of drugs that bind α1-acid glycoprotein

decreased
decreased
increased
increased

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Metabolism

Hepatic metabolism
* hepatic blood flow
* enzyme expression and activity
* protein binding

In general: hepatic enzyme expression and activity may be ___ in some critically ill patients
* limited data

decreased

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Renal Elimination

Renal dysfunction is a common complication during critical illness
* shock, sepsis-related organ failure
* nephrotoxic drugs
* HD or continuous renal replacement therapy (e.g., CVVH, etc) is common in
ICU
* Some disease states may be associated with ___ renal elimination
* burns
* trauma

increased

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Sepsis

life threatening ___ dysfunction caused by dysregulated response to
infection
* immune ___
* coagulation and thrombosis leading to endothelial injury
* high mortality rates (~30%)
* can occur in response to any ___ (bacterial most common) and any site of infection (common: lungs, bloodstream, urinary tract)
* no specific drug therapy, early detection and supportive therapy is critical
* antibiotic therapy (broad spectrum IV antibiotics) and source control

organ
dysregulated
pathogen

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Septic shock

sepsis associated with ___ collapse
- ___ related to decreased vascular tone

treatment
* ___ (crystalloids, colloids)
* ___ (increase vascular tone, potentially cardiac output)
* target MAP ≥ 65 mm Hg
* ___ preferred, also phenylephrine, epinephrine, dopamine
* ___ (add-on)
* ___ (inotrope, not a vasopressor)
* corticosteroids (IV ___ ) if refractory

CV
hypotension
fluids
vasopressors
norepinephrine
vasopressin
dobutamine
hydrocortisone

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Respiratory Failure

respiratory failure/mechanical ___ is a common reason for ICU admission
causes: airway compromise, hypoventilation, hypoxic failure (poor air exchange), inability to
protect airway, etc

Acute Respiratory Distress Syndrome (ARDS)
* life threatening respiratory failure characterized by acute, diffuse ___ lung injury
* 25-40% mortality
* risks include pneumonia, sepsis, trauma, aspiration, others
* often requires mechanical ventilation with ___ , potentially ___ blockade
* ___ may decrease mortality in severe ARDS

ventilation
inflammatory
sedation, neuromuscular
corticosteroids

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General Supportive Care

“FAST HUGS BID”

F: feeding/fluids
A: analgesia
S: sedation
T: thromboprophylaxis

H: HOB elevation
U: Ulcer (stress ulcer) prophylaxis
G: glycemic control
S: spontateous awakening trial, spontaneeous breathing trial

B: bowel regimen
I: indewelling catherters
D: de-escalation of antibiotics/delirium assessment

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General Supportive Care

Feeding
* many ICU patients unable to take adequate oral intake

may have specialized nutritional requirements
* liver, renal failure
* ___ caloric, nutrient needs (trauma, surgery, burn)

enteral nutrition (“tube feeds”) and parenteral nutrition (“TPN”) common
* ___ preferred (”if the gut works, use it”)
* can be complicated by decreased GI motility, underlying disease states

increased
enteral

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General Supportive Care

Fluids
* goal is adequate ___ and meeting ___ requirements without causing fluid overload
* carefully monitor “IN’s” and “OUT’s”

resuscitation
maintenance

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General Supportive Care

Thromboprophylaxis

most critically patients have risk factors for venous thromboembolism (VTE)
- ___
- trauma, surgery, use of vascular catheters, sepsis, hypercoagulable states
- cancer, obesity, prior history of VTE

can be complicated by underlying bleeding risks, active bleeding, need for
invasive procedures, neuraxial anesthesia

the majority of ICU patients should receive pharmacological VTE ___ unless sufficiently mobile and very low risk OR contraindications to pharmacological prophylaxis

immobility
prophylaxis

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General Supportive Care

Thromboprophylaxis
* ___ generally preferred over UFH
* others: fondaparinux, bivalrudin, argatroban, warfarin, dabigatran, rivaroxaban, apixaban

___ prophylaxis in patients with contraindications to pharmacologic prophylaxix

LMWH
mechanical

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General Supportive Care - Thromboprophylaxis

UFH dosing and monitoring
* ___ U SC q __ h or q12h (possibly 7500 U SC q12h)
* monitoring: s/s of ___, CBC (platelets for ___ )
* no adjustment for ___ dysfunction

enoxaparin
* __ mg SC q12h, __ mg SC q __ h (may dose base on anti-Xa activity in selected patients)
* monitoring: s/s of ___ , CBC (platelets for ___ )
* CrCl < ___ ml/min: __ mg SC q __ h

dalteparin
* ___ USC q24h
* monitoring: s/s of bleeding, CBC (platelets for HIT)
* CrCl < 30 ml/min: no adjustment necessary

5000, 8
bleeding, HIT
renal
30, 40, 24
bleeding, HIT
30, 30, 24
5000

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General Supportive Care

Head of Bed Elevation
- to reduce ___ risk

aspiration

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General Supportive Care

Stress Ulcer Prophylaxis

stress related mucosal damage
* superficial lesions commonly involving the mucosal layer of the ___ following major stressful events
* clinically important bleeding likely uncommon (1.5%-5%), but associated with high morbidity and mortality (12.5%-20%)

risk factors
* shock, coagulopathy, chronic liver disease
* mechanical ___ /respiratory failure (?)
* others: neurotrauma, burn injury, extracorporeal life support
* drugs: antiplatelet agents, anticoagulants, ___

stomach
ventilation
NSAIDs

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General Supportive Care

Stress Ulcer Prophylaxis

prophylaxis (“SUP”)
* H2RAs
* PPIs
* ___ feeding - should not be used as sole prophylaxis in high-risk patients (add SUP)

PPIs vs H2RA is controversial
* guidelines do not recommend one vs the other
* some suggestion that PPIs may be more effective in preventing clinically important ___
* ___ SUP when risk factors no longer present

enteral
bleeding
d/c

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Stress Ulcer Prophylaxis

H2RAs (2)
* enteral or parenteral
* ADRs: potential ___ (rare)

thrombocytopenia

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Stress Ulcer Prophylaxis

PPIs (5)
- enteral or parenteral
- potential for risk ___ colitis, nosocomial pneumonia
- effect on mortality controversial

C. diff

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SUP Summary

Prophylaxis generally considered to be warranted in critically ill patients
considered to be at high risk:
- mechanical ___
- chronic ___ disease
- shock
- coagulopathy

PPI vs H2RA controvercial
- PPIs have less ___ but more ___

d/c prophylaxis when risk factors no longer present

ventilation
liver
bleeding, infection

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General Supportive Care

Glycemic Control

___ is associated with increased ICU mortality

multifactorial causes (not limited to patients with underlying diabetes)
- underlying stress, TPN

in general target BG ___ - ___ mg/dl

initiate insulin if BG > ___ mg/dl
* sliding scale
* ___ infusion
* electronic glucose management systems
* avoid ___ insulin formulations in unstable patients

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hyperglycemia
144-180
180
continuous
long-acting

General Supportive Care

Spontaneous Awakening trial, Spontaneous Breathing Trial
- helps prevent ___ and promotes weaning from mechanical ___

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oversedation
ventilation

General Supportive Care

Bowel Regimen

hypomotility is common in critical illness
- particularly in patients on high dose/prolonged opioids

constipation
* stool softeners (e.g., ___ )
* laxatives ( ___, docusate sodium, lactulose)

gastroparesis
* promotility agents ( ___, ___)

D/C if patient is having diarrhea/frequent stools

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senna
polyethylene glycol
metoclopramide, erythromycin

General Supportive Care

Indwelling Catheters
- assess need, ___ regularly, remove if infected

De-escalation of Antibiotics
- often start with ___ coverage, refine and de-escalate based on culture results and clinical response

Delerium Assessment

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replace
broad spectrum

# Neuromuscular Blocking Agents (NMBA’s, “paralytics”) two types

depolarizing nondepolarizing

# Succinylcholine Physically resembles acetylcholine (Ach) - activates Ach receptors - sustained ___ of neuromuscular junction = muscle contraction canʼt occur - hydrolyzed much more ___ than Ach - May cause initial muscle ___ - Dose: 1.5 mg/kg IV - Onset: ~1 minute - Duration ~3-5 minutes - Elimination: rapidly hydrolyzed in serum by the enzyme pseudocholinesterase

- depolarization - slowly - contractions

# Succinylcholine Used for ___ ___ ___ (RSI) * placement of an endotracheal tube * permits complete airway control and simplifies visualization of vocal cords can cause initial muscle contractions * may pre-administer defasciculating dose of ___ NMBA immediately prior to succinylcholine **NOT used for ___ neuromuscular blockade**

- rapid sequence intubation - nondepolarizing - sustained

# Succinylcholine: ADRs ___ -> need to be ready to intubate Muscle ___ -> deep aching muscle pain, may persist for days Hyper ___ : precise mechanism unknown - asynchronous ___ of muscle cells - alterations in receptor sensitivity **contraindicated in major ___ , __ injury, and upper motor ___ disease** - potential life threatening ___ - unclear the precise duration that these contraindications should persist

- apnea - fasciculations - hyperkalemia - depolarization - burns, crush, neuron - hyperkalemia

# Succinylcholine: ADRs Prolonged ___ * result of impaired ___ activity or decreased levels * Intracranial pressure (ICP) ___ (controversial in TBI) * Increased intraocular pressure (? clinically significant)

apnea - pseudocholinesterase - elevation

# Nondepolarizing NMBA’s Competitively block the action of Ach (i.e., do NOT ___ receptors) * do not cause initial ___ * competitive 2 general classes: ___ and ___ reversal possible, but generally not used in ICU * acetylcholinesterase inhibitors ( ___ and ___) * ___ - modified A-cyclodextrin for reversal of rocuonium/vecuronium

- activate - fasciculations - aminosteroidal, benzylisoquinolinium - pyridostigmine, neostigmine - sugammadex

# Aminosteroidal NMBA’s 3 drugs

- pancuronium - vecuronium - rocuronium

# Benzylisoquinolinium NMBA’s 2 drugs

- atracurium - cisatracurium

# NDNMBA’s: Clinical Indications May use for both ___ / ___ paralysis Mechanical Ventilation * generally in patients with acute lung injury or ___ * 25-50% of ARDS patients, recommended to administer as a ___ infusion prevents ___ with ventilator, stops spontaneous respiratory effort * improves gas exchange * facilitates “nontraditional” methods of ventilation * ___ required in all mechanically ventilated patients!

- immediate/sustained - ARDS - continuous - NOT

# NDNMBA’s: Clinical Indications Operative Settings * muscle relaxation RSI * if contraindications to ___ (e.g., ___ , etc.) * fast-acting agent Manage Increased ___ * typically reserve for patients with severe posturing, difficulties in mechanical ventilation, refractory increased ICP Therapeutic ___ * body temp 32-34 C post cardiac arrest * prevent/treat ___ ___ Oxygen Consumption * controversial -> severe ___ may be associated with high oxygen demands, may improve “supply-demand” relationship

- succinylcholine, burns - ICP - hypothermia - shivering - decrease

# NDNMBA’s: ADR’s Paralysis of ___ muscles/ ___ * safeguards to prevent unplanned extubation Inadequate ___ and ___ * NMBAʼs do NOT provide analgesic, sedative, or anxiolytic effect * patients still feel pain and anxiety, however are unable to communicate * no longer able to assess typical symptoms of pain and anxiety * patients **must be optimized on ___ and ___ drugs** (ideally ___ to initiation of NMBA)

- respiratory, apnea - pain, sedation - sedative, analgesic, prior

# NDNMBA’s: ADR’s Prolonged Paralysis/Muscle Weakness - ICU-acquired skeletal muscle weakness (ICUAW) - acute quadriplegic myopathy syndrome (AQMS) - critical illness myopathy (CIM) - critical illness polyneuropathy (CIP) multifactorial: * pharmacokinetic effected ( ___ ) possible pharmacodynamic effects * risk increased with ___ NMBA administration, possibly increased with ___ , ___ , or ___ shock * drug holidays may decrease the incidence of AQMS | all those are the same thing

- accumuation - polonged - corticosteroids, sepsis, septic | corticosteroid thing controversial

# NDNMBA’s: ADR’s Msc ADRʼs related to immobility * ___ prophylaxis * ocular ___ agent specific ADRʼs * Drug Interactions - ___ and NMBAʼs (note that contribution is controversial)

- DVT - lubricants - corticosteroids

# Monitoring Sustained NMB Challenging (and often misunderstood) * Associated with significant ___ in response * Goal: ___ dose possible, minimization of ADRʼs * efficacy endpoint -> based on clinical indication * difficult to assess

- variability - lowest

# Monitoring Sustained NMB ___ endpoint -> Peripheral nerve stimulation (“twitch monitoring”, train-of-four [TOF] assessment): - nerve stimulated 4 times - 4/4 = < 75% suppression - 3/4 = 75% suppression - 2/4 = 80% suppression - 1/4 = 90% suppression - 0/4 = 100% suppression **titrating to ___ should be avoided** - adjust dose to 1-2 twitches of train

- toxicity - 0/4

PADIS

pain, agitation/sedation, delirium, immobility, sleep

# Pain and Analgesia poorly treated in hospitalized patients - most (≥50%) ICU patients experience pain - many unable to self report pain related stress response * increases ___ nervous system activation, raises ___ levels * vaso ___ , impaired tissue perfusion * catabolism/ ___ * impaired wound healing/increased wound infection * ___ suppression * can alter ___ patterns and mechanics

- sympathetic, catecholamine - vasoconstriction - hypermetabolism - immunosuppression - breathing

# Pain Assessment if unable to self report * ___ : facial expression, upper limb movements, compliance with mechanical ventilation (each rated on scale of 1-4, total score 3-12) * ___ : facial expression; body movements; muscle tension; compliance with mechanical ventilation OR vocalization (each rated on scale of 0-2, total score 0-8

- BPS: Behavioral Pain Scale - CPOT: Critical Care Pain Obseravtion Tool

in general, IV ___ preferred for non-neuropathic pain in critically ill patients - equally effective when titrated to similar endpoints - note that opioids may have ___ effects non-opioid analgesics may be used to ___ opioid requirements (mulit- modal approach) - acetaminophen - ___ pain medications (gabapentin, pregabalin, carbamazepine) - NSAIDs (don't routinely use) - ketamine (post surgery)

- opioids - sedative - decrease - neuropathic

# Agitation/Sedation agitation = state of anxiety accompanied by motor restlessness frequent in critically ill patients, associated with adverse clinical outcomes * ventilator ___ * inappropriate verbal behavior * physical ___ * increased motor activity * increases in oxygen consumption * inadvertent removal of devices and indwelling lines and catheters

- dysynchrony - aggression

# Agitation/Sedation underlying causes of agitation

- pain - mechanical ventilation - delirium - hypoxia - hypotension - withdrawal (EtOH, drugs)

# Treatment of Agitation nonpharmacologic efforts * maintenance of patient comfort * provision of adequate ___ * frequent reorientation * optimization of environment to maintain normal ___ pattern * many (this used to say most) patients requiring mechanical ___ will require some pharmacological ___

- analgesia - sleep - ventilation - sedation

# Treatment of Agitation-Sedation pharmacologic sedation should be started after providing adequate ___ and treating reversible physiological causes should not be used as a method of restraint, coercion, discipline, convenience, or retaliation

analgesia

# Treatment of Agitation-Sedation degree of sedation in part depends on patient’s need/ability to protect ___ * over sedation is problematic * increase time on mechanical ___ * ___ ICU and hospital length of stay * obscure neurological function testing

airway - ventilation - increase

# Treatment of Agitation-Sedation Goal: adequate sedation, but not over sedation * LESS IS BEST * calm ___ patient, able to purposefully follow simple commands Benefits - decreased duration of mechanical ventilation - decrease in ICU LOS - possible decrease in mortality (controversial) efforts to achieve light sedation should be empoyed - daily sedation ___ - nursing-protocolized target sedation

- arousable - interruption

# Assessment of Sedation assessment facilitates titration of sedatives to pre-determined endpoints - subjective assessment is difficult in patients with altered level of mentation or inability to outwardly express anxiety 2 sedation scales: ___ and ___

- Richmond-Agitation-Sedation Scale (RASS) - Sedation-Agitation Scale (SAS)

# Assessment of Sedation ____ ___ ___ Scale ( ___ ): * 10-point scale * four levels of anxiety or agitation (1 to 4) * one level to denote a calm and alert state (0) * 5 levels of sedation (-1 to -5) ___ : * consciousness and agitation from a 7-item list * 1=unarousable * 7=dangerously agitated

- Richmond Sedation Agitation Scale (RASS) - SAS

# Assessment of Sedation objective assessment ___ ___ ( ___ ): * digital scale from 100 (completely awake) to 0 (isoelectric EEG) guidelines suggest using in patients in whom other measures are not feasible (e.g., deep sedation, neuromuscular blockade) - currently do not recommend BIS monitoring (or other objective measures of brain function) in all sedated ICU patients - recommend EEG monitoring for non-convulsive seizure activity in ICU patients with known/suspected seizures or to titrate medications to achieve burst suppression

- Bispectral Index (BIS)

Acute Care Flashcards

(52 cards)