Critical Care Flashcards
(125 cards)
1
Q
absorption problems in ICU
A
- gastric emptying / motility
- enteral tube interactions (drugs)
- GI injury / disease
2
Q
criticially ill patients Vd of hydrophillic drugs
A
high because theyre pumped with fluids
3
Q
hydrophillic drugs that are better absorbed with larger Vd
A
aminoglycosides
4
Q
album and protein binding in critically ill patients is
A
decreased due to underlying stress
5
Q
protein binding of what drugs is increased in critical illness
A
drugs binding alpha 1 acid glycoprotein
6
Q
how is hepatic metabolism in critically ill pts
A
decreased
7
Q
disease states associated with decreased renal elimination
A
shock
sepsis
organ failure
nephrotoxic drugs
8
Q
disease states that may have increased renal elimination
A
burns
trauma
9
Q
how do we detect changes in renal function
A
urine output
10
Q
what is sepsis
A
life threatening organ dysfunction caused by response to infection
11
Q
what can happen in sepsis
A
immune dysregulation
coagulation and thrombosis
12
Q
what is most common pathogen that sepsis happens from
A
bacterial
13
Q
most common sites of sepsis infection
A
blood, lungs, urinary tract
14
Q
treatment of sepsis
A
supportive therapy
broad spectrum IV antibiotics
15
Q
symptoms of septic shock
A
cardiovascular collpase
hypotension
16
Q
drug classes given in septic shock
A
fluids
vasopressors
corticosteroids
17
Q
fluids given in septic shock
A
crystalloids / colloids
18
Q
vasopressors used in septic shock
A
norepinephrine preferred
can add vasopressin
19
Q
goal mean arterial pressure in septic shock (MAP)
A
> 65 mm Hg
20
Q
corticosteroid used in septic shock
A
IV hydrocortisone
21
Q
what is acute respiratory distress syndrome (ARDS)
A
life threatening respiratory failure categorized by lung injury
25-40% mortality
22
Q
risks for ARDS
A
sepsis, pnemonia, trauma, aspiration
23
Q
treatment for ARDS
A
mechanical vent
corticosteroids dec mortality
23
Q
FAST HUGS BID
A
F - feeding/fluids
A - analgesia
S - sedation
T - thrombophrophylaxis
H - HOB elevation
U - ulcer prophylaxis
G - glycemic control
S - spontaneous awakening trial
B - bowel regimen
I - indwelling catheters
D - de-escalation antiobiotics / delirium
24
risk factors for VTE
immobility
trauma, surgery, sepsis
cancer, obesity, VTE hx
25
who should receive VTE prophylaxis
everyone except:
- mobile
- very low risk
- contraindications
26
what do we use for thromboprophylaxis
UFH or LMWH
LMWH preferred
27
what if patient has contraindication to pharmacologic thromboprophylaxis
mechanical prophylaxis
28
UFH dose prophylaxis
5000 units SC q8h or q12h
no renal adjustments
29
enoxaparin dose prophylaxis
30 mg SC q12h
40 mg SC q24h
CrCl < 30: 30 mg SC q24h
30
monitoring for UFH and enoxaparin
bleeding
CBC (platelets for HIT)
31
stress ulcer happens how
lesions on mucosal layer of the GI caused by stress
32
are stress ulcers clinically importnat
not always, if bleeding important its deadly
33
risk factors for stress ulcers
shock
coagulopathy
liver disease
neurotrauma
burn
MECHANICAL VENTILATION
drugs
34
drugs with high risk for ulcer
NSAIDS, antiplatelets, anticoagulants
35
what do we use for stress ulcer prophylaxis (class)
PPI or H2RA
PPI may be better
36
H2RA drugs used for stress ulcer prophylaxis
famotidine
ranitidine
37
adverse reactions of H2RAs
potential thrombocytopenia
38
when do we d/c stress ulcer prophylaxis
once risk factor gone
39
side effect of PPI
increase risk c diff
nosocomial pnemonia
40
dosing consideration for H2RAs
renal adjustment
41
why do we keep glycemic control in ICU
hyperglycemia increased mortality
pts with stress / TPN can get even w/o diabetes
42
BG target in ICU
144-180
43
what kind of insulin should we not use in ICU
long acting
44
what does spontaneous awakening trial help prevent
oversedation
promotes weaning from mechanical vent
45
what is succinylcholine and how does it work
depolarizing NMBA
binds ACh receptor and prevents ACh from binding so muscle contraction can't occur
- may cause initial muscle contraction
46
dose onset and duration of succinylcholine
1.5 mg/kg
onset: 1 min
duration: 3-5 min
47
how is succinylcholine eliminated
neither renal or hepatic
48
what is succinylcholine used for
rapid intubation
NOT sustained neuromuscular blockade
49
what can we preadminister before succinylcholine so we don't have initial contractions
non-depolarizing NMBA imediatley prior
50
succinylcholine ADRs
apnea
hyperkalemia
muscle contractions
incr intracranial pressure
incr intraocular pressure
51
succinylcholine contraindications
burn
crush victim
upper neuron disease (ALS)
52
what are non-depolarizing NMBAs
competitively block ACh receptors
do not cause muscle contractions
53
classes of non-depolarizing agents
aminosteroidal
benzylisoquinolinium
54
reversal agents for non-depolarizing NMBAs
ACh esterase inhibs (stigmines)
suggamedex
55
non-depolarizing NMBA ending
-oniums
56
who gets non-depolarizing NMBAs in mechanical vent
not everyone
often in ARDS - continuous administration
57
indications for NDNMBAs
mechanical vent ARDS common
contraindication to succ: burn, crunch, neuron dx
operative
increased intracranial pressure
hypothermia
58
adverse effects of NDNMBAs
apnea
inadequate pain and sedation
prolonged paralysis
DVT
ocular dryness
59
what must patients be on before sedative given
optimized on analgesia and sedative
60
drug interaction with NMBAs
corticosteroids
61
whats the efficacy endpoint in NMB
are we seeing improvement
62
how do we monitor the toxicity endpoint in NMBAs
peripheral nerve stimulation, twitch monitor
more twiches = less suppression
4/4 < 75%
3/4 75%
2/4 80%
1/4 90%
0/4 100%
63
how many twitches do we want to dose adjust to
1-2 twitches
64
what is delirium
acute onset of cerebral dysfunction with
change in baseline mental status
inattention
disorganized thinking
altered level of consciousness
65
cardinal feautre of delirium
disturbed level of consciousness/attention
and
change in cognition or development hallucinations /delusions
66
gold standard for pain if pt can communicate
what the pt says
67
pain scale if pt cant commuicate
behavioral pain scale (BPS)
critical care pain oversavation tool (CPOT)
proxy - caretaker suggestion
68
what pain meds preferred for non-neuropathic pain
IV opioids, can cause sedation
69
non-opioids used to decrease opioid requirement
tylenol
ketamine (post surgery)
gapapentin/pregabalin
NSAID - bleed risk tho
70
how do we give opioids IV
bolus or continuous
71
causes of agitation in ICU
pain
mechanical vent
hypoxia
hypotension
withdrawal EtOH, drugs
delirium
72
nonpharm treatment of agitation
patient comfort
analgesia
reorientation
optimization of sleep environment
73
who gets sedatives in agitation
adjunct for anxiety/agitation
non-pharm supplement
many on mechanical vent, not all
74
what should we not use sedative for
restraint
coercion
discipline
convenience
retaliation
"you dont like them"
75
pharm treatment of agitation can be given after what
analgesia and reversible physiollogic causes treated
76
why is over sedation dangerous
longer time on vent
longer time in ICU
no neruological testing
77
sedation goal
calm but arousable so can follow simple commands
78
how do we assess sedation and titrate subjectively
richmond agitation sedation scale (RASS)
sedation agitation scale (SAS)
79
how do we assess sedation for patients on a NMBA or if we cant use typical scales
bispectral index (BIS): EEG
80
benzos used in ICU
lorazepam
midazolam
81
benzos adverse effects
respiratory depression
withdrawal
prolonged sedation/duration
delirium association
82
onset and duration of lorazepam
long duration
delayed onset
less titratable
83
lorazepam elimination
not renally or hepatially eliminated
no dose accumulation
84
IV formulation of lorazepam has what solvent
propylene glycol
85
how can we detect prpylene glycol toxicity
calculate osm gap
high dose lorazepam
86
lorazepam not a good choice if what
want to wake quickly
87
midazolam metabolized how
CYP3A
88
midazolam halflife and duration
short halflife
unpredicitible duration
89
midazolam reccommended over loraZepam for what
quick sedation
short term use
90
propofol onset and offset
quick onset
quick offset
91
propofol given as what
infusion
92
propofol popular in wht
surgery
general anesthesia
neurosurgery dec ICP
93
propofol dosage form
emulsion
lipid vehicle
watch for hypertriglyceridemia
safe in egg/soy allergy
94
adverse effects of propofol
apnea
hypotension
bradycardia
pain upon infusion
hypertriglyceridemia
propofol infusion syndrome
allergic reactions
95
what is propoofol infusion syndrome
acidosis
bradycardia
lipidemia
- associated with high mortality
96
propofol not reccoemmended for who
high doses in peds
97
what should we monitor in propofol
triglyerides after 48 hours
caloric intake - 1.1 kcal/mL
propofol infusion syndrome
98
propofol affect on body
CNS depression
99
dexmedetomidine class
alpha 2 agonist
decrease NE release in CNS
100
dexmed level of sedation
light sedation, can wake pts up
101
dexmed differences
some analgesia and dec opioid requirement
light sedation
anxiolysis like Benzos
no respiratory depression
102
dexmed halflife
short, titratable
103
dexmed elimination
hepatic, might have to dose reduce
104
how do we administer dexmed
NO loading dose
just do infusion
105
adverse effects with dexmed
bradycardia
hypotension
increase BP with rapid admin
106
who should we not use dexmed in
hypovolemic
shock
hemodynamically unstable
107
which sedative has least delirium
dexmed
108
types of delirium
hyperactive - agitated
hypoactive - calm, sedated
109
who gets delirium
80% of mechanical vent patients
110
delirium can cause what after ICU
cognitive impairment
mortality maybe
111
delirium risk factors
benzos use
blood transfusions
older age
dementia
severity of illness
112
assessmnet scales used for delirium
ICDSC
CAM-ICU
113
nonpharm way to decrease delirium
early mobilization
optimization of sleep
optimization of hearing/vision
114
when do we use drugs in delirium
no prophylaxis
no routine treatment
short term with significant stress
115
what drugs used in delirium
dexmed
haloperidol
atypical antipsychotics
116
what drug can we used in delirium if we cant get them off the vent
dexmed
117
haloperidol usea
mild sedation for agitation/delirium
118
haloperidol dosing
NO continuous infusion
every 1 hour boluses
119
haloperidol risk
QT prolongation - torsades
high dose IV
seizure
EPS
NMS
120
atypical antipsychotics benefit in delirium
safety benefit
decreased risk of torsades but still could cause torasad and QT
121
atypical antipsychotics used
risperidone
olanzapine
quetiapine
122
adverse effects antipsychotics
Qt prolong
torasad
123
which med used for stress with delirium
antipsychotics
124
which med for acute agitaiton with delirium
haloperidol
