Intro to critical care

Question 1

ICU role

Answer 1

A specialized section of a hospital that provides comprehensive care for persons who are critically ill

Question 2

What makes ICU different from medical floor?

Answer 2

ATC monitoring and treatment
Staffed with specially trained healthcare professionals
Makes sure staffing ratio smaller
1:2 ratio vs 1:5
Contains sophisticated monitoring equipment

Question 3

Role of clinical pharmacist in ICU - direct patient care

Answer 3

Interdisciplinary patient care rounds
Code blue/code stroke response
Perform medication histories
prevent/manage ADR and med errors
PK PD monitoring
Patient and caregiver education

Question 4

Role of clinical pharmacist in ICU - INdirect patient care

Answer 4

Policy and protocol development
Formulary management
Research
Participation in committees

Question 5

Therapeutic considerations in the critically ill

Answer 5

1. PKPD changes (fluid, renal, hepatic)
2. Specific prophylaxes (FASTHUGS BID)
3. Nutrition considerations

Question 6

FASTHUGS BID

Answer 6

Feeding
Analgesia
Sedation
Thromboembolism

Head of Bed (intubated)
Ulcer
Glycemic control
Spontaneous breathing trial (intubated)

Bowel regimen
Indwelling catheter
De-escalate abx

Question 7

Feeding Importance

Answer 7

Malnutrition = impaired immunity
* infection
* impaired wound healing
* bacterial overgrowth GI
* risk for decubitus ulcer development

Question 8

Feeding considerations

Answer 8

ASAP clinically stable
Enteral > Parenteral
- physiologic, fewer complications, less GI bleeding
TPN if gut not working or not tolerated

Question 9

Analgesia Importance

Answer 9

Pain d/t trauma, surgery, standard ICU care (lines, tubes, repositioning, PT)

Adequate pain relief optimizes comfort + reduces risk of developing agitation
Minimizes:
- acute stress response, hypermetabolism
- O2 consumption
- hypercoagulability
- immune fnc alteration

Question 10

Analgesia considerations

Answer 10

Assess pain using ICU validated pain scales
- CPOT (critical care pain obs tool)
- BPS (behavioral pain scale)
Treat based on type of pain: nociceptive (opioids, APAP) vs neuropathic (gaba)
Duration: bolus vs long acting agents
Account for home pain regimen: make sure not underdosing

Question 11

Sedation importance

Answer 11

anxiety, pain, no homeostasis, withdrawal, BZD use, sleep wake cycle disruption

Appropriate sedation = comfort, reduce acute stress response, patient safety

Question 12

Sedation considerations

Answer 12

Assess + re-assess using validated tool
- RASS (Richmond agitation-sedation scale)
- SAS (sedation agitation scale)

Light sedation RASS 0 to -2 for most situations

Drugs: Propofol, Dexmedetomidine > > BZD

Question 13

Analgosedation

Answer 13

Manage pain first – many ICU patients were over sedated and undertreated for their pain
fentanyl or hydromorphone provides analgesia + light sedation

Question 14

Benzodiazepines - why bad for sedation

Answer 14

Associated with delirium, agitation, and neurocognitive implications

Question 15

Thromboembolism PPX considerations

Answer 15

ALL ICU patients receive VTE PPX
initiation of ppx dependent on VTE risk + bleed risk

Question 16

ICU patient additional risk factors for VTE

Answer 16

CVC - catheter
Immobility
Trauma/burns
Critical illness (sepsis)

= hypercoagulable state

Question 17

VTE PPX common treatment

Answer 17

LMWH - enoxaparin 40mg SQ QD or 30mg SQ BID
Renal dysfuncion: unfractionated heparin 5000 IU SQ Q8H

Question 18

VTE PPX if high bleed risk

Answer 18

Nonpharm prophyaxis
- compression stockings
- intermittent pneumatic compression devices

Question 19

VTE PPX if high VTE risk

Answer 19

combo mechanical (nonpharm) + pharm
generally not recommended ….

Question 20

Head of bed importance

Answer 20

Only considered for patients on mechanically ventilation (VAP prophylaxis)

Reduces occurrence of GI reflux nosocomial pneumonia

Question 21

Head of bed tx

Answer 21

Elevate head/thorax above the bed at 30-45 degree angle

Apply antiseptic mouthwash to oral cavity TID to maintain hygiene, prevent bacterial growth with endotracheal tube

Question 22

Ulcer PPX importance

Answer 22

Stress related mucosal damage (SMRD) causes clinically significant bleeding
SMRD mortality is 50-70% in critically ill

Question 23

Ulcer PPX major risk factor (1 req)

Answer 23

Mechanical ventilation > 48 hours
OR
Coagulopathy
* INR>1.5
* PTT > 2x ULN
* PLT < 50,000

Question 24

Ulcer PPX minor risk factors (2+ req)

Answer 24

Drugs : warfarin, steroids, heparin
shock/sepsis/hypotension/vasopressors
hepatic/renal failure
Multiple trauma
Burns >35% total SA
Organ transplant
head/spinal trauma
Hx upper GI bleed or PUD

Question 25

Ulcer PPX drug options

Answer 25

PPI 40mg QD
H2RA 20mg BID

Question 26

Glycemic control importance

Answer 26

Hyperglycemia common d/t stress, medications (steroids, BB, vasopressors), exogenous glucose (TPN)

Proper glycemic control decrease incidence of complications
* Decreased wound healing
* Increased infection risk
* Variable glucose = worse morbidity/mortality
* May not tolerate hypoglycemia, delayed detection

Question 27

Glycemic control goal ICU

Answer 27

maintain BG 140-180 mg/dL
give as sliding scale insulin
If substantial amount - also give long acting
Cont long acting if patient eating

Question 28

Spontaneous breathing trial importance

Answer 28

See if patient can breathe on minimal or no ventilatory support
Assess if respiratory mechanics are enough to consider liberation from ventilator
Switch to mode where patient needs to work to breathe

Question 29

Bowel regimen

Answer 29

fundamental for QOL
Monitoring BM at least daily
CONSTIPATION: Provide bowel regimen
- If lots of opioids / constipation
Diarrhea:
CONSIDER; Infection, feeds, TOO aggressive bowel regimen

Question 30

Indwelling catheters importance

Answer 30

Lines are assessed at least daily for signs of infection
Assessing the need for these lines or if they can be removed

Question 31

De-escalating abx

Answer 31

Broad spectrum common in critical care
Apply standard antimicrobial stewardship principles should be standard of care in the critical care setting

De-escalate abx based on culture

Select appropriate abx duration per setting

Provide necessary dose adjustment based on
* PK changes
* renal/hepatic