Intro To The ICU

Question 1

What is the ICU?

Answer 1

Around-the-clock monitoring & treatment of critically ill patients
Staffed with specialized healthcare professionals
High ratio of nurses to patients (ie. 1 nurse : 2 patients)
Contains sophisticated monitoring equipment

Question 2

What are some ICUs that exist?

Answer 2

MICU
SICU (surgical)
CVICU (cardiovascular)
TICU
NSCU (neurosurgical)
PICU (peds)
NICU (neonatal)

Question 3

What are some DIRECT patient care roles of a clinical pharmacist in an ICU?

Answer 3

Interdisciplinary pt care rounds
Code blue/stroke responses
Perform medication histories/reconciliations
Prevent/manage ADEs and med errors
PK/PD monitoring
Pt and caregiver education

Question 4

What are some INDIRECT patient care roles of a clinical pharmacist in an ICU?

Answer 4

Policy + protocol development
Formulary management
Research
Committee participation

Question 5

What are some PK/PD considerations in critically-ill patients? (3)

Answer 5

Fluid shifts
Renal dysfunction
Hepatic dysfunction

Question 6

What are some prophylactic considerations for critically-ill patients? (3)

Answer 6

Ventilator-associated pneumonia (VAP)
Stress-ulcer prophylaxis
VTE prophylaxis

Question 7

What is a nutritional consideration for critically-ill patients?

Answer 7

Enteral vs parenteral feed

Question 8

What is the pneumonic for important aspects of critical care medicine + what does each letter stand for? How many times a day should these be applied?

Answer 8

Feeding
Analgesia
Sedation
Thromboprophylaxis

Head of bed (VAP prophy)
Ulcer prophylaxis
Glycemic control
Spontaneous breathing trial

Bowel regimen
Indwelling catheters
De-escalation of antibiotics

Applied BID (2x a day)

Question 9

Is enteral or parenteral feeding preferred and why?

Answer 9

Enteral - stimulates gut (“if it works, use it”), less risk of GI bleed and less infection risk

Parenteral only used if gut is not functional or enteral feeds not tolerated (NPO)

Question 10

Proper analgesia can minimize what?

Answer 10

Acute stress response
Hypermetabolism
Overconsumption of O2
Hypercoagulability
Changes in immune function

Question 11

When considering what kind of analgesia to use, what THREE factors do we want to account for?

Answer 11

Type of pain (nociceptive or neuropathic)
Duration of pain (long-acting or need boluses PRN?)
Home pain regimen (don’t want to accidentally underdose inpatient)

Question 12

What are common pain meds used in the ICU? (4)

Answer 12

Fentanyl
Hydromorphone
Morphine
Oxycodone

Question 13

Sedation assessment is done mainly using WHICH tool?

Answer 13

Richmond Agitiation-Sedation Scale (RASS)
- usually light sedation (RASS 0 to -2) is supported for ICU use

Question 14

What TWO sedative medications are preferred in the ICU?

Answer 14

Propofol and Dexmedetomidine
(Better than benzos, which have increased delirium and cognitive AEs)

Question 15

Who should get VTE prophylaxis in the ICU?

Answer 15

EVERYONE in the ICU should get!

Question 16

What are the two medication & doses for VTE prophy and which is preferred in renal dysfunction? What non-pharm option is available for high bleeding risk?

Answer 16

Enoxaparin 40 mg SQ daily OR 30 mg SQ BID
Unfractionated heparin 5000U SQ q8hr
- Preferred in renal dysfunction
High bleed risk = mechanical prophy (compression socks)

Question 17

What is the term for VAP prophylaxis and how is done?

Answer 17

“Head of bed”
Elevate head and thorax above the bed at a 30-45 degree angle to reduce GI reflux and nosocomial pneumonia
Apply antiseptic mouthwash to the inside of the mouth TID

Question 18

Ulcer prophylaxis: Critically ill patients develop ___________ _______ ________ __________ potentially leading to clinically significant bleeding

Answer 18

Stress-related mucosal damage (SRMD) - acute, erosive inflammatory damage to upper GI tract

Question 19

What risk factors are indications for ulcer prophylaxis?

Answer 19

Major (require 1 of these!)
- Mechanical ventilation for ≥48 hrs
- INR >1.5 or PTT >2x ULN or PLT < 50,000

Minor (require 2 of these)
- drugs that increase bleed (steroids, warfarin, heparin, DOACs)
- Shock/sepsis/hypotension/vasopressors
- Hepatic or renal failure
- Multiple trauma
- Burns > 35% BSA
- Organ transplant pt
- Head or spinal trauma
- History of GI bleed or PUD!

Question 20

What is the BG goal in acutely critically-ill patients?

Answer 20

140-180 mg/dL

Question 21

What is a Spontaneous Breathing Trial?

Answer 21

Assesses how well a pt can breath on their own and checks extubation readiness

Question 22

What are some medications that can aid with constipation in critically-ill patients?

Answer 22

Docusate
Senna
PEG
Bisacodyl suppositiories

Question 23

What are FOUR kinds of catheters that are used in critical care settings?

Answer 23

Peripheral venous catheter - catheter in peripheral vein to administer IV meds
Central venous catheter - lines that terminate in the superior vena cava above right atrium
Arterial line - catheter placed in lumen of artery to continuously measure BP and access frequent arterial sampling
Foley catheter - flexible tube passing through the urethra into the bladder to drain urine