Lecture 4 - Critical Care and the Role of the Pharmacist

Question 1

Name the 4 different names for critical care

Answer 1

Critical care
ITU
ICU
HDU

Question 2

Define level 0

Answer 2

Patients who’s needs can be met through normal ward care in an acute hospital

Question 3

Define level 1

Answer 3

Patient at risk of deteriorating or those relocated from higher levels of care who’s needs can be met on an cute ward with additional advice and support from the critical care team

Question 4

Define level 2

Answer 4

Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care or those ‘stepping down’ from level 3 care

Question 5

Define level 3

Answer 5

Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least 2 organ systems. This includes all complex patients requiring support for multi-organ failure

Question 6

Name some examples of people that come to critical care

Answer 6

Post-op
serious short-term condition e.g. cardiac arrest
serious infections e.g. pneumonia and sepsis
Shock - septic or circulatory
Trauma
Pancreatitis
Renal failure requiring renal replacement therapy (RRT)
Severe neurological conditions - Guilliain Barre

Question 7

Name the types of non-invasive respiratory support

Answer 7

Nasal canula
Oxygen mask
Nasal High Flow (NHF)
CPAP

Question 8

Name the types of invasive respiratory support

Answer 8

Endotracheal tube
Tracheostomy

Question 9

What are the reasons for invasive respiratory support?

Answer 9

Protect the airway
Treat profound hyperaemia
post-operative - major surgery
progressive weakness of both the inspiratory and expiratory muscles
Rest exhausted patients - RR>30/min
Avoid or control hypercapnia

Question 10

When is sedation used?

Answer 10

Alleviation of pain
Facilitation tolerance and reduce distress
endotracheal tubes
to augment the effectiveness treatment (some distressing settings)
Seizure control or management of intra-cranial pressure etc
Reduce anxiety and control agitation
During neuromuscular blockade

Question 11

Reasons for analgesia use in critical care

Answer 11

Polytrauma
Post-op pain
Precipitating medical illness
Placement of drains
Prolonged immobility
Nursing care and therapy interventions
Endotracheal tube
Placement of lines

Question 12

Give an example of a opioid anaesthetic

Answer 12

Alfentanil

Question 13

Give an example of general anaesthetic

Answer 13

Propofol

Question 14

What is the target mean arterial pressure (MAP)?

Answer 14

Probe inserted indirectly into the artery for a more accurate reading >65 (most patients), >80 (in CVD event

Question 15

What happens if we do not address circulation?

Answer 15

If not addressed we the shock
Not getting enough oxygen going to where we need it
Deficiency of blood flow to the peripheral tissues of the body
Cellular hypoxia and metabolic acidosis

Question 16

What can ICU delirium impact on?

Answer 16

Patients recovery
Increase morbidity
Mortality
Length of hospital stay

Question 17

Name the two types of delirium

Answer 17

Hyperactive delirium
Hypoactive delirium
Mixed - move between the two subjects

Question 18

Define hyperactive delirium

Answer 18

Really restless
Heightened arousal, restlessness, agitation, aggression

Question 19

Define hypoactive delirium

Answer 19

Sleepiness, lack of interest in daily activities, quiet and withdrawn

Question 20

Define CAM-ICU

Answer 20

Measures clarity of thought in ICU patients by measuring judgement and attentiveness

Question 21

What are the non-pharmacological treatments for delirium?

Answer 21

Optimising environmental factors
Reduce noise, reassure, and re-orientate
Provide glasses/ hearing aids
Music therapy
Encourage normal sleep by optimising light and disturbance
Consider melatonin

Question 22

Name the pharmacological treatments for delirium

Answer 22

Haloperidol, Clonidine, Quetiapine. Olanzapine

Question 23

Define hypernatraemia

Answer 23

Dehydrated/ sodium overload
- High levels of sodium

Question 24

Define hyponatraemia

Answer 24

Dilutional / SIADH
- Low levels of sodium

Question 25

Why is AKI common in critically ill patients?

Answer 25

Impaired renal function
Medication
Primary renal disease

Question 26

How is AKI/ risk of AKI managed?

Answer 26

Correcting circulation and optimising perfusion
Avoid nephrotoxic medications
May need RRT

Question 27

Define CCVHD

Answer 27

Continuous venovenous haemodiafiltration
Run 24/7
Flow rates lower

Question 28

What are the indications for CVVHD?

Answer 28

Not based on SeCr/ eGFR
Metabolic acidosis
Hyperkalaemia
Hypernatraemia
Hyperphosphataemia
Overdose/ poisoning
Fluid overload
Uraemia

Question 29

What is given to reduce clot risk in patients on RRT?

Answer 29

Sodium citrate - citrate binds to calcium in blood inhibiting the clotting cascade, calcium is replaced into blood exiting the machine
Heparin

Question 30

What are the common types of fluids?

Answer 30

Colloids Vs crystalloids
Sodium chloride 0.9%
‘Balanced’ fluids - Hartmanns, Plasmalyte

Question 31

How is fluid balance managed?

Answer 31

Fluid restriction/ concentration preparation
Pharmacological treatments - diuretics, RRT

Question 32

When should parenteral nutrition be considered?

Answer 32

When there is inadequate nutrition for 4-7 days, should be considered pre-admission

Question 33

What does parenteral nutrition composed of?

Answer 33

Water soluble and fat soluble vitamins, electrolytes

Question 34

What is monitored on PN?

Answer 34

U and Es and LFTs

Question 35

Why is enteral nutrition considered in critically ill patients?

Answer 35

Require a higher protein content in their nutrition for recovery

Question 36

Define central venous catheter

Answer 36

Large vein
higher flow rates
larger blood volume

Question 37

Define peripheral line

Answer 37

Standard IV therapy
Limited conc and strengths due to risk of extravasation resulting in tissue damage/necrosis
Limited lumens