Overview of Critical Care

Question 1

FASTHUG MAIDENS

Answer 1

Clinical screening process
Care for an ICU patient

Question 2

F: Feeding

Answer 2

Type of nutrition - TPN, enteral, oral, fluids only
Route of administration of medicines - e.g. unlicensed if NG tube
Dosage form - can’t crush tabs can give injections
Interaction with feed
Absorption

Question 3

A: Analgesia

Answer 3

Need - trauma, surgery, pre-existing conditions
Assess pain scale
S/E
Route of administration
Long acting vs Short acting
If patient is intubated - give sedative with opioid
Opioids are given most of the time
Managing patient’s pain without knocking them out

Question 4

S: Sedation

Answer 4

Mainly for intubated patients - need to protect their airways
Appropriate choice - propofol (given with analgesics), opioids, benzodiazepines
Consider the duration of action
S/E - e.g. propofol - propofol infusion syndrome (PRIS), opioids - GI / respiratory
Assess short term or long term sedation and indication
Assess medical history, GCS vs RASS

Question 5

T: Thromboprophylaxis

Answer 5

VTE risk assessment
Assess current status - bleeding vs clotting, hyper-coagulopathy (patient already taking anticoag, risk of clotting and bleeding if given more), pre-existing conditions e.g. PE, AF
Assess renal function - UFH (short acting) vs LMWH (long acting)
Mechanical (stockings) vs pharmacological

Question 6

H: Hyper - Hypo active Delirium

Answer 6

IV drug users - more prone especially opioid users as they have high tolerance to it
Three types - hyper, hypo and mixed
Assessment - ICU-CAM
Assess cause - alcohol, encephalopathy, infection
Give patient time instead of pharmacological management unless it works for the patient - e.g. antipsychotics, benzodiazepines, A2-agonists
Quetiapine - for acute

Question 7

U: Ulcer prophylaxis

Answer 7

Mostly for gastric ulcers
Stess ulcer is common and high risk - can be due to mechanical ventilation, sepsis, shock
Establish feeding
Can be due to surgery, stress
Assess pre-existing conditions
Assess organ failure - renal, hepatic

Question 8

G: Glucose Control

Answer 8

Assess target range
Assess diabetic vs non-diabetic - type 1 (need to be more careful as it is dependent on insulin) or type 2
Assess type of feeding
Assess drugs that can excerbate or vice versa - steroids, antipsychotics, adrenaline

Question 9

M: Medicines Reconciliation

Question 10

A: Antibiotics and Anti-infectives, Antimicrobials

Answer 10

Stewardship - Indication, choice of drug, duration, IV to oral switch, stop date
Dosing - septic, CRRT (continuous dialysis due to kidney function), resistance, organism, organ dysfunction (renal, hepatic)

Question 11

I: Indication for medications

Question 12

D: Dosing

Answer 12

Liver and renal impairment - ADME, PK considerations
Augmented renal clearance - for ICU patients, kidneys are overworking resulting to high CrCl thus drug needs to be in max dose to achieved plasma concentration
CRRT - continuous renal replacement therapy
Particular care with anti-infectives
PK and PD

Question 13

E: Electrolytes and Biochemistry

Answer 13

FBC - anaemia, infection, oncology
U&E - K+, Na+, Mg2+ phosphate, renal
Coagulation
LFTs

Question 14

N: No Drug Interactions

Question 15

S: Stop Dates

Question 16

Arterial Blood Gas

Answer 16

O2 sat and how much the CO2 the patient is having - determine respiratory condition
Partial oxygen and carbon dioxide pressure - PiO2 and PiCO2
pH - acid balance base
Acidosis vs alkalosis
Respiratory vs metabolic

Question 17

Systems review: Organs - Brain

parameters to monitor

Answer 17

Neurology
GCS
Richmond Agitation Sedation Scale (RAAS)
?awake
?intubated

Question 18

Systems review: Organs - Heart

parameters to monitor

Answer 18

HR
Rhythm
BP
Monitoring devices
Cardiac output (CO)
Systemic vascular resistance (SVR)

Question 19

Systems review: Organs - Lungs

parameters to monitor

Answer 19

Mechanical ventilaton
Stroke volume (SV)
Trachy
RR

Question 20

Systems review: Organs - GI

parameters to monitor

Answer 20

Absorbing feed
Ulcer prophylaxis
Eating and drinking (E+D)

Question 21

Systems review: Organs - Liver

parameters to monitor

Answer 21

Liver enzymes
Coagulation factors / clotting
Medical history
Imaging

Question 22

Systems review: Organs - Endocrine

parameters to monitor

Answer 22

Pre-existing diabetes
Steroids
Thryoid
Pituitary
Adrenal

Question 23

Systems review: Organs - Kidneys

parameters to monitor

Answer 23

U&E,
Urine output (UO)
Transplant
CKD vs AKI
End-Stage Renal Failure (ESRF)

Question 24

Drug administration considerations

Answer 24

Refer to FASTHUG MAIDENS - sedated vs awake, confused vs normal, swallowing assessment
Acess - appropriate route of administration
Drug choice - urgency, available formulation, interactions and compatibility with other drugs, dose, indication, S/E
PK - ADME, bioavailability, hydrophilic (eliminated in kidneys), lipophilic (in tissues)

Question 25

Common Drugs

Answer 25

Fluids - hartmann's, NaCl 0.9%, dextrose, crystalloids (NaCl) vs colloids (bloods) Inotropes (increases HR) - dobutamin, milrinone, adrenaline Vasopressors (works on peripheral BP) - noradrenaline, metaraminol Antimicrobials GI ulcer prophylaxis - PPI Eye care - exposure to atmosphere due to eyes not closing VTE prophylaxis Bowel care - laxatives