ICU supportive care

theresashibilski's version from 2015-04-30 15:03

Section 1

Question Answer
analgesia: CPOT score goal<3; if greater than 3 than must titrate up
fentanyl25-200 mcg/hr; fastest onset/offset, easiest to titrate; no dose adjustments in renal or hepatic
morphine2.5-20 mg/hr; 10-20 min onset; itching (histamine release, could lead to hypotension)
hydromorphone0.25-2 mg/hr;
when adding a an opioid you need..bowel regimen

Section 2

Question Answer
sedation: goal RASS score0, -1, -2
SATspontaneous awakening trial daily for pts recieving sedation infusions greater than 12 hrs
dexmedetomidine0.4-1.5 mcg/kg/hr; dose dep hypotension; okay in MAPs >65; can increase dose of vasopressors needed; bradycardia (not in <60); less delirium; can extubate while using; awaken easily; expensive; half hr onset; some anagesic effect
propofol5-80 mcg/kg/min; easiest to titrate; quickest onset/offset; can cause resp depression so needs to be off when during breathing trial
propofol infusion syndromedoses >80, even 50 tho; acidosis;
propofol allergiesegg and soybean
propofol pancreatitis/hypertrigb/c lipid emulsion; TG after 5 days of being on it; adds calories; no CI is pancreatitis in past; check TG, if > 500 dont use
lorazepam0.5-4 mg/hr; accumulates = slow awakening; increased deliurium risk; propylene glycol toxicity (acidosis, renal toxicity)
midazolam0.5-2 mg/hr; quick onset; lipophilic but accumulates in fat so dont wake up right away; more delirium risk

Section 3

Question Answer
delirium preventionearly mobilization; awakening trials daily during the day; good sleep hygiene/normal sleep wake cycle
haloperidolIV, PO; QTc prolongation; use as IV push b/c of this risk; IVP: pt at risk of harming themselves/others; hyperactive (combative, pulling tubes, agitated)
quetiapineonly PO; more risk of QTc than olanzapine; sedating (can be +); BID; smaller dose during the day, bigger at night
olanazpinealternative to quetiapine; PO; IV; anticholingeric side effects
QTc cut offif prolonged to 500 is where we avoid using these agents; 450 could use olanapine b/c has the lowest risk
monitoring for delirium: CAM-ICUeither + or - for delirium

Section 4

Question Answer
DVT prophylaxissince immobile, really just start it so it doesnt get forgotten;
enoxaparinSCr, platelets; HIT
heparinplatelets; HIT
if pt had HITfondaparinux; xarelto

Section 5

Question Answer
SUPmechanical ventilation > 48 hrs, platelets less than 50000; just start so dont forget it down the rd
PPIpantoproazole: IV, PO; increased risk of pneumonia, C diff
H2RAsfamotidine; IV, PO; renal adjustment

Section 6

Question Answer
glucose controlinsulin if BG > 180; start IV infusion 1-2 units/hr; check BG q 1 hr untill good dose; monitor less when more stable
BG target range140-180; more mortality in 110-140 b/c hypoglycemia

Section 7

Question Answer
calculating MAP(1 x SBP) + (2 x DBP) /3; if <65 has septic shock
SIRS criteriaHR; WBC; RR; Temp
sepsisSIRS with source of infection (ex: pnemonia)
when do you start vasopressorsbegin if unresponsive to fluid boluses to maintain MAP; goal is MAP >/= 65
norepi1st; 0.5-20 mcg/min; a/b (vasoconstrict alpha to increase BP); b increased ino/chronotropic effects
epinephrine2nd; 1-10 mcg/min; a/b
vasopressin3rd; 0.03 units/min; V1/V2 receptors
dopamine10-20 mcg/kg/min: a/B; more a; side effect: tachy arrhythmias
phenylephrine10-220 mcg/min; just a; good for HR b/c no extra push on the heart; ischemia; hypoperfusion; extravasation
when starting a pressor add what?corticosteriod; 200 mg/day constant infusion (less hyperglycemia); decreases the amount of time on pressor and mortality) reduces inflammation

Section 8

Question Answer
maintenace IVNS; lactated ringers
goal CVP8-12 mmHg
goal urine output>/= 0.5 mL/kg/hr

Section 9

Question Answer
sepsis managementantibiotics STAT
HAP>48 hrs after admitted; non MDR (day 3 and 4 of hospitalization)
MDRantibiotic therapy in last 90 days; hospital 5 days or more; local resistance; immunosuppressed; family mem; HCAP risk factors (hos past 90 days, LTC, home infusion, hemodialysis; home wound care)
non-MDRuse single agent; cetriaxone; ertapenem; levo/cipro; amp/sulf
MDRpick from each cat: on 3 antibiotics
days of therapy7 days unless pseudomonas (14 days)
antipsudomonalbeta lactam (carbapenems (meropenem, imipenem, doripenem); cephalosporins (cefepime or ceftrazidime); PCN (pip/taz)
MRSAvanco or linezolid
FQ or AQ-