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Week 10 - ICU Supportive Care

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tylerwise's version from 2015-05-02 23:19

SIRS/Sepsis Facts

Question Answer
SIRS CriteriaTemp >38C (100.4F) or <36C (96.8F)
HR >90
RR >20 or pCO2 <32
WBC >12,000 or <4,000
Criteria for sepsisTwo or more SIRS criteria AND source of infection
Criteria for septic shockSevere sepsis AND...
>MAP < 60
>MAP > 60 but requiring dopamine > 5mcg/kg/min or NE > 0.25mcg/kg/min
Goal MAP>65
<65 requires vasopressors
Formula to calculate MAPMAP = ([1 * SBP] + [2 * DBP]) / 3
When to consider corticosteroids in septic shockHypotension remains poorly responsive to adequate fluid resuscitation and vasopressors after one hour
Blood glucose considerationsIdeal is 140-180 mg/dL
Only consider insulin drip (1-2 units/hr) when levels exceed 180 mg/dL
memorize

Vasopressor Agents

Question Answer
DopamineDose-related receptor activity
> beta 2: 3-10 mcg/kg/min
> beta 1: 3-20 mcg/kg/min
> alpha 1: 10-20 mcg/kg/min
First-line therapy
May be particularly useful in compromised systolic function
Commonly causes arrhythmias
NorepinephrineMixed a1/b1 activity (a1>>>b1)
First-line therapy
Very little effect on HR and stroke volume
ICU's "Golden Standard"
EpinephrineMixed a1/b1 activity
First-line therapy
May be added to NE when it is running at maximum
PhenylephrinePure a1 agonist
Second-line
May be used in patients experiencing tachyarrhythmia
Least likely to cause tachycardia
VasopressinV1 receptor agonist that causes organ-specific vasodilation
Second-line
May be used adjunctively with NE for refractory patients
memorize

Sedative Agents

Question Answer
Goal RASS-2 to 0
-2 = light sedation, but arousable
0 = alert and calm
MidazolamOnset: 2-5 minutes
Accumulates in peripheral tissues
>Limit use to <48 hours!
Avoid in renal or hepatic dysfunction
LorazepamOnset: 5-20 minutes (low comparable lipophilicity)
Metabolism not affected by liver/kidney failure
Potentials with propylene glycol accumulation (tubular necrosis)
PropofolOnset: 1-2 minutes
Short duration of action
Okay in hepatic/renal insufficiency
Issues with propofol infusion syndrome (HF, metabolic acidosis, bradycardia, hypotension, and rhabdomyolysis)
Watch for pancreatitis
Monitor triglycerides every 3 days
Easiest to titrate!
DexmedetomidineShortest time to extubation
Associated with less delirium
Easy-to-intermediate titration
memorize

Analgesic Agents

Question Answer
MorphineOnset: 10-20 minutes
DOA: 3-7 hours following bolus administration
Caution in kidney dysfuction (accumulation of metabolites)
Significant issues with histamine release (itching and hypotension)
HydromorphoneOnset: 10-20 minutes
DOA: 2-3 hours following bolus administration
Safe in hemodynamic instability
Okay in renal insufficiency
FentanylGold standard in ICU care
Onset: 1-3 minutes
DOA: 1.5-6 hours
Safe in hemodynamic instability
Okay in renal/liver dysfunction
Most easily titrated
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DVT Prophylaxis

Question Answer
Who requires DVT prophylaxis?Immobilized patients
Patients on mechanical ventilation
Sepsis patients
Trauma/surgery patients
ICU patients (except with contraindications)
Elderly
Contraindications for heparin/LMWH prophylaxisThrombocytopenia
Severe coagulopathy
Active bleeding
Recent intercranial hemorrhage
Non-pharmacologic prophylaxisGraduated compression stockings
Intermittent compression devices
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Stress Ulcer Prophylaxis

Question Answer
Who?Practically everyone in the ICU regardless of criteria, but...
>Mechanical ventilation > 48 hours
>Coagulopathy (platelets < 50,000 or INR > 1.5)
>GI bleeding or ulceration within the last year
memorize

Nosocomial Pneumonia

Question Answer
HAP vs. CAP
Diagnosis criteria for normal patient
Pneumonia considered CAP if developed before Day 3 of hospitalization
Considered HAP if 3+ days or hospitalized within last 30 days
Criteria for MDR HAPAntibiotic use within 30 days
Current hospitalization of 5+ days
High frequency of antibiotic resistance on ICU
Dialysis, home wound care or infusion
Resident of nursing home or LTCF
Treatment for HAP (non-MDR)Ceftriaxone
or
Levofloxacin
or
Ampicillin/sulbactam
or
Ertapenem
Treatment for MDR HAPCefepime or Ceftazidime
or
Antipseudomonal carbapenem
or
Pip/tazo
PLUS
Fluoroquinolone or Aminoglycoside
PLUS
Linezolid or Vancomycin
memorize

ICU Delirium

Question Answer
How is it measured?CAM-ICU
>Positive = delirium present
>Negative = no delirium
Non-pharmacologic preventionEarly mobilization
Maintain normal sleep cycle (no nighttime interruptions)
Calendar and clock in the room
Access to hearing aids/glasses
Lights on during the day/off at night
Pharmacologic treatmentQuetiapine
>May decrease duration of delirium
>Causes drowsiness (used often)

Olanzapine
>High anticholinergic activity (avoid in elderly)

Haloperidol
>Option for agitation
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Drip Rates

Question Answer
Dopamine10-20 mcg/kg/min
Phenylephrine40-200 mcg/min
Vasopressin0.03 units/min
Epinephrine1-10 mcg/min
Norepinephrine0.5-30 mcg/min
Fentanyl25-200 mcg/hr
Morphine2.5-20 mg/hr
Hydromorphine0.25-2 mg/hr
Propofol5-80 mcg/kg/min
Dexmedetomidine0.4-1.5 mcg/kg/hr
Midazolam0.5-2 mg/hr
Lorazepam0.5-4 mg/hr
memorize