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Critical Care Module
| Question | Answer |
|---|---|
| What are shockable rhythms in cardiac arrest with AED? | Ventricular Fibrillation (VFib) Pulseless Ventricular Tachycardia (pVT) |
| What are non-shockable rhythms in cardiac arrest with AED? | Asystole Pulseless electrical activity (PEA) |
| What is the dose and frequency of epinephrine in cardiac arrest? | 1mg IV/IO Q3-5mins |
| What are the key outcomes for epinephrine in the PARMEDIC-2 trial? | epinephrine improved 30-days and 3-month mortality in combination with standard of care resuscitation. |
| What are the reversible causes that can be treated during cardiac arrest? | hypoxia, hypovolemia, hydrogen ion, hypo/hyperkalemia, hypothermia toxins, tamponade (cardiac), thrombosis (PE/coronary), tension pneumothorax |
| Which IV antihypertensive agents can be used for coronary ischemia/infarction? | nitroglycerin, esmolol, labetalol, metoprolol |
| Which IV antihypertensive agents can be used for acute ischemic or hemorrhagic stroke? | clevidipine, nicardipine, labetalol |
| Which IV antihypertensive agents can be used for Acute Aortic Dissection? | esmolol, labetalol, metoprolol |
| Which IV antihypertensive agent can be used for PE? | nitroglycerin |
| Which IV antihypertensive agent can be used for acute left ventricular failure? | nitroglycerin, enalaprilat |
| Which IV antihypertensive agent can be used for catecholamine excess? | phentolamine |
| Which antihypertensive agents can be used in pregnancy? | hydralazine, labetalol |
| What is hypertensive emergency? | BP > 200/120 mmhg with concurrent target organ dysfunction |
| What is hypertensive urgency? | BP >/= 180/110 mmhg without evidence of target organ damage |
| What is HTN crisis? | severe HTN that confers a high risk of complications. |
| What are some of the symptoms of elevated ICP? | most common - headache, depressed global consciousness (GCS </= 8), vomiting other - IV palsy, papilledema, spontaneous periorbital bruising, bradycardia / respiratory depression / HTN (Cushing's Triad), fixed & dilated pupils. |
| What is the MOA of osmotic agents (Hypertonic Saline and Mannitol) in elevated ICP? | creates osmotic gradient that draws CSF from intracranial space into the vasculature. |
| What is the dose of 3% Hypertonic Saline in elevated ICP? | 2.5 - 5mL/kg infused over 15 minutes (max 150- 250mL) |
| what is the dose of 23.4% Hypertonic Saline in elevated ICP? | 15 - 30mL IV infused over 15-30mins Q6hrs |
| What are the monitoring parameters involved with Hypertonic Saline use for elevated ICP? | serum osmolality, serum NA, Serum K, serum creatinine, urine output |
| What is a special administration recommendation associated with Hypertonic Saline use for elevated ICP? | central venous catheter or intraosseous line recommended for concentrations >/= 3% |
| Which antiseizure drugs are recommended as an option for early prevention of post-traumatic seizure within the first 7 days after TBI? | phenytoin/fosphenytoin, levetiracetam |
| What is the dose of phenytoin/fosphenytoin in early prevention of post-traumatic seizure? | LD: 15-20mg/kg IV once MD: 100 - 150mg IR IV Q8hours or 300 - 400mg ER IV Qhs x 7days |
| What is the dose of levetiracetam in early prevention of post-traumatic seizure? | LD: 15 - 20mg/kg IV once MD: 500-1000mg IR IV Q12hrs x 7days |
| What are the risks associated with the use of mannitol for elevated ICP? | hypotension, diuresis (hypovolemia), fluid shifts, renal insufficiency |
| What are the risks associated with the use of Hypertonic Saline for elevated ICP? | Overcorrection of NA (AKI), intravascular volume expansion, hyperchloremic metabolic acidosis |
| What could be done to reduce extravasation (fluid leakage) of osmotic agents used in elevated ICP? | administer via a large bore peripheral IV line. |
| What is status epilepticus (SE)? | >/= 5mins of continuous seizure activity or >/= 2 discrete seizures between which there is incomplete recovery of consciousness |
| What is refractory status epilepticus (RSE)? | status epilepticus that persists after standard treatment |
| What is the classification of Generalized convulsive SE? | impaired consciousness, stiffening symmetric clonus, risk of serious complications |
| What is the classification of focal motor SE? | with/without impaired consciousness, unilateral clonus of the limb or widespread. |
| What is the classification of myoclonic SE? | Rapid, lower amplitude clonus, frequent clonus (rhythmic or arrhythmic), various etiologies. |
| What is the classification of tonic SE? | maintenance of tonic posture (no frank convulsions), typically affect children with major neurologic or cognitive deficits (rare in adults). |
| What are first line pharmacotherapies for SE and when ideally should pharmacotherapy intervene? | BZDs (lorazepam preferred) within the first 10 - 20 mins |
| What is the regimen for lorazepam against SE? | 4mg IV/IM once, increase to 8mg IV/IM if still seizing. For children: weight-based dosing 0.1mg/kg |
| What is/are the advantage(s) of using lorazepam against SE? | effective duration (4-12hours) of anti-seizure activity |
| What is/are the disadvantage(s) of using lorazepam against SE? | slow onset (2-5mins) |
| What is/are the advantage(s) of using diazepam PR against SE? | rapid onset (10-20seconds) |
| What is/are the disadvantage(s) of using diazepam PR against SE? | short duration (approx. 20minutes) of anti-seizure activity, variable PK, supply shortages |
| What is/are the advantage(s) of using midazolam IV against SE? | suitable onset (<60secs), stability, multi-routes of administration, indicated for SE&RSE |
| What is/are the disadvantage(s) of using midazolam IV against SE? | short T1/2 in CNS |
| What are some of the non-BZD pharmacotherapies used to prevent the recurrence of seizure activity? | fosphenytoin/phenytoin, levetiracetam, valproic acid, lacosamide, phenobarbital |
| Which non-BZD pharmacotherapy for prevention of SE recurrence is safe in hepatic dysfunction? | levetiracetam |
| Which non-BZD pharmacotherapy for prevention of SE recurrence is associated with cardiac effects such as hypotension? | fosphenytoin |
| Which non-BZD pharmacotherapy for prevention of SE recurrence is associated with hepatotoxicity & thrombocytopenia? | valproic acid |
| Which non-BZD pharmacotherapy is associated with purple glove syndrome and at what dose? | phenytoin at an infuse rate > 50mg/min. |
| What are the non-BZD pharmacotherapies used for urgent treatment refractory SE patients? | phenobarbital & lacosamide |
| Which non-BZD pharmacotherapy for urgent treatment refractory SE patient, is associated with 2nd and 3rd degree AV block? | lacosamide |
| Which non-BZD pharmacotherapy for patients with SE who are refractory to first line urgent treatment, is associated with prolonged sedation, respiratory depression, hypotension? | phenobarbital (t1/2 = 87 -100hours) |
| What is the advantage of using lacosamide for patients refractory to first line urgent treatment? | preserves higher level of consciousness. |
| What is the dosing regimen for mannitol in elevated ICP? | 0.25-1g/kg IV infused over 15 minutes Q4-6hrs |
| What is the value of sustained ICP that indicates the need for treatment? | ICP > 22mmhg (normal range = 7 - 12 mmhg) |
| Which symptoms will a patient present to the ED with that is indicative of urgent intervention for elevated ICP treatment? | i. Head trauma induced sudden severe headache. ii. unilateral/ bilateral fixed & dilated pupils iii. decorticated / decerebrated posturing iv. Cushing's Triad (Bradycardia/HTN/Respiratory Depression) v. GCS </= 8 vi. absence of reversible causes |
| Which treatment can be used if patient remains non-responsive to epinephrine therapy during cardiac arrest? | amiodarone (preferred) or lidocaine |
| Which treatment is effective for ROSC if cardiac arrest is caused by TdP? | IV magnesium |
| What is the next step in BLS after AED identifies a non-shockable rhythm? | Administer Epinephrine ASAP (Q3-5mins) followed by CPR x 2mins. |
| What is the next step in BLS after AED identifies a shockable rhythm? | SHOCK! followed by CPR x 2mins. |
| What is the next step in BLS after ROSC? | post-cardiac arrest care |
| What does post-cardiac arrest care entail? | Target Temperature Management (TTM), Identify & treat acute coronary syndromes, optimize ventilation, support organ systems, assess prognosis 72hrs post ROSC |
| What are the treatment goals for HTN emergency? | 25% reduction in MAP (maintain DBP > 100mmhg) within the 1st hour, SBP = 160mmhg within 2- 6hour, remaining neurologically intact ICU monitoring required, IV medications for BP lowering. |
| What are the treatment goals for HTN urgency? | Slow BP lowering within first 24-48hours, PO medications (often restarting at-home meds), NO ICU admission required. |
| What are the BP targets for Acute Aortic Dissection HTN emergency? | HR < 60 bpm & SBP < 100mmhg within 5 -10mins. |
| What are the BP targets for Acute Ischemic Stroke HTN emergency? | BP </= 185/110mmhg (thrombolytic therapy) BP </= 220/120mmhg & 10 - 20 % reduction in MAP over 24 hours (BP tx other than thrombolytic therapy) |
| What are the BP targets for Intracerebral hemorrhage HTN emergency? | SBP <140 -160 mmhg without elevated ICP, SBP <180 mmhg & MAP <130mmhg / 24hours with extreme elevation of ICP, large hematomas |
| Which IV antihypertensive agents are contraindicated in acute decompensated heart failure (ADHF) patients? | Beta blockers |
| Which IV antihypertensive agent is contraindicated for patients with egg/soybean allergies? | clevidipine (Cleviprex) |
| Which IV antihypertensive agent is not useful for HTN crisis patients with liver dysfunction? | nicardipine (Cardene) |
| Which IV antihypertensive agent is associated with prolonged hypotension, increase risk of reflex tachycardia and lupus-like syndrome? | hydralazine (Apresoline) |
| Which IV antihypertensive agent is associated with tachyphylaxis within first 24-48 hours and ADE such as flushing, headache, erythema, nausea, vomiting? | nitroglycerin (Nitrostat) |
| Which IV antihypertensive agent has a BBW for cyanide toxicity? | sodium nitroprusside (Nitropress), avoid doses > 10mcg/kg for > 10mins. |
| What are the key outcomes that resulted from the NICE-SUGAR (2009) multicenter landmark trial? | i. Intensive BG 81 - 108 mg/dL (IBG) NOT associated with benefit in ICU or Hospital LOS, days of mechanical ventilation (MV) or need for Renal Replacement Therapy (RRT) ii. IBG associated with increased 90-day mortality & severe hypoglycemia. |
| What is the ACCCM BG target recommendation for general ICU patients? | BG >/= 150mg/dL & absolutely </= 180mg/dL |
| What is the ACCCM BG target recommendation for Cardiac surgery & adult trauma patients? | BG > 150mg/dL |
| What is the ACCCM BG target recommendation for Ischemic Stroke, Intracranial Hemorrhage (ICH) & TBI patients? | BG < 180mg/dL & absolutely > 100mg/dL |
| What are some monitoring recommendations for ICU patients BG? | i. Monitor BG Q1-2hrs, NLT Q4hrs (until stable BG) ii. BG < 70mg/dL = hypoglycemia iii. patients with stable BG readings should be transitioned from IV continuous insulin to SC insulin therapy |
| How should hypoglycemia in the ICU be treated? | i. HOLD insulin therapy, ii. administer D50W solution (10-20g) iii. Repeat BG reading Q15mins with additional D50W until BG reading >70mg/dL |
| What are the key distinguishing features of DKA? | i. younger, leaner patients with T1DM ii. fast onset (ketoacidosis) + health deteriorates rapidly. iii. Hyperglycemia, ketosis (urine & serum) & acidosis iv. N/V, abdominal pain, polyuria/dipsia, weight-loss, fruity-breathe, less-altered mental status |
| What are the key distinguishing features of HHS? | i. older, obese patients with T2DM ii. slower onset of symptoms iii. hyperglycemia, hyperosmolality, No ketoacidosis iv. N/V, abdominal pain, polyuria/dipsia, pronounce altered mental status. |
| What is the first step in treatment of DKA/HHS according to the ADA? | i. IV Fluid resuscitation with normal saline 15-20mL/kg within the first hour (in the absence of cardiac compromise) ii. when BG <200 - 250mg/dL, add D5W |
| [1] should be used as IV Fluid when corrected NA normal to high (>140mEq/L) while [2] should be used as IV Fluid when corrected NA low (<140mEq/L) for DKA/HHS treatment. | [1] half normal saline 0.45% solution [2] normal saline 0.9% solution |
| (True / False) Patients who present with hypokalemia during hyperglycemic crisis should be given insulin therapy until serum K > 3.3 mEq/L. | False. HOLD insulin therapy until serum K > 3.3 mEq/L for patients with hypokalemia during DKA/HHS episode. |
| When should [serum K] be treated and at what dose should K be supplemented? | i. [serum K] < 3mEq/L ii. 20-40mEq/L |
| When should phosphate supplementation begin during hyperglycemic crisis? | [serum phosphate] < 1mg/dL ii. patient symptomatic - metabolic encephalopathy, impaired cardiac contractility, significant muscle weakness |
| What ADE is associated with rapid correction of [serum phosphate]? | hypocalcemia |
| What is the dosing regimen for IV insulin in hyperglycemic crisis? | 0.14units/kg/hr IV continuous infusion monitor BG Q1hour decrease >/= 50% IV insulin when BG < 200mg/dL DKA or BG 300mg/dL HHS |
| What are the clinical features that indicates DKA resolution with IV insulin treatment? | i. BG < 200mg/dL ii. >/= 2 of the following: [HCO3] >/= 15mEq/L, pH >/= 7.3, AG </=12 mEq/L |
| What are the clinical features indicative of HHS resolution with IV insulin treatment? | i. normalized BG (<180mg/dL) ii. serum osmolality </= 310 mOsm/kg iii. recovered mental status. |
| What are the complications of hyperglycemic crisis (DKA / HHS)? | hypoglycemia, hypokalemia, hyperchloremic NAGMA, cerebral edema |
| Describe the stepwise process of rapid sequence induction (RSI). | i. Preparation ii. Pre-oxygenation iii. Pre-treatment iv. Paralysis v. Positioning vi. Placement vii. Post Intubation |
| What are the drugs used for induction? | etomidate, ketamine, propofol, midazolam |
| What is the dose of etomidate in RSI? | 0.3mg/kg IVP |
| What are the pros and cons of etomidate? | Pros: minimal hemodynamics effects Cons: adrenal suppression |
| What is the dose of ketamine? | 1-2mg/kg IVP |
| What are the pros and cons of ketamine? | Pros: Bronchodilation, increased HR & MAP Cons: decrease CO (if catecholamine depleted), nystagmus, cholinergic effects |
| Which induction agent in RSI provides both analgesia and sedation? | ketamine |
| What is the dose of propofol in RSI? | 1-2mg/kg IVP |
| What does pros and cons of propofol? | Pros: decrease ICP, stimulate Bronchodilation, anticonvulsive effects Cons: Hypotension, Bradycardia, allergies (soy, egg, peanuts) |
| Which induction agent is beneficial for neuro populations? | Propofol |
| What is the dose of midazolam in RSI? | 0.1 - 0.3mg/kg IVP |
| What are the pros and cons of midazolam in RSI? | Pros: anticonvulsive effects Cons: unfavorable PK, longer onset and duration than other sedatives, Hypotension |
| What is the purpose of an induction agent in RSI? | To help facilitate humane use of paralyzing agent. |
| What is the purpose of a paralytic agent in RSI? | To facilitate passage of endotracheal tube. |
| What are the paralytic agents used in RSI? | succinylcholine & rocuronium |
| What is the dose of succinylcholine in RSI? | 1 - 1.5mg/kg IVP |
| What are the pros and cons of succinylcholine use in RSI? | Pros: short duration of action Cons: exaggerated hyperkalemia, diffuse fasciculations (twitching), risk of malignant hyperthermia |
| What are the absolute contraindications of succinylcholine use in RSI? | i. muscular dystrophy -> hyperkalemia ii. genetic plasma cholinesterase deficiency iii. personal/family history of malignant hyperthermia iv. neuromuscular disease -> hyperkalemia v. MS -> hyperkalemia |
| What is the dose of rocuronium in RSI? | 1mg/kg IVP |
| What are the pros and cons of rocuronium use in RSI? | Pros: few undesirable effects, non-depolarizing (no risk of fasciculations) cons: prolonged duration of paralysis, prolonged with hepatic & renal failure |
| What is provided during post intubation of RSI? | analgesia and sedation ASAP |
| What are the ABC principles of mechanical ventilation? | A =Trigger phase B=inspiration (limit) phase C= cycling phase |
| What are the direct causes of lung injury? | pneumonia, aspiration, trauma |
| what are the indirect causes of lung injury? | sepsis, transfusion injury, pancreatitis, burn injury, trauma. |
| What are the phases of ARDS? | exudative, proliferative & fibrotic |
| What are the Berlin definition ARDS classification variables? | i. timing (<1week of known clinical insult or new/worsening respiratory symptoms) ii. chest imaging (bilateral opacities or lobar/lung collapse or nodules) iii. origin of edema (respiratory failure beyond cardiac failure or fluid overload) |
| What is the ARDS classification for mild O2 status and required treatment? | 200mmhg < PaO2/FiO2 </= 300mmhg ii. Tx with PEEP or CPAP >/= 5cm H2O |
| What is the ARDS classification for moderate O2 status and required treatment? | 100mmhg < PaO2/FiO2 </= 200mmhg ii. Tx with PEEP >/= 5cm H2O |
| What is the ARDS classification for severe O2 status and required treatment? | PaO2/FiO2 </= 100mmhg ii. Tx with PEEP >/=5cm H2O |
| What are the management strategies involved in ARDS? | i. mechanical ventilation ii. prone positioning iii. fluid management iv. Neuromuscular blocking agents (NMBA v. aerosolized pulmonary vasodilators. |
| Which management strategy should be avoided in ARDS due to lack of mortality benefit? | corticosteroids |
| What is the dose of low tidal volume used in mechanical ventilation for ARDS? | 4 - 8mL/kg of predicted body weight |
| What is the recommended duration of proning for patients with severe ARDS? | 16 hours |
| What are the benefits of prone positioning in ARDS? | i. reduce risk of ventilator-induced lung injury ii. less lung compression & more efficient gas exchange in the lungs iii. improve heart ftn & O2 delivery to the body. iv. better drainage of secretions produced in diseased lungs. |
| What types of fluids are used to managed ARDS? | balance fluids like IV crystalloids, NS or LR + diuresis (furosemide) |
| what is the purpose of NMBA in ARDS? | To improve patient-ventilator synchrony and oxygenation in patients whose lungs are severely damaged. patients MUST be mechanically ventilated & under deep sedation. |
| When should NMBA be administered in ARDS and for how long? | administer NMBA within 48hours of ARDS ONSET over 48hours |
| What is the preferred paralytic agent in ARDS? | cisatracurium (controversial benefit) |
| What is the rationale for aerosolized pulmonary vasodilators in ARDS patients? | may provide selective vasodilation of the pulmonary vasculature to improve ventilation-perfusion mismatching in ARDS (limited data on difference in clinical outcomes such as LOS & mortality) |
| what are aerosolized pulmonary vasodilators used in ARDS? | i. Inhaled Nitric Oxide (NO) ii. Inhaled prostacyclin (epoprostenol or Treprostinil) more cost-effective option |
| What is shock? | circulatory failure that leads to inadequate oxygen utilization by cells indicated by the following clinical signs: i. SBP < 90mmhg or MAP <70mmhg ii. decrease tissue perfusion iii. elevated lactic acid |
| What are the different types of shock? | i. Distributive/vasodilatory ii. Cardiogenic iii. Hypovolemic iv. Obstructive |
| What are clinical characteristics of Distributive/ Vasodilatory Shock? | i. associated with Septic / anaphylactic reactions. ii. DECREASE SVR iii. HIGH CO (typically) iv. variable PCWP/CVP |
| What are the clinical characteristics of Cardiogenic Shock? | i. associated with Acute MI > Acute HF, Arrhythmias ii. DECREASE CO iii. increase SVR iv. increase PCWP/CVP |
| What are the clinical characteristics of Hypovolemic Shock? | i. associated with internal / external fluid loss ii. acute blood loss from trauma/surgery/hemorrhage iii. decrease CO iv. increase SVR v. DEcrease PCWP/CVP |
| What are the clinical characteristics of Obstructive Shock? | i. associated with PE & Cardiac Tamponade/Tension Pneumothorax ii. obstruction outside of the heart impairs ftn of circulatory system iii. decrease CO iv. increase SVR v. increase PCWP/CVP |
| What is the initial treatment of Sepsis? | i. Fluid resuscitation>>Vasopressors>>steroids ii. concomitant Emperic antibiotic & source control throughout |
| What is the appropriate regimen for fluid resuscitation during Sepsis? | i. dose 30mL/kg infuse 1L/hr. <3hours. ii. monitor to avoid fluid overload (increase PCWP/CVP) |
| What are the types of fluids used to resuscitation Septic patients? | i Crystalloids (NS/LR/D5W) (balance fluids preferred) ii. Colloids (albumin/blood products/hetastarch) |
| What are the goals of hemodynamic support with vasopressors? | i. MAP >65mmhg ii. restore tissue perfusion (normalize mental status/urine output/ lactic acid levels) |
| Which vasoactive agent is the first line treatment for Sepsis and what is the MOA? | i. Norepinephrine ii. MOA alpha-1 & Beta-1 agonist which increase SVR & CO respectively. |
| What are the vasopressors used in Sepsis treatment? | norepinephrine, epinephrine, dopamine, phenylephrine, vasopressin, dobutamine |
| When should dopamine be considered as an alternative to norepinephrine? | Septic patients with low risk of tachyarrhythmias & bradycardia |
| [True/False]. Low-Dopamine should be used for renal protection in Septic patients. | False. DO NOT use low dose dopamine for renal protection.. |
| For Septic patients with ongoing hypoperfusion despite adequate fluids and use of vasopressors (NE/Epi/vasopressin), which other vasoactive agent should be considered? | Dobutamine |
| Where are Alpha-1 receptors located and what are effects of alpha-1 receptor stimulation? | i. Vascular Smooth Muscle ii. vasoconstriction |
| Where are Beta-1 receptors located and what are the effects of Beta-1 receptor stimulation? | i. Heart ii. increase HR & contractility = increase CO |
| Where are Beta-2 receptors located and what are the effects of Beta-2 receptor stimulation? | i. Lungs & Vascular Smooth Muscle ii. bronchodilation & vasodilation |
| Where are V1/2 receptors located and what are the effects of V1/2 receptor stimulation? | i. Vascular Smooth Muscle & Kidney ii. vasoconstriction & Fluid retention |
| Which other vasoactive agents should be added to NE to help septic patients achieve MAP goal (>65mmhg)? | vasopressin & epinephrine |
| What are some of the safety considerations associated with angiotensin II (Giapreza) use as vasoactive agent in Septic patients? | i. administer via Central Line ii. VTE prophylaxis recommended with administration iii. monitor for hyperglycemia, acidosis, delirium, peripheral ischemia, |
| Which vasopressor would increase blood pressure without increasing heart rate? | phenylephrine & vasopressin |
| What is the type and dose of the steroid used for septic patients within ongoing vasopressor requirements? | IV hydrocortisone 200mg/day continuous infusion & taper when vasopressors no longer required (NMT 7days) |
| [True/False]. NMBA recommended as a intermittent bolus for septic patients with concomitent ARDS. | True. NMBA intermittent bolus recommended over continuous infusions in patients with Sepsis & ARDS |
| What is the blood glucose level recommended for Septic shock patients? | BG< 180mg/dL |
| What is the preferred agent for VTE prophylaxis in Septic patients? | LMWH |
| What is recommended for Septic shock patients at risk of GI bleeding? | stress ulcer prophylaxis (IV PPI) |
| Which agents have recommendations against their use in Septic shock treatment? | IVIG, NAHCO3 (pH>7.2), IV vitamin C |
| Give 3 examples of mechanical support provided to patient experiencing septic shock to improve circulation.. | i. Intra-Aortic Balloon Pump (IBP) ii. Extracorporeal Membrane Oxygenation (ECMO) iii. Ventricular Assist Device |
| Which mechanical support device is most commonly used in cardiogenic shock patients? | Intra-Aortic Balloon Pump (IBP) |
| [i] functions as lungs and heart & [ii] functions as the lungs for septic shock patients who required mechanical support to improve circulation. | [i] Veno-Arterial (VA) ECMO [ii] Veno-Venous (VV) ECMO |
| Which mechanical support device used for septic shock patients allows the body time to recover in cases of life-threatening, refractory illnesses? | Extracorporeal Membrane Oxygenation (ECMO) |
| Which mechanical support device used in septic shock patients replaces the function of the ventricle(s) (temporarily or permanently) & can be destination therapy (final) or bridge to transplant? | Ventricular Assist Device |
| According to the PADIS guideline, what is the gold standard of pain assessment in the ICU? | self-reporting by patients if able to communicate using the numerical rating scale (NRS). |
| [True/False] According to the PADIS guidelines vital signs are recommended for pain management especially increase HR & BP. | False. Vital signs are not recommended for pain assessment. However, increase HR & BP is appropriate to prompt further investigation using recommended pain assessment tools. |
| How often should pain assessments be done in ICU patients according to PADIS guideline? | Q4hrs |
| What are the PADIS recommended pain assessment tools for non-comatose, +/- mechanically intubated delirious adult ICU patients who are not able to reliably self-report absence or presence of pain? | Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT) |
| Which score on the Behavioral Pain Scale (BPS) indicates significant pain? | BPS score > 5 |
| Which score on the Critical-Care Pain Observation Tool (CPOT) indicates significant pain? | CPOT score > 3 |
| What are the components of the BPS pain assessment tool? | i. Facial expression ii. Upper Limbs iii. Compliance with ventilation |
| What are the components of the CPOT pain assessment? | i. Facial expression ii.Body movements iii. Muscle tension evaluation by passive flexion and extension of upper extremities iv. compliance with ventilation (intubated patients) v. vocalization (extubated patients) |
| What is the goal of Analog Sedation or Analgosedation? | In line with the PADIS recommendation to prioritize pain assessment and treatment (management) before administering sedative medications. |
| What is the difference between Analgesia-first and Analgesia-based Analog Sedation recommended for ICU adult patients? | Analgesia-first involves the use of an analgesic before sedative to reach sedation goal whereas Analgesia-based involves the use of an analgesic instead of sedative to reach sedation goal. |
| what are the preferred analgesic for pain management in ICU patients? | opioids |
| What are the outcomes associated with Analgosedation in ICU patients? | Decrease in the following: i. sedative requirements ii. duration of mechanical ventilation iii. ICU LOS iv. pain intensity v. agitation associated with pain |
| What is the PADIS recommendation for Opioids in ICU adult patients pain management? | An Opioid should be used at the lowest effective dose for pain at rest and procedural pain management in critically ill adults. |
| What are examples of some Opioids used in ICU pain management? | fentanyl, hydromorphone, morphine, methadone, remifentanil, oxycodone |
| What can be done to minimize the ADEs of Opioids in pain management? | i. utilization of BPS/CPOT/NRS scales for assessing pain and titrating pain medications ii. using intermittent doses vs continuous infusions |
| Which opioid is tolerated more in patients with hemodynamic instability? | fentanyl |
| What are the safety concerns associated with fentanyl use in pain management for ICU patients? | i. accumulates in hepatic impairment as well as prolonged infusions (lipophilic) ii. tachyphylaxis with long-term use iii. risk of serotonin syndrome |
| Which Opioids are the best options for critically ill patients in ICU who are hemodynamically stable? | fentanyl, hydromorphone, morphine |
| Which Opioids are the best option for patients in the ICU with significant renal & hepatic impairment? | fentanyl (use cautiously in hepatic impairment) & hydromorphone |
| Which opioid pain management treatment is reserved for opioid tolerant patients in ICU? | methadone |
| When should bowel regimens begin for ICU patients on opioid therapy pain management and how often should bowel movement be observed in those patients? | i. Day 1 of Opioid use (unless contraindicated) ii. Q24-48 hrs. |
| What are some non-Opioid adjunctive therapy for pain management in ICU patients? | i. acetaminophen ii. nefopam iii. ketamine iv. anticonvulsants (gabapentin, carbamazepine, pregabalin) |
| Which are some non-Opioid adjunctive therapy not routinely suggested for pain management in ICU patients? | i. IV lidocaine ii. COX-1 selective NSAIDs iii. local analgesia iv. Nitrous Oxide v. inhaled volatile anesthetic. |
| Which non-opioid adjunctive therapy use in pain management of ICU patients is associated with hepatotoxicity? | acetaminophen |
| Which non-opioid adjunctive therapy use in pain management of ICU patients is associated with hallucinations? | ketamine |
| Which non-opioid adjunctive therapy use in pain management of ICU patients is associated with tachycardia? | nefopam |
| What are some of the non-pharmacologic recommendations in pain management of ICU patients? | i. Music therapy ii. Massage therapy iii. Cold therapy iv. relaxation therapy & hypnosis |
| What is the PADIS guideline goal for agitation/sedation of ICU patients? | To improve long-term, post-ICU outcomes |
| What are the PADIS guideline recommendations for agitation/sedation of ICU patients? | i. use validated assessment scales, determine frequency of assessment & determine treatment goal for each patient. ii. maintain light sedation in mechanically ventilated patients (using non-BZDs) iv. utilize daily sedation awakening trials |
| What are the validated agitation/sedation scales used for ICU patients? | i. Richmon Agitation-Sedation Scale (RASS) ii. Sedation-Agitation Scale (SAS) |
| What is the goal of score of RASS & SAS for agitation/sedation in ICU patients? | i. RASS > 3 to 4 ii. SAS > (-2) to 0 |
| What are the benefits of light sedation over deep sedation for critically ill mechanically ventilated patients? | i. shorter time to extubation ii. reduced instance of tracheostomy |
| What are the non-BZDs therapies used to maintain light levels of sedation in ICU patients? | propofol & dexmedetomidine |
| Which non-BZDs therapy should be avoided in acute liver failure or pancreatitis? | propofol due to the risk of propofol infusion syndrome (PRIS) |
| What are the safety considerations associated with the use of propofol in ICU patients for light sedation? | i. NO analgesic effect ii. accumulate in hepatic impairment and prolonged infusion iii. injection site rxn iv. hypotension v. PRIS (rare) |
| What are the safety considerations associated with dexmedetomidine use in ICU patients for light sedation? | i. hypotension & bradycardia |
| What is the purpose of Sedation Awakening Trials (SATs)in ICU patients? | i. ensure sedation goals are maintained ATC ii. minimize the likelihood of medication accumulation. |
| What are the delirium assessment screening tools endorsed by PADIS guidelines? | i. Confusion Assessment Method for the ICU (CAM-ICU) ii. Intensive Care Delirium Screening Checklist (ICDSC) |
| Which ICDSC score is associated with delirium? | ICDSC score >/ = 4 |
| Which medication classes are commonly associated with medication-induced delirium? | Anticholinergics, BZDs, Opiates, Antipsychotics, Antispasmodics, Anticonvulsants, Corticosteroids. |
| Which medications have a PADIS recommendation against their use in critically ill adults to prevent Delirium? | haloperidol (atypical antipsychotic), dexmedetomidine, HMG-CoA reductase inhibitors, ketamine |
| [{True/False]. The PADIS guideline currently makes no recommendations regarding the using melatonin or dexmedetomidine to improve sleep in critically ill patients. | True. |
| What is the PADIS recommendation for Delirium monitoring & prevention in critically ill patients? | Monitor at least Q8-12hours & document in medical chart (strong recommendation) |
| What is the protocol recommended for critically ill patients assessed to be delirium positive? | i. correct all underlining causes & decrease ongoing risk factors ii. implement non-pharmacologic preventative & treatment methods |
| What are the non-pharmacologic management strategies for Delirium in critically ill patients? | i. early mobilization (ICU mobility scale) ii. decrease night time disturbances iii. optimize sleep environment iv. decrease use of BZDs and anticholinergics |
| What is the dose of quetiapine used to treatment critically ill patients in ICU suffering from Delirium? | 50mg PO Q12hrs. titrated to a max of 200mg PO Q12hrs. |
| What are the ADEs associated with typical /atypical antipsychotics used in delirium patients? | QTc prolongation, anticholinergic (can't see, pee, s***, sweat), sedation, EPS, NMS (except for quetiapine) |
| which atypical antipsychotics used to treat delirium is not associated with neuroleptic malignant syndrome (NMS)? | quetiapine (Seroquel) |
| What are the typical & atypical antipsychotics used to treat Delirium in critically ill patients in ICU? | i. typical = haloperidol (Haldol) ii. atypical = quetiapine (Seroquel), olanzapine (Zyprexa), risperidone (Risperdal), ziprasidone (Geodon) |
| Which antipsychotic used in the ICU to treat Delirium of critically ill patients is associated with orthostatic hypotension? | quetiapine & risperidone |
| What is the Beer Criteria recommendation regarding the treatment of Delirium in geriatric population? | AVOID antipsychotics for behavioral problems of dementia or delirium UNLESS non-pharmacological options have failed or are not possible & patient is threatening substantial harm to self or others. |
| What are the Highest risk factors for SRMD related GI bleeding? | i. mechanical ventilation without enteral nutrition ii. chronic liver disease |
| What are the high-risk factors for SRMD related GI bleeding? | i. concerning coagulopathy ii.>/= 2 "moderate risk factors" |
| What are the moderate risk factors for SRMD related GI bleeding? | i. mechanical ventilation with enteral nutrition ii. acute kidney injury iii. sepsis iv. shock |
| What are the low risk factors for SRMD related GI bleeding? | i. critically ill patients without any risk factor ii. acute hepatic failure iii. use of steriods/immunosuppression iv. use of anticoagulants v. cancer vi. male gender |
| Which patients does the 2020 Clinical Practice Guideline recommend use of GI bleeding prophylaxis? | critically ill patients with high or highest risk factors for SRMD or GI bleed risk >/= 4% highest risk (8-10%) high risk (4-8 %) |
| What is the dose of famotidine in SUP for critically ill patient with normal renal ftn? | 20mg IV/PO Q12hrs |
| What is the dose of famotidine used in SUP for critically ill patient with CrCl </= 50mL/min? | 20mg IV/PO Qday |
| What is the dose of pantoprazole used in SUP for critically ill patients? | 40mg PO packet/IV Qday |
| What is the dose of omeprazole used in SUP for critically ill patients? | 20 mg PO (DR/IR/suspension) Qday |
| What are the complications associated with SUP use? | i. Pneumonia/C.difficile infections ii. overuse & continuation of SUP beyond hospitalization |
| 2020 clinical practice guideline recommend the use of [i] > [ii] for critically ill patients who require SUP and recommend not using [iii]. | [i] PPIs [ii] H2RAs [iii] sucralfate |
| What are the preventative measures for VAP? | i. avoid/limit duration of intubation ii. minimize deep levels of sedation iii. early mobility iv. minimize secretions v. head of bed 30-45 degrees vi. chlorhexidine mouth rinse for oral care |
| What is the dose of cefazolin for 130kg male undergoing Hip&Knee arthroplasty to prevent SSI? | Cefazolin 3g IV once dose by weight >120kg = 3g IV once <120kg = 2g IV once |
| What is the dose of vancomycin used in surgical patients to prevent SSI? | 15mg/kg IV once |
| What is the dose of clindamycin used in surgical patients to prevent SSI? | 600-900mg IV once |
| What is the dose of gentamicin used in surgical patients to prevent SSI? | 4.5-5mg/kg IV (IBW) once |
| What is the dose of levofloxacin used in surgical patients to prevent SSI? | 500mg IV once |
| When should pre-op prophylaxis with antibiotics begin to prevent SSI? | i. within 1hour to surgical incision (except FQs & Vancomycin, with 2hours) ii. intraoperative/redosing --> if procedure > 2 T1/2 of drug or excessive blood loss |
| What are the common pathogens that cause SSI? | S. aureus S. epidermidis (gram +) Klebsiella, Proteus, Enterobacter, Enterococci (gram -)) |
| What are the risk factors for VAP? | i. Day 0-5 of Mechanical Ventilation ii. underlying chronic lung disease iii. acute lung injury iv. aspiration v. coma vi. chest trauma, TBI vii. burns |
| What are the risk factors for MDRO-VAP? | i. prior IV antibiotic is preceding 90days ii. acute RRT before VAP onset iii. >/= 5 days of hospitalization before occurrence of VAP iv. septic shock at time of VAP v. ARDS preceding VAP |
| Which RSI agent would be appropriate for a patient with low BP and severe pain? | Ketamine improve HR & MAP provide analgesia & sedation |
| Which RSI agent would be appropriate for patient with high BP and delirious? | propofol decrease BP anticonvulsive properties (sedative) |
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