thera test 1 ICU pharmacotherapy

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coal
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thera test 1 ICU pharmacotherapy
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2014-02-14 15:11:41
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thera test ICU pharmacotherapy
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thera test 1 ICU pharmacotherapy
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thera test 1 ICU pharmacotherapy
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  1. 4 types of shock
    • hypovolemic
    • cardiogenic
    • distributive
    • obstructive
  2. 4 characteristics of hypovolemic shock
    • intravascular volume depleted
    • decrease CO & LV filling pressure
    • increased systemic vascular resistance (bodies reaction)
  3. 3 common causes of hypovolemic shock
    • hemorrhage
    • vomiting
    • severe diarrhea
  4. 4 characteristics of cardiogenic shock
    • defect in cardiac function
    • decrease CO & LV filling pressure
    • increase in systemic vascular resistance
  5. 2 common causes of cardiogenic shock
    • MI
    • valve dysfunction
  6. 4 characteristic of distributive shock
    • loss of peripheral vascular tone
    • norm or increase CO
    • norm or decrease LV filling pressure
    • decrease systemic resistance
  7. 4 characteristics of obstructive shock
    • impedance of adequate cardiac filling
    • decrease CO
    • variable LV filling pressure
    • increase systemic vascular resistance

    rare
  8. common cause of distributive shock
    • sepsis
    • anaphylaxis
  9. common cause of obstructive shock
    • tamponade
    • pneumothorax
    • pulmonary embolus
  10. 2 general Tx's of shock
    • decrease oxygen consumption
    • increase oxygen delivery
  11. primary goal of treating shock
    increase oxygen delivery to tissues by increasing cardiac output and optimizing oxygenation of blood
  12. goal of vasopressors
    restore adequate arterial pressure
  13. goal of inotropes
    improve myocardial contractility to increase cardiac output
  14. first line vasopressor in shock
    norepinephrine
  15. adverse effect of dopamine
    tachyarrythmias
  16. adverse effect of epinephrine
    can induce myocardial ischemia
  17. adverse effect of phenylephrine
    may reduce cardiac output, but this could be positive in pts who have experienced tahycardi/arrhythmia with other vasopressors
  18. 2 situations when to use phenylephrine
    if pt experiences tachycardia/arrhythmia with other agents because it may reduce cardiac output

    if you needed a rapid onset, short duration
  19. 5 adverse effects of vasopressors
    • tachycardia
    • tachyarrythmias
    • coronary artery constriction-MI
    • stress ulceration
    • limb ischemia, necrosis
  20. first line in cardiogenic shock
    dobutamine
  21. watch for with dobutamine
    • increase HR & myocardial O2 demand = can exacerbate ischemia
    • variable effects on BP, be cautious in HoTN pts
  22. second line for cardiogenic shock
    milrinone
  23. milrinone caution
    renally excreted
  24. definition of hypertensive crisis
    acute elevation of blood pressure with SBP > 180 mm Hg or diastolic > 110 mm Hg
  25. 5 risk factors for hypertensive crisis
    • medication nonadherence
    • renal impairment
    • heart failure
    • stroke
    • cocaine use
  26. 6 types of hypertensive emergency
    • acute renal failure
    • acute myocardial infarction
    • acute LV failure w/pulmonary edema
    • aortic dissection
    • eclampsia
    • intracranial hemorrhage or ischemic stroke
  27. 5 strategies for treating hypertensive emergencies
    • systolic goal of 160
    • controlled lowering of BP to avoid hypoperfusion and ischemia/infarction of vital organs
    • reduce MAP by no more than 25% in first 1-6h
    • treat with rapid acting IV agent
    • select agent based on end organ damage present
  28. when treating hypertensive emergencies with beta blockers what should you watch out for
    pts with asthma, because you can cause bronchospasms
  29. what to watch for with nitroprusside when treating hypertensive emergencies
    kidney failure, you will increase the amount of cyanide and cause poisoning
  30. a drug for treating hypertensive emergencies that is safe in pregnancy and CI in pregnancy
    • safe = hydralazine
    • CI = ACEI (enalaprilat)
  31. 4 causes of agitation in the ICU
    • pain
    • delirium
    • inability to communicate
    • excessive stimulation (lights, noise, etc)
  32. non-pharm treatments of agitation in the ICU
    • frequent reorientation
    • maintenance of pt discomfort
    • optimization of environment to maintain normal sleep-wake patterns
    • provision of adequate pain relief
  33. 3 guidelines to pharmacologic mgmt. of agitation in the ICU
    • maintain light levels of sedation
    • nonbenzo sedation preferred (propofol or precede (dexmedetomidine)
    • daily sedation holidays recommended
  34. dexedetomidine (precede) in sedation
    • selective alpha 2 agonist
    • sedation, analgesic, anxiolytic effect
    • not for deep sedation (<24h)
  35. benzos for sedation of agitation in the ICU (6)
    • anxiolytic, amnestic, sedating, hypnotic
    • NO analgesic
    • elderly more sensitive
    • all metabolized hepatically
    • IV forms of lorazepam can cause AKI
    • prolonged administration can lead to delayed return from sedation
  36. propofol (diprovan) for sedation in agitation in the ICU(4)
    • NO analgesia
    • highly lipid soluble = rapid onset
    • 10% lipid emulsion= increase risk pancreatitis
    • PRIS
  37. 5 risk factors for delirium in the ICU
    • preexisting demetia
    • history of HTN
    • history of alcoholism
    • high severity of illness at admission
    • coma
  38. which medications reduce duration of delirium in ICU pts
    • atypical antipsychotics
    •   olanzapine - zyprexa
    •   ziprasidone - Geodon
    •   quetiapine - seroquel
  39. when would you not use antipsychotics for the Tx of delirium
    pt at risk of torsades - benzos could be an alternative
  40. what is the target glucose level in ICU pts
    < 180 mg/dL
  41. what are the results of the NICE-SUGAR trial
    intensive glucose targets have not shown benefit in mortality, but may increase mortality and hypoglycemia events

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