Avoiding Common ICU Errors
This is a summary of the incredible book by Lisa Marcucci et al., published by Wolters Kluwer
1. Monitor Patients who have received preservative free intrathecal morphine
has a first peak ~20 minutes after admin, but has a second peak at 12-24 hours. Be very careful giving any long-acting opioids prior to the 2nd peak. Need close monitoring for the first day
2. Characteristics of commonly used ICU opioids
Morphine metb in liver and excretion from kidneys. Metabolite is active, so reduce doses in renal failure. Hydromorphone also metab in liver, excreted in kidneys, but metab not active, so reduce dose in hepatic fx. Fentanyl after the first 24 hours is a long-lasting drug. Metab in liver to inactive, so reduce dose in liver fx.
3. Clonidine for Drug Withdrawal
How to use the patch:
Day 1: Place the patch and give 0.1 mg TID
Day 2: 0.1 mg BID
Day 3: 0.1 mg QD
Day 4-7: just the patch
5. Avoid concomitant use of steroids, nmbs, and aminoglycosides to lessen risk of crit-illness myopathy
7. Specifically query for previous steroid use
equivalent of 5 mg of prednisone for at least 2 weeks in the previous year puts pts at risk for adrenal insufficiency
9. Use cisatracurium for patients who need NMBs and have hepatic and renal failure
Nimbex is cleared by hoffman elimination and does not cause histamine release. Onset 3-5 minutes, lasts ~30 minutes
10. Differentiate between Neostigmine and Neosynephrine
should call it phenylephrine to avoid confusion
Neostig dosing:
40-50 mcg/kg to reverse panc, 20-30 mcg/kg for atra, vec and roc
do not give more than 0.07 mg/kg. Mix with equal amount cc for cc with glyco
13. Amiodarone causes Hypothyroidism
causes hyper or hypo, but hypo is more common. Blocks conversion of T4 to T3 and uptake by tissues. Check TFTs if patient is on chronic every 3-6 months. IF PT IS ADMITTED TO ICU ON AMIO, CHECK TFTs
16. Furosemide has a sulfa moiety
unknown if this really cross-reacts with the sulfonamide abx
19. Be alert to met acidosis in patients on Ativan Drip
Ativan, in addition to etomidate, nitroglycerin, phenytoin, and diazepam, uses propylene glycol as its vehicle. Each cc of ativan contains 0.8 cc (830 mg) of prop glycol. Max dose of prop glycol is 25 mg/kg/day.
20. Be alert for the development of cyanide toxicity when admin nitroprusside
limit dose to less than 8 mcg/kg/min
23. Cardiac Pressors/Inotropes do not work in a low pH environment
below ~7.15, these agents are less effective. (the literature I have seen disputes this though)
32. Beware of Metabolites
meperedine obviously, but morphine in renal failure. Renal impairment may extend versed considerably. Valium can become extremely long-acting. Ativan has no active metabolites, nor does fentanyl.
33. Do not use erythromycin in patients on Tacrolimus or Cyclosporine
will sharply elevate drug levels
34. Use lovenox rather than UFH for proph in trauma patients
UFH is less effective in these patients
37. Do not use Lantus in the ICU without also using a short acting form
should only be used at low doses for basal needs, if it should be used at all
38. Patients with insulin deficiency need basal insulin even when they are NPO
DKA can develop otherwise
39. Look for med-induced causes of hyperglycemia in ICU pts
thiazides, beat agonists, diazoxide, steroids, ethanol, cyclosporine, pentamidine
40. Do not use versed and ativan interchangeably
Versed’s onset is 0.5-5 minutes b/c like diazepam, it turns into a highly lipid state after admin. Ativan takes 15-20 min to cross the BBB. Versed lasts ~2 hours while ativan lasts 6-10. As a drip, long infusions of midazolam will gather in the peripheral tissues, and have an unpredictable wake time. Consider using versed for the first 48-72 hours and then switching to ativan. Even if a patient is on ativan, use versed boluses for the control of acute agitation.
41. Benzos are lousy drugs to promote sleep
use ambien, chloral hydrate, or trazadone/mirtazapine
45. Check triglycerides in pts on propofol
contains 1 kcal/cc as soybean lipid. Causes excess trigly. which can lead to pancreatitis.
46. HIV patients can get drug-related pancreatitis; consider bowel rest if they do
do drug-drug interaction check for all patients on HAART
47. Consider fluconazole proph in crit ill pts with severe pancreatitis, abd sepsis, or multiple abd surgeries
Give 800 first dose and then 200-400 mg per day
48. Avoid Benzocaine to limit MetHb
methylene blue will show up as MetHb on co-ox
50. Know which weight to use when dosing meds
in the obese dose aminoglycosides, heparin, and amio by adjusted, not actual body weight
52. Dose diamox once a day
250-500 mg qd x 3-4 days
54. Do not give atrovent MDI in patients with nut allergy
59. Avoid the RIJ approach in pts post cardiac transplant
it is often used for biopsy post-op
68. In normal physiology, the PA Wedge should be less than PA diastolic
69. Do not use PA when there is tricuspid regurg
measurements will be inaccurate
90. Change the foley when a patient is dx with a UTI
93. Understand the IABP
contraindications AI, aortoiliac disease, irreversible myocardial disease
Confirm all on arrival to icu with xray
normally synched to ecg, but if arrythymia is present, switch to aline
94. Right heart fx is common side effect of LVAD
rising CVP with constant or decreasing LVAD flows is one of the signs.
treat any underlying abnormalities, give NO
95. Understand problems with ECMO
bleeding is the most common complication of VA. If heparin is sharply reduced or turned off, moust have a 2nd primed ECMO circuit standing by
Low flow states can be caused by compression of inflow cannula, clot
Regional ischemia of distal leg
96. Treat any milky fluid from the chest or abd as chylous until proven otherwise
get triglycerides
> 110 mg/dl is chyle 99% of the time
<50 chyle <5% of the time
101. Pulse ox is inaccurate with Saturations< 83%
104. Preoxygenate before Intubation
Deep breaths will increase FRC
109. Use bronch during trach, do not use electrocautery
If you feel compelled to use the cautery lower fio2 to 21%
121. Be careful about excess PEEP after single lung transplant
123. Do not reverse NMBs unless the patient is warm
hypothermia can extend duration of the competetive agents significantly. At 34 C duration of vec is doubled.
125. Do not reverse NMBs unless there is a twitch
126. Remove BiPAP masks for 30 minutes ~ every 4 hours to avoid necrosis
127. Treat VAP appropriately
Treat for 8 days, 14 for pseudomonas or acinetobacter
Vanco/Zosyn, Vanco/Imipenem, Vanco/Cefepime
129. Use CPIS (Clinical Pulmonary Infection Score) to diagnose VAP
score>6 is correlated well
130. Do not extubate based on clinical picture alone
Give 120 minute SBP
RSBI 80-105 has a poorer rate of success
131. Consider Heliox in severe asthmatic or post-extubation stridor
132. Parvovirus B19 INfection can cause anemia or Pancytopenia
especially in patients with hemolytic anemia for other reasons
133. Give abx proph if leeches are used on a free flap
bactrim, fluroquin, or 3rd gen ceph
134. Treat MRSA for a minimum of 14 days
135. Linezolid causes thrombocytopenia and neutropenia
136. Avoid caspofungin and voriconazole in patients with liver disease
137. Also do not use them in patients with UTI, as very little goes to the urine
138. Give a dose of abx before bile system is instrumented or manipulated
139. Administer a dose of abx before upper urinary obstruction is relieved
140. Enterococcus is a rare invasive pulmonary tract infection
141. Lack of positive blood cultures does not rule out endocarditis
143. Black lips or black spot on nasal or oral mucosa is a surgical emergency
Think mucormycosis
Start on ampho
need debridement
144. Check for cryptosporidium in immunosuppressed patients with chronic, severe, or refractory diarrhea
145. Pay attention to the morphology reported on fungal cultures
Yeast-candida and cryptococcus
Mold-they will report hyphae, think aspergillus
146. Consider fungal infection in patients with hypothermia and bradycardia
149. Aim for peak of 10 times the MIC when treating pseudomonas with aminoglycosides
concentration dependent killing
solely dependent on time above the MIC, not how high above the mic
Other conc. dependent-quinolones, flagyl, daptomycin
150. Know the definition of catheter-related bloodstream infection
158. If there is a normal platelet count, it can not be Hantavirus-Pulmonary Syndrome
163. Use inopressors, not large volume fluid resus for PE
164. If it looks like sepsis, it could be adrenal insufficieny, anaphylaxis, cirrhosis, thyrotoxicosis
165. Any spine surg can cause a large SIRS response
suspect ibfection instead if still present on day 4
166. Always consider Abdominal Compartment Syndrome
167. Abd pain out of proportion to exam is always mesenteric ischemia until proven otherwise
170. Most patients get mannitol when going on the bypass pump so urine output is not reliable post-op as a marker of volume status
for the first 12 hours you can not use this marker
171. Do not use urine output as a measure if the patient is cold
if they are not diureseing, they need more volume
172. Don’t overhydrate post-op liver transplant patients
use blood products and albumin rather than crytalloid if possible. They had the equivalent of a huge volume paracentesis. If cvps get elevated liver gets congested.
174. Do not rplete calcium if phosphorus is high and vice versa
can cause calciphylaxis
175. Check Phos post-op
especially after liver resection and live-donor ops. also transplants, open hearts, and AAAs. <2.5 needs repletion. Less than 1 mg/dL is lifethreatening.
177. If you need to correct met alkalosis, keep K at high normal levels.
182. Keep patients with dural tears flat for 24-48 hours
183. Know the spinal stability status for all post-op and trauma patients
185. Be alert for autonomic dysreflexia in spinal cord patients
stabilize blood pressure asap
187. Start a bowel regimen on SCI patients immediately
216. Do not test pain at the toes or feet
even brain dead patients can have a reflex arc elicited here
219. Post HTN can be from hypercapnia
221. Argatroban will increase INR/PT, but this can not be used to monitor its effects, it does not affect the direct system
222. Check serial MetHb levels while pt on Nitric Oxide
measure Q4-6 hours
224. Ask the lab for a synergy panel in resistant pseudomonas infections
have labs test effect of the combo you will use, not often predictable before testing
226. Check Thyroid levels in critically ill patients
227. Use empty lab tube to check stoma viability
233. Enteral feeds can lower phenytoin levels
237. Use elemental or semielemental feeds in patients with albumin less than 2.5 g/dL
241. Be alert for hypophosphotemia in renal patients receiving dialysis
CVVH and CVVHD are continuous, will eventually suck out all phosphate
243. CRRT will mask temp spikes
244. Do not give Fludrocortisone or ACEI to patients on CRRT
255. Check CK levels after prolonged surgeries for Rhabdo
267. Bleeding from direct thrombin inhibitors is not reversible
factor viia may work
305. Call the transplant team immediately if urine output decreases in a kidney transplant
Resuscitation Version
Never do needle decompression in the ED
Never give sux to a patient with contraindications