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