{"id":5077,"date":"2011-07-14T20:23:10","date_gmt":"2011-07-14T20:23:10","guid":{"rendered":"http:\/\/crashtext.org\/misc\/avoiding-common-icu-errors.htm\/"},"modified":"2015-08-15T11:24:16","modified_gmt":"2015-08-15T15:24:16","slug":"avoiding-common-icu-errors","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/intensive-care\/avoiding-common-icu-errors.htm\/","title":{"rendered":"Avoiding Common ICU Errors"},"content":{"rendered":"
This is a summary of the incredible book by Lisa Marcucci et al., published by Wolters Kluwer<\/strong><\/p>\n <\/p>\n 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<\/p>\n 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.<\/p>\n How to use the patch:<\/p>\n Day 1: Place the patch and give 0.1 mg TID<\/p>\n Day 2: 0.1 mg BID<\/p>\n Day 3: 0.1 mg QD<\/p>\n Day 4-7: just the patch<\/p>\n equivalent of 5 mg of prednisone for at least 2 weeks in the previous year puts pts at risk for adrenal insufficiency<\/p>\n Nimbex is cleared by hoffman elimination and does not cause histamine release. Onset 3-5 minutes, lasts ~30 minutes<\/p>\n should call it phenylephrine to avoid confusion<\/p>\n Neostig dosing:<\/p>\n 40-50 mcg\/kg to reverse panc, 20-30 mcg\/kg for atra, vec and roc<\/p>\n do not give more than 0.07 mg\/kg. Mix with equal amount cc for cc with glyco<\/p>\n 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<\/strong><\/p>\n unknown if this really cross-reacts with the sulfonamide abx<\/p>\n 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.<\/p>\n limit dose to less than 8 mcg\/kg\/min<\/p>\n below ~7.15, these agents are less effective. (the literature I have seen disputes this though)<\/p>\n meperedine obviously, but morphine in renal failure. Renal impairment may extend versed considerably. Valium can become extremely long-acting.\u00a0 Ativan has no active metabolites, nor does fentanyl.<\/p>\n will sharply elevate drug levels<\/p>\n UFH is less effective in these patients<\/p>\n should only be used at low doses for basal needs, if it should be used at all<\/p>\n DKA can develop otherwise<\/p>\n thiazides, beat agonists, diazoxide, steroids, ethanol, cyclosporine, pentamidine<\/p>\n 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.<\/p>\n use ambien, chloral hydrate, or trazadone\/mirtazapine<\/p>\n contains 1 kcal\/cc as soybean lipid. Causes excess trigly. which can lead to pancreatitis.<\/p>\n<\/span>1. Monitor Patients who have received preservative free intrathecal morphine<\/span><\/h3>\n
<\/span>2. Characteristics of commonly used ICU opioids<\/span><\/h3>\n
<\/span>3. Clonidine for Drug Withdrawal<\/span><\/h3>\n
<\/span>5. Avoid concomitant use of steroids, nmbs, and aminoglycosides to lessen risk of crit-illness myopathy<\/span><\/h3>\n
<\/span>7. Specifically query for previous steroid use<\/span><\/h3>\n
<\/span>9. Use cisatracurium for patients who need NMBs and have hepatic and renal failure<\/span><\/h3>\n
<\/span>10. Differentiate between Neostigmine and Neosynephrine<\/span><\/h3>\n
<\/span>13. Amiodarone causes Hypothyroidism<\/span><\/h3>\n
<\/span>16. Furosemide has a sulfa moiety<\/span><\/h3>\n
<\/span>19. Be alert to met acidosis in patients on Ativan Drip<\/span><\/h3>\n
<\/span>20. Be alert for the development of cyanide toxicity when admin nitroprusside<\/span><\/h3>\n
<\/span>23. Cardiac Pressors\/Inotropes do not work in a low pH environment<\/span><\/h3>\n
<\/span>32. Beware of Metabolites<\/span><\/h3>\n
<\/span>33. Do not use erythromycin in patients on Tacrolimus or Cyclosporine<\/span><\/h3>\n
<\/span>34. Use lovenox rather than UFH for proph in trauma patients<\/span><\/h3>\n
<\/span>37. Do not use Lantus in the ICU without also using a short acting form<\/span><\/h3>\n
<\/span>38. Patients with insulin deficiency need basal insulin even when they are NPO<\/span><\/h3>\n
<\/span>39. Look for med-induced causes of hyperglycemia in ICU pts<\/span><\/h3>\n
<\/span>40. Do not use versed and ativan interchangeably<\/span><\/h3>\n
<\/span>41. Benzos are lousy drugs to promote sleep<\/span><\/h3>\n
<\/span>45. Check triglycerides in pts on propofol<\/span><\/h3>\n