{"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":"

<\/span>Avoiding Common ICU Errors<\/span><\/h2>\n

This is a summary of the incredible book by Lisa Marcucci et al., published by Wolters Kluwer<\/strong><\/p>\n

 <\/p>\n

<\/span>1. Monitor Patients who have received preservative free intrathecal morphine<\/span><\/h3>\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

<\/span>2. Characteristics of commonly used ICU opioids<\/span><\/h3>\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

<\/span>3. Clonidine for Drug Withdrawal<\/span><\/h3>\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

<\/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

equivalent of 5 mg of prednisone for at least 2 weeks in the previous year puts pts at risk for adrenal insufficiency<\/p>\n

<\/span>9. Use cisatracurium for patients who need NMBs and have hepatic and renal failure<\/span><\/h3>\n

Nimbex is cleared by hoffman elimination and does not cause histamine release. Onset 3-5 minutes, lasts ~30 minutes<\/p>\n

<\/span>10. Differentiate between Neostigmine and Neosynephrine<\/span><\/h3>\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

<\/span>13. Amiodarone causes Hypothyroidism<\/span><\/h3>\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

<\/span>16. Furosemide has a sulfa moiety<\/span><\/h3>\n

unknown if this really cross-reacts with the sulfonamide abx<\/p>\n

<\/span>19. Be alert to met acidosis in patients on Ativan Drip<\/span><\/h3>\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

<\/span>20. Be alert for the development of cyanide toxicity when admin nitroprusside<\/span><\/h3>\n

limit dose to less than 8 mcg\/kg\/min<\/p>\n

<\/span>23. Cardiac Pressors\/Inotropes do not work in a low pH environment<\/span><\/h3>\n

below ~7.15, these agents are less effective. (the literature I have seen disputes this though)<\/p>\n

<\/span>32. Beware of Metabolites<\/span><\/h3>\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

<\/span>33. Do not use erythromycin in patients on Tacrolimus or Cyclosporine<\/span><\/h3>\n

will sharply elevate drug levels<\/p>\n

<\/span>34. Use lovenox rather than UFH for proph in trauma patients<\/span><\/h3>\n

UFH is less effective in these patients<\/p>\n

<\/span>37. Do not use Lantus in the ICU without also using a short acting form<\/span><\/h3>\n

should only be used at low doses for basal needs, if it should be used at all<\/p>\n

<\/span>38. Patients with insulin deficiency need basal insulin even when they are NPO<\/span><\/h3>\n

DKA can develop otherwise<\/p>\n

<\/span>39. Look for med-induced causes of hyperglycemia in ICU pts<\/span><\/h3>\n

thiazides, beat agonists, diazoxide, steroids, ethanol, cyclosporine, pentamidine<\/p>\n

<\/span>40. Do not use versed and ativan interchangeably<\/span><\/h3>\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

<\/span>41. Benzos are lousy drugs to promote sleep<\/span><\/h3>\n

use ambien, chloral hydrate, or trazadone\/mirtazapine<\/p>\n

<\/span>45. Check triglycerides in pts on propofol<\/span><\/h3>\n

contains 1 kcal\/cc as soybean lipid. Causes excess trigly. which can lead to pancreatitis.<\/p>\n

<\/span>46. HIV patients can get drug-related pancreatitis; consider bowel rest if they do<\/span><\/h3>\n

do drug-drug interaction check for all patients on HAART<\/p>\n

<\/span>47. Consider fluconazole proph in crit ill pts with severe pancreatitis, abd sepsis, or multiple abd surgeries<\/span><\/h3>\n

Give 800 first dose and then 200-400 mg per day<\/p>\n

<\/span>48. Avoid Benzocaine to limit MetHb<\/span><\/h3>\n

methylene blue will show up as MetHb on co-ox<\/p>\n

<\/span>50. Know which weight to use when dosing meds<\/span><\/h3>\n

in the obese dose aminoglycosides, heparin, and amio by adjusted, not actual body weight<\/p>\n

<\/span>52. Dose diamox once a day<\/span><\/h3>\n

250-500 mg qd x 3-4 days<\/p>\n

<\/span>54. Do not give atrovent MDI in patients with nut allergy<\/span><\/h3>\n

<\/span>59. Avoid the RIJ approach in pts post cardiac transplant<\/span><\/h3>\n

it is often used for biopsy post-op<\/p>\n

<\/span>68. In normal physiology, the PA Wedge should be less than PA diastolic<\/span><\/h3>\n

<\/span>69. Do not use PA when there is tricuspid regurg<\/span><\/h3>\n

measurements will be inaccurate<\/p>\n

<\/span>90. Change the foley when a patient is dx with a UTI<\/span><\/h3>\n

<\/span>93. Understand the IABP<\/span><\/h3>\n

contraindications AI, aortoiliac disease, irreversible myocardial disease<\/p>\n

Confirm all on arrival to icu with xray<\/p>\n

normally synched to ecg, but if arrythymia is present, switch to aline<\/p>\n

<\/span>94. Right heart fx is common side effect of LVAD<\/span><\/h3>\n

rising CVP with constant or decreasing LVAD flows is one of the signs.<\/p>\n

treat any underlying abnormalities, give NO<\/p>\n

<\/span>95. Understand problems with ECMO<\/span><\/h3>\n

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<\/p>\n

Low flow states can be caused by compression of inflow cannula, clot<\/p>\n

Regional ischemia of distal leg<\/p>\n

<\/span>96. Treat any milky fluid from the chest or abd as chylous until proven otherwise<\/span><\/h3>\n

get triglycerides<\/p>\n

> 110 mg\/dl is chyle 99% of the time<\/p>\n

<50 chyle <5% of the time<\/p>\n

<\/span>101. Pulse ox is inaccurate with Saturations< 83%<\/span><\/h3>\n

<\/span>104. Preoxygenate before Intubation<\/span><\/h3>\n

Deep breaths will increase FRC<\/p>\n

<\/span>109. Use bronch during trach, do not use electrocautery<\/span><\/h3>\n

If you feel compelled to use the cautery lower fio2 to 21%<\/p>\n

<\/span>121. Be careful about excess PEEP after single lung transplant<\/span><\/h3>\n

<\/span>123. Do not reverse NMBs unless the patient is warm<\/span><\/h3>\n

hypothermia can extend duration of the competetive agents significantly. At 34 C duration of vec is doubled.<\/p>\n

<\/span>125. Do not reverse NMBs unless there is a twitch<\/span><\/h3>\n

<\/span>126. Remove BiPAP masks for 30 minutes ~ every 4 hours to avoid necrosis<\/span><\/h3>\n

<\/span>127. Treat VAP appropriately<\/span><\/h3>\n

Treat for 8 days, 14 for pseudomonas or acinetobacter<\/p>\n

Vanco\/Zosyn, Vanco\/Imipenem, Vanco\/Cefepime<\/p>\n

<\/span>129. Use CPIS (Clinical Pulmonary Infection Score) to diagnose VAP<\/span><\/h3>\n

score>6 is correlated well<\/p>\n

\"\"<\/a><\/p>\n

<\/span>130. Do not extubate based on clinical picture alone<\/span><\/h3>\n

Give 120 minute SBP<\/p>\n

RSBI 80-105 has a poorer rate of success<\/p>\n

<\/span>131. Consider Heliox in severe asthmatic or post-extubation stridor<\/span><\/h3>\n

<\/span>132. Parvovirus B19 INfection can cause anemia or Pancytopenia<\/span><\/h3>\n

especially in patients with hemolytic anemia for other reasons<\/p>\n

<\/span>133. Give abx proph if leeches are used on a free flap<\/span><\/h3>\n

bactrim, fluroquin, or 3rd gen ceph<\/p>\n

<\/span>134. Treat MRSA for a minimum of 14 days<\/span><\/h3>\n

<\/span>135. Linezolid causes thrombocytopenia and neutropenia<\/span><\/h3>\n

<\/span>136. Avoid caspofungin and voriconazole in patients with liver disease<\/span><\/h3>\n

<\/span>137. Also do not use them in patients with UTI, as very little goes to the urine<\/span><\/h3>\n

<\/span>138. Give a dose of abx before bile system is instrumented or manipulated<\/span><\/h3>\n

<\/span>139. Administer a dose of abx before upper urinary obstruction is relieved<\/span><\/h3>\n

<\/span>140. Enterococcus is a rare invasive pulmonary tract infection<\/span><\/h3>\n

<\/span>141. Lack of positive blood cultures does not rule out endocarditis<\/span><\/h3>\n

<\/span>143. Black lips or black spot on nasal or oral mucosa is a surgical emergency<\/span><\/h3>\n

Think mucormycosis<\/p>\n

Start on ampho<\/p>\n

need debridement<\/p>\n

<\/span>144. Check for cryptosporidium in immunosuppressed patients with chronic, severe, or refractory diarrhea<\/span><\/h3>\n

<\/span>145. Pay attention to the morphology reported on fungal cultures<\/span><\/h3>\n

Yeast-candida and cryptococcus<\/p>\n

Mold-they will report hyphae, think aspergillus<\/p>\n

<\/span>146. Consider fungal infection in patients with hypothermia and bradycardia<\/span><\/h3>\n

<\/span>149. Aim for peak of 10 times the MIC when treating pseudomonas with aminoglycosides<\/span><\/h3>\n

concentration dependent killing<\/p>\n

solely dependent on time above the MIC, not how high above the mic<\/p>\n

Other conc. dependent-quinolones, flagyl, daptomycin<\/p>\n

<\/span>150. Know the definition of catheter-related bloodstream infection<\/span><\/h3>\n

<\/span>158. If there is a normal platelet count, it can not be Hantavirus-Pulmonary Syndrome<\/span><\/h3>\n

<\/span>163. Use inopressors, not large volume fluid resus for PE<\/span><\/h3>\n

<\/span>164. If it looks like sepsis, it could be adrenal insufficieny, anaphylaxis, cirrhosis, thyrotoxicosis<\/span><\/h3>\n

<\/span>165. Any spine surg can cause a large SIRS response<\/span><\/h3>\n

suspect ibfection instead if still present on day 4<\/p>\n

<\/span>166. Always consider Abdominal Compartment Syndrome<\/span><\/h3>\n

<\/span>167. Abd pain out of proportion to exam is always mesenteric ischemia until proven otherwise<\/span><\/h3>\n

<\/span>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<\/span><\/h3>\n

for the first 12 hours you can not use this marker<\/p>\n

<\/span>171. Do not use urine output as a measure if the patient is cold<\/span><\/h3>\n

if they are not diureseing, they need more volume<\/p>\n

<\/span>172. Don’t overhydrate post-op liver transplant patients<\/span><\/h3>\n

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.<\/p>\n

<\/span>174. Do not rplete calcium if phosphorus is high and vice versa<\/span><\/h3>\n

can cause calciphylaxis<\/p>\n

<\/span>175. Check Phos post-op<\/span><\/h3>\n

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.<\/p>\n

<\/span>177. If you need to correct met alkalosis, keep K at high normal levels.<\/span><\/h3>\n

<\/span>182. Keep patients with dural tears flat for 24-48 hours<\/span><\/h3>\n

<\/span>183. Know the spinal stability status for all post-op and trauma patients<\/span><\/h3>\n

<\/span>185. Be alert for autonomic dysreflexia in spinal cord patients<\/span><\/h3>\n

stabilize blood pressure asap<\/p>\n

<\/span>187. Start a bowel regimen on SCI patients immediately<\/span><\/h3>\n

<\/span>216. Do not test pain at the toes or feet<\/span><\/h3>\n

even brain dead patients can have a reflex arc elicited here<\/p>\n

<\/span>219. Post HTN can be from hypercapnia<\/span><\/h3>\n

<\/span>221. Argatroban will increase INR\/PT, but this can not be used to monitor its effects, it does not affect the direct system<\/span><\/h3>\n

<\/span>222. Check serial MetHb levels while pt on Nitric Oxide<\/span><\/h3>\n

measure Q4-6 hours<\/p>\n

<\/span>224. Ask the lab for a synergy panel in resistant pseudomonas infections<\/span><\/h3>\n

have labs test effect of the combo you will use, not often predictable before testing<\/p>\n

<\/span>226. Check Thyroid levels in critically ill patients<\/span><\/h3>\n

<\/span>227. Use empty lab tube to check stoma viability<\/span><\/h3>\n

<\/span>233. Enteral feeds can lower phenytoin levels<\/span><\/h3>\n

<\/span>237. Use elemental or semielemental feeds in patients with albumin less than 2.5 g\/dL<\/span><\/h3>\n

<\/span>241. Be alert for hypophosphotemia in renal patients receiving dialysis<\/span><\/h3>\n

CVVH and CVVHD are continuous, will eventually suck out all phosphate<\/p>\n

<\/span>243. CRRT will mask temp spikes<\/span><\/h3>\n

<\/span>244. Do not give Fludrocortisone or ACEI to patients on CRRT<\/span><\/h3>\n

<\/span>255. Check CK levels after prolonged surgeries for Rhabdo<\/span><\/h3>\n

<\/span>267. Bleeding from direct thrombin inhibitors is not reversible<\/span><\/h3>\n

factor viia may work<\/p>\n

<\/span>305. Call the transplant team immediately if urine output decreases in a kidney transplant<\/span><\/h3>\n

<\/span>Resuscitation Version<\/span><\/h2>\n

Never do needle decompression in the ED<\/p>\n

Never give sux to a patient with contraindications<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Summary of Points from the book of the same name<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[18],"tags":[],"yoast_head":"\nAvoiding Common ICU Errors - Crashing Patient<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/crashingpatient.com\/intensive-care\/avoiding-common-icu-errors.htm\/\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"CrashMaster\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"9 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/crashingpatient.com\/intensive-care\/avoiding-common-icu-errors.htm\/\",\"url\":\"https:\/\/crashingpatient.com\/intensive-care\/avoiding-common-icu-errors.htm\/\",\"name\":\"Avoiding Common ICU Errors - 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