42 Questions
What is the importance of initiating enteral feeding in critically ill patients?
To prevent malnutrition and impaired immune function
What is the goal of pain management in critically ill patients?
To minimize the acute stress response
What is the benefit of elevating the head of the bed in mechanically ventilated patients?
Reducing the occurrence of GI reflux and nosocomial pneumonia
What is the purpose of daily sedative interruption in critically ill patients?
To assess and reassess sedation levels
Why is stress ulcer prophylaxis important in critically ill patients?
To prevent clinically significant bleeding
What is the importance of thromboembolic prophylaxis in critically ill patients?
To reduce the risk of VTE
What is the purpose of assessing pain regularly with a validated tool in critically ill patients?
To assess and manage pain effectively
What is the benefit of maintaining light levels of sedation in critically ill patients?
To reduce the acute stress response
Why is analgesia important in critically ill patients?
To minimize the acute stress response
What is the importance of considerating VTE and bleeding risks when initiating thromboembolic prophylaxis?
To balance the risks of VTE and bleeding
What is the recommended blood glucose level for acutely ill patients when blood glucose concentrations are ≥ 150 mg/dL?
140-180 mg/dL
What is the primary importance of glycemic control in critically ill patients?
To decrease the incidence of complications
What does the 'S' stand for in the updated FAST-HUGS BID mnemonic?
Spontaneous breathing trial
What is the primary focus of the MAIDENS mnemonic?
Medication management
What is the purpose of daily checklists in the FAST-HUG approach?
To provide a framework for standardization and regulation of interventions
What is the 'I' component in the FAST-HUGS BID mnemonic?
Indwelling catheter removal
What is the 'D' component in the MAIDENS mnemonic?
Drug dosing
What is the 'N' component in the MAIDENS mnemonic?
No drug interactions, allergies, duplications, adverse effects
Why is Sucralfate not recommended for routine use?
Due to adverse effects and interactions
What is the main mechanism of action of H2RAs?
Competitive blockade of histamine receptors
Why does tolerance occur with the use of H2RAs?
Due to the up-regulation of alternative pathways
What is the effect of H2RAs on gastric pH?
An increase in gastric pH
What is a potential benefit of H2RAs in animal models?
Attenuation of reperfusion injury
What is the current practice for administering H2RAs?
Intermittent administration without pH monitoring
What adjustment is required for H2RAs?
Renal dosing adjustment
Why are Sucralfate and H2RAs used in SRMD-related bleeding?
To maintain a pH greater than 4
What percentage of patients in the H2RA group received H2RA exclusively?
63.4%
What is the definition of occult bleeding?
Presence of guaiac-positive stools or nasogastric aspirate
What is the range of incidence of endoscopically evident mucosal damage in ICU patients?
75%-100%
What is the relative risk of clinically important bleeding with PPI versus H2RA?
0.73
What is the primary cause of stress ulcer-related bleeding?
Hypovolemia and decreased cardiac output
Which of the following is a mechanism common to critical illness that leads to reduced splanchnic blood flow?
Proinflammatory mediator release
What is the percentage of patients in the PPI group who received PPI exclusively?
82.5%
What is a risk factor for stress-related bleeding?
Respiratory failure requiring mechanical ventilation for 48 hours or longer
What is the definition of overt or clinically evident bleeding?
Hematemesis, melena, or hematochezia
What is the range of incidence of clinically important bleeding in ICU patients?
1%-5%
What is the result of decreased gastric blood flow and mucosal ischemia?
Stress ulcer-related bleeding
Why may increases in gastric pH lead to infectious complications?
Due to promotion of bacterial overgrowth
What is a consequence of reperfusion injury after prolonged periods of hypoperfusion?
Stress ulcer-related bleeding
What is the incidence of bleeding in patients with at least one risk factor?
3.7%
What is the result of acid back-diffusion in the stomach?
Stress ulcer-related bleeding
What is the difference between peptic ulcers and stress ulcers?
Cause of the lesions
Study Notes
Supportive and Preventive Medicine
- The FAST-HUG mnemonic emphasizes important aspects of ICU medicine that can be applied daily to all critically ill patients to ensure safe, effective, and efficient care.
- Key elements of the FAST-HUG approach include:
- Feeding: initiate enteral feeding as soon as possible, typically within the first 24-48 hours after stabilization
- Analgesia: optimize patient comfort and minimize acute stress response
- Sedation: assess and reassess with a validated tool, maintain light levels of sedation, and consider daily sedative interruption
- Thromboembolic prophylaxis: initiate appropriate prophylaxis, considering VTE and bleeding risks
- Head of bed elevation: elevate the head and thorax above bed to a 30-45 degree angle to reduce the occurrence of GI reflux and nosocomial pneumonia
- Stress ulcer prophylaxis: consider discontinuing acid-suppressive medications when risk factors are no longer present
- Glycemic control: maintain blood glucose at 140-180 mg/dL in critically ill patients
Additional Mnemonics
- FAST-HUGS BID: a mnemonic that includes spontaneous breathing trials, bowel regimen, indwelling catheter removal, and de-escalation of antimicrobials
- MAIDENS: a mnemonic with a medication focus that includes medication reconciliation, antibiotics or anti-infectives, indications for medications, drug dosing, electrolytes, and no drug interactions, allergies, duplications, or adverse effects
Pathophysiology of Stress-Related Mucosal Damage (SRMD)
- Decreased gastric blood flow and mucosal ischemia are the primary causes of SRMD-related bleeding
- Additional factors leading to SRMD-related bleeding include:
- Decreased gastric mucosal bicarbonate production
- Decreased gastric emptying of irritants and acidic contents
- Acid back-diffusion
- Reperfusion injury
Risk Factors and Prevention of Stress-Related Bleeding
- Independent risk factors for SRMD and bleeding include respiratory failure requiring mechanical ventilation for 48 hours or longer and coagulopathy
- Prevention strategies include:
- Sucralfate (Carafate): not recommended for routine use due to adverse effects and interactions
- H2RAs: competitive blockade of histamine receptors on the basolateral membrane of the parietal cells, not reliably inhibiting vagally induced acid secretion
- PPIs: reduce the incidence of clinically important bleeding compared to H2RAs
Review critical care pharmacy topics, including general care of critically ill patients, with a focus on the FAST-HUG mnemonic and other essential concepts. Prepare for the ACCP Updates in Therapeutics 2022 exam with this comprehensive review.
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