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10/12/2012

FAST-HUG

Mnemonic device hihlighting general


considerations in all ICU patients
Give Your Patients a FAST- Feeding
HUG g
Analgesia
Sedation
ICU Clinical Pearl
Thromboembolic prophylaxis
Charles Darling, PharmD Head-of-bed elevation
PGY-2 Critical Care Pharmacy Resident
Greenville Memorial Hospital, Greenville, SC Stress Ulcer Prophylaxis
Glucose control

Crit Care Med 2005; 33:1225-1229

Feeding Analgesia
Should be initiated within first 24-48 hours of Pain assessment in ICU can be difficult
admission Mechanical ventilation/ sedation
Oral> enteral> parenteral Alternative ways to assess for pain
If the gut works, use it!
Grimacing
Typically require 25-35 mg/kg day
Tachycardia
Critically ill patients may require more calories
Elevated blood pressure
Monitoring
Pre-albumin Medications for pain
Not accurate in critically ill patients NSAIDs
BUN Acetaminophen
Marker of possible over-feeding
Crit Care Med 2005; 33:1225-1229
Opioids Crit Care Med 2005; 33:1225-1229

Analgesia Sedation
Many ICU patients require IV pain control Mechanical ventilation often requires
Opioids are most effective sedation
May be given by continuous infusion and bolus MV is uncomfortable
Patient controlled analgesia (PCA) Propofol most common agent used
Beware side effects Propofol Infusion Syndrome (PRIS)
Respiratory depression Cardiac failure, renal failure, rhabdomyolysis
Fentanyl least likely
Hypertriglyceridemia
Constipation
Tolerance does NOT develop Beware over sedation
Hypotension Dont sedate just to quiet a patient!
Hallucinations Daily sedation holiday
Rash May shorten ICU LOS
Morphine

Crit Care Med 2005; 33:1225-1229 Crit Car Med 2005; 33:1225-1229/ Intensive Care Med. 2003 Sep;29(9):1417-25

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10/12/2012

Thromboembolic Prophylaxis Head-of-bed Elevation


Can occur between 13-31% of patients not Bed inclined >45 degrees
receiving prophylaxis
May be higher in trauma patients Many benefits
Heparins are most often used Gastroesophogeal reflux
Unfractionated heparin 5000 units Q8
Q8-12
12 hours Lower
L rates
t off nosocomial
i l pneumonia
i
Enoxaparin 30mg Q12 hrs or 40mg Q24 hrs (HCAP/VAP)
Renal function!
Dalteparin 5000 units Q24 hrs Less aspiration
Heparin induced thrombocytopenia (HIT)
Platelets drop >50% or below absolute count
<100,000
Occurs 5-7 days after initiation
Crit Care Med 2005; 33:1225-1229 Crit Care Med 2005; 33:1225-1229

Stress Ulcer Prophylaxis Stress Ulcer Prophylaxis


Goal: Prevent stress related Therapy options
gastrointestinal hemorrhage H2RAs- adjust for CrCl <50 mL/min
Ranitidine 150 mg BID
Most ICU patients will require prophylaxis Famotidine 20 mg BID
Mechanical ventilation PPIs (p
(pantoprazole,
p , lansoprazole)
p )
Pantoprazole 40 mg Qday
Coagulation abnormalities Lansoprazole 30 mg Qday
Other indications Adverse reactions
History of gastric ulcers CNS disturbances (H2RAs)
Multiple trauma Anxiety, confusion, agitation
C. difficile infections (PPIs)
Glasgow Coma Score <10
Spinal cord injury
Crit Care Med 2005; 33:1225-1229

Glucose Control Glucose Control


Many patients in ICU will have hyperglycemia NICE trial
Mostly stress induced due to acute illness Compared ranges of glucose control
Corticosteroids 81-108 mg/dL vs. <180 mg/dL
Diuretics
Mortality
Hyperglycemia associated with adverse 27.5% in intensive control group
outcomes in ICU
24.9% in conventional control group
Increased hospital and ICU lengths of stay
P= 0.02
Increased risk for infections
OLD practice No difference
ICU or hospital LOS
The tighter the better (80-110 mg/dL)
Mechanical ventilation days
Renal replacement therapy
Crit Care Med 2005; 33:1225-1229 N Engl J Med 2009; 360:1283-1297

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10/12/2012

Glucose Control
NEW practice
Achieve glucose levels <180 mg/dL
Insulin Give Your Patients a FAST-
Most effective way to control glucose in ICU setting
Sliding
g scale HUG
Effective, but more resource intensive
Basal insulin (glargine, detemir) ICU Clinical Pearl
Use if hyperglycemic is expected to occur for many days
Calculate by the amount of SSI patient has been getting in 24 Charles Darling, PharmD
hrs
PGY-2 Critical Care Pharmacy Resident
Transitioning off continuous infusion (if stable)
Greenville Memorial Hospital, Greenville, SC
Calculate rate from past 6-8 hours X3 (24 hrs)
Administer long acting insulin 2 hours before infusion is
stopped

Crit Care Med 2005; 33:1225-1229