sterile products used in the critical care practice...

Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series

ProCE, Inc.www.ProCE.com 1

Sterile Products Used in the Critical Care Practice SettingNovember 13, 2015

LUNCH AND LEARN

Featured Speaker: Jeremy P. Hampton, PharmD, BCPS

Clinical Assistant ProfessorUniversity of Missouri ‐ Kansas City School of PharmacyClinical Specialist ‐ Emergency MedicineTruman Medical Center

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CE Activity Information & Accreditation

ProCE, Inc. (Pharmacist and Tech CE)

1.0 contact hour

Funding: This activity is self‐funded through

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g y gPharMEDium.

It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Dr. Hampton has no relevant commercial and/or financial relationships to disclose.



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Sterile Products in the Critical Care Practice

SettingSettingJeremy P. Hampton, PharmD, BCPS

Clinical Assistant Professor

University of Missouri-Kansas City School of Pharmacy

Emergency Medicine Clinical Specialist

Truman Medical Center

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Objectives

• Identify the therapeutic areas often of concern in the critical care patientconcern in the critical care patient.

• List the indication(s) of 4 medications used in critical care patients.

• Describe the appropriate dosing and administration of 4 medications used in

iti l ti tcritical care patients.• Describe the mechanism of action of 4

medications used in critical care patients.

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What is Critical Care?• Direct delivery of

medical care for a critically ill or injured patient.

• One or more vital organ systems impaired– Imminent deterioration

or death

• Requires high complexity medical decision-making 8



Types of ICUsMedical (MICU)Surgical (SICU)Trauma TransplantTrauma, Transplant (TICU)Neonatal (NICU)Pediatric (PICU)Cardiovascular (CVICU)Coronary Care (CCU)Cardiac (CICU)Cardiac (CICU)Burn (BICU)Neurosurgical (NSICU)

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Protocols and Checklists

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A Common Approach to Care

FAST HUGFeeding

Analgesia

Sedation

Thromboembolism prophylaxis

Head of bed

Ulcer (stress) prophylaxis

Glucose control

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is for Feeding

Malnourishment associatedwith poor outcomes

Often undernourished on admission

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is for Analgesia

The blunting or absence of painor noxious stimuli

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The Problem with

Inadequate sleep Protein catabolismq p

Hypercoagulability Increased myocardial oxygen consumption

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Take the Pain Away

• 5,957 patients undergoing painful

dprocedure– Over 63%; NO

ANALGESIA prior

• Among ICU patients– 82% remember

intubation related painp– 38% say pain is most

traumatic memory…6 months later!

– 27% show signs and symptoms of PTSD

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Options

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Opiate Pharmacology

Agent Typical dose Onset Duration Comments

Fentanyl 0.35 – 0.5 mcg/kgIV push q1h

0.7-10 mcg/kg/hour IV infusion

1-2 min 2-4 hr Minimal histamine release

Morphine 2 – 4 mg IV push q1-2h

5-10 min

3-4 hr Histamine release -> hypotension;q1 2h

2 – 30 mg/hour IV infusion

min hypotension; Active metabolites

Hydromorphone 0.2 – 0.6 mg IV push q2-4h

0.5 – 3 mg/hour IV infusion

5-15 min

2-3 hr Option for those with fentanyl or morphine tolerance

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is for Sedation

Agitation and anxiety common

Associated with negativeoutcomes if untreated

Treat underlying causes

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Depth of Sedation

Easier to take care of deeply sedateddeeply sedated patients?

They’re getting good sleep right?

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Deeper isn’t always better…

Increased time on the vent

Increased rates of delirium

Increased mortality

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Sedation Options

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Propofol

Fast!– Onset in seconds

– 3-10 minute duration

Bolus: 0.5 – 2 mcg/kg IV

Infusion: 5-75 mcg/kg/min IV

Lipid emulsion

Negative inotrope

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is for Thromboembolic Prophylaxis

Pulmonary embolism (PE)

13-31% incidence without prophylaxis

(Higher in trauma)

Deep venous thrombosis (DVT)

(Higher in trauma)

Significant morbidityand mortality

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Heparin

• Considered standard of careR d i id f DVT/PE b 78% i• Reduces incidence of DVT/PE by 78% in high risk patients

• Rapid onset• Short half-life (1.5h)• Prophylaxis: 5,000 units SQ Q8HProphylaxis: 5,000 units SQ Q8H• May be used as continuous infusion

for treatment of DVT/PE

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H E P A R I NH E P A R I N

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is for Head of Bed Elevated

45 degrees (if intubated)

Decreases incidenceDecreases incidenceof gastroesophagealreflux (GERD)

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is for Ulcer Prophylaxis

• Stress-related mucosal damage (SRMD)

• Mortality: 24% 57%

• Greatest risk in – Intubated patients

– Coagulopathy

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Famotidine

Histamine H(2)-receptor antagonistg

20mg IV Q12h

Rapid onset

Renal dysfunction?– 50 for 50

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is for Glucose Control

Correlation between glucose

and mortality

Keep between 140-180 mg/dl

Insulin drip

Dextrose bolus or infusion

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Common Systems Affected

C di lCardiovascular

Respiratory

Metabolic Gastrointestinal

Central Nervous SystemCentral Nervous System

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Shock / Hypotension

C di iCardiogenic

Hypovolemic

Di t ib tiDistributive

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The Receptors

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Vasopressors

Norepinephrine

Epinephrine

Vasopressin

Dopamine

Phenylephrine

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Norepinephrine

α1, α2, and β1 agonism

First line vasopressor

Dosing:0.01 – 3 mcg/kg/min IV

Central vs. peripheralinfusion

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Vasopressin

V1 receptor agonist

Adjunct treatment

Dosing:0.04 units/min IV

Works in acidotic environment

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Drug α1 β1 β2 DA V1

Dopamine +++ ++++ ++ ++++ -

Pressors and Potencies

Epinephrine +++++ ++++ +++ - -

Norepinephrine +++++ +++ ++ - -

Phenylephrine +++++ - - - -

Vasopressin - - - - +

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Hypertensive Emergency

High blood pressure with end

organ damage

Avoid dropping i i lprecipitously ~25%

Nicardipine37

Heart Failure

The failure to pump sufficient blood to makethe kidneys excrete daily the necessaryamounts of fluid

Reduction of preloadand afterload are key

Ernest Starling38



Furosemide

Blocks reabsorption ofBlocks reabsorption of sodium and chloride in the loop of Henle

Profound increase in urine outputp

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FurosemideIndividualized bolus dosing:

1 – 2.5mg IV x oral dose OR

20 – 40mg IV

May double Q2h if no response

B l i f i ?Bolus vs. infusion?

Onset: 30 minPeak: 1-2 hours

Half-life: 2 hours (IV)40



Atrial Fibrillation

Irregularly-irregular rhythm

Ab f PAbsence of P waves

Fast atrial fibrillation = rapid ventricular response

Emergent rate control indicated 41

DiltiazemNon-dihydropyridine calcium channel blocker

Onset: 3 minutes

Duration: 0.5 – 10 hours

Bolus: 0 25 mg/kg IV followed byBolus: 0.25 mg/kg IV followed by 0.35 mg/kg IV after 5-15 min (if no response)

Infusion: 5 – 15 mg/hour42



Amiodarone“Broad-spectrum” antiarrhythmic

Reserved for heart failureReserved for heart failure

Variable dosing • 300 mg IV bolus over 1 hour

followed by 10-50 mg/hrOR

• 150mg IV bolus over 10 minfollowed by infusion of 1 mg/min x 6 hr, then 0.5 mg/minx 18 hours.

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SummaryThe ICU can be a setting of controlledgchaos

An ICU for everyoccasion

HUG “FAST” d ftHUG: “FAST” and often

Systems-based approach recommended

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References• Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005

Jun;33(6):1225-9• Barr J, Fraser GL, et al. Clinical practice guidelines for the management of pain, agitation,

and delirium in adult patients in the intensive care unit Crit Care Med 2013; 41(1):263 306and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41(1):263-306• Peitz GJ, Balas MC, et al. Top 10 myths regarding sedation and delirium in the ICU. Crit

Care Med 2013; 41(9):S46-56• Bussey H. Traditional Anticoagulant therapy: Why abandon half a century of success?

AJHP 2002;59(Suppl 6):53-6• Peura DA, Johnson LF. Cimetidine for prevention and treatment of gastroduodenal

mucosal lesions in patients in an intensive care unit. Ann Int Med 1985; 103:173-177 • Nurmohamed MT, Rosendaal FR, Buller HR, et al. Low molecular- weight heparin versus

standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet 1992; 340:152–156

• Kanter J, DeBlieux P. Pressors and inotropes. Emerg Med Clin N Am 2014; 32:823-34Lindenfeld J Albert NM et al HFSA 2010 Comprehensive Heart Failure Practice• Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16(6):e1

• Yancy CW, Jessup M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240.

• Goralnick E, Bontempo LJ. Atrial Fibrillation. Emerg Med Clin N Am 2015; 33:597-612

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