ICU – helpful tips

Sedatives:

  • ***Propofol (usually start here; can increase TG and can decrease BP and decrease HR – monitor)
  • Versed (Midazolam – benzodiazepine) – helpful when sedating patient with substance abuse/withdrawal
  • Fentanyl (helps with pain) – add Colace to mitigate constipation
  • Precedex (when trying to extubate; very expensive, limit use) – often used with difficult extubations/patients with substance abuse histories
  • Paralysis:
    • Rarely, may need to paralyze patient on vent to correct dyssynchrony (Pt with elevated RR even when on vent):
      • Will allow RR of patient to match that of vent (pt will not fight the vent, pt may require deeper sedation, allow for “permissible hypercapnia”). May be used if patient in ARDS or very severe lung failure requiring very high PEEP to maintain oxygenation. Helpful if high peak pressures, high autoPEEP.
        • Norcuron 10mg IV q2hr.
          • Starting Norcuron and/or elevating PEEP with decrease BP. May need Levophed drip PRN.
        • Cisatracurium besylate (Nimbex) drip – 3mcg/kg/min IV
          • Good option for renal and/or hepatic failure.***

Pressors:

Arterial line needed for accurate MAP measurement (Goal MAP >65) and if frequent ABGs

Central line to give vasopressors longer term and to monitor CVP (Goal: 8-12, if low, patient needs fluids). [CVP = central venous pressure]

  1. ***Levaphed (NE) (usually 1st start here) – can cause arrhythmia
    • +A1 (vasoconstriction) and +B1 (inotropic, better squeeze, increase CO)
    • Max dose: 30
  2. Epinephrine: Start 2nd with Levophed
    • + A1, +B1, +B2 = vasoconstriction and increase CO – can cause worsening tachycardia
  3. Vasopressin: Do NOT use alone, use as an add-on combo with other pressors. Start 2nd with Levophed if tachycardic already.
    • Pure vasoconstriction
    • Max dose: 0.04
    • When titrating down when patient is on Levophed 30 (max) and Vasopressin 0.04 (max):
      • Continue both but titrate down on Levophed until Levophed <15, then stop Vasopressin
  4. Dopamine: Action is dose dependent: 1-5 vasodilate, 5-10 +B, >10 +A
  5. Phenylephrine (Neo-Synephrine) – thought to be less effective, added last
    • Used primarily after surgery because it acts as pure vasoconstriction (treat vasoplagia).
    • Max dose: 180-200

Cardiogenic shock*** New evidence suggests Levaphed alone may be used alone in Cardiogenic shock.

  • Dobutamine or Dopamine
    • Dobutamine: canNOT be used alone; order with Levaphed.
    • ***Dopamine: CAN use alone! Order if bradycardic and hypotensive.
      • Caution: Dopamine may induce arrhythmias as well.
    • Correct underlying cause of cardiogenic shock:
      • Ex: Hyperkalemia causes Vtach with poor CO.

Less often used pressors:

  • Isoproterol (similar to Dopamine, used for rate control by cardio)
  • Milrenone: PDE MOA

Assess CO:

  • Start Vigileo.

If local infiltration of pressor to subcutaneous tissue, order:

  • Phentolamine 10mg subQ X 1.

Recommend setting up orders in EPIC for Sedatives and Pressors ahead of time and starring saved orders:

Levophed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


dopamine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neo

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

***Also consider adding Solu-Cortef IV (Hydrocortisone) 100mg IV q8hr. (Order random Cortisol level 1st). Consider that the patient may have adrenal insufficiency and therefore give a steroid since the patient’s body may not be able to produce enough cortisol on its own. Cortisol causes blood vessels to become more sensitive to NE and therefore facilitates vasoconstriction to maintain BP. When Cortisol level is low, such as in the presence of adrenal insufficiency, the patient may remain hypotensive and not respond well to NE.

For sepsis:

  • Give 30cc/kg of IV fluid within first 3 hours (about 2L IV fluid bolus stat).
  • Order Lactate level and trend lactate
  • Give IV antibiotics.
  • Order blood cultures too!
  • Complete “sepsis protocol note:” Type “.sepsis” (EPIC), and it will come up.

Bicarb:

  • Add bicarb drip if low pH (on ABG): pH <7.2
  • Can give IV pushes (2-5 amps at a time). Note: 1amp = 50ml = 50mEq, so 2amps = 100mEq = 100ml
    • 2 amps is isotonic while 3 amps in D5 is hypertonic.

Stat labs to order during a code: Glucose – fingerstick, CBC, BMP, Magnesium, Phosphate, ABG, Troponin, lactic acid, PT/INR

To mitigate development of arrhythmias:

  1. Maintain Magnesium > 2.0
  2. Maintain Potassium > 4.0

After intubation: Always order portable chest x-ray to confirm proper placement.

  • Example initial ventilator settings: FiO2 100%, TV 450, PEEP 5, RR 14.
  • Example initial BiPAP settings: IPAP: 10-12 cm H2O, EPAP: 5 cm H2O, Rate: 12, and FiO2 to maintain O2 saturation > 88%
  • Example initial CPAP settings: 8-10 cm H2O and FiO2 to maintain O2 saturation > 88%

Bristol ICU:

  • Intubation: Stat page anesthesia – Anesthesia will come emergently to intubate.
    • Order stat portable chest x-ray and check for proper placement.
  • Central line/arterial line: Page surgery resident to place until you are signed off.

Random:

  • If complete white out of one lung, patient may have mucus plugging (may require bedside bronch to remove)

ICU with intractable seizures:

1. Control intractable seizures:

  • Ativan PRN
  • Consider Propofol vs Versed drip
    • Propofol can cause a decrease in BP, so if patient has hypotension too, choose Versed.
  • Fosphenytoin (Cerebyx) loading dose
    • Order Fosphenytoin 1,800mg PE in NS 50ml IV.
      • Dose: 18mg PE/kg IV X 1 dose.
  • Phenytoin (Dilantin) 100mg IV q8hr
    • Order to follow the Fosphenytoin (Cerebyx) loading dose.
  • Vimpat (Lacosamide) 200mg in NS 100ml IV
    • Dose: 200mg IV q12hrs

Example: Tonic-clonic seizure-like activity, new onset following cardiac arrest with ROSC: Patient has received multiple doses of Ativan IV. Started Versed drip for sedation and for anti-epileptic properties. Spoke with pharmacy: Started Fosphenytoin one time loading dose. Started Phenytoin IV.

2. Prevent seizures:

  • Keppra 500mg IV q12 hours.

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