LUNCH AND LEARN. November 13, 2015

Transcription

1 LUNCH AND LEARN Sterile Products Used in the Critical Care Practice Setting November 13, 2015 Featured Speaker: Jeremy P. Hampton, PharmD, BCPS Clinical Assistant Professor University of Missouri Kansas City School of Pharmacy Clinical Specialist Emergency Medicine Truman Medical Center 1 CE Activity Information & Accreditation (Pharmacist and Tech CE) 1.0 contact hour Funding: This activity is self funded through PharMEDium. It is the policy of 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

2 Online Evaluation, Self-Assessment and CE Credit Submission of an online self assessmentand and evaluation isthe only way to obtain CE credit for this webinar Go to Print your CE Statement online Live CE Deadline: December 11, 2015 CPE Monitor CE information automatically uploaded to NABP/CPE Monitor within 1 to 2 weeks of the completion of the self assessment and evaluation Event Code Code will be provided at the end of today s activity Event Code not needed for On Demand 3 Ask a Question Submit your questions to your site manager. Questions will be answered at the end of the presentation. Your question...? 4 2

3 Sterile Products Used in the Critical Care Practice Setting Resources Visit to access: Handouts Activity information Upcoming live webinar dates Links to receive CE credit 5 Sterile Products in the Critical Care Practice Setting Jeremy P. Hampton, PharmD, BCPS Clinical Assistant Professor University of Missouri-Kansas City School of Pharmacy Emergency Medicine Clinical Specialist Truman Medical Center 6 3

4 Objectives Identify the therapeutic areas often of concern 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 critical care patients. t Describe the mechanism of action of 4 medications used in critical care patients. 7 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 4

5 Types of ICUs Medical (MICU) Surgical (SICU) Trauma, Transplant (TICU) Neonatal (NICU) Pediatric (PICU) Cardiovascular (CVICU) Coronary Care (CCU) Cardiac (CICU) Burn (BICU) Neurosurgical (NSICU) 9 Protocols and Checklists

6 A Common Approach to Care FAST HUG Feeding Analgesia Sedation Thromboembolism prophylaxis Head of bed Ulcer (stress) prophylaxis Glucose control 11 is for Feeding Malnourishment associated with poor outcomes Often undernourished on admission

7 is for Analgesia The blunting or absence of pain or noxious stimuli 13 The Problem with Inadequate sleep Hypercoagulability Protein catabolism Increased myocardial oxygen consumption

8 5,957 patients undergoing painful procedure Over 63%; NO ANALGESIA prior Take the Pain Away Among ICU patients 82% remember intubation related pain 38% say pain is most traumatic memory 6 months later! 27% show signs and symptoms of PTSD 15 Options

9 Opiate Pharmacology Agent Typical dose Onset Duration Comments Fentanyl Morphine Hydromorphone mcg/kg IV push q1h mcg/kg/hour IV infusion 2 4 mg IV push q1-2h 2 30 mg/hour IV infusion mg IV push q2-4h mg/hour IV infusion 1-2 min 2-4 hr Minimal histamine release hr Histamine release - min > hypotension; Active metabolites 5-15 min 2-3 hr Option for those with fentanyl or morphine tolerance 17 is for Sedation Agitation and anxiety common Associated with negative outcomes if untreated Treat underlying causes

10 Easier to take care of deeply sedated patients? Depth of Sedation They re getting good sleep right? 19 Deeper isn t always better Increased time on the vent Increased rates of delirium Increased mortality

11 Sedation Options 21 Fast! Onset in seconds 3-10 minute duration Propofol Bolus: mcg/kg IV Infusion: 5-75 mcg/kg/min IV Lipid emulsion Negative inotrope

12 is for Thromboembolic Prophylaxis Pulmonary embolism (PE) Deep venous thrombosis (DVT) 13-31% incidence without prophylaxis (Higher in trauma) Significant morbidity and mortality 23 Heparin Considered standard of care Reduces incidence id of DVT/PE by 78% in high risk patients Rapid onset Short half-life (1.5h) Prophylaxis: 5,000 units SQ Q8H May be used as continuous infusion for treatment of DVT/PE

13 H E P A R I N 25 is for Head of Bed Elevated 45 degrees (if intubated) Decreases incidence of gastroesophageal reflux (GERD)

14 is for Ulcer Prophylaxis Stress-related mucosal damage (SRMD) Mortality: 24% 57% Greatest risk in Intubated patients Coagulopathy 27 Famotidine Histamine H(2)-receptor antagonist 20mg IV Q12h Rapid onset Renal dysfunction? 50 for

15 is for Glucose Control Correlation between glucose and mortality Keep between mg/dl Insulin drip Dextrose bolus or infusion 29 Common Systems Affected Cardiovascular Respiratory Metabolic Gastrointestinal Central Nervous System

16 Shock / Hypotension Cardiogenic i Hypovolemic Distributive ib ti 31 The Receptors

17 Vasopressors Norepinephrine Epinephrine Vasopressin Dopamine Phenylephrine 33 Norepinephrine α 1, α 2, and β 1 agonism First line vasopressor Dosing: mcg/kg/min IV Central vs. peripheral infusion

18 Vasopressin V 1 receptor agonist Adjunct treatment Dosing: 0.04 units/min IV Works in acidotic environment 35 Pressors and Potencies Drug α 1 β 1 β 2 DA V 1 Dopamine Epinephrine Norepinephrine Phenylephrine Vasopressin

19 Hypertensive Emergency High blood pressure with end organ damage Avoid dropping precipitously ~25% Nicardipine 37 Heart Failure The failure to pump sufficient blood to make the kidneys excrete daily the necessary amounts of fluid Reduction of preload and afterload are key Ernest Starling

20 Furosemide Blocks reabsorption of sodium and chloride in the loop of Henle Profound increase in urine output 39 Furosemide Individualized bolus dosing: 1 2.5mg IV x oral dose OR 20 40mg IV May double Q2h if no response Bolus vs. infusion? i Onset: 30 min Peak: 1-2 hours Half-life: 2 hours (IV)

21 Atrial Fibrillation Irregularly-irregular rhythm Absence of P waves Fast atrial fibrillation = rapid ventricular response Emergent rate control indicated 41 Diltiazem Non-dihydropyridine calcium channel blocker Onset: 3 minutes Duration: hours Bolus: 0.25 mg/kg IV followed by 0.35 mg/kg IV after 5-15 min (if no response) Infusion: 5 15 mg/hour

22 Amiodarone Broad-spectrum antiarrhythmic Reserved for heart failure Variable dosing 300 mg IV bolus over 1 hour followed by mg/hr OR 150mg IV bolus over 10 min followed by infusion of 1 mg/min x 6 hr, then 0.5 mg/min x 18 hours. 43 Summary The ICU can be a setting of controlled chaos An ICU for every occasion HUG: FAST and often Systems-based approach recommended

23 References Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med Jun;33(6): 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): 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: 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: Kanter J, DeBlieux P. Pressors and inotropes. Emerg Med Clin N Am 2014; 32: Lindenfeld J, AlbertNM NM, etal al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16(6):e1 Yancy CW, Jessup M, et al 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: