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
1
CE Activity Information & Accreditation
ProCE, Inc. (Pharmacist and Tech CE)
1.0 contact hour
Funding: This activity is self‐funded through
2
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.
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 2
Submission of an online self‐assessment and evaluation is the
Online Evaluation, Self-Assessmentand CE Credit
Submission of an online self assessment and evaluation is the only way to obtain CE credit for this webinar
Go to www.ProCE.com/PharMEDiumRx
Print your CE Statement online
Live CE Deadline: December 11, 2015
CPE Monitor
3
– 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 activityEvent Code not needed for On‐Demand
Ask a Question
Submit your questions to your site manager.
Questions will be answered at the end of the presentation.
4
Your question. . . ?
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 3
Resources
Visit www.ProCE.com/PharMEDiumRx to access:
Handouts– Handouts
– Activity information
– Upcoming live webinar dates
– Links to receive CE credit
5
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
6
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 4
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.
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
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 5
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)
9
Protocols and Checklists
10
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 6
A Common Approach to Care
FAST HUGFeeding
Analgesia
Sedation
Thromboembolism prophylaxis
Head of bed
Ulcer (stress) prophylaxis
Glucose control
11
is for Feeding
Malnourishment associatedwith poor outcomes
Often undernourished on admission
12
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 7
is for Analgesia
The blunting or absence of painor noxious stimuli
13
The Problem with
Inadequate sleep Protein catabolismq p
Hypercoagulability Increased myocardial oxygen consumption
14
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 8
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
15
Options
16
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 9
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
17
is for Sedation
Agitation and anxiety common
Associated with negativeoutcomes if untreated
Treat underlying causes
18
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 10
Depth of Sedation
Easier to take care of deeply sedateddeeply sedated patients?
They’re getting good sleep right?
19
Deeper isn’t always better…
Increased time on the vent
Increased rates of delirium
Increased mortality
20
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 11
Sedation Options
21
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
22
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 12
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
23
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
24
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 13
H E P A R I NH E P A R I N
25
is for Head of Bed Elevated
45 degrees (if intubated)
Decreases incidenceDecreases incidenceof gastroesophagealreflux (GERD)
26
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 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 antagonistg
20mg IV Q12h
Rapid onset
Renal dysfunction?– 50 for 50
28
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 15
is for Glucose Control
Correlation between glucose
and mortality
Keep between 140-180 mg/dl
Insulin drip
Dextrose bolus or infusion
29
Common Systems Affected
C di lCardiovascular
Respiratory
Metabolic Gastrointestinal
Central Nervous SystemCentral Nervous System
30
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 16
Shock / Hypotension
C di iCardiogenic
Hypovolemic
Di t ib tiDistributive
31
The Receptors
32
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 17
Vasopressors
Norepinephrine
Epinephrine
Vasopressin
Dopamine
Phenylephrine
33
Norepinephrine
α1, α2, and β1 agonism
First line vasopressor
Dosing:0.01 – 3 mcg/kg/min IV
Central vs. peripheralinfusion
34
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 18
Vasopressin
V1 receptor agonist
Adjunct treatment
Dosing:0.04 units/min IV
Works in acidotic environment
35
Drug α1 β1 β2 DA V1
Dopamine +++ ++++ ++ ++++ -
Pressors and Potencies
Epinephrine +++++ ++++ +++ - -
Norepinephrine +++++ +++ ++ - -
Phenylephrine +++++ - - - -
Vasopressin - - - - +
36
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 19
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
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 20
Furosemide
Blocks reabsorption ofBlocks reabsorption of sodium and chloride in the loop of Henle
Profound increase in urine outputp
39
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
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 21
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
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 22
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.
43
SummaryThe ICU can be a setting of controlledgchaos
An ICU for everyoccasion
HUG “FAST” d ftHUG: “FAST” and often
Systems-based approach recommended
44
Sterile Products Used in the Critical Care Practice SettingPharMEDium Lunch and Learn Series
ProCE, Inc.www.ProCE.com 23
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
45
46