1What is FAST HUGS BID?
Feeding
Analgesia
Sedation
Thromboembolic prophylaxis
Head of bed elevation
Ulcer (stress) prophylaxis
Glycemic control
Spontaneous breathing trial
Bowel regimen
Indwell catheter removal
De-escalation of antimicrobials
2What is virchows triad?
The three most likely things that cause VTEs
3What are the three members of virchows triad?
Venous stasis
Injury
Hypercoagulable state
4What are some risk factors for venous stasis?
Age>60
Obesity
Prolonged Immobility*
pregnancy
5What are some risk factors for hypercoagulable state?
Genetics
Prior VTE
active malignancy
hormonal treatment
acute MI/CVA
sepsis
6What are the 4 independent risk factors of VTE?
Personal or family history of VTE
End stage renal failure
platelet transfusion
vasopressor use
7ICU VTE low risk score
0-8
8ICU VTE med risk score
9-14
9ICE VTE high risk score
15-18
10enoxaparin (low molecular weight heparin, LMWH) dosing for VTE prophylaxis
30mg SQ Q12H
40mg SQ daily
11enoxaparin (LMWH) dosing for VTE prophylaxis in renally impaired patients
30mg SQ daily
12unfractionated heparin (UFH) dosing for VTE prophylaxis
5000 SQ Q8-12H (no major difference in efficacy between 2 and 3 times daily)
13unfractionated heparin (UFH) dosing for VTE prophylaxis in renally impaired patients
No change nescessary
14primary CHEST (american college of chest physicians) recommendations for VTE prophylaxis
No ultrasound or IVC filters
Use mechanical prophylaxis (intermittent pneumatic compression devices) with our without pharmacologic therapy if bleeding risk isn't extreme
15CHEST guidlines when to use UFH vs LMWH
UFH preferred in medical and non-orthopedic surgery patients
LMWH preferred in orthopedic surgery patients
16American society of hematology (ASH) primary recommendations for VTE prophylaxis
LMWH usually preferred over UFH
Prefer pharmacologic therapy over mechanical but usually use both
LMWH over oral medications (DOACs)
17What are the highest risk factors for SRMD (stress related mucosal disease) GI bleeding
Mechanical ventilation without enteral nutrition
Chronic liver disease
18What are the high risk factors for SRMD (stress related mucosal disease) GI bleeding
Concerning coagulopathy
2 or more moderate risk factors
19What are the moderate risk factors for SRMD (stress related mucosal disease) GI bleeding
mechanical ventilation with enteral nutrition
Acute kidney injury
Sepsis
Shock
20What are the low risk factors for SRMD (stress related mucosal disease) GI bleeding
Critically ill patients without other risk factors
Acute hepatic failure
Use of steroids/immunosuppression
Use of antigcoagulants
Cancer
Male
21What is the first key guidline for SRMD prophylaxis
Use acid supression therapy in patients with a high or higher risk of GI bleeds
22Calcium carbonate (tums) (antacid) dose for SRMD prophylaxis
500mg PO/NG Q12H
23Calcium carbonate (tums) (antacid) considerations for ICU
interacts with absorption of some drugs, frequent oral administration makes it hard to manage and not preferred
24Sucralfate dose for SRMD prophylaxis
1 gram PO/NG QID
25Sucralfate considerations for ICU
Less effective than H2RAs
26Famotidine (pepcid) (H2RA) dosing for SRMD prophylaxis
20mg IV/PO Q12H
27Famotidine (pepcid) (H2RA) dosing for SRMD prophylaxis in renally impaired patients
CrCl <50mL/min: 20mg IV/PO QD
28PPI drug interactions to keep in mind
All are metabolized by CYP enzymes, drug interactions with CYP 3A4, 2C19, 1A2
Clopidogrel absorption much lower in the prescense of omeprazole (2C19)
29Pantoprazole (PPI) dosing for SRMD prophylaxis
40mg QD PO packet or IV**
30Omeprazole (prilosec) (PPI) dosing for SRMD prophylaxis
20mg QD, capsules, tablets, powders for suspension, but no IV dosing
31PPI dose adjustment in renally impaired patients
No dose adjustment needed
32How to choose between PPIs and H2RAs?
PPIs generally preferred, less frequent administration
consider side effects and renal availability
33Individual risk factors for VAP (ventilator ascociated pneumonia)
Days 0-5 of mechanical ventilation
Underlying chronic lung disease
Acute lung injury
Aspiration
Coma
Chest trauma
Traumatic brain injury
Burns
34Risk factors for MDRO-VAP (multi drug resistant)
Prior IV antibiotic therapy within 90 days
Acute renal replacement therapy before VAP onset
>5 days of hospitalization before VAP onset
Septic shock at time of VAP
ARDS (acute respiratory disress syndrome) preceding VAP
35What are the primary prevention methods for VAP?
Minimize levels of sedation
Head of bed 30-45 degrees
Chlorhexidine mouth rinse
36Cefazolin (ancef) dose for SSI (surgical site infection) prophylaxis
<120kg: 2gm IV
>120kg: 3gm IV
37When to use vancomycin for SSI prophylaxis
Known or high MRSA risk
38When to use clindamycin, gentamicin, or levofloxacin for SSI prophylaxis
Alternatives for patients with PCN allergy