Routine Prescriptions “Routine Prescriptions” - PowerPoint Presentation

1. Routine Prescriptions

2. “Routine Prescriptions”No patient is standardAlways think before you prescribeMedicationInfusionsThink aboutRoutes of administrationRoutes of metabolismParameters

3. MedicationVTE prophylaxisStress related mucosal damageAnalgesiaBowel managementOpiates cause constipationSodium Docusate/SennaEye protectionCelluvisc 1% TDSPlus VitA-POS nocte

4. Venous ThromboembolismNICE guidelines:Assess all people admitted to critical care for risk of VTE and bleedingProvide LMWH to people admitted to critical care if pharmacological VTE prophylaxis is not contraindicatedConsider mechanical VTE prophylaxis for people admitted to the critical care unit if pharmacological prophylaxis is contraindicated based on their condition or procedure If using mechanical VTE prophylaxis, start it on admission and continue until the person no longer has reduced mobility relative to their normal or anticipated mobility Reassess VTE and bleeding risk daily for people in critical care units Assess VTE and bleeding risk more than once a day in people admitted to the critical care unit if the person's condition is changing rapidly

5. VTE ProphylaxisIncidence of DVT 13-31% (US)PE Found at post mortem in 27%LMWH reduces incidence by 50%Enoxaparin 40mg (20mg when GFR <30)Mechanical?May be effective as monotherapyFlowtronsSeparate COVID guidelinesIVC Filter

6. Eye ProtectionHealth of the eye depends on:Ability to produce tearsAbility to blinkAbility to close eyes with sleepImpaired on ICU by:Disease (facial oedema, reduced conscious level, neurological injury)ProningTreatments Drying effect of gasesMuscle relaxantsSedation reduces blink rate

7. Problems affecting the eyesDirect injury to cornea – usually corneal abrasionExposure keratopathyChemosis Conjunctivitis and keratitis

8. Exposure Keratopathy/Corneal AbrasionCorneal abrasion - epithelial defect glows yellow on fluroscein stainingExposure keratopathy – much larger epithelial defect as eyes don’t shut completely

9. ChemosisConjunctival oedema which causes the conjunctiva to bulge outRisk factors:Compromised venous return from ocular structuresStates with generalised oedemaStates which increase capillary leak

10. Microbial ConjunctivitisThe eye commonly becomes colonized with bacteria (in a time-dependent fashion) on ICUas many as 77% of ventilated medical patients being colonised by at least one abnormal bacterial species in 7-42 days40% of those with prolonged ventilation and sedation with multiple bacteriaThe most common isolated organisms are Pseudomonas aeruginosa, Acinetobacter spp. and Staphylococcus epidermidis

11. Protecting the eyesManual closure of the eyes or taping the eyes shut. Lid taping is not always necessary and can be distressing to relatives. Grade 2 exposure onlyLiberal use of lubricants into the eye: ointment (such as simple eye ointment, LacrilubeTM and VitA-POSTM) is recommended as drops do not last long enough. Superior to manual eye closure alone and to the (once prevalent) application of GelipermTM Grade 1 exposure

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13. Gut ProphylaxisStress related mucosal damage affects 74-100%25% GI bleedReduced to 0.6-4% with treatment(Barrier protectionSucraflate) H2 antagonistRanitidine 50mg tds IVI?increased VAP rateTachyphylaxis after 48hPPIOmeprazole/lansoprazoleLittle evidence?C. Diff

14. InfusionsInsulin – sliding scaleSedation/analgesiaAlfentanil and propofol as defaultAlfentanil and midazolam if AKIMorphine and Midazolam if longerRemember infusion strength and bolus dosesVasopressors/inotropesNoradrenalineRemember set limit (1 ml/kg/h)PotassiumUnless contraindicatedMaintenance fluidUsually required first 24 hoursPrescribe for 24 hours if possiblePlasmalyteNutritionFeed as soon as possiblemmo/lHartmann’sPlasma-Lyte 148Na133140Cl11198K55Ca20Mg01.5Lactate290Acetate027Gluconate023Osmolarity279 mOsm294 mOsm

15. ParametersAs a minimumSpO2PaCO2TVMAPU/OSpecific

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