Critically ill

Each time the blood pressure is obtained, the nurse uses the same arm and the patient is placed in die same position (eg, standing, sitting, or lying down). In some instances, die primary care provider may order die blood pressure taken in one or more positions, such as standing and lying down. The nurse monitors the blood pressure and pulse every 1 to 4 hours if the patient has severe hypertension, does not have the expected response to drug therapy, or is critically ill. 

TH E PATIEN T WITH ED EM A. Fhtients with edema caused by heart failure or other causes are weighed daily or as ordered by the primary health care provider. A daily weight is taken to monitor fluid loss. Weight loss of about 2 lb/d is desirable to prevent dehydration and electrolyte imbalances. The nurse carefully measures and records the fluid intake and output every 8 hours. The critically ill patient or the patient with renal disease may require more frequent measurements of urinary output. The nurse obtains the blood pressure, pulse, and respiratory rate every 4 hours or as ordered by the primary health care provider. An acutely ill patient may require more frequent monitoring of the vital signs. 

TH E PATI ENT WITH HYPERTENSION. The nurse monitors the blood pressure, pulse, and respiratory rate of patients with hypertension receiving a diuretic, or a diuretic along with an antihypertensive drug, before the administration of the drug. More frequent monitoring may be necessary if the patient is critically ill or the blood pressure excessively high. 

These drug are used for the medical treatment of agastric or duodenal ulcer, gastric hypersecretory (excessive gastric secretion of hydrochloric acid) conditions, and GERD. These drug may also be used as prophylaxis of stress-related ulcers and acute upper GI bleeding in critically ill patients. 

Some clinicians advocate a baseline cortisol level <15 mcg/dlV or <25 mcg/dL in critically ill patients as the diagnostic threshold for relative (or functional) adrenal insufficiency... 

Note Critically ill patients (e.g., elderly, organic mental syndrome, pulmonary, cardiac, renal, and/or hepatic impairment) may be at increased risk for adverse drug events. Start with the lowest dose and titrate very carefully. 

In patients who have received a recent course of vancomycin and/or are critically ill (based on a high APACHE II score)... 

In critically ill patients, may give protein calories in excess of energy requirements in order for this macronutrient to be utilized for tissue repair and synthesis (controversial)... 

Small bowel resection, severe diarrhea, intractable vomiting, bowel obstruction, and fistulas ° Critically ill patients with nonfunctioning GI tract... 

Critical care medicine is a cutting-edge medical field that is highly evidence-based. Studies are continuously published that alter the approach to patient care. As a critical care clinician, I am aware of the tremendous commitment required to provide optimal evidence-based care. Pocket Guide to Critical Care Pharmacotherapy covers the most common ailments observed in adult critically-ill patients. I utilize an algorithmic, easy-to-follow, systematic approach. Additionally, I provide references and web links for many disease states, for clinicians who want to review the available literature in greater detail. 

Use of Packed Red Blood Cell Transfusions and Erythropoietin in Critically-Ill Patients... 

Practitioners must have a good understanding of cardiovascular physiology to diagnose, treat, and monitor circulatory problems in critically ill patients. Eugene Braunwald, a renowned cardiologist, described the interrelationships between the major hemodynamic variables (Fig. 10-1).1 These variables include arterial blood pressure, cardiac output (CO), systemic vascular resistance (SVR), heart rate (HR), stroke volume (SV), left ventricular size, afterload, myocardial contractility, and preload. While an oversim-... 

Upon stabilization, placement of a pulmonary artery (PA) catheter may be indicated based on the need for more extensive cardiovascular monitoring than is available from non-invasive measurements such as vital signs, cardiac rhythm, and urine output.9,10 Key measured parameters that can be obtained from a PA catheter are the pulmonary artery occlusion pressure, which is a measure of preload, and CO. From these values and simultaneous measurement of HR and blood pressure (BP), one can calculate the left ventricular SV and SVR.10 Placement of a PA catheter should be reserved for patients at high risk of death due to the severity of shock or preexisting medical conditions such as heart failure.11 Use of PA catheters in broad populations of critically ill patients is somewhat controversial because clinical trials have not shown consistent benefits with their use.12-14 However, critically ill patients with a high severity of illness may have improved outcomes from PA catheter placement. It is not clear why this was... 

Stress-related mucosal damage occurs most frequently in critically ill patients and is thought to be caused by factors such as compromised mesenteric perfusion rather than HP or NSAIDs. Its onset is usually acute, and in a small proportion of patients may progress to deep ulceration and hemorrhage. 

Patients at greatest risk for mortality from acute pancreatitis are those who have multi-organ failure (e.g., hypotension, respiratory failure, or renal failure), pancreatic necrosis, obesity, volume depletion, greater than 70 years of age, and an elevated APACHE II score.3,4 The Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score is a rating scale of disease severity in critically ill patients. 

Given the severity of acute pancreatitis, patients are monitored closely in the intensive care setting. Patients with mild disease can be managed more conservatively with observation and supportive care. Critically ill patients may require surgery and aggressive life support measures.16,28... 

Nathens AB, Curtis JR, Beale RJ, et al. Management of the critically ill patient with severe acute pancreatitis. Crit Care Med 2004 32 2524-2536. 

Acute renal failure (ARF) is a potentially life-threatening clinical syndrome that occurs primarily in hospitalized patients and frequently complicates the course of the critically ill. It is characterized by a rapid decrease in glomerular filtration rate (GFR) and the resultant accumulation of nitrogenous waste products (e.g., creatinine and urea nitrogen), with or without a decrease in urine output. A recent consensus statement... 

Between 5% and 25% of all hospitalized patients develop ARF.2 A greater prevalence of ARF is found in critically ill patients.3 Despite improvements in the medical care of individuals with ARF, mortality generally exceeds 50%.4... 

The most comprehensive study evaluating the efficacy of low-dose dopamine to date is the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group study.19 Low-dose dopamine was compared to placebo in critically ill... 

Concentrated electrolytes (potassium chloride, potassium phosphate, and sodium chloride greater than 0.9%) should not be stored in patient care areas as a patient safety measure. Serum magnesium levels do not correlate well with total body magnesium stores. For this reason, magnesium supplementation is often given empirically to critically ill patients. 

For acute symptomatic hypocalcemia, 200 to 300 mg of elemental calcium is administered IV and repeated until symptoms are fully controlled. This is achieved by infusing 1 g of calcium chloride or 2 to 3 grams of calcium at a rate no faster than 30 to 60 mg of elemental calcium per minute. More rapid administration is associated with hypotension, bradycardia, or cardiac asystole. Total calcium concentration is commonly monitored in critically ill patients. Under normal circumstances, about half of calcium is loosely bound to serum proteins while the other half is free. Total calcium concentration measures bound and free calcium. Ionized calcium measures free calcium only. Under usual circumstances, a normal calcium level implies a normal free ionized calcium level. Ionized calcium should be obtained in patients with comorbid conditions that would lead to inconsistency between total calcium and free serum calcium (abnormal albumin, protein, or immunoglobulin concentrations). For chronic asymptomatic hypocalcemia, oral calcium supplements are given at doses of 2 to 4 g/day of elemental calcium. Many patients with calcium deficiency have concurrent vitamin D deficiency that must also be corrected in order to restore calcium homeostasis.2,37,38... 

The symptoms produced by respiratory alkalosis result from increased irritability of the central and peripheral nervous systems. These include light-headedness, altered consciousness, distal extremity paresthesias, circumoral paresthesia, cramps, carpopedal spasms, and syncope. Various supraventricular and ventricular cardiac arrhythmias may occur in extreme cases, particularly in critically ill patients. An additional finding in many patients with severe respiratory alkalosis is hypophosphatemia, reflecting a shift of phosphate from the extracellular space into the cells. Chronic respiratory alkalosis is generally asymptomatic. 

The mainstay of treatment for vaso-occlusive crisis includes hydration and analgesia (see Table 65-7). Pain may involve the extremities, back, chest, and abdomen. Patients with mild pain crises may be treated as outpatients with rest, warm compresses to the affected (painful) area, increased fluid intake, and oral analgesia. Patients with moderate to severe crises should be hospitalized. Infection should be ruled out because it may trigger a pain crisis, and any patient presenting with fever or critical illness should be started on empirical broad-spectrum antibiotics. Patients who are anemic should be transfused to their baseline. Intravenous or oral fluids at 1.5 times maintenance is recommended. Close monitoring of the patient s fluid status is important to avoid overhydration, which can lead to ACS, volume overload, or heart failure.6,27... 

Most initial antimicrobial therapy is empirical because cultures usually have not had sufficient time to identify a pathogen. Empirical therapy should be based on patient- and antimicrobial-specific factors such as the anatomic location of the infection, the likely pathogens associated with the presentation, the potential for adverse effects in a given patient, and the antimicrobial spectrum of activity. Prompt initiation of appropriate therapy is paramount in hospitalized patients who are critically ill. Patients who receive initial antimicrobial therapy that provides coverage against the causative pathogen survive at twice the rate of patients who do not receive adequate therapy initially.8... 

Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections A risk factor for hospital mortality among critically ill patients. Chest 1999 115(2) 462M74. 

Peritonitis may be classified as primary, secondary, or tertiary. Primary peritonitis, also called spontaneous bacterial peritonitis, is an infection of the peritoneal cavity without an evident source of bacteria from the abdomen.1,2 In secondary peritonitis, a focal disease process is evident within the abdomen. Secondary peritonitis may involve perforation of the gastrointestinal (GI) tract (possibly because of ulceration, ischemia, or obstruction), postoperative peritonitis, or posttraumatic peritonitis (e.g., blunt or penetrating trauma). Tertiary peritonitis occurs in critically ill patients and is infection that persists or recurs at least 48 hours after apparently adequate management of primary or secondary peritonitis. 

Sepsis is a continuum of physiologic stages characterized by infection, systemic inflammation, and hypoperfusion with widespread tissue injury.1 The American College of Chest Physicians and the Society of Critical Care Medicine developed definitions to utilize for sepsis (Table 79—l).2 They provide physiologic parameters categorizing patients as having bacteremia, infection, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock, or multiple-organ-dysfunction syndrome (MODS).2 Standardized definitions have been developed for infections in critically ill patients.3... 

Sepsis is the leading cause of morbidity and mortality for critically ill patients, and the tenth leading cause of death overall.1,4 Sepsis causes 660,000 to 750,000 cases annually, a four-fold increase from 1979.1,4,5 Care of septic patients costs 17 billion in the United States annually ( 22,000 to 50,000 per patient).4,6... 

Anti-infective regimens should be broad-spectrum since there is little margin for error in critically ill patients. 

Patients with progressive hypoxia leading to ARDS require mechanical ventilation. Critically ill patients may require sedation when high ventilator settings are used or when patients fight the ventilator. Mechanically ventilated patients should receive sedation by a protocol that includes a daily interruption or lightening of a sedative infusion until the patient is awake.24 The utilization of sedation protocols decreases the duration of mechanical ventilation, length of hospitalization, and tracheostomy rates. 

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