This chapter gives an overview of how to provide high-quality supportive care to the sickest patients. It summarizes about a dozen chapters within the IBCC. This is intended as a quick guide for folks who don't work full-time in an ICU (e.g. residents rotating through the unit).
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The IBCC chapter is located here.
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Comments are below.
- There isn't a podcast for this chapter, because it covers too much material. (We will continue to gradually unpack this information over the coming years with a series of podcasts… Stay tuned.)
Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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Isn’t saying that 25/hr of fentanyl =120mg a day of oxy a bit misleading because of fentanyl’s much shorter duration or action? Or dose the agent build up enough that it’s duration of action is greatly extended?
When examining any medication given as a continuous infusion you need to understand the context sensitive halftime, which is the half life of a medication given as a continuous infusion. This can change significantly the longer the medication is given. After several hours continuous infusion fentanyl has a half life equivalent to morphine, So it’s not really shorter acting.
Thanks Martin, you beat me to the punch. Initially a lot of the fentanyl will distribute into the fat tissue (away from the brain, which gives it a short half-life), but over time eventually fat tissue becomes saturated and the half-life of fentanyl extends (“context-sensitive half-life”). These conversions aren’t perfect but the point is that when you see a patient stuck on a fentanyl infusion of 100-200 mcg/hr for days at a time you really need to ask the question – does this patient need so much opioid?? Or is the opioid really just being used for its sedative properties?… Read more »
Cool
Thanks!
What compelling evidence do you have for dosing UFH BID instead of q8h for dvt ppx? I can’t say I’ve ever dosed it that way nor would I feel comfortable with my patients on that without a compelling study.
zero evidence, this is the practice pattern that I’m used to. Would you dose 5000 IV q8 in renal failure? will need to look into this.
Fair enough, by the same token q8h is the practice pattern I’m used to. My shop doesn’t renally adjust prophylactic heparin, and I’m not aware of any evidence to suggest we should. As far as I’ve been trained and what I’ve studied, renal impairment does not significantly affect kinetics of heparin.
Looked into literature on this. Nothing definitive I can find. Agree that renal impairment doesn’t affect heparin kinetics, the rationale for the lower heparin dose is that uremic patients tend to be have an increased risk of bleeding complications. That said, most references seem to recommend 5000 q8 in this situation. I’ve changed the chapter to 5000 q8hr as this seems to be the more commonly used dose. Thanks much.
Hi Josh
I loved this chapter. Great work.
How would remifentanil fit into your analgesic ladder?
How would you dose the remifentanil?
What doses of dexmedatomidine are you using alongside ketamine?
Is there any utility for lidocaine infusions or simply insufficient evidence at this time to recommend lidocaine infusions for the ICU patient?
About DVT and renal clearence <30ml/min
Unfractionated heparin is used here, because it’s cleared by the kidneys.
the sentence shouldn’t be “because it is NOT cleared by the kidneys?”
yes you’re right, thank you! (have fixed it).
Excellent chapter. Do you evaluate risk of bleeding before starting full anticoagulation? What’s your threshold to start in a fib or UE DVT? I’ve seen enough unnecessary bleeds and I’m much more conservative with full anticoagulation
Hi Josh, I think the chapter is missing the reference for the Pandharipande study about lorazepam and delirium risk in the ICU. It is something along the lines of: Pandharipande, Pratik, Ayumi Shintani, Josh Peterson, Brenda Truman Pun, Grant R. Wilkinson, Robert S. Dittus, Gordon R. Bernard, and E. Wesley Ely. “Lorazepam Is an Independent Risk Factor for Transitioning to Delirium in Intensive Care Unit Patients.” Anesthesiology: The Journal of the American Society of Anesthesiologists 104, no. 1 (January 1, 2006): 21–26. Also the PubMed ID in the graph is slightly off – it should be 16394685 (not 1649485). Thanks… Read more »
Best resource ever