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PTHER 544 - Cardiorespiratory > 15. Critical Care And ARDS > Flashcards

15. Critical Care And ARDS Flashcards

1
Q

Levophed

A

Blood pressure medication (increases)

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2
Q 
Discuss the following vitals
Some abdominal distension noted 
• Vitals: Febrile 38.9°C
HR 109   BP 101/64  RR   22  SpO-93%
• Labs: Hb 124    WBC   18.7    Plt    267
A 
Temp: high
HR: high
BP: low
RR: high 
SpO: normal 
Hb: 
WBC: 
Plt:
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3
Q

Discuss the following values

PC 22 PEEP 10 FiO2 0.55

A
  • High level of support
  • Machine is breathing for her (rate and depth)
    PC
    PEEP
    FiO2
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4
Q

Midazolam

A

Sedation

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5
Q

Rocuronium

A

Paralysis (alpha 2 blocker)

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6
Q

Following surgery:
Hb 124. WBC 18.7. Plt 257.

Overnight:
Hb 102. WBC 25.6. Plt 154.

Why is there a decrease in Hb/Plt .

A

Diffusion effect form all the fluids she is receiving.

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7
Q

What is sepsis?

A

The presence of harmful bacteria and their toxins in tissue, through infection of wound.

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8
Q

ABG: PaO2 59, PaCO2 57, pH 7.21, HCO3 21

ABG suggest acidosis, why is HCO3 so low?

A

Due to sepsis

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9
Q

What does the following values indicate

PaO2/FiO2 = 73

A

Severe form of Acute Lung Injury (ALI) —> ARDS

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10
Q

What is ARDS?

A

Bilateral and diffuse alveolar damage due to an acute insult

  • stiffening of alveolar walls
  • no perfusion of oxygen
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11
Q

Risk factors for ARDS

A

Direct Risk:

  • pneumonia
  • aspiration of gastric contents
  • pulmonary contusion
  • inhalation injury
  • near drowning

Indirect Risk

  • Sepsis
  • Non-thoracic trauma or hemorrhagic shock
  • Pancreatitis
  • Major Burn
  • Drug overdose
  • Transfusion of blood products
  • Cardiopulmonary
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12
Q

Anatomical Changes to the lung in response to injury (exudative phase).

  1. Risk of what pathology?
  2. Increase of fluid due to what type of response?
  3. Response to injury
A
  1. Decreased surfactant = increased risk of atelectasis due to increased surface tension
  2. Exudative fluid
  3. Response
    - Pulmonary capillary becomes engorged
    - Increased permeability of alveolar-capillary membrane
    - Interstitial and Intra-alveolar oedema
    - Scattered areas of haemorrhaging alveolar consolidation
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13
Q

Anatomical Changes to the lung in response to injury (proliferation phase/week-days)

  1. Response
  2. Lung pathology that can develop
  3. Can lead to which lung disorder
  4. VQ matching
A
  1. Intra-alveolar walls thickened with hyaline membrane (fibrin, cellular debris)
  2. Intra-alveolar fibrosis (fibrin and exudative develop)
  3. Restrictive lung disease
  4. Worsened VQ matching - hypoxia, pulmonary hypertension
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14
Q

Physiological Changes to the lung in response to injury.

A
  • Lungs become very stiff (decreased compliance) and therefore are difficult to ventilate
  • Small areas of the lung are still functioning normally
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15
Q

What is non-cardiogenic pulmonary edema

A
  • Pulmonary Capillary Wedge Pressure (PCWP) < 18mmHg
    (pressure required to occlude the artery)
  • Acute hypoxaemic respiratory failure
  • Leaking into the lungs is not due to the heart, stead due to sepsis or other external cause; nothing we do to the heart will improve oedema.
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16
Q

Managing ARDS until lungs start to improve

A

Manage symptoms

  • support BP
  • ABx to fight infection
  • monitor skin integrity
  • nutritional support
  • Prisma/dialysis, if renal impairment is present
17
Q

ARDS patient

  1. Hemodynamics
  2. Ventilators support
  3. ABGs
A
  1. Unstable
    - simple turning can desaturated or cause hypotension
    - will be on multiple drugs to support blood pressure (e.g. NE, E, vasopressin)
  2. High Ventilators support (PC, PEEP, and FiO2)
  3. Poor ABG (permissive hypercapnia) due to low TV (6ml cf 10-12ml)
18
Q

Best position for ARDS patients.

A

Prone with pillows on chest

  • Abdomen freed to allow for expansion into lower lobes
  • Increased VQ matching: Improved oxygenation, perfusion more evenly distributed
  • No adverse effects on hemodynamic status
19
Q

Adverse Effects of putting ARDS patients in prone

A
  • facial oedema
  • requires manpower (up to 8 people to turn/manage lines)
  • difficult to manage lines/tubes
  • not appropriate for all patients: orthopaedic, neurological
20
Q

Compare the following ABG:

Before:
Ventilation: PC 24, PEEP 16, FiO2 0.8
ABG: PaO2 59, PaCO2 57, pH 7.21, HCO3 21
PaO2/FiO2 = 78

After:
Ventilation: PC 24, PEEP 14, FiO2 0.95
ABG: PaO2 48, PaCO2 51, pH 7.29, HCO3 22
PaO2/FiO2 = 50

What could be the main precipitating factor for this laparotomy patient?

A
  • slight improvement in ventilation but still high level of dependence on ventilators support
  • no significant improvement, uncompensated respiratory acidosis; septic and febrile
  • lower the ratio, the worse the disease process = renal failure, multi-organ failure
  • sepsis, non-cardigenic oedema
21
Q

Ventilation: PC 24, PEEP 14, FiO2 0.95
ABG: PaO2 48, PaCO2 51, pH 7.29, HCO3 22
PaO2/FiO2 = 50

What is the main role of PT for this patient?

A

Very limited

  • main roles:
    1) Maintain ROM
    2) Positioning
  • underlying issues of sepsis and non-cardiogenic oedema must be controlled as this is a precipitating factor
  • Chest PT may worsen outcome as it is in inflammatory process
22
Q

Compare the following:

Before
Ventilation: PC 24, PEEP 14, FiO2 0.95
ABG: PaO2 48, PaCO2 51, pH 7.29, HCO3 22
PaO2/FiO2 = 50

After
Ventilation: SIMV PC 20 PEEP 12 PiO2 0.65
ABG: PaO2 62, PaCO2 47, pH 7.36, HCO3 31
PaO2/FiO2 = 95

A

Patient is getting better

  • SIMV = shared work between ventilator and patient: machine does most of the breathing, when pt takes breath it allows her to
  • decreased dependence on ventilator
  • ABG: compensated respiratory acidosis
  • PaO2 = normalized
23
Q

Ventilation: SIMV PC 20 PEEP 12 PiO2 0.65
ABG: PaO2 62, PaCO2 47, pH 7.36, HCO3 31
PaO2/FiO2 = 95

What is the main PT management for this patient

A

Still not able to do a whole lot of intervention possible

  • Sit up in bed 30-40degrees
  • PROM, especially ankles
  • Positioning
  • Check chest
24
Q

ARDS Prognosis

A

Survivors are at high risk for

  • cognitive decline
  • depression
  • PTSD
  • persistent skeletal-muscle weakness

Return to work is very slow (less than half the first year)

25
Q

Red Flag - Heart Rate

A
  • Recent myocardial ischemia

- Heart rate < 40 and > 130 beats/min

26
Q

Red Flag - Mean Arterial Pressure (normal 90-100)

A

Mean Arterial Pressure
< 60mmHg
> 110mmHg

27
Q

Red Flag - oxygen saturation

A

< 90% (desaturation)

28
Q

Red Flag - ventilation

A

FiO2 > 0.6

Positive End Expiratory Pressure (PEEP) > 10cm H20

29
Q

Red Flag - Respiratory Frequency (RR)

A

> 40 breath/min

30
Q

Red Flag - temperature

A

> 38.5*C

< 36*C

31
Q

Red Flag - Level of consciousness, dose of Inotrope

A

Level of consciousness: RASS -4, -5, 3, 4
Dopamine: >10mcg/kg/min
Nor/adrenaline > 0.1mcg/kg/min

32
Q

Safety in ICU - Cardiovascular Status

A
  • Sufficient Reserve > 50% APMHR (age predict maximal heart rate)
  • BP stability
  • ECG abnormality
33
Q

Safety in ICU - Respiratory status

A
  • PaO2/FiO > 300 (PF ratio)
  • SpO2 > 90%
  • Satisfactory Respiratory Pattern
  • Mechanical ventilation if required
34
Q

Safety in ICU - Vitals

  • Hb
  • WBC
  • Plt
  • CI
A
  • Hb > 70
  • WBC 4.8-10
  • Plt > 20, 000
  • CI: no neurological or orthopaedic contraindications
35
Q

When vitals stable for a patient with ARDS what is the PT management?

A
  • Start with: Mechanical lift or tilt table
    • early mobilization is key

Progress as able:

  • Strengthening: Active assist and active strengthening ex.
  • Deep breathing exercise
  • Mobilization/Dangle
36
Q

ARDS Recovery timeline

A
  • Respiratory function return to normal 6-12 month after cessation of mechanical ventilation
  • Week to months of rehab: D/C to ward, then rehab facility before home.

PTHER 544 - Cardiorespiratory (12 decks)

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