321 Approach to the Patient with Critical Illness

Question 1

It is the presence of multisystem end-organ hypoperfusion

Answer 1

Shock

Question 2

What are the clinical indicators of shock?

Answer 2

Reduced mean arterial pressure (MAP)
Tachycardia
Tachypnea
Cool skin and extremities
Acute altered mental status
Oliguria

Question 3

Clinical evidence of diminished cardiac output

Answer 3

Narrow pulse pressure

Cool extremities with delayed capillary refill

Question 4

Clinical evidence of increased cardiac output

Answer 4

Widened pulse pressure (particularly with a reduced diastolic pressure)
Warm extremities with bounding pulses
Rapid capillary refill

Question 5

It is a better predictor of fluid responsiveness

Answer 5

Change in right atrial pressure as a function of spontaneous respiration

Question 6

It is the most common cause of high-cardiac-output hypotension

Answer 6

Sepsis

Question 7

Other causes of high cardiac hypotension

Answer 7

Liver failure,
Severe pancreatitis
Burns and other trauma that elicit the systemic inflammatory response syndrome (SIRS)
Anaphylaxis
Thyrotoxicosis
Peripheral arteriovenous shunts

Question 8

Reasons for the institution of endotracheal intubation and mechanical ventilation

Answer 8

Acute hypoxemic respiratory failure

Ventilatory failure

Question 9

It often occurs as a consequence of an increased load on the respiratory system in the form of acute metabolic (often lactic) acidosis or decreased lung compliance due to pulmonary edema

Answer 9

Ventilatory Failure

Question 10

This type of respiratory failure occurs with alveolar flooding and sub- sequent intrapulmonary shunt physiology

Answer 10

TYPE I: ACUTE HYPOXEMIC RESPIRATORY FAILURE

Question 11

This type of respiratory failure is seen in sepsis, gastric aspiration, pneumonia, near drowning, multiple blood transfusions, and pancreatitis

Answer 11

TYPE I: ACUTE HYPOXEMIC RESPIRATORY FAILURE

Question 12

This syndrome is defined by acute onset (≤1 week) of bilateral opacities on chest imaging that are not fully explained by cardiac failure or fluid overload and of shunt physiology requiring positive end-expiratory pressure (PEEP)

Answer 12

ARDS

Question 13

This type of respiratory failure is a consequence of alveolar hypoventilation and results from the inability to eliminate carbon dioxide effectively

Answer 13

TYPE II RESPIRATORY FAILURE

Question 14

The mechanisms involved in this type of respiratory failure are categorized by impaired central nervous system (CNS) drive to breathe, impaired strength with failure of neuromuscular function in the respiratory system, and increased load(s) on the respiratory system

Answer 14

TYPE II RESPIRATORY FAILURE

Question 15

Examples of conditions in this type of respiratory failure are drug overdose, brainstem injury, sleep disordered breathing, and severe hypothyroidism, myasthenia gravis, Guillain-Barré syndrome, amyotrophic lateral sclerosis, myopathy, electrolyte derangements, and fatigue

Answer 15

TYPE II RESPIRATORY FAILURE

Question 16

What is the mainstays of therapy for type II respiratory failure?

Answer 16

Reverse the underlying cause(s) of ventilatory failure

Question 17

Subclassification of overall load on the respiratory system

Answer 17

Resistive Loads (bronchospasm)

Loads due to reduced lung compliance (e.g., alveolar edema, atelectasis, intrinsic positive end-expiratory pressure [auto-PEEP]

Loads due to reduced chest wall compliance (e.g., pneumothorax, pleural effusion, abdominal disten- tion)

Loads due to increased minute ventilation requirements (e.g., pulmonary embolus with increased dead-space fraction, sepsis)

Question 18

This form of respiratory failure results from lung atelectasis

Answer 18

TYPE III RESPIRATORY FAILURE

Question 19

This is also called preoperative respiratory failure

Answer 19

TYPE III RESPIRATORY FAILURE

Question 20

This form of respiratory failure results from hypoperfusion of respiratory muscles in patients in shock

Answer 20

TYPE IV RESPIRATORY FAILURE

Question 21

Screening criteria for spontaneous breathing trial

Answer 21

oxygenation is stable (i.e., PaO2/FIO2 [partial pressure of oxygen/fraction of inspired oxygen] >200 and PEEP ≤5 cmH2O)

Cough and airway reflexes are intact
No vasopressor agents or sedatives are being administered

Question 22

Criteria for failure of spontaneous breathing trial

Answer 22

(1) respiratory rate >35/min for >5 min
(2) O2 saturation <90%
(3) heart rate >140/min or a 20% increase or decrease from baseline
(4) systolic blood pressure <90 mmHg or >180 mmHg
(5) increased anxiety or diaphoresis.

Question 23

What is the mainstay of therapy for pain control in mechanically ventilated patients?

Answer 23

Opiates

Question 24

Indications for sedation

Answer 24

Anxiolysis

Treatment of subjective dyspnea

Psychosis

Facilitation of nursing care

Reduction of autonomic hyperactivity, which may precipitate myocardial ischemia

Reduction of total O2 consumption (VO2)

Question 25

It is defined by the simultaneous presence of physiologic dysfunction and/or failure of two or more organs

Answer 25

MULTIORGAN SYSTEM FAILURE

Question 26

It is the gold standard for evaluation of respiratory gas exchange

Answer 26

ABG

Question 27

Two variables that determine the peak airway pressure

Answer 27

Airway resistance Respiratory system compliance

Question 28

The difference between the peak (airway resistance + respiratory system compliance) and plateau (respiratory system compliance only) airway pressures provides a quantitative assessment of?

Answer 28

Airway resistance

Question 29

It is defined by the change in pressure of the respiratory system per unit change in volume

Answer 29

Lung compliance

Question 30

Normal respiratory system compliance

Answer 30

~100 mL/cmH2O

Question 31

Processes that reduce chest wall compliance

Answer 31

Pleural effusions, pneumothorax, and increased abdominal girth

Question 32

Conditions that reduce lung compliance

Answer 32

Pneumonia, pulmonary edema, interstitial lung disease, or auto-PEEP

Question 33

It is determined by the hemoglobin concentration, the arterial hemoglobin saturation, and dissolved O2 not bound to hemoglobin

Answer 33

Content of O2 in the arterial blood (CaO2)

Question 34

Oxygen delivery (QO2) in normal adult is equal to

Answer 34

1058 mL O2 per min

Question 35

Conditions that reduced mixed venous O2 saturation

Answer 35

Inadequate cardiac output Reduced hemoglobin concentration Reduced arterial O2 saturation

Question 36

Conditions that may abnormally increased VO2 in peripheral tissues

Answer 36

Fever, agitation, shivering, and thyrotoxicosis

Question 37

It is defined as the presence of SIRS in the setting of known or suspected infection

Answer 37

Sepsis

Question 38

It is the leading cause of death in noncoronary ICUs in the United States

Answer 38

Sepsis

Question 39

All ICU patients are at high risk for this complication because of their predilection for immobility

Answer 39

DVT

Question 40

DVT Prophylaxis

Answer 40

Subcutaneous low-dose heparin injections and sequential compression devices for the lower extremities, Enoxaparin, Fondaparinux

Question 41

Stress ulcer prophylaxis

Answer 41

Histamine-2 antagonists or proton pump inhibitors

Question 42

These are important issues that may be associated with respiratory failure, impaired wound healing, and dysfunctional immune response in critically ill patients

Answer 42

NUTRITION AND GLYCEMIC CONTROL

Question 43

This state is defined by (1) an acute onset of changes or fluctuations in mental status, (2) inattention, (3) disorganized thinking, and (4) an altered level of consciousness (i.e., a state other than alertness)

Answer 43

Delirium

Question 44

True or False: Very early physical and occupational therapy in mechanically ventilated patients has been demonstrated to reduce delirium

Answer 44

True

Question 45

Treatment for vasospasm

Answer 45

Nimodipine, aggressive IV fluid administration, and therapy aimed at increasing blood pressure

Question 46

It is the most effective benzo- diazepine for treating status epilepticus and is the treatment of choice for controlling seizures acutely

Answer 46

Lorazepam