5. Critical Care Flashcards
essence of critical care
correcting the imbalance of disordered perfusion
shock
abnormality of circulatory system that causes inadequate organ perfusion and tissue oxygenation
hypodynamic shock
low cardiac index
vasoconstriction
inadequate BF
hyperdynamic shock
high cardia index
vasodilation
maldistribution of blood
types of hypodynamic shock
hypovolemic
cardiogenic
obstructive
hypovolemic shock
decr cardiac filling pressures
causes of hypovolemic shock
hemorrhage
dehydration
massive capillary leak
cardiogenic shock
normal cardiac filling pressures
most common cause of cardiogenic shock
acute MI involving 40% L ventricular mass
other causes of cardiogenic shock
cardiomyopathies
valvular lesions
obstructive shock
incr cardiac filling pressures
what causes change to cardiac filling pressure in obstructive shock?
incr cardiac filling pressures due to:
- outflow obstruction
- decr ventricular compliance
causes of obstructive shock
pericardial tamponade
acute pulm embolism
tension pneumothorax
type of hyperdynamic shock
septic
traumatic
septic shock
direct mediators of inflammation and tissue hyperperfusion result in cellular injury/organ dysfunction
traumatic shock
inflammatory mechanism
distributive immunologically mediated response to injury
traumatic shock results from
hemorrhage
what do sepsis and severe trauma have in common?
systemic inflammation
if you have a localized infection/trauma is the response localized or systemic?
typically localized
sepsis
life-threatening
organ dysfunction causes by dysregulated host response to infection
what type of dysfunction is sepsis?
circulatory
cellular/metabolic
sepsis hypoperfusion resuscitation
30 ml/kg over 3 hours
additional sepsis resuscitation is guided by
reassessment of vitals
with sepsis you need to ______ to guide treatment
diagnose the source of the sepsis to guide abx therapy
sepsis infection treatment
empirical broad-spectrum abx
within 1 hr of diagnosis
how often should you reasses abx choice in sepsis
1x daily
sepsis treatment is focused on
source control
(origin of infection)
when should you continue volume resuscitation in sepsis pts?
if the pt is responsive
what fluids should you not give sepsis pts
HES can cause renal injury
black box warning
what fluid do you want to give sepsis pts?
albumin to incr oncotic pressure
MAP goal in sepsis
65
vasopressor priority for sepsis pts
1: NE (beta/alpha)
2: epi (alpha/beta)
3: vasopressin
which drug to avoid in sepsis
dopamine causes arrythmias
inotrope of choice in sepsis
dobutamine
steroids _____ immune response
decr immune response
should you give steroids to sepsis pts who are stable?
NO
should you give steroids to sepsis pts who are unstable?
maybe - decr immune response may help curb sepsis symptoms
hb target for transfusion
7-10 g/dL
ventilator goals in sepsis-ARDS
normal CO2
SpO2 > 93%
sepsis-ARDS TV
4-6 mL/kg
sepsis-ARD RR
incr
sepsis-ARDS PEEP
increased
CVVH
continuous renal replacement therapy
(continuous dialysis commonly used in ICU)
CVVH rate
slower rate of solute and fluid removal
sepsis blood glu goal
Glu < 180 mg/dL
systemic inflammatory response syndrome (SIRS)
- acute proinflammatory response mediated by incr in innate immune gene expression (SIRS)
- anti-inflammatory response that modulate proinflammatory response (CARS)
proinflammatory response
cytokines
SIRS diagnosis
2+:
temp > 36-38C
HR > 90 bpm
RR > 20
PCO2 < 32 mmHg
WBC > 12 or < 4
SIRS pts ventialtion
hyperventilation
- respiratory compensation for metabolic process
how many stages of SIRS
5 (SIRS -> MODS)
MODS
multiorgan dysfucntion syndrome
Compensatory anti-inflammatory response syndrome (CARS)
body tries to regain immunological balance but overcompensates
CARS pts have incr susceptibility to
nosocomial infections
Persistent inflammation, Immunosuppresion, and catabolism syndrome (PICS)
pt never fully recovers and requires constant ICU care
persistent genomic changes
what equation is used to determine basal energy expenditure
Harris-Benedict equation
(BEE)
stress _____ BEE
stress increases BEE
minimally stressed
25 kcal/kg/day
~ 1.1 BEE
post surgical stressed
30 kcal/kg/day
sepsis stressed
30-35 kcal/kg/day
burn stressed
35-40 kcal/kg/day
~ 2 BEE
minimal stress protein need
1 g protein/kg/day
burn pt protein need
2.5 g protein/kg/day
ICU nutrition intake options
enteral
parenteral
enteral nutrition
through gut
NG or nasojejunal tube
parenteral nutrition
through vein
PICC line
what % of calories needed to admin into gut to mx gut integrity?
50-60%
overfeeding risks
incr O2 consumption
incr CO2 production
prolonged vent
immune suppression
hyperglycemia
incr infection risk
when is overfeeding risk higher
actual body weight is»_space; IBW
refeeding syndrome
rapid initiation of enteral/parenteral feeding in malnourished pt
refeeding syndrome SE
arrythmias
confusion
respiratory failure
death
refeeding syndrome treatment
correct electrolyte and volume deficits
give thiamine before feeding
slow initiation of feeding
Glu range
80-110 mg/dL (Van de berge)
140-180 mg/dL
NICE-SUGAR result
incr in hypoglycemia
incr in mortality
due to too tight blood sugar control
sick euthyroid syndrome
Low T3 state (acute)
Low T4 state
Low T3 in sick euthyroid timeline
< 24 hrs
Low T4 in sick euthyroid timeline
T4 decline correlates with more severe illness
mortality and T4 levels
T4 levels < 2 ug/dL indicate 80% risk of mortality
can you treat sick euthyroid w/thyroid hormones?
no indication that hormone replacement helps
Relative adrenal insufficiency
inability of adrenal gland to produce enough adrenocortical steroids to supply need
primary adrenal insufficiency
autoimmune system destroys 90% of adrenal cortex
secondary adrenal insufficiency
low ACTH levels
primary cause of secondary adrenal insufficiency
sepsis
other causes of secondary adrenal insufficiency
impaired pituitary ACTH release
reduction in cortisol synth
impaired cortisol transport
impaired response to cortisol
acute renal dysfunction occurs in ____ of ICU pts
1/3 of ICU pts
acute renal dusfunction S+S
hypotension
sepsis
nephrotoxic drugs
acute renal dysfunction risks
age
kidney disease
oliguria < 400 ml/day
sepsis
what scale defines severity of acute renal dysfucntion
KDIGO
KDIGO 1
1.5-1.9 fold Cr
Cr > 0.3 mg/dL in 48hrs
urine < 0.5 ml/kg/hr 6 hrs
KDIGO 2
2-2.9 fold Cr
< 0.5 ml/kg/hr 12 hrs
KDIGO 3
> 3 fold cr
4 mg/dL cr
< 0.3 ml/kg/hr for 24 hrs
scales used to direct sedation
RASS
Sedation-Agitation scale
delerium
altered level of consciousness
decr ability to focus and change cognition
resuscitation
treat deficit and ongoing losses
maintenance
treat normal daily fluid lose
Adjusted body weight =
IBW + 1/3*(ABW-IBW)
ICU mx fluid
hypotonic
5% dextrose
resuscitation fluids
crystalloids
dextroses free
IV volume
25% of ECV
interstitial volume
75% of ECV
LR risks
hyponatremia in prolonged use
LR Na+
130 mEq/L
Normal saline Na+/Cl-
154 mEq/L
NS risks
hyperchloremia metabolic acidosis
hypertonic saline admin
central line
3% saline risks
acid/base and electrolyte imbalances
which pts cannot receive albumin
TBI
enteral feeds pt NPO status
NPO bypass stomach
TPN changes before surgery
cut rate by 1/4-1/2 prior to surgery
do not stop entirely
universal donor
O-
antibodies screened in cross match
kidd
kell
duffy
pts with higher risk for transfusion complications
previous transfusions
prior pregnancy
surgical site infections (SSI) types
superficial inciisional
deep incisional
organ/organ space
SSI risk factors: pts
elderly
immunosuppression
obese
DM
smoking
renal failure
chronic inflammation
PVD
microbial carrier
SSI risk factors: procedure
duration
hypoxemia
hyperthermia
abx
skin/instrument sterility
SSI preventitive measures
skin prep
normoglycemia
normothermia
avoid hypoxemia
Abx
SSI abx timeline
within 60 mins of SSI
how long does it take abx to circulate
20 mins
total joint VTE prophylaxis
10-14 days post-op
LMWH
fondaparinux
apixaban
dabigatran
rivaroxaban
warfarin
aspirin
compression
hip fracture VTE prophylaxis
LMWH 12+ hrs prior to surgery
high VTE risk / low bleed risk
LMWH + compression
high bleed risk
compression only
options if heparin is CI
aspirin
fondaparinux
compression
DM and HbA1C
HbA1C has lower O2 carrying capacity in DM
DM rirsk
incr CAD
incr PVD
decr GI motility
ETC
elevated A1C correletes with
incr complication rates
steroid dosing in OR
recommended for all pts who have received steroid in the last year
glucocorticoid mech
mediate catecholamine induced incr in contractility and vascular tone
glucocorticoid SE
abnormal would healing
incr infection
body temp is controlled by
neg feedback loop in hypothalamus
hypothermia complications
cardiac arrythmias
wound infection
coagulopathy
prolonged recovery
ICU transport go bag
airway supply
vasopressors
atropine
sux
muscle relaxant
narcotic
sedative
flushes/alcohol
CI to ICU transport
inability to adequately oxygenate/ventilate
HD unstable
