Anaesthesiology SC002: The Patient Is Critically Ill: Intensive Care Medicine; Unstable Vital Organ Function Flashcards
1
Q
Intensive Care Unit
A
- Specially staffed and equipped, separate + self-contained area of a hospital dedicated to:
1. Management of patients with life-threatening illnesses, injuries / complications
2. Monitoring of potentially life-threatening conditions - Provide special expertise + facilities for ***support of vital functions (e.g. Circulation, Respiration, Renal function) + uses the skills of medical, nursing + other personnel experienced in management of these problems
Nursing considerations:
- Require a high intensity of nursing care
- 1:1 for ventilate patients
- 1:2 for lower acuity
- majority should have post-registration qualification in ***Intensive care
- competent to provide ***advance life support (e.g. extracorporeal care)
Medical staffing considerations: - Headed by a full time Medical Director - Sufficient specialist staff with experience in Intensive care medicine to provide for patient management, administration, teaching, research, audit + ICU-based activities outside of the ICU as required - In HK, specially trained doctors: —> Anaesthesiologists —> Physicians - Preferably full time
Functional considerations:
- Intensive **therapy + **Organ support (e.g. RRT, ventilation, circulatory support)
- Intensive **monitoring (for patients at **high risk of deterioration but may not be too sick)
- Organ support for potential organ donors (possibly)
2
Q
Multidisciplinary care in ICU
A
- ICU doctors (main attending doctors + make decisions) + nurses
- Physicians
- Surgeons
- Microbiologists
- Physiotherapists
- Pharmacists
- Dietitians
3
Q
Intensive Monitoring
A
More comprehensive monitoring
- CVP, ECG, Urine output
- Invasive Artery BP monitoring (by Radial arterial catheter: Real time monitoring —> pick up early deterioration)
- Other monitoring
- Cardiac output measurements
4
Q
Organ failures in ICU
A
ICU:
- Prevent
- Manage
- Monitor
Support failing organs aiming at:
- Salvage important organ function before irreversible damage
- Buy time for eventual organ recovery
- Provide definitive treatment if possible to enhance recovery (cannot be controlled, no drugs aim at recovery)
Common organ failures:
- Respiratory failure
- Circulatory failure
- Renal failure
- Hepatic failure
- Neurological failure
- Metabolic failure
- Drug toxicities
- Other life support
5
Q
- Respiratory failure
A
Most common organ failure requiring care in general ICU
- Type 1 respiratory failure
- Type 2 respiratory failure
Organ support:
- Invasive mechanical ventilation
- Non-invasive mechanical ventilation
- Other respiratory support:
- Tracheostomy, Oxygen therapy
- ECMO (Extracorporeal membrane oxygenation)
6
Q
- Circulatory failure
A
- Hypertensive crisis
- Acute heart failure
- Pulmonary edema - Shock
- Cardiogenic
- Hypovolaemic
- Distributive (Septic, Anaphylactic, Neurogenic)
- Obstructive - Post-resuscitation care (e.g. Targeted temperature management (TTM))
7
Q
- Renal failure
A
- Acute renal failure
- Acute on chronic renal failure
Renal replacement therapy (Extracorporeal blood purification):
- Continuous renal replacement therapy
- Haemofiltration - Acute haemodialysis
- Acute peritoneal dialysis
8
Q
- Hepatic failure
A
Supportive care for Acute / Acute-on-chronic liver failure
- Hepatic coma care
- “Liver dialysis”
- Molecular Adsorbent Recycling System (MARS) (nearly obsolete) - Care around liver transplant
9
Q
Other organ failure
A
- Neurological failure
- Acute coma care
- Acute post-infectious polyneuropathy - Metabolic failure
- DKA
- Diabetic Hyperosmolar coma
- Thyroid storms
- Major electrolyte disturbances - Drug toxicities
- Drug overdose
- Drug desensitisation - Other life support
- Temperature regulatory problems
- Haematological emergencies
- Obstetrics emergency
- Complicated wound care: Burns
10
Q
Who are the patients that would benefit from ICU care
A
- Patient preference
- Care in ICU is an option requiring patient’s consent -
**Triage
- one of key functions of ICU —> ICU resources are always **limited
- 3 criteria for consideration:
—> **Disease severity (between moderate to severe: “sick but not very sick” i.e. too ill to benefit from ICU care)
—> **Reversibility (difficult to ascertain)
—> ***QoL (difficult to ascertain)
11
Q
Is ICU admission always good?
A
Pros:
- More intensive therapy + monitor
- Maybe the only mean to save life
Cons:
- Invasive procedures
- Infection risks (multi-resistant organisms)
- Loss of self esteem
- Other sequels
12
Q
ICU performance
A
NOT only measured by ***crude mortality of patients
- **Standardised Mortality Ratio (SMR)
- adjusted for severity of patients
- Mortality of ICU compared to reference data base
- Prediction models
1. ***APACHE score (Acute Physiology and Chronic Health Evaluation) - AP (Acute physiology): 12 most abnormal physiological parameters in first 24 hours of ICU stay
- A (Age)
- CH (Chronic health): underlying chronic diseases —> Immunocompromised, Renal, Resp, Heart, Liver failure
2. SAPS score (Simplified Acute Physiology Score)
3. MPM (Mortality Prediction Model)
13
Q
End of life decisions
A
Death is a natural process: might be for the benefits of some patients
> 50% of ICU death as occurred with a decision of Do-Not-Resuscitate (DNACPR) / some form of withdrawal of treatment:
- Withdrawal of inotropes / vasopressors
- Limiting blood products
- Limitation of ventilator settings
- Stopping renal replacement therapy
- Mainly a decision by medical doctors
14
Q
Ethical principles in considering DNACPR
A
- Medical futility (i.e. not beneficial to patient)
- Beneficence (i.e. best interest to let go)
- Autonomy
- Non-abandonment (i.e. even if not do CPR —> comfort always e.g. keep comfortable + warm)
- Non-maleficence
