Crit Care: 1 pages 58-66 Flashcards
Guidelines recommend that supplemental parenteral nutrition should be considered only after ___ to ___ days of meeting less than ___% of energy and protein requirements by the enteral route alone.
7-10
60%
Why is early mobilization important in the ICU?
long-term follow-up of patients with critical illness demonstrates persistent weakness at 1 and 5 year
Admission to the ICU for respiratory insufficiency is prompted by what three basic conditions/categories
- hypoxemic respiratory failure,
- hypercapnic respiratory (ventilatory) failure
- upper airway impairment
Therapies for hypoxemia include ____ or ____
- increasing the inhaled oxygen concentration
2. applying positive end-expiratory pressure to open up flooded or collapsed alveoli.
Upper airway impairment is usually a manifestation of
either ___ or ___
- obstruction of the airway (e.g., angioedema)
2. inability to protect the airway (e.g., opiate intoxication).
Evidence now suggests that supplementing oxygen for patients whose oxygen saturation is already ___ or higher actually increases mortality.
96%
Recommendations include both that an SpO2 of 1.___or lower should be maintained in patients receiving oxygen therapy and that oxygen therapy should not be started for patients with acute myocardial infarction or stroke and an SpO2 of 2.___ or higher
- 96%
2. 93%
What conditions may benefit from SaO2 over 96% ( 4 examples)
- carbon monoxide poisoning (a specific case in which SpO2 may be unreliable and SaO2 should be used instead),
- cluster headache
- sickle cell crisis
- pneumothorax.
Evidence favors the use of NPPV in the critical care setting in patients with what 5 conditions?
- COPD exacerbations
- cardiogenic pulmonary edema
- neuromuscular disease
- obesity hypoventilation syndrome
- patients at high risk of failing extubation (e.g., those >65 years old or with heart failure or COPD).
How often to monitor or adjust NPPV
At least every 2 hours
Contraindications to the use of NPPV (8)
- persistent altered mental status
- increased airway secretions
- emesis, gastric distention
- airway obstruction
- recent esophageal surgery
- cardiac arrest
- inability to protect the airway, facial trauma/surgery (including oral, nasal, or sinus),
- patient intolerance of the mask.
over distension of alveoli causes
volutrauma
collapse of alveoli with expiration causes
atelectrauma
SBT length
at least 30 minutes and no more than 2 hours in length
SBT PEEP
≤8 cm H2O
VC:
Control Variable:
Breath Sequence:
Control Variable: The ventilator controls the flow (volume) during the mandatory breath. If the patient’s effort, lung compliance, or resistance changes, the ventilator will still deliver the set tidal volume.
Breath Sequence: All breaths are mandatory. The patient may or may not trigger the breath, but the ventilator always ends (cycles) the breath when the tidal volume is delivered.
PC
Control Variable:
Breath Sequence:
Control Variable: The ventilator controls the pressure during the mandatory breath. If the patient’s effort, lung compliance, or resistance changes, the ventilator will still deliver the set inspiratory pressure (but the tidal volume delivered will change).
Breath Sequence: All breaths are mandatory. The patient may or may not trigger the breath, but the ventilator always ends the breath when the preset inspiratory time elapses.
PS
Control Variable:
Breath Sequence:
Control Variable: The ventilator controls the pressure during the breath.
Breath Sequence: All breaths are spontaneous. The patient triggers and cycles the breath.
Benefits of VC
Ensures minimum minute ventilation
Ability to limit tidal volume delivered
Serves the goal of safety
Drawback to VC
Least likely to allow comfort for patient because of limitation in flow
Benefits of PC
Prevents barrotruama
Comfort
Drawback of PC
tidal volume delivery will increase and decrease with changes with patient compliance (can cause volutruama)
IO lines should be removed within
24 hours
Criteria to Perform SBT (5)
- Cause of respiratory failure improved
- FIO2 ≤40% and PEEP ≤5-8 cm H2O
- pH >7.25
4, Hemodynamic stability
- Able to spontaneously breathe
Dobutamine: Type of shock to use for, Receptor Target, Primary Effect
Type of shock: Cardiogenic, Cardiogenic
Receptor Target: β1, β2
Primary Effect: ↑Inotropy
First choice for cardiogenic shock without hypotension
Add-on therapy for distributive shock with depressed cardiac function
Criteria to pass SBT
At Least 30 Minutes Without the Following (6)
Clinical evidence of respiratory distress
SpO2 <90%
Respiration rate >35/min
New arrhythmias
Tachycardia
Hypotension or hypertension
Dopamine: Type of shock to use for, Receptor Target, Primary Effect
Type of Shock: Cardiogenic only in cases of severe bradycardia in septic shock !
Receptor Target: D, α1, β1
Primary Effect: ↑ SVR, ↑ inotropy -
Not going to do the high vs low thing since no one uses dopamine and that’s probably not even real
Epinephrine: Type of shock to use for, Receptor Target, Primary Effect
Type of Shock: Cardiogenic, Distributive, Hypovolemic
Receptor Target: α1, α2, β1, β2
Primary Effect: ↑ SVR, ↑ inotropy
First choice anaphylactic (distributive) shock
Norepi: Type of shock to use for, Receptor Target, Primary Effect
Type of Shock: Cardiogenic, Distributive, Hypovolemic
Receptor Target: α1, α2, β1
Primary Effect: ↑ SVR, ↑ inotropy
First choice in cardiogenic, distributive, and hypovolemic shock
Phenylephrine: Type of shock to use for, Receptor Target, Primary Effect
Type of Shock: Distributive
Receptor Target: α1
Primary Effect: ↑ SVR
May be used when norepinephrine is contraindicated (tachyarrhythmias) or after failure of first-line drugs; may depress cardiac output by causing reflex bradycardia
Vasopressin: Type of shock to use for, Receptor Target, Primary Effect
Type of Shock: Distributive
Hypovolemic
Receptor Target: V
Primary Effect: ↑ SVR
