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QUESTION NOTES > CRIT CARE > Flashcards

CRIT CARE Flashcards

1
Q

Factors that lead to vent-induced lung injury

A
  • volume- pressure- oxygen
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2
Q

Factors that determine oxygenation

A
  • FiO2- PEEP- mean airway pressure
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3
Q

Factors that determine ventilation

A
  • RR- TV*assessed w/ PaCO2
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4
Q

Plateau pressure

A

measure at inspiratory pause; reflects alveolar pressure (ideal <30)

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5
Q

Peak airway pressure

A

total amount airway pressure delivered to overcome resistive and elastic work; if high represents large airway obstruction or bronchospasm, etc

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6
Q

Tobin index

A

rapid shallow breathing index = RR/TV; if <100 good indicator pt may come off vent (if <65, 90% sensitivity)

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7
Q

Negative inspiratory force (NIF)

A

expiratory pause - check neg pressure that pt can generate in lungs; if <20 then unlikely to be able to extubate. predictor of failure (not a good predictor of success)

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8
Q

ARDS Berlin definition

A

PaO2/FiO2 ratio + within 1wk insult + CXR + not due to fluid overload (check Echo)mild: 200-300mod: 100-200severe: <100

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9
Q

MOA dopamine

A

dose-dependentlow -> dopaminergic receptor in kidneysmed -> B1high -> alpha

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10
Q

MOA NE (levo)

A

alpha (B1 at low doses)

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11
Q

MOA Epi

A

equal alpha + B1

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12
Q

MOA phenyephrine

A

pure alpha (typically only to treat neurogenic shock 2/2 spinal cord injury)

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13
Q

MOA vasopressin

A

acts on V1 (vasopressor receptor)

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14
Q

MOA dobutamine

A

more B1 (good for cardiac failure), but has some B2 vasodilatory effect (no alpha)

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15
Q

MOA milrinone

A

PDE inhibitor; increases cAMP -> increases CO, vasodilatory

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16
Q

EKG change in PE

A

S1, Q3, T3; MC is sinus tachy

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17
Q

CVP tells us…? By measuring…?

A

volume status; by measuring RVED pressure

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18
Q

Wedge pressure tells us…? By measuring…?

A

preload; by measuring LVED pressure

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19
Q

Equation: CO

A

CO = SV x HR

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20
Q

Equation: CI

A

CI = CO/patient BSA

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21
Q

Equation: O2 delivery

A

O2 delivery = 1.36 x O2sat x (CO x Hgb)

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22
Q

Equation: O2 consumption

A

O2 consumption = (O2 arterial - O2 venous) x CO

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23
Q

Direct thrombin (Factor 2a) inhibitors

A

dabigatran, argatroban

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24
Q

Equation: respiratory quotient

A

RQ = CO2 produced/O2 consumed

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25
Q

RQ >0.9

A

giving too many carbs and cannot get off vent

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26
Q

TPN ratio of carbs vs. fat

A

Carbs 75%, 25% fat

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27
Q

Essential fatty acids

A
  • linoleic- alpha linoleic
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28
Q

Caloric content of carbs? lipids? protein? dextrose?

A

carbs = 4 kcal/glipids = 9protein = 4dextrose = 3.4

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29
Q

Airway pressure release ventilation

A

long inhalation period to open airway, then short period where pressure drops and pt allowed to exhale (pressure never 0)

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30
Q

Post-intubation initial tidal volume is…?

A

5-7 mg/kg

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31
Q

Neuroleptic malignant syndrome sxs

A

muscle rigidity, obtundation, tachycardia, fever

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32
Q

Mgmt neuroleptic malignant syndrome

A

bromocriptine, dantrolene

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33
Q

Drugs at risk neuroleptic malignant syndrome

A

haldol, metoclopramide

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34
Q

What kind of Cx ordered for BAL to dx vent-associated pneumonia?

A

quantitative cx (threshold 10^4 used to dx)

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35
Q

Absolute C/I bronchoscopy

A

severe refractory hypoxia w/ inability to maintain adequate oxygenation during procedure (cx of sedation and partial airway obstruction)

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36
Q

How to ventilate ARDS pts

A
  • low TV (4-6)- PEEP titrated to keep alveoli open- permissive hypercapnia (as long as pH >7.2)
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37
Q

If ARDS pt failing conventional therapy, what other method therapies with proven benefit?

A
  • proning (will improve P/F ratio)- neuromuscular blockade
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38
Q

New definition of sepsis

A

Sepsis 3 = if >2 increase SOFA score (sequential organ failure assessment)

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39
Q

Definition of septic shock

A

pt that needs pressor support to maintain MAPS >65 AND who has sustained lactate >2 (despite resus)

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40
Q

Mgmt sepsis resuscitation

A

within 3 hrs -> Cx, Abx, trend lactate (to guide resus), bolus w/ 30cc/kg for lactate >4within 6 hrs -> start pressors to maintain MAPS, look at tissue perfusion, guide resus based on lactate

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41
Q

Use for procalcitonin in ICU

A

indicates bacterial infection- when normalizes can think to stop Abx- if normal, can r/o sepsis- if elevated, ?? bc sensitive, not specific

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42
Q

Tests for invasive candidiasis

A
  • 1,3 beta-D-glucan- mannin- anti-mannin Ab
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43
Q

Where do you draw mixed venous O2?

A

pulmonary artery

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44
Q

RQ gives idea of what fuel pt is burning… so what is RQ for fat? protein? carbs?

A 
fat = 0.7
protein = 0.8
carbs = >1.0
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45
Q

Equation: nitrogen balance

A

nitrogen IN (protein in g/day via protein/6.25g) - urine loss - 4 (insensible loss)

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46
Q

Adverse effects too much carbs

A

high RQ -> difficult wean venthyperglycemiaimmunosuppressant effect

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47
Q

Adverse effects of too much fats

A

pro-inflammatory

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48
Q

How much protein generally give pts? in renal failure pts? in liver failure pts?

A

1g/kg/day renal -> ensure have essential AAliver -> branch chain AA

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49
Q

MC long-term pulmonary defect of ARDS

A

reduced diffusing capacity (DLCO) 2/2 replacement of type 1 lining cells by cuboidal cells + pulm fibrosis

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50
Q

Allen test used to…?

A

determine if ulnar artery can provide distal perfusion to hand

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51
Q

Mechanism of IABP

A
  1. inflation during diastole -> increased MAP2. rapid deflation just prior to systole -> decreases afterload on heart
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52
Q

MC organism vent-associated pneumonia

A

sensitive GP (MSSA, strep sp) and H.influ

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53
Q

Which location for arterial catheterization are at higher risk thrombosis?

A

brachial and radial (but easier to cannulate and less risk to injury to nerves)

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54
Q

Effect of permissive hypoventilation for ARDS pts

A
  • duration of mech vent support longer, but greater survival%- can disregard pCO2 unless pH <7.28 or ICP >15- C/I head injury pts w/ elevated ICP
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55
Q

Pathophysiological changes associated with development of ARDS

A

2/2 diffuse alveolar damage; diffuse inflam causing…- increased vasc permeability -> hypoxemia + diffuse b/l alveolar infiltrates on XR- alveolar edema- acute inflam of alveolar walls- hyaline membranes

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56
Q

Standard confirmation of ET tube is with…?

A

end-tidal CO2 detection - CO2 released from lungs after initial 3-4 breaths

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57
Q

How to measure intra-abdominal pressure re: abd compartment syndrome?

A

bladder pressure @ end-expiration:- instill 70cc saline into bladder via clamped foley- pressure transducer via needle in aspiration port

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58
Q

Settings in which PA cath is still used

A
  • RV failure- pulm HTN- weaning failure of cardiac origin- post-cardiac surgery
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59
Q

Normal cardiac index (PA cath)

A

2.5-4 L/min

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60
Q

How does trauma affect tissue O2 consumption?

A

decreased. trauma -> decreased cardiac output -> decreased tissue perfusion

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61
Q

Mgmt air embolism

A

prevent air from entering RV (LL decubitus + Trendelenburg), then aspirate air from cath and place on 1.0 FiO2 to attempt reabsorption of air

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62
Q

Does septic shock respond to vasopressors?

A

No. hypotension 2/2 failure of vasc smooth muscle to constrict bc upreg of iNOS in vessel walls, which lasts for sustained time, rending vasoconstrictive agents ineffective

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63
Q

Where should PA cath tip sit on CXR?

A

@ PA or RA (not RV bc risk arrhythmia)

64
Q

Relative C/I PA cath insertion

A
  • left BBB (bc PA cath may induce right BBB -> rare risk transient complete block)- hx HIT (PA cath hep-coated)
65
Q

When would you delay insulin therapy in DKA?

A

if K <3.3

66
Q

Most signif increase of DO2 (oxygen delivery) would be after increase in what factor?

A

Hgb

67
Q

Cause of hypoventilation-related resp failure acutely after extubation from laparoscopic surgery?

A

CO2 pneumoperitoneum increases pt’s circulating partial pressure CO2 (therefore, need end-tidal CO2 to normalize before extubation)

68
Q

Why not wet-to-dry dressing for open abdomen wound?

A

risk for fistula formation via trauma to intestinal wall

69
Q

How to dx VAP?

A

BAL (differentiate btwn lung inflammation vs. infection)

70
Q

Appropriate size ET tube for peds pts?

A

(Age/4) + 4can also estimate w/ child’s little finger

71
Q

In setting of normal PCO2, a low PO2 indicates…?

A

inadequate perfusion or shunting (indicates degree of vent-perfusion mismatch)

72
Q

Sodium bicarb therapy only rec for pH < …?

A

<7.15

73
Q

In critically ill adults, rec blood glucose target of…?

A

140-180 mg/dL

74
Q

Quickest CVC access is…?

A

femoral vein

75
Q

Sxs of lidocaine toxicity

A
  • CNS: dizziness, numbness, seizure- CV: arrhythmia, myocardial contractility- HTN, tachycardia followed by myocardial depression w/ mild hypotension -> brady -> ventricular arrhythmias -> CV collapse
76
Q

CPAP or BiPAP in pts with SBO, risk…?

A

risk aspiration if stomach not decompressed

77
Q

Refeeding syndrome 2/2…?

A

electrolyte shifts by influx of glucose, and insulin promotes synthesis of proteins and fats -> hypoP/Mg/K

78
Q

Reversal of benzos

A

flumazenil

79
Q

MC inherited coagulopathy associated with bleeding

A

vWD

80
Q

Berline Definition of ARDS

A
  • resp sxs <1-wk clinical insult- CXR: bilateral opacities consistent with pulm edema- resp failure must not be completely explained by cardiac failure or fluid overload- classified as mild (P/F 200-300) vs. moderate (100-200) vs. severe (<100)** definition hypoxia calculated with PEEP >5
81
Q

Early enteral nutrition (within 36hrs) in post-damage control laparotomy pts have lower rates of…?

A

pneumonia

82
Q

EKG changes: hypoMg

A
  • wide QRS- transition from peaked to flattened T-waves- prolonged PR interval- polymorphic v.tach
83
Q

Spinal cord injury-associated bradycardia can be Tx with…?

A

atropine (usually resolves 2-6 wks)

84
Q

If new onset a.fib <48hrs… mgmt?

A

rate control, no additional AC necessary.

85
Q

If new onset a.fib, time of onset unknown and need cardiovert… mgmt?

A

AC prior to cardioversion

86
Q

Post-traumatic organ failure… early vs. late?

A

Early -> inadequate tissue perfusion -> cardiopulm failureLate -> infection -> pulm/hepatic failure

87
Q

Sudden onset hypotension and jugular vein distention after subclavian CVC placement, think…?

A

tension pneumothorax

88
Q

What is synchronized cardioversion?

A

timed (synced) with QRS complex, avoiding shock delivery during relative refractory portion of cardiac shock, which could produce v.fib

89
Q

Severe neonatal respiratory failure most effectively treated with…?

A

ECMO

90
Q

Mgmt open abdomen pt after damage control laparotomy

A
  1. correction of lethal triad2. early enteral nutrition initiation when intestinal continuity is restored
91
Q

MOA antithrombin III

A

serine protease inhibitor that forms complex w/ thrombin + Factor Xa, causing them to lose their pro-coagulant activity

92
Q

Compared to NE, how does dopamine fare as a vasopressor agent?

A

associated w/ signif increased risk both supraventricular and ventricular arrhythmias + higher short-term mortality risk

93
Q

Typical parameters (not predictors) for successful in SBT includes…

A
  • vital capacity 12-15 mL/kg
  • tidal volume 5-7 mL/kg
  • RR <25 bpm
  • max inspiratory force at least -30 cmH2O
  • minute ventilation <10 L/min
94
Q

RF pulmonary artery rupture 2/2 catheter

A
  • migration of cath into distal pulmonary arteries

- pre-existing pulmonary HTN

95
Q

Immediate cause of mortality from pulmonary artery rupture 2/2 catheter?

A

flooding of OPPOSITE lung with blood -> hypoxia, asphyxiation

96
Q

Positioning after pulmonary artery rupture 2/2 catheter misplacement

A

Lateral decubitus to side of misplacement - prevents bleeding from extending to opposite lung mainstem bronchus

97
Q

Mgmt pulmonary artery rupture 2/2 catheter misplacement

A
  1. lateral decub positioning on to side of misplacement
  2. withdraw catheter to proximal pulm artery (distal ruptured area can vasoconstrict/spasm to tamponade)
  3. thoracotomy
98
Q

Recommended dose for haldol for acute delirium

A

1-5mg/hr, not to exceed 20mg/24hrs

99
Q

Adverse outcomes of haldol

A

prolonged QT -> ventricular arrhythmia (torsade de pointes) – pts on routine haldol need daily EKG

100
Q

Drugs preferred for acute delirium in elderly pts

A
  • dexmedetomidine (precedex)
  • propofol
  • haldol
101
Q

Adverse effect dexmedetomidine

A

bradycardia

102
Q

Mgmt massive PE (with associated hypotension)

A

systemic thrombolytic therapy (tPA) - if fail, then consider embolectomy open vs. catheter

103
Q

Mgmt submassive PE (wo associated hypotension)

A

systemic AC with heparin

104
Q

Vent types: Inverse ratio ventilation (IRV)

A

may be useful for ARDS - extends inspiratory time; so inspiration:expiration ratio 1:1 or 2:1 -> increases mean airway pressure wo raising peak alveolar pressure
*however, develops auto-PEEP bc does not allow for complete expiration -> risk pneumothorax

105
Q

Vent types: airway pressure release ventilation

A

bilevel mode of breathing in which continuous positive airway pressure maintained, with set timed releases to allow for CO2 exhalation

106
Q

Vent types: High-frequency oscillatory ventilation (HFOV)

A

very small tidal volumes (5-20cc) over rapid rate (>200 bpm) - limits alveolar overdistention and large variation in mean alveolar pressure - pts need to be sedated and paralyzed

107
Q

Vent types: proportional assist ventilation (PAV) vs. neurally adjusted ventilatory support (NAVA)

A

both: improve pt-vent synchrony
PAV: varies vent support based on pt’s inspiratory effort on each breath
NAVA: does this via diaphragmatic electromyogrphy signal (via NGT) to control flow

108
Q

Absolute C/I to ECMO use

A

any condition that precludes use of AC (ie. traumatic brain injury)

109
Q

Indications for ECMO in ARDS

A
  • severe hypoxemia (P/F <80, despite high levels PEEP)
  • uncompensated hypercapnia with acidemia (pH <7.15)
  • excessively high end-inspiratory plateau pressure (>35-45 cm H2O)
110
Q

How does morphine induce hypotension?

A

histamine release (not seen in dilaudid or fentanyl)

111
Q

Adverse effect of propofol

A

hyperTG (bc is a lipid carrier)

112
Q

PerQ trachesotomy is performed where anatomically?

A

between second and third tracheal rings

113
Q

Advantages to perQ over open tracheostomy

A
  • faster
  • fewer infections
  • less stoma inflammation
  • reduces risk of postprocedural major bleeding episodes
114
Q

Tx central vs. nephrogenic DI

A

central: vasopressin
peripheral: FREE water mgmt

115
Q

Why have physiologic anemia in pregnancy?

A

Increase in plasma (due to alterations of RAAS -> increase in volume) more rapid than increase in RBC

116
Q

Inferior MI and hemodynamic instability in post-operative pt… next step?

A

TEE to eval for acute MR due to rupture of chordae tendineae or papillary muscle - if yes, then stabilize with afterload reduction + diuretics -> urgent coronary arteriography vs. MV repair

117
Q

Mgmt that decreases mortality in ARDS

A
  • volume control w/ 6 mL/kg tidal volume (low)
  • prone positioning
  • short duration of chemical paralysis
118
Q

Early feeding to full enteral support in critically ill pts associated with…?

A

more Cx such as VAP - bc in well-nourished pt, full enteral support can be delayed for up to 7-days
*also do not need to start early parenteral bc high IV glucose not appropriate in critically ill pts

119
Q

Protein requirement for:

  1. critically ill pt
  2. ”” + obese BMI 30-40
  3. ”” + obese BMI >40
  4. ”” + 40% TBSA
  5. ”” + renal failure
  6. ”” + need CRRT
A
  1. 1.2-3 g protein/kg/day
  2. 2.0
  3. 2.5
  4. 2.5
  5. 1.25-1.75
  6. 2.5
120
Q

Continuous etomidate infusion for sedation of critically ill trauma pts is associated with…?

A

increased mortality due to primary adrenal suppression 2/2 reversible inhibition of 11B-hydroxylase

121
Q

Drug of choice for pts in traumatic shock + pain, but at risk of hypotension?

A

ketamine - stimulates circulatory system, preserves protective airway reflexes, sedative + analgesic

122
Q

TEG: normal time (r)

A

<4 min

123
Q

TEG: normal angle (alpha)

A

66-82 degrees (cryo if <45)

124
Q

TEG: normal amplitude (MA)

A

54-72 min (desmopressin if 48-54; plt if bleeding and <48)

125
Q

TEG: normal clot lysis (LY30)

A

0-3%

126
Q

Caloric req for:

  1. critically ill + sepsis/trauma/burn/MOF
  2. ”” + sedated/vent
  3. ”” + sedated/vent/chemical paralysis
  4. ”” + BMI >30
A
  1. 30 kCal/kg/day
  2. 25
  3. 20
  4. 11-14 (hypocaloric feeding -> improved insulin sensitivity -> decrease vent days)
127
Q

TRALI (acute lung injury)

A
  • during or within 6-hr of transfusion
  • noncardiogenic pulm edema
  • 2/2 donor-related antileukocyte Ab
  • will have transient leukopenia 2/2 sequestration of neutrophils in pulm capillaries
  • Mgmt: vent support
128
Q

TACO (circulatory overload)

A
  • during or within 6-hr of transfusion
  • RF: elderly, overloaded, fast rates transfusion, underlying renal insuff or cardiac dysfxn
  • Mgmt: diuretics
129
Q

Do not use silvadene in what pts?

A
  • pregnant pts, newborns (risk kernicterus)

- not on face

130
Q

Adverse effect silvadene

A

neutropenia

131
Q

Electrolyte abnormalities associated with use of silver nitrate

A

hypoNa, hypoCl

132
Q

Gold standard for temperature monitoring for hypothermic pts

A

pulmonary artery catheter

133
Q

Atrial natriuretic peptide released due to…?

A

atrial wall stretch (ie. cardiogenic shock)

134
Q

Brain natriuretic peptide released from where?

A

ventricular myocytes

135
Q

Natriuretic peptide leads to…?

A

vascular SM dilation via cGMP formation

136
Q

Role of sodium polystyrene for hyperK

A

binds PO in GI tract -> remove K+ via stool

137
Q

Mechanism of hypoNa+ in pts with low intravascular volume

A

hypovolemia -> stimulate release of ADH -> water retention -> hypoNa

138
Q

Ideal glucose range during sepsis

A

80-110

139
Q

Initial medical mgmt hepato-renal syndrome

A
  • supportive

- terlipressin (vasopressor) + albumin

140
Q

If fail medical mgmt hepatorenal syndrome…?

A
  • TIPS
  • if elevated Cr, consider dialysis before TIPS
  • liver tx last resort
141
Q

Normal CVP (PA cath)

A

2-6 mmHg

142
Q

Normal PAWP (PA cath)? What level suggests LHF?

A

6-12 mmHg

>18 suggests LHF

143
Q

Normal PAP (pulm artery pressure)

A

25/10 mmHg

144
Q

Normal SvO2 (PA cath)

A

65-70%

145
Q

Normal SVR (systemic vascular resistance)

A

1100-1500 dyne/sec/cm2

146
Q

Normal RV pressure

A

25/4 mmHg

147
Q

Normal AO (aortic pressure)

A

120/79 mmHg

148
Q

RV: 25/15 , PA: 25/15 , PAWP: 15 … suggestive of?

A

cardiac tamponade - equalization of RA/RV/PAWP

149
Q

Difference in PA cath readings between early vs. late septic shock

A

Early: high CI
Late: low CI

150
Q

Subclavian central-line access associated with… ? CRBSI, ? DVT, ? pneumothorax compared to internal jug

A

lower rate CRBSI
lower rate pneumothorax
3x higher pneumothorax

151
Q

Decreased lung compliance in ARDS 2/2…?

A

alveolar flooding of inflam exudate and chemical mediators -> which inactivates alveolar surfactant -> alveolar collapse -> fewer alveoli to accommodate tidal volume -> forcing increased stretch of remaining functional alveoli -> decreased compliance

152
Q

What is vital capacity

A

(inspiratory capacity + expiratory reserve volume)

total amount of air that can be expelled after a max inhalation

153
Q

Eq. to determine arterial O2 content (CaO2)

A

1.34HgbSaO2 + 0.003*PaO2

154
Q

Stages of ARDS

A

1 (exudative): protein-rich fluid move into alveolar spaces -> leukocytes -> intrinsic lung injury + poor oxygenation
2 (fibroproliferative): fibrosis and collagen formation -> stiff, noncompliant lung (reversible)
3 (resolution): remodeling, clearing of pulm edema

155
Q

Which pneumocytes responsible for surfactant production?

A

Type II

156
Q

Tx for pt w/ COPD and new onset atrial fibrillation RVR

A

rate control with CCB (not BB)

157
Q

Which type of shock would benefit from Trendelenburg + vasopressors?

A

neurogenic shock - position to get blood back to heart

QUESTION NOTES (28 decks)

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