Critical Care Flashcards
What are the SpO2 targets?
General px: >94%
COPD: 88-92%
- Condition causes them to be chronic retainers of CO2
- Hypoxia (instead of hypercapnia) drives them to breathe
Hyperbaric O2 in specific px
- ^ pressure allows ^ dissolving of O2 in blood
What are the indications for intra-arterial line insertion?
- Need for continuous monitoring of arterial BP
~ More accurate
~ For titration of inotropes - Frequent blood sampling
~ eg ABG - Identification of abnormal waveform patterns
- Evaluation of natural changes in BP during breathing to predict fluid responsiveness
What are the contra-indications for IA line site and insertion?
Site:
- Absence of collateral circulation
- Infected or synthetic graft materials present
- Previous vascular surgery done
Insertion:
- Peripheral vascular disease
- Hemorrhagic disorder
- Use of anti-coagulants or thrombolytic agents
What are the common arteries used for IA lines?
- Radial artery (wrist)
- Femoral artery
Not as recommended:
- Axillary artery (difficult to access)
- Brachial artery (occlusion of artery is dangerous as there are no collateral arteries)
- Posterior tibial artery/Dorsalis pedis artery (not as accurate as too low)
What is the nursing care for IA lines?
- Modified Allen’s test (to test if radial artery can be used)
~ Px makes a fist for 30 sec -> Press down on ulnar and radial arteries to obstruct blood flow -> Unclench fist -> Should blanch
~ If colour does not appear -> do not use - Maintain pressure bag at 300mmhg
- Fast flush
- Phlebostatic axis at 4th ICS
What are the complications for IA line?
- Arterial spasm
- Arterial occlusion
- Ischemia
- Internal bleeding
- Infection
What is a central venous catheter and what are the indications?
Indwelling catheter in a large central vein
Indications:
- Infusions/medications compatible with peripheral access
- Venous access in emergency/difficult peripheral access
- Central venous pressure monitoring
~ To measure venous retun, right heart function and fluid status
- Initiation of extracorporeal therapy for kidney
- Venous interventions needed
What are the contra-indications for CVC?
- Active skin infections
- Vascular injury at site
- Presence of other device
- Bleeding risk
- Uncooperative awake px
- Trauma or congenital anomalies at site
- Morbid obesity
What are the common access sites for CVC?
- Internal jugular
~ Right IJ has the most direct path to the SVC - Subclavian
~ Has higher pneumothorax rates
~ Choice if there is a c-spine injury - Femoral
~ Easily compressible if coagulopathic
What are the common complications from CVC and what are the interventions?
1) Pneumothorax
- Proper positioning during insertion (supine or Trendelenburg)
2) Occlusion from clot
- Routine flushing
- Do not flush against resistance
- Prevent kinks
- Do not mix meds with precipitation
3) Central line associated blood stream infection (CLABSI)
- CLABSI prevention bundle
~ Valved needleless connectors, CHG dressing, ABx-coated catheters, early removal
4) Air embolism
- Due to pressure gradient that allows air to enter bloodstream during flushing or catheter removal
- Use valved needleless connectors
- Do not expose hubs to air
- Clamp line when not in use
- If air embolism present, put px in Trendelenburg position and give high flow O2
5) Dislodgement of migration of catheter
- Avoid pulling or manipulating catheter
- Do not readvance if migrated externally
- Escalate if migrated internally
What are the common POCT?
- ECG
- ABG
- Lactate
~ 2-4
~ Most common cause of metabolic acidosis in hospitals
~ICU biomarker for tissue perfusion - BGM
~ 4-8 mmol/L
~ Hyperglycemia more common
BiPAP vs CPAP?
BiPAP + CPAP:
Both non-invasive ventilation
- Delivers positive pressure into lungs w/o ETT
BiPAP:
- 2 modes
~ Spontaneous
~ Spontaneous/Timed
- 2 pressures, for inhalation and exhalation
- For ventilation problem
- For COPD exacerbation w pH <7.25
CPAP:
- Continuous flow
- For oxygenation problem
- For acute pulmonary edema
What are the contraindications of BiPAP and CPAP?
Absolute:
- Facial trauma//burns
- Fixed upper airway obstruction
- Active vomiting
- Respiratory or cardiac arrest
Relative:
- Recent facial, upper airway or upper GI surgery
- Altered mental status or condition, cannot initiate own breaths
- Life-threatening hypoxemia
- Copious secretions
- Undrained pneumothorax
- Bowel obstruction
What is end-tidal capnography?
Non-invasive measurement of PaCO2 in exhaled breath over time
- To see if px is being adequately ventilated and effectiveness of resuscitation during cardiac arrest
Used to:
- Verify ETT placement
What are the assessment scales that can be used for agitation and confusion?
1) Richmond Agitation-Sedation Scale (RASS)
- Assess the level of alertness and agitated behaviour in ICU px
- -5 (unarousable) to 0 (alert and calm) to 4 (Combative)
2) Critical-care pain observation tool (CPOT)
- Rates critically ill px pain based on clinical observation
- Over 8
3) Confusion assessment method in ICU )CAM-ICU)
- Short test to detect delirium in high-risk settings
- Tests for inattention, altered level of consciousness and disorganized thinking
