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
What is the ICU liberation bundle?
- Liberate ICU px from pain, oversedation, delirium, MV, immobility and isolation
1) Assess, prevent and manage pain
2) Both SAwakeningT and SBreathingT
3) Choice of analgesia and sedation
4) Assess for delirium
5) Early mobility and exercise
6) Family engagement and empowerment
What are the bundles for reducing nosocomial infx?
1) Ventilator associated pneumonia (VAP) bundle
- Head of bed 45 deg
- Oral care with chlorhex
- Turning or mobilization
- Stress ulcer disease prophylaxis
- DVT prophylaxis
- Daily SBT and SAT
2) CAUTI bundle
- Insertion using sterile technique
- Proper perineal care
- Early removal
- Closed drainage system
3) CLABSI bundle
- Insertion using sterile technique
- Use chlorhexidine-impregnated dressing
- Early removal
