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Critical Care Flashcards

1
Q

Hypovolemic Shock

A

GI bleed, hemorrhage

Low CI
Low PCWP
High SVR (reflex)

Treat with fluid resuscitation
Blood products if Hgb <7 or actively bleeding
Pressors if hypotension not improved after fluids

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2
Q

Cardiogenic Shock

A

Acute MI, ADHF, valvular injury

Low CI
High PCWP (impaired blood flow causes congestion)
High SVR (reflex vasoconstriction)

Treat based on acute cardiovascular diseases

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3
Q

Obstructive Shock

A

Massive PE, Tamponade

Low CI
Low PCWP, if tamponade
High PCWP, if massive PE, aortic stenosis)
High SVR

Treat obstruction to reverse shock
PE: thrombectomy or thrombolytics
Tamponade: remove fluid

Fluids & vasopressors may improve symptoms but not outcomes

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4
Q

Distributive Shock

A

Sepsis

Early:
High CI
Low PCWP
Low SVR

Late:
Low CI
High PCWP
Low SVR

Antibiotic & fluid resuscitation in first hour

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5
Q

Sepsis

A

life-threatening end organ dysfunction caused by dysregulated response to infection

Do not use qSOFA as only screening tool

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6
Q

Septic shock

A

subset of sepsis
profound circulatory, cellular, and metabolic abnormalities are associated with greater mortality risk than sepsis alone

criteria: vasopressor need for MAP >65 and lactate > 2 despite fluid resuscitation

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7
Q

Surviving Sepsis Campaign 1 hour bundle

A

1) Baseline lactate
2) Obtain blood cultures prior to antibiotics
3) Administer broad spectrum antibiotics
4) 30mL/kg crystalloid infusion (LR may be > NS)
5) Initiate vasopressors if hypotensive during or after fluids for MAP > 65
6) Reassess if persistent arterial hypotension

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8
Q

Vasopressor extravasation

A

Get central venous access ASAP but may start peripherally to not delay administration

If extravasation occurs, stop immediately and switch to another site

Inject phentolamine (alpha receptor antagonist) around site ASAP to reduce tissue necrosis

Alternatives in shortage: nitroglycerin ointment or SC terbutaline

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9
Q

Vasopressor treatment cascade

A

1) DOC: Norepinephrine
2) Vasopressin may be added if needed at 0.03 units/minute
3) Epinephrine can be added if inadequate MAP on norepi + vasopressin

Alternative: Dopamine
Phenylephrine

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10
Q

Norepinephrine vs Dopamine

A

No difference in 28-day mortality

Dopamine associated with higher risk of arrhythmia, more days on vasopressor therapy, and needed another pressor.

Norepi does not improve mortality but is safer and more effective.

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11
Q

Norepinephrine (dose, receptors, info)

A

0.01-3 mcg/kg/min

alpha&raquo_space; B1
No activity at B2 or DA

Decrease renal perfusion
Increase SVR, MAP
No change or increase CO
May cause peripheral ischemia
Can induce tachyarrhythmia & Myocardial ischemia

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12
Q

Vasopressin (dose, receptors, info)

A

0.03-0.04 unit/min - no titration

No adrenergic activity at alpha, B1, B2, or DA
V1 agonism = peripheral vasoconstriction

No adrenergic activity = effective during acidosis & hypoxia
High dose = coronary vasoconstriction, peripheral necrosis

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13
Q

Epinephrine (Dose, receptors, info)

A

0.04-1mcg/kg/min

alpha&raquo_space;>B1=B2
No activity at DA
low doses = beta adrenergic

Positive inotrope/chronotrope = tachyarrhythmia & myocardia ischemia

May increase lactate (type B lactic acidosis) and blood glucose
May reduce splanchnic circ = gut ischemia

Used in refractory hypotension

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14
Q

Phenylephrine (dose, receptors, info)

A

0.5-8 mcg/kg/min

alpha only (no B1, B2, DA) - minimal cardiac activity

Reduce renal perfusion
Increase SVR, MAP

Primarily used to raise BP. Can rapidly inc SBP, DBP which may cause bradycardia = reduction in CO.

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15
Q

Low dose dopamine (dose, receptors, info)

A

1-3 mcg/kg/min = lower inotropic dose

+/- alpha
+ B1
+/- B2
++++ DA

Causes renal, coronary, mesenteric, and cerebral arterial vasodilation & natriuretic response

Do not use for renal protection. No evidence to support

Complements vasoconstrictive effects of norepi

May induce arrhythmia. May cause endocrine changes.

Immediate precursor to norepi. Prolonged infusion can deplete norepi stores = loss of vasopressor response

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16
Q

Moderate dose dopamine (dose, receptor, info)

A

3-10 mcg/kg/min

+ alpha
++ B1
0 B2
++ DA

May increase contractility and SVR

Can induce arrhythmia. Can cause endocrine changes.

Immediate precursor to norepi. Prolonged infusion can deplete norepi stores = loss of vasopressor response

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17
Q

High dose dopamine (dose, receptors, info)

A

10-20 mcg/kg/min

alpha +++
B1 ++
B2 0
DA +

Vasodilatory effect on renal blood flow may be lost due to predominant alpha1 vasoconstrictive effects

Can induce arrhythmia. Can cause endocrine changes.

Immediate precursor to norepi. Prolonged infusion can deplete norepi stores = loss of vasopressor response

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18
Q

Dobutamine (dose, receptor, info)

A

2-20 mcg/kg/min

B1&raquo_space;> alpha = B2
0 DA

Positive inotrope = increased CO

B2 stimulation = possible hypotension

Higher doses can cause tachyarrhythmia and changes in BP which may cause myocardial ischemia

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19
Q

Milrinone (dose, receptor, info)

A

50 mcg/kg load over 10 min, then 0.375-0.75 mcg/kg/min
*Load often omitted due to increased risk of vasodilation - vasodilation can cause hypotension, arrhythmia

Nonadrenergic
PDE type 3 inhibitor

Positive inotrope = increased CO

Renally adjust

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20
Q

Angiotensin II (dose, receptor, info)

A

10-80 ng/kg/min then 1.25-40 ng/kg/min

Nonadrenergic
Causes smooth muscle contraction & vasoconstriction

Increased thrombotic risks
May cause increased HR, LA, infections, delirium

ACE-I = exaggerated response
ARB = reduced response

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21
Q

Antibiotic cascade in SSC

A

Broad spectrum abx initiated within an hour (septic shock) after 2 sets of blood cultures and other cultures obtained

Each 1 hour delay = increase risk of mortality by 7.6%

Infuse broadest antibiotic first as rapidly as possible

Limit empiric antibiotic to 3-5 days

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22
Q

SSC steroid recommendation

A

Hydrocortisone 200mg/day

Unsure if mortality benefit, but has short term benefits

Do not use corticotropic stimulation test

Initiate when norepinephrine needs of > 0.25mcg/kg/min for at least 4 hours

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23
Q

Ascorbic acid in septic shock

A

Possible anti-inflammatory, antioxidant properties

2021 guidelines recommend against use of ascorbic acid

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24
Q

Metabolic acidosis

A

pH <7.35
pHCO3 <22

Compensation: increase RR to decrease pCO2

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25
Metabolic alkalosis
pH > 7.45 pHCO3 > 26 Compensation: decrease RR to increase pCO2
26
Respiratory acidosis
pH < 7.35 pCO2 > 45 Compensation: increase HCO3 (kidneys regulate this)
27
Respiratory alkalosis
pH > 7.45 PCO2 < 35 Compensation: decrease in HCO3 (kidneys regulate this)
28
Anion gap calculation
Na - [Cl + HCO3] Normal: 6-12 >12: primary metabolic acidosis For every 1 decrease in albumin less than 4, AG decreases by 2.5-3
29
Respiratory acidosis causes
Think - Decreased respirations Bronchospasm Cardiac arrest CNS depression PE Pneumonia Pulmonary edema Spinal cord injury Sedatives Stroke
30
Respiratory acidosis treatment
Correct cause Invasive/noninvasive ventilation
31
Respiratory alkalosis causes
Think - increased respirations Anxiety, pain CNS tumor Stroke Head injury Hypoxia Stimulants Reduced oxygen-carrying capacity Reduced alveolar oxygen extraction RR stimulation Extracorporeal removal
32
Respiratory alkalosis treatment
Correct cause O2 supplement Invasive/noninvasive ventilation Hypoventilation Sedation
33
Anion gap metabolic acidosis causes
MUDPILES Methanol Uremia DKA Propylene glycol Intoxication, infection Lactic acidosis Ethylene glycol Salicylate
34
Non-anion gap metabolic acidosis causes
F-USED CARS Fistula (pancreatic) Uteroenteric conduits Saline excess Endocrine (hyperparathyroid) Diarrhea Carbonic anhydrase inhibitors Arginine, lysine, chloride Renal tubular acidosis Spironolactone
35
Metabolic acidosis treatment
Correct cause Base use (sodium bicarbonate) may be considered but controversial
36
Metabolic alkalosis Urine Cl > 25 causes
Chloride resistant Hyperaldosteronism Increased mineralocorticoid
37
Metabolic alkalosis Urine Cl < 25 causes
Chloride responsive Vomiting NG suction Diuretic
38
Metabolic alkalosis Urine Cl > 25 treatment
Correct cause Potassium Aldosterone antagonist Acetazolamide
39
Metabolic alkalosis Urine Cl < 25 treatment
Correct cause 0.9% NaCl Consider acetazolamide Consider HCl if severe
40
Vfib or pulseless Vtach in CPR
shock therapy
41
PEA or asystole in CPR
epinephrine
42
Med admin in CPR
Do not stop compressions Central venous access preferred IO > ET administration Peripheral: follow with 20 ml of IV fluid
43
Meds that can be administered in ET tube
ET "LANE" during CPR 2-2.5x IV dose, diluted in 5-10 ml sterile water Lidocaine Atropine Naloxone Epinephrine
44
General post cardiac arrest care
1. Sao2 >= 94% 2. Hypotension (SBP <90) treated w/ fluid bolus, pressors 3. Avoidance of fever 4. TTM for first 24 hours to 32-37.5 C (0.3-0.5 C every hour)
45
Complications of TTM
1. Shivering 2. Reduced drug metabolism - use lower doses 3. Bleeding risk 4. Dehydration thru renal loss of water 5. Arrhythmia, hypotension 6. Hyperglycemia during cooling, hypoglycemia in rewarming 7. Infection 8. Hypokalemia/magnesemia/phosphatemia during cooling
46
Meds to reduce shivering
Sedatives (precedex, ketamine) Anesthetics Analgesics (meperidine, tramadol, fentanyl) Dexamethasone Clonidine Buspirone Ondansetron Magnesium Avoid paralytics
47
Potassium in TTM
Decreases during cooling phase Increases during warming phase due to electrolyte shift Do not over-replete during cooling.
48
Behavioral Pain Scale (BPS)
Use to monitor pain in adults in ICU Takes into account facial expression, upper limb movements, and compliance with mechanical ventilation >=6: significant pain
49
Critical Care Pain Observation Tool (CCPOT)
Use to monitor pain in adults in ICU Takes into account facial expression, body movements, muscle tension, compliance with ventilator, and vocalization (if extubated) >=3: significant pain
50
Richmond Agitation-Sedation Scale (RASS)
Assesses quality & depth of sedation Individualize goal but typically 0 (alert & calm) to -2 (light sedation)
51
Sedation Agitation Scale (SAS)
Assesses quality & depth of sedation Individualize goal but typically 3 (sedated) - 4 (calm & cooperative)
52
Propofol-related infusion syndrome
Rates of 80mcg/kg/min for at least 48 hours Metabolic acidosis, cardiac failure, bradycardia, cardiac arrest, rhabdomyolysis, hyperkalemia, kidney failure
53
Calories from propofol
1.1 kcal/mL (in 10% lipid emulsion)
54
Propofol dosing, AE
Preferred sedative 5 mcg/kg/min, increase by 5 mcg/kg/min every 5 minutes to achieve certain RASS Avoid bolus dosing = hypotension Sedative only, does not provide pain relief. AE: Respiratory depression (must be intubated), Elevated trigs (stop if 500-800), propofol-related infusion syndrome
55
Dexmedetomidine dosing, AE
0.2-0.7 mcg/kg/hr (possible up to 1.5 mcg/kg/hr), max 24 hours Does not cause respiratory depression (do not need to be intubated) ADR: bradycardia, hypotension (do not bolus in ICU) Noninferior to propofol for sedation Can use clonidine to help wean off
56
Ketamine place in therapy, AE
Analgesic & sedative properties May use w/ opioid in postsurgical patients, no other routine role hypertension, tachycardia, delirium
57
Lorazepam dosing, ADR
1-4mg q2-6 hours 1mg/hr continuous infusion but RISK of proplyene glycol toxicity ("P" in mudpiles) Preferred in hepatic dysfunction - lack of active metabolites
58
Midazolam dosing, ADR
1-4mg q15min - 1 hour or 1mg/hr continuous infusion May accumulate in renal & hepatic dysfunction, has active metabolites Must be mechanically ventilated for continuous infusion
59
IV Diazepam place in therapy
alcohol withdrawal - long half-life, fast onset May cause hypotension, thrombophlebitis
60
Analgesia cascade in critically ill
1) Opioids are first line therapy for pain 2) May add gabapentin > carbamazepine for nerve pain 3) Tylenol and ketamine can be added for multimodal pain relief, keep doses lower 4) Avoid NSAIDs (risk of bleed, kidney injury in critically ill) 5) Non-benzo > benzo sedatives
61
Delirium
Acute change in cognitive function characterized by disorganized though, altered level of consciousness, and inattentiveness Associated w/ increased mortality, prolonged length of stay in ICU, and cognitive impairment after ICU discharge Nonpharm >>> pharm treatment!
62
Confusion Assessment Method for ICU (CAM-ICU) Intensive Care Delirium Screening Checklist (ICDSC)
Validated delirium screen CAM-ICU: detect delirium at time of testing ICDSC: detect delirium during nursing shift
63
Pharm treatment for delirium
Haloperidol Quetiapine Olanzapine Ripseridone Ziprasidone All have QTc risk, less with olanzapine and risperidone Atypicals besides risperidone have sedative benefit Nonpharm preferred
64
Cisatracurium dosing, place in therapy
0.1mg/kg load then 2-10 mcg/kg/min May use in severe ARDS x 48 hours -- persistently hypoxemic or risk for ventilator injury MUST be completely sedated with adequate pain control Precedex should not be used for sedative
65
Neuromuscular blockade concerns
Masks seizure activity Critical illness poly-neuromyopathy Masks insufficient analgesia, sedation Increased risk of VTE Increased risk of skin breakdown, decubitus Corneal abrasion due to lack of blinking
66
Paralytics prolonged in renal, hepatic failure
Vecuronium Rocuronium
67
Electrolyte disorders on paralytics
Hypermagnesemia, hypocalcemia, hypokalemia: potentiate blockade Hypercalcemia, hyperkalemia: antagonize blockade
68
Meds that may potentiate blockade
Steroids Antibiotic (aminoglycosides, clinda, tetracycline, polymyxins) CCBs Type Ia antiarrhythmics Furosemide Lithium
69
Meds that may antagonize blockade
Aminophylline Theophylline Carbamazepine Phenytoin
70
Glucose control in ICU
Insulin infusion to maintain blood glucose 140-200 Avoid SC insulin if on vasopressor, significant edema, or need for rapid correction Draw whole blood glucose instead of finger prick
71
Stress ulcer prophlyaxis warranted in these pts
Mechanical ventilation for > 48 hours Plt < 50,000 INR > 1.5 PTT > 2x normal Recent GI bleed
72
Risk of PPIs for stress ulcer prophylaxis
Ventilator-associated pneumonia Cdiff infection
73
VTE prophylaxis in critically ill
LMWH or LDUH better than mechanical or no ppx Choose pharm or mechanical - not both LMWH all therapeutically equivalent and less risk of HIT than LDUH Rivaroxaban approved for medically ill ppx, not critically ill
74
VTE ppx if CrCl < 30
Dose adjust LMWH. If <20, avoid May use dalteparin if <30 due to minimal renal metabolism Avoid fondaparinux LDUH safe to use in reduced kidney function
75
VTE ppx in major trauma
Enoxaparin 30mg q12h
76
Caloric requirements in critically ill
non obese: 12-25 kcal/kg ABW BMI >30: 11-14 kcal/kg ABW
77
Protein requirements in critically ill
nonobese: 1.2-2 g/kg ABW BMI >30: 2-2.5 g/kg IBW
78
Glasgow Coma Scale
Assesses level of consciousness Higher the score = more conscious 15 is highest score
79
ICH Blood pressure control
If SBP 150-220, lower to 140 using nicardipine or clevidipine (or other IV titratable agent)
80
Aminocaproic acid
Antifibrinolytic therapy recommended if delay of 72 hrs to intervention for intracranial hemorrhage 4-5g load followed by 1g/hr Preferred over TXA Monitor VTE
81
Vasospasm prevention in aneurysmal SAH
Nimodipine 60mg q4H for 21 days. May cause hypotension.
82
Types of intracranial hemorrhage
Intraparenchymal hemorrhage Subarachnoid hemorrhage (worst headache of life) Subdural hematoma Epidural hematoma

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