critical care Flashcards
Define ARDS
Criteria developed. at conference in Berlin 2012 - 4 criteria
1) Onset within 1 week
2) Imaging shows bilateral opacity not fully explained by effusion, collapse or nodules
3) Origin of oedema not HF or overload
4)PaO2 to FiO2 ration (Art Ox Tension)
-Mild - 201-300mmHg. >39.0-26.6 KPA with PEEP >5cmH2O
-Moderate-101-200 26.6-13.3
-Severe <100 <13.3
Causes of ARDS
Pulmonary - infection, trauma,aspriation, inhalation, near drowning, thrombotic
Systemic - major burns or trauma
Other- Massive transfusion, pancreatitis, DIC, Bypass, Drugs, OD
Pathophysiology of ARDS
2 phases
1) Acute inflammatory phase - (increase in Neut/Mac and activation of complement and coat cascades and decrease in surfactant and type 1 and 2 pneumocystis). Get fluid leaks into airspaces
2)fibroproliferative phase - 5-10days later. Proliferation of type 2 pneumocystis and fibroblasts
Define Sepsis
Updated in 2016 -3rd International consensus
Life threatening organ dysfunction caused by dysregulated host response to infection
Organ dysfunction can be represented by increase in SOFA score of 2 or more
qSOFA - Resp >22, Altered mental state, SBP<100
Septic shock was redefined where their is coexistence of persistent hypotension requiring vasopressors to maintain MAP >60, lactate >2 in the abscess of hypovolaemia
Timings for return to theatre
ACPGBI guidelines
Should achieve source control:
-18hrs if leak
-6hs if organ dysfunction
-3hours if shock
Referring syndrome
Occurs after prolonged periods of starvation and malnutrition
Switch from catabolism to anabolism
Increase in insulin secretion and therefore cellular uptake of K, Mg, Phosphate and thiamine utilisation
Results in profound electrolyte and metabolic disturbances
Manifest as resp, cardiac, renal and hepatic failures and seizures
Risk factors for refeeding
One or more: BMI<16, >15% weightless over 36months, no intake for >10days, low K, Mg and Phosphate levels
Or 2 or more
BMI<18.5, weightloss>10% over last 36months, little or no intake for 5days, alcohol absuse or meds:insulin, chemo, antacids, diuretics
Management of referring and when to use TPN refeeding
ESPEN 2017 Guidlines
Correct electrolytes and hypovolamaeia, supplements for first 10days, Support started at 10KCal/Kg then increased per day to meet or exceed needs by 47days
Unable to get adequate intake via entral route - (<50% energy met for >7days.
CPEX testing
Looking at Anaerobic threshold, Respiratory exchange ration (RER) and VO2
>11 mL/min/Kg-improved outcomes, <85% VO2 significant exercise limitation, RER >1.15 -adequate test.
No RCTs - Level 3 evdicne but recommended but British Journal of Anaesthesia 2017
AKI classification
Acute kidney injury working Group of KDIGO
Defines as: Increase in Serum Creat 0.3mmol/dl or more within 48hrs, Increase in serum creat 1.5 or more from baseline (within 7 days), urine volume <0.5ml/Kg/hr for 6hrs
AKI1 Creat 1.5-1.9x baseline (<0.5ml/Kg/hr 6-12hrs)
AKI2 - Creat 2-2.9 (<0.5ml/Kg/hr >12hrs)
AKI3 - Creat >3 <0.3ml/Kg/hr 24hrs or anuric for >12
Abdominal Compartment syndrome
World Society of Abdominal Compartment syndrome 2013
Normal pressure 5-7mmHG
Abdominal HTN -IAP >12mmHg
Grade 1 -12-15
Grade 2 - 16-20
Grade3 - 21-25
Grade 4 >35
ACS = IAP over 20 or Perfusion pressure <60 with new onset organ dysfunction
Measure via transvesical - recommended by WSACS 2006
Tests for bleeding disorders
FBC - Plt count and morphology
APTT - Intrinsic and common pathways
PT/INR - Extrinsic and common
TT - fibrinogen abnormalities
Coagulation factor assays - specific deficiencies
Fibrin degradation products - Looking for DIC
Common bleeding disorders
Haemophilia A and B - X linked
VWF - autosomal inheritance
Common thrombophilia
Fact Vor Leiden - 50%
Prothombin mutation (factor 2) - doubles changes of VTE)
Protein C deficiency -1in500 adults
Protein s deficiency - 1in500
Antithrombin 3 - 1in 2000
Lung Compliance
Change in lung volume for a unit rise in Pressure
