Critical Care Flashcards
Berlin Criteria
For the diagnosis of ARDS “Berlin criteria” of 2012 by the European Society of Intensive Care Medicine, endorsed by the American Thoracic Society and the Society of Critical Care Medicine. They are a modification of the previously used criteria:[5][6] - Acute onset - Bilateral infiltrates on chest radiograph sparing costophrenic angles - Pulmonary artery wedge pressure
normal central venous pressure tracing consists of
three positive waves (a, c, v) two negative troughs (x, y).
A-wave on CVP tracing
what is it?
when are the exaggerated ?
when are they absent?
Presystolic a wave:
produced by venous distention consequent to right atrial contraction.
Large a waves
right atrium is contacting against increased resistance:
- tricuspid stenosis
- pulmonary stenosis
- pulmonary hypertension
The a wave is absent in patients with atrial fibrillation and junctional rhythm.
what is the c-wave in CVP wave form
c wave: produced by bulging of the tricuspid valve into the right atrium during ventricular systole.
how does the x wave look in constrictive pericarditis
With constrictive pericarditis, there is accentuation of the x descent,
Y-decent on the CVP wave
The y descent follows tricuspid valve opening with rapid inflow of blood into the right ventricle.
treatment of pulmonary contusions with Blast Injury
Treatment principles for blast lung injury parallel those for lung contusion due to other causes with the exception:
- the use of mechanical positive-pressure ventilation in patients with blast lung injury should be avoided.
- Early aggressive positive-pressure ventilation in the initial emergency management can quickly convert a salvageable patient to an unsalvageable patient.
- bronchoscope examination is not necessary in the management of lung contusion.
- avoid fluid overload with crystalloid and colloid (including hetastarch) solutions,
- prophylactic antibiotics are not indicated
- Corticosteroids are not of proven value and, therefore, should not be used.
Medications given preoperatively shown to decrease the likelyhood of postoperative atrial fibrillation
Observational and randomized trials have demonstrated a reduction in the incidence of this complication in CABG patients when they are pre-treated with:
- statins
- beta blockers,
- amiodarone
(ACC/AHA guidelines Level of Evidence: B).
sotalol
non-selective competitive beta-adrenergic receptor blocker that also exhibits Class III antiarrhythmic properties. pre-operative administration does not help post op atrial fibrillation
Does pre CABG statin help postoperative a-fib
Yes ACC/AHA guidelines Level of Evidence: B
Does pre CABG Dignoxin help post a-fib
No
Does pre CABG beta-blocker help post operative a-fib
yes ACC/AHA guidelines Level of Evidence: B
Does pre op sotalol help post op afib
No
Does pre CABG amiodarone help post op afib
Yes ACC/AHA guidelines Level of Evidence: B
Does pre-Cabg non-DHPR Ca Blocker help prevent post afib
No
Bundle of kent
Accessory pathway between the atria and ventricle seen in WPW
Treatment of WPW
Immediate tx of an episode can be synchronized cardioversion if hemodynamically unstable
Procainamide or amiodarone can stabalize heart rate,
Nodal blocking agents should be avoided
Definitive tx - ablation of the acessory pathway
Early tx of post infarct VSD
- Early surgical intervention, before the development of end-organ dysfunction.
- _Preoperative managemen_t should focus on reducing systemic vascular resistance.
- Lower blood pressure may limit infarct expansion, minimize the left-to-right shunt and maximize forward systemic cardiac output.
- The intra-aortic balloon pump will help by reducing afterload and augmenting coronary perfusion pressure.
- Isolated coronary grafting and “conventional” supportive medical management should _not_ be considered as care options.
Risk factors for post operative transfusion
- advanced age
- female gender
- co-morbidities
- small body size
- low preoperative hematocrit
- preoperative antiplatelet
- preop antithrombotic medications
- redo and complex procedures,
- emergency operations
Trigger for cryoprecipitate
1 pool cryo for fibrinogen > 400
Non-hemolytic febrile reaction
- Etiology:
- Clinical presentation:
Non-hemolytic febrile reaction
-
Etiology:
- Caused by recipient antibodies against donor HLA and leukocyte specific antigen on leukocytes and platelets
- Cytokine release -à mild pyrexia about 1 hour after the transfusion
- Clinical presentation:
- High grade fever, rigors , nausea, and vomiting
- Severity of the symptoms is proprition to the number of leukocytes in the transfused blood.
diagnosis for type 5 MI
Type 5 - MI following CABG according to the universal definition of coronary artery diease
- The serum cardiac troponin I test is favored, and the definition of perioperative MI following on-pump CABG is 5 times the 99th percentile of that range during the first 72 hours after CABG.
- This enzyme level reflects significant myocardial cell damage, but the number is not reliable if the patient had an MI in evolution before the operation.
- Additionally, therefore, either new Q waves or new LBBB on ECG, or evidence on imaging of myocardial loss or wall motion defect are supportive of the enzyme elevation criterion.
Southwest Oncology Group Trial 9416 (Intergroup Trial 0160).
neoadjuvant therpay for superior sulcus tumors
5 year survival for superior sulcus lung tumors
44-54%
The National Lung Screening Trial (NLST)
population indicated for screening based on this surgery
smokers (> 30 pack-year history)
ages 55-74 years
who quit less than 15 years ago.
Frequency of anatomotic leak after Esophagectomy ?
occurs in 9-14% of cases
Frequency of gastric tip necrosis after esophagectomy
2-9%
what to do about gatric tip necrosis after esophagectom y
Early endoscopy is needed to evaluate the viability of the gstric tube
if confirmed:
Immediate surgery
Resectioin of the necrotic stomach
- exclusion with cervical esophagostomy
Chylothorax following esophagectomy
frequency ?
Mortality
occurs in 1-8% of patients
overall mortality: 50%
Types of hypernatremia
- Hypovolemic
- Euvolemic
- Hypervolemic hypernatremia
Most common form of hypernatremia ?
what causes it ?
Hypovolemic
The most common type
usually due to an inadequate intake of water.
Euvolemic Hypernatremia
- what is the pathophysiology and underlying mechanism ?
Euvolemic
- excessive excretion of water as a result of diabetes insipidus
due to either:
- an inadequate amount of vaspressin secreted from the pineal gland
- an impaired response to the hormone by the kidneys.
How to calculate how to fix hypernatremia
TBW = weight (kg) x a correction factor.
Change in serum Na+ = (infusate Na+ - serum Na+) ÷ (TBW + 1)
Correction must be done slowly to avoid rapid fluid shifts that can cause cerebral edema.
maximal rate of 0.5 mEq/(L*hour) prevents cerebral edema and convulsions.
The goal should be 145 mEq/L.
How to calculate total body water ?
TBW = weight (kg) x a correction factor.
- The correction factor is different for children and nonelderly men (0.6),
- for women and elderly men (0.5),
- and for elderly women (0.45).
TBW calculation correction factor for children ?
TBW = weight (kg) x a correction factor.
children and nonelderly men (0.6),
for women and elderly men (0.5),
and for elderly women (0.45).
TBW Calculation correction factor for non elderly men?
TBW = weight (kg) x a correction factor.
The correction factor is different for children and nonelderly men (0.6),
for women and elderly men (0.5),
and for elderly women (0.45).
TBW Calculation Correction factor for women?
TBW = weight (kg) x a correction factor.
for children and nonelderly men (0.6),
for women and elderly men (0.5),
and for elderly women (0.45).
TBW correction factor for elderly men?
TBW = weight (kg) x a correction factor.
for children and nonelderly men (0.6),
for women and elderly men (0.5),
and for elderly women (0.45).
Total body water calculation correction for elderly women?
TBW = weight (kg) x a correction factor.
for children and nonelderly men (0.6),
for women and elderly men (0.5),
and for elderly women (0.45).
calculation for correction of hypernatremia per infusate
Change in serum Na+ = (infusate Na+ - serum Na+) ÷ (TBW + 1)
correction rate for hypernatremia
0.5 mEq/(L*hour)
half life of albumin
21 days
Transferrin half life
8-9 days
WBC level suggestive of malnutrition
< 1500
WBC level suggestive of severe malnutrition
< 900
Prealbumin half life
2-3 days
RIFLE Criteria
what does rifle stand for?
Risk
Injury
Failure
Loss
ESRD
RIFLE CRITERIA
Risk - GFR/Creatinine criteria
Risk - increase in creatinine x 1.5
GFR decrease by 25%
RIFLE Criteria
Risk - UOP criteria
UOP < 0.5/ml/kg/hr for 6hrs
RIFLE Criteria
Injury - GFR / creatinine criteria
increase in creatinine x 2
or GFR decrease by 50%
RIFLE Criteria
Injury - uop criteria
< 0.5 ml/kg//hr for 12 hours
RIFLE Criteria
Failure
creatinine / GFR criteria
increase in creatinine by 3x
GFR decrease by 75%
RIFLE Criteria
Failure
UOP criteria
UOP < 0.3 ml/kg/hr for 24 hours
or anuric for 12 hours
RIFLE Criteria
Loss criteria
persistent ARF - complete loss of renal function for 4 weeks
RIFLE criteria
ESRD criteria
ESRD > 3 months
NIF and extubation parameters
. This pressure generated is called a maximum inspiratory pressure (MIP) or negative inspiratory force (NIF).
-30 cm H20 or less: the likelihood of successful extubation is great;
greater than -20 cm H20: it implies poor reserve and a high likelihood of reintubation.
Respiratory rate and predicting extubation
RR > 40 has a low likelihood of extubation
Minute ventilation (total ventilation) predictive of extubation
Total ventilation of 5-6 L/min is normal for an adult patient,
and if after a spontaneous breathing trial the total ventilation remains <10 L/min, a positive outcome is more likely.
Diagnosis of vancomycin nephrotoxicity
Vancomycin-induced nephrotoxicity is assumed if 2-3 consecutive serum creatinine values show an increase of 0.5 mg/dL or ≥50% increase from baseline unless there is an alternate explanation
Therapeutic range for a vancomycin trough
The therapeutic reference range for vancomycin trough levels is 10-20 µg/mL (15-20 µg/mL for complicated infections).
ECG
time of a single small square
0.04 ms
ECG
Normal P-R (Q) interval
0.12 to 0.2ms
(3-5 small squares
Treatment of torsades
- Cardiovert immediately for HD compromise or prolonged episodes
- Administer KCl (unless hyperkalemia)
- shorten the OT interval
- V-pace at 30-100 or start isoproterenol infusion at 1-4 ug/min
- shorten AP to prevent early after depolarization
- Magnesium 1-2g and beta-blockers
- Prevent recurrence but do not shorten the QT interval
what type of double lumen endotracheal tube do most anesthesiologists prefer?
Left-sided
what type of ETT is preferred when the source of hemotypsis is unknown?
double lumen
