Critical care: General info

Question 1

What is the double effect?

Answer 1

Opioid treatment on end of life care causes respiratory depression and therefore hastens death

Question 2

What is the ramsay sedation scale?

Answer 2

score to illustrate a patients rousability whilst sedated (used in ICU)

Question 3

What are the triggers and their parameters for calling critical care?

Answer 3

1. Respiratory - RR>25 or <8; SaO2 < 90
2. CVS - HR < 50 or > 125, SBP < 90 or >40 fall
3. Renal - Oliguria > 4hrs or UO < 0.5ml/kg/hr
4. Metabolic - repeated hypoglycaemia
5. Neuro - prolonged reduced level of conciousness

Question 4

When is critical care outreach contacted?

Answer 4

NEWS of 7 or single parameter of 3

Question 5

How do you assess brainstem death? Who needs to be present?

Answer 5

• Specialist doctor, at least 2 doctors (one being a consultant on ICU)

1. Identify irreversible pre-condition that has contributed to brainstem death
2. Exclude reversible causes of coma
3. Exclude reversible causes of apnoea
4. Assess brainstem function:
   - Pupils fixed and unreactive (CNII + III)
   - Corneal reflex absent
   - absent Occulovestibular cough reflex on bronchial stem
   - absent gag reflex on pharyngeal stimulation
   - absent motor response to pain on supra-orbital notch
5. Apnoea test -
   - 100% oxygenate for a few mins prior to test
   - Reduce minute ventilatory volume until CO2 > 6kpa (As confirmed by ABG)
   - Switch off ventilator and switch to anaesthetic water’s circuit
   - Observe for 5 mins for any signs of respiratory effort
   - Repeat ABG at 5 mins and notice CO2 increased by further 0.5kpa
   - Reattach ventilator
6. Repeat all tests

Question 6

What are the levels of care?

Answer 6

0 - ward
1 - additional support required but managed through advice; often O2 support required
2 - Single organ support (HDU)
3 - Advanced respiratory support or 2+ organ support (ICU)

Question 7

What is the nurse to patient ratio in the ward, HDU and ICU

Answer 7

Ward 1:10
HDU 1:2
ICU 1:1

Question 8

What agent are patients sedated under during intubation in HDU/ICU? What is a caution of this agent?

Answer 8

Propofol

Propofol infusion syndrome (doses > 5mg/kg/hr) - metabolic acidosis, hyperkalaemia, hypertriglyceridaemia, renal failure, CV collapse, heptomegaly

Question 9

How do you diagnose CV death?

Answer 9

1. Pre-condition:
   - Patient incurred simultaneous apnoea and unconsciousness due to known condition
   - Patient has DNACPR, failed CPR attempts, or withdrawn life saving tx
2. Assessing CV death:
   - community: observe for 5 mins absence of central pulse and heart and breath sounds
   - Hospital: asystole on continuous ECG, absent pulsatile flow on arterial pressure monitor, absent contractility on echo
3. Asess brain stem death:
   - absence of pupils, cornea, pain response to supraorbital pressure
4. Time of death at end of tests