Critical Care Kanani V

Question 1

Define the cardiac output.

Answer 1

The cardiac output is the product of the heart rate and the stroke volume. It is in the order of 5–6 l/min.

Question 2

Define the cardiac index.

Answer 2

The cardiac index is the cardiac output divided by the body surface area. The minimum acceptable level for adequate tis- sue perfusion is 2.2–2.5 l/min/m2.

Question 3

What is a pulmonary artery catheter and

what purpose does it serve?

Answer 3

This is a multi-lumen, balloon-tipped, f low-directed catheter that is passed through the right heart and into the pulmonary artery.

In certain instances, it provides a more useful picture of left heart function than CVP measures alone, and can be used to calculate a number of useful parameters of cardiovascular function in the critically ill, thus providing both severity assessment and therapeutic guidance.

Question 4

By which principle does it reflect left heart function?

Answer 4

When ‘wedged’ in a branch of the pulmonary artery (balloon inf lated in a branch of the PA), there is a continuous column of blood beyond the tip of the catheter that extends to the left atrium. Thus, the pulmonary artery pressure at the ‘wedged’ position is equal to the left atrial pressure.

Question 5

Give some indications for its use.

Answer 5

The indications for its use are controversial, variable and not absolute:

Concomitant with the use of inotropic support, especially
vasodilators
Post-cardiac surgery in those with poor left ventricular
function and pulmonary hypertension
Those with suspected ARDS and pulmonary oedema
Shock of any cause, e.g. assessing the systemic vascular resistance in those with septic shock
Those with multi-organ failure
Multiple injury with thoracic injury

Question 6

What physiological parameters does it measure directly?

Answer 6

Mean arterial pressure (MAP)
Heart rate
Mean pulmonary artery pressure (MPAP)
Cardiac output (CO)
Pulmonary artery occlusion pressure (PAOP)
Ejection fraction
Mixed venous oxygen saturation

Question 7

What are the derived variables?

Answer 7

Cardiac index (cardiac output/body surface area)
Stroke volume
Systemic vascular resistance (SVR)
Pulmonary vascular resistance (PVR)
Indexed SVR and PVR (these values divided by the Body Surface Area)
Oxygen delivery and oxygen consumption

Question 8

What are the complications of insertion?

Answer 8

Those complications of any central line insertion: see ‘Central line insertion’
Cardiac arrhythmias: most commonly atrial and ventricular ectopics. Ventricular tachycardia and ventricular fibrillation as well as heart block also reported
Cardiac valve injury: leading to incompetence of the tricuspid or pulmonary valves
Pulmonary artery rupture: this presents as shock and haemoptysis. Occurs from injury by the J-wire, or following balloon inf lation
Pulmonary infarction: if the balloon is kept in the wedged position for too long. Also occurs if there is embolisation of a thrombus formed at the catheter tip, or catheter
migration
Catheter knotting
Sepsis

Question 9

By which principle is the cardiac output measured?

Answer 9

The cardiac output is measured using the indicator dilution or the thermodilution techniques. Both of these have similar principles.With the indicator dilution technique, indocyanine green is injected into the circulation and samples are taken peripherally from the radial artery. A graph of the concentration of the dye in the peripheral blood over time is plotted. The cardiac output equates to the amount of dye injected divided by the area under the curve.

In the case of the thermodilution method, 10 ml of cold crys- talloid is injected peripherally, and the change of temperature detected by a thermistor at the end of the catheter. A graph is also plotted for the change of temperature of the blood passing the thermistor against time. This graph is used to calculate the cardiac output.

Question 10

What is the mechanism of action of heparin?

Answer 10

Heparin augments the activity of antithrombin III, an inhibitor of activated factors IX, X, XI and XII, preventing the conversion of fibrinogen to fibrin.

Question 11

What is the mechanism of action of warfarin?

Answer 11

Warfarin prevents the reduction of vitamin K epoxide to vita- min K, thereby inhibiting the vitamin K-dependant binding of factors II, VII, IX and X to calcium and phospholipid membrane surfaces during the clotting cascade.

Question 12

What types of continuous renal replacement therapies are there?

Answer 12

There are a number of continuous renal replacement modal- ities, depending on whether they rely on dialysis or filtration, and on the pattern of vascular connection

Question 13

How does peritoneal dialysis work?

Answer 13

Peritoneal dialysis is a slow form of continuous dialysis that relies on the peritoneum and its capillary network to act as the selectively permeable membrane. As with haemodialy- sis, solute f lows down a diffusion gradient, and f luid f lows by osmosis. The dialysate is introduced into the peri- toneum by way of a Tenckhoff catheter and dwells within the abdomen for several hours before being drained off. This technique has been used in the intensive care setting, but has been superseded by other replacement therapies that are faster and more effective in removing urea and other solutes. However, it still has a place in the haemody- namically unstable patient, and the ambulating patient with chronic renal failure.

Question 14

What is the classical infective complication? How is this recognised and treated?

Answer 14

The important infective complication is peritonitis that occurs following introduction of exogenous organisms. It may initially be recognised by the presence of a turbid effluent when the dialysate is drained, with

Question 15

Which of the lung volumes may be measured directly?

Answer 15

Tidal volume: normally 7 ml/kg
Vital capacity: normally 10–15 ml/kg
Inspiratory capacity: inspiratory reserve volume

Question 16

Define the functional residual capacity (FRC).What factors affect its volume?

Answer 16

The functional residual capacity is the volume of gas remain- ing in the lung at the end of a quiet expiration.

Factors that increase the FRC are
Obstructive pulmonary diseases
PEEP – which increases the intrathoracic pressure
(i.e. makes it less negative) Factors that reduce the FRC are
Increased age and obesity
Supine position
Factors limiting lung expansion: pleural effusion,
abdominal swelling and incision, thoracic incision, interstitial lung disease

Question 17

What are the obstructive pulmonary diseases?

Answer 17

Chronic bronchitis
Emphysema
Asthma
Bronchiectasis

Question 18

How do you differentiate obstructive from restrictive diseases on spirometry?

Answer 18

In cases of obstructive lung disease, there is an increase in the total lung capacity and residual volume due to air trapping. For restrictive diseases, there is a reduction of all of the lung vol- umes. The differences may be seen in the following diagrams:

Question 19

How may respiratory failure be classified?

Answer 19

Respiratory failure is classified as types I, II and mixed, depending on the CO2.
Type I (hypoxaemic) failure: when PaO2

Question 20

Give some examples of the different causes of respiratory failure. Type 1

Answer 20

Type I
Shunt: intracardiac, e.g. cyanotic congenital heart disease,
Eisenmenger’s syndrome

V/Q mismatch:
Pneumonia (shunting may also occur at some lung
units that are not being ventilated owing to
inf lammatory exudate)
Pulmonary embolism
Pulmonary oedema, e.g. cardiac failure, ARDS
Bronchiectasis, asthma

Question 21

Give some examples of the different causes of respiratory failure. Type 2

Answer 21

Type II
Cerebral lesion: head injury, brainstem stroke, drug
induced, e.g. barbiturates
Spinal lesion: high cervical trauma, poliomyelitis
Peripheral nerve lesion: motorneurone disease, Guillan–Barre syndrome
Neuromuscular junction lesion: myasthenia gravis
Muscular lesion: exhaustion, e.g. late acute severe asthma
Thoracic cage lesion: flail chest injury with inefficient ventilation
Lung parenchymal lesion: COPD with CO2 retention, obstructive sleep apnoea

Question 22

What is the systemic inflammatory response syndrome (SIRS)?

Answer 22

The SIRS is the syndrome arising from the body’s reaction to critical illness, such as overwhelming infection or trauma. Its presence is recognised and defined according to a number of clinical criteria

Question 23

Have you heard of the ‘two-hit’ hypothesis in the development of SIRS?

Answer 23

Yes, this is the observed f inding that those with SIRS who are recovering can have a rapid systemic response to a seemingly trivial second insult, such as a urinary tract or line infection. This may lead to a rapid and terminal deterioration in the patient’s state.

Question 24

What is pseudohyponatraemia?

Answer 24

This is hyponatraemia that occurs as a peculiarity of the way in which the sodium concentration of the plasma is measured and expressed. In the presence of hyperlipidaemia or hyper- proteiaemia, the sodium concentration may be falsely low if it is expressed as the total volume of plasma, and not just the aqueous phase (which it is normally confined to).

Question 25

What is the TURP syndrome?

Answer 25

This is a syndrome of cardiovascular and neurological symp- toms that occur following the use of hypotonic glycine- containing irrigation f luid with transurethral resection of the prostate.
The f luid and glycine are absorbed through the injured ves- sels to produce volume overload and hyponatraemia. It leads to bradycardia, blood pressure instability and confusion. In severe cases leads to convulsions and coma.

Question 26

Which disease processes may trigger the syndrome of inappropriate ADH secretion (SIADH)?

Answer 26

SIADH may be triggered by the following:
Lung pathology:
Chest infection and lung abscess
Pulmonary tuberculosis

Malignancy:
Small cell carcinoma of the lung
Brain tumours
Prostatic carcinoma
Intracranial pathology:

Question 27

What are the spinal cord syndromes associated with incomplete injuries?

Answer 27

There are three neurological syndromes associated with incomplete cord injuries:

Central cord syndrome: tends to occur in older individuals following hyperextension of the C-spine and compression of the cord against degenerative discs. Cord damage is centrally located
Anterior spinal cord syndrome: the anterior aspect of the cord is injured, sparing the dorsal columns
Brown–Sequard syndrome: following spinal hemisection

Question 28

What are the patterns of deficit seen in each of the three syndromes?

Answer 28

Central cord syndrome: motor weakness affects mainly the
upper limbs. Sensory loss is usually less severe
Anterior spinal cord syndrome: there is loss of motor function. There is also loss of pain and temperature sensation, but light touch, proprioception, and vibration sense are unaffected owing to preservation of the dorsal columns
Brown–Sequard Syndrome: There is motor loss below the lesion, with contralateral loss of pain and temperature sensation. There is ipsilateral loss of dorsal column function

Question 29

What deficits are seen in cases of complete injury?

Answer 29

The following deficits occur:

Motor deficit: initial f laccid paralysis below the level of the
lesion gives way to a spastic paralysis with increased tone
and deep tendon ref lexes due to loss of upper motorneurone input into the cord

Sensory deficit: affecting the anterolateral and posterior columns. These therefore affect the somatic and visceral components to sensation

Autonomic deficit: affecting the sympathetic and parasympathetic outputs of the cord

Question 30

What is the difference between a Jefferson fracture and a hangman’s fracture?

Answer 30

Jefferson fracture: this is a burst fracture of C1 (atlas), best
seen on the peg view. Seen as widening of the lateral masses and loss of congruity with the axis beneath. This is generally a stable injury

Hangman’s fracture: a fracture of C2 (axis) caused by hyperextension of the neck with the force of the occiput and the atlas bearing down on pedicle of C2

Question 31

Why is bupivicaine not used as a local anaesthetic during bedside drain insertion?

Answer 31

Bupivicaine is an amide local anaesthetic, which although has a longer duration of action than lignocaine, has a slower onset
of action. For this reason, it is not a suitable agent when being used on the conscious patient.