Critically Ill patient Flashcards
Stress ulcer prophylaxis
oral PPI, or IV H2 blockers or oral antacids. Depends on if pt can eat.
Stop prophylaxis after extubated and doing well.
Risk factors for stress ulcer
Hx of GI bleeding in past year, evidence of coagulopathy, mechanical ventilation >48 hrs, severe CNS injury (TBI or spinal cord injury) , severe burns, combination of sepsis, prolonged ICU stay and high dose steroid use for greater than one week.
When to order ancillary tests to confirm brain dead
unable to examin cranial nerves
pts with neuromuscular paralysis or heavy sedation, unable to complete apnea test or inconclusive results, numerous confounding variables (multiorgan failure)
Neuro examination of a brain dead patient
comatose pt
absent cranial nerve reflexes and motor responses (including flexor or extensor posturing)
absent oculovestibular reflex (caloric response)
absent cough with tracheal suctioning
absent sucking or rooting reflexes
apnea by apnea test
clinical criteria for someone who is brain dead
lack of spontaneous respirations
CT MRI with devastating CNS event or known cause
absent of confounding factors (sedative medications or metabolic or HDS derangements)
no confirmed confounding drug intoxication or poisoning
core temperature >36 and systolic BP >100
what is the apnea test?
confirms brainstem failure if the patient cannot generate spontaneous breaths or triggers ventilators in response to elevated PaCO1 levels >10 minutes after disabling control mode
what to do based on bedside apnea test?
negative - pt is not brain dead
inconclusive or pts is unable to tolerate - needs ancillary testing
positive - repeat clinical exam and if suggestive of brain dead then patient is clinically brain dead. If repeat exam is non conclusive needs ancillary testing.
positive apnea test is defined as
no spontaneous respirations for approximately 10 minutes and ABG must confirm PaCO2>60 mmHg or have increased >20 mmHg from baseline ABG.
if spontaneous respirations are observed and the patient is not brain dead
gold standard for brain dead confirmation
cerebral blood flow testing - cerebral angiogram but this is highly invasive and not routinely done and never as a first step in diagnosing. Can be used if having difficulty distinguishing if braindead
DO we use EEG or ECI for brain death confirmation?
no because it’s is suspecepitble to excessive artifact from other electronic defices in ICU and so less reliable. Also very sensitive to effects of sedative medications and metabolic derangements and so can be confounded.
do we use the atropine response test
no. IT’s not been validated in confirming brain dead
it’s supposed to see increase in heart rate by 3% via the vagus nerve which is the last brain functions lost
nutritional support in critically ill pts
enteral nutrition is preferred
start enteral nutrition in 24-48 hrs and advance to goal over 48-72 hrs
Gastric feeding preferred
Jejunal feeding if intolerance to gastric feeding or high risk for aspiration prokinetic agents if feeding intolerance
when to hold enteral nutriition?
if hypotensive and escalating doses of vasopressors
or decreased intravascular volume due to risk for bowel ischemia
Absence of bowel sounds or flatus is not a contraindication to early enteral feeding even in pts who have undergone surgery for bowel perforation
When do we use post pyloric feeding tubes?
in patients who are at high risk for aspiration.
when do we start parenteral nutrition?
can be started after 7 days if EN is not feasible.
what is parenteral nutrition associated with?
hyperglycemia, hypertriglyeridemia and intestinal mucosal atrophy and increased risk for infections.
when and how much to give patients IV corticosteroids?
hydrocortisone 200-300 mg/day if there’s adrenal insufficnecy
Surviving Sepsis and early goal directed therapy include:
CVP pressure of 8-12 mmg, MAP>65 mmg, central venous oxygen sat>70% and urine output 0.5 ml/kg/hr
what causes pneumothoraces?
can be spontaneous or iatrogenic. Nonspontaneous include trauma and from positive pressure ventilation, CVC, thoracentesis.
Treatment of large pneumothorax
Chest tube.
If shows signs of hypotension, tachycardia and hypoxemia need urgent decompression of pleural space with needle. Place at 2nd intercostal space.
what helps to reduce incidence of stress ulcers?
early enteral feeding alone
Who gets stress ulcer prophylaxis?
1 or more of the RF mentioned gets prophylaxis.
When to start enteral nutrition in a critically ill but hemodynamically stable pt is:
start within 48 hrs has been shown to improve outcomes.
DON’T start in hemodynamically unstable pts due to risk for bowel ischemia.
complication of pneumothorax
can see obstructive shock happen with decreased cardiac output from poor venous return in setting of high intrathoracic pressures and impaired cardiac pumping from compressed ventricles.
presentation of pneumothorax:
dyspnea, pleuritic chest pain, tachypnea, hypoxia, and decreased breath sounds affected side
see hyperresonance to percussion
If pt who has pneumothorax that involves <20% of chest then pt can be
observed for 24 hrs with oxygen as needed
repeat imaging in 24 hrs.
if Pnuemothorax is gone then can be discharged with 48 hr follow up
if persistence of pneumothorax is still there without progression pt can be discharged with follow up in 48 hrs
chest tube for pnuemothorax is:
progression from initial CXR
initial pneumothorax >20% or if pt develops severe sympotms
how to know when to remove a chest tube?
need to look for airleak
if none ok to take out chest tube.
if present then need to repeat checking in one day (24 hrs later) after getting CXR
if this persists consider getting a CT surgery consult.
what is a side effect or complication on being on prolonged PPI for stress ulcer prophylaxis
increased risk for nosocomial pneumonia
PPI can reduce gastric acid and promote bacterial growth and with GERD can lead to colonization of endotracheal tube and increase risk of pneumonia.
who gets spontaneous pneumothorax
tobacco use Marfan syndrome homocystinuria thoracic endometriosis family history
mild cases of pneumothorax definition and management
2-3 cm of trapped areas
managed conservatively with observation for 6 hrs
give supplementary oxygen until symptoms resolve and repeat CXR shows stability and resolution of the pneumothorax
what is hypoxic ischemic encephalopathy (HIE) is a syndrome
acute global brain injury resulting from critical reduction or loss of blood flow.
most common clinical presentations include disorders of consciousness, seizures, and myoclonus.
when does spontaneous pneumothorax happen?
in young and otherwise healthy patients can be tolerated
