ICU Flashcards
What can you use Sugammadex for?
rapid reversal of neuromuscular blockade from rocuronium or vecuronium
when can you safely use neostigmine to reverse neuromuscular blockade
patient must have at least 1-2 twitches on train of four
when in breathing cycle do you measure intra-abdominal pressure?
end-expiration
what is the best initial treatment for cardiogenic shock?
administration of an ionotrope (e.g. dobutamine w/goal of CI > 2.0)
what is a clinically relevant dose of dobutamine?
5-20 ug/kg/min
Parkland Formula
4 mL/kg per percent of body burned
- half of volume in first 8 hours
normal PCWP
4-12 mmHg
normal SVR
900-1400 dyn/s/cm
normal Cardiac Index
2.5-4 L/min/m^2
how do corticosteroids cause hyperglycemia
- decrease insulin production
- decrease insulin secretion
- increase gluconeogenesis
how quickly can you correct hyponatremia
no more than 0.5 mEq per hour OR 8 mEq per 24 hours
how do you determine the mEq of sodium needed to correct someone’s sodium
(desired Na - measure Na) x total body water
initial resuscitation goal for sepsis
30 mL/kg as a bolus over two hours
If this does not correct hypotension start vassopressor
first line treatment for DIC
- supportive care of sepsis
- low dose heparin 5-8 units/kg/hr
what metabolic derangements would you expect with refeeding syndrome
- hypophosphatemia
- hypomagnesia
- hypokalemia
what kind of culture do you perform on a BAL for suspected VAP?
quantitative culture
threshold of 10,000 or 100,000 to indicate positive culture
you’re trying to get femoral vein access for an IVC, what maneuver can you perform when you are unsure if the structure you are looking at is in fact the femoral vein?
locate greater saphenous vein (superficial and medial) and tract it back to femoral vein
Patient with hypocalcemia, what EKG changes would you expect
prolonged QT interval
- hypocalcemia specifically lengthens the ST segment
What is the main benefit of providing 100% oxygen in a patient with carboxyhemoglobin toxicity
reduces half life of carboxyhemoglobin to 1 hour from 3 hours
How does increasing PEEP increase arterial oxygen content?
increases functional residual capacity by recruiting alveoli
would you give larger or smaller doses of opioids to a cirrhotic patient and why
- smaller
- opioids are protein bound, patient is presumed to have hypoalbunemia therefore plasma concentration of opioids is going to be higher
most sensitive test to detect species causing ventilator associated pneumonia
bronchiole alveolar lavage
Respiratory Quotient 0.7
- fat metabolism
Respiratory Quotient 0.8
protein metabolism
Respiratory Quotient 1.0
carbohydrate metabolism
Respiratory Quotient > 1.0
overfeeding
which sedative provides good hypnotic dosing and opioid sparing analgesia
Ketamine
also doesn’t suppress cardiac function
What kind of cardiac complications can you expect with hypermagnesia?
- peaked T waves
- prolonged PT interval
- prolong QRS complex
- essentially first degree AV block
findings of severe hypokalemia on EKG
- U wave elevation
- T wave depression
findings of severe hyperkalemia on EKG
- peaked T waves
- P wave flattening
- wide QRS complex
what kinds of medications are contraindicated in a right sided heart attack
- nitric oxide (decreases pre-load)
- alpha-1 agonists (increase after load)
what is the range for severe hypothermia
< 28 degrees celsius
what minimizes the rate of tracheal stenosis after intubation
- cuff pressures less than 30 mm Hg
- minimizing the size of the ETT in comparison to the trachea
Commonly found organisms in ventilator associated pneumonia
- Staphylococcus aureus
- Pseudomonas Aeruginosa
- Haemophilus Influenzae
- Streptococcus Pneumoniae
- Enterobacter Cloacae
what is a positive value for a protected specimen brush on a ventilated patient
> 1000 CFU/mL
what is part of the qSOFA score
- GCS (<15 = 1 point)
- respiratory rate (>22 = 1 point)
- Systolic BP (< 100 = 1 point)
what is the maximum score for qSOFA
3
what does a qSOFA score of 2-3 mean
3-14 fold increased risk of in-hospital mortality
what kind of central venous catheter is associated with the lowest rates of line infection
subclavian CVCs
what CVCs are associated with the highest rates of mechanical complications
subclavian CVCs
Components of a qSOFA
- respiratory rate > 22
- GCS < 15
- SBP < 100
1 point for each
Neurogenic shock
disruption of hemodynamic parameters (typically hypotension associated with bradycardia)
Spinal shock
loss of:
reflex
motor
sensory function
- below the level of spinal cord injury
in morbidly obese critically ill patients, which equation should be used to estimate energy requirements (assuming indirect calorimetry is unavailable)
Penn state equation
What is the vasopressor of choice in refractory anaphylactic shock
epinephrine
Dose and frequency of naloxone for respiratory depression in the setting of opioid use/administration?
40 mcg doses at 5 minute intervals till spontaneous recovery occurs
what does crossmatching look for prior to a transfusion
looks for potential antibodies to blood that is about be given
mechanism of action of Dexmedetomidine
highly selective, centrally acting alpha-2 agonist
- anxiolytic, sedative, and some analgesic properties
two greatest risk factors that lead to the development of stress gastritis
- > 48hours on ventilator
- coagulopathy
What receptors does norepinephrine work on?
- predominant alpha agonist
- some beta agonist activity
what receptors does epinephrine work on
- predominant beta agonist at low doses
- predominant alpha agonist at high doses
why is norepinephrine preferred over epinephrine when treating septic shock?
Norepinephrine is less cardio-active and less arrhythmogenic when compared to epinephrine
first line agent in cardiogenic shock
dobutamine
which receptors does Dobutamine work on
- primarily a beta agonist
- mild alpha agonist
dosing for epinephrine IM, anaphylaxis
0.3-0.5 mg every 10-15 minutes
dosing for epinephrine IV, anaphylaxis
50-100 ug every 10-15 minutes
Why do you not use epinephrine in cardiogenic shock?
can cause increase in afterload from alpha agonist activity. in cardiogenic shock you don’t want to increase afterload and tax the heart further
best way to determine resting energy requirements?
Indirect Calorimetry
- via metabolic cart
what dose of hydrocortisone can you use in patients with hypotension refractory to volume and pressors?
200 mg daily, followed by taper
what amino acid is considered “semi-essential” in regards to wound healing
Arginine
liver lesion associated with elevated AFB and Neurotensin, what is this most likely?
Hepatic Fibrolamellar carcinoma
first line treatments for SVT
- Vagal maneuvers
- Adenosine 6mg first then 12 mg
cause of anion gap metabolic acidosis
MUD PIILES
Methanol, Uremia, Diabetic ketoacidosis, Propylene glycol, Isoniazid , Iron, Lactic acidosis, ethylene glycol, Salicylates
Long term complications of TPN
Metabolic bone disease
liver disease
cholelithiasis
nephrolithiasis
bloodstream infections
