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Plastic Surgery > ICU > Flashcards

ICU Flashcards

1
Q

3 Indications for IVF (intravenous fluid resuscitation)

A

Resuscitation, Replacement and maintenance.

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2
Q

Why would we need IVF?

A

Enteral intake is insufficient and losses through GIT and UT, Trauma, surgery, sepsis.

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3
Q

List the stages of resuscitation

A

ROSE
Resuscitation
Optimization
Stabilization
Evacuation

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4
Q

Elaborate on the ROSE concept (individually)

A

R - Bolus of 4ml/kg over 10-15mins with EAFM
O - within a few hours, degree of positive fluid balance - risk of polycompartment syndrome. Treat shock
S - Over days, fluid is for normal maintenance and replacement. Absence of shock. Daily weight, fluid balance and organ function.
E - Patients must transition from “ebb” phase of shock to the flow phase. Develop global increased permeability syndrome. Overload causes end organ dysfunction. requires late goal directed fluid removal.

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5
Q

Targets for each ROSE phase
MAP, CL, PPV, LVEDAI, IAP, APP, GEDVI

A

R - MAP > 65, CL >2.5L/min, PPV<12%, LVEDAI >8cm/m2
O - MAP > 65, CL >2.5L/min, PPV<14%, LVEDAI >8-12cm/m2 IAP <15mmhg, APP >55mmhg, GEDVI 640-800ml
S - Neutral or negative fluid balance
E - organ function and enteral feeds.

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6
Q

What happens with critically ill patients with their salt and water balance

A

Experience overload, thus will reach spontaneous diuresis. If not can use the aid of diuretics.

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7
Q

Side effects of excessive IVF use?

A

Dilutional coagulopathy and diffuse tissue oedema - increases the distance that electrolytes and oxygen need to travel within the organ.
Increase need for blood transfusion, kidney injury and prolonged ventilatory support.

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8
Q

When is Albumin indicated as a resuscitative fluid?

A
  1. Hypoalbuminea patient
  2. Cirrhosis
  3. Hepatorenal syndrome
  4. Post heart, lung or liver transplant (anasarca)
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9
Q

When should albumin be avoided?

A

Sepsis and trauma

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10
Q

What is Hempure and its function and who can use this?

A

Modified haemoglobin that acts as a oxygen carrier only. Can be used in jehovas witness, oncology and general surgery patients, but more studies are required.

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11
Q

List static parameters of monitoring intravascular volume status

A

Static parameters
- BP and HR
-CVP (8-12mmhg) only in spontaneous breathing patients
- UO: 0.5ml/kg/hr kids and 1ml adults
Mixed venous oxygen saturation

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12
Q

List dynamic parameters of monitoring intravascular volume status

A

Dynamic hemodynamic parameters
- Respiratory variation (arterial pressure waveform): pulse pressure variation (PPV), stroke volume variation (SVV), systolic bloof pressure variation (SPV), change in IVC diameter.
- Stroke volume estimates
- Left ventriular size (ECHO)
- PAssive leg raise test: positive = increase SV by 10%
- Fluid challenge
- Lab tests: Cr, lactate levels.

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13
Q

Fluids in sepsis - which guidelines to use and elaborate

A

Surviving sepsis guidelines

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14
Q

Which cases should adopt restrictive fluid policy?

A

Penetrating thoracic injuries and TBI
- MAP >65 and until in the OR and bleeding is controlled can aim for higher MAPS. This helps prevent further hemorrhaging.

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15
Q

Pros of balanced salt solutions

A

more physiological in terms of lower NA and CL levels thus less effects on PH e.g ringers and hartmans solution.

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16
Q

Example of synethetic colloid and a side effect

A

HES - hydroxyethyl starch - tissue storage and coagulopathy, and increases the need for blood products in the critically ill.

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17
Q

limitations of crystalloids

A

use it until blood products are available. Helps to start inotropes, fluid challenge, HR, metabolic acidosis and clearance of lactate.

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18
Q

What can be used to help identify individuals who will require massive transfusion?

A

Blood consumption score

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19
Q

What are the principles of damage control resuscitation and damage control surgery

A

This improves survival rate and the principles are:
1. minimising crystalloid use
2. permissive hyportension
3. hemostatic resus with balanced ratio of blood products and goal directed correction of coagulation, rewarming, correction of acidosis, arrest of hemorrhage.

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20
Q

What is the PROPPR trial?

A

ratio of 1:1:1 use of blood products resulted in a reduced mortality within 1st 24 hours.

21
Q

List 4 fluid response assessment

A

Bedside US (IVC)
Increase MAP with fluid bolus
Improving UO
PLR test

22
Q

List the fluid responsive patient types and why do we need to know this?

A

Responders - imrove
Transient responders - improve then deteriotate
Non-responders - deteriorate

To see who will rebleed or have ongoing bleeding in order to initiate blood products.

23
Q

ATLS principles for damage control resuscitation in Adults

A
24
Q

ATLS principles for damage control resuscitation in paediatrics

A
  • initial bolus 20ml/kg
  • 10-20ml/kg packed RBCs
  • 10-20ml/kg of FFP/platelets (MTP)
  • clear fluids must be isotonic and balanced
    -Colloids such as human plasma and albumin is preferred
  • maintenance fluids can be hypotonic but limited to 2ml/kg/hr via flow controller.
25
Q

ATLS principles for damage control resuscitation in elderly

A

anyone above 65 and the vascular system is less compliant.
- avoid prolonged hyperventilation with PCO2 <25. SBP >100.

26
Q

ATLS principles for damage control resuscitation in crush injury or syndrome

A
  • initial 20-40ml/kg followed by 10-20ml/kg/hr.
  • use 0.45% saline and 5% dextrose to prevent hypernatraemia and hyperchloraemic acidosis.
  • No ringers due to hyperkalaemia.
  • dialysis for diuresis not loop or osmotic diuretics.
27
Q

ATLS principles for damage control resuscitation in pregnancy

A

> 20 gestational weeks - risk of aorto-caval syndrome thus 20 degree tilt to left.

28
Q

ATLS principles for damage control resuscitation in burns

A

deeper and extensive burns require alot of fluid but be aware of pulmonary odema.

29
Q

Goals of resuscitation in penetrating, blunt trauma, TBI.

A

Penetrating SBP 50-70
Blunts SBP 80-90
TBI SBP 100-110
Clearing lactate <2
Base deficit <-5
Improving PH >7.3
Normathermia T>35.5

30
Q

What is the rationale of prophylatic antibiotic use

A

for operative procedures that have high rate of surgical site sepsis and should be covering aerobic and anaerobic pathogens, given 30-60min before surgery, can be repeated if surgery is more than 2-4 hours.

31
Q

What is the rationale of empiric antibiotic use

A

Have a high suspicion of infection that you can not wait for the blood culture. Commenced within the first hour of sepsis or shock and the drug of choice depends on the unit, hospital and individual risk factor.

32
Q

List strategies to ensure an optimal response

A

Early source control
Early initiation
correct dosing
Risk factors for resistance
Avoid identical use of antibiotics within 3 months
Narrowing therapy with culture

33
Q

Do patients undergoing renal replacement therapy require dose adjustments of drugs?

A

No

34
Q
A
35
Q
A
36
Q
A
37
Q

How long should patients stay on antibiotics

A

3-5 days to see clinical improving and change to oral once oral diet is tolerable. if persists for more than 5-7 days, aggressive investigation is required.

37
Q

How to monitor effective response to antibiotics?

A

clinically - shock resolution, degress vasopressors, PR, Temp and RR.
Biomarkers - Procalcitonin, WCC and CRP trends.

37
Q

How to prevent antibiotic resistance in ICU?

A
  1. use of prophylaxis when there is proven efficacy
  2. use of narrowest spectrum of AB with proven efficacy
  3. use of the least number of agents for the shortest length to reach efficacy
  4. appropiate AB dosing to max effect.
38
Q

What are the main mechanisms of resistance to antibiotics caused by

A
  1. inactivation or modification of AB
  2. An alteration of the protection of the target site of the AB that reduces its binding capacity
  3. modification of the metabolic pathways to circumvent the AB effects
  4. Reduced intracellular AB accumulation by decreasing permeability and or increasing active efflux of the AB
39
Q

Effects of malnutirtion

A

increased morbidity and mortality
immunodeficiency
increased risk of infection
poor wound healing
increase risk of bedsores
GI overgrowth
increase nutrient loss in stool.

40
Q

methods to determine patients nutritional requirement and how often should it be done?

A
  1. indirect calorimetry
  2. a published predictive equation
  3. A weight based equation (25-30kcal/kg/day)

once a week

41
Q

What is total energy made up of

A
  1. Protein 1.2-1.5g.kg.day
  2. Lipids 2g/kg/day
  3. Carbs 3-6g/kg/day
    ratio of 20%, 30%, 50%
42
Q

How to do a nutritional assessment

A

Clinically
- Hx: eating habits, drugs, alcohol
-Examination: Muscle weakness, fatigue, depression, wasting, skin and hair changes, oedema, BMI
Nutrition risk screening (NRS 2002)
- NUTRIC SCORE
- Lab tests : not sensitive due to acute phase reactants
-US: muscle mass

43
Q
A
44
Q

What are the ERAS principles

A

a bundle of interventions that is multimodal, MDT, integrated and standardized.

44
Q

What are the key aspects of the ERAS principles in periooperative care

A
  1. integration of nutrition into the management of the patient
  2. Avoidance of long periods of fasting
  3. Eat ASAP after surgery
  4. Start nutritional therapt ASAP
  5. Metabolic control - glcose
  6. reduce factors that cause stress or impair GIT function
  7. Minimise paralytic agents for ventilation
  8. Early mobilisation to help with protein synthesis.
45
Q
A

Plastic Surgery (3 decks)

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