ICU Flashcards
1.5 years s/p renal transplant fever work-up
cxr CBC blood cx UA renal bx
adrenal function
tenderness over graft
1.5 years s/p renal transplant fever and interstital process on cxr: dx, w/u, tx
CMV
fiber optic bronch
need to rule out any bacterial causes.
CMV cultures,
and send IgO and IgM titers and would start the patient on
ganciclovir .
on broad-spectrum antibiotics, to
cover the gram-positive,
Vancomycin for gram-negative,
prophylactic antifungal ie. fluconazole; Bactrim for Pneumocystis carinii prophylaxis.
CAT scan of the chest and
abdomen.
I would continue the ganciclovir for six weeks and after that, I
will switch the patient to acyclovir.
Frank:
Starling curve is optimized
for fluid ressus of patient with recent MI and peritonitis from diverticulitis
shooting for a cardiac index of more than 2,
wedge pressure of 14 to 18,
SVR less than 1,000
V tach (or V fib) ACLS
CPR
One mg epinephrine (repeated every three minutes)
Shock 300 jewels
CPR
300 mg amiodarone
Shock 360 jewels
CPR
150 mg amiodarone
Shock 360 jewels
Also try given:
Magnesium 2 – 3 g IV
Procainamide 100 mg Q5 minutes
Bicarb 1 amp
Lidocaine 1 mg per kilogram IV
5 Hs and 5 Ts
these are cause of PEA and Asystole:
Hypovolemia, Hypoxia, Hydrogen ion (acidosis),
Hyper-/hypokalemia, Hypoglycemia, Hypothermia.
think cardiopulm bypass and what is associated with stopping the heart: hyper k (cardioplegia), acidosis hypothermia, hypotension, hypoxia
The T’s include:
Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and pulmonary), and Trauma.
think trauma box work up:
Tenssion ptx, tamponade, trauma, thrombosis, toxins
ABG
pH 7.4 7.35 to 7.45
Pa02 90mmHg 80 to 100 mmHg
Sa02 93 to 100%
PaC02 40mmHg 35 to 45 mmHg
HC03 24mEq/L 22 to 26mEq/Lpost arrest care
EKG
Echo
ABG, lytes, cbc, lactate, base def
Inotropic and vasopressor support can mitigate the myocardial dysfunction that is common during the first 24 to 48 hours after cardiac arrest [20,39].
no evidence demonstrating the superiority of any one vasopressor in the post-cardiac arrest patient. Commonly employed vasopressors include
dopamine (5 to 20 mcg/kg per minute),
norepinephrine (0.01 to 1 mcg/kg per minute; 0.5 to 70 mcg/minute),
epinephrine (0.01 to 1 mcg/kg per minute; 0.5 to 70 mcg/minute).
In cases of cardiogenic shock (eg, global
dobutamine (2 to 15 mcg/kg per minute) or milrinone (loading dose: 50 mcg/kg over 10 minutes, then 0.375 to 0.75 mcg/kg per minute)
Either agent may cause hypotension from vasodilation; dobutamine may cause tachyarrhythmias.
Antiarrhythmic drugs should be reserved for patients with recurrent or ongoing unstable arrhythmias.
No data support the routine or prophylactic use of antiarrhythmic drugs after the return of spontaneous circulation following cardiac arrest, even if such medications were employed during the resuscitation.
Determining and correcting the underlying cause of the arrhythmia (eg, electrolyte disturbance, acute myocardial ischemia, toxin ingestion) is the best intervention. (See ‘Determining the cause and extent of injury after cardiac arrest’ above.)
low UOP w/u
flush foley bladder scan (FeNa if urine) renal US BMP / lytes UA - spec grav / proteinuria / casts myglobin
CXR
EKG
(enzymes)
CVP / swan
Indications for renal replacement therapy
acidosis refractory
Acute severe electrolyte changes - hyper K!
Toxins: methanol/ethanol
Volume overload Uremia: Encephalopathy Severe azotemia – BUN > 100 Significant bleeding Uremic pericarditis
A – Acidosis – metabolic acidosis with a pH 6.5 mEq/L or rapidly rising potassium levels; see previous postfor a review of the causes and management of hyperkalemia
I – Intoxications – use the mnemonic SLIME to remember the drugs and toxins that can be removed with dialysis: salicylates, lithium, isopropanol, methanol, ethylene glycol
O – Overload – volume overload refractory to diuresis
U – Uremia – elevated BUN with signs or symptoms of uremia, including pericarditis, neuropathy, uremic bleeding, or an otherwise unexplained decline in mental status (uremic encephalopathy)
Medication associated with adrenal insufficiency
Etomidate–though, usually not one time bolus
SSx of adrenal insuf
Inability to wean from the ventilator
Persistent hypotension that is vasopressors dependent
Low sodium and high potassium
Unexplained fever
Weakness
vague abd pain
adrenal insuf test
Cortisol may be checked at any time in the critically ill
proposed as the appropriate minimum value :
18 is considered normal stress repsonse
for being in the ICU - below this is insuf
(range, 10 to 34 μg/ dL);
“18 year olds are old enough for trauma and have enough cortisol)
(ACTH) stimulation NOT USEFUL in TRAUMA / ICU
administering 250 μg of ACTH (cosyntropin) either intravenously or intramuscularly.
Cortisol levels 30 and 60 minutes
delta 9
who showed a change in baseline cortisol levels by 9 μg/ dL at 30 or 60 minutes during the ACTH stimulation test had lower mortality rates if they received corticosteroids. This test is thought to demonstrate adrenal reserve in the face of critical illness or sepsis but
low-dose version of the ACTH stimulation test
only 1 µg of cosyntropin is administered intravenously.
Due to the low dose, it is thought that it is more sensitive for partial AI.
best steroid replacement
The administration of hydrocortisone (150 to 200 mg daily for 5 to 7 days) has been shown to lead to a decreased vasopressor requirement as well as improved organ dysfunction, fewer ventilator days, fewer ICU days, and most importantly lower 28-day mortality.
50 mg IV q 6 hr
or
100 mg q 8 hr
The differential diagnosis of severe hypoxemia in this patient ICU
Aspiration pneumonia
or
pneumonitis
Pulmonary embolus
Heart failure
Pulmonary edema
Transfusion-associated acute lung injury (TRALI)
Acute respiratory distress syndrome (ARDS)
ARDS is a syndrome defined by
1 acute onset
2 pao2 / fio2
Workup The workup for ARDS includes
exclude the other potential diagnoses of the acute hypoxemic respiratory failure.
Transthoracic Echocardiography This diagnostic test is used to evaluate for cardiogenic pulmonary edema.
no evidence of right heart strain or right ventricular dysfunction that may be present in patients with pulmonary embolus.
Laboratory Tests Arterial blood gas confirms hypoxemia,
PaO2 of 85 mm Hg on FiO2 1.0, which confirms a PaO2/ FiO2 ratio ≤ 200 mm Hg.
Brain (B-type) natriuretic peptide (BNP) levels are elevated in acutely decompensated heart failure, so low levels may be indicative of a diagnosis of ARDS.
Sputum Respiratory cultures should be obtained to evaluate for possible bacterial or aspiration pneumonia as the etiology of the patient’s acute respiratory failure.
Electrocardiogram Electrocardiogram (EKG) without MI or Right heart strain
consider Duplex
consider CT chest
vent goals for ARDS
lung protective vol 6 cc /kg vol
permissive hypercapnea
incr PEEP
fluid conservative considered if ressuss done
good lung down
others:
incr PEEP
(watch ptx)
reverse I:E
prone
Airway release ventilation
or
high-frequency oscillatory ventilation
RESCUE: Recruitment maneuvers Prone position Inhaled nitric oxide Inhaled prostaglandin ECMO
vent setting for ARDS
Plateau pressure goal less than 30
PH goal 7.3 point three– 7.4
VAP reduction
head of bed 30
Oral care
silver impreg
REcruitment
cont positive airway pressure:
30 cm h20 PEEP for 30 sec
risk ptx, hypoxia, hypotension
ECMO
veno-venus
VAP basic definition
Defined as a pulmonary infection that starts after 48 hours of mechanical ventilation
leading cause of death in ICU!
second most common nosocomail infection in ICU
Criteria to diagnose VAP
Fever
WBC
New infiltrate
–
Fever WBC Lung infiltrate Nature of tracheal secretion Oxygenation \+/- bronchoalveolar lavage gram stain finding of
neutrophils OR bacteria
NO sputum
Collecting source to w/u BAL
bronchoscope
or
coaxial catheter that is inserted blindly through the endotracheal tube.
The latter approach, called the mini-BAL -diagnostic yield is considered similar to conventional bronchoscopy.
Additionally, some ICUs use a protective brush inserted via a bronchoscope to obtain direct cultures from the affected area of the lung.
The brush is then retrieved and directly plated onto the culture media.
bacterial burden of more than 10 to the 4 CFU/ mL.
bacteria and abx VAP
early ( 4 ventilator days).
early VAP Enterobacteriaceae or gram-positive organisms such as staph
second-generation cephalosporins,
fluoroquinolones,
extended-spectrum penicillins as a single agent.
Late VAP
invariably resistant organisms
methicillin-resistant
Staphylococcus aureus (MRSA),
Pseudomonas species,
Acinetobacter species
combination therapy
vancomycin plus beta lactams
(third-generation cephalosporins, carbapenems)
or
fluoroquinolones +/ − aminoglycosides is
Torsadeselectrolyte disturbances
hypokalemia
and
hypomagnesemia
Treatment of intermittent torsades
stable patients
correcting any underlying metabolic or electrolyte abnormalities
INCRASE! the heart rate to shorten ventricular repolarization.
Intravenous magnesium sulfate is also effective in treating paroxysmal torsades.
early Sepsis swan findings
high output cardiac failure,
SVR is decreased due to toxins that produce vasodilation.
SvO2 should be HIGH because the tissues are unable to extract oxygen from the blood effectively.
what type of line has the highest DVT risk
Femoral catheters (complete contratindicaiton in peds)
list order of lest to greatest infection risk with lines
Sublavian (lowest infection)
IJ
Femoral (highest infection)
cause of hypoxemia in pulmonary embolism
Ventilation-perfusion (V/Q) mismatch
increase the p50 of normal hemoglobin Increased:
2,3-DPG,
temperature,
PCO2
(incr Hydrogen / decreased pH
