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Oral Boards > ICU > Flashcards

ICU Flashcards

1
Q

When would you avoid using a cell saver?

A

conditions leading to contamination

  • amniotic fluid
  • fecal material
  • tumor cells
  • betadine
  • bone cement
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2
Q

When would you avoid using acute normovolemic hemodilution?

A

Pre-existing cardiac disease –> anemia in myocardial work and demand

Severe renal disease –> extra volume poorly excreted –> CHF

Baseline Hb already low (<11)

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3
Q

What is the cause of uremic thrombocytopenia

A

Dec vWF
Inc nitric oxide, prostacyclin which inhibit platelets
Uremia induced anemia dec viscosity, dec platelet interaction with endothelial surfaces

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4
Q

How do you treat uremic induced thrombocytopenia

A 
DDAVP
Erythropoietin 
Cryo 
Platelets
Dialysis
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5
Q

How do you calculate MELD

A

Cr + Bilirubin + INR

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6
Q

What is Hepatopulmonary syndrome

A

Liver disease + A-a >20 or PaO2 <70mmHg + intrapulmonary vascular dilation

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7
Q

How would you determine if ESLD patient’s elevated Cr was due to hepatorenal syndrome?

A

Fluid challenge 1.5L - improved = pre-renal azotemia and not HRS

Urinary Na >10, casts, sediment = ATN

Look for nephrotoxic agents, contrast

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8
Q

What is the pathophysiology of HRS?

A

Inc endothelial (prostacyclin and nitric oxide) vasodilators –> splanchnic vasodilation –> reduced “effective” blood volume sensed by kidney –> activation of RAAS and sympathetics

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9
Q

Concern with OLT pre-op PAP >35?

A

> 35 - moderate pulmonary HTN at inc risk of right heart and liver failure post-op.

Contraindicated with >50

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10
Q

What is V-V bypass?

A

Femoral or portal veins cannulated –> axillary, subclavian or jugular veins to improve hemodynamic stability, perfusion during an hepatic phase, improve cardiac filling and improve surgical field.

Disadvantages - air embolism, thromboembolism, arm lymphedema, hematoma, vascular injury and nerve injury

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11
Q

Describe the stages of liver transplantation

A
  1. Pre-anhepatic - dissection
  2. Anhepatic - clamping of hepatic artery –> removal of native liver, implantation of donor
  3. Reperfusion - completion of anastomosis, hemostasis until completion
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12
Q

How do you calculate GCS

A 
Eye opening (1-4)
- none, pain, verbal, spontaneous
Verbal response (1-5)
- non-verbal, sounds, inappropriate words, confused, oriented

Motor response
- none, extension, flexion, withdraws, localizes, follows commands

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13
Q

How would you intubate an uncooperative, morbidly obese patient with potential facial and c-spine injuries?

A

Goal is to safely secure airway while attempting to avoid things that may increase his ICP (hypoxia, hypercarbia, sympathetic stim), hypotension, C-spine injury, aspiration

DI equipment, surgeon for trach, reverse T-berg, Pre-O2, careful titration of ketamine to maintain spontaneous vent, remove c-collar and apply cricoid and in-line stabilization

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14
Q

What is vWD?

A

A qualitative or quantitative defect in vWF
- important role in platelet adhesion, platelet-to-platelet aggregation

Type 1 = most common, quantitative = DDAVP
Type 2 = qualitative, varying degrees
Type 3 = severely low levels

Other tx options = Cryo, FFP, Humate P if type is unknown or having major surgery

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15
Q

Systemic effects of renal failure?

A

HyperK, HypoCa, acidosis

HypoNa
- Assess for AMS, weakness, HA –> cardiac arrest, cerebral edema, coma, brainstem herniation

Autonomic neuropathy, seizures, uremic encephalopathy, delayed gastric emptying, cardiac arrhythmia, conduction blocks, uremic pericarditis

Retention of Na, and water –> HTN, LVH, CHF

Dec erythropoietin production –> hemodilution, bone marrow suppression, impaired platelet function

Exaggerated effect of drugs (dec protein binding + uremic induced disruption of BBB)

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16
Q

Systemic manifestations with OSA

A

Chronic hypoxemia and hypercarbia –> inc catecholamine levels

  • pulmonary HTN –> RV failure
  • systemic HTN
  • arrythmias
  • polycythemia
  • inc platelet aggregation
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17
Q

How would you adjust med dose with obesity?

A

Lipophilic drugs - larger Vd = TBW

  • Sux
  • Opioids
  • Benzos
  • Precedex
  • Neostigmine

Hydrophilic drugs = IBW
- NMBDs

However the effects are do not always mirror expectations so it would be reasonable to use IBW and titrate additional dosing to clinical effect

IBW = height (cm) - 100
LBW = IBW + 20-30%
18
Q

anaphylaxis vs anaphylactoid

A

Anaphylaxis - IgE antibodies –> degranulation

Anaphylactoid - direct interaction of mast calls with certain allergens = do not require prior sensitization

19
Q

Tx methHb

A

Methylene blue 2mg/kg

G6PD deficiency = exchange transfusion

20
Q

Would you treat acidosis with bicarbonate?

A

Probably not

My concerns are:

  1. generation of addition CO2 –> worsening intracellular acidosis
  2. left shift of O2-Hb curve –> dec O2 unloading and tissue hypoxia
  3. hyperosmolar state due to excessive Na
  4. Development of hypoK

So i would avoid using unless he developed life threatening hyperK, pH <7.1 or Bicarb <10 which can lead to dysrhythmias, hypotension, myocardial depression

21
Q

Cardiovascular changes with burns

A

First 24-48hrs:

  • dec CO d/t myocardial depressants
  • inc SVR
  • dec coronary BF
  • dec response to catecholamines

–> hyper dynamic, CO 2x, SVR reduced

22
Q

Surgery begins and the patient suddenly loses 850ml of blood, would you begin transfusion?

A

If hx of HTN, IDDM would prefer to maintain Hct 30% but in addition to allowable blood loss i would consider current surgical hemostasis, hemodynamic stability, signs of tissue ischemia or inadequate organ perfusion

23
Q

What is the pathophysiology of bone-cement implantation syndrome?

A

hardening and expansion of cement inc intramedullary pressure –> embolization of marrow debris

When large enough –> inc PVR, RV strain, ventricular dysfunction.

Cement –> dec SVR

Cytokines –> microthrumbus and plum HTN

Tx = supportive - 100% O2, fluids, vasopressors

24
Q

Post-op from burn and trauma, temp is 38.9, are you concerned?

A

Early post-op fever usually not infectious.

most likely hypothalamus-mediated inc in temp assoc with major burns.

May represent hyper metabolic response to thermal injury - fat, protein wasting inc O2 consumption –> tissue hypoxia, renal failure, infection

Tx = inc room temp, pain control red catecholamine release, nutrition avoiding hyperglycemia, cholestasis

25
Q

What is the mechanism of anemia in chronic renal failure?

A

Dec erythropoietin
Dec cell survival

Tolerated d/t metabolic acidosis and inc 2,3 DPG –> right shift offloading O2

26
Q

Are there any meds you would avoid in a patient with chronic renal failure?

A

Meds dependent on renal elimination or with active metabolites

  • pancuronim
  • atropine
  • glyco
  • ketamine
  • morphine
  • diazepam
  • meperidine

Red highly protein bound drugs - benzos

27
Q

What are the risk factors for aspiration?

A 
Obesity (higher volume, lower pH)
Delayed gastric emptying (DM, pain)
Pregnancy
Bowel obstruction
Hx GERD
Extremes of ages
28
Q

What are the biggest risk factors for developing aspiration pneumonitis?

A 
#1 = gastric pH <2.5
Volume >25ml

No role for steroids
Antibiotics only if demonstrated a bacterial infection through cultures

29
Q

What are the systemic effects of cirrhosis/liver failure?

A

Cardiac

  • hyper dynamic circulation (low SVR, high CO)
  • portal HTN, varices
  • pulm HTN

Pulmonary

  • intrapulmonary dilations, shunt
  • Dec FRC
  • restrictive lung disease
  • pleural effusions
  • resp alkalosis, hypoxemia

Heme
- Thrombocytopenia and factor deficiencies –> coagulopathy

Ammonia –> encephalopathy

Renal
- HRS

Metabolic
- hypoK, glycemia, albuminemia

30
Q

What are causes of AGMA?

A

MUDPILES

  • methanol
  • uremia
  • DKA
  • paraldehyde
  • Iron
  • lactic acidosis
  • ethylene glycol
  • salicylate
31
Q

Calculate maintenance fluids for 80kg patient

A

60ml + 1ml/kg for every 1kg over 20

60 + 60 =120ml/hr

Third space losses

  • 1-3ml/kg/hr minor case
  • 3-7 ml/kg/hr intermediate case
  • 9-11ml/kg/hr major case
32
Q

Indications for albumin

A

Large volume paracentesis

  • > 4L w/ cirrhosis
  • 6-8g/L ascites

HRS/Cr >1.5 acute renal dysfunction
SBP
Post-cardiac, liver, lung transplant with albumin <3, edema and not responsive to crystalloid therapy (>3L)

25% = 25g/100ml

33
Q

What is refeeding syndrome?

A

syndrome of electrolyte imbalance associated with TPN use

  • hypoPhos
  • hypoMag
  • glucose imbalance
  • vitamin deficiency
34
Q

What are the complications of TPN?

A 
Infection
VTE
Acidosis
Hypercarbia
Fatty liver
35
Q

When would you use lasix in response to oliguria?

A

It would be beneficial in avoiding fluid overload and facilitating mechanical ventilation, oxygenation in particular

36
Q

CI 3.5L/min/m2, MAP 68, on epi gtt, PaO2 65 on FiO2 0.6. How will you manage ventilation?

Will you use PEEP and what are the consequences of PEEP?

A

Hypoxic –> yes I would use PEEP to improve oxygenation

Low tidal volume lung protective strategy
PEEP inc RV afterload, dec venous return and LV compliance compromising CO

Give volume, inc tone and contractility to compensate for effects of PEEP and dec mean airway pressure with low Tv ventilation and permissive hypercapnia

37
Q

How would you determine optimal PEEP?

A

I would use the sliding scale from ARDS-NET

- increase PEEP based on increasing need for FiO2

38
Q

What is a lung protective ventilation strategy?

A
  1. calculate 6ml/kg PBW
  2. Set RR and Tv to achieve optimal MV
  3. Permissive hypercapnia to pH 7.3-7.4
  4. Pplat <30
  5. SpO2 88-95, PaO2 55-80
  6. Inc PEEP with inc FiO2
39
Q

What are your target Factor VIII levels before surgery?

A

High risk of bleeding - >80%

Normal surgery - >50%

Want >30% for 10 days post-op

40
Q

What are your treatment options for hemophilia A and B?

A

A

  • DDAVP
  • factor concentrate
  • cryo

B
- factor concentrate

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