iCU Flashcards
Sepsis definition (ie. qSOFA)
qSOFA
2/3 of:
- RR ≥22/min
- SBP ≤100 mmHg
- Altered Mentation (GCS<15)
Septic Shock Definition
qSOFA plus:
Both:
1)Lactate > 2 mmol/L
2)Vasopressors to keep MAP ≥ 65 in absence of hypovolemia
Distensibility index that predicts fluid responsiveness in intubated and non-intubated patient?
IVC Variation-Distensibility
• Intubated fully ventilated distensibility Index >15-20% likely fluid responsive
• Intubated breathing spontaneously not validated
• Not Intubated breathing spontaneously distensibility index >40% likely fluid responsive
Note: Low distensibility index ≠ non-responder!
*Fluid responsiveness defined an increase in Stroke Volume (SV) or Cardiac Output (CO) by
10-15% after a 250-500cc fluid bolus
Norepinephrine dose range
Recommended First Line (0.03-0.35 mcg/kg/min)
Contraindications to NIPPV
- Facial surgery, trauma, obstruction
- Decreased LOC (*relative)
- Inability to clear secretions
- Respiratory arrest
- Hemodynamic instability (reduces preload)
Surgeries that are ok:
– Supra-diaphragm sx (eg. lung Ca)
– GI sx (including esophageal)
– Pelvic Sx
How do you perform an apnea test? What are the parameters for completion?
- Correct/address confounding factors first
- Pre-oxygenate and obtain ABG (baseline ABG PaCO2 35-45, pH = 7.35-7.45)
- Disconnect from ventilator
- Monitor for respiratory efforts
- Serial ABGs
Thresholds for completion: PaCO2 > 60 mmHg and > 20 mmHg above the pre-apnea baseline and pH ≤ 7.28.
Indications for Fomepizole or etoh in toxic alcohol ingestion?
• Serum methanol >6.2mmol/L or ethylene glycol >3.2mmol/L
OR
• Documented recent history of ingestion of toxic amounts of methanol or ethylene glycol and an osmolar gap>10
OR
• Suspicion of ingestion and 2 of the following:
– pH <7.3 OR Bicarb <20 OR OG>10 OR urine oxalate crystals
Indications for dialysis in ASA OD?
Indications: –Salicylate Level >7.2mmol/L –Hypoxemia requiring supplemental O2 –Altered mental status –Renal failure (and level >6.5mmol/L) –Progressive deterioration of vital signs –Severe acid –base or electrolyte imbalance –Hepatic compromise with coagulopathy
Hunter Criteria for diagnosing Serotonin Syndrome
Hunter criteria
Needs to take a serotonergic agent and ONE of -Spontaneous clonus
-Ocular clonus
-Inducible clonus + diaphoresis or agitation -Tremor + Hyperreflexia
-Hypertonic + temp>38 PLUS ocular or inducible clonus
Treatment for Serotonin syndrome
- Stop the agent, support
- Sedate with benzos (goal is to eliminate agitation, hypertonia, normalize vitals)
- If fails–>cyprohepatdine
Treatment for NMS
- Stop the agent, Support, Cooling blankets
- Benzos are mainstay
- Dantrolene and Bromocriptine are adjuncts
How much crystalloid fluid should be administered in the first 4 hours of sepsis resuscitation?
30 ml/kg crystalloid in first 4 hours
DYNAMIC variables that can be used to predict fluid responsiveness? NOTE: CVP is a static measure
– Passive leg raise – Fluid Challenge (250 cc Crystalloid) – Pulse pressure variation (PPV) – Stroke volume variation (SVV) on PoCUS – IVC Variation-Distensibility
Patient in septic shock is not responding to fluid resus or pressors. You plan to give steroids as per the new recommendations. What steroid and how much?
IV Hydrocortisone 200mg daily
Parameters for tidal volume and plateau pressure when treating ARDS
- Tidal Volume 4-8 mL/kg predicted body weight (based on height)
- Plateau Pressure < 30 cm H2O
Others: • Prone Positioning > 12 h/d for severe ARDS • Higher PEEP/FiO2 for mod/ severe ARDS • Targets: O2 saturation 88-95%, PaO2 55-80, pH 7.25-7.35.
Strategies with mortality benefit in ARDS
- Increase PEEP
- Prone positioning
INCREASED DEATH WITH HIGH FREQUENCY OSSCILLATION
Highest predictors of difficult intubation in order of +LR (best—>worst)
- Grade 3 upper lip bite test (lower incisor cannot reach upper lip)
- Short Hyomental distance
- Retrognathia (mandible < 9 cm from angle jaw to tip chin)
- Combination of findings (Wilson Score) (should be second according to LR in chart but not what TO listed)
- Mallampati Score (≥3)
What RAAS should we target in ICU patients?
• Target RASS -2 to +1
+1=Anxious, apprehensive, but not aggressive
-2=Lid sedation, briefly awakens < 10 seconds
Key difference between critical illness myopathy vs critical illness polyneuropathy?
Critical illness polyneuropathy has decreased pin prick sensation and distal>proximal.
(in CI myopathy, sensation is intact and proximal> distal)
In TCA overdose, serum levels are not helpful. Although, you can screen for TCA in urine. What would give a false positive TCA level in the urine?
- seroquel (quetiapine)
- benadryl (diphenhydramine),
- flexiril (cyclobenzaprine)
How do you treat TCA overdose?
Treatment mainly supportive care:
Seizures
Benzos—>propofol—>Phenobarb no Phenytonin
Hypotension
NS or Bicarb bolus
Wide complex tachy cardia
Bicarb bolus then infusion (target pH 7.50-7.55)
If fails Mg sulphate—>Lidocaine
What should never be given for seizures in a TCA overdose for fear of enhancing cardiac toxicity?
PHENYTONIN
Which one of the toxic alcohols cause hypocalcemia?What should you look out for on ECG?
Ethylene Glycol. Watch for prolonged Qtc
What is the Osm Gap calculation when accounting for etoh ingestion?
Calculated Osm=2Na+gluc+bun+1.25xEtOH
