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Appendix > ICU > Flashcards

ICU Flashcards

1
Q

What is an adequate cerebral perfusion pressure?

A

55-60 mmHg

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2
Q

How do we calculate CPP?

A

MAP - ICP = CPP

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3
Q

In coma pts, suspected of etoh abuse, what do we give before glucose?

A

thiamine 1mg/kg first

glucose after

**if glucose given first can precipitate Wernicke’s encephalopathy

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4
Q

In pts with opioid induced coma, what do we give?

A

naloxone 0.4 to 2 mg

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5
Q

Coma due to benzo intoxication, we give what?

A

flumazenil 0.2 mg

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6
Q

Hyperventilation is effective in lower ICPs, but this effects is lost within?

A

24 hrs

brain normalizes to lower PaCO2

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7
Q

Monro-Kelli hypothesis?

A

pressure inside the head will rise if any intracranial component will rise (blood, CSF, brain) because the cranial vault is fixed

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8
Q

Tx for status epilepticus?

A

benzos like lorazepam (0.1 mg/kg) followed by phenytoin 1g

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9
Q

Major complications assc. w/seizures?

A

rhabdomyolysis
hyperthermia
cerebral edema

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10
Q

Sedation scales used in ICU?

A

Richmond Agitation Severity Scale
0= alert and calm
4= combative, dangeorus to staff
-5= unarousable

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11
Q

When is skeletal muscle relaxation warranted in ICU setting?

A

minimize o2 consumption

facilitate patient-ventilator synchrony (prone positioning)

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12
Q

Two classes of neuromuscular blocking drugs?

A

depolarizing NMBs

non-depolarizing NMBs

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13
Q

This drug is a depolarizing NMBs:

A

succinylcholine

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14
Q

How does depolarizing NMB like succinylcholine work?

A

binds to ACh receptor at motor end plate

cause muscle depolarization –> seen as muscle fasciculations

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15
Q

Onset and half life of succinylcholine?

A

rapid onset

short half-life

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16
Q

When do we use succinylcholine?

A

paralytic of choice for RSI

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17
Q

SE of succinylcholine?

A

rhabdomyolysis
hyperkalemia
muscle pain
malignant hyperthermia

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18
Q

How do non-depolarizing NMBs work?

A

bind ACh receptors but do not activate them

block receptor, inhibit it’s function

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19
Q

What are the two types of non-depolarizing NMBs?

A

steroidal

non-steroidal

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20
Q

What are the amino steroidal non-depolarizing NMBs?

A

rocuronium
vecuronium
pancuronium

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21
Q

When do we use rocuronium?

A

rapid onset of action

intermediate duration

**used for short procedures and prolonged relaxation

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22
Q

Onset of action of vecuronium?

A

NMB within 1-2 minutes

lasts 30 minutes

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23
Q

With vecuronium we have to worry about?

A

renal and liver impairment

leads to prolonged response

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24
Q

Pancuronium contraindicated in pts with?

A

CAD

causes tachycardia

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25
Q

Non-steroidal non-depolarizing NMBs include?

A

atracurium

cis-atracurium

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26
Q

Atracurium is intermediate acting with minimal cardiovascular effects, but it does have;

A

histamine release

** can be used in pts with liver/kidney dysfunction

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27
Q

When placing arterial catheters which are preferred sites?

A

radial and DP arteries

thrombosis and distal ischemia can be minimized by placing a-lines in places with good collateral circulation

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28
Q

How do we calculate MAP?

A

MAP = DBP + 1/3 (SBP - DBP)

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29
Q

Two basic modes of positive pressure ventilation?

A

volume control–> tidal volume is pre-selected and automatically delivered by ventilator

pressure control–> inflation pressure is pre-selected

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30
Q

During volume control ventilation, whats happening to the airway pressure?

A

pressure rises steadily until pre-selected volume delivered

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31
Q

What’s Peak pressure?

A

airway pressure at the end of each lung inflation

pressure needed to overcome both elastic and resistive forces in the lungs and chest wall

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32
Q

What is the plateau pressure?

A

peak pressure in the alveoli at the end of inspiration

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33
Q

Peak pressure of alveoli at end of inspiration?

A

plateau pressure

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34
Q

How do we check plateau pressures?

A

prevent the pt from exhaling with an inspiratory hold (for 1 second)

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35
Q

What is ZEEP?

A

in a normal lung, there is no airflow at the end of expiration

at that time, pressure in alveoli is equal to atmospheric pressure

this is called zero-end-expiratory pressure

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36
Q

What do we use PEEP for?

A

prevents collapse of distal airspaces at the end of expiration

and to open collapsed alveoli

37
Q

What is occult PEEP?

A

auto-PEEP

when we see continued airflow at end of expiration
lungs do not completely empty and alveoli remain positive even though proximal airway pressure falls to atmospheric pressure (0)

38
Q

Where do we see auto-PEEP?

A

seen as result of dynamic hyperinflation in pts with COPD/asthma

or vent settings where pts have decreased time for exhalation

39
Q

What’s mean airway pressure?

A

avg pressure in airways during a ventilatory cycle

5-10 cm H20 in normal lungs
10-20 cm H20 in lungs w/airway obstruction
20-30 cm H20 for non-compliant lungs (stiff)

40
Q

How do we prevent atelectrauma?

A

during normal positive pressure ventilation opening and closing of alveoli causes shear forces and damage

PEEP keeps small airways open during expiration

41
Q

What is barotrauma?

A

positive pressure ventilation can cause leaks from rupture in airways and distal spaces

air escapes and can cause pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumoperitoneum

42
Q

Lung protective ventilation guidelines?

A

ventilation begins with tidal volume of 8cc/kg of predicted body weight, weaned down to 6cc/kg after

keep plateau pressure less than 30 cm H20

PEEP of 5 minimum, is used to prevent alveolar collapse

permissive hypercapnia allowed

43
Q

How does positive pressure influence cardiac function?

A

positive intrathoracic pressure venous return to heart

positive pressure on outer surface of heart also decreases ventricular filling during diastole

positive pressure ventilation increases pulmonary vascular resistance which impacts right ventricular stroke output, so RV becomes distended and affects LV size, which affects LV function (also because of increased vascular resistance, you have less oxygenated blood returning to LV)

44
Q

What are the two basic modes of positive pressure lung inflation?

A

volume control; where inflation volume is constant

pressure control; where inflation pressure is constant

45
Q

What are the 6 basic modes of positive pressure lung ventilation?

A

Volume Control

Pressure Control

Assist Control

Pressure support

Intermittent Mandatory Ventilation

Positive end-expiratory pressure

46
Q

Describe volume control ventilation?

A

the inflation tidal volume is pre-selected

lungs are inflated at a constant flow rate until desired volume is delivered

47
Q

Advantage of volume control ventilation?

A

able to deliver a constant volume despite changes in mechanical properties of lungs

48
Q

In volume control ventilation, how does ventilator deliver constant volume when airway resistance increase or lung compliance decrease?

A

ventilator will generate higher pressure to deliver preselected volume

this maintains the desired minute ventilation

49
Q

Disadvantage of volume controlled ventilation?

A
  1. airway pressures and end of inspiration are higher for VC vs PC ventilation

but this does not affect barotrauma/atelectrauma

  1. duration of inspiration is short, can lead to uneven alveolar filling
50
Q

Describe pressure control ventilation?

A

desired inflation pressure is selected

51
Q

Advantage of pressure control ventilation?

A

ability to control peak alveolar pressures, which relates to alveolar overdistention and lung injury

maintain this < 30 cm H20

52
Q

Why is pressure control ventilation more comfortable for pts than volume control ventilation?

A

high initial flow rates

longer duration of inspiration

53
Q

Which is preferred by pts, PC or VC ventilation?

A

pressure control; has higher initial flow rates and longer duration of inspiration

54
Q

Major disadvantage of pressure control ventilation?

A

see decrease in alveolar volume when there is increase in airway resistance or decrease in lung compliance

55
Q

What is Assist-Control Ventilation?

A

allows pt to initiate a ventilator breath

if this is not done by pt, ventilator breaths are delivered by machine at a pre-selected rate

ventilator breaths during AC can be volume or pressure

56
Q

What are the two triggers for assist-control ventilation?

A
  1. patient triggered breath via spontaneous inspiratory effort
  2. absence of spontaneous inspiratory effort by pt (no interaction between pt and ventilator); so ventilator will deliver breaths at a pre-selected rate
57
Q

What’s the ratio of inspiration;expiration that we strive for?

A

inspiration; expiration ratio of 1;2

58
Q

Why do we want an inspiration;expiration ratio of 1;2?

A

to prevent breath stacking

you want complete exhalation before you deliver another breath or else you get dynamic hyperinflation and auto-PEEP

59
Q

What is SIMV?

A

synchronized intermittent mandatory ventilation

designed to allow spontaneous breathing between ventilator breaths

ventilator breaths in SIMV can be volume or pressure

60
Q

Disadvantages of IMV?

A

increased work of breathing

decrease in cardiac output in pts with LV dysfunction

61
Q

Major indication for Intermittent mandatory ventilation?

A

pts with rapid breathing and incomplete exhalation during assist control ventilation

62
Q

We don’t use IMV in which pts?

A

pts w/resp muscle weakness and left heart failure

63
Q

What is alveolar recruitment?

A

low levels of PEEP 5-10 cm H20 help prevent collapse of distal airspaces

high levels of PEEP 20-30 cm H20 help reopen distal airspaces that are consistently collapsed

this increases available surface area in lungs for gas exchange

64
Q

What is the dilemma with alveolar recruitment?

A

how do we know if high PEEP is promoting alveolar recruitment vs alveolar overdistention in the already normal parts of lung?

when PEEP is causing alveolar recruitment; lung compliance increase

when PEEP causing alveolar overdistention; lung compliance decreases

65
Q

What does the PaO2/Fio2 ratio signify?

A

efficiency of gas exchange in lungs

66
Q

How can we use PaO2/Fio2 ratio to help us use PEEP for alveolar recruitment?

A

when PEEP is causing recruitment, the ratio will increase

when PEEP is not causing recruitment, the ratio will remain the same or decrease

67
Q

Assist control AKA?

A

CMV; continuous mandatory ventilation

68
Q

How does assist control (CMV) work?

A

patient triggers the vent

pt takes a breath, and negative pressure sensor is detected in ventilator

ventilator then delivers a specific volume

if pt does not take a breath, ventilator is already preset to a specific rate, say 12, and will deliver those 12 regardless

69
Q

How does pressure support work?

A

pt initiates all the breaths
occurs only during inhalation
popular weaning mode

pt receives anywhere from 5-15 cm H20 pressure

70
Q

In AC mode, we program in a set volume for delivery into lungs, what is variable?

A

pressure is variable depending on lung compliance

71
Q

What is peak vs plateau pressure?

A

peak pressure==> pressure when there is airflow going into lungs, resistance felt along the airways as air is moving in

plateau pressure–> measured when airflow stop, air is in alveolis, and has to do with lung compliance

72
Q

What can give you high peak pressures?

A

problem with the airways

bronchospasm
secretions
mucus plug
ETT occluded

73
Q

What can give you high plateau pressures?

A

things that decrease lung compliance;

pneumo
Pulmonary edema
ARDS
pneumonia

74
Q

What is the rapid shallow breathing index?

A

tobin index for extubation

RR/TV (20/.5)= 40

tobin index > 105 is not good
tobin index < 105 is good

75
Q

Explain air leak test;

A

when you put ETT down trachea and inflate balloon, that balloon can cause inflammation around the trachea, when someone is ready to be extubated you do an air leak test

balloon is deflated and you listen for air to come up around the tube, if no air leak is heard, means there is some inflammation and if you pull tube out, risk of closing off trachea

76
Q

THings to check before weaning pt from ventilator?

A

secretions?

oxygenating well? Pao2/Fio2 >200, Fio2 <40? PEEP < 5-8?

can pt protect their airway

pulmonary function adequate ?

77
Q

One of the most effective means of preventing stress gastritis?

A

early enteral feeding

78
Q

What is abdominal compartment syndrome?

A

increased intra-abdominal pressure assc with adverse physiological consequences

79
Q

What is secondary abdominal compartment syndrome?

A

ACS in absence of abdominal/pelvic pathology

usually due to shock and edema from aggressive resuscitation

80
Q

Cardiovascular effects of abdominal compartment syndrome?

A

decreased CO due to diminished venous return because of increased abdominal pressures

81
Q

Increased abdominal pressures effects on lungs?

A

decreased diaphragmatic excursion

decreased pulm compliance

high airway pressures

decreased tVolumes

resp acidosis

82
Q

Most common cause of oliguria in surgical icu pts is?

A

pre-renal hypovolemia

83
Q

How can a spot urine sodium tell us if AKI is pre-renal vs intrinsic AKI?

A

U sodium less than 20== pre-renal

U sodium > 40 == intrinsic

84
Q

RIFLE criteria used for what?

A

assess for AKI

85
Q

FeNA < 1% means what?

A

pre-renal cause of AKI

86
Q

FeNA >3% means what?

A

renal parenchymal or post-renal problem of AKI

87
Q

Primary bacterial peritonitis occurs in >20% of cirrhotic pts with ascites and usually has what type of bacteria?

A

monomicrobial (pneumococcus)

polymicrobial peritonitis usually indicative of intra-abdominal abscess or perforated viscus

88
Q

What is hepato-renal syndrome?

A

renal problem seen in pt with end-stage liver disease due to systemic vasodilation, hypovolemia, and increased RAAS

pts have azotemia, oliguria, low urine Na (<10), high urine osmolality

89
Q

In AC mode ventilation, what type of breaths can the pt get?

A

pt can get a breath delivered by the machine, triggered by a set time (every 6 seconds, machine delivers 500cc of volume for example)

pt can get a breath when they trigger it on their own (aside from set volume delivered every 5-6 seconds by machine, pts can themselves trigger a breath, when it’s triggered machine will deliver another breath to pre-set volume, only difference is this is not triggered by time, but by the patient)

Appendix (39 decks)

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