ICU Flashcards
Options for management of gas trapping (aka AutoPeep)
Decrease RR
Decrease TV
Increase expiration time in I:E ratio
Differentiate septic from cardiogenic shock based on Central venous gas
CVO2 >80% = sepsis/high flow
CVO2 <60% = cardiogenic
qSOFA
-define sepsis and septic shock
Sepsis: 2/3 of:
1) RR>=22
2) SBP <=100
3) Altered LOC (GCS<15)
Septic shock: lactate >2mmol/L and requiring pressors for MAP>65
Dynamic Measures of Fluid responsiveness
Fluid challenge (500cc): Increases SV by 10-15% or increased pulse pressure by 15%
Passive leg raise (inc BP by 10-15%)
Lactate
Cap refill: press glass slide on finger until white for 10s if time to normal color <3s = NORMAL
IVC Distendability index
- NOT intubated: >40% IVC collapse with inspiration
- Intubated & ventilated on controlled mode: >15-20% distension with expiration
- Intubated breathing spontaneously - CANNOT Use
Hemodynamic Effect: Norepinephrine and Dopamine
Norepi: ++ SVR, + HR, +/nil CO, + PCWP (all up)
Dopamine: + SVR, + HR, + CO, + PCWP
(all up; same as norepi but higher risk tachy)
Hemodynamic Effect: Epinephrine
+ SVR, ++ HR, + CO, - PCWP
same as norepi except PCWP drops; higher risk tachy
Hemodynamic Effect: Vasopressin
+ SVR, nil HR, nil CO, + PCWP
*S/E: digit/gut ischemia bc peripheral vasoconstrict
Hemodynamic Effect: Phenylephrine
+ SVR, - HR, - CO, + PCWP
(opposite dobutamine; similar to vaso but drops HR and CO - reflex brady)
*use in opioid induced hypotension
Hemodynamic Effect: Dobutamine/Milrinone
- SVR, + HR (Dob>Milrinone), + CO, - PCWP
* Milrinone long halflife, not for renal failure
Indications for corticosteroids in septic shock
MAP <65 despite fluids and norepi or epi >0.25mcg/kg/min x4h (dose = 200 mg/day hydrocortisone or 50mg q6h)
Norepinephrine dose range
0.03-0.35 mcg/kg/min
Strategies to improve ventilation in intubated hypoxic resp failure:
- Increase FiO2
- Increase PEEP
- Sedate and Paralyze
- Prone or roll on good lung down to increase VQ mismatch
- Inhaled NO
- ECMO
Strategies to improve ventilation in hypercarbic resp failure:
- Increase RR
- Increase TV
- Increase I:E ratio
4 Types of Respiratory Failure
1) Hypoxic (PaO2 <60)
2) Hypercapenic (PaCO2 >45)
3) Post-op - due to atelectasis, dec FRC
4) Circulatory collapse
Indications for NIPPV
1) Mild-Severe hypercapneic COPD (RR 20-40, pCO2 >45, pH<= 7.35) if LOC not significantly altered
2) Cardiogenic pulmonary edema
3) Avoid intubation: IC, post-op (GI/pelvic, supra-diaphragm sx) with resp failure, high risk post-extubation pt (Age >=65, resp/CV comorbidity)
Contraindications to NIPPV
1) Altered LOC - unable to protect airway
2) Inability to clear secretions
3) Hemodynamically unstable (reduces preload)
4) Facial fractures/ surgery/ obstruction
5) Indication for intubation, failed extubation
Definition ARDS
1) Acute resp failure (PF ratio <300 on PEEP 5) +
2) Developed within 1 week of acute insult (local - PNA, aspiration, contusion; systemic - sepsis, pancreatitis, drug ingestion, TRALI)
3) Bilateral airspace opacities on CXR not fully explained by cardiogenic pulmonary edema, effusions, lobar/lung collapse or nodules
Severity of ARDS
PF 200-300 = Mild
PF 100-200 = Moderate
PF <100 = severe
*PaO2/FiO2
Treatment strategies ARDS
1) Lung protective vent: Vt 4-8 cc/kg, P plat <30, PIP <40
- Keep RR <35 and PaCO2<25 to target pH 7.3-7.45
- I:E ratio 1:1 - 1:3
2) High PEEP (if FiO2 >=50%) - Target SpO2 88-95%, PaO2 55-80,
3) Prone (>12hr/day) - mort benefit when PF ratio <150
4) Sedation/Paralysis if:
- PF <150
- Vent asynchrony
- Not for mild or mod/severe on lung protective vent w/ light sedation
- Unclear mortality benefit: Recruitment maneuvers, ECMO, diuresis
- *No mortality benefit: Statin, steroids, inhaled NO (may improve oxygenation)
- **HARM: DO NOT do high-frequency oscillation