Indications 2 Flashcards
1
Q
A
2
Q
Criteria for resolution of DKA are
A
- plasma glucose <11.1 mmol/L (<200 mg/dL)
- serum bicarbonate >18 mmol/L (>18 mEq/L)
- venous pH>7.3
- anion gap <10
3
Q
Indications of IV calcium in treatment of hypocalcemia
A
- symptomatic patients (carpopedal spasm, tetany, seizures)
- patients with a prolonged QT interval
- serum corrected calcium ≤7.5 mg/dL (1.9 mmol/L)
4
Q
Indications of dialysis in hypercalcemia
A
- serum calcium levels greater than 18 mg/dL (4.5 mmol/L) with:
** neurologic symptoms or
** acute kidney injury
5
Q
Methanol and ethylene glycol toxicity, dialysis indications
A
- Metabolic acidosis, regardless of drug level
- Elevated serum methanol or ethylene glycol levels (more than 50 mg/dL; or methanol 15.6 mmol/L, ethylene glycol 8.1 mmol/L), unless arterial pH is above 7.3
- Evidence of end-organ damage (eg, visual changes, renal failure)
6
Q
Renal indications for plasmapheresis
A
- TTP/HUS
- ANCA-associated rapidly progressive glomerulonephritis if associated with pulmonary hemorrhage or dialysis dependent patients
- Anti-glomerular basement membrane disease (Goodpasture’s syndrome)
- Catastrophic antiphospholipid syndrome (APS)
- kidney transplant: FSGS recurrence or Acute Antibody-mediated rejection in kidney transplant
- Myeloma cast nephropathy
7
Q
Indications for urgent dialysis
A
- Acid-base disturbances: Specifically, persistent metabolic acidosis (pH <7.1) refractory to conventional therapy.
- Electrolyte disorders: Mainly hyperkalemia with serum potassium concentration >6.5 mEq/L or rapidly rising potassium levels resistant to medical therapy; occasionally hypercalcemia or complications from tumor lysis syndrome.
- Specific drug and toxin intoxications that are dialyzable
- Fluid overload or congestive heart failure that is refractory to diuretics.
- Uremic symptoms such as pericarditis, neuropathy, an otherwise unexplained decline in mental status, or bleeding.
8
Q
Prerequisites for performing the apnea test
A
- Core body temperature >36.5°C
- Systolic blood pressure ≥90 mm Hg (may use intravenous fluids or dopamine to achieve)
- Eucapnia (PaCO2 approximately 40 mm Hg) if possible
- Normoxemia (PaO2 ≥200 mm Hg) if possible (typically 10 min at an FiO2 of 1.0 will achieve)
9
Q
Indications for ICP and CPP monitoring
A
- Patients with GCS <8 and an abnormal CT scan (i.e., hematoma, contusion, swelling, herniation, or compressed basal cisterns)
- Patients with GCS <8 and normal CT scan and at least two of the following on admission:
- Age >40
- Unilateral or bilateral motor posturing
- Systolic BP <90 mm Hg
10
Q
Indications for decompressive hemicraniectomy in acute stroke
A
- Clinical signs of MCA infarction, NIHSS score > 15
- Decreased level of consciousness, score ≥1 on item 1a on NIHSS
- CT infarct ≥50% MCA territory
** ± additional infarction of anterior/posterior cerebral artery on same side or
** Infarct volume > 145 cm3 on diffusion-weighted MRI
11
Q
Indication of ancillary testing
A
- After the first test to confirm indeterminate apnea test
- If significant doses of CNS depressants have been administered recently
- Toxic level of sedative drugs
- Severe facial trauma
- Pupillary abnormalities
- Severe chronic CO2 retention
12
Q
Surgical Intervention in ICH
A
- Cerebellar ICH that is ≥3 cm or causing brainstem compression
- ICH causing obstructive hydrocephalus leading to clinical/neurologic deterioration
- Posterior fossa hemorrhage >3 cm
- IVH causing hydrocephalus and necessitating EVD
- Complicated cases requiring ICP monitoring
13
Q
Indications for haemodialysis in salicylate overdose
A
- Serum concentration > 700 mg/L
- Metabolic acidosis resistant to treatment
- Acute renal failure
- Pulmonary oedema
- Seizures
- Coma
14
Q
Indications for fomepizole
A
- Serum concentration > 20 mg/dl
- Ingestion confirmed/suspected plus 2 of:
- Osmolar gap > 10 mOsm
- Arterial pH < 7.30
- HCO3− > 20 mmol/l ??
- Presence of urinary oxalate crystals
15
Q
Indications for hemodialysis in aspirin poisoning
A
- Cerebral or pulmonary edema
- Renal failure that interferes with salicylate excretion
- Severe acid-base or electrolyte disturbances despite appropriate therapy
- A plasma salicylate concentration of:
** 100 mg/dL (7.2 mmol/L) in cases of acute ingestion, or
** 60 mg/dL (4.3 mmol/L) in cases of chronic ingestion - Clinical or hemodynamic deterioration despite aggressive and appropriate supportive care
16
Q
Indications for IVC filters
A
- Acute venous thromboembolism (VTE), including deep vein thrombosis (DVT) or pulmonary embolism (PE), when anticoagulation is contraindicated (e.g., due to active bleeding or high risk for bleeding) [Strong Recommendation]
- Recurrent VTE despite adequate anticoagulation therapy [Strong Recommendation]
17
Q
Hemodialysis indications in patient with tumor lysis syndrome
A
- patients who are oliguric or anuric,
- have persistent hyperkalemia, or
- have hyperphosphatemia-induced symptomatic hypocalcemia.
18
Q
Indications for ICP monitoring in traumatic brain injury
A
- Any moderate-to-severe TBI (GCS < 12) who cannot be serially neurologically assessed, for example if sedated
- Any severe TBI (GCS < 8) with an abnormal CT head scan
- Any severe TBI (GCS < 8) with a normal CT head scan if 2 of the following are present:
- Age > 40 years,
- SBP < 90,
- Abnormal motor posturing
19
Q
King’s College Hospital criteria for liver transplantation (paracetamol liver failure)
A
- Arterial pH < 7.3, 24 hours after ingestion or
- all of the following:
- prothrombin time > 100 seconds,
- creatinine > 300 µmol/l,
- grade III or IV encephalopathy
20
Q
King’s College Hospital criteria for liver transplantation (non-paracetamol induced ALF)
A
- INR > 6.5 (PT>100 seconds) or
- any three of the following:
- Age <11 or >40 years,
- Etiology non-A, non-B hepatitis, or idiosyncratic drug reaction (i.e. not hyperacute),
- Time from onset of jaundice to encephalopathy >7 days,
- INR >3.5 (PT >50 seconds),
- Serum bilirubin >300 μmol/l
21
Q
Absolute contraindications to thrombolysis
A
- Any prior ICH
- Intracranial neoplasm, aneurysm, AVM
- Ischemic stroke or closed head trauma w/in 3 mo
- Head/spinal surgery w/in 2 mo
- Active internal bleeding or known bleeding diathesis
- Suspected aortic dissection
- Severe uncontrollable HTN
- For SK, SK Rx w/in 6 mo
22
Q
Relative contraindications to thrombolysis
A
- History of severe HTN, SBP >180 or DBP >110 on presentation (? absolute if low-risk MI)
- Ischemic stroke >3 mo prior
- CPR >10 min
- Trauma/major surgery w/in 3 wk
- Internal bleed w/in 2-4 wk
- Active PUD
- Noncompressible vascular punctures
- Pregnancy
- Current use of anticoagulants
- For SK, prior SK exposure
23
Q
Contraindications to Intraaortic Balloon Pump (IABP)
A
- Severe aortic regurgitation
- Aortic dissection
- Significant peripheral artery disease, including iliac artery stents and iliofemoral grafts/stents
- Active sepsis
- Active bleeding or bleeding disorders
24
Q
Contraindications to permissive hypercapnia
A
- Patients with acute cerebral disease: Permissive hypercapnia is generally avoided in patients with cerebral disease (eg, mass lesions, trauma, and cerebral edema) or a seizure disorder for several theoretical reasons outlined below. However, the data to support clinically impactful harm are poor
- Patients with coronary artery disease, heart failure, cardiac arrhythmias, or pulmonary hypertension with right ventricular dysfunction: Hypercapnia increases sympathomimetic output that may be poorly tolerated by patients who have cardiac disease. Beta blockade may limit the sympathomimetic effect of hypercapnia
- Patients with hypovolemia: Hypercapnia can induce systemic vasodilation, predisposing patients to hypotension (especially those who are hypovolemic). Hypovolemia should be corrected prior to the initiation of hypercapnic ventilatory strategies
25
Contraindications to prone ventilation
* Acute bleeding (eg, hemorrhagic shock, massive hemoptysis)
* Multiple fractures or trauma (eg, unstable fractures of femur, pelvis, face)
* Spinal instability
* Raised intracranial pressure >30 mmHg or cerebral perfusion pressure <60 mmHg
* Tracheal surgery or sternotomy within two weeks
26
Relative contraindications to prone ventilation
* Shock (eg, persistent mean arterial pressure <65 mmHg)
* Anterior chest tube(s) with air leaks
* Major abdominal surgery
* Recent pacemaker
* Clinical conditions limiting life expectancy (eg, oxygen or ventilator-dependent respiratory failure)
* Severe burns
* Recent lung transplant recipient
27
Indications for Initiation of ECMO (VV-ECMO)
* Hypoxemic respiratory failure due to any cause
* Hypercarbic respiratory failure
* Bridge to lung transplantation
* Surgeries requiring apnea
* Severe air leak
* ARDS/hypoxemic respiratory failure: P/F ratio <150 with Murray Score 2–3 correlates with 50% mortality
* P/F ratio <100 with Murray score 3–4 despite optimal care correlates with 80% mortality risk (ELSO)
* Carbon dioxide retention on mechanical ventilation despite high ventilating pressure (plateau pressure >30 cm H2O) with or without pH <7.15
* To help prevent intubation in a patient expecting lung transplantation
* Any sudden cardiac or respiratory collapse that is unresponsive to optimal care can be considered
[Link](https://drive.google.com/file/d/1Co-d3n-CC4saJFmb52RhnUCB1WhzhgHD/view?usp=drivesdk) [Link](https://drive.google.com/file/d/1MkLtAbSKmvQ4TmC-3sShn-TKiZnRL2BU/view?usp=drivesdk)
28
Indications for Initiation of ECMO (VA-ECMO)
* Refractory cardiogenic shock that persists despite adequate volume resuscitation or use of vasopressors & inotropes +/– intra-aortic balloon pump counterpulsation (ELSO), typical causes: massive PE, refractory cardiac arrest, fulminant myocarditis
* Bridge-to-heart transplantation or ventricular assist device placement
* Primary graft failure following heart transplantation
* Acute myocardial infarction
* Peripartum cardiomyopathy
* Septic shock with myocardial dysfunction can be an indication
29
Contraindications for Initiation of Extracorporeal Life Support (ECMO) - Strong Contraindications
* Extended mechanical ventilation (usually more than 7 days)
* Central Nervous System (CNS) catastrophes, including significant anoxic brain injury, diffuse axonal injury, massive intracranial hemorrhage, or herniation
* Irreversible lung disease not amenable to lung transplantation
* Unrecoverable heart condition and not a candidate for heart transplant or Ventricular Assist Device (VAD)
* Chronic severe organ dysfunction such as emphysema, cirrhosis, or renal failure
* Non-compliance due to psychosocial, financial, or cognitive issues, particularly in cases requiring a bridge to device or transplant
[MCQs](https://docs.google.com/document/d/1X6uKQQEpNqnHDuQBBC4U8fyGdw6TnL9iaWtZBrfx2ZI/edit?usp=drive_link)
30
Relative contraindications for initiation of extracorporeal life support (ECMO)
* Age over 70 years
* Immunocompromised state from solid-organ or stem-cell transplant, solid-organ or hematologic malignancy, chronic immunosuppressive therapy, HIV/AIDS, or inherited immunodeficiency syndromes
* Chronic CNS deficit or unknown CNS status
* High risk for anticoagulation
* Multisystem organ dysfunction syndrome
* Patient is not a candidate for lung or heart transplant or VAD due to poor social support, severe aortic insufficiency, or preexisting renal failure
31
Indications for elective surgical repair in patients with AAA
* AAA >5.5 cm
* saccular aneurysms
* symptomatic (back pain, abdominal pain)
[MCQs](https://docs.google.com/document/d/1mApwsjoxZhDeabht4T8Bo_vtqwks8s7p-NuvJUiUJqU/edit?usp=drive_link)
32
Consider head CT to r/o mass effect before LP if
* age>60 y, immunosupp.
* h/o CNS disease
* new-onset seizure
* change in MS
* focal neuro findings
* papilledema
Absence of all these has NPV 97%; however, in Pts w/ mass effect, herniation may occur w/o LP and may not occur even w/ LP
[MCQs](https://docs.google.com/document/d/14oSnrXaqXmplmW-RVK9YIGGj1_VrNgcbiDrt7TgVUBE/edit?usp=drivesdk)
33
LP contraindications
* Possible raised intracranial pressure
* Thrombocytopenia or other bleeding diathesis (including ongoing anticoagulant therapy)
* Suspected spinal epidural abscess
34
Subtotal colectomy in Clostridium difficile colitis
* Toxic megacolon
* Perforation
* Progressive dz not likely to respond to medical therapy alone
35
Indications for surgical consultation in the management of CDI
* Hypotension with or without required use of vasopressors
* Fever ≥38.5°C
* Ileus or significant abdominal distention
* Peritonitis or significant abdominal tenderness
* Mental status changes
* WBC ≥20,000 cells/mL
* Serum lactate levels >2.2 mmol/L
* Admission to intensive care unit for CDI
* End organ failure (mechanical ventilation, renal failure, etc.)
* Failure to improve after three to five days of maximal medical therapy
36
Intravenous catheter-related infections: when to remove
* Severe sepsis
* Suppurative thrombophlebitis
* Endocarditis
* Bloodstream infection that continues despite seven days of appropriate antimicrobial therapy
* Hemodynamically unstable conditions
* Tunnel or pocket infection
* Metastatic infection (osteomyelitis)
* Infections associated with the following organisms: Staphylococcus aureus, Pseudomonas aeruginosa, Fungi (e.g., Candida), Mycobacteria - In the case of Enterococcal infection, short-term catheters should be removed; for long-term catheters, salvage may be attempted
[MCQs](https://docs.google.com/document/d/1shYKjGFaAWtP2EhzvDsr5v6txf5vmh0mWRkfC9M8iDw/edit?usp=drive_link)
37
Indications for surgery in infective endocarditis
* Refractory heart failure due to severe valvular dysfunction
* Uncontrolled infection (e.g., periannular abscess, persistent sepsis)
* Infection by resistant organisms (e.g., S. aureus, fungal species)
* Recurrent systemic emboli or large vegetations with severe AI/MR
* Prosthetic valve complications (e.g., dysfunction, dehiscence)
* Aortic abscess indicated by lengthening PR interval
[Link](https://drive.google.com/file/d/139QJtDkFlKBZC8Lpb_gBELpCCRDFxs6_/view?usp=drivesdk) [MCQs](https://docs.google.com/document/d/1LvppeaxwzRPuVuR7PQGa-K2vR5oxBA2q8dzpmimk06U/edit?usp=drivesdk)
38
Limitations of PPV and SVV
* Spontaneously breathing patients
* Low tidal volumes (< 8 ml/kg)
* Arrhythmias
* ?Intra-abdominal hypertension
* RV failure/ pulmonary hypertension
* Need arterial catheter
[MCQs](https://docs.google.com/document/d/1kzs8D-A905YbUsme4a4L7RMjJ-P3jvs_1MlBbfAysm8/edit?usp=drive_link)
