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ICU OSCE > Indications 2 > Flashcards

Indications 2 Flashcards

1
Q
A
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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

MCQ

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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)
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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
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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)

Link

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6
Q

Renal indications for plasmapheresis

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  • 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
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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.
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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)
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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

MCQs

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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
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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
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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
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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
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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
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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
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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.

MCQs

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

MCQs

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

MCQs

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
Q

Contraindications to prone ventilation

A
  • 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
Q

Relative contraindications to prone ventilation

A
  • 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
Q

Indications for Initiation of ECMO (VV-ECMO)

A
  • 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 Link

28
Q

Indications for Initiation of ECMO (VA-ECMO)

A
  • 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
Q

Contraindications for Initiation of Extracorporeal Life Support (ECMO) - Strong Contraindications

A
  • 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

30
Q

Relative contraindications for initiation of extracorporeal life support (ECMO)

A
  • 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
Q

Indications for elective surgical repair in patients with AAA

A
  • AAA >5.5 cm
  • saccular aneurysms
  • symptomatic (back pain, abdominal pain)

MCQs

32
Q

Consider head CT to r/o mass effect before LP if

A
  • 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

33
Q

LP contraindications

A
  • Possible raised intracranial pressure
  • Thrombocytopenia or other bleeding diathesis (including ongoing anticoagulant therapy)
  • Suspected spinal epidural abscess
34
Q

Subtotal colectomy in Clostridium difficile colitis

A
  • Toxic megacolon
  • Perforation
  • Progressive dz not likely to respond to medical therapy alone
35
Q

Indications for surgical consultation in the management of CDI

A
  • 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
Q

Intravenous catheter-related infections: when to remove

A
  • 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

37
Q

Indications for surgery in infective endocarditis

A
  • 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 MCQs

38
Q

Limitations of PPV and SVV

A
  • Spontaneously breathing patients
  • Low tidal volumes (< 8 ml/kg)
  • Arrhythmias
  • ?Intra-abdominal hypertension
  • RV failure/ pulmonary hypertension
  • Need arterial catheter

MCQs

ICU OSCE (19 decks)

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