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
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
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
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)
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
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
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
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
