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Final Exam > Intensive Care > Flashcards

Intensive Care Flashcards

1
Q

What are the long-term complications of prolonged intensive care admission?

SS_IC 1.11

A
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2
Q

How do you manage a brain dead patient awaiting organ donation?

SS_IC 1.13

A

CVS/Resp/Renal/Liver/Endo

  1. Lost SNS (BS herniation)
    - resus fliod
    - vasopressin (0.01-0.04 units/min) or Norad
  2. DI (pituitary ischaemia)
    Def:
    a) UO >4ml/kg/h
    b) SNa >145mmol/L
    c) Sosm > 300
    d) Uosm < 200
    = fluid loss + electrolyte disturbance
    - - Rx - DDAVP
  3. Ventilation
    - Vt / PEEP/ sat >92%
    - regular chest physio
  4. VTE prophylaxis
  5. Gastric aspirates

Inc ICP
- cushing’s
- brady/hypotension

https://academic.oup.com/bjaed/article/12/5/225/289066

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3
Q

What is the difference between sepsis, septic shock, and systemic inflammatory response syndrome (SIRS)?

SS_IC 1.15

A
  1. sepsis as life-threatening organ dysfunction secondary to a dysregulated host response to infection
  2. organ dysfx =
    SOFA score inc by 2+ (10% inc in in-hospital mortality)
  3. Septic shock should be defined as a subset of sepsis in which particularly profound *circulatory, *cellular, and *metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.

Clinical:
1. Vasopressor to MAP>65 AND
2. lactate > 2mmol/L with no hypovolaemia (mort > 40%)

SIRS vs sepsis
SIRS - APPROPRIATE host response

SIRS (MCQ)
2+
1. Temp >38 or <36
2. HR > 90
3. RR >22 or PaCO2 < 32
4. WCC > 12 or < 4

qSOFA - prompt ix / screen for sepsis
- RR > 22
- Altered mentation
- sBP < 100

Source:
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) 2016

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4
Q

What are the principles of managing sepsis according to the ‘Surviving Sepsis’ guidelines?

SS_IC 1.19

A

SS 2021

MAP > 65

qSOFA bad

Abx <1hr if
- sepsis is definite
- sepsis probable with shock

**Vasopressor
1st - norad (strong)
weak
- IAL
- peripheral vasopressor
- 2nd - vasopressin
- adrenaline/dobutamine - cardiac dysfx

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5
Q

How would you ventilate a severely hypoxic asthmatic patient?

SS_IC 1.48

ICU – severe asthma intubation/ventilation

[07B07] A 25-year-old, 65kg woman with acute severe asthma requires intubation and ventilation. Explain the problems associated with initiating ventilatory support in this patient and describe how you would overcome them.

A

Issues
1. consent (distressed)
2. Not fasted
3. ?Resp failure
4. ?infection
5. SE to asthma rx
- b-blocker - tachy, acidosis
6. Remote location ED
7. Issue when intubate

Path
1. Dynamic hyperinflation
- autoPEEP –> inc ITP –> dec VR
2. Flattening of diaphram
- hyperinflation
- poor TV
3. V/Q mismatch-
- inc zone 1

Intubate
if significant dec VR –> cardiac arrest!

Vent target
1. Large ETT
2. Low FiO2 for SpO2 90-92% - hyperoxia - bad - lose hypoxic drive
3. VCV
4. TV small 4-6mL/kg
5. Low RR (10)
6. Low I:E (1:3-4)
7. PEEP - zero to min
8. Permissive hypercap (tit to pH < 7.3)
9. Pplat < 25cmH2O (alv hyperinfl)
10. Paralysie, sedate, VA, heliox

Rx
1st tier
- O2 90-92%
- neb b-agonost
- neb antichol
- steroid

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6
Q

How does ventilator-associated pneumonia develop and what are the risk factors? What prevention strategies can you use to reduce the incidence of VAP?

SS_IC 1.51

[13B14] Intensive care patients may be at risk of ventilator-associated pneumonia (VAP).

a) Describe the likely aetiology of, and risk factors for, VAP. (50%)

b) Outline prevention strategies that reduce the incidence of VAP. (50%)

A

VAP - HAP after > 48h after intubation
Considered:
1. CXR infiltrates +
- purulent secretion
- WCC >12 <4
- Fever > 38

  1. aspiration from the *nasopharynx,
  2. local spread and
  3. haematogenous spread of *infection.

Prevention
1. Avoid/min intubation
2. Prevent aspiration
3. Reduce colonisation

  1. hand wash
  2. limit abx use
  3. Change ventilator circuits q1week
  4. avoid relxants
  5. remove NGT
  6. Oral > nasal intubation
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7
Q

What is Acute Respiratory Distress Syndrome (ARDS) and how is it treated?

SS_IC 1.55

ICU - ARDS

[12A10] An adult patient from the intensive care unit with severe adult respiratory distress syndrome (ARDS) requires a laparotomy for an acute abdomen.
a) What are the features of ARDS? (30%)
b) Explain your perioperative ventilation strategy. (70%) …(also 07A01)

A
  1. Defn
  2. Features
  3. Strategies
  4. TV
  5. RR
  6. end exp pressure
  7. PaCO2
  8. Paw

Rx
1. NO
2. Neb PG
3. Fluid -liberal vs restriction

Trials
1. ARMA 2000
- low TV
2. FACTT 2006
- fluids
-

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8
Q

What are the principles of managing acute pancreatitis in the ICU?

SS_IC 1.93

A

Cause:
1. Biliary (35-40%)
2. EtOH (35%)

Ranson criterea

Scoring

*extent of necrosis
*risk of infected necrosis

Mx
Imaging

Fluid therapy

Surgery
- ERCP

Pharm
- somatostatin/octreotide

TPN/EN

Oh’s 8th Ed P. 570

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9
Q

How do you manage a patient who has survived a near drowning?

SS_IC 1.102

ICU – CPR from drowning

[07A13] Ambulance officers are performing CPR with bag and mask ventilation on a young female who has been rescued from a swimming pool.
a) Describe how basic life support should be provided in the emergency department if she has no pulse and her ECG shows ventricular fibrillation.
b) Outline the advanced life support algorithm you would follow.

A

Hx

Ex

Ix

CVS

Resp support

Cerebral protection

Oh’s 8th Ed P.970

=====

VF post drowning

BLS

ALS

+ Wet consideration
1. Hypothermia -
2. AED - dry chest

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10
Q

How do you diagnose and manage disorders of sodium haemostasis such as Diabetes insipidus and cerebral salt wasting in ICU patients?

SS_IC 1.87

A

DI
Polyuria polydipsia

Dilute urine
1. Low SG <1.005
2. Low URINE osmo <200 mOsmol/kg
3. High SERUM osmo >285 mOsmol/kg

  1. NDI
  2. CDI
  3. GDI

P. 741

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11
Q

What are the principles of postoperative care of the renal transplant recipient?

SS_IC 1.73

A
  1. Fluids
  2. Haemodynamics
  3. Analgesia - PCA
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12
Q

How do you manage a brain dead patient awaiting organ donation?

SS_IC 1.13

A

A: ETT
B: VT 6-8mL/kg
C:

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13
Q

What complications may occur after partial hepatectomy and how do you manage them?

SS_IC 1.95

A

Liver fx
Pain

Post op liver insuff
1. COAG
2. ENCEPH
–> timing of epi cath remove –> FFP cover

Postop renal dysfx
Hypogly
sepsis
IA infection

Oxf Anaes P.706

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14
Q

What are the principles of managing thyroid storm in ICU?

SS_IC 1.77

A

Life threatening exacerbation of hyperthyroid state
+
Decomp 1+ organ system

Sx
1. Fever
2. Sweating
3. ST >140bpm
4. coma
5. N/V/D

Mx
1. Rehydrate IV fluids
2. Hyperthermia - sponge + paracetamol
3. Propranolol 1mg increment to 10mg OR esmolol
4. Hydrocortisone 200mg IV QID (ADRENAL INSUFF)
5. PTU - inhibit TSH

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15
Q

What are the principles of managing adrenocortical insufficiency in ICU?

SS_IC 1.77

A

Steroid replacement!
1. Hydrocort**
2. Fludricort for aldosterone

Adrenal crisis
1. Hypotension
2. Low Na
3. High K
4. Low sugar
5. Abdo pain

Mx
1. IVfluid + glucose
3. cortisol + ACTH prior hydrocort

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16
Q

ICU – pneumonia / T1RF

[21B03] You have just intubated a patient who has respiratory failure due to severe bacterial pneumonia. They remain hypoxaemic with an SpO2 of 82%. Describe your immediate actions and justify your strategies to improve oxygenation whilst awaiting the patient’s retrieval to a tertiary centre.

A

PR 83.6%

Cause of hypoxaemia
- Fi H vs D

Causes
1. Pt
- V/Q mismatch
- Atelectasis
- Bronchospasm
- Hypotension
- Anaphylaxis
- PTX
- PE

  1. Anaes
    - ETT
    - inadequate FiO2
17
Q

ICU - NIV

[19B06] Discuss the advantages and disadvantages of non-invasive ventilation (NIV) methods in the intensive care unit.

A

Pros
1. Avoid intub
2. Ease/simple
3. Certain demo (COPD, CCF, OSA, chest trauma)

  • communication
  • lower nursing ratio
  • Humified

Cons
1. Pt coop
2. No AW protect
3. CI (unrx PTX, resp arrest, life threatening hypoxaemia)

  • seal
  • mask leak
  • facial pressure
  • delay intubation
  • aerosolisation
18
Q

ICU – Transport ventilator features (in ARDS)

[17B15] Describe the features you require of a transport ventilator for a patient with severe ventilator-dependent acute respiratory distress syndrome.

A

Key:
- Transport
- ARDS

ARDS vent strat + modes
1. PCV

  1. lung p
  2. ## improve O2

ARDS setting + portability
1. Vent setting
- modes - PCV/VCV
- Fio2
- gas flow
- fx on RA > compressed gas
- P/V sensors
- Alarms

  1. Connectors
  2. Durability - compact/microprocessor
  3. Lightweight/portable
  4. Battery
  5. Min maintenance
19
Q

ICU - oliguria

[18A09] An 80-year-old man is admitted to the high dependency unit following laparotomy for relief of a large bowel obstruction. He has a urinary catheter in situ. Three hours later he remains oliguric. (same as 12A03)

What are the potential causes of oliguria in this patient? (50%) How would you differentiate between these causes? (50%)

A

91.1%
Potential pathologies
DIfferentiate - pre/intra/post

Pre
1. Hypoperfusion
- fluid responsiveness
- CO

Intra
1. Nephrotoxin (NSAID, contrast, abx)
- Hx/Ex/records/charts
2. Inflammation
- sepsis markers

Post
1. Obstruction
- IDC check, CT KUB, US KUB

20
Q

ICU - TPN

[12B07] In regard to total parenteral nutrition (TPN): a) What are the indications? (30%)
b) What are the complications? (70%)

A

34.9%

A) Indication
- Malabsorption
- Muscle wasting
- Wound healing

B) Complication
1. Delivery
- insertion - bleeding etc
- late - thrombus, infection
2. Metabolic
- Refeeding
- Overfeeding
- Volume
- Sugar

21
Q

ICU - hypothermia
[10B01] … (also 04B01)

a) What are the clinical consequences of hypothermia to 340C in adults? (50%)

b) How can you manage body temperature in a multi-trauma patient? (50%)

20A03 consequence of peri-op hypothermia

A

20A03 = 48.6%.
Poorly answered. Need to discuss

  1. potential MI or conduction issues,
  2. increased infection rates,
  3. inc blood loss,
  4. altered metabolism.

CVS
- potential MI
- conduction - QT prolong, J wave, bradycardia

Resp

CNS
- dec CBF CMRO2
- impaired conscious

Renal
- cold diuresis (dec ADH)

Immune
- dec cytokines, WCC –> inc infection

Haem
- Blood loss (Coagulapathy)

METABOLIC
1. Dec BMR
2. Met acidosis
3. inc catecholamine –> inc BGL

Maintain body temp
1. Dry
2. Limit exposure
3. Inc amb temp
4. Prewarm
5. Passive - blanket
6. Active - FAW, warm flush, heater, matress, lavage, ECMO

22
Q

ICU - DKA

[10B13] Outline the principles of an initial management plan for diabetic ketoacidosis, having regard to the physiological derangements involved.

A

Diabeetus -
D - BSL >11
K - ketone 2+ or >3mmol/L
A - pH < 7.3 or bicab < 15

Path
INSULIN DEFICIENT –> above
D: inc GLUCONEO, dec gluc use
K - inc glucagon, cortisol, GH –> FFA –> ketone
A: ketone disso –> H+

Mx
1. Fluid resus (renal loss - hypergly) - 10ml/kg/hr
2. Replace electrolyte
3. Insulin - REVERSE fat catabolism and ketone production (0.1u/kg/hr)
+ IV glucose
4. Supportive vent if metabolic acidosis ++

Aim
ketone <0.6
glucose inf when BSL <14

Cause!
1. Infection
2. Non-comp insulin
3. New T1DM

23
Q

ICU – Bacterial endocarditis

[09B09] a) What are the indications for prophylaxis against perioperative bacterial endocarditis? (50%) b) Justify your choice of antibiotics. (50%)

A

Indication
- previous endo
- CHD
- prosthetic valves
- cardiaa tx with valvuloplasty

  • dental - gum/breach cavity
  • GI/uro dx procedure in presence of infection
  • T+A - resp tract mucosa

Choices
1. Dental - strep virians –> amp/ceph/clinda

  1. Resp
    - as per dental
    - ?staph aureus –> flucox/ceph/vanc - depend on sens
  2. GI/uro - enterococci –> amp/vanc
24
Q

ICU ECMO

Outline indications for use of ECMO in respiratory failure and outline principles of delivery of ECMO

A

VV ECMO
- RESP FAIL despite max vent mx

  1. ARDS
  2. COPD
  3. Bridge to TXP

Complete pulm support
1. Removed Co2
2. Limit develop of VILI

VA ECMO
Cardiac failure refrac cardiogenic shock
AMI (80%)
Massive PE

HD + resp support (full CPB)

Indication
1. Rescue therapy
2. Bridging therapy
a) Recovery - ARDS
b) Transplant (H / L)
c) Adv Rx - per LVAD

https://resources.wfsahq.org/atotw/basics-of-ecmo-part-1/

https://resources.wfsahq.org/atotw/basics-of-ecmo-part-2/

Final Exam (28 decks)

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