Intensive Care Flashcards
What are the long-term complications of prolonged intensive care admission?
SS_IC 1.11
How do you manage a brain dead patient awaiting organ donation?
SS_IC 1.13
- Lost SNS
- resus fliod
- vasopressin (0.01-0.04 units/min) or Norad - DI
- DDAVP - Ventilation
- Vt / PEEP/ sat >92%
- regular chest physio - VTE prophylaxis
- Gastric aspirates
6.
What is the difference between sepsis, septic shock, and systemic inflammatory response syndrome (SIRS)?
SS_IC 1.15
- sepsis as life-threatening organ dysfunction secondary to a dysregulated host response to infection
- organ dysfx =
SOFA score inc by 2+ (10% inc in in-hospital mortality) - 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
What are the principles of managing sepsis according to the ‘Surviving Sepsis’ guidelines?
SS_IC 1.19
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
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.
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
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%)
VAP - HAP after > 48h after intubation
Considered:
1. CXR infiltrates +
- purulent secretion
- WCC >12 <4
- Fever > 38
- aspiration from the *nasopharynx,
- local spread and
- haematogenous spread of *infection.
Prevention
1. Avoid/min intubation
2. Prevent aspiration
3. Reduce colonisation
- hand wash
- limit abx use
- Change ventilator circuits q1week
- avoid relxants
- remove NGT
- Oral > nasal intubation
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)
- Defn
- Features
- Strategies
- TV
- RR
- end exp pressure
- PaCO2
- Paw
Rx
1. NO
2. Neb PG
3. Fluid -liberal vs restriction
Trials
1. ARMA 2000
- low TV
2. FACTT 2006
- fluids
-
What are the principles of managing acute pancreatitis in the ICU?
SS_IC 1.93
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
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.
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
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
DI
Polyuria polydipsia
Dilute urine
1. Low SG <1.005
2. Low URINE osmo <200 mOsmol/kg
3. High SERUM osmo >285 mOsmol/kg
- NDI
- CDI
- GDI
P. 741
What are the principles of postoperative care of the renal transplant recipient?
SS_IC 1.73
- Fluids
- Haemodynamics
- Analgesia - PCA
How do you manage a brain dead patient awaiting organ donation?
SS_IC 1.13
A: ETT
B: VT 6-8mL/kg
C:
What complications may occur after partial hepatectomy and how do you manage them?
SS_IC 1.95
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
What are the principles of managing thyroid storm in ICU?
SS_IC 1.77
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
What are the principles of managing adrenocortical insufficiency in ICU?
SS_IC 1.77
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
