Intensive Care Flashcards
What are the levels of care?
- Pt needs met on normal ward, jobs >4hrly
- Pt at risk of deterioration, advice & support from CCT
- Pt requiring more detailed jobs/interventions, single failing organ, post-op care, basic response support, burns, neuro, renal support
- Pt requiring advanced resp support alone, support for 2 organ systems, multi-organ failure
Who can go to ICU?
- Potentially reversible clinical condition
- Underlying level of long-term health allowing pt to survive & benefit from critical care
- Some pre-planned following major surgery
What interventions can be given on ICU?
- Physiological control: constant monitoring, invasive intravascular monitoring, sedation & analgesia, glucose control
- Specific therapy: stopping iatrogenic issues
- VTE & ulcer prophylaxis
- Fluids
- Nutritional support
- Infusion of vasoactive drugs: Inotropes & vasopressors
- Mechanical organ support: Renal replacement therapy, ventilation, extracorporeal oxygenation
When would the critical care outreach team be called to review a patient?
NEWS >7
NEWS of >3 in any one parameter
What do NEWS scores correlate to in regards to monitoring?
0: Minimum 12hourly obs
1-4: LOW, minimum 4hourly obs
5/ 3in one parameter: MEDIUM, minimum 2hourly obs
7: HIGH, minimum, 1hourly obs
In ICU, which patients are candidates for organ donation?
DBD: Donation after brainstem death
e.g RTA w/serious head injury
DCD: Donation after circulatory death
e.g out of hospital cardiac arrest= widespread ischaemia
What is the mnemonic for what to check when monitoring/assessing a patient on ICU?
F- Feeding A- Analgesia S- Sedation T- Thromboembolic prophylaxis H- Head up U- Ulcer prophylaxis G- Glucose
What pathology can put someone in a coma?
A- Addison's/Alcohol/Arrhythmia E- Epilepsy/electrolytes/encephalopathy I- Infection O- Overdose/opiates U- Uraemia T-Trauma (head)/thyroid I- Insulin (sugars) P- Psych S- SDH, Stroke
What is the range for blood sugars in a query stroke?
3-22
When is sedation used?
- Allows patients to tolerate painful/distressing procedures (e.g. endotracheal intubation, invasive lines)
- Optimise mechanical ventilation (e.g. tolerate permissive hypercapnea)
- Used to decrease O2 consumption (e.g. sepsis)
- Decrease ICP in neurosurgical patients (results in immobility so limits metabolic requirements)
- Facilitate cooling (e.g. therapeutic hypothermia)
- Control agitation
Are there any side effects or complications of sedating someone?
hypotension respiratory depression arrhythmias drug specific effects sleep disturbance withdrawal delirium
What are the dose dependant effects of sedation?
Anxiolysis – Relief of apprehension or agitation with minimal alteration of sensorium
Amnesia – memory loss for a period of time
Analgesia – relief of pain without an altered sensorium
Anaesthesia – loss of sensation
What are the depths of sedation?
- Minimal sedation: anxiolysis only
- Moderate sedation: responsive to verbal/tactile stimuli, airway reflexes, spont ventilation, CV function maintained
- Deep sedation: responsive purposefully to repeated or painful stimuli; airway reflexes or spont ventilation may not be maintained, but CV function preserved.
- GA: state of unconsciousness & unresponsiveness such that the autonomic nervous system is unable to respond to surgical or procedural stimuli.
- Dissociation: cause a disconnection between the thalamoneocortical system and the limbic systems, preventing higher centers from receiving sensory stimuli. Airway reflexes, spontaneous ventilation, and cardiovascular function are all maintained.
How is death diagnosed?
- Respond to verbal stimuli
- Respond to painful stimui
- Fixed and dilated pupils (corneal reflex test)
- Feel for carotid pulse
- Auscultate for heart sounds for 2mins
- Auscultate for respiratory sounds for 3mins
What is the Monro-Kellie doctrine
- If other masses in the brain cavity
- Brain will push out CSF first then blood then the brain
- Dec blood: Cerebral ischaemia
- Dec brain: Coning
What is ARDS?
- Acute respiratory distress syndrome
- Non-cardiogenic pulmonary oedema and diffuse lung inflammation syndrome that often complicates critical illness
How is ARDS diagnosed?
1) Acute onset (within 1 week)
2) bilateral opacities on CXR
3) PaO2/FiO2 (inspired oxygen) ratio of ≤300 on PEEP or CPAP ≥5 cm H2O
What are the most common opportunistic infections?
- Candidiasis: Respiratory tract
- Kaposi’s sarcoma: Capillaries anywhere in body affected
- Pneumocystis carinii: Lungs
- Mycobacterium: Throughout the body
- Toxoplasmosis of brain
- Cytomegalovirus: Lungs, GI tract, brain, retina
- Cryptosporidiosis: GI tract
How is raised ICP managed? Reason for things..
- CSF drainage
- Raise head of the bed: Improve venous drainage
- Sedation: Dec anxiety/fear
- Steroids: Reduce oedema
- Mannitol: Dec blood viscosity, reduces cerebral parenchymal cell water, restoration of normal cellular resting membrane potential and cell volume
- Decrease PEEP
- Loosen ET tube ties: Inc venous cerebral outflow
What does intracranial pressure affect?
Cerebral perfusion pressure
Cerebral blood flow
What is the difference between haemodialysis and filtration?
Dialysis: Concurrent fluid of higher osmolarity than blood causes solutes/toxins to move out of the blood by DIFFUSION, quick- rapid change in patient, always has a small amount of filtration
Filtration: +ve Pressure in blood compartment & -ve pressure in dialysis compartment used to move fluid & solutes by CONVECTION across a semi-permeable membrane, independent of solute conc, takes a long time, used for ICU patients who need slower more stable change
What is PEEP?
Positive End Expiratory Pressure
Used to keep pressures in the lungs up during expiration so lungs don’t collapse= atelectasis
What are the indications for renal replacement therapy?
- Fluid overload (Diuretic resistant pulmonary oedema)
- Hyperkalemia (Resistant)
- Metabolic acidosis due to RF
- Uraemia: (pericarditis, encephalopathy, bleeding)
- Non-renal: Dialyzable intoxications (Li, OH, salicylates), temp control, resistant hyperNa, removal of inflammatory cytokines
What are patients given when having haemodialysis and why?
Heparin
Prevent formation of clots against the foreign surface.
What type of traumatic condition can send people into multi-organ failure rapidly?
Burns
What is a sign of urological organ failure?
Urine output <0.5mg/kg/hour for an adult
How does multi-organ dysfunction occur?
Cellular hypoxia
What is a sign of respiratory organ failure?
Supplementary oxygen
Ventilation
What are the drawing up doses of:
- Atropine
- Fentanyl
- Metaraminol
A: 1ml neat
F: 2ml neat
M: Dose made up to 10ml with NaCl
What are the common side effects of vasoactive medications?
Ephedrine: ↑HR & contractility, ↑BP, acts on alpha & beta receptors
Phenylepherine: ↑BP by vasoC, ↓ HR
Metaraminol: ↑BP by vasoC,
When would you give:
Ephedrine
Metaraminol/Phenylepherine
NorA, Adrenaline
E: Low BP & HR
M&P: Low BP, High HR
NorA/A: ICU, Sepsis
How is hypotension treated in ICU?
Noradrenaline
Adrenaline
Dobutamine
How is hypotension treated in surgery?
Ephedrine
Metaraminol
Phenylephrine
When is a tracheostomy used?
Patients
requiring
prolonged
airway
or
ventilatory
support.
Tolerated
better
than
ETTs
- provide
a
more
comfortable
airway
May
permit
withdrawal
of
sedation
and
aid
weaning
from
mechanical
ventilation.
Where is a tracheostomy placed?
Inserted
through
an
incision
between
the
tracheal
cartilaginous
rings.
The
cuff
is
then
inflated
to
form
a
seal
against
the
tracheal
wall
The
insertion
is
usually
observed
by
a
second
operator
using
a
bronchoscope
to
ensure
correct
stoma
and
tube
placement.
What are the early & late complications of a tracheostomy?
Early: Haemorrhage
, PT, Misplacement
, Surgical
emphysema
, Blockage
with
secretions
, Stomal
infection, Mucosal
ulceration
&
perforation, tracheo‐ oesophageal fistula
Late
Complications:
Late
haemorrhage
(erosion
into
innominate
artery)
, Tracheal
granulomata
, Tracheal
stenosis, Scarring,
Persistent
sinus
, Tracheal
necrosis
What is ECMO?
Extracorporeal membrane oxygenation
Used in acute, severe, reversible resp/cardiac failure w/high risk of death
Blood removed from the body, oxygenated by machine then returned
