Intensivtherapie (insb. Covid) Flashcards by Kateryna Goloshchapova

prophylaxis of deep venous thrombosis

LMH s.c. enoxaparin 4000 UI/d, in case of overweight 6000 UI/d, & obesity 4000 UI 2x/d, GFR < 30 ml/min UFN 5000 UI 2x/d, hight risk of bleeding intermittent pneumatic compression (evidence???)

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Prophylaxis of stress ulcers

Mucosal injury: 75-100% in endoscopic studies (risk factor: respiratory failure, coagulopathy, liver disease, renal replacement therapy // protective factor: enteral feeding)
occult bleeding: 5-25 %
clinically important bleeding: 1.5 %

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prophylaxis of stress ulcer

benefit: protects against clinically important bleeding
risk: increases the incidence of C. difficile
low risk patient: no prophylaxis
high risk patients: mechanical ventilation > 48 h, ICU stay > 7 d, coagulopathy, dual antiplatelet therapy, occult bleeding > 6 d, sepsis, high dose steroids, renal replacement therapy

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ROX index

(saturation * FiO2)/respiratory rate

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ROX index:

in patients with acure respiratory failure (ARF) and pneumonia, the ROX index can identify patients at low risk for HFNC failure in whom therapy can be continued after 12 hours

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English-German

PPE: personal protective equipment 
to don: anziehen
to doff: ausziehen
gown: das Kleid 
apron: Schürze 
goggles: Schutzbrille
snuggly: kuschlig 
redeployment: Umgruppierung 
commence: beginnen 
jaw thrust: Kiefer-Handgriff

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What is the primary parameter to recognize a respiratory deterioration?

respiratory rate 
inability to talk in full sentences 
use of accessory muscles of breathing 
saturation 
increased requirement of supplementary oxygen 
late: cyanosis, drowsiness

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symptoms of respiratory failure

air hunger
chest tightness
inability to breathe deeply

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pathophysiology of respiratory failure

type 1 respiratory failure: problem of a gas exchange

type 2 respiratory failure: problem of hypoventilation

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etiology of type 1 respiratory failure

pneumonia
heart failure, pulmonary edema
asthma (leichte Stadien)
pulmonary embolism (Perfusions-Diffusions-Mismatch)

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etiology of type 2 respiratory failure

opiate toxicity: reduced respiratory drive
iatrogenic over-oxygenation in patient witho metabolic compensation of hypercapnia
neuromuscular disease
reduced chest wall compliance
increased airway resistance
severe impairment of gas exchange in COPD

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Covid-19 symptoms

14% type 1 respiratory failure (dyspnoe is disproportionately mild relative to the severity of disease)
5 % critically unwell

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pathophysiology of the respiratory syndrome in covid-19 infection

early phase: damage of the pulmonary blood vessels –> impaired transfer of oxygen –> oxygenation via nasal cannula
late phase: typical ARDS –> mechanical ventilation

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symptoms of respiratory distress

chest tightness
inability to breath deeply
anxiety

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target SpO2 during the covid-19 pandemic

92-96 % (sufficiently to alleviate dyspnoea and maintain tissue oxygenation, avoiding the potentially harmful effects of hyperoxia and conserving hospital oxygen supplies) for type 1 respiratory failure
88-92 % for type 2 respiratory failure

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Choice of respiratory support in type 1 respiratory failure

nasal cannula: 1-6 L/min, FiO2 25-50%
simple face mask: 5-10 L/min, FiO2 40-60%
reservoir mask: 15 L/min FiO2 60-90 %
nasal high flow oxygen: up to 70 L/min, FiO2 up to 100 %
CPAP: 15 L/min, up to 100 % FiO2

treatment of type 1 respiratory failure (T1RF)

increasing the fraction of inspired oxygen (FiO2)
applying positive end expiratory pressure (PEEP) by means of CPAP: opens the lower airways and increases the surface area
proning: minimizes ventilation/perfusion mismatch

What is the benefit of venturi mask?

It delivers a precise FiO2 in patients who are susceptible to T2RF

contraindication of CPAP

agitated, uncooperative patient
rediced condcious level with inability to protect airway
facial burns or trauma
persistent vomiting
unstable cardiorespiratory status or respiratory arrest
copious respiratory secretions
nond-drained pneumothorax

Targtets to treat type 2 respiratory failure (T2RF)

increasing the minute centilation: product of respiratory rate and tidal volume

increasing the respiratory rate: beyond a certain level, further increases of respiratory rate do not clear more carbon dioxide due to dead-space ventilation of airways
increasing of tidal volume

Indication of Non-invasive ventilation: high level of evidence

hypercapnic COPD exacerbation

pulmonary edema,

physiologic inspiratory negative pressure

-4…-5 cmH2O

Define a CPAP

airway pressure remains positive during the entire breathing cycle through the application of a certain level of positive end-expiratory pressure

Difference of CPAP and NIV

during CPAP the patient breathes spontaneously and does all the work of breathing

Why do not use CPAP mode on a ventilator connected to helmet?

because of the risk of CO2 rebreathing

CPAP nach Boussignac

In einem speziell geformten Kunststoffzylinder wird das Beatmungsgas durch seitliche Kanäle geführt. Durch die Verjüngung der Kanäle in distaler Richtung erhöht sich die Strömungsgeschwindigkeit des Gases. Aus den Kanälen wird das Beatmungsgas mit dieser hohen Geschwindigkeit in das Zentrum des Zylinders geleitet und verwirbelt dort. Dieser Wirbel erzeugt einen steuerbaren Druck, dass virtuelle Ventil, durch welches der Patient ohne einen zusätzlichen mechanischen Widerstand ausatmen kann. Das System ist auf diese Weise jederzeit offen und gewährleistet gleichzeitig auf der Patientenseite den gewünschten positiven Druck. Zusätzlich wird der erzeugte Druck über ein Nebenstromverfahren gemessen und der Wert auf einem Manometer dargestellt. Die Orientierungsgröße für den gewählten Druck ist dabei der Wert zum Ende der Exspiration, der PEEP. Die Größe des PEEP hängt hierbei von der Menge des zugeführten Gases ab. Eine Einstellung des PEEP erfolgt bei CPAP nach Boussignac einzig über die Regulierung der Durchflussrate des Beatmungsgases. Der PEEP kann somit stufenlos an die Bedürfnisse des Patienten angepasst werden. Es sind keine unterschiedlichen Ventile für die verschiedenen PEEP-Werte notwendig.

Principle of noninvasive positive pressure ventilation (NIPPV)

requires mechanical ventilator during expiration keeps a preset PEEP level during inspiration provides a preset level of positive pressure the patient and the ventilator share the work of breathing

contraindications of NIPPV

``` coma inability to clear secretions haemodynamic instability and shock gastroenteric non controlled bleeding recent upper GI or airways surgery problems in device positioning, intolerance ```

Which monitoring during NIV?

clinical evaluation heart reat, blood pressure, ECG SpO2 BGA, lactate

Which monitoring during NIV?

clinical evaluation: vital signs, mental status, skin, capillary refill heart reat, blood pressure, ECG SpO2 BGA, lactate

Prediction of NIV failure

``` HACOR score: Heart rate acidosis consciousness oxygenation respiratory rate if >=5 after 1 h of NIV: highly predictable for NIV failure ```

Risk of NIV

Risk of the contaminations, viral mask may be applied

Predict difficult airway

``` 5 mallampati score III or IV 2 OSAS 1 reduced mobility of cervical spine 1 limited mouth openin < 3 cm 1 coma 1 secere hypoxemia < 80 % 1 nonanesthesiologist ```

ARDS: Definitionskriterien

1. respiratorische Insuffizienz binnen 7 d nach angenommenem Erstereignis 2. Horowitz < 300 3. bipulmonale Infiltrate im CXR bei Ausschluss vom kardialen Lungenödem