Lecture 20-21: critical care Flashcards
what is critical care?
complex med management of seriously ill/injured person
lvl of illness/injury involves:
acute impairment of >/= one vital organ system, high probability of life threatening deterioration of pt condition, support of organ systems to prevent failure of body systems
prevent failure of which body systems?
CNS, circ, renal, hepatic, metabolic, resp, shock
types of ICUs in Canada
general med/surgical, specialized, pediatric/neonatl
____ model of care for ICU most common because:
closed; smaller and have one intensivist there that refers out
Canadian ICU have ___% mortality rate and ___% need invasive mechanical ventilation
9; 33
what is invansive mech ventilation?
endotracheal intubation
what is non-invasive mech ventilation?
BiPAP
a clinical (inflammatory) response to nonspecific insult of either infectious or noninfectious origin
SIRS
inflammatory cascade is complex process involving ___ and ___ responses, complement, and ___ cascades
humoural; cellular; cytokine
possible causes of SIRS?
ischemia, inflammation, trauma, infection, multiple insults
SIRS criteria defined as 2+ of following:
temp >38 or <36, elevated HR, resp rate high or PaCO3 low, WBC high or low
sepsis is response to ___
infection
severe sepsis is systemic response to infection + ________
organ dysfunction ,hypoperfusion, hypotension
septic shock is persistent hypotension and perfusion abnormalities despite ______
adequate fluid resuscitation
state of physio derangements in which organ fxn not capable maintainng homeostasis
multiple organ dysfunction syndrome (MODS)
metabolic response to stress is driven by:
macrophage activation, counter regulatory hormones, more pro inflammatory cytokines
metabolic response to stress involves liver doing _____
gluconeogenesis
shock phase characterized by:
conservation of energy and blood volume
shock phase needs this kind of resuscitation:
aggressive fluid resuscitation, vasopressor therapy, mechanical ventilation, early antibiotic therapy
catabolic phase is characterized by:
^ immune/inflamm response, catabolic response
goal in catabolic phase?
mobilization of energy stores
what happens in ICU in catabolic phase?
immobilization/bedridden, sedation, neuromusc blockade agents, corticosteroids, hyperglycemia and anabolic resistance
recovery phase often coincides with _____
liberation from mechanical ventilation and discharge from ICU
shock phase also called:
ebb phase
catabolic phase also called:
flow phase
flow phase consists of ___ phase and __ phase
acute; post-acute
acute phase composed of these two periods:
early period and late period
early period defined by:
metabolic instability and severe increase in catabolism
late period defined by:
significant muscle wasting and stabilization of metabolic disturbances
low muscularity is associated with:
^ mortality, v ventilator free days, ^ ICU and hospital LOS
head to toe assessment of critically ill pt involves:
neuro, resp, cardio, GI, genitourinary, infectious diseases, physical assessment
propofol is a ___ suspended in ___% lipid emulsion
sedative; 10
units to use for propofol:
kcal/mL
how to calculate mL/h for propofol?
dose (mcg/kg/min) x actual body wt (kg) x 60 min/g / 10 000 mcg/mL
what is APACHE II?
acute physiology and chronic health evaluation II score
APACHE 2 was developed to estimate ___ and is commonly reported in ____
ICU mortality; research
APACHE II is based on variables in first ___h of ICU admission, such as:
24; age, temp, MAP, pH, HR, RR, Na, K, Creat, Hct, WBC, etc
in APACHE II there are scores ranging from __ to ___
0; 77 (> = more severe)
what is SOFA?
sequential organ failure assessment score
what SOFA used for?
determine extent of organ fxn/rate of failure
SOFA is based on these 6 organ dysfunction indicators:
resp, neuro, cardiac, liver, coagulation/liver, kidney
score range of SOFA?
0-24 (>=worse)
what is NUTRIC score?
nutrition risk in critically ill score
NUTRIC score used to measure:
risk of critically ill pt whose neg outcomes could be modified thru aggressive nutr therapy
6 variables of NUTRIC?
age, APACHE II, SOFA, # comorbidities, days from hospital to ICU admission, IL6
what is diff about modified NUTRIC?
exclude measure of IL6 cuz not commonly measured in pt and difficult to obtain
NUTRIC scored in range _____ and modified range ____
0-10; 0-9
why wt not accurate in critically ill?
swelling, edema (fluid resusc)
general guiding principles for feeding:
MNT should be considered for all pt with ICU LOS >48h, every critically ill pt in ICU >48h should be considered at risk for malnutrition
instead of using rate, we are moving toward __ based feeding models
volume
energy administration of around defined target, referred to as ___ diet
isocaloric
energy administration below 70% of target considered to be:
hypocaloric (underfeeding)
minimal administration of nutr having beneficial effects referred to as:
trophic feeding
trophic feeding typically ____mL
5-10
some of the beneficial effects of trophic feed?
preserve intestinal epithelium, stim secretion brush border enzymes, enhance immune fxn, preserve epithelial tight cell junctions, prevent bacterial translocation
overfeeding is energy admin of ____% above target
110
low protein diet is pro admin below ___g/kcal/d
0.5
nrg recommendations (ASPEN) in non obese:
25-30kcal/kg or predictive equation (in absence of IC)
nrg recommendations ESPEN in non obese:
use VO2 from pulmonary arterial catheter or VCO2 derived from ventilator, or 20-25kcal/kg
nrg recommendations obese pt (ASPEN)
goal of EN/PN not exceed 65-70% target energy rqts as measured by IC
why need to underfeed for obese?
achieve some degree of wt loss via hypocaloric feeding may ^ insulin sensitivity, facilitate nursing care, reduce risk of comorbidities
in absence of IC, BMI 30-50 should have ____ kcal/d actual wt, and BMI >50 should have ____ kcal/kg ideal body wt
11-14; 22-25
what is ideal body weight in Canada?
BMI 25
ESPEN guidelines for nrg in obese pt:
use adjusted body wt (ideal wt + 1/3 actual BW)
measurements in IC need to be taken in:
steady state conditions
IC measures ___ in the body, specifically:
oxidation; O2 consumption, CO2 production, RQ (substrate utilization)
lipogenesis is indicative of ____
overfeeding
RQ < __ suggests underfeeding; RQ > ___ suggests overfeeding, lipogenesis, ^ resp demand
0.82; 1.0
protein is most important nutrient for:
wound healing, immune fxn, maintain LBM
protein recommended to be ___g/kg actual BW in non-obese
1.2-2
pro recommendations for obese pt (ASPEN):
BMI 30-40: 2 g/kg ideal body wt, BMI >40: up to 2.5 g/kg
protein recommendations (ASPEN) should be adjusted using ____ studies with goal of achieving _____ if possible
nitrogen balance; nitrogen equilibrium
ESPEN guidelines for obese pt:
delivery guided by urinary N losses or LBM determination
ESPEN obese pro requirements determined to be ___ g/kg adjusted BW if urinary N losses/Lbm determination not available
1.3
UUN ____ in sickest of pt because of ____ due to inflammation/disease
increases; protein catabolism
what is N balance equation?
N balance = (pro intake in g / 6.25) - (UUN excretion in g + 4 g)
abnormal or unstable BP, esp. associated with hypotension:
hemodynamic instability
broad definition of hemodynamic instability:
global/regional perfusion not adequate to support normal organ fxn
____ are meds given for hemodynamic support
inotropes and vasopressors
what do inotropes do?
alter (increase) force of energy of musc contractions (heart)
what do vasopressors do?
cause constriction of blood vessels
risk of __ if feeding hemodynamically unstable pt
bowel ischemia–>necrosis
EN may be provided with caution to pt on chronic, low doses of ___
vasopressors
EN should be withheld in pt who are:
hypotensive (MAP<50mmHg), catecholamine agents initiated, escalating doses of pressors required
signs of intolerance that need to be monitored:
ab distention, ^ NG output/GRVs, v passage of stool/gas, hypoactive bowel sounds
other circumstances warranting delay in initiate EN?
shock uncontrolled, uncontrolled hypoxemia/hypercapnia/acidosis, active upper GI bleeds, overt bowel ischemia, high output intestinal fistula, ab compartment syndrome
what is early enteral nutrition defined as in ICU?
initiation of EN within 24-48 hrs of ICU admission
ASPEN recommend early EN initiated in critically ill pt if unable maintain ____
volitional intake
benefits of EN?
maintain gut integrity, modulate stress/systemic immune response, attenuate disease severity, + outcomes like v infection/LOS/rates of organ fail
obese pt have lower ___ but higher ___ guidelines
kcal; protein
exclusive PN should be withheld over first __ days after admission for pt with low nutr risk (ASPEN)
7
what is low nutr risk?
NUTRIC <5
(ASPEN) PN should be initiated ASAP if pt deemed at high nutrition risk of NUTRIC score > ___ or severely ___
5; malnourished
ESPEN PN guidelines:
PN should be implemented within 3-7 days if can’t oral or EN
supplemental PN should be considered when (ASPEN):
unable meet >60% nrg and pro rqts via EN after 7-10 days
supplemental PN not started until all strategies to maximize EN tolerance have been attempted (ESPEN), should be weighed on _____ basis
case by case
what is renal replacement therapy?
dialysis for managing renal failure
what is continuous renal replacement therapy (CRRT)?
used in ICU treat critically ill pt with acute kidney injury or renal failure
if acute kidney injury need energy ___kcal/kg, pro ___g/kg actual body wt, normal formulation
25-30; 1.2-2
if on CRRT, need ____ kcal/kg nrg, pro up to max of ___g/kg
25-30; 2.5
reasons for high protein when on CRRT?
CRRT associated with significant aa loss (10-15 g/d) and LBM losses in pt with AKI are 1.4-1.8 g/kg/d
