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General Surgery 1 > Managing the ICU Patient > Flashcards

Managing the ICU Patient Flashcards

1
Q

Two criteria for selecting patients for surgery

A
  • Patient’s pathology (diagnosis, staging, etc.)
  • Patient’s overall health (i.e, are they going to be able to recover from the grave wounds we plan to inflict upon them?)
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2
Q

Series of events from intake to discharge

A
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3
Q

indications for ICU

A
  • There are essentially three indications for ICU….*
    • Respiratory insufficiency
    • Hemodynamic (cardiovascular) insufficiency
    • Depressed consciousness or coma
      • * or the threat of these conditions!
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4
Q

ICU notes

A
    1. Identify patient
      * Name, age, days in ICU, primary team
    1. Main problem (why admitted), new problems
    1. Background information
      * Medical history, ICU history
    1. Current problems
    1. Physical findings (I’s & O’s, labs, vitals, exam)
    1. Evaluation of patient by system
      * Observation, intervention, impression (stable?)
    1. Overall impression
    1. Plan for the next 24 hours
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5
Q

what are the systems

A
  1. Respiratory
  2. Cardiovascular
  3. Neurological
  4. GI and Nutrition
  5. Hematology
  6. Electrolytes
  7. Renal
  8. Infectious Disease
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6
Q

respiratory

A
  • ICU patients are often on mechanical ventilation.
  • Require a lot of interventions.
    • Oxygenation, vent settings, sedation, suctioning, etc.
  • Patient will already be intubated with an endotracheal tube.
  • This is a requirement for using the ventilator with positive pressure ventilation
  • Real time observations from the patient will guide ventilator therapy.
  • Respiratory rate, O2 sat, arterial blood gases.
  • Review the vent history; is the patient improving? Declining?
  • Long-term vent therapy requires that a patient undergo a tracheostomy.
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7
Q

three main types of ventilation modes

A
  • Assist-control (AC)
  • Intermittent Mandatory Ventilation (IMV/SIMV)
  • Pressure Support Ventilation (Spontaneous)
  • Breathing is protected, airway is protected
  • Modes: frequency that it pushes air into the patient
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8
Q

Assist-control ventilation

A
  • Fixed respiratory rate and fixed tidal volume
  • Patient can initiate breaths, and each gets full TV
  • Required for patients in deep coma or sedation
  • Deep coma/sedation is required for AC
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9
Q

intermittent mandatory ventilation (IMV/SIMV)

A
  • Periodic breaths at set rate (minimum)
  • Patient can initiate breaths above set rate
  • Patient determines TV for spontaneous breaths, and breaths are supported by positive pressure.
  • More comfortable for patients who are more awake.
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10
Q

Pressure support ventilation (spontaneous)

A
  • Patient initiates every breath (no set rate)
  • Breaths are supported by positive pressure
  • Least invasive, most comfortable for awake patients
  • Used when weaning from mechanical ventilation
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11
Q

how to document (or order) mechanical ventilation

A
  • Mode RR(actual) TV FiO2 PEEP PSV
  • Example:
  • SIMV 12(14) 400 50% PEEP=5 PSV=8
  • RR – you put what its set to and what you actually observe
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12
Q

Mode

A
  • AC
  • IMV/SIMV
  • Spontaneous (Spont)
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13
Q

Respiratory Rate (breaths per minute)

A
  • Not just important for oxygenation.
  • The rate controls how much CO2 is being expired.
  • The higher the rate, the more CO2 is removed.
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14
Q

Tidal volume

A
  • (milliliters per breath)
  • Normal tidal volume is about 6ml/kg (e.g., 80kg person would have a normal TV of 480ml).
  • Higher volumes are associated with barotrauma.
  • With critically ill patients, the general practice is low volume ventilation, with tidal volumes as low as 4ml/kg.
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15
Q

fractional concentration of inspired oxygen (FiO2)

A
  • Expressed as a percentage.
  • Start with 100% when beginning mechanical ventilation, and titrate down, monitoring O2 saturation.
  • >60% for 48 hours can be toxic.
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16
Q

Positive end-expiratory pressure (PEEP)

A
  • Residual positive pressure at the end of expiration.
  • Keeps alveoli open.
  • Useful in people with “stiff lungs” (e.g., ARDS).
  • 5 cm H2O is helpful in promoting oxygenation and reducing barotrauma.
  • High PEEP measurement is an indication that the person is not ready to be off ventilation
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17
Q

pressure support (PSV)

A
  • Used in IMV and spontaneous ventilation.
  • Positive pressure applied with patient-initiated breaths.
  • Helps to overcome the resistance of the ventilator circuit (“sucking through a straw”).
  • This overcomes the narrowness of the tube
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18
Q
A
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19
Q

three things needed for cardiovascular system to work

A
  • A functioning pump
  • Sufficient fluid volume
  • Regulated resistance
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20
Q

Cardiovascular shock

A
  • Pump dysfunction
    • Cardiogenic shock
  • Volume depletion
    • Hypovolemic shock
  • Resistance dysfunction
    • Septic/neurogenic/anaphylactic shock
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21
Q

three things to know when managing shock

A
  • Cardiac output (SV x HR)
  • Central Venous Pressure (CVP)
    • CVP = what is their fluid status
  • Systemic Vascular Resistance (SVR)
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22
Q

cardiogenic shock

A
  • ↓ Cardiac output
  • ↑ Central venous pressure
  • ↑ Systemic vascular resistance
23
Q

how to manage cardiogenic shock

A
  • Dobutamine (start 0.5mcg/kg/min, to max of 40mcg)
    • Inotropic, so will ↑CO (by ↑ stroke volume)
    • Patient will experience ↓ SVR, due to baroreceptor response
    • Does not ↑ arterial BP, so may need additional drugs
24
Q

hypovolemic shock

A
  • ↓ Cardiac output
  • ↓ Central venous pressure
  • ↑ Systemic vascular resistance
25
Q

how to treat hypovolemic shock

A
  • GIVE THE PATIENT FLUID!
  • Total body fluid: 80kg man (48L), 60kg woman (30L).
  • Blood volume: 80kg man (5.3L), 60kg woman (3.6L).
  • Can lose up to 15% of blood volume and compensate.
  • Start to get into trouble between 15 and 30%.
  • After 30%, will go into shock.
26
Q

Volume replacement

A
  • Calculate fluid loss (% blood loss x total)
  • Give four (4) times the loss in IV crystalloid
  • Example: 35% x 5.3L = 1.9L, so replace with 7.5-8L
  • Target is CVP between 5-10mm Hg (12-15 can mean fluid overload)
  • Follow electrolytes and Hgb during replacement.
27
Q

Septic/neurogenic/anaphylactic shock

A
  • ↑ Cardiac output
  • ↓↔ Central venous pressure
  • ↓ Systemic vascular resistance
28
Q

how to treat septic/neurogenic/anaphylactic shock

A
  • Dopamine (start 1.0mcg/kg/min, titrate to effect)
    • Dose dependent response.
    • Low dose (1-5mcg): specifically increases blood flow to renal, mesenteric, and cerebral regions, by increasing SVR in other regions.
    • Intermediate dose (5-10mcg): stimulates β receptors in heart, ↑ cardiac output.
    • High dose (>10mcg): stimulates α receptors in systemic and pulmonary circulation, increasing SVR while preserving CO, thus helping to correct hypotension.
    • Complications: tachycardia at intermediate doses, and ischemic limb necrosis even at low doses (consider prompt α blocker, e.g., phentolamine).
29
Q

hypertensive emergency

A
  • Give anti-hypertensives
    • Drips of nitroprusside/nicardipine/clevidipine/esmolol
    • PRN labetalol or hydralazine
    • Wean off and transition to longer-acting PO meds
30
Q

Pulmonary artery (swan ganz) catheter

A
  • Invented in 1970, was the first device to measure hemodynamic phenomena in real time.
  • Several studies have shown there to be NO improved outcomes when using PA catheters.
  • Echocardiography and other measures are safer.
31
Q

Closed head injury

A
  • Start with ABCs
  • Depending on injury, may need invasive monitoring to monitor intracranial pressures (ICP).
  • The problem is that trauma causes edema, which leads to ↑ ICPs, which leads to ↓ in oxygen delivery to brain tissue and/or herniation of brainstem through the foramen magnum (i.e., brain death).
  • If blood cant get into the brain, then the brain cant get oxygen and the brain begins to die – this can then cause the brain to push out through the foramen magnum – this will compress the brainstem against the skull and will prevent you from ever waking up again
32
Q

The goal for neurological patients

A
  • The goal is to keep oxygen flowing to brain so it can heal.
  • Need to maintain favorable pressure gradient, called cerebral perfusion pressure (CPP).
  • CPP = MAP - ICP
  • So, for critical head injuries, we need to be able to monitor (and control) both intracranial pressure AND blood pressure.
  • Goal CPP is often around 60mm Hg (may vary)
  • Goal ICP is generally <22mm Hg
  • Thus, MAP should be maintained at ≥ 80mm Hg
  • To maintain CPP, we can lower ICP (preferable), or raise MAP (less preferable)
  • Other methods of lowering ICP include paralysis, mannitol, and surgical decompression (definitive)
  • You can also use hypertonic saline to decrease the pressure
33
Q

ICP monitoring

A
  • Camino Bolt
    • Threaded, is screwed into skull.
    • Rests just under dura
    • Provides real time ICP data
34
Q

Licox monitor

A
  • Inserted like a Camino bolt
  • Measures O2 content of blood
  • Considered more useful than Camino, because it measures direct oxygenation, rather than perfusion pressures (which only correlate with oxygenation).
35
Q

ventriculostomy

A
  • A catheter inserted into the lateral ventricle
  • Provides real time ICP monitoring
  • Also provides means to drain CSF from brain, which can reduce ICP
  • May be used in conjunction with Licox
  • GOLD STANDARD FOR CRANIAL PRESSURE MONITORING
36
Q

subarachnoid hemorrhage and aneurysms

A
  • Subarachnoid hemorrhage and aneurysms
  • “Worst headache of my life.”
  • May be traumatic, or due to an aneurysm.
  • Aneurysms are worse.
  • A weak point in a cerebral artery.
  • Often asymptomatic.
  • Usually devastating.
  • 50% never make it into the hospital.
  • 50% in hospital die.
  • Once in ICU, these patients are placed on a protocol.
  • Critical BP control, neuro checks, seizure prophylaxis, vasospasm prophylaxis.
  • The goal is to repair the aneurysm before it bleeds again.
  • Surgery (clipping) or interventional radiology (coiling) are the methods.
  • Once repaired, patient stays in ICU.
  • High risk for vasospasm, so gets neuro checks, HHH (hypervolemic-hypertensive-hemodilution) therapy, and nimodipine.
  • These patients get a lot of IV fluid, and are allowed to have SBP as high as 200, for a week or longer.
  • Vasospasm requires emergent transluminal balloon angioplasty.
37
Q

the big three

A
  • Respiratory insufficiency, cardiovascular insufficiency, and neurological injury.
  • Know your history.
  • Read the chart, especially the previous notes.
  • Sweat the “small stuff.”
38
Q

the “small stuff”

A
  • Just because they’re “small” doesn’t mean they’re not critical to keeping your patient moving rightward.
    • It does mean that they tend to kill your patient slowly, rather than quickly.
    • The “Small Five”
    • GI/nutrition, hematology, electrolytes, renal, infectious disease
39
Q

gut and nutrition

A
  • Most ICU patients are too obtunded to eat. They’re either NPO (on purpose) or they need nutrition.
  • Nutrition is critical to surviving a stay in the ICU.
  • Patients can be fed through NGT (at first), Dobhoff tubes (longer term), or G-tubes (longest term).
  • Tube feeds are recommended by our nutritionists.
  • Prophylaxis
40
Q

hematology

A
  • ICU patients tend to become anemic.
  • Hemorrhage, consumption, malnutrition, phlebotomy
  • We follow Hgb; if it falls below 8.0, we consider transfusion.
  • We also follow coags (INR), and correct as needed.
  • Prophylaxis
41
Q

electrolytes and renal

A
  • Following I’s & O’s
    • In: IVF (including meds), TF, oral
    • Out: UOP, BM, drains, emesis, NG output, insensate
      • Insensate fluid loss in a healthy adult: 400ml H2O from lungs, 400ml H2O from skin
  • Follow over 24°, and over multiple days. We prefer that I’s & O’s (plus insensate losses) are balanced.
42
Q

renal protocol

A
  • For renal, we follow urine output, and blood urea nitrogen and creatine. Minimum UOP should be ≥20ml/hr. BUN/Cr should not be climbing.
  • Pre-renal: ↓ blood flow to kidney (hypovolemia, renal artery obstruction)
  • Intrinsic: damage to kidney (drugs, ischemia, infection)
  • Post-renal: obstruction of urinary tract (stones, catheter, BPH)
43
Q

hyponatremia

A
  • May be chronic in ICU patients (125-130). Can be caused by malnutrition, drug side effects, fluid overload.
  • Best to treat the underlying problem first.
  • If really low (<120) and symptomatic (nausea, malaise, headache → coma, seizures, arrest), replace sodium, with continuous infusion of 3% (hypertonic) NaCl IV. Start oral repletion.
44
Q

hypernatremia

A
  • Hypernatremia (>145)
  • Usually caused by hypovolemia, renal disease, or diabetes insipidus (DI).
  • Give more fluid, but NOT normal saline.
  • Slow correction is the general rule.
  • DDAVP is indicated some cases of DI (patients will have ↑ UOP, ↓ urine SG, and ↑ serum osmolality).
45
Q

hypokalemia

A
  • Patients generally asymptomatic until ≤ 3.0
  • Correct the underlying disorder, and give K+
  • Oral is preferable (KCl tabs, or KCl elixir). IV is frequently necessary. 20-40mEq at a time.
  • Prophylaxis
46
Q

hyperkalemia

A
  • Mild (<6.0): Give loop diuretic (40-80mg Lasix), and Kayexalate (30gm in 50ml of 20% sorbitol PO or PR)
  • Moderate (<6.0-7.0): Sodium bicarb, insulin with D50, albuterol nebs)
  • Severe (>7.0 or lower w/ EKG changes): CaCl or calcium gluconate IV, hemodialysis
47
Q

hypomagnesemia

A
  • Normal range is 1.7-2.3
  • Very low levels (≤ 0.7) can cause fatal arrhythmias
  • Seen in drinkers
  • Correct with MgSO4 1-2gm IV slow push
  • Prophylaxis
48
Q

infectious disease

A
  • Infection can be the cause of a patient’s critical condition, or a complication. Every ICU patient is at risk for a life-threatening infection.
  • Pay special attention to WBC and temp in writing your note. Also follow antibiotics: What are they on now? What have they been on? How long?
  • If patient has a new fever or ↑ WBC, then get “pan cultures” (blood, sputum, urine) and CXR to start.
49
Q

GI/nutrition prophylaxis

A
  • Feed patient as soon as you can. Give them a multivitamin to help prevent electrolyte problems.
  • Most, if not all, ICU patients need to be on a proton pump inhibitor (Nexium, Pepcid). Especially patients who are NPO, on steroids, or head injured.
  • Bowel regimen: stool softener (colace), stimulant laxative (senna), suppositories (dulcolax).
50
Q

hematology prophylaxis

A
  • Deep venous thrombosis and pulmonary embolism
  • Every patient should be wearing sequential compression devices (aka “pumpy leg things”).
  • Every patient should get prophylactic heparin or LMWH when hemodynamically stable.
  • Confirm this every day, even if already ordered.
51
Q

medications

A
  • Review all medications every day.
  • Which meds can or should be removed?
  • Which should the patient be on?
  • Do any meds need to be renewed?
  • Do we need to check serum drug levels on anything?
52
Q

sedation

A
  • Does the patient have adequate sedation and pain control?
  • Is the patient over-sedated or over-narced?
  • Always document what meds are being used, and the usage history of these meds.
  • Some meds have toxic profiles when used for a long time (e.g., propofol, toradol); check labs accordingly.
53
Q

integumentation

A
  • Skin breakdown is a huge concern among bedbound patients.
  • Is the patient being turned? Is there any sign of skin breakdown?
  • Do they need a special mattress (e.g., airflow mattress)?
  • Any new rashes or lesions?
54
Q

ICU note summary

A
  1. Identify patient
  2. Main problem (why admitted), new problems.
  3. PMHx, ICU Hx
  4. Current problems
  5. Vitals, vent status, I’s & O’s, labs, meds, physical exam
  6. Overall impressions
  • Respiratory
  • Cardiovascular
  • Neuro
  • GI/Nutrition
  • Heme
  • FEN/Renal
  • ID
  • Prophylaxis
  1. General plan for the next 24 hours

General Surgery 1 (9 decks)

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