Managing the ICU pt. Flashcards
What are the 2 criteria in selecting pts for surgery?
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?)
RN ratio to pt in ICU? SDU? Med/surg?
ICU — 2:1 (or even 1:1)
SDU — 3:1(step down unit)
Med/Surg — 5:1
What are the 3 indications for ICU?
Respiratory insufficiency
Hemodynamic (cardiovascular) insufficiency
Depressed consciousness or coma
* or the threat of these conditions!
When viewing a pt you dont write a soap note!!! ICU notes comprise?
1. Identify patient Name, age, days in ICU, primary team 2. Main problem (why admitted), new problems 3. Background information Medical history, ICU history
- Current problems
- Physical findings (I’s & O’s, labs, vitals, exam)
- Evaluation of patient by system
Observation, intervention, impression (stable?) - Overall impression
- Plan for the next 24 hours
When evaluating the pt by system, what are the systems?
- Respiratory
- Cardiovascular
- Neurological
- GI and Nutrition
- Hematology
- Electrolytes
- Renal
- Infectious Disease
Respiratory.
Whats a requirement for using the ventilator with NPPV?
The pt must be intubated…
What are the 3 types of ventilatory modes?
Assist-control (AC)
Intermittent Mandatory Ventilation (IMV/SIMV)
Pressure Support Ventilation (Spontaneous)
What consists of Assist-Control Ventilation
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
What consists of Intermittent Mandatory Ventilation (IMV/SIMV)?
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.
What consists of Pressure Support Ventilation (Spontaneous)
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
How would you document these things?
When documenting (or ordering) mechanical ventilation, it’s written this way: Mode RR(actual) TV Fi02 PEEP PSV Example: SIMV 12(14) 400 50% PEEP=5 PSV=8
The “mode” setting involves 3 things?
AC
IMV/SIMV
Spontaneous (Spont)
What makes up resp rate?
Not just important for oxygenation.
The rate controls how much CO2 is being expired.
The higher the rate, the more CO2 is removed.you can control the ph of the pt.
What makes up Tidal Volume?
Normally should be 10-12ml/kg.
Higher volumes are associated with barotrauma.
With critically ill patients, the general practice is low volume ventilation, with tidal volumes of 6-8ml/kg.
What makes up FiO2 (fractional conentration if inspired oxygen)?
Expressed as a percentage.
Start with 100% when beginning mechanical ventilation, and titrate down, monitoring O2 saturation.
>60% for 48 hours can be toxic.
What makes up Positive end-expiratory pressure (PEEP)
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.
Why is pressure support (PSV) important?
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”).
Long-term vent therapy requires that a patient undergo a?
tracheostomy
The cardiovascular system needs three things to work
A functioning pump
Sufficient fluid volume
Regulated resistance
When one or more of these are absent, it’s called….
What comprises Shock?
Pump dysfunction Cardiogenic shock Volume depletion Hypovolemic shock Resistance dysfunction Septic/neurogenic/anaphylactic shock
what are the 3 things you need to know to manage shock?
Cardiac output (SV x HR)
Central Venous Pressure (CVP)
Systemic Vascular Resistance (SVR)
What comprises Cardiogenic shock?
↓ Cardiac output
↑ Central venous pressure
↑ Systemic vascular resistance
Whats the treatment for cardiogenic shock?
Dobutamine
Inotropic, so will ↑CO (by ↑ stroke volume)
Patient will experience ↓ SVR, due to baroreceptor response
Does not ↑ arterial BP, so may need additional drugs
What 3 things comprise Hypovolemic shock
↓ Cardiac output
↓ Central venous pressure
↑ Systemic vascular resistance
Whats the treatment?
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.
Volume replacement.
what do you do?
whats your target?
what do you follow during replacement?
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 ∼ 15mm Hg
Follow electrolytes and Hgb during replacement.
What 3 things comprise Septic/Neurogenic/Anaphylactic shock
when we talk about cardiovascular system?
↑ Cardiac output
↓↔ Central venous pressure
↓ Systemic vascular resistance
And whats the treatment?
Dopamine (vasopressure) (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)
What do you do in a Hypertensive emergency
Give anti-hypertensives
Drips of nitroprusside or nicardipine
PRN labetalol or hydralazine
Wean off and transition to longer-acting PO meds
The pulmonary artery catheter.
whats the big deal?
Several studies have shown there to be NO improved outcomes when using PA catheters.
Echocardiography and other measures are safer.
Know your neuro exam!!!!!!
(Glasgow Coma Score, pupils, movement, reflexes)
cerebral perfusion pressure (CPP)
What caues it?
whats the goal?
whats the equation to figure it out?
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
The goal is to keep oxygen flowing to brain so it can heal.
CPP = MAP - ICP
ICP Monitoring
Camino Bolt
Threaded, is screwed into skull.
Rests just under dura
Provides real time ICP data
Whats a Licox Monitor?
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).
Whats a Ventriculostomy
and when do you use it?
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
What are the goals for CCP, ICP, MAP?
Goal CPP is often around 60mm Hg (may vary)
Goal ICP is generally <20mm 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)
When it comes to SAH, which is worse?
traumatic, or aneurysm?
Aneurysm A weak point in a cerebral artery. Often asymptomatic. Usually devastating. 50% never make it into the hospital. 50% in hospital die
What do you order for pts once aneurysm is repaired?
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.
Know the big 3
Respiratory insufficiency, cardiovascular insufficiency, and neurological injury.
Know your history.
Read the chart, especially the previous notes.
The “Small Five”
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
Nutrition is critical to surviving a stay in the ICU.
How do you feed them?
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
Heamtology.
ICU pts tend to become anemic from?
What do we follow as far as test wise?
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
For I’s and O’s what considered the out way for fluid?
In: IVF (including meds), TF, oral
Out: UOP, BM, drains, emesis, NG output, insensible
Insensible 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 insensible losses) are balanced.
For renal, we follow?
What can fuck up Pre-renal?
What can mess up Intrinsic?
And Post-renal?
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)
What are the 2 criteria in selecting pts for surgery?
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?)
RN ratio to pt in ICU? SDU? Med/surg?
ICU — 2:1 (or even 1:1)
SDU — 3:1(step down unit)
Med/Surg — 5:1
What are the 3 indications for ICU?
Respiratory insufficiency
Hemodynamic (cardiovascular) insufficiency
Depressed consciousness or coma
* or the threat of these conditions!
When viewing a pt you dont write a soap note!!! ICU notes comprise?
1. Identify patient Name, age, days in ICU, primary team 2. Main problem (why admitted), new problems 3. Background information Medical history, ICU history
- Current problems
- Physical findings (I’s & O’s, labs, vitals, exam)
- Evaluation of patient by system
Observation, intervention, impression (stable?) - Overall impression
- Plan for the next 24 hours
When evaluating the pt by system, what are the systems?
- Respiratory
- Cardiovascular
- Neurological
- GI and Nutrition
- Hematology
- Electrolytes
- Renal
- Infectious Disease
Respiratory.
Whats a requirement for using the ventilator with NPPV?
The pt must be intubated…
What are the 3 types of ventilatory modes?
Assist-control (AC)
Intermittent Mandatory Ventilation (IMV/SIMV)
Pressure Support Ventilation (Spontaneous)
What consists of Assist-Control Ventilation
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
What consists of Intermittent Mandatory Ventilation (IMV/SIMV)?
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.
What consists of Pressure Support Ventilation (Spontaneous)
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
How would you document these things?
When documenting (or ordering) mechanical ventilation, it’s written this way: Mode RR(actual) TV Fi02 PEEP PSV Example: SIMV 12(14) 400 50% PEEP=5 PSV=8
The “mode” setting involves 3 things?
AC
IMV/SIMV
Spontaneous (Spont)
What makes up resp rate?
Not just important for oxygenation.
The rate controls how much CO2 is being expired.
The higher the rate, the more CO2 is removed.you can control the ph of the pt.
What makes up Tidal Volume?
Normally should be 10-12ml/kg.
Higher volumes are associated with barotrauma.
With critically ill patients, the general practice is low volume ventilation, with tidal volumes of 6-8ml/kg.
What makes up FiO2 (fractional conentration if inspired oxygen)?
Expressed as a percentage.
Start with 100% when beginning mechanical ventilation, and titrate down, monitoring O2 saturation.
>60% for 48 hours can be toxic.
What makes up Positive end-expiratory pressure (PEEP)
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.
Why is pressure support (PSV) important?
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”).
Long-term vent therapy requires that a patient undergo a?
tracheostomy
The cardiovascular system needs three things to work
A functioning pump
Sufficient fluid volume
Regulated resistance
When one or more of these are absent, it’s called….
What comprises Shock?
Pump dysfunction Cardiogenic shock Volume depletion Hypovolemic shock Resistance dysfunction Septic/neurogenic/anaphylactic shock
what are the 3 things you need to know to manage shock?
Cardiac output (SV x HR)
Central Venous Pressure (CVP)
Systemic Vascular Resistance (SVR)
What comprises Cardiogenic shock?
↓ Cardiac output
↑ Central venous pressure
↑ Systemic vascular resistance
Whats the treatment for cardiogenic shock?
Dobutamine
Inotropic, so will ↑CO (by ↑ stroke volume)
Patient will experience ↓ SVR, due to baroreceptor response
Does not ↑ arterial BP, so may need additional drugs
What 3 things comprise Hypovolemic shock
↓ Cardiac output
↓ Central venous pressure
↑ Systemic vascular resistance
Whats the treatment?
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.
Volume replacement.
what do you do?
whats your target?
what do you follow during replacement?
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 ∼ 15mm Hg
Follow electrolytes and Hgb during replacement.
What 3 things comprise Septic/Neurogenic/Anaphylactic shock
when we talk about cardiovascular system?
↑ Cardiac output
↓↔ Central venous pressure
↓ Systemic vascular resistance
And whats the treatment?
Dopamine (vasopressure) (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)
What do you do in a Hypertensive emergency
Give anti-hypertensives
Drips of nitroprusside or nicardipine
PRN labetalol or hydralazine
Wean off and transition to longer-acting PO meds
The pulmonary artery catheter.
whats the big deal?
Several studies have shown there to be NO improved outcomes when using PA catheters.
Echocardiography and other measures are safer.
Know your neuro exam!!!!!!
(Glasgow Coma Score, pupils, movement, reflexes)
cerebral perfusion pressure (CPP)
What caues it?
whats the goal?
whats the equation to figure it out?
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
The goal is to keep oxygen flowing to brain so it can heal.
CPP = MAP - ICP
ICP Monitoring
Camino Bolt
Threaded, is screwed into skull.
Rests just under dura
Provides real time ICP data
Whats a Licox Monitor?
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).
Whats a Ventriculostomy
and when do you use it?
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
What are the goals for CCP, ICP, MAP?
Goal CPP is often around 60mm Hg (may vary)
Goal ICP is generally <20mm 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)
When it comes to SAH, which is worse?
traumatic, or aneurysm?
Aneurysm A weak point in a cerebral artery. Often asymptomatic. Usually devastating. 50% never make it into the hospital. 50% in hospital die
What do you order for pts once aneurysm is repaired?
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.
Know the big 3
Respiratory insufficiency, cardiovascular insufficiency, and neurological injury.
Know your history.
Read the chart, especially the previous notes.
The “Small Five”
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
Nutrition is critical to surviving a stay in the ICU.
How do you feed them?
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
Heamtology.
ICU pts tend to become anemic from?
What do we follow as far as test wise?
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
For I’s and O’s what considered the out way for fluid?
In: IVF (including meds), TF, oral
Out: UOP, BM, drains, emesis, NG output, insensible
Insensible 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 insensible losses) are balanced.
For renal, we follow?
What can fuck up Pre-renal?
What can mess up Intrinsic?
And Post-renal?
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)
What can cause Hyponatremia
in ICU pts?
How do you handle it?
What if its really low and causing sx’s?
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 100ml 3% NaCl IV at a time.
What is the usual etiology of Hypernatremia (>145)?
What can you give?
And whats the general rule?
Usually caused by hypovolemia, renal disease, or diabetes insipidus (DI).
Give more fluid, but NOT normal saline.
Slow correction is the general rule.
How to treat Hyperkalemia
Mild (7.0 or lower w/ EKG changes): CaCl or calcium gluconate IV, hemodialysis
How to treat Hypomagnesemia
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
Certain things need to be done for EVERY patient in the ICU? Think GI/Nutrition
GI/Nutrition
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).
And another thing to watch?
Hematology
Deep venous thrombosis and pulmonary embolism
Every patient should be wearing sequential compression devices (aka “pumpy leg things”).
Every patient should get Lovenox (40mg SQ daily) when hemodynamically stable.
Confirm this every day, even if already ordered.(must be re-ordered as it will stop after 72hrs)
Medications?
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?
Integumentation?
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?
Breakdown the ICU note summary?
- Identify patient
- Main problem (why admitted), new problems.
- PMHx, ICU Hx
- Current problems
- Vitals, vent status, I’s & O’s, labs, meds, physical exam
- Overall impressions
RespiratoryCardiovascularNeuroGI/NutritionHemeFEN/RenalIDProphylaxis - General plan for the next 24 hours
