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FFICM > Numberwang > Flashcards

Numberwang Flashcards

1
Q 
Steroid equivalence (mg) 
Pred, hydrocort, methylpred, dex
A

Pred 5
Hydrocort 20
Methylpred 4
Dex 0.75

Cortisol 10-30mg secreted/day endogenously

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2
Q

Opioid equivalence ratios
Morphine, oxycodone, tramadol, codeine
Buprenorphine and fentanyl patches

A 
Oral: 
Morphine 1 
Oxycodone 2 
Tramadol 0.15 
Codeine 0.1

Transdermal:
Buprenorphine 5mcg/h patch = 12mg Oramorph
Fentanyl 50mcg/h patch = 180mg Oramorph

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3
Q

Incidence of inherited diseases

  • Down’s syndrome
  • CF
  • MD
  • CHD
  • HCM
  • SCD
  • Bicuspid AV
  • Autism
  • RA
  • MH
A

Down’s 1 in 1000 live births
CF 1 in 2500 live births (1 in 25 carrier allele)
MD 1 in 8000 prevalence
CHD 1% live births
HCM 1 in 500 prevalence (25% cases obstructive)
SCD 1 in 2000 live births
Bicuspid aortic valve 0.5-2.5%
Autism 1%
RA 1-2%
MH 1 in 5000-10,000 susceptible; 1 in 40,000-100,000 GAs

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4
Q

Prevalence of acquired diseases

  • Diabetes
  • Post tonsillectomy bleed
  • Asthma
  • COPD
  • IHD
  • HTN
  • Obesity
  • AF
  • PD
  • OSA
  • Dementia
  • AS and aortic sclerosis
  • GBS
  • MG
  • Phaeo
  • Latex allergy
  • Penicillin allergy
  • Anaphylaxis
  • Alcohol misuse
  • PONV
A

Diabetes 9% (90% type 2)
Post tonsillectomy bleed 0.5-2%
Asthma 12% (>1400 deaths/y)
COPD 2% (diagnosed; much more undiagnosed)
IHD 4%
HTN 30%
Obesity 27%
AF 5.5% (50% perm, 25% persis, 15% paroxys)
PD 1% of >65s
OSA 5-10%
Dementia 1% (7% of >65s)
AS 3% >65s, aortic sclerosis 25% of >65s (9% progress to AS)
GBS 1-2 in 100,000 (3-5% mortality)
MG 1 in 1000
Phaeo 1 in 100,000
Latex allergy 4.3% (9.7% in healthcare workers)
Penicillin allergy 10% reporting rate (90% of which are not truly allergic)
Anaphylaxis 1/5000-1/20,000, 3:1 female preponderance
Alcohol misuse 9% men, 4% women
PONV 30%

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5
Q

Commonest cancers

A

Breast 15%
Lung 13%
Prostate 13%
Bowel 11%

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6
Q

Oral bioavailability (%)

  • Morphine
  • Methadone
  • Tramadol
  • Pethidine
  • Codeine
A 
Morphine 30 
Methadone 75 
Tramadol 70 
Pethidine 50
Codeine 50 (but only 10% metab to morphine)
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7
Q

Oxygen consumption (adult/child)

A

Adult: 3.5 ml/kg/min (about 250ml/min at BMR)
Child: 6 ml/kg/min

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8
Q

Incidences

  • Delirium in ICU pts
  • PTSD in relatives of ICU pts
  • Proportion of AKI thought to be preventable
  • Anaemia in ICU
  • Treated cardiac arrests in UK/year
  • Hospital discharge post cardiac arrest in pts who went to ICU
  • VTE in critical illness
  • VAP
  • Proportion of line sepsis that occurs >day 5 post CVC insertion
  • C.difficile carrier rate
  • Stroke aetiology
A

Delirium: 30% overall but 60-80% in sick, ventilated pts
PTSD in relatives: 33% in one study
Preventable AKI: 20%
Anaemia: 60-80% ICU pts (only 10-15% having been anaemic pre ICU admission)
Cardiac arrests: 50k/y
Hospital discharge: 33% (80% of whom go to usual residence)
VTE: 80% without prophylaxis; 40% with
VAP: 10-20% ICU pts
Line sepsis: 72% occur after day 5
C.diff: 3% general pop but 20% pts on abx
Stroke: 85% ischaemic, of which 35% large artery thromboembolism, 24% cardiac (AF/SBE/thrombus), 18% small vessel disease, remainder vasculitis/dissection/unknown.

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9
Q

Daily nutritional requirements

A

Calories: 25-35 kCal/kg/day (NICE) or 20-25 initially, rising to 25-30 (ESPEN); much higher in burns/hypermetabolism (e.g. up to 80), lower in obesity (but need high protein), slightly lower in the elderly

Carbohydrate 4g/kg (as 50% dextrose; should provide 60% of non-protein calories)
Protein 1.5g/kg (as 10% amino acid solution)
Fat 1g/kg (as 10% lipid emulsion; up to 40% of non-protein calories)
H2O 30 ml/kg/day (or 2ml/kg/h) + losses

Na+ 1-2 mmol/kg
Cl- 1-2 mmol/kg
K+ 1 mmol/kg
Ca2+ 0.1 mmol/kg
Mg2+ 0.1 mmol/kg
PO4 0.4 mmol/kg
(Electrolytes guided by plasma levels)
Nitrogen 14g

Successful feeding = at least 40ml/h with 4h aspirates under 250ml. Aspirates >500ml are considered failure.

Normal blood glucose = 100mg/dL = 5.5mmol/L.
Basal insulin requirement = about 50 units/day.
For every 1C rise in temperature, BMR rises by 5-7%

pH for NGT: <5.5

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10
Q

Sedation/TIVA dosing

A

Propofol
Induction 1-2.5mg/kg
Maintenance 50-200mcg/kg/min (6-12mg/kg/h)
Effect site conc for GA 2-6mcg/ml
Sedation 25-100mcg/kg/min (max 4mg/kg/h)

Remi
Induction 0.5-1mcg/kg
Maintenance 0.25-0.5mcg/kg/min
Effect site conc as part of GA TIVA 1-8ng/ml (usually 5-8)

All tailored to pt age, clinical response, DoA monitoring etc.

Paeds
Midazolam 60-300 mcg/kg/h
Morphine 10-40 mcg/kg/h

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11
Q

Shelf lives of blood products

A

RBC: 42d
FFP/cryo: 1y
HAS: 5y
Plt: 5d

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12
Q

pKa

A 
Aspirin 3.0 
Midaz and alfentanil 6.5 
Remi 7.1
Thio and diamorph 7.6 
Prilocaine 7.7 
Lidocaine 7.9
Morphine 8.0 
Bupivacaine and ropivacaine 8.1 
Fentanyl 8.4 
Cocaine 8.6
Pethidine 8.7
Propofol 11.0
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13
Q

Cardiac output by organ

A 
Brain - 15% - 750ml/min 
Heart - 5% - 250ml/min 
Kidneys - 20% - 1L/min 
Liver - 25% - 1.5L/min 
Gravid uterus - 12%
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14
Q

BP targets

A 
Neuro 
TBI: SBP 110-150, MAP>90 
SAH: SBP 110-160 (or SBP<140 preop / SBP<180 postop) 
SCI: MAP>85 for 7d post injury 
ICH: SBP<150 
Acute ischaemic stroke: 
- SBP 140-185 if thrombolysing 
- SBP <220 if not

Other
Burns: MAP>60 (fluid creep)
Permissive hypotension in trauma (no TBI): SBP 80-90/MAP>50 if normal mentation and palpable peripheral pulses
Aortic dissection: SBP 100-120 within 20m
Malignant HTN: reduce by 10-20% in first hour and aim for 25% reduction at 24h
Immediately post ROSC: SBP>100
Post aortic surgery: SCPP>80

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15
Q

Defib energies

A

Defibrillation (biphasic): 200, 300, 360J
Cardioversion: 100, 200, 360J
ICD: 30-50J

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16
Q

Airway assessment

A

3/6/12
Thyromental distance: should be >6.5cm; <6cm predicts 75% of difficult larygoscopies
Sternomental distance: <12cm a/w difficulty
Interincisor distance: <3cm a/w difficulty

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17
Q

Transfusion triggers: trials and NHS National Blood Transfusion Committee

A

70

  • General ICU population (TRICC Hb 70 vs. 100)
  • Septic shock (TRISS Hb 70 vs. 90)
  • Upper GI bleed (Villanueva Hb 70 vs. 90) (but consider 80 in active bleed stage)
  • TBI (70-90)
  • Stable chronic IHD

80

  • ACS (80-90)
  • Transfusion dependent anaemia
  • Active bleeding

90

  • Post elective cardiac surgery (Murphy)
  • TBI with cerebral ischaemia
  • Ischaemic stroke
  • SAH
  • Early phase sepsis if clear evidence of reduced O2 delivery (ScvO2<70%)

100

  • Sickle crisis
  • Chronic renal disease

110
- Radiotherapy (weak evidence)

Ones without citations are guidelines rather than direct evidence-based.

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18
Q

Platelet transfusion triggers/limits

A

10
- Reversible acute BM failure

20

  • Non-bleeding pts with severe sepsis or haemostatic abnormalities
  • CVC insertion

30
- Clinically significant bleeding

40
- LP/spinal

50

  • DIC with bleeding
  • Major haemorrhage
  • Liver bx/major surgery

80
- Epidural

100
- Critical site bleeding or surgery

Other indications (no specific target): anti-plt agents, inherited plt disorders. Generally only if severe bleeding or emergency pre-procedure. Avoid in ITP/TTP.

19
Q

Trache rate in ICU

A

7-9% pts
90% percutaneous
Complication rate 23% in ICU and 30% on the ward (major ones: displacement, obstruction, PTX, haemorrhage)

Source: NCEPOD report ‘On the right trach’

20
Q

Body compartment pressures

  • Pleural
  • Compartment
  • Abdominal
  • ICP
  • Portal venous
A

Pleural
-5cmH2O at start of inspiration, down to -8cmH2O at end inspiration

Compartment
<30mmHg or <30mmHg difference between compartment pressure and DBP

Abdo
Normal 5-7mmHg
IAH = >12
ACS = >20 with new organ failure

ICP
8-12mmHg

Portal venous
<5mmHg. >5 = HTN, >10 risk of variceal haemorrhage.

21
Q

Cardiac axis

A

If I, II and either III or aVF are positive, axis is normal.

Perpendiculars:
I and aVF 
II and aVL 
III and aVR 
(On ECG - star shape) 
Round clock face: 
aVL = -30 (normal) 
I = 0 (normal) 
II = +60 (normal) 
aVF = +90 (normal) 
III = +120 (RAD) 
aVR = -150 (extreme/north west)
22
Q

Pleural fluid pH

A

Normal 7.62
Empyema <7.2

High amylase:

  • ca
  • pancreatitis
  • oesophageal rupture
23
Q

Cannula flow rates

A 
14 - orange - 270ml/min 
16 - grey - 236 (about 4m for 1L)
18 - green - 103 (about 10m for 1L) 
20 - pink - 67
22 - blue - 42
24
Q

PAC variables and normal values

A 
Directly measured 
CVP 0-8mmHg 
RAP 0-8mmHg
RVP 15-30/0-8mmHg
PAP 15-30/4-12mmHg 
PCWP 6-12mmHg 
CO 4.5-6 L/m
SvO2 75% 
ScvO2 70% 
HR 60-100bpm 
Derived 
CI 2.5-4 L/min/m2
SV 60-80ml 
SVI 35-65ml/m2 
SVR 800-1200 dynes/s/cm5
SVRI 1600-2400 dynes/s/cm5/m2
PVR 50-120 dynes/s/cm5
PVRI 250-340 dynes/s/cm5/m2 
CaO2 180ml/L
CvO2 130ml/L 
DO2 850-1050ml/min 
VO2 180-300ml/min
25
Q 
How far in? 
Oesophageal Doppler
PAC
Sengstaken-Blakemore
NG 
NJ 
ETT 
Temp probe
A 
Oesophageal Doppler 35-40cm (T5/6) 
PAC 40-55cm 
Sengstaken-Blakemore 50cm 
NG 60-70cm 
NJ 100cm 
ETT 4-5cm above carina, T4 (T2 in paeds) 
Perc trache T2/3 usually 
Temp probe: 10cm NP, 40cm distal oesophagus
26
Q

Cardiac arrest survival to discharge

A

In hospital: 15-20%
Out of hospital: 5-10%
If pt came to ICU: 33% survival, 80% of whom to usual residence

27
Q

Minimum size ICU bedspace

Minimum proportion of side rooms

A

20m2 (25m2 for side rooms)

Min 20% side rooms

28
Q

ICU beds/cost/staffing/readmission

A

No. ICU beds in England in 2013: 3829 (77.1% occupancy)
Cost of a day in ICU: £1600-1900
Costs: 60% staffing (mainly nursing)

Readmission rate (within 48h) target: <1.8%

29
Q

Minimum staffing ratios

A

Nursing
Level 1 - 1:4
Level 2 - 1:2.5
Level 3 - 1:1

Medical
Resident 1:8
Consultant 1:15

Physio
Level 3 - 1:4

Pharmacy
Level 3 - 1:10

+ dietician, OT, SALT, micro, radiology etc

30
Q

Failed extubation rate (<72h)
Accidental extubation rate
Post-extubation stridor

A

Ideal 10-20%

Higher = pts being extubated too early 
Lower = pts being extubated too late

Accidental extubation rate about 16%

Post-extubation stridor 16%

31
Q

ICU survival

A

80% to hospital discharge

Lone 2016 - SICSAG data - ICU survivor 5y survival 53% vs 27% for matched hospital controls

32
Q

High risk surgery

A

A group that accounts for 80% of surgical mortality but only 12.5% of procedures

<15% of high risk patients are admitted to ICU

RCS Higher Risk General Surgical Patient Report 2011

  • Mortality risk ax for every pt e.g. P-POSSUM
  • > 5% risk needs consultant input at all stages
  • > 10% needs direct involvement of consultant surgeon and consultant anaesthetist, and postop critical care as standard practice

Major cardiac surgery - overall mortality 2%

33
Q

Acceptable drain output post major cardiac surgery

A 
400ml first hour 
or 
200ml/h first 2h 
or 
100ml/h first 4h
34
Q

AKI in critical illness

A 
Incidence up to 25% 
Independent predictor of mortality 
57-80% mortality if RRT required 
15-30% RRT dependent at hospital discharge 
Double the 1y mortality of MI!
35
Q

VTE

A

60k deaths/year in UK

PE
27% in ICU pts
15% in hospital pts overall

MOF/major trauma pts have >50% probability of DVT if not anticoagulated.

80% of DVTs are clinically undetectable

LMWH first line, UFH second, fondaparinux in HIT

Avoid if plt<50 or INR>1.5

IVC filters - for prevention of PE in patients with a DVT and a CI to thromboprophylaxis. Still start LMWH as soon as no longer CI.

36
Q

SvO2

A 
70-80% = optimal
<60% = inadequate perfusion
<50% = too low for aerobic metabolism
>80% = hyperdynamic e.g. sepsis

Causes of low SvO2

  • increased O2 demand (exercise, pyrexia, shivering, pain)
  • reduced O2 supply (low CaO2, inadequate CO)

Normally SvO2 (mixed) > ScvO2 (central) because O2 extraction higher from upper body/brain. But can swap round in critical illness as renal/splanchnic blood supply falls whilst that to brain and heart are maintained.

37
Q

CPR

A

Good quality CPR perhaps MAP of 40 and CO 1L/m
Circulatory arrest causes LOC in about 5s
ROSC under 11m can restore full brain function
ROSC up to 60m can restore some brain function

38
Q

Normal serum urea:creatinine ratio

A

1:15

39
Q

Normal serum WBC:RBC ratio

A

1:500

Therefore expect up to this ratio in a ‘bloody tap’

More WBCs indicates infection

40
Q

Normal PFR

A

13.3/0.21 = 63.3

41
Q

pH range over which humans can survive

A

6.8-7.8

42
Q

Spinal cord injuries

A 
C3 and above: ventilator dependent
C4-6: most common site of injury
T1-4: cardioaccelerator outflow 
T6 and above: neurogenic shock, autonomic dysreflexia  
T9-11: artery of Adamkiewicz 
T12 and above: poor cough
43
Q

Vital capacity

A

Normal 60-70ml/kg

Intubation threshold 15ml/kg

44
Q

PaCO2 targets

A

3.5-4 - ventilated third trimester (‘normal’ will make fetus acidotic)
4-4.5 - temporisation of high ICP
4.5-5 - standard neuroprotection

EtCO2 is about 0.5kPa lower than PaCO2 because of dilution by other gases. The difference can increase to 1kPa or more in the presence of V/Q mismatch or shunt.

FFICM (8 decks)

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