Random stuff Flashcards
Causes of hepatosplenomegaly and massive splenomegaly
Kala-Azar (visceral leischmaniasis) Malaria Myelofibrosis Sarcoidosis Amyloidosis Chronic myeloid leukaemia (CML) Lymphoma Chronic liver disease
Risks for pressure ulcers
Duration of surgery Faecal incontinence and/or diarrhoea Low albumin concentrations Disturbed sensory perception Obesity Moisture of the skin Impaired circulation Use of inotropic drugs Diabetes mellitus Too unstable to turn, or other reason for decreased mobility, High APACHE II score. Waterlow’s score, Braden’s score or other valid scores
Why may RA patient have DI in ICU
Poor neck extension due to C-spine arthritis
Risk of spinal cord injury due to atltantoaxial subluxation
Poor mouth opening due to TMJ arthritis
Poor vocal cord opening due to laryngeal arthritis or crico-arytenitis
Poor respiratory reserve due to pulmonary fibrosis
Difficulty assessing all of these issues in the context of an ICU intubation - you are not seeing this person in the pre-admission clinic; likely they are trying to die in some sort of advanced life support scenario.
how may rheumatoid arthritis influence intensive care management
Related to the RA itself
RA can be a multisystem disease.
Respiratory – pulmonary fibrosis, pleural effusion, reduced chest wall compliance.
Cardiac – increased risk of IHD, pericardial disease, valvular insufficiency, cardiac failure.
Renal – insufficiency directly related to the RA is rare, although does occur (GN, IN, amyloid).
Haematological – e.g. anaemia (chronic disease), thrombocytopenia (Felty’s).
Amyloidosis – cardiac, renal, hepatic.
Skin / pressure sores.
Difficult venous / arterial access – limb deformity.
Analgesia requirement.
Secondary amyloidosis affecting liver spleen and kidneys.
Decisions re-extubation if difficult intubation.
Post-extubation – difficulties with chest physiotherapy, mobilisation.
Psychosocial aspects of patient with chronic illness.
Related to the treatment for RA
Immunosuppression – infectious complications.
Other cytopaenias – anaemia, thrombocytopenia.
Need for adequate steroid replacement if long-term use.
Pulmonary – e.g. ILD from MTX, gold.
Renal – more likely related to medications that RA itself – e.g. NSAIDS, cyclosporine, penicillamine, gold.
Hepatic – e.g. MTX, Azathioprine.
Upper GI bleeding – NSAID, SSZ use.
Myopathy, skin breakdown, hyperglycaemia – steroids.
Drug interactions.
Potentially life threatening causes of delirium
Hypoxia Hypoglycaemia Intra-cerebral haemorrhage Meningitis/Encephalitis Poisoning Wernicke’s Encephalopathy Infection: local (wound, anastomotic leaks etc.), UTI, lung etc. Withdrawal from drugs Hypertensive encephalopathy Metabolic derangements – sodium, renal, liver.
Pulmonary changes in rheumatoid arthritis
Pleurisy/pleural effusion Pneumothorax Rheumatoid nodulosis Interstitial pulmonary fibrosis Caplan's syndrome is the combination of rheumatoid nodules and pneumoconiosis Bronchiectasis Pulmonary vasculitis Methotrexate-induced interstitial pulmonary fibrosis
Role of physiotherapist
Overall - respiratory, neurological, cardiovascular, MSSK roles
Respiratory optimisation; aid in clearning of secretions and maintaining or recruiting lung volumes
- manual hyperinflation, suction, inspiratory muscle training, positioning, percussion/vibration
Musculoskeletal optimisation
- Mobilisation, joint-protective positioning, tone-improving positioning
Orthopedic
- Management of immobilisation devices, application and removal of plaster casts, fitting of collars, braces and slings
Rehabilitation
- Exercise and education to improve function following a period of critical illness
Ultrasound signs of PTx
Loss of comet tails and “marching ants” appearance
Ribs and pleura move together
“Lung point” – motionless horizontal lines are replaced by normal lung appearance moving from non-dependent to dependent region and also seen with inspiration and the probe held stationary.
Loss of “waves on the beach” appearance in M-mode
Daily sedation breaks
- benefits, risks and evidence
Exposure to sedating agents is undesirable, given that most agents have unpleasant side-effects
Interruptions in sedation may decrease the total dose of sedation over the course of one’s ICU stay
Proposed advantages
- More rapid weaning from ventilation
- Reduction in ICU length of stay
- Reduced need for vasopressors
- Reduced need for fluid boluses
Expected disadvantages
- Greater risk of self-extubation
- Greater psychological distress; potential for PTSD
- Increased nursing workload
- Increased patient-ventilator dyssynchrony
Cochrane verdict (2014) - meta-analysis, n=1282; no strong evidence in support of this practice. Tracheostomy may be performed less often.
Structure for retrieval question
Vehicle Equipment Monitoring Drugs Pt preparation Personel Communication (NOK and receiving hospital)
CLABSI rate
= confirmed blood stream infections / central line days x 1000
i.e. Number of confirmed blood stream infections per 1000 central line days
Acceptable is <1/1000 days
standardised mortality ratio (SMR) - calculation
observed number of deaths / expected number of deaths
therefore need to know;
- A time interval (you decide - three months, one year, etc.)
- A measurement of the observed number of deaths (ICU mortality numbers should be available widely)
- An estimate of the predicted mortality (this can be achieved using a scoring system; averaged out for the sample population)
SMR - results
An SMR of 1 means the mortality is as expected.
An SMR of < 1 is better than expected, and >1 is worse than expected.
Reasons for an elevated SMR
Apparent increase -
- scoring system data incorretly entered and underestimates mortality (eg no entry for chronic diseases, GCS just put as 15 for all)
- “Lead time bias” - treatment received prior to ICU admission may result in artifically normalised acute physiology scores
- “Healthy worker effect” - there are more well patients being admitted eg following elective surgery
Actual increase
- External to ICU;
A population with greater pre-ICU morbidity is suddenly available - eg suddenly providing ecmo
Pre-ICU care has changed its practice (for the worse)
Parameters which govern ICU admission have changed - pressure from other specialties/wards
Discharge arrangements have changed - eg no access to pall care
- Internal to ICU; actual underperfomance;
many causes - new/poorly trained staff, poor equipment
Good guidelines statement should:
Identify the organisation responsible
Define the purpose of the guideline
List individuals and groups responsible for its development
Document clearly the process of evaluation of the evidence
Provide a bibliography
Detail the assumptions
Record public policy and economic questions which were considered
Identify the need for special training required for implementation
Record how consumer concerns were taken into account
Detail methods for dissemination
Detail the timeframe for evaluation
The process of writing guidelines should include
Identify the practice
Compose the guidelines panel - form a multidiciplinary working party
Identify the question
Develop research strategies
Write the guidelines
Recursive improvement
Implementation
Audit and quality assurance
Revision
Capabilities of a level I ICU
Mechanical ventilation
Simple invasive cardiovascular monitoring
24-hour timeframe is the limit unless staffed by a FCICM
Capabilities of a level 2 ICU
Complex multi-system life support for an indefinite period
Minimum of 6 beds
At least 4 full time specialists on the roster
Capabilities of a level 3 ICU
Tertiary referral unit
Complex multi-system life support for an indefinite period
Commitment to academic education and research
At least 4 full time specialists per 12-bed “pod”
Staffing requirements in an ICU
A medical director
At least one specialist rostered
At least one other doctor rostered
Patient reviews at least daily, and ideally twice daily
1:1 nursing for ventilated patients and 1:2 for HDU-level patients (any fewer nurses, andmortality seems to increase)
There should be a nursing team leader, and nurse in charge of the unit
There should be at least one nurse educator per 50 nurses
There should be a documented educational program
Structure/practical set up consdierations for an ICU
All patients should be easily visible.
At least 20m2 per patient, or 25m2 per single room
At least one isolation room per every 6 patient beds
At least one wash basin for every 2 patient cubicles
At least 16 powerpoints per bed space
Windows are “desirable”.
There should be several dedicated areas: A staff working area and adequate storage space A pharmacy preparation room An equipment storage room A dirty utility A staff room offices seminar room A family room for relatives A cleaner's room A blood gas machine Library facilities
Approach to a fire
Remove the staff and patients from immediate danger.
Alert the switch board and fire department
Contain the fire by closing doors and windows
Extinguish the fire if it is practical and safe to do so.
And after that, you evacuate the remaining patients.Reverse triage is applied at this stage.
Follow orders from the fire warden
Risk factors for medication error:
Illness severity Extremes of age Unexpected admission Sedation Prolonged hospital stay Doses of drugs which require dosage calculations High staff stress, poor nurse-to-patient ratios Multiple simultaneous care providers
Prevention of medication error
Standardise the medications
Medication reconciliation (reconciling the list of ICU medications with the normal list of medications which the patient takes at home)
Computerise dose calculation and infusion devices
Adequate staffing
Checklist for drug administration
Avoid excessive working hours
Pharmacist participation in ICU care
The ideal scoring system would have the following characteristics:
- Scores calculated on the basis of easily/routinely recordable variables
- Well calibrated
- A high level of discrimination
- Applicable to all patient populations in ICU
- Can be used in different countries
- The ability to predict mortality,functional status or quality of life after ICU discharge
APACHE (Acute Physiology and Chronic Health Evaluation)
Includes the three factors that influence outcome in critical illness-
pre-existing disease, patient reserve and severity of
acute illness
Calculted using; Physiological variables, chronic health conditions and emergency /elective admissions and post- operative/non- operative admissions
Based on the most abnormal measurements in the first 24 hours of ICU stay
Can be used to calculate standardised mortality ratios for a population
A score of 25 represents a predicted mortality of 50% and a score of over 35 represents a predicted mortality of 80%.
SOFA (Sequential Organ Failure Assessment)
Degree of organ dysfunction related to acute illness
Defined score ( 1-4) for each of six organ systems- respiratory, CVS, CNS, Renal, coagulation and liver
Daily scoring of individual and composite scores possible during course of ICU stay
Can follow an individuals trend overtime
How to promote handwashing
System change
- Regular workplace survey to assess unmet goals
0 Ensure that products for hand hygiene are available at the point of care.
- Improve tolerability of hand hygiene products
- Improve ward infrastructure to improve access to handwashing facilities
Training and education
- Health-care workers should check each others’ compliance
- Regular education meetings
- Engage external educators
- Engage internal educations who can act as role models
- Focus on the doctors, who are generally the worst offenders
Reminders in the workplace
- Posters
- Promotions and rewards
- Schedule presentations
- Frequent educational sessions
Evalation and feedback
- Regular monitoring of compliance
- System of observers with centralised reporting
- Rewards and demerits for compliance (or its lack)
- Audit of changes in incidence of health care associated infections
- Establish a system for continuous recording and reporting hand hygiene product consumption
How are scoring systems useful
They (try to) predict outcome and length of stay
They can be used to compare predicted and observed outcome
They stratify patients for clinical trials, according to disease severity
They assess ICU performance
They allow resources to be allocated to ICUs according to the illness severity of their patients
They allow a comparison of ICUs
APACHE
APACHE stands for Acute Physiology, Age and Chronic Health Evaluation (I-IV).
APACHE II is the most commonly used one 12 variables are measured Scores range from 0 to 71 The risk of hospital death is computed by combining APACHE II score with Knaus' weighted coefficient for different types of disease entities. A score of 25 represents a predicted mortality of 50% and a score of over 35 represents a predicted mortality of 80%. Derived from histrical data set
