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Surgical Recall > SR 65 - Surgical Intensive Care > Flashcards

SR 65 - Surgical Intensive Care Flashcards

1
Q

How is an ICU note written?

A 
By systems:
- Neuro (GCS, MAE, pain control)
- Pulmonary (vent settings)
- CVS (pressors, swan numbers)
- GI (gastrointestinal)
- Heme (CBC)
- FEN (Chem10, nutrition)
- Renal (urine output, BUN, Cr)
- ID (Tmax, WBC, antibiotics)
Assessment/plan
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2
Q

Possible causes of fever in the ICU?

A 
Central line infection
Pneumonia/atelectasis
UTI, urosepsis
Intra-abdominal abscess
Sinusitis
DVT
Thrombophlebitis
Drug fever
Fungal infection, meningitis, wound infection
Endocarditis
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3
Q

What sit he most common bacteria in ICU penumonia?

A

Gram-negative rods

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4
Q

Basic ICU care checklist?

A

FAST HUG

  • Feeding
  • Analgesia
  • Sedation
  • Trhomboembolic prophylaxis
  • Head-of-bed elevation
  • Ulcer prevention
  • Glucose control
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5
Q

What is CO?

A

Cardiac output = HR X SV

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6
Q

What is normal CO?

A

4-8L/min

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7
Q

What factors increase CO?

A

Increased contractility, HR, preload

Decreased afterload

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8
Q

What is CI?

A

Cardiac index = CO/BSA

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9
Q

What is normal CI?

A

2.5-3.5L/min/M2

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10
Q

What is SV?

A

Stroke volume
Amount of blood pumpoed out of the ventricle each ebat
EDV-ESV or CO/HR

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11
Q

What is normal SV?

A

60-100cc

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12
Q

What is CVP?

A

Central venous pressure

Indirect measurement of intravascular voume status

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13
Q

What is normal CVP?

A

4-11

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14
Q

What is PCWP?

A

Pulmonary Capillary Wedge Pressure

Indirectly measures left atrial pressure, which is an estimate of intravascular volume (LV filling pressure)

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15
Q

What is the normal PCWP?

A

5-15

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16
Q

What is the anion gap?

A

Na - (Cl + HCO3)

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17
Q

What are the normal values for anion gap?

A

10-14

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18
Q

Why do you get an increased anion gap/

A

Unmeasured acids are unmeasured anions in teh equation that are part of the ‘counterbalance’ to the sodium cation

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19
Q

What are the causes of incrased anion gap acidosis in surgical patients?

A 
Starvation
Alcohol (ethanol, methanol)
Lactic acidosis
Uremia (renal failure)
DKA
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20
Q

What is SVR?

A

Systemic vascular resistance

MAP - CVP / CO x 80

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21
Q

What is SVRI?

A

Systemic Vascular Resistance Index

SVR/BSA

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22
Q

What is normal SVRI?

A

1500-2400

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23
Q

What is MAP?

A

Mean arterla pressure
DBP + 1/3 SBP

(not the mean b/c diastole lasts longer)

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24
Q

What is PVR?

A

Pulmonary vascular resistance

PA (mean) - PCWP / CO X 80

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25
Q

What is the normal PVR value?

A

100 +/- 50

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26
Q

What is the formula for arterial oxygen content?

A

Hb X SaO2 x 1.34

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27
Q

What is the basic formula for oxygen delivery? Full formula?

A

CO x (oxygen content)

CO x (1.34 x Hg x SaO2) x 10

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28
Q

What factors can increase oxygen delivery?

A

Increased CO by increasing SV, HR or both

Increased O2 content by increasing Hb content, SaO2 or both

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29
Q

What is mixed venous oxygen saturation?

A

SvO2
The O2 saturation of teh blood in teh right ventricle or pulmonary artery
An indirect measure of peripehral oxygen suplly and demand

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30
Q

Which lab values help assess adequate oxygen delivery?

A

SvO2 - low with inadequate delivery
Lactic acid - elevated
pH - acidosis
Base deficit

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31
Q

What is FENa?

A

Fractional Excretion of Sodium

(Una x Pcr / Pna x Ucr) x 100

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32
Q

What is the prerenal FENa value?

A
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33
Q

How long das Lasix effect last?

A

Six hours

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34
Q

What is the formula for flow/pressure/resistance?

A

Pressure = Flow x Resistance

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35
Q

Effect of PaCO2 on acid-base status?

A

For every increase in PaCo2 by 10mmHg, pH falls by 0.08

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36
Q

One liter of O2 via nasal canula raises FiO2 by how much?

A

3%

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37
Q

SICU Drugs:

Dopamine

A

Site of action - dependant on doses

  • Low dose (1-3ug/kg/min): Dopa agonist, renal vasodilation
  • Intermediate dose (4-10): + a1, ++B1; positive ionotropy and some vasocontriction
  • High dose (>10): +++a1 agonist; marked afterload increase from arteriolar vasoconstriction
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38
Q

Has ‘renal dose’ Dopamine been shown to decrease renal failure?

A

No

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39
Q

SICU Drugs:

Dobutamine

A

SOA: +++B1 agonist, ++B2
Effect: increased inotropy; increased chronotropy; decrase in SVR

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40
Q

SICU Drugs:

Isoproterenol

A

SOA: +++B1 and B2 agonist
Effect: Increase inotropy, increased chronotropy; vasodilation of skeletal and mesenteric vascular beds

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41
Q

SICU Drugs:

Epinephrine

A

SOA: ++ a1, a2, ++++B1/2 agonist
Effect: Increased inotropy, increased chronotropy

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42
Q

SICU Drugs:

Norepinephrine

A

SOA: +++a1, a2, +++B1/2 agonist
Effect: Increased inotropy, increased chronotropy, ++ increas in BP

43
Q

What is the effect of Epinephrine at high doses?

A

Vasoconstriction

44
Q

What is the effect of high dose Norepinephrine?

A

Severe vasoconstriction

45
Q

SICU Drugs:

Vasopressin

A

Effect: Vasoconstriction, increases MAP, SVR
Indications: Hypotension, refractory to other vasoporessors

46
Q

SICU Drugs:

Nitroglycerine

A

SOA: +++venodilation, +ateriolar dilation
Effect: Increased venous capacitance, decreased preload, coronary arteriole vasodilation

47
Q

SICU Drugs:

Sodium nitroprusside

A

SOA: +++ venodilation, +++ arteriolar dilation
Effect: Decreased preload and afterload, allowing BP titration

48
Q

What is the major toxicity of Sodium Nitroprusside?

A

Cyanide toxicity

49
Q

Define Preload

A

Load on the heart msucle taht stretches it to EDV = intravascular volume

50
Q

Define afterload

A

Load or resistance the heart must pump against = vascular tone = SVR

51
Q

Define contractility

A

Fource of heart muscle contraction

52
Q

Define compliance

A

Distensibility of heart by the preload

53
Q

What is the Frank-Starling curve?

A

Cardiac output increases with increasing preload up to a point

54
Q

What is the clinical significance of the steep slope of the Starling curve relating EDV to CO?

A

Demonstrates the importance of preload in determining CO

55
Q

What factors influence the oxygen content of whole blood?

A

Hemoglobin concentration and the arterial oxygen saturation

Partial pressure of oxygen dissolved in plasma plays a minor role

56
Q

What factors influence mixed venous oxygen saturation?

A

Oxygen delivery (Hb concentration, arterial O2 sat, CO) and oxygen extraction by the peripheral tissues

57
Q

What lab test for tissue ischemia is absed on teh shift from aerobic to anaerobic metabolism?

A

Serum lactic acid levels

58
Q

Define dead space

A

Part of inspired aire that does not participate in gas exchange

59
Q

Define Shunt fraction

A

Fraction of pulmonary venous blood that does not participate in gas exchange

60
Q

What causes increased dead space?

A

Overventilation (emphysema, excessive PEEP)

Underperfusion (PE, low CO, pulmonary artery vasoconstriction)

61
Q

At high shunt fractions,w aht is the effect of increased FiO2 on arterial PO2?

A

Shunt fraction>50%, changes in FiO2 have NO effect on arterial PO2
You want to minimize FiO2 to prevent oxygen toxicity

62
Q

Define ARDS

A

Acute respiratory distress syndrome

Lung inflammation causing respiratory failure

63
Q

What is the ARDS diagnostic triad?

A

CXR:

- Capillary wedge pressure

64
Q

What does the classic CXR look like with ARDS?

A

Bilateral fluffy infiltrates

65
Q

At what concentration does O2 toxicity occur?

A

FiO2 >60% x 48hrs

66
Q

What is the only ventilatory parameters that have been shown to decreased mortality in ARDS patients?

A

Low tidal volumes (

67
Q

What are the main causes of CO2 retention?

A

Hypoventilation
Increased dead space ventilation
Increased CO2 production (hypermetabolic states)

68
Q

Why are carbohydrates minimized in patient having difficulty with hypercapnia?

A

Respiratory Quotione is ration of Co2 production to O2 consumptoin
The RQ is highes for carbohydrates (1.0) and lowest for fats (0.7)

69
Q

Why are indwelling arterial lines used for BP monitoring in critically ill patients?

A

Need for frequent measurments
Inaccuracy of repeated cuff measurements
Inacuraccy of cuff measurements in hypotension
Need for frequent ABGs

70
Q

Which values are obtained from a SGC?

A

CVP, PA pressures
PCWP, CO, PVR, SVR
Mixed venous O2 sat

71
Q

What is PCWP?

A

PCP after ballon occlusion of the PA, which eaquals elft atrial pressure
LAP is equal to LVP/EDP, left heart preload, and intravascular volume status

72
Q

What is the primary use of PCWP?

A

Indirect measure of preload = intravascular volume

73
Q

Has use of SGC been shown to decrease mortality in ICU patients?

A

No

74
Q

Define ventilation

A

Air moving through the lungs

Monitored by PCO2

75
Q

Define oxygenation

A

Oxygen delivery to the alveoli

Mesasured by O2Sat and PO2

76
Q

What can increase ventilation to decrease PCO2?

A

Increased RR
Increased TV
(Increasing minute ventilation)

77
Q

What is minute ventilation?

A

Volume of gas ventilated through the lungs

RR x TV

78
Q

Define tital volume

A

Volume delived with each breath

6-8cc/kg on ventilator

79
Q

Are ventilation and oxygenation related?

A

No - you can have an O2Sat of 100% and PCO2 of 150

O2Sat do NOT tell you anything abotu PCO2

80
Q

What can increase PO2 in the ventilated patient?

A

Increased FiO2

Increased PEEP

81
Q

Define IMV

A

Intermittent Mandatory Ventilation
Patient can breath on their own, but if they don’t breath within a specific time, the machine breathes
Can breath above the mandatory rate without help from the ventilator

82
Q

Define SIMV

A

Synchronous IMV
Delivers mandatory breath synchronously with patient’s initiated effort. If no breath is initiated, breath will be initiated by machine.
Patient’s breath triggers the machine to supplement the breath

83
Q

Define A-C

A

Assist-Control venitlation
Ventilator delievers breath when patient initiates a breath
If the patient does not breath , ventilator takes control
All breaths are by the ventilator

84
Q

Define CPAP

A

Continuous Positive Airway Pressure
Delieves continuous pressure during expiration and inspiration, but no volume breaths
Patient breaths on own

85
Q

Define Pressure Support

A

Pressure is delieved with initiated breaths
Decreases work of breathing by overcoming the resistance in the venitlatory circuts
Patient breaths on own

86
Q

Define APRV

A

Airway Pressure Release Ventilation

HIgh airway pressure intermittently released to a low airway pressure

87
Q

Define HFV

A

High frequency ventilation

Rapid rates of venitlation with small tidal volumes

88
Q

What is the effect of PP ventilation in patients with hypovolemia or low lung compliance?

A

Decreased VR

Decreased CO

89
Q

Define PEEP

A

Positive end expiration pressure

Pressure maintained at the end of a breath - keeps alveoli open

90
Q

What is ‘physiologic PEEP’?

A

5cmH2O

Approximates normal pressure in normal non-intubated people caused by the closed glottis

91
Q

What are the AE of increasing levels of PEEP?

A

Barotrauma (injury to airway = PTX)

Decreased CO from decreased preload

92
Q

What are the typical initial vent settings?

A 
IMV
TV = 6-8ml/kg
VR = 10bpm
FiO2 = 100% and wean down
PEEP = 5cmH2O

Then change based on ABGs

93
Q

What is normal I:E?

A

1:2

94
Q

When would you use an inverse I:E ratio?

A

Ex - 2:1, 3:1
To allow for longer inspiration inpatients with poor compliance
To allow for alveolar recruitment

95
Q

When would you use a prolonged I:E ratio?

A

Ex. 1:4
COPD
To allow time for complete exhalation
Prevents ‘breath stacking’

96
Q

What clinical situations cause increased airway resistance?

A 
Airway or endotracheal tube obstruction
Bronchospasm
ARDS
Mucous plug
CHF --> pulmonary edema
97
Q

What are the presumed advantages of PEEP?

A

Prevention of alveolar collapse and atelectasis
Improved gas exchange
Increased pulmonary compliance
Decrease shunt fraction

98
Q

What are the possible disadvantages of PEEP?

A 
Decreased CO (esp in Hypovolemia)
Decreased gas exchange
Decreased compliance with high levels of PEEP
Fluid retention
Increased ICP
Barotrauma
99
Q

What parameters must be evaluated in deciding if a patient is ready to be extubated?

A 
Alert and able to protect airway
Gas exhange (PaO2 >70, PaCO2 5cc/kg)
Minute ventilation (
100
Q

What is the Rapid-Shallow Breathing (AKA Tobin) Index?

A

RR:TV

101
Q

What is the possible source of fever in a patient with an NG or nasal endotracheal tube?

A

Sinusitis

Diagnose by sinus films or CT

102
Q

What medications can be delievered via an endotracheal tube?

A 
Narcan
Atropine
Vasopressin
Epinephrine
Lidocaine
'NAVEL'
103
Q

What conditions should you think of with increased peak airway pressure and decreased urine output?

A

Tension pneumonthorax

Abdominal compartment syndrome

Surgical Recall (32 decks)

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