Surgical- ICU

Question 1

two major reasons for admittance to the ICU

Answer 1

1. Organ failure affecting biologic homeostasis that cannot be appropriately managed on a regular floor
   Ex: Respiratory distress
2. Concern for progressive worsening of conditions that could warrant the need for close and frequent monitoring
   ex: Multiple rib fractures in a fragile patient

Question 2

3 mortality risk scoring systems. why do these matter for the ICU?

Answer 2

APACHE (Acute Physiology and Chronic Health Evaluation)
SAPS (Simplified Acute Physiologic Score)
MPM (Mortality Probability Model)
* The key is to transfer patients out of ICU as fast as possible once they have stabilized.

Question 3

central venous access is placed with the assistance of what?

Answer 3

visualization with US guidance

except sometimes not for subclavian placement- US on bone doesnt work

Question 4

central venous line: types of access, what to know about each?

Answer 4

Femoral
Subclavian
IJ
PICC (periph. inserted central cath: like IV in the arm)

Question 5

what are the risks for each type of central line access? femoral, subclavian, IJ

Answer 5

Femoral: “Dirty”: near the groin– should change to access site that is less likely to become infected ASAP
Subclavian – increased risk of Pneumothorax
IJ – close to carotid!! (don’t accidentally dilate this!)

Question 6

what is the benefit of the PICC central line?

Answer 6

allows for prolonged access in patients required prolonged IV therapy. They can go home with this

Question 7

types of lines

Answer 7

MML (multi-med line)

Vascath (larger for more viscous fluid)

Question 8

what are 4 types of meds used for sedation in the ICU?

Answer 8

Benzos
Propofol (Diprivan)
Precedex (Dexmetomidine)
Haloperidol (Haldol)

Question 9

benefit of using Benzos (ex/ versed, ativan) for sedation? Cons to using benzos?

Answer 9

sedation + amnesia
- amnesia can prevent the PTSD assoc. with ICU stay
Cons: overdose, withdrawal

Question 10

what is the RASS score?

Answer 10

a scoring system used to measure the patient’s sedation. providers tell the nurse a score range in which they want their patient to be at. (+4 combative down to -5 unarousable sedation)

Question 11

don’t provide sedation without _____

Answer 11

analgesia

Question 12

4 drugs used for analgesia

Answer 12

IV morphine
IV fentanyl 
epidural  
Toradol (NSAID) 
*PCA (patient- controlled-Analgesic)

Question 13

IV morphine vs IV fentanyl

Answer 13

*both need titrated dosing

Morphine: active metabolites can accumulate in renal failure (dose reduction by 50%), increased incidence of vasodilation and hypotension due to stimulation of histamine release;

Fentanyl: faster acting than morphine, no active metabolites, less likely to decrease BP, absorbed readily into CNS so quicker onset of action and shorter acting;

Question 14

SIRS criteria

Answer 14

At least 2 of the following
Temperature >38C or <36 C
Heart rate > 90 bpm
RR > 20 bpm or pCO2 < 32 mmHg
WBC >12,000 or < 4,000
Or >10% bands

Question 15

what is SIRS?

Answer 15

Systemic Inflammatory Response Syndrome

Question 16

what is sepsis?

Answer 16

SIRS due to infection

Question 17

severe sepsis vs septic shock

Answer 17

Severe Sepsis: One or more vital organ dysfunction/failure

Septic Shock: Severe sepsis + hypotension refractory to volume resuscitation

Question 18

shock that causes hypovolemia, what order of fluids are you giving the pt?

Answer 18

two liters of crystalloid- switch to a colloid: if blood counts are low - give blood, if blood counts are normal and they need volume- give albumin

Question 19

MODS and MOF stand for what?

Answer 19

MODS (Multiorgan Dysfunction Syndrome) and MOF (Multiorgan Failure)

Question 20

what 4 organs are frequently injured in SIRS and sepsis?

Answer 20

Lungs: ARDS (Acute Respiratory Distress Syndrome) – see in about 40% of severe sepsis cases
Kidneys
CV system
CNS (encephalopathy)

Question 21

benefits of Propofol (Diprivan) for sedation?

maybe weeds

Answer 21

• rapid acting, short-term, amnesia
• head injury
• reduction in delerium tremens (alc withdrawal)

Question 22

two things to consider when using propofol

maybe weeds

Answer 22

Dosage based on IBW (ideal body weight) and not actual body weight
Prepared in lipid emulsion: Check triglycerides and CK

Question 23

two uses of precedex for sedation?

maybe weeds

Answer 23

• Sedation without respiratory depression (for pts who are not ventilated, for other meds you need a ventilator)
• used for weaning from sedation

Question 24

ADRs for precedex (maybe weeds)

Answer 24

Hypotension and Bradycardia (may be severe)

Question 25

two uses for haldol for sedation

maybe weeds

Answer 25

Sedation and antipsychotic

Good in patients with delirium

Question 26

3 ADRs for Haldol

maybe weeds

Answer 26

1. extraparamyidal reactions
2. Neuroleptic malignant syndrome
3. torsades with prolong QT

Question 27

what analgesia is good for rib fractures?

Answer 27

epidural

Question 28

4 step approach to SIRs/ Sepsis

Answer 28

1. Treat underlying cause
2. Do not cause further damage - take off meds that will further injury/damage
3. Address organ failure (encephalopathy and vol. status)
4. vasopressors (if needed, if you can’t manage BP with vol. replacement)

Question 29

when addressing for organ failure in the approach to SIRs/Sepsis, what should the volume status vitals show? (MAP, UOP, CVP, SvO2)
(maybe weeds)

Answer 29

MAP >65%
UOP >0.5ml/kg per hour
CVP 8-12 mmHg
SvO2 or ScvO2>70% - Oxyhemoglobin saturation in mixed venous and central venous blood

Question 30

ABGs: what level is acidic vs alkalotic blood?

Answer 30

acidic < 7.35

alkalotic > 7.45

Question 31

What variable is typically changed, and in what direction, in a respiratory acidosis?
Metabolic acidosis?

Answer 31

incraesed CO2

decreased HCO3

Question 32

ICU monitoring: 3 ways to measure blood pressure?

Answer 32

CVP
pulm wedge pressure
EV1000

Question 33

when is EV1000 used over CVP?

Answer 33

EV 1000- most accurate for ventilator dependent and regular Heartbeat.

Question 34

what is EV1000?

Answer 34

Measure SV and SVV (Stroke Volume Variation)
–> variation between SV with each beat : (reverses the pulses parodoxis -b/c positive pressure of ventilator)

-As SVV goes down, SV increases

Question 35

EV 1000: what is the target SVV?

Answer 35

SVV < 10% - not preload responsive

Target SVV 10-15% (ish) (ex/ if its 20%, they need volume)

Question 36

ventilator settings (RR, FiO2, PS, PEEP)

Answer 36

RR -set rate
Volume - tidal volume
FiO2 - how much O2 is provided through the ventilator
PS - pressure support
PEEP - positive end expiratory pressure (enough pressure to keep alveoli open)

Question 37

why do we worry about endocrine response in the ICU?

Answer 37

Critical illness may alter glucose metabolism

Question 38

endocrine response: DM vs non-DM pt

Answer 38

non DM pt- stress-induced hyperglycemia
Check HgA1C

DM pt – Cont Metformin?? - No b/c they are not in their normal state, they need more than what the meds usually provide.
SSI - sliding scale insulin
Strict glycemic control: keep around 120 <170

Question 39

why do we use anticoagulation in ICU?

Answer 39

ICU pts are in a hyperCoag state

Question 40

4 types of anti-coag

Answer 40

heparin
lovenox (LMW heparin)
warfarin
ASA

Question 41

what are the benefits of using heparin for ICU hypercoag? what about ASA?

Answer 41

common- short acting. if back and forth for surgery (take on and off easily)
if needed to combat plt. aggregation, to decr. clot risk

Question 42

nutrition: when is TPN used?

Answer 42

TPN: total parental nutrition in prolonged NPO status-

—> bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs

Question 43

why do we need to check ABGs?

Answer 43

if on ventilator and needing to stabilize, calc. anion gap, etc.