Surgical- ICU Flashcards
two major reasons for admittance to the ICU
- Organ failure affecting biologic homeostasis that cannot be appropriately managed on a regular floor
Ex: Respiratory distress - Concern for progressive worsening of conditions that could need for close monitoring
ex: Multiple rib fractures in a fragile patient
3 mortality risk scoring systems. why do these matter for the ICU?
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.
central venous access is placed with the assistance of what? (KNOW)
visualization with US guidance
except sometimes not for subclavian placement- US through bone doesnt work
central venous line: types of access? (4) KNOW
Femoral
Subclavian
IJ
PICC (periph. inserted central cath: like IV in the arm)
what are the risks for each type of central line access? femoral, subclavian, IJ (KNOW)
1) . Femoral: “Dirty”: near the groin– should change to access site that is less likely to become infected ASAP
2) . Subclavian – increased risk of Pneumothorax
3) . IJ – close to carotid!! (don’t accidentally dilate this!)
what is the benefit of the PICC central line? (KNOW)
allows for prolonged access in patients required to have prolonged IV therapy. They can go home with this
2 types of central venous lines (KNOW)
MML (multi-med line)
Vascath (larger for more viscous fluid)
what are 4 types of meds used for sedation in the ICU? (KNOW)
Benzos
Propofol (Diprivan)
Precedex (Dexmetomidine)
Haloperidol (Haldol)
benefit of using Benzos (ex: versed or ativan) for sedation? Cons to using benzos? who do you not give them to? (KNOW)
- sedation + amnesia
- amnesia can prevent the PTSD assoc. with ICU stay
Cons: overdose, withdrawal
** DONT give to elderly, heart failure or resp/hepatic insufficency
what is the RASS score? (KNOW)
a scoring system used to measure the patient's sedation. \+4 combative \+3 very agitated \+2 agitated \+1 Restless 0 alert and calm -1 drowsy -2 light sedation -3 mod sedation -4 deep sedation -5 unarousable sedation)
don’t provide sedation without ________ (KNOW)
analgesia
5 drugs used for analgesia (KNOW)
IV: morphine, fentanyl, PCA
epidural
Toradol (NSAID)
*PCA (patient- controlled-Analgesic)
IV morphine vs IV fentanyl (KNOW)
*both need titrated dosing
Morphine: metabolites can accumulate in renal failure (dose reduction by 50%), increased vasodilation and hypotension due to stimulation of histamine release;
Fentanyl: faster acting, less likely to decrease BP, absorbed readily into CNS (quicker onset of action and shorter acting)
SIRS criteria (KNOW)
*systemic inflammatory response syndrome* 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
what is sepsis?
SIRS due to infection
severe sepsis vs septic shock
Severe Sepsis: One or more vital organ dysfunction/failure
Septic Shock: Severe sepsis + hypotension refractory to volume resuscitation
shock that causes hypovolemia, what order of fluids are you giving the pt?
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
MODS and MOF stand for what?
MODS (Multiorgan Dysfunction Syndrome) and MOF (Multiorgan Failure)
what 4 organs are frequently injured in SIRS and sepsis?
1) Lungs: ARDS (Acute Respiratory Distress Syndrome) – see in about 40% of severe sepsis cases
2) . Kidneys
3) . CV system- volume probs
4) CNS- altered mental status (encephalopathy)
what analgesia is good for rib fractures? (KNOW)
epidural
4 step approach to SIRs/ Sepsis
- Treat underlying cause
- Do not cause further damage - take off meds that will further injury/damage
- Address organ failure (encephalopathy and vol. status)
- vasopressors (used if you can’t manage BP with vol. replacement)
ABGs: what level is acidic vs alkalotic blood?
acidic < 7.35
alkalotic > 7.45
What variable is typically changed, and in what direction, in a respiratory acidosis?
Metabolic acidosis?
increased CO2
decreased HCO3
ICU monitoring: 3 ways to measure blood pressure?
CVP
pulm wedge pressure
EV1000
when is EV1000 used over CVP?
EV 1000- most accurate for ventilator dependent and regular Heartbeat.
what is EV1000?
Measure SV and SVV (Stroke Volume Variation)
-As SVV goes down, SV increases
EV 1000: what is the target SVV?
Target SVV under 15% (ish) (ex/ if its 20%, they need volume)
do we continue metformin in DM pt in the ICU?
NO, they are not in their normal state, they need more than what the meds usually provide
1st- SSI - sliding scale insulin
Strict glycemic control: keep around 120 <170
2nd- if SSI isn’t working after 2 doses, switch to insulin drip
why do we use anticoagulation in ICU? when do we use each type?
ICU pts are in a hyperCoag state
- heparin: short acting (taking pt back and forth to OR)
- Lovenox: can reverse
- Aspirin: combat platelet aggregation, arterial injuries
nutrition: when is TPN used?
TPN: total parental nutrition in greater than 7 days of NPO status-
—> bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs
why do we need to check ABGs?
if on ventilator and needing to stabilize, calc. anion gap, etc.
why do you want to manage use of Toradol? (KNOW)
inhibits platelet aggregation and impairs renal function (no more than 5 days)
How do you manage someone’s pain with a RASS score of -1 to 0? (KNOW)
continuous infusion, once patients sedation level improves then the pain management can decrease
what blood levels are checked to monitor lovenox dosing?
10A
pros of using propofol for sedation? Cons? USES (2) KNOW
-Pros: rapid acting, short lasting, amnesia
-Cons: change diet bc a lot of fat in it
USES** those with head injury (dec cerebral O2 consumption), those withdrawing from alcohol (dec DT’s)
what two levels do we check when a patient is on propofol sedation?
CK and LD (if elevated then we change sedation type)
Pros of precedex sedation? Cons? USES (2) KNOW
-Pros: sedation WITHOUT resp depression, sed + anxiolytic + mild pain relief
-Cons: hypotension and bradycardia
USES** great for WEANING from sedation or those who withdrawal easily
Pros of Haldol sedation? Cons? USE (know)
-Pros: sedation and anti psychotic
-Cons: 10-20 mins to take effect, extrapyramidal rxns, torsades, neuroleptic malignant syndrome
USE** patients with delirum
shock types
1) . Hypovolemic: hemorrhagic vs non hemorrhagic
2) . distributive: neuro, septic, adrenal
3) . cardiogenic: AMI
4) . obstructive: tamponade, PE, tension pneumo
