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Acute Care Block-Year 4 > The Patient Who Needs Escalation > Flashcards

The Patient Who Needs Escalation Flashcards

1
Q

what is the role of ICU?

A

Care for patients with severe life threatening illness who require enhanced monitoring an organ support ie ‘supportive care’

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2
Q

what patients go to ICU?

A
  • Require high level monitoring or organ support (eg ventilator/haemodialysis)
  • Reversible pathology (eg pneuomia on ventilator whilst antibiotics therapy)
  • Physiological reserve to survive intensive/invasive treatment
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3
Q

LEVELS OF CARE

what is level 0?

A

patients whose needs can be met through normal ward care in an acute hospital (IV treatment, nursing care (1:8), IG feeding etc)

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4
Q

LEVELS OF CARE

what is level 1?

A

patients at risk of their condition deteriorating or those recently relocated from higher levels of care whose needs can be met on an acute ward with additional advice and support with critical care team (not found in all hospitals) eg vascular patients post surgery – high level nursing care, perioperative care 1:4 nursing

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5
Q

LEVELS OF CARE

what is level 2?

A

patients requiring more detailed observation or intervention including support for a single failing organ system or post operative care and those stepping down from higher levels of care 2:1 nursing

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6
Q

LEVELS OF CARE

what is level 3?

A

patients requiring advanced respiratory support alone or basic respiratory support together with support of at least 2 organ systems. This level includes all complex patients requiring support for multi-organ failure. 1:1 nursing

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7
Q

what is nasal high flow?

A
  • Level 1 or 2 care
  • Like a big nasal cannula
  • FiO2 upto 95% + (facemask = 60%. 15L = 80%)
  • 1-60L/min depending on brand
  • Humidified/warmed
  • Allows patient to talk and eat
  • Small amount of PEEP (positive end expiratory pressure – small amount of O2 remains in alveoli and keeps them open so increases O2)
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8
Q

what is CPAP?

A

used in level 2 care
• CPAP: continuous positive pressure ventilation
• Positive pressure via mask or hood – increases oxygenation
• Fi -100% oxygen
• Allows titration of PEEP or EPAP
• Push airs in from outside - Increases intrathoracic pressure – BP (hypotension)/reduced preload effects
• Treatment for T1RF or heart failure

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9
Q

what is BiPAP?

A

brand name (bilevel positive pressure)
• Same as CPAP but can give 2 levels of pressure
• EPAP increases oxygenation. IPAP increases CO2 removal
• Treatment for T2RF

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10
Q

what is mechanical ventilation?

A
  • Level 3
  • Fully controlled ventilation or supported (PC/PS)
  • Can set ‘IPAP and EPAP’
  • Required I+V (sedation)
  • Problems with sedation (paralysis) – hypotension, arrythmias, opiate withdrawal, sleep problems, PTSD, weakness, airway trauma and oedema etc
  • IPPV>CPAP if consolidation
  • Requires significant physiological reserve
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11
Q

what is ECMO?

A
  • Level 3
  • Extracorporeal membrane oxygenation
  • Llike cardiac bypass machine (heart keeps beating)
  • Allows oxygenation and removal of CO2
  • Very specific criteria – often reserved for young patients waiting for lung transplant or patients ‘stuck’ on bypass after surgery
  • Required very large central venous access (like a hosepipe)
  • Closest centre is Leicester
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12
Q 
renal replacement therapy
what is it?
what are the types?
what are indications?
what level of care is it?
A
  • Allows replacement of renal function and filtering of toxic substances
  • Acutely – can be either continuous (filtration) or intermittent (haemodialysis)
  • Chronic – also includes eg peritoneal dialysis
  • Acute indications: refractory fluid overload, severe hyperkalaemia, signs of uraemia (pericarditic/encephalopathy), severe metabolic acidosis, removal of certain toxins (lithium/ethanol/methanol/salicylate)
  • Level 3
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13
Q

describe intermittent haemodialysis?

A
  • Chronic use (via AV fistula)
  • Acutely often via central access
  • Large fluid shift- no replacement of fluid
  • Intermittent – sessions take a few hours
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14
Q

describe continuous -CRRT?

A
  • Continuous counter current
  • Can use if hypotensive – more gradual fluid shift as volume replaced during session
  • Usually via large central access
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15
Q

what are the potential methods of cardiovascular support?

A
  • IV fluids – input – output
  • Invasive haemodynamic monitoring
  • Cardiac output measurement
  • Vasoactive drugs
  • Organ ‘replacement’ – balloon pump, ECMO
  • ECMO
  • balloon pump - insert directly into heart - keeps circulation
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16
Q

what are the methods of invasive haemodynamic monitorning (and what level of care does this represent)?

A

level 2
arterial line
central line/PA catheter
transoesophageal ECHO

17
Q

describe the role of arterial line in haemodynamic monitoring?

A
  • Usually radial
  • Real time BP monitoring
  • Can take bloods/arterial gas
  • Non invasive cardiac output monitoring
18
Q

describe the role of central line/PA catheter in haemodynamic monitoring?

A
  • Venous line in neck – goes into right side of heart and pulmonary tree
  • Measures pressure in central veins/ right atria/ventricle/pulmonary artery
19
Q

describe the role of transoesophageal ECHO in haemodynamic monitoring?

A

Real time monitoring of cardiac output/contractility

20
Q

what are vasoactive drugs?

A

alpha and beta receptors (sympathetic nervous system)

Some can be given peripherally (via cannula). Most require venous access

vasopressors - alpha receptors

inotropes - beta recepters (can be alpha)

21
Q

what affect do vasopressors have?

A
  • Cause vasoconstriction peripherally
  • Increase BP
  • Increase cardiac output
22
Q

what affect do inotropes have?

A
  • Increase cardiac contractility (stroke volume and rate
  • Good If heart attack
  • Can be given peripherally but weaker
  • Noradrenaline, dobutamine, adrenaline
23
Q

give examples of neurological support?

A
  • ICP monitoring

* Ventilation strategies

24
Q

give examples of gastrointestinal support?

A
  • Parenteral nutrition

* Liver replacement – coagulopathy, protein loss, MARS)

25
Q

give examples of scoring systems used in ICU?

A 
APACHE II – score greater than 35 suggests patient is unlikely to survive 
APACHE III
SAPS
TISS
SOFA
26
Q

what does ReSPECT stand for?

A

recommended summary plan for emergency care and treatment

27
Q

what is ReSPECT?

A

summary of personalised recommendations for a persons clinical care in future emergency where they don’t have capacity to make or express choices
It is intended to respect patient preference and clinical judgement

28
Q

how is a ReSPECT form created and where should it be kept?

A

created through conversations with patient and a health professional involved in their care. It should stay with the patient and be available to health care professionals in emergency situations. The ReSPECT form can be used in the persons home, ambulance, carehome, hospice or hospital

29
Q

when are DNA CPR decisions considered?

A
  • when a patient with capacity refuses CPR or a patient without capacity has recorded their refusal of CPR in advance
  • when CPR is judged very unlikely to be effective because the patient is dying from an irreversible condition
  • when the potential burdens of CPR outweigh the potential benefits
30
Q

what is a ceiling of treatment?

A

the predetermined highest level of intervention deemed appropriate by a medical team, aligning with patient and family wishes, values and beliefs. These crucial early decisions aim to improve the quality of care for patients in whom they are deemed appropriate.

31
Q

what is the purpose of safety netting?

A

Protect patient and doctor. Doctors see a large number of patients with symptoms which may or may not be a presentation of serious underlying condition. It is particularly important for patients with risk factors for specific disease or where specific complications are recognised as part of illness or treatment.

32
Q

why can poor documentation be a problem for professional?

A

a complaint several months after the encounter, the records may be the only version of events which doctors can refer to as they may have no memory of what was discussed

33
Q

what are some fundamental principles of safety netting?

A
  • be specific in advice ‘ if X happens ring surgery or out of hours provider immediately’
  • provide timescale for when symptoms should resolve (so they can come back to see you if need be)
  • book follow up appointment to review progress
  • give written information and patient leaflets
  • document the advice given
  • ensure patients know how to access advice if you’re not available
  • bear in mind the need to re-assess if symptoms not settling or response to treatment
34
Q

how can medical errors arise and give examples?

A

poor communication skills, or lack of experience
eg breach of confidentiality, not recognising importance of consent when examining a patient or taking blood from them, or working outside your scope of competence

35
Q

how should you respond to a medical error?

A

apologise to patient, tell them what went wrong, actions being taken to prevent this happening
be honest
tell someone as soon as possible

Acute Care Block-Year 4 (8 decks)

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