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Flashcards in ICU Deck (82)
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1

1.5 years s/p renal transplant fever work-up

cxr
CBC
blood cx
UA
renal bx

adrenal function

tenderness over graft

2

1.5 years s/p renal transplant fever and interstital process on cxr: dx, w/u, tx

CMV
fiber optic bronch

need to rule out any bacterial causes.

CMV cultures,
and send IgO and IgM titers and would start the patient on
ganciclovir .

on broad-spectrum antibiotics, to
cover the gram-positive,
Vancomycin for gram-negative,
prophylactic antifungal ie. fluconazole; Bactrim for Pneumocystis carinii prophylaxis.

CAT scan of the chest and
abdomen.

I would continue the ganciclovir for six weeks and after that, I
will switch the patient to acyclovir.

3

Frank:
Starling curve is optimized

for fluid ressus of patient with recent MI and peritonitis from diverticulitis

shooting for a cardiac index of more than 2,

wedge pressure of 14 to 18,

SVR less than 1,000

4

V tach (or V fib) ACLS


CPR
One mg epinephrine (repeated every three minutes)

Shock 300 jewels

CPR
300 mg amiodarone

Shock 360 jewels

CPR
150 mg amiodarone

Shock 360 jewels

Also try given:

Magnesium 2 – 3 g IV
Procainamide 100 mg Q5 minutes
Bicarb 1 amp
Lidocaine 1 mg per kilogram IV

5

5 Hs and 5 Ts

these are cause of PEA and Asystole:

Hypovolemia, Hypoxia, Hydrogen ion (acidosis),

Hyper-/hypokalemia, Hypoglycemia, Hypothermia.

think cardiopulm bypass and what is associated with stopping the heart:
hyper k (cardioplegia), acidosis hypothermia, hypotension, hypoxia

The T’s include:

Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and pulmonary), and Trauma.

think trauma box work up:
Tenssion ptx, tamponade, trauma, thrombosis, toxins

6

ABG

pH 7.4 7.35 to 7.45
Pa02 90mmHg 80 to 100 mmHg
Sa02 93 to 100%
PaC02 40mmHg 35 to 45 mmHg
HC03 24mEq/L 22 to 26mEq/L

7

post arrest care

EKG
Echo
ABG, lytes, cbc, lactate, base def

Inotropic and vasopressor support can mitigate the myocardial dysfunction that is common during the first 24 to 48 hours after cardiac arrest [20,39].

no evidence demonstrating the superiority of any one vasopressor in the post-cardiac arrest patient. Commonly employed vasopressors include

dopamine (5 to 20 mcg/kg per minute),

norepinephrine (0.01 to 1 mcg/kg per minute; 0.5 to 70 mcg/minute),

epinephrine (0.01 to 1 mcg/kg per minute; 0.5 to 70 mcg/minute).

In cases of cardiogenic shock (eg, global

dobutamine (2 to 15 mcg/kg per minute)
or
milrinone (loading dose: 50 mcg/kg over 10 minutes, then 0.375 to 0.75 mcg/kg per minute)

Either agent may cause hypotension from vasodilation; dobutamine may cause tachyarrhythmias.

Antiarrhythmic drugs should be reserved for patients with recurrent or ongoing unstable arrhythmias.

No data support the routine or prophylactic use of antiarrhythmic drugs after the return of spontaneous circulation following cardiac arrest, even if such medications were employed during the resuscitation.

Determining and correcting the underlying cause of the arrhythmia (eg, electrolyte disturbance, acute myocardial ischemia, toxin ingestion) is the best intervention. (See 'Determining the cause and extent of injury after cardiac arrest' above.)

8

low UOP w/u

flush foley
bladder scan
(FeNa if urine)
renal US
BMP / lytes
UA - spec grav / proteinuria / casts
myglobin

CXR
EKG
(enzymes)

CVP / swan

9

Indications for renal replacement therapy

acidosis refractory
Acute severe electrolyte changes - hyper K!

Toxins: methanol/ethanol

Volume overload
Uremia:
Encephalopathy
Severe azotemia – BUN > 100
Significant bleeding
Uremic pericarditis

A – Acidosis – metabolic acidosis with a pH 6.5 mEq/L or rapidly rising potassium levels; see previous postfor a review of the causes and management of hyperkalemia

I – Intoxications – use the mnemonic SLIME to remember the drugs and toxins that can be removed with dialysis: salicylates, lithium, isopropanol, methanol, ethylene glycol

O – Overload – volume overload refractory to diuresis

U – Uremia – elevated BUN with signs or symptoms of uremia, including pericarditis, neuropathy, uremic bleeding, or an otherwise unexplained decline in mental status (uremic encephalopathy)

10

Medication associated with adrenal insufficiency

Etomidate–though, usually not one time bolus

11

SSx of adrenal insuf


Inability to wean from the ventilator

Persistent hypotension that is vasopressors dependent

Low sodium and high potassium

Unexplained fever

Weakness

vague abd pain

12

adrenal insuf test

Cortisol may be checked at any time in the critically ill
proposed as the appropriate minimum value :

18 is considered normal stress repsonse
for being in the ICU - below this is insuf
(range, 10 to 34 μg/ dL);

"18 year olds are old enough for trauma and have enough cortisol)


(ACTH) stimulation NOT USEFUL in TRAUMA / ICU

administering 250 μg of ACTH (cosyntropin) either intravenously or intramuscularly.

Cortisol levels 30 and 60 minutes

delta 9



who showed a change in baseline cortisol levels by 9 μg/ dL at 30 or 60 minutes during the ACTH stimulation test had lower mortality rates if they received corticosteroids. This test is thought to demonstrate adrenal reserve in the face of critical illness or sepsis but



low-dose version of the ACTH stimulation test

only 1 µg of cosyntropin is administered intravenously.
Due to the low dose, it is thought that it is more sensitive for partial AI.

13

best steroid replacement

The administration of hydrocortisone (150 to 200 mg daily for 5 to 7 days) has been shown to lead to a decreased vasopressor requirement as well as improved organ dysfunction, fewer ventilator days, fewer ICU days, and most importantly lower 28-day mortality.

50 mg IV q 6 hr

or

100 mg q 8 hr

14

The differential diagnosis of severe hypoxemia in this patient ICU

Aspiration pneumonia
or
pneumonitis

Pulmonary embolus

Heart failure

Pulmonary edema

Transfusion-associated acute lung injury (TRALI)

Acute respiratory distress syndrome (ARDS)

15

ARDS is a syndrome defined by

1 acute onset

2 pao2 / fio2

16

Workup The workup for ARDS includes

exclude the other potential diagnoses of the acute hypoxemic respiratory failure.

Transthoracic Echocardiography This diagnostic test is used to evaluate for cardiogenic pulmonary edema.

no evidence of right heart strain or right ventricular dysfunction that may be present in patients with pulmonary embolus.

Laboratory Tests Arterial blood gas confirms hypoxemia,
PaO2 of 85 mm Hg on FiO2 1.0, which confirms a PaO2/ FiO2 ratio ≤ 200 mm Hg.

Brain (B-type) natriuretic peptide (BNP) levels are elevated in acutely decompensated heart failure, so low levels may be indicative of a diagnosis of ARDS.

Sputum Respiratory cultures should be obtained to evaluate for possible bacterial or aspiration pneumonia as the etiology of the patient’s acute respiratory failure.

Electrocardiogram Electrocardiogram (EKG) without MI or Right heart strain

consider Duplex

consider CT chest

17

vent goals for ARDS

lung protective vol 6 cc /kg vol

permissive hypercapnea

incr PEEP

fluid conservative considered if ressuss done

good lung down

---
others:
incr PEEP
(watch ptx)

reverse I:E

prone


Airway release ventilation

or

high-frequency oscillatory ventilation

RESCUE:
Recruitment maneuvers
Prone position
Inhaled nitric oxide
Inhaled prostaglandin
ECMO


18

vent setting for ARDS


Plateau pressure goal less than 30

PH goal 7.3 point three– 7.4

19

VAP reduction

head of bed 30
Oral care

silver impreg

20

REcruitment

cont positive airway pressure:

30 cm h20 PEEP for 30 sec

risk ptx, hypoxia, hypotension

21

ECMO

veno-venus

22

VAP basic definition

Defined as a pulmonary infection that starts after 48 hours of mechanical ventilation

leading cause of death in ICU!

second most common nosocomail infection in ICU

23

Criteria to diagnose VAP

Fever
WBC
New infiltrate

--

Fever
WBC
Lung infiltrate
Nature of tracheal secretion
Oxygenation
+/- bronchoalveolar lavage gram stain finding of

neutrophils OR bacteria

NO sputum

24

Collecting source to w/u BAL

bronchoscope
or

coaxial catheter that is inserted blindly through the endotracheal tube.

The latter approach, called the mini-BAL -diagnostic yield is considered similar to conventional bronchoscopy.

Additionally, some ICUs use a protective brush inserted via a bronchoscope to obtain direct cultures from the affected area of the lung.

The brush is then retrieved and directly plated onto the culture media.

bacterial burden of more than 10 to the 4 CFU/ mL.

25

bacteria and abx VAP

early ( 4 ventilator days).

early VAP
Enterobacteriaceae
or
gram-positive organisms such as
staph

second-generation cephalosporins,
fluoroquinolones,
extended-spectrum penicillins as a single agent.

Late VAP
invariably resistant organisms

methicillin-resistant
Staphylococcus aureus (MRSA),
Pseudomonas species,
Acinetobacter species

combination therapy

vancomycin plus beta lactams

(third-generation cephalosporins, carbapenems)

or

fluoroquinolones +/ − aminoglycosides is

26


Torsadeselectrolyte disturbances

hypokalemia

and

hypomagnesemia



27

Treatment of intermittent torsades

stable patients

correcting any underlying metabolic or electrolyte abnormalities

INCRASE! the heart rate to shorten ventricular repolarization.

Intravenous magnesium sulfate is also effective in treating paroxysmal torsades.

28

early Sepsis swan findings

high output cardiac failure,

SVR is decreased due to toxins that produce vasodilation.

SvO2 should be HIGH because the tissues are unable to extract oxygen from the blood effectively.

29

what type of line has the highest DVT risk


Femoral catheters (complete contratindicaiton in peds)

30

list order of lest to greatest infection risk with lines

Sublavian (lowest infection)
IJ
Femoral (highest infection)