iCU Flashcards
Sepsis definition (ie. qSOFA)
qSOFA
2/3 of:
- RR ≥22/min
- SBP ≤100 mmHg
- Altered Mentation (GCS<15)
Septic Shock Definition
qSOFA plus:
Both:
1)Lactate > 2 mmol/L
2)Vasopressors to keep MAP ≥ 65 in absence of hypovolemia
Distensibility index that predicts fluid responsiveness in intubated and non-intubated patient?
IVC Variation-Distensibility
• Intubated fully ventilated distensibility Index >15-20% likely fluid responsive
• Intubated breathing spontaneously not validated
• Not Intubated breathing spontaneously distensibility index >40% likely fluid responsive
Note: Low distensibility index ≠ non-responder!
*Fluid responsiveness defined an increase in Stroke Volume (SV) or Cardiac Output (CO) by
10-15% after a 250-500cc fluid bolus
Norepinephrine dose range
Recommended First Line (0.03-0.35 mcg/kg/min)
Contraindications to NIPPV
- Facial surgery, trauma, obstruction
- Decreased LOC (*relative)
- Inability to clear secretions
- Respiratory arrest
- Hemodynamic instability (reduces preload)
Surgeries that are ok:
– Supra-diaphragm sx (eg. lung Ca)
– GI sx (including esophageal)
– Pelvic Sx
How do you perform an apnea test? What are the parameters for completion?
- Correct/address confounding factors first
- Pre-oxygenate and obtain ABG (baseline ABG PaCO2 35-45, pH = 7.35-7.45)
- Disconnect from ventilator
- Monitor for respiratory efforts
- Serial ABGs
Thresholds for completion: PaCO2 > 60 mmHg and > 20 mmHg above the pre-apnea baseline and pH ≤ 7.28.
Indications for Fomepizole or etoh in toxic alcohol ingestion?
• Serum methanol >6.2mmol/L or ethylene glycol >3.2mmol/L
OR
• Documented recent history of ingestion of toxic amounts of methanol or ethylene glycol and an osmolar gap>10
OR
• Suspicion of ingestion and 2 of the following:
– pH <7.3 OR Bicarb <20 OR OG>10 OR urine oxalate crystals
Indications for dialysis in ASA OD?
Indications: –Salicylate Level >7.2mmol/L –Hypoxemia requiring supplemental O2 –Altered mental status –Renal failure (and level >6.5mmol/L) –Progressive deterioration of vital signs –Severe acid –base or electrolyte imbalance –Hepatic compromise with coagulopathy
Hunter Criteria for diagnosing Serotonin Syndrome
Hunter criteria
Needs to take a serotonergic agent and ONE of -Spontaneous clonus
-Ocular clonus
-Inducible clonus + diaphoresis or agitation -Tremor + Hyperreflexia
-Hypertonic + temp>38 PLUS ocular or inducible clonus
Treatment for Serotonin syndrome
- Stop the agent, support
- Sedate with benzos (goal is to eliminate agitation, hypertonia, normalize vitals)
- If fails–>cyprohepatdine
Treatment for NMS
- Stop the agent, Support, Cooling blankets
- Benzos are mainstay
- Dantrolene and Bromocriptine are adjuncts
How much crystalloid fluid should be administered in the first 4 hours of sepsis resuscitation?
30 ml/kg crystalloid in first 4 hours
DYNAMIC variables that can be used to predict fluid responsiveness? NOTE: CVP is a static measure
– Passive leg raise – Fluid Challenge (250 cc Crystalloid) – Pulse pressure variation (PPV) – Stroke volume variation (SVV) on PoCUS – IVC Variation-Distensibility
Patient in septic shock is not responding to fluid resus or pressors. You plan to give steroids as per the new recommendations. What steroid and how much?
IV Hydrocortisone 200mg daily
Parameters for tidal volume and plateau pressure when treating ARDS
- Tidal Volume 4-8 mL/kg predicted body weight (based on height)
- Plateau Pressure < 30 cm H2O
Others: • Prone Positioning > 12 h/d for severe ARDS • Higher PEEP/FiO2 for mod/ severe ARDS • Targets: O2 saturation 88-95%, PaO2 55-80, pH 7.25-7.35.
