Approach to Critical Illness Flashcards by Shield Lim

Organ systems assessed in Sequential Organ Failure Assessment (SOFA) scoring

6 (six)
Respiration
Coagulation
Liver
Cardiovascular
Central Nervous System
Renal

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SOFA scoring diagnostic of SEPSIS

Increase of atleast 2 points in SOFA scoring from baseline, in the setting of suspected or documented infection

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qSOFA parameters

RR >/= 22 bpm
Altered mental status
SBP = 100 mmHg

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Most commonly used SOI scoring system in North America

THE APACHE II scoring system

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What is shock?

Presence of multisystem end-organ hypoperfusion

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Clinical indicators of Shock

Reduced MAP
Tachycardia
Tachypnea
Cool skin and extremities
Acute altered mental status
Oliguria

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End result of multiorgan hypoperfusion

Tissue hypoxia, often accompanied by lactic acidosis

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Mean Arterial Pressure

Cardiac Output x Systemic Vascular Resistance

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Components of APACHE II scoring system

Rectal temperature
Mean blood pressure
Heart rate
Respiratory rate
Arterial pH
Oxygenation
Serum Sodium
Serum Potassium
Serum Creatinine
Hematocrit
WBC count
Glasgow Coma Score
Ag
Chronic Health Conditions

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Clinical evidence of diminished cardiac output

Narrow Pulse Pressure
Cool extremities with delayed capillary refill

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Signs of increased cardiac output

Widened pulse pressure ( ⬇️ diastolic pressure)
Warm extremities with bounding pulses
Rapid capillary refill

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In hypotensive patients, with clinical signs of increased cardiac output, reduced BP is due to ___

Decreased Systemic vascular resistance

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Better predictor of fluid responsiveness in hypotensive patients with reduced cardiac output

Change in right atrial pressure as a function of spontaneous respiration

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Most common cause of High Cardiac Output Shock

Sepsis

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Causes of Acute Hypoxemic Respiratory Failure

-Cardiogenic Shock
-Pulmonary Edema
-Septic shock with pneumonia
-ARDS

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Causes of Ventilatory Failure

Increased load on the respiratory system
-Acute Metabolic (Lactic) Acidosis

Decreased Lung compliance
-Pulmonary Edema

Inadequate perfusion to respiratory muscles in the setting of shock

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Predictor of fluid-responsiveness in spontaneously breathing patient

Inferior vena cava collapse seen on ultrasound

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Signs of Respiratory Distress

-Inability to speak full sentences
-Accessory use of respiratory muscles
-Paradoxical abdominal muscle activity
-Extreme tachypnea (>40 bpm)
-Decreasing RR despite increasing drive to breathe

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Goals in Mechanical Ventilation (2)

Initially assume all or the majority of the work of breathing
Facilitate a state of minimal respiratory muscle work

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Decline in MAP seen during Mechanical Ventilation is caused by:

Impeded venous return from positive-pressure ventilation
Reduced endogenous catecholamine secretion once the stress associated with respiratory failure abates
Actions of drugs used to facilitate endotracheal intubation
Increase in RV afterload from positive-pressure ventilation in patients with Right Heart Dysfunction and Preexisting Pulmonary Hypertension

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How to prevent decrease in MAP during intubation?

IV volume administration
Vasopressor support pre-intubation

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This type of respiratory failure occurs with alveolar flooding and subsequent ventilation-perfusion mismatch and intrapulmonary shunt physiology

Type 1: Acute Hypoxemic Respiratory Failure

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Categories of Pulmonary Edema

Elevated Pulmonary Microvascular Pressures
A. Heart Failure
B. Intravascular Volume Overload
Low pressure Pulmonary Edema
A. Acute Respiratory Distress Syndrome

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The pressure-volume relationship of the lung in ARDS in ______

Not linear

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Principles in management of ARDS

1. Low tidal volume 6mL/kg of IBW and High PEEP 2. Prone positioning** improve survival 3. Neuromuscular blockade 4. Fluid-Conservative management strategy

This type of respiratory failure is a consequence of alveolar hypoventilation resulting from the inability to eliminate CO2 effectively

Type II: Hypercapneic Respiratory Failure

Mechanisms of Type II Respiratory Failure

1. Impaired CNS drive to breathe A. Drug Overdose B. Brainstem Injury C. Sleep-disordered breathing D. Severe hypothyroidism 2. Impaired strength A. Impaired neuromuscular transmission -Myasthenia Gravis -GBS -Amyotrophic lateral sclerosis B. Respiratory Muscle Weakness -Myopathy -Electrolyte derangements -Fatigue 3. Increased load on the respiratory system A. Resistive Loads - Bronchospasms B. Reduced Lung Compliance - Alveolar edema -Atelectasis -Intrinsic PEEP (Auto-PEEP) C. Reduced chest wall compliance -Pneumothorax -Pleural Effusion -Abdominal Distention D. Increased Minute Ventilation -Pulmonary Embolism -Increased dead-space fraction -Sepsis

Treatment of Hypercapnic Respiratory Failure

Non-invasive positive-pressure ventilation with tight-fitting facial or nasal mask with avoidance of endotracheal intubation

This form of respiratory failure results from lung atelectasis

Type III: aka Perioperative Respiratory Failure

Pathophysiology of Lung atelectasis in Perioperative period

General anesthesia causes decrease in FRC --> Collapse of dependent lung units

Management of Type 3 Respiratory Failure

1. Frequent changes in position 2. Chest physiotherapy 3. Upright positioning 4. Control of incisional/abdominal pain 5. Non-invasive Positive-pressure ventilation (Regional Atelectasis)

This form of respiratory failure results from hypoperfusion of respiratory muscles in patients with shock

Type IV Respiratory Failure

Management of Type IV Respiratory Failure

Intubation and Mechanical Ventilation ** This can allow redistribution of the cardiac output away from the respiratory muscles and back to vital organs while shock is being treated

Mainstay of therapy for analgesia in Mechanical Ventilation

Opiates

Indication for sedation in mechanically ventilated patients

1. Adequate pain control 2. Anxiolysis 3. Treatment of subjective dyspnea 4. Reduction of autonomic hyperactivity

Sedative associated with increased delirium and worse patient outcomes

Benzodiazepines

Neuromuscular blocking agent like CISATRACURIUM, occasionally used in patients with profound ventilator dyssynchrony despite optimal sedation, may result in prolonged weakness-- a myopathy known as ___

Postparalytic syndrome

Amnesia can be best achieved by which drugs?

Propofol Benzodiazepines (Lorazepam, Midazolam)

Parameters of Daily Screening of Respiratory Function

1. If oxygenation is stable -PFR >200 -PEEP = 5 2. Cough and Airway reflexes are intact 3. No vasopressor/sedatives

Spontaneous Breathing Trial

30-120 min of either: 1. CPAP 5 cm H20 with/out low level pressure support 2. Open T-piece system

Spontaneous Breathing Trial is declared a failure and stopped if any of the following occur:

1. RR>35 bpm >5 min 2. O2 sat <90% 3. HR>140 bpm or a 20% increase or decrease from baseline 4. SBP <90 mmHg or >180 mmHg 5. Increased anxiety or diaphoresis

Percentage of patients who develop respiratory distress after extubation

10%

Simultaneous presence of physiologic dysfunction and/or failure of two or more organs

Multiorgan system failure

Gold standard for evaluation of respiratory gas exchange in critical illness

Arterial Blood Gas

Most commonly utilized non-invasive technique for monitoring respiratory function

Pulse oximetry

Variables to measure PEAK AIRWAY PRESSURE

1. Airway Resistance 2. Respiratory System Compliance

End respiratory pause

Plateau Pressure

Quantitative Measure of Airway Resistance

Peak Airway Pressure -Plateau Pressure Normal: >10-15 mmHg

Definition of Respiratory System Compliance

The change in volume of the respiratory system per unit change in pressure

Normal respiratory system compliance

~100 mL/cm H20

Causes of decreased chest wall compliance

Pleural Effusion Pneumothorax Increased abdominal girth

Decreased lung compliance

Pneumonia Pulmonary edema Alveolar hemorrhage Interstitial lung disease Auto-PEEP

What is auto-PEEP?

Occurs when there is insufficient time for emptying of alveoli before the next inspiratory cycle

Common cause of Auto-PEEP

Obstructed DISTAL airways 1. Asthma 2. COPD

Leading cause of death in non-Coronary ICUs in the USA

Sepsis

Life threatening organ dysfunction caused by dysregulated response to infection

Sepsis

More effective for DVT prophylaxis in high risk patients, with lower incidence of heparin-induced thrombocytopenia

Low molecular weight heparin e.g. Enoxaparin

Possible complications of PPI use

Increased risk of Pneumonia Increased risk of Clostridium difficile colitis

Glucose goal in Critically ill patients

= 180 mg/dL

Complications of TPN

Hyperglycemia Fatty liver Cholestasis Sepsis

ICU-acquired weakness most commonly occur ____

~ 1 week in the ICU

___ may reduce polyneuropathy in critical illness

Intensive Insulin Therapy

Causes of Anemia in the ICU

Chronic Inflammation Phlebotomy

Most common underlying etiology of AKI in critically ill patients

Acute Tubular Necrosis

Definition of Delirium

1. Acute onset of changes or fluctuations on mental status 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness

Sedative that has been less strongly associated with ICU delirium

Dexmedetomidine

Surgical procedure that relieves increased intracranial pressure in the setting of space-occupying lesions or brain swelling from stroke

Decompressive Craniectomy

Treatment for Cerebral Vasospasm in SAH

1. CCB (Nimodipine) 2. Aggressive IV fluid hydration 3. Vasoactive drugs (Phenylephrine)

Hydrocephalus is typically heralded by _____.

Decreased level of consciousness

Most effective Benzodiazepine for treating status epilepticus

Lorazepam

Treatment of choice for controlling seizures acutely

Lorazepam

Diagnosis of Brain death requires:

1. Absence of Cerebral Function -No response to External Stimulus 2. No brainstem function -Unreactive Pupils -Lack of ocular movement in response to head turning or ice water irrigation of ear canals -Positive apnea test

Reversible Causes of Coma

1. Sedative effect 2. Hypothermia 3. Hypoxemia 4. Neuromuscular paralysis 5. Severe hypotension

Approach to Critical Illness Flashcards

(74 cards)