CRIT CARE Flashcards
(157 cards)
1
Q
Factors that lead to vent-induced lung injury
A
- volume- pressure- oxygen
2
Q
Factors that determine oxygenation
A
- FiO2- PEEP- mean airway pressure
3
Q
Factors that determine ventilation
A
- RR- TV*assessed w/ PaCO2
4
Q
Plateau pressure
A
measure at inspiratory pause; reflects alveolar pressure (ideal <30)
5
Q
Peak airway pressure
A
total amount airway pressure delivered to overcome resistive and elastic work; if high represents large airway obstruction or bronchospasm, etc
6
Q
Tobin index
A
rapid shallow breathing index = RR/TV; if <100 good indicator pt may come off vent (if <65, 90% sensitivity)
7
Q
Negative inspiratory force (NIF)
A
expiratory pause - check neg pressure that pt can generate in lungs; if <20 then unlikely to be able to extubate. predictor of failure (not a good predictor of success)
8
Q
ARDS Berlin definition
A
PaO2/FiO2 ratio + within 1wk insult + CXR + not due to fluid overload (check Echo)mild: 200-300mod: 100-200severe: <100
9
Q
MOA dopamine
A
dose-dependentlow -> dopaminergic receptor in kidneysmed -> B1high -> alpha
10
Q
MOA NE (levo)
A
alpha (B1 at low doses)
11
Q
MOA Epi
A
equal alpha + B1
12
Q
MOA phenyephrine
A
pure alpha (typically only to treat neurogenic shock 2/2 spinal cord injury)
13
Q
MOA vasopressin
A
acts on V1 (vasopressor receptor)
14
Q
MOA dobutamine
A
more B1 (good for cardiac failure), but has some B2 vasodilatory effect (no alpha)
15
Q
MOA milrinone
A
PDE inhibitor; increases cAMP -> increases CO, vasodilatory
16
Q
EKG change in PE
A
S1, Q3, T3; MC is sinus tachy
17
Q
CVP tells us…? By measuring…?
A
volume status; by measuring RVED pressure
18
Q
Wedge pressure tells us…? By measuring…?
A
preload; by measuring LVED pressure
19
Q
Equation: CO
A
CO = SV x HR
20
Q
Equation: CI
A
CI = CO/patient BSA
21
Q
Equation: O2 delivery
A
O2 delivery = 1.36 x O2sat x (CO x Hgb)
22
Q
Equation: O2 consumption
A
O2 consumption = (O2 arterial - O2 venous) x CO
23
Q
Direct thrombin (Factor 2a) inhibitors
A
dabigatran, argatroban
24
Q
Equation: respiratory quotient
A
RQ = CO2 produced/O2 consumed
25
RQ >0.9
giving too many carbs and cannot get off vent
26
TPN ratio of carbs vs. fat
Carbs 75%, 25% fat
27
Essential fatty acids
- linoleic- alpha linoleic
28
Caloric content of carbs? lipids? protein? dextrose?
carbs = 4 kcal/glipids = 9protein = 4dextrose = 3.4
29
Airway pressure release ventilation
long inhalation period to open airway, then short period where pressure drops and pt allowed to exhale (pressure never 0)
30
Post-intubation initial tidal volume is...?
5-7 mg/kg
31
Neuroleptic malignant syndrome sxs
muscle rigidity, obtundation, tachycardia, fever
32
Mgmt neuroleptic malignant syndrome
bromocriptine, dantrolene
33
Drugs at risk neuroleptic malignant syndrome
haldol, metoclopramide
34
What kind of Cx ordered for BAL to dx vent-associated pneumonia?
quantitative cx (threshold 10^4 used to dx)
35
Absolute C/I bronchoscopy
severe refractory hypoxia w/ inability to maintain adequate oxygenation during procedure (cx of sedation and partial airway obstruction)
36
How to ventilate ARDS pts
- low TV (4-6)- PEEP titrated to keep alveoli open- permissive hypercapnia (as long as pH >7.2)
37
If ARDS pt failing conventional therapy, what other method therapies with proven benefit?
- proning (will improve P/F ratio)- neuromuscular blockade
38
New definition of sepsis
Sepsis 3 = if >2 increase SOFA score (sequential organ failure assessment)
39
Definition of septic shock
pt that needs pressor support to maintain MAPS >65 AND who has sustained lactate >2 (despite resus)
40
Mgmt sepsis resuscitation
within 3 hrs -> Cx, Abx, trend lactate (to guide resus), bolus w/ 30cc/kg for lactate >4within 6 hrs -> start pressors to maintain MAPS, look at tissue perfusion, guide resus based on lactate
41
Use for procalcitonin in ICU
indicates bacterial infection- when normalizes can think to stop Abx- if normal, can r/o sepsis- if elevated, ?? bc sensitive, not specific
42
Tests for invasive candidiasis
- 1,3 beta-D-glucan- mannin- anti-mannin Ab
43
Where do you draw mixed venous O2?
pulmonary artery
44
RQ gives idea of what fuel pt is burning... so what is RQ for fat? protein? carbs?
```
fat = 0.7
protein = 0.8
carbs = >1.0
```
45
Equation: nitrogen balance
nitrogen IN (protein in g/day via protein/6.25g) - urine loss - 4 (insensible loss)
46
Adverse effects too much carbs
high RQ -> difficult wean venthyperglycemiaimmunosuppressant effect
47
Adverse effects of too much fats
pro-inflammatory
48
How much protein generally give pts? in renal failure pts? in liver failure pts?
1g/kg/day renal -> ensure have essential AAliver -> branch chain AA
49
MC long-term pulmonary defect of ARDS
reduced diffusing capacity (DLCO) 2/2 replacement of type 1 lining cells by cuboidal cells + pulm fibrosis
50
Allen test used to...?
determine if ulnar artery can provide distal perfusion to hand
51
Mechanism of IABP
1. inflation during diastole -> increased MAP2. rapid deflation just prior to systole -> decreases afterload on heart
52
MC organism vent-associated pneumonia
sensitive GP (MSSA, strep sp) and H.influ
53
Which location for arterial catheterization are at higher risk thrombosis?
brachial and radial (but easier to cannulate and less risk to injury to nerves)
54
Effect of permissive hypoventilation for ARDS pts
- duration of mech vent support longer, but greater survival%- can disregard pCO2 unless pH <7.28 or ICP >15- C/I head injury pts w/ elevated ICP
55
Pathophysiological changes associated with development of ARDS
2/2 diffuse alveolar damage; diffuse inflam causing...- increased vasc permeability -> hypoxemia + diffuse b/l alveolar infiltrates on XR- alveolar edema- acute inflam of alveolar walls- hyaline membranes
56
Standard confirmation of ET tube is with...?
end-tidal CO2 detection - CO2 released from lungs after initial 3-4 breaths
57
How to measure intra-abdominal pressure re: abd compartment syndrome?
bladder pressure @ end-expiration:- instill 70cc saline into bladder via clamped foley- pressure transducer via needle in aspiration port
58
Settings in which PA cath is still used
- RV failure- pulm HTN- weaning failure of cardiac origin- post-cardiac surgery
59
Normal cardiac index (PA cath)
2.5-4 L/min
60
How does trauma affect tissue O2 consumption?
decreased. trauma -> decreased cardiac output -> decreased tissue perfusion
61
Mgmt air embolism
prevent air from entering RV (LL decubitus + Trendelenburg), then aspirate air from cath and place on 1.0 FiO2 to attempt reabsorption of air
62
Does septic shock respond to vasopressors?
No. hypotension 2/2 failure of vasc smooth muscle to constrict bc upreg of iNOS in vessel walls, which lasts for sustained time, rending vasoconstrictive agents ineffective
63
Where should PA cath tip sit on CXR?
@ PA or RA (not RV bc risk arrhythmia)
64
Relative C/I PA cath insertion
- left BBB (bc PA cath may induce right BBB -> rare risk transient complete block)- hx HIT (PA cath hep-coated)
65
When would you delay insulin therapy in DKA?
if K <3.3
66
Most signif increase of DO2 (oxygen delivery) would be after increase in what factor?
Hgb
67
Cause of hypoventilation-related resp failure acutely after extubation from laparoscopic surgery?
CO2 pneumoperitoneum increases pt's circulating partial pressure CO2 (therefore, need end-tidal CO2 to normalize before extubation)
68
Why not wet-to-dry dressing for open abdomen wound?
risk for fistula formation via trauma to intestinal wall
69
How to dx VAP?
BAL (differentiate btwn lung inflammation vs. infection)
70
Appropriate size ET tube for peds pts?
(Age/4) + 4can also estimate w/ child's little finger
71
In setting of normal PCO2, a low PO2 indicates...?
inadequate perfusion or shunting (indicates degree of vent-perfusion mismatch)
72
Sodium bicarb therapy only rec for pH < ...?
<7.15
73
In critically ill adults, rec blood glucose target of...?
140-180 mg/dL
74
Quickest CVC access is...?
femoral vein
75
Sxs of lidocaine toxicity
- CNS: dizziness, numbness, seizure- CV: arrhythmia, myocardial contractility- HTN, tachycardia followed by myocardial depression w/ mild hypotension -> brady -> ventricular arrhythmias -> CV collapse
76
CPAP or BiPAP in pts with SBO, risk...?
risk aspiration if stomach not decompressed
77
Refeeding syndrome 2/2...?
electrolyte shifts by influx of glucose, and insulin promotes synthesis of proteins and fats -> hypoP/Mg/K
78
Reversal of benzos
flumazenil
79
MC inherited coagulopathy associated with bleeding
vWD
80
Berline Definition of ARDS
- resp sxs <1-wk clinical insult- CXR: bilateral opacities consistent with pulm edema- resp failure must not be completely explained by cardiac failure or fluid overload- classified as mild (P/F 200-300) vs. moderate (100-200) vs. severe (<100)** definition hypoxia calculated with PEEP >5
81
Early enteral nutrition (within 36hrs) in post-damage control laparotomy pts have lower rates of...?
pneumonia
82
EKG changes: hypoMg
- wide QRS- transition from peaked to flattened T-waves- prolonged PR interval- polymorphic v.tach
83
Spinal cord injury-associated bradycardia can be Tx with...?
atropine (usually resolves 2-6 wks)
84
If new onset a.fib <48hrs... mgmt?
rate control, no additional AC necessary.
85
If new onset a.fib, time of onset unknown and need cardiovert... mgmt?
AC prior to cardioversion
86
Post-traumatic organ failure... early vs. late?
Early -> inadequate tissue perfusion -> cardiopulm failureLate -> infection -> pulm/hepatic failure
87
Sudden onset hypotension and jugular vein distention after subclavian CVC placement, think...?
tension pneumothorax
88
What is synchronized cardioversion?
timed (synced) with QRS complex, avoiding shock delivery during relative refractory portion of cardiac shock, which could produce v.fib
89
Severe neonatal respiratory failure most effectively treated with...?
ECMO
90
Mgmt open abdomen pt after damage control laparotomy
1. correction of lethal triad2. early enteral nutrition initiation when intestinal continuity is restored
91
MOA antithrombin III
serine protease inhibitor that forms complex w/ thrombin + Factor Xa, causing them to lose their pro-coagulant activity
92
Compared to NE, how does dopamine fare as a vasopressor agent?
associated w/ signif increased risk both supraventricular and ventricular arrhythmias + higher short-term mortality risk
93
Typical parameters (not predictors) for successful in SBT includes...
- vital capacity 12-15 mL/kg
- tidal volume 5-7 mL/kg
- RR <25 bpm
- max inspiratory force at least -30 cmH2O
- minute ventilation <10 L/min
94
RF pulmonary artery rupture 2/2 catheter
- migration of cath into distal pulmonary arteries
| - pre-existing pulmonary HTN
95
Immediate cause of mortality from pulmonary artery rupture 2/2 catheter?
flooding of OPPOSITE lung with blood -> hypoxia, asphyxiation
96
Positioning after pulmonary artery rupture 2/2 catheter misplacement
Lateral decubitus to side of misplacement - prevents bleeding from extending to opposite lung mainstem bronchus
97
Mgmt pulmonary artery rupture 2/2 catheter misplacement
1. lateral decub positioning on to side of misplacement
2. withdraw catheter to proximal pulm artery (distal ruptured area can vasoconstrict/spasm to tamponade)
3. thoracotomy
98
Recommended dose for haldol for acute delirium
1-5mg/hr, not to exceed 20mg/24hrs
99
Adverse outcomes of haldol
prolonged QT -> ventricular arrhythmia (torsade de pointes) -- pts on routine haldol need daily EKG
100
Drugs preferred for acute delirium in elderly pts
- dexmedetomidine (precedex)
- propofol
- haldol
101
Adverse effect dexmedetomidine
bradycardia
102
Mgmt massive PE (with associated hypotension)
systemic thrombolytic therapy (tPA) - if fail, then consider embolectomy open vs. catheter
103
Mgmt submassive PE (wo associated hypotension)
systemic AC with heparin
104
Vent types: Inverse ratio ventilation (IRV)
may be useful for ARDS - extends inspiratory time; so inspiration:expiration ratio 1:1 or 2:1 -> increases mean airway pressure wo raising peak alveolar pressure
*however, develops auto-PEEP bc does not allow for complete expiration -> risk pneumothorax
105
Vent types: airway pressure release ventilation
bilevel mode of breathing in which continuous positive airway pressure maintained, with set timed releases to allow for CO2 exhalation
106
Vent types: High-frequency oscillatory ventilation (HFOV)
very small tidal volumes (5-20cc) over rapid rate (>200 bpm) - limits alveolar overdistention and large variation in mean alveolar pressure - pts need to be sedated and paralyzed
107
Vent types: proportional assist ventilation (PAV) vs. neurally adjusted ventilatory support (NAVA)
both: improve pt-vent synchrony
PAV: varies vent support based on pt's inspiratory effort on each breath
NAVA: does this via diaphragmatic electromyogrphy signal (via NGT) to control flow
108
Absolute C/I to ECMO use
any condition that precludes use of AC (ie. traumatic brain injury)
109
Indications for ECMO in ARDS
- severe hypoxemia (P/F <80, despite high levels PEEP)
- uncompensated hypercapnia with acidemia (pH <7.15)
- excessively high end-inspiratory plateau pressure (>35-45 cm H2O)
110
How does morphine induce hypotension?
histamine release (not seen in dilaudid or fentanyl)
111
Adverse effect of propofol
hyperTG (bc is a lipid carrier)
112
PerQ trachesotomy is performed where anatomically?
between second and third tracheal rings
113
Advantages to perQ over open tracheostomy
- faster
- fewer infections
- less stoma inflammation
- reduces risk of postprocedural major bleeding episodes
114
Tx central vs. nephrogenic DI
central: vasopressin
peripheral: FREE water mgmt
115
Why have physiologic anemia in pregnancy?
Increase in plasma (due to alterations of RAAS -> increase in volume) more rapid than increase in RBC
116
Inferior MI and hemodynamic instability in post-operative pt... next step?
TEE to eval for acute MR due to rupture of chordae tendineae or papillary muscle - if yes, then stabilize with afterload reduction + diuretics -> urgent coronary arteriography vs. MV repair
117
Mgmt that decreases mortality in ARDS
- volume control w/ 6 mL/kg tidal volume (low)
- prone positioning
- short duration of chemical paralysis
118
Early feeding to full enteral support in critically ill pts associated with...?
more Cx such as VAP - bc in well-nourished pt, full enteral support can be delayed for up to 7-days
*also do not need to start early parenteral bc high IV glucose not appropriate in critically ill pts
119
Protein requirement for:
1. critically ill pt
2. "" + obese BMI 30-40
3. "" + obese BMI >40
4. "" + 40% TBSA
5. "" + renal failure
6. "" + need CRRT
1. 1.2-3 g protein/kg/day
2. 2.0
3. 2.5
4. 2.5
5. 1.25-1.75
6. 2.5
120
Continuous etomidate infusion for sedation of critically ill trauma pts is associated with...?
increased mortality due to primary adrenal suppression 2/2 reversible inhibition of 11B-hydroxylase
121
Drug of choice for pts in traumatic shock + pain, but at risk of hypotension?
ketamine - stimulates circulatory system, preserves protective airway reflexes, sedative + analgesic
122
TEG: normal time (r)
<4 min
123
TEG: normal angle (alpha)
66-82 degrees (cryo if <45)
124
TEG: normal amplitude (MA)
54-72 min (desmopressin if 48-54; plt if bleeding and <48)
125
TEG: normal clot lysis (LY30)
0-3%
126
Caloric req for:
1. critically ill + sepsis/trauma/burn/MOF
2. "" + sedated/vent
3. "" + sedated/vent/chemical paralysis
4. "" + BMI >30
1. 30 kCal/kg/day
2. 25
3. 20
4. 11-14 (hypocaloric feeding -> improved insulin sensitivity -> decrease vent days)
127
TRALI (acute lung injury)
- during or within 6-hr of transfusion
- noncardiogenic pulm edema
- 2/2 donor-related antileukocyte Ab
- will have transient leukopenia 2/2 sequestration of neutrophils in pulm capillaries
- Mgmt: vent support
128
TACO (circulatory overload)
- during or within 6-hr of transfusion
- RF: elderly, overloaded, fast rates transfusion, underlying renal insuff or cardiac dysfxn
- Mgmt: diuretics
129
Do not use silvadene in what pts?
- pregnant pts, newborns (risk kernicterus)
| - not on face
130
Adverse effect silvadene
neutropenia
131
Electrolyte abnormalities associated with use of silver nitrate
hypoNa, hypoCl
132
Gold standard for temperature monitoring for hypothermic pts
pulmonary artery catheter
133
Atrial natriuretic peptide released due to...?
atrial wall stretch (ie. cardiogenic shock)
134
Brain natriuretic peptide released from where?
ventricular myocytes
135
Natriuretic peptide leads to...?
vascular SM dilation via cGMP formation
136
Role of sodium polystyrene for hyperK
binds PO in GI tract -> remove K+ via stool
137
Mechanism of hypoNa+ in pts with low intravascular volume
hypovolemia -> stimulate release of ADH -> water retention -> hypoNa
138
Ideal glucose range during sepsis
80-110
139
Initial medical mgmt hepato-renal syndrome
- supportive
| - terlipressin (vasopressor) + albumin
140
If fail medical mgmt hepatorenal syndrome...?
- TIPS
- if elevated Cr, consider dialysis before TIPS
- liver tx last resort
141
Normal CVP (PA cath)
2-6 mmHg
142
Normal PAWP (PA cath)? What level suggests LHF?
6-12 mmHg
| >18 suggests LHF
143
Normal PAP (pulm artery pressure)
25/10 mmHg
144
Normal SvO2 (PA cath)
65-70%
145
Normal SVR (systemic vascular resistance)
1100-1500 dyne/sec/cm2
146
Normal RV pressure
25/4 mmHg
147
Normal AO (aortic pressure)
120/79 mmHg
148
RV: 25/15 , PA: 25/15 , PAWP: 15 ... suggestive of?
cardiac tamponade - equalization of RA/RV/PAWP
149
Difference in PA cath readings between early vs. late septic shock
Early: high CI
Late: low CI
150
Subclavian central-line access associated with... ? CRBSI, ? DVT, ? pneumothorax compared to internal jug
lower rate CRBSI
lower rate pneumothorax
3x higher pneumothorax
151
Decreased lung compliance in ARDS 2/2...?
alveolar flooding of inflam exudate and chemical mediators -> which inactivates alveolar surfactant -> alveolar collapse -> fewer alveoli to accommodate tidal volume -> forcing increased stretch of remaining functional alveoli -> decreased compliance
152
What is vital capacity
(inspiratory capacity + expiratory reserve volume)
| total amount of air that can be expelled after a max inhalation
153
Eq. to determine arterial O2 content (CaO2)
1.34*Hgb*SaO2 + 0.003*PaO2
154
Stages of ARDS
1 (exudative): protein-rich fluid move into alveolar spaces -> leukocytes -> intrinsic lung injury + poor oxygenation
2 (fibroproliferative): fibrosis and collagen formation -> stiff, noncompliant lung (reversible)
3 (resolution): remodeling, clearing of pulm edema
155
Which pneumocytes responsible for surfactant production?
Type II
156
Tx for pt w/ COPD and new onset atrial fibrillation RVR
rate control with CCB (not BB)
157
Which type of shock would benefit from Trendelenburg + vasopressors?
neurogenic shock - position to get blood back to heart
