Critical Care Flashcards
(19 cards)
What are the indications for tracheostomy on intensive care?
- Aid weaning from mechanical ventilation
- Secretion management and airway protection
- Patients with upper airway obstruction e.g. burns
- Support medium or long-term patients with neuromuscular weakness e.g. c-spine, GBS
Advantages of trache over ETT in ICU
- More comfortable - less sedation or none
- Better mouthcare
- Shorter length of stay - can be d/c to ward
- Improved communication - can speak
- Allows gradual weaning from mech vent –> dec work of breathing
- Avoids laryngeal injury as a result of prolonged ETT
What study looked at early vs. late trache
TracMan
Early = <4 days ICU
Late = 10+ days ICU
Pts expected to have further 7 days vent
No diff mortality
No diff ventilator days
Significantly less sedation in trache
What are the contra-indications to perc trache
Anatomy
1. Aberrant vessels
2. Abnormal tracheal anatomy
3. Abnormal thyroid anatomy
4. Morbid obesity
5. Inability to extend neck
6. Prev. trache
Others:
- High resp support PEEP >10, FiO2 >0.6
- Coagulopathy
- Localised infection
Issues with under-sedation
Increased sympathetic nervous system activity
Increased catabolism
Increased O2 consumption
Inability to co-operate with interventions
Development of PTSD
0 to +4 in RASS
+4 = combative, immediate danger
+3 = very agitated, pulling lines
+2 = agitated
+1 = restless and anxious
0 = alert and calm
0 to -5 in RASS
0 = alert and calm
-1 = drowsy
- 2 = light sedation, awakens to voice
- 3 = moderate sedation, movement to voice
- 4 = deep sedation, movement to physical
- 5 = unrousable
What is the definition of ICU weakness. List features
‘Clinically detected weakness in critically ill patients in whom there is no plausible aetiology other than critical illness’
Features:
1. MRC power score <48 detected on 2 occasions more than 24hrs apart
2. Symmetrical, flaccid weakness involving multiple muscle groups, sparing CN
3. Developing after critical illness
4. Dependence on mechanical ventilation
5. Other causes of weakness excluded
Differentials for ICU weakness
- Gullain-barre disease
- Critical illness MYOPATHY
- Severe electrolyte disturbance e.g. hypophosphataemia
- Spinal cord dysfunction
- Motor neuron disease
- Myasthenia
- Residual NMBDs
Classified as CIP or CIM
Critical illness myopathy = muscles
Or polyneuropathy = motor and sensory nerves
Risk factors for CIP/CIM
Severe sepsis with MOF
Prolonged mechanical ventilation
Prolonged bed rest
Glucose and electrolyte abnormalities
Use of parental nutrition/RRT/steoids/NMBDs/vasopressors/aminoglycosides
What is in a Ventilator Care Bundle
Elevation of head to 30deg
GI ulcer prophylaxis
DVT prophylaxis
Daily oral care with chlorhexidine
What is in Central Line Care Bundle
Appropriate hand hygiene
Chlorhexidine skin prep
Barriers for insertion (sterile)
Using subclavian/IJ as preferred site
Reviewing lines daily and removing those unnecessary
Describe the course of the Left Phrenic Nerve
Describe the course of the Right Phrenic Nerve
Systems affected by chronic liver disease
Cardiac
- High CO low SVR state
- Vasodilation of splenic and splanchnic circulation
Resp
- Splinting of diaphragm by ascites/hepatomegaly
—> VQ mismatch, low FRC
- Hepatopulmonary syndrome
—_> hypoxaemia from intrapulmonary shunts
- Portopulmonary hypertension
—> Intrapulmonary vasoconstriction from patients with portal hypertension
Neurological
- Hepatic encephalopathy
GI
- Portal htn from varices, ascites, splenomegaly
- SBP
Metabolic
- Malnutrition
- Muscle wasting
- Low glucose
- Low alb
Haem
- Prolonged PT/INR time
- Thrombocytopenia (splenomegaly)
Renal
- Acute/chronic renal impairment
- Hepatorenal sx
Dx criteria hepatorenal sx
Form of AKI seen in patients with advanced liver disease
Cirrhosis with ascites
Creat >133micromol/L
Abscence of shock
Abscence of nephrotoxins/intrinsic renal
No improvement after diuretic withdrawal/vol expansion
Urine low Na+ (<130) and higher osmolality than plasma
Type 1 = rapid progress decrease
Type 2 = slower course, diuretic resistant ascites
Abnormal renal autoregulation, renal vasoconstriction, splanchnic vasodilation
What is delirium
Acute change in consciousness and awareness that fluctuates over time
Neurological dysfunction as a result of another medical condition
Features:
- Altered state of consciousness, reduced ability to focus
- Change in cognition, memory deficit, disorientation, language disturbance
- Onset hrs to days
Hyperactive vs. Hypoactive vs. Mixed
Delirium scoring systems
CAM-ICU - 4 criteria
Intensive Care Delirium Screening Checklist - 8 criteria
