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Clinical Medicine II > Critical Care > Flashcards

Critical Care Flashcards

1
Q

ID a patient who is in need of mechanical ventilation

- (2 parts)

A
  1. Respiratory Failure: cannot ventilate adequately on own (Hypoxia, Hypercarbia)
  2. Inability to protect airway
  3. Failed non-invasive ventilation (BiPAP or CPAP)
  4. Procedures requiring general anesthesia (breathing is paralyzed)
    [Pulmonary Disease]
    - ARDS, pulmonary edema, hypoventilation, failed trail of extubation, forseeable protracted course of respiratory failure, infection, ventilatory failure (lactic acidosis, dec lung compliance)
    [Circulatory]
    - Cardiopulmonary arrest
    - Shock
    [Airway Support]
    - Diminished mental status, compromised airway anatomy, diminished airway reflexes, fluctuating consciousness, sedation, pharyngeal instability
    [Other]
    - ELEV Intracranial Pressure, requiring hyperventilation
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2
Q

Recall complications of endotracheal intubation

A

***Reduced MAP (mean arterial pressure: avg of arterial pressure t/o 1 cardiac cycle) is common b/c
- RED Venous return from positive pressure ventilation
- RED Endogenous catecholamine secretion
- Admin of drugs used to facilitate intubation
^Leading to volume responsive hypotension
[Common]
1. RT main stem intubation
2. Esophageal intubation
3. Gastric aspiration > PNA
4. Dental trauma
5. ET tube migration
6. Laryngeal damage
——–
[Others]
- Arrhythmias, hemodynamic instability, mucosal lac/tear/ulceration, otitis, sinusitis, tracheoesophageal fistula, vocal cord paralysis, tracheomalacia (collapse), tracheal stenosis (narrowed)

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3
Q

Tenets of intubation

A
  • Always intubate under direct visualization of the vocal cords
  • Always confirm ET tube placement with auscultation of all lung fields
  • F/U CXR
  • Proper position of ET tube is 3-5cm above Carina
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4
Q

ID a patient who is a candidate for Tracheostomy

A
  • Preferred method for long-term ventilation
  • Long-term or permanent airway obstruction
  • Long-term mechanical ventilator
  • Unable to clear their airway secretions
  • Facilitate liberation from mechanical ventilator
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5
Q

Explain common complications of Tracheostomy

A 
[Acute]
1. Hemorrhage
2. Mal-positioning 
3. Pneumothorax/pneumomediastinum
4. Neck hematoma 
[Long Term Complications]
1. Tracheoesophageal fistula
2. Tracheo-innominate fistula 
3. Tracheomalacia
4. Tracheal stenosis
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6
Q

Fraction of inspired oxygen (FiO2)

A
  • Fraction of oxygen in the volume being measured
  • should be lowest possible FiO2 possible to meet oxygenation goals – usu 90-96% SAT
  • INC FiO2 can lead to O2 toxicity, parynchemal injury, hypercapnia, + absorption atelectasis
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7
Q

Positive End Expiratory Pressure (PEEP)

A
  • Pressure added at the end of expiration that prevents alveolar collapse
  • initial dose 5 cm - 20cm, recruits alveoli that have collapsed > INC SA
  • ARDS = TX with low TV, high PEEP
  • INC PEEP > DEC cardiac function, barotrauma, + impaired cerebral venous outflow
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8
Q

Tidal Volume

A
  • The amount of air delivered with each breath
  • Ideal = 6-8 mL/kg of IBW
  • ARDS; low TV, <6
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9
Q

Pressure Support - Definition

A
  • A set pressure that is delivered during inspiration (driving pressure)
  • 0-30 mmH20; Norm 7-10
  • Higher the PS, larger the TV
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10
Q

Volume Control

A

*PT receives a set volume of air, a set # of times, per min
set it and forget it modes less useful for awake pts, uncomfortable

  1. Synchronized Intermittent Mandatory Ventilation (SIMV)
    - Allows for patient to take independent breath b/t sets; better preservation of respiratory muscle fxn
    - PT triggered breaths: wont get set TV, will get set pressure support
    - Tachypneic PT has high likelihood of vent dysynchrony
  2. Assist Control (AC)
    - Newly intubated or sedated pts, clinicians set the minimal ventilation via RR + TV
    - PT triggered breaths will get TV, do not use their own muscles
    - Tachypneic PT has high likeihood of Auto-PEEP (or incomplete expiration b/f the initiation of next breath > air trapping)
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11
Q

Pressure Control - PC

A

*Each breath is given a set amt of pressure via Ventilator
clinician sets the Inspiratory Pressure + Time resulting TV depends on set driving pressure > TV will be varied
(+) Can have strict control over airway pressure, can help w/ barotrauma + fresh suture lines
(-) can not wean from this mode, can be very comfortable

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12
Q

Pressure Support - PS; ventilator mode

A
  • Only set the pressure support + PEEP
  • TV and RR are not set; pt receives assistance with each breath - pt needs to initiate breath
  • ideal for weaning, comfortable
  • pt needs close monitoring due to no set TV & minute ventilation > hypoventilation
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13
Q

Non-Invasive Ventilation (BiPAP)

A

*Non-intubated patients, impending respiratory failure or who are struggling after extubation
- provides assistance with mechanics of ventilating (O2 + CO2 regulation), can adjust inspiratory + expiratory pressures > achieve desired TV
(+) can prevent intubation, intermittent use
(-) claustrophobia, can’t tolerate it, cannot eat or drink, can dry up secretions + cx mucus plugs

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14
Q

Mechanical Ventilation Complications

A
  1. Barotrauma (PNEUMOTHORAX, SQ emphysema, p-mediastinum, p-peritoneium, alveolar rupture)
  2. Lung injury
  3. Ventilation/Perfusion mismatch
  4. DEC Hemodynamics
  5. Myopathy - (dysfxn of diphag)
  6. Ventilator-Assisted PNA
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15
Q

ID a patient who is ready to be extubated

A
  • Underlying cx reversed or improved?
  • Hemodynamically stable?
  • Awake, alert, + following commands?
  • Protect airway? Strong enough to manage secretions?
  • Stable on minimal ventilator settings?
    FiO2 <50%, PaO2 by blood gas >60 PEEP <10, PS <7
  • pass the Spontaneous Breathing trial (SBT)?
    PSV w/ PS 7, PEEP 5 Rapid-shallow breathing index (RSBI) —ratio of RR to TV; <100
    `no evidence of INC work or hemodynamic instability
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16
Q

Acute Respiratory Distress Syndrome - DEF, CXR findings

A

*acute, diffuse, inflammation form of lung injury that is assoc with variety of etios
DX —
1. Bilateral infiltrates on CXR
2. Progressive respiratory failure
3. Hypoxemia that does not respond to INC FiO2
Etios —
- Sepsis, PNA, Trauma, Multiple transfusions, Aspiration of gastric contents
~ 30% Mortality

17
Q

ARDS — (3) Phases

A
  1. Exudative -
    alveolar edema from injury to alveolar barrier > high cxns of inflammatory cytokines > recruitment of leukocytes occurs w/i 7 Ds of CXR
  2. Proliferative -
    next 7-21 Ds, assoc with recover can wean to extubation, but may still have sx
    `fibrotic chngs can occur, poor outcome predictor
  3. Fibrotic -
    Not all patients get here - INC mortality risk Dvlp Interstitial Fibrosis with Emphysematous changes
18
Q

ARDS — TX

A

Syndrome, TX underlying DZ process!!!
- Ventilator Support:
**LOW TIDAL VOLUMES IN ARDS
lowest possible settings for PEEP, TB, and FiO2, achieve PaO2 via ABG og 55mmHg + pH of >7.3 protect lungs from barotrauma w/ low TV’s; <6 - (6-8 is goal)
- Avoid aggressive fluids; CVP <4, PCWP <8
- Avoid unnecessary procedures
- Aggressive TX for suspected infxns
- Prophylaxis agnst VTE + gastritis

19
Q

Radial Arterial Line

A

(+) Least invasive

(-) smallest artery, tends to be most positional/unreliable, usu annoying to PT

20
Q

Brachial Arterial Line

A

(+) Most comfortable for pt, larger than radial > less positional issues
(-)**Thrombus puts entire arm @ risk for compromised BS!!

21
Q

Axillary Arterial Line

A

(+) Durable, long-lasting, reliable, sturdy + rarely positional, larger than radial w/ less risk of complete occlusion
(-) Most difficult to place, INC risk of vascular injury, harder to compress, HIGH risk of Hematoma

22
Q

Femoral Arterial Line

A

(+) Most central arterial line - most accurate, easy + quick access, if patient is coding - USE this!
(-) Risk of vascular injury, retroperitoneal bleed, higher risk of infxn (dirty area)

23
Q

Arterial Lines

A

*Catheter placed directly into the artery, allows for continous real-time BP monitoring
INDIC FOR
Unstable PTS who require Vasopressor support Severely HTTN pts requiring IV antiHTTN
`Strict BP control for neuro pts
(-) prone to error from pt position, vasospasm, or cath occlusion

*Use bad waveforms to indicate under/over TX
Overdamped - falsely low, moving/clot
Underdamped - falsely high, extrafling

24
Q

Explain the most common complications from arterial lines

A

1. Arterial occlusion – can cause limb ischemia

  1. Limited mobility
  2. Line infxn – rare, but possible
25
Q

Internal Jugular Central Line

A

(+) Easily accessible via US, provides a “straight shot” to the RT atrium, ideal for Swans + pacing wires
`close proximity to carotid artery - relatively superficial, easy to US
(-) Uncomfortable for PTS - larger line, hangs off neck

26
Q

Subclavian Central Line

A

(+) The “ideal vein”, least risk of infxn, most comfortable
(-) **INC risk of PneumoT, most difficult to place, INC risk of hematoma, unable to use US
`performed w/ anatomy landmarks b/c US difficult from bone interference - insert needle @ 15 angle w. needle pointing at sternal notch > advance needle till you hit clavicle > press down under

27
Q

Femoral Central Line

A

(+) Easily accessible, best sites for ER access
gold standard is US guided Iinsertion site BELOW inguinal ligament
(-) Risk of vascular injury, INC risk of bleeding, limited mobility, INC risk of infxn (dirty area)
`xray not useful

28
Q

Central Venous Lines

A

*large catheter placed directly into a centrally located vein
INDIC
- Long-term access (7-14 D, v.s 3 for IV v.s wks/mths PICC line)
- ADMIN of certain meds
- Dialysis access
- Close monitoring of central pressures
- Freq/recurrent lab draws
*Locate anatomy, sterile procedure, confirm placement via US, then confirm via xray

29
Q

Central Venous Lines - Complications

A
  1. Venous air embolism - (keep pt in Trendelenburg position during placement)
  2. PneumoT
  3. Catheter tip malposition - (always check xray b/f use for IJ + SC lines)
  4. Thrombotic occlusion
  5. Venous thrombosis - (fem line w/ HIGH risk)
  6. INFXN – (should be chnged 7-14 Ds)
    MC pathogen = coag-neg Staphylococci, Staph Aureus, GN Bacilli should have HIS for any pt w. a central line in >48 hrs with new leukocytosis + fever
  7. Blood CX
  8. Remove line, replace in new location
  9. Empiric anbx - narrow w/ culture, 10-14 D course
30
Q

Describe the use of Swan-Ganz catheters

A

*specialized cath that gives cont. measurements of RT heart filling pressures + indirect LT heart filling pressures
- CVP, RV, PAP, PCWP
can also assess…
- CO, Cardiac Index (CI), mixed venous O2 SAT

31
Q

Central Venous Pressure - (CVP)

A

*reflects central venous pressure; equal to the RA pressure

Norm = <8 mmHg

32
Q

Pulmonary Artery Pressure - (PAP)

A

*measures the cont pressure in the Pulmonary Artery

Norm: Sys = 15-30/Dia = 0-8 mmHg

33
Q

Pulmonary Capillary Wedge Pressure - (PCWP)

A

*obtained with balloon inflation - estimated LT side of heart pressure (least accurate)
Norm = <12 mmHg

34
Q

Recall the complications of Swan-Ganz catheters

A

1. Mal-positioning

  1. Myocardial or pulmonary injury - (always advance cath with balloon inflated)
  2. Cardiac valve injury - (always pull back with balloon deflated)
  3. Cardiac AA’s - (tip can irritate RV - SVT, VT, afib)
  4. Infection - (sim to central line)
  5. ***Pulmonary Artery rupture - (rare, but DEADLY complication caused by over-wedging cath - in too far, inflating)
35
Q

ID a patient who would benefit from vasopressor support

A

*PT whose blood pressure keeps dropping
1. Norepinephrine -
caution = AAs, peripheral ischemia in higher doses
2. Phenylephrine -
caution = bradyc
3. Vasopressin
caution = coronary constriction

36
Q

Recall the importance of inotopic support:

A

*IF pt needs augmented CO/CI - INC contractility of heart; (+) inotropes
1. Dobutamine
caution = AAs, worsening HCM
2. Epinephrine
caution = lactic acidosis @ high doses
3. Milirinone
caution = hypoT, AAs, HA, renal fxn
4. Dopamine
caution = AAs

37
Q

Summarize the importance of anti-hypertensives

A

*IF need to keep blood pressure down
1. Esmolol
caution = slows AV conduct, bradyc, heart block
2. Nicardipine
caution = critical aortic stenosis
3. Nitroglycerin
c = HA, INC ICP
4. Nitroprusside
c = cyanide accumulation, kidney, liver

38
Q

Recall when an ICU patient should be initiated on tube feeds

A

*Feeding gut prevents atrophy of barrier against infection. Poor nutrition > longer ICU stay + healing
Start If…
*inadequate nutrition for 3 D or if HIGH risk of infxn
Standard NG - directly into stomach
Dobhoff tube - smaller, usually post-pyloric

39
Q

Explain whether to use tube feeding or TPN for nutrition

A

TPN:

  • indicated when enteral nutrition is not possible - wait 5-7 D w/o nutrition b/f start
  • high complication + infxn risk; does not prevent intestinal atrophy

Clinical Medicine II (9 decks)

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