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Flashcards in Critical Care Medicine Deck (76):
1

DIC:
What is the difference between DIC, TTP and HUS

DIC: thrombocytopenia with coagulopathy (prolong PT, PTT and INR)
TTP/HUS: thrombocytopenia without coagulopathy (PT, PTT, and INR wnl)

2

DIC:
What are the most common causes of DIC?

Sepsis;
Malignancy;
Trauma/surgery;
OBGYN complications;
Intravascular hemolysis

3

DIC:
What are 2 types of DIC?

Acute DIC and chronic DIC

4

DIC:
Acute DIC:
Clinical manifestations:

Recent trauma, sepsis, malignancy (APL);
Bleeding, oozing from trauma, catheters or drains;
Thrombocytopenia;
Prolonged PT and PTT;
Low plasma fibrinogen;
Elevated DDimer;
Abnormal coag testing;
Microangiopathic changes on peripheral blood smear.

5

DIC:
Chronic DIC:
Clinical Menifestation:

Hx of malignancy, especially pancreatic, gastric, ovarian or brain;
Venous or arterial thromboembolism;
Mild or no thrombocytopenia;
Normal or mildly elevated PT and PTT
Normal of ever slightly elevated plasma fibrinogen;
Elevated DDimer;
Microangiopathic changes on peripheral blood smear

6

DIC:
How to Dx?

Clinical AND Labs

7

Hypoxemic Respiratory Failure
What is the definition?

Arterial PaO2 less <=60 or ;
SaO2<=89% on RA, and/or;
Arterial PaO2/FIO2<=200mmHg.

8

Hypoxemic Respiratory Failure
What is the most common cause?

Conditions lead to mismatch of V/Q mismatch

9

Hypoxemic Respiratory Failure
Which kind of V/Q mismatch does not respond to O2?

Low V/Q mismatch: pneumonia or atelectasis
Low gas and more blood

10

Hypoxemic Respiratory Failure
Which kind of V/Q mismatch does respond to O2?

High V/Q mismatch: PE
More volume and less blood

11

ARDS
What is the diagnosis Criteria?

Berlin Definition

12

ARDS
What is Berlin Definition?

Presentation within 1 week of known insult, or with worsening respiratory symptoms;
PaO2/FiO2<=300 mmgHg with PEEP>=5cm H2O;
Bilateral otherwise unexplained opacities seen on frontal chest imaging.

13

ARDS
What is the severity levels of ARDS?

Mild: 200< PaO2/FiO2 <=300;
Moderate 100< PaO2/FiO2 <=200;
Severe: PaO2/FiO2<=100

14

ARDS
What are 2 management strategies?

Ventilatory and Nonventilatory management

15

ARDS
Rx
What is ventilatory management?

Lung-protective ventilator strategies

16

ARDS
Rx-ventilatory management
What is lung-protective ventilator strategies?

1. Limiting the tidal volume to 6mg/kg of ideal body weight;
2. Limiting the plateau pressure no more than 30cmH2O;
3. Use adequate PEEP

17

ARDS
Rx-ventilatory management
What is permissive hypercapnia?

Limit volume and pressure as much as tolerated, even allowing blood levels of CO2

18

ARDS
Rx-ventilatory management
What is ventilator-induced lung injury?

Volutrauma (overdistention of alveoli);
Atelectrauma (repeated opening and closing of alveoli);
Biotrauma (release of inflammatory mediators in the lung or systemic circulation).

19

ARDS
Rx - nonventilatory management
What is role of steroids?

Not recommended.

20

ARDS
Rx - nonventilatory management
What is conservative fluid management?

Keep lung as dry as possible:
1. Limit fluids.
2. Use diuretics.
3. However no survival benefit

21

ARDS
Rx - nonventilatory management
Inhaled vasodilators (nitric oxide or prostacyclin and steroids)

Symptoms benefit;
No survival benefit

22

ARDS
Rx - nonventilatory management
What is prone positioning?

1. Mortality benefit
2. Prone position for 16 hours daily to improved to PaO2/FiO2 at least 150mmHg

23

ARDS
Rx - nonventilatory management
ECMO

1. Very limited candidate
2. Very limited facility

24

Hypercapnic (ventilatory) Respiratory Failure
What are 3 causes?

1. Decreased respiratory drive;
2. Restrictive defects of the lung, chest wall, or respiratory muscles;
3. conditions that increase dead space in the lungs so that much of the inspired air does not reach areas of gas exchange with the blood

25

Hypercapnic (ventilatory) Respiratory Failure
Decreased respiratory drive
What are the most common causes?

Sedative and analgesic drugs (especially opioids)

26

Hypercapnic (ventilatory) Respiratory Failure
Decreased respiratory drive
What are the other causes?

1. Stroke when leading to increased intracranial pressure;
2. Metabolic such as hyoglycemia and hypothyroidism

27

Hypercapnic (ventilatory) Respiratory Failure
Decreased respiratory drive
Rx

1. Ventilatory support;
2. Reverse of known or suspected suppressive agents.

28

Hypercapnic (ventilatory) Respiratory Failure
Restrictive lung disease
What are 3 causes?

1. Diffuse parenchymal lung disease;
2. Extrapulmonary restriction;
3. Neuromuscular weakness.

29

Hypercapnic (ventilatory) Respiratory Failure
Restrictive lung disease
Diffuse parenchymal lung disease, what are presentations?

1. Fibrotic changes on high-resolution CT
2. Reduced lung volumes
3. Reduction in the diffusing capacity of the lungs
4. Hypoxic is also severe.

30

Hypercapnic (ventilatory) Respiratory Failure
Restrictive lung disease
Extrapulmonary restrictions- Rx

Positive pressure ventilation

31

Hypercapnic (ventilatory) Respiratory Failure
Restrictive lung disease
Extrapulmonary restrictions- causes

1. Deformities
2. Diseases of chest wall, spine or abdomen

32

Hypercapnic (ventilatory) Respiratory Failure
Restrictive lung disease
Neuromuscular weakness--causes

ALS (with bulbar function impariment);
Spinal cord injury (above C3, C4, C5)

33

Hypercapnic (ventilatory) Respiratory Failure
Restrictive lung disease
Neuromuscular weakness-
Clinical manifestation

1. Orthopnea
2. Dyspnea
3. Paradoxical inward motion of the abdomen with inspiration
4. Accessory muscle usage for breathing
5. Choking, dysphagia, coughing, slurred speech

34

Hypercapnic (ventilatory) Respiratory Failure
Restrictive lung disease
Neuromuscular weakness-
PFT test

1. Restriction pattern on PFT
2. Normal diffusing capacity

35

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
What is the mechanism?

The resistance to expiratory flow causes air trapping, leading to elevated intrathoracic pressure-->auto-PEEP or intrinsic PEEP

36

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
Causes?

Asthma;
COPD;
Tumors, abscesses, trauma, angioedema or inhalational injury.

37

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
Rx- responding to O2?

Usually responding to O2 supplement if hypoxic.

38

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
Rx: what if not responding to O2 when hypoxic?

Other causes should be considered

39

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of asthma exacerbation
Clinical presenations?

Tachypnea;
Inability to speak in full sentences;
Accessory respiratory muscle use;
Diminished air entry with pulsus paradoxus due to hyperinflation.

40

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of asthma exacerbation
Dx test?

ABG-hypocapnia;
FEV1 or PEF

41

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of asthma exacerbation
What's indicating respiratory muscle fatigue and impending failure?

ABG showed normal or elevated CO2

42

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of asthma exacerbation
What's indicating ICU admission?

When FEV1 and PEF do not increase to above 40% of predicted in response to aggressive bronchodilator and glucocorticoid therapy

43

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of asthma exacerbation
What's indicating immediate intubation?

Cannot perform FEV1 and PEF; or
AMS;
Increasing work of breathing; or
Agonal respiration

44

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of asthma exacerbation
Challenges of management?

Auto-PEEP could be worsened by ventilation-->
Physiology or tension PTX and decreased venous return

45

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of asthma exacerbation
Rx

Glucocorticoids and bronchodilators;
Empiric antibiotics only suspicion of infection

46

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of COPD exacerbation
Dx- ABG

Ususally CO2 is high

47

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of COPD exacerbation
What's the goal of O2 sat?

90-92%
Rely on PaO2 for respiratory drive

48

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of COPD exacerbation
Challenges of management?

Auto-PEEP could be worsened by ventilation-->
Physiology or tension PTX and decreased venous return

49

Hypercapnic (ventilatory) Respiratory Failure
Obstructive lung disease
ICU care of COPD exacerbation
Rx

Glucocorticoids and bronchodilators;
Empiric antibiotics only suspicion of infection

50

Sepsis
What is sepsis:

Intense host inflammatory response to a known or suspected infection that causes systemic manifestations remote from the sit of infection

51

Sepsis
What is severe sepsis

Inadequate organ perfusion or outright organ dysfunction

52

Sepsis
What is septic shock

Sepsis-related hypotension that persists despite fluid resuscitation

53

Sepsis
What are early signs of sepsis?

Bounding pulses and warm extremities

54

Sepsis
What can confound signs of early sepsis?

Dementia;
Beta-blockers

55

Sepsis
Dx for early sepsis

Plasma lactate;
Indicating the need for IVF in the setting of normal BP.

56

Sepsis
What are the 3 main treatments?

Inital resuscitation;
Empiric treatment of infection;
Diagnostic studies

57

Sepsis Rx
Initial resuscitation
What is the treatment plan?

Early goal directed therapy (EGDT)

58

Sepsis Rx
Initial resuscitation
What is EGDT?

1. Adequate fluid resuscitation with IVF
2. Vasopressors supporting BP
3. Early treatment of infection

59

Sepsis Rx
Initial resuscitation
What is hypoperfusion?

SBP<90 or
MAP<70.
Lactic acidosis can supports organ injury due to hypoperfusion

60

Sepsis Rx
Initial resuscitation
What to use?

Crystalloid infusion:
NS or LR

61

Sepsis Rx
Initial resuscitation
Dose of IVF?

30mL/kg;
usually 2-4 L as initial

62

Sepsis Rx
Initial resuscitation
How to measure if IVF is adequate?

Central venous pressure (CVP) of 8-12mmHg;
Urine output 0.5mL/kg/h or greater (not feasuable with AKI);
Central venous oxygen saturation (ScvO2) >=70%

63

Sepsis Rx
Initial resuscitation
What's indicating failure of IVF resuscitation?

For thoes with elevated lactate-->reduce lactate by 10-20% over the first 6 hours. or
Failure to achieve target ScvO2 during the first 6 hours (debateble).

64

Sepsis Rx
Initial resuscitation
What's next step if the failure of IVF resuscitation?

Inotropes and blood transfusion

65

Sepsis Rx
Initial resuscitation
What is the goal MAP after initiating of inotropes?

>=65mmHg

66

Sepsis Rx
Initial resuscitation
What inotropes to choose?

Norepinephrine-first line;
Dopamine--if bradycardia;
Vasopressin, epinephrine, and phenylephrine-->when norepinephrine is not sufficient.

67

Sepsis Rx
Antibiotic therapy
What should be done before start antibx?

2 sets of Blood culture

68

Sepsis Rx
Antibiotic therapy
When to initiate antibx?

Within 1 hour of diagnosis

69

Sepsis Rx
Antibiotic therapy
What antibx to start?

Broad, empiric actibx covering MRSA and pseudomonas.

70

Sepsis Rx
Antibiotic therapy
What to do if no response to inotropes and fluids?

IV hydrocortisone 200mg daily

71

Sepsis Rx
Antibiotic therapy
When to give stress dose of hydrocortisone?

If persistently hypotensive with absline adrenal insufficiency;
And at risk patients such as those on chronic, low-dose systemic glucocorticoids.

72

Sepsis Rx
Glucose control
What is the glucose target for ICU patient?

140-200mg/dL

73

Sepsis Rx
When there is thrombocytopenia, when to transfusion

Transfuse if <10,000/uL;
if fever, recent minor hemorrhage, rapid decline in plt count and concomitant coagulation abnormalities-->transufse if <20,000/uL

74

Sepsis Rx
If thrombocytopenia, what is the DVT ppx strategy?

Only venodyes when plt<50,000/uL.

75

Central Venous Access Indications:

1. Volume resuscitation
2. Emergency venous access
3. Nutritional support
4. Administration of caustic medications (eg, vasopressors)
5. Hemodialysis or plasmapheresis
6. Pulmonary artery catheterization
7. Central venous pressure monitoring
8. Transvenous pacing wire introduction

76

Arterial line indication

1. Continuous direct BP monitoring in patients who are morbidly obese, are very thin, have severe extremity burns, or have very low blood pressures;
2. Inability to use indirect BP monitoring (eg, in patients with severe burns or morbid obesity)
3. Frequent blood sampling
4. Frequent ABG