Flashcards in ICU Deck (82):
1.5 years s/p renal transplant fever work-up
tenderness over graft
1.5 years s/p renal transplant fever and interstital process on cxr: dx, w/u, tx
fiber optic bronch
need to rule out any bacterial causes.
and send IgO and IgM titers and would start the patient on
on broad-spectrum antibiotics, to
cover the gram-positive,
Vancomycin for gram-negative,
prophylactic antifungal ie. fluconazole; Bactrim for Pneumocystis carinii prophylaxis.
CAT scan of the chest and
I would continue the ganciclovir for six weeks and after that, I
will switch the patient to acyclovir.
Starling curve is optimized
for fluid ressus of patient with recent MI and peritonitis from diverticulitis
shooting for a cardiac index of more than 2,
wedge pressure of 14 to 18,
SVR less than 1,000
V tach (or V fib) ACLS
One mg epinephrine (repeated every three minutes)
Shock 300 jewels
300 mg amiodarone
Shock 360 jewels
150 mg amiodarone
Shock 360 jewels
Also try given:
Magnesium 2 – 3 g IV
Procainamide 100 mg Q5 minutes
Bicarb 1 amp
Lidocaine 1 mg per kilogram IV
5 Hs and 5 Ts
these are cause of PEA and Asystole:
Hypovolemia, Hypoxia, Hydrogen ion (acidosis),
Hyper-/hypokalemia, Hypoglycemia, Hypothermia.
think cardiopulm bypass and what is associated with stopping the heart:
hyper k (cardioplegia), acidosis hypothermia, hypotension, hypoxia
The T’s include:
Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and pulmonary), and Trauma.
think trauma box work up:
Tenssion ptx, tamponade, trauma, thrombosis, toxins
pH 7.4 7.35 to 7.45
Pa02 90mmHg 80 to 100 mmHg
Sa02 93 to 100%
PaC02 40mmHg 35 to 45 mmHg
HC03 24mEq/L 22 to 26mEq/L
post arrest care
ABG, lytes, cbc, lactate, base def
Inotropic and vasopressor support can mitigate the myocardial dysfunction that is common during the first 24 to 48 hours after cardiac arrest [20,39].
no evidence demonstrating the superiority of any one vasopressor in the post-cardiac arrest patient. Commonly employed vasopressors include
dopamine (5 to 20 mcg/kg per minute),
norepinephrine (0.01 to 1 mcg/kg per minute; 0.5 to 70 mcg/minute),
epinephrine (0.01 to 1 mcg/kg per minute; 0.5 to 70 mcg/minute).
In cases of cardiogenic shock (eg, global
dobutamine (2 to 15 mcg/kg per minute)
milrinone (loading dose: 50 mcg/kg over 10 minutes, then 0.375 to 0.75 mcg/kg per minute)
Either agent may cause hypotension from vasodilation; dobutamine may cause tachyarrhythmias.
Antiarrhythmic drugs should be reserved for patients with recurrent or ongoing unstable arrhythmias.
No data support the routine or prophylactic use of antiarrhythmic drugs after the return of spontaneous circulation following cardiac arrest, even if such medications were employed during the resuscitation.
Determining and correcting the underlying cause of the arrhythmia (eg, electrolyte disturbance, acute myocardial ischemia, toxin ingestion) is the best intervention. (See 'Determining the cause and extent of injury after cardiac arrest' above.)
low UOP w/u
(FeNa if urine)
BMP / lytes
UA - spec grav / proteinuria / casts
CVP / swan
Indications for renal replacement therapy
Acute severe electrolyte changes - hyper K!
Severe azotemia – BUN > 100
A – Acidosis – metabolic acidosis with a pH 6.5 mEq/L or rapidly rising potassium levels; see previous postfor a review of the causes and management of hyperkalemia
I – Intoxications – use the mnemonic SLIME to remember the drugs and toxins that can be removed with dialysis: salicylates, lithium, isopropanol, methanol, ethylene glycol
O – Overload – volume overload refractory to diuresis
U – Uremia – elevated BUN with signs or symptoms of uremia, including pericarditis, neuropathy, uremic bleeding, or an otherwise unexplained decline in mental status (uremic encephalopathy)
Medication associated with adrenal insufficiency
Etomidate–though, usually not one time bolus
SSx of adrenal insuf
Inability to wean from the ventilator
Persistent hypotension that is vasopressors dependent
Low sodium and high potassium
vague abd pain
adrenal insuf test
Cortisol may be checked at any time in the critically ill
proposed as the appropriate minimum value :
18 is considered normal stress repsonse
for being in the ICU - below this is insuf
(range, 10 to 34 μg/ dL);
"18 year olds are old enough for trauma and have enough cortisol)
(ACTH) stimulation NOT USEFUL in TRAUMA / ICU
administering 250 μg of ACTH (cosyntropin) either intravenously or intramuscularly.
Cortisol levels 30 and 60 minutes
who showed a change in baseline cortisol levels by 9 μg/ dL at 30 or 60 minutes during the ACTH stimulation test had lower mortality rates if they received corticosteroids. This test is thought to demonstrate adrenal reserve in the face of critical illness or sepsis but
low-dose version of the ACTH stimulation test
only 1 µg of cosyntropin is administered intravenously.
Due to the low dose, it is thought that it is more sensitive for partial AI.
best steroid replacement
The administration of hydrocortisone (150 to 200 mg daily for 5 to 7 days) has been shown to lead to a decreased vasopressor requirement as well as improved organ dysfunction, fewer ventilator days, fewer ICU days, and most importantly lower 28-day mortality.
50 mg IV q 6 hr
100 mg q 8 hr
The differential diagnosis of severe hypoxemia in this patient ICU
Transfusion-associated acute lung injury (TRALI)
Acute respiratory distress syndrome (ARDS)
ARDS is a syndrome defined by
1 acute onset
2 pao2 / fio2
Workup The workup for ARDS includes
exclude the other potential diagnoses of the acute hypoxemic respiratory failure.
Transthoracic Echocardiography This diagnostic test is used to evaluate for cardiogenic pulmonary edema.
no evidence of right heart strain or right ventricular dysfunction that may be present in patients with pulmonary embolus.
Laboratory Tests Arterial blood gas confirms hypoxemia,
PaO2 of 85 mm Hg on FiO2 1.0, which confirms a PaO2/ FiO2 ratio ≤ 200 mm Hg.
Brain (B-type) natriuretic peptide (BNP) levels are elevated in acutely decompensated heart failure, so low levels may be indicative of a diagnosis of ARDS.
Sputum Respiratory cultures should be obtained to evaluate for possible bacterial or aspiration pneumonia as the etiology of the patient’s acute respiratory failure.
Electrocardiogram Electrocardiogram (EKG) without MI or Right heart strain
consider CT chest
vent goals for ARDS
lung protective vol 6 cc /kg vol
fluid conservative considered if ressuss done
good lung down
Airway release ventilation
high-frequency oscillatory ventilation
Inhaled nitric oxide
vent setting for ARDS
Plateau pressure goal less than 30
PH goal 7.3 point three– 7.4
head of bed 30
cont positive airway pressure:
30 cm h20 PEEP for 30 sec
risk ptx, hypoxia, hypotension
VAP basic definition
Defined as a pulmonary infection that starts after 48 hours of mechanical ventilation
leading cause of death in ICU!
second most common nosocomail infection in ICU
Criteria to diagnose VAP
Nature of tracheal secretion
+/- bronchoalveolar lavage gram stain finding of
neutrophils OR bacteria
Collecting source to w/u BAL
coaxial catheter that is inserted blindly through the endotracheal tube.
The latter approach, called the mini-BAL -diagnostic yield is considered similar to conventional bronchoscopy.
Additionally, some ICUs use a protective brush inserted via a bronchoscope to obtain direct cultures from the affected area of the lung.
The brush is then retrieved and directly plated onto the culture media.
bacterial burden of more than 10 to the 4 CFU/ mL.
bacteria and abx VAP
early ( 4 ventilator days).
gram-positive organisms such as
extended-spectrum penicillins as a single agent.
invariably resistant organisms
Staphylococcus aureus (MRSA),
vancomycin plus beta lactams
(third-generation cephalosporins, carbapenems)
fluoroquinolones +/ − aminoglycosides is
Treatment of intermittent torsades
correcting any underlying metabolic or electrolyte abnormalities
INCRASE! the heart rate to shorten ventricular repolarization.
Intravenous magnesium sulfate is also effective in treating paroxysmal torsades.
early Sepsis swan findings
high output cardiac failure,
SVR is decreased due to toxins that produce vasodilation.
SvO2 should be HIGH because the tissues are unable to extract oxygen from the blood effectively.
what type of line has the highest DVT risk
Femoral catheters (complete contratindicaiton in peds)
list order of lest to greatest infection risk with lines
Sublavian (lowest infection)
Femoral (highest infection)
cause of hypoxemia in pulmonary embolism
Ventilation-perfusion (V/Q) mismatch
increase the p50 of normal hemoglobin Increased:
(incr Hydrogen / decreased pH
peripheral and splanchnic vasoconstriction.
The most important determinant of Arterial oxygen content
The most important determinant in this equation is the hemoglobin level
1.34 x Hgb
CaO2 = (1.34 x Hgb x SaO2) + (0.003 x PaO2).
The SaO2 and the PaO2 play a smaller percentage in determining the overall content.
A sudden drop in end tidal CO2 upon induction of pneumoperitoneum
should raise the suspicion for a CO2 embolus from the pneumoperitoneum.
Careful, this is paradoxical that endtital CO2 is low with too much CO2 collected in vascular system -> heart!
Managment of A sudden drop in end tidal CO2 upon induction of pneumoperitoneum
Suspect a CO2 embolus from the pneumoperitoneum
the ventilator tubing should checked
discontinue the pneumoperitoneum,
place the patient in the left lateral decubitus position,
attempt to aspirate the air from a central line in the right atrium.
Hyperventilating can help to diffuse the carbon dioxide.
increase in end tidal CO2 is indicitive of what beside MH and what is treatment
Increasing the tidal volume is the treatment for
This patient has SIADH as evidenced by
hyponatremia (water in more than Na)
urine osmolality greater than 100 mOsm/kg
urine sodium greater than 20 mEq/L (concentrating urine)
current guidelines recommend a delay of how long before withdrawing DUAL antiplatelet therapy for a nonurgent operation for bare metal vs drug-eluting stent
4–6 weeks after placement of a BARE METAL stent
6–12 months! after deployment of a DRUG ELUTING
The incidence of perioperative death, myocardial infarction, and stent thrombosis may be as high as 30% within the first month, regardless of the type of implanted stent.
Although this risk decreases over time, some studies have suggested that the risk remains high for up to 2–3 years for drug-eluting stents.
The original indication for stent placement—stable angina versus acute coronary syndrome—appears, however, to be a more powerful predictor of perioperative cardiac complications than the type of stent deployed.
The VAP bundle includes
a daily sedation holiday,
stress gastritis prophylaxis,
elevation of the head of bed,
deep vein thrombosis prophylaxis,
daily oral care.
OTHER measures that may help prevent VAP include enhanced use of noninvasive positive pressure ventilation and
continuous aspiration of subglottic secretions.
The treatment of hypernatremia is to replace the free water deficit.
correction of 10–12 mmol/L per day.
Severe or rapidly evolving hyponatremia from replacing toto fast can lead to seizures, coma, permanent brain damage, respiratory arrest, brain-stem herniation - CPM, and death.
The treatment of hypernatremia is to replace the free water deficit.
Free water deficit =
TBW × [(serum Na+/140) – 1]
Note. TBW = estimated total body water (normal TBW for men = 0.6 and women = 0.5 times the ideal body weight).
The current recommendations for patients with hypernatremia for longer than 24 hours is a correction of 0.5 mmol/L per hour or roughly a maximum correction of 10–12 mmol/L per day.
acute transection of the spinal cord. Clinical manifestations include warm skin,
secondary to a loss of sympathetic tone causing subsequent vasodilatation and increased venous capacitance.
Treatment includes administration of alpha-adrenergic vasoconstrictive agents, such as phenylephrine, to re-establish peripheral vascular tone and decrease venous capacitance.
This is different the brain Cushing reflex of HYPERtension and brady!
proven earlier liberation from mechanical ventilation with
daily spontaneous breathing trials (SBT),
patients breathe through a T-tube
using a small amount of continuous positive airway pressure,
SBT had more ventilator-free days, fewer days in intensive care, and fewer days in the hospital.
Although these results are early, both sedation vacation and SBT are recommended standard practice and should be paired when possible.
vasopressin secretion continues despite a low plasma tonicity/osmolality.
seen in patients with central nervous system disturbances
Plasma osmolality is less than 270 mOsm/kg,
urine sodium is more than 20 mEq/L.
The patient’s volume status is an essential differentiator between SIADH and cerebral salt wasting, because both can be seen in neurologically injured patients.
The treatment of SIADH is fluid restriction
slow sodium replacement, again often with hypertonic saline.
impaired secretion of vasopressin (opposite of SIADH)
rapidly developing hypernatremia.
Excess free water replacement leads to a hypervolemic relative hyponatremia with high urine output.
lowered plasma oncotic pressure
lead to an effective volume contraction
low flow state
that stimulates vasopressin release
causes renal sodium and water retention and causes peripheral edema.
Surviving sepsis guidelines
Abx in first hour if not normal (get blood cxs first)
CVP eight – 12
MAP greater than 65
UOP greater than 0.5
Blood culture (pre-antibiotic)
If blood pressure is decreased and lactate is increased:
Fluids 30 mL per kilogram
If still decreased blood pressure - norepinephrine– Drive the MAP >65
Repeat physical exam!
Bedside cardiac ultrasound SS food response
Norepinephrine two – 20 µg per kilogram
Max this out first
Then add epinephrine
Two – 20 µg per kilogram
(dopamine alternative to epinephrine if a low risk for arrhythmia)
Then add vasopressin 0.03 µg per minute
NO phenylephrine unless epinephrine causing arrhythmia
Steroids if cannot adequately fluid resuscitate:
Hydrocortisone 200 mg per day
(taper when off of pressers)
Do not need corozal or ACTH stem test
Blood glucose goal 150
Plateau pressure ventilator in less than 30 cm of water (survival benefit!)
Insulin drives into cell:
This causes cardiac depression
Also causes die from weakness
Acute liver failure lab findings
Acetaminophen acute liver failure criteria
PH less than 7.3
Lactate greater than three
Temperature greater than 38 last 36
WBC greater than 12 less than 4
Respiratory rate greater than 20
PaO2 listen 32
Management of unstable myocardial infarction
Entra aortic balloon pump
NIF less than 30
minute ventilation less than 10 meters per minute
Title volume less than five – 7 mL per kilogram
continuous aterial venous hemofiltration
works by: convection
from opposite legs
RIGHT femoral ARTERY cordis
LEFT femoral vein tripple lumen
7.5 fr cath
preserves cardiac preload and decompression of splancnic vasculature
land marks for IJ placement
sternal and clavicular heads apex with clavicle as base
palpate carotid pulse
(this is medial to vein)
point to IPSILATERAL nipple
Markers of pulmonary embolism
INCREASED pulmonary artery pressure
Increased central venous pressure
DECREASE PaO2 AND pCO2
ventilation perfusion mismatch
gas is not seeing blood
Right heart failure
Fourth heart sound
mean arterial pressure
calculation map equals diastolic pressure +1/3 (systolic pressure minus diastolic pressure)
cardiac output divided by meter squared
systemic vascular resistance
SVR = (MAP - CVP) x 80/CO
mixed venous oxygen content
15 cc O2 in 100 cc
lift things that cause improvement of Frank Starling curve with ventricular dysfunction
how does dopamine
compared to norepinephrine dopamine and baby nor epinephrine
trade name for norepinephrine
Immediate treatment for myocardial infarction
angio / anticoag
Gen. mechanism dopamine: Heart rate,
heart rate increased
Gen. mechanism dobutamine:
Heart rate INCREASE
Contractility INCREASE the
Gen. mechanism nitroprusside
heart rate no change
Contractility no change
how is pediatric Parkland formula modified
Parkland PLUS maintenance
Kidsneed D5 and a little K.
(approximately 15% above Parkland)
Trauma definition of systolic hypotension
Classify severity of base deficit
Mild: -3 to -5
Moderate: -6 to -9
Severe: Greater than -10
Mortality and percentage the patient with a base deficit of -6 25% and trauma related
And INR 1.5 on arrival to ICU as what percent mortality
and what is treatment
This common causes of vasodilatory shock
MOST common SEPTIC
Acute adrenal insufficiency
cardiogenic, cardiopulmonary bypass
ventilator scenarios with ABGs, PEEP, high peak airway pres- sures,
PC/inverse ratio, swan placement etc
Studies to a very low urine output
post void residual study
Evaluate for ureteral obstruction/injury
Is Irene's kidney function
If you suspect ureteral injury
EKG if troponins are positive
Normal cardiac index
2.5 - 5 L/min
11+ and -4
Examples of obstructive etiologies causing the low urine output
Indications for dialysis
PaO2/F I O2
Less than 200
How low can you go on pH with permissive hypercapnia