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ICU Flashcards

1
Q

Options for management of gas trapping (aka AutoPeep)

A

Decrease RR
Decrease TV
Increase expiration time in I:E ratio

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2
Q

Differentiate septic from cardiogenic shock based on Central venous gas

A

CVO2 >80% = sepsis/high flow

CVO2 <60% = cardiogenic

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3
Q

qSOFA

-define sepsis and septic shock

A

Sepsis: 2/3 of:

1) RR>=22
2) SBP <=100
3) Altered LOC (GCS<15)

Septic shock: lactate >2mmol/L and requiring pressors for MAP>65

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4
Q

Dynamic Measures of Fluid responsiveness

A

Fluid challenge (500cc): Increases SV by 10-15% or increased pulse pressure by 15%
Passive leg raise (inc BP by 10-15%)
Lactate
Cap refill: press glass slide on finger until white for 10s if time to normal color <3s = NORMAL
IVC Distendability index
- NOT intubated: >40% IVC collapse with inspiration
- Intubated & ventilated on controlled mode: >15-20% distension with expiration
- Intubated breathing spontaneously - CANNOT Use

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5
Q

Hemodynamic Effect: Norepinephrine and Dopamine

A

Norepi: ++ SVR, + HR, +/nil CO, + PCWP (all up)
Dopamine: + SVR, + HR, + CO, + PCWP
(all up; same as norepi but higher risk tachy)

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6
Q

Hemodynamic Effect: Epinephrine

A

+ SVR, ++ HR, + CO, - PCWP

same as norepi except PCWP drops; higher risk tachy

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7
Q

Hemodynamic Effect: Vasopressin

A

+ SVR, nil HR, nil CO, + PCWP

*S/E: digit/gut ischemia bc peripheral vasoconstrict

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8
Q

Hemodynamic Effect: Phenylephrine

A

+ SVR, - HR, - CO, + PCWP
(opposite dobutamine; similar to vaso but drops HR and CO - reflex brady)
*use in opioid induced hypotension

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9
Q

Hemodynamic Effect: Dobutamine/Milrinone

A
  • SVR, + HR (Dob>Milrinone), + CO, - PCWP

* Milrinone long halflife, not for renal failure

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10
Q

Indications for corticosteroids in septic shock

A

MAP <65 despite fluids and norepi or epi >0.25mcg/kg/min x4h (dose = 200 mg/day hydrocortisone or 50mg q6h)

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11
Q

Norepinephrine dose range

A

0.03-0.35 mcg/kg/min

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12
Q

Strategies to improve ventilation in intubated hypoxic resp failure:

A
  • Increase FiO2
  • Increase PEEP
  • Sedate and Paralyze
  • Prone or roll on good lung down to increase VQ mismatch
  • Inhaled NO
  • ECMO
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13
Q

Strategies to improve ventilation in hypercarbic resp failure:

A
  • Increase RR
  • Increase TV
  • Increase I:E ratio
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14
Q

4 Types of Respiratory Failure

A

1) Hypoxic (PaO2 <60)
2) Hypercapenic (PaCO2 >45)
3) Post-op - due to atelectasis, dec FRC
4) Circulatory collapse

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15
Q

Indications for NIPPV

A

1) Mild-Severe hypercapneic COPD (RR 20-40, pCO2 >45, pH<= 7.35) if LOC not significantly altered
2) Cardiogenic pulmonary edema
3) Avoid intubation: IC, post-op (GI/pelvic, supra-diaphragm sx) with resp failure, high risk post-extubation pt (Age >=65, resp/CV comorbidity)

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16
Q

Contraindications to NIPPV

A

1) Altered LOC - unable to protect airway
2) Inability to clear secretions
3) Hemodynamically unstable (reduces preload)
4) Facial fractures/ surgery/ obstruction
5) Indication for intubation, failed extubation

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17
Q

Definition ARDS

A

1) Acute resp failure (PF ratio <300 on PEEP 5) +
2) Developed within 1 week of acute insult (local - PNA, aspiration, contusion; systemic - sepsis, pancreatitis, drug ingestion, TRALI)
3) Bilateral airspace opacities on CXR not fully explained by cardiogenic pulmonary edema, effusions, lobar/lung collapse or nodules

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18
Q

Severity of ARDS

A

PF 200-300 = Mild
PF 100-200 = Moderate
PF <100 = severe

*PaO2/FiO2

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19
Q

Treatment strategies ARDS

A

1) Lung protective vent: Vt 4-8 cc/kg, P plat <30, PIP <40
- Keep RR <35 and PaCO2<25 to target pH 7.3-7.45
- I:E ratio 1:1 - 1:3
2) High PEEP (if FiO2 >=50%) - Target SpO2 88-95%, PaO2 55-80,
3) Prone (>12hr/day) - mort benefit when PF ratio <150
4) Sedation/Paralysis if:
- PF <150
- Vent asynchrony
- Not for mild or mod/severe on lung protective vent w/ light sedation

  • Unclear mortality benefit: Recruitment maneuvers, ECMO, diuresis
  • *No mortality benefit: Statin, steroids, inhaled NO (may improve oxygenation)
  • **HARM: DO NOT do high-frequency oscillation
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20
Q

Risks and Benefits High PEEP Strategy

A

Benefits:

  • Increase alveolar recruitment
  • Decrease lung strain
  • Decrease atelectrauma

Risks:

  • Overdistension –> dead space
  • Increase pulmonary vascular resistance and intrapulmonary shunt
21
Q

Criteria for extubation

A
  • Underlying cause for intubation resolved
  • PF ratio >150 or SpO2 >90% on FiO2<=40% and PEEP of <=5
  • pH >7.25
  • Adequate CV status (on minimal pressors)
  • Adequate mentation/LOC
22
Q

SBT Steps

A

Screen w/ rapid shallow breathing test: RR/Vt 100-105 is a pass; >105 predictive of failed extubation

Reduce inspiratory/expiratory assistance for 30-120 min and see if patient can tolerate (desat, RR, distress, vitals). If ok, passed!

Weaning Methods:

1) Reduce pressure support during PSV/PEEP (eg 0 on 0) for 30 min OR
2) CPAP OR
3) T piece

23
Q

Treatment ICU Delirium

A

Non-pharm = 1st line
Pharm:
- Analgesia (opioids) > Antipsychotics (Atyp >Typ) > Sedatives (Benzos) = HARM
- IV Bolus > Infusion
- Consider dexmedetomidine (S/E: brady/hypotension) to help facilitate extubation in ICU delirium

24
Q

ICU Sedation target

A

RASS -2 to +1
-2 = moderate sedation, but moves and opens eyes
+1 = anxious but not aggressive or agitated

25
ICU Sedation: Preferred agents
Propofol Opioids Dexmedetomidine NO BENZOS
26
Definition Brain Death
Irreversible cessation of brain and brainstem function
27
Definition Persistent Vegetative State
Severe anoxic brain injury --> wakefulness without awareness or purposeful response Sleep wake cycles intact
28
Definition Minimally Conscious State
Awake with limited interaction | Follows basic commands and/or vocalizes
29
Neurologic Determination of Death (NDD) Criteria
1. Agreed by 2 MDs 2. Injury compatible with NDD 3. 24hs after inciting event eg cardiac arest 4. No brainstem reflexes: pupil, gag, cough, corneal, oculovestibular (no response to caloric testing) 5. No movement: spontaneous or response to noxious stim (B/L and above/below clavicles; EXCLUDES spinal relexes) 6 Positive apnea testing: pCO2 >60 AND >20 above pre-apnea baseline AND pH <=7.28 once disconnected from vent 7. No confounding factors: shock, hypothermia <34C, metabolic abn (PO4<0.4, Ca<1, Mg<0.8, Na>160 or <125, Gluc <4), neuromuscular blockade, interfering drugs, Nerve/Muscle dysfcn (GBS, botulism, MG) , hypoxic ischemic encephalopathy * if confounding factors: ancillary testing to show absent cerebral blood flow via radionuclide/CT/MR/ 4 vessel angiography (CANNOT use EEG)
30
Donation after Cardiocirculatory Death (Controlled) Criteria
1. Non-recoverable illness with dependence on life support and intention to withdraw with imminent death once withdrawn 2. More than 24 hours from inciting event 3. Maximum time from withdrawal of life support to death is 1-2 hours (depending on organ)
31
JAMA: Will this patient be difficult to intubate?
+ LR: Best = Grd 3 upper lip bite test (lower incisor can't reach top lip) Hyomental distance <3 cm Retrognathia (mandible <9cm from angle jaw to tip chin) Malampati >=3
32
Stages of Hypothermia and their treatment
HT1: T32-35, conscious and shivering - Passive rewarming (warm enviro/clothes), + mvment HT2: T28-32, imp LOC, no shivering, VSS - Cardiac monitors, active external warming (warm blanket, bear-hugger), warmed IV fluids, avoid mvment (to avoid arhythmias) HT3: T24-28, unconscious, VS abn but present - Same warming as HT2, external + warmed IV fluids, avoid mvement - Airway management + ECMO/Bypass if cardiac instability HT4: T<24, no vitals - CPR w/ epi and defib, with active external and INTERNAL rewarming
33
Shock differential
Hypovolemic: hemorrhage, pancreatitis Obstructive: PE, tamponade, tension PTX Cardiogenic: ACS, arrhythmia, valvulopathy, HF Distributive: septic, anaphylaxis, SIRS, pancreatitis, mitochondrial dysfcn (eg cyanide), endocrine (thyroid, adrenal crisis), HLH, meds, liver failure, neurogenic shock
34
SIRS
``` 2/4: WBC>12, <4, or >10% bands T>38 or <36 HR>90 RR>20 or PCO2<32 ```
35
Tx for sepsis/septic shock
Initial: Measure lactate and repeat in 2-4h if >2mmol/L Cultures + abx w/i 1h if shock/unclear (otherwise can delay up to 3h) Fluids at least 30ml/kg w/i first 3h Vasopressors to keep MAP >65 Later: Steroids if MAP<65 despite fluid and 1 pressor x4h Transfuse if Hgb <70 , consider if hypoxic, hemorrhage, acute MI VTE ppx (LMWH>UFH) Stress ulcer ppx (lansoprazole 30 or Panto 40) if coagulopathic, liver dz, shock, or intubated BG target 8-10 (Insulin if BG>10) Bicarb if pH<7.2 AND AKI Feed within 72h if no escalating pressor reqment *Do NOT give: immunoglobulins, polymyxin, Vit C, activated prot C, angiotensin ii, O2>96%
36
Reasons to use NS over RL
Refractory hyperK TBI Hx of mitochondrial disease
37
Adrenergic receptors
Alpha 1: increase SVR Alpha 2: Decrease SVR (eg clonidine) Beta 1: Inotropy, chronotropy, domotrophy (conduction) Beta 2: bronchodilation, relax smooth muscles, gallbladder, uterus
38
HFNC benefits
- Heated/humidified gas --> increased secretion clearance and less bronchoconstriction - Washout CO2 decreased dead space - High nasal inspiratory flow (up to 60L/min) decreases upper air resistance - Positive airway pressure recruits leads to recruitment of atelectasis (gives minimal PEEP) - Decreased entrainment ambient air increases FiO2
39
When to use / not use HFNC:
Use: - Type 1 Resp failure - NIVV breaks - Low/mod risk extubation failure non-surgical patients - HFNC or conventional O2 in post-op patients at low risk of respiratory complications; if high risk (HFNC or NIV) Not use: - High risk extubation failure patients - Acute hypercapneic resp failure secondary to COPD - trial NIV before HFNC
40
CPAP vs BIPAP
CPAP improves oxygenation | BiPAP improves oxygenation when you increase EPAP and ventilation when you increase IPAP
41
Refractory hypoxia on vent
- Optimize lungs: diurese, no new PNA - Optimize PEEP, electric impedance tomogaphy, esophageal balloon - Offload lungs (NG to decompression stomach, elevate HOB) - Sedate - Prone if PF<150 - Neuromuscular blockade if mod/severe and cannot achieve lung protective vent (eg hypoxic, vented prone, dysynchronous/high plat P)
42
COVID therapies
1) Dex 6mg PO/IV x10d (if req O2, hospitalized, intubated; NOT for outpatients) - reduced mort and need for MV 2) Remdesivir 200mg IVx1 then 100mg IVx4d (if need O2 but NOT intubated) 3) Tocilizumab (if need O2/intubation, with CRP>75 and wosening despite 1-2d steroids) - reduced mort 4) Casirivimab + imdevimab and sotrovimab - specific cases 5) VTE prevention Not recommended: empiric abx, colchicine, IFN, vit D, Plaquenil, Ivermectin, Lopinavir, ritonavir
43
Findings of Migrated ETT, PTX, Collapse/Plug
ETT migrated to R: trachea displaced to left w/ decreased air entry and percussion on left PTX: trachea away from affected w/ decreased air entry and percussion on affected Collapse: trace towards affected w/ decreased air entry and percussion on affected side
44
Gas Trapping causes
ETT: kinked, clogged by sputum, patient biting on ETT --> suction or fix Vent: high RR, high I:E ratio --> lower RR or lengthen I:E ratio (1:4/5) or decrease VT Patient: high RR, bronchospasm --> bronchodilate Last line tx: disconnect vent and press on chest, Heliox, high freq oscillation, extracorporeal carbon dioxide removal
45
Critical illness myopathy vs critical illness polyneuropathy vs glucocorticoid induced myopathy
Motor: affected in all 3, flaccid quadriparesis + failue to wean in CIM and CIP Sensory affected in CIP, but spared in CIM and GIM Reflexes: normal/low in CIM, low in CIP, nomal GIM CIM: CK up, dx w/ EMG and NCS, no tx CIP: sepsis is RF GIM: cushing like syndrome, dx by reducing steroid dose and monitor sx
46
Highest LR+ for neuroprognostication (poor outcome)
No N20 somatosensory evoked potential cortical wave 24-72h after cardiac arrest or rewarming M1/M2 motor score at 72hr+
47
ETCO2 monitoring during CPR target
10mmHg
48
Pregnant ACLS
Left lateral uterine displacement >20wks IV above diaphragm Stop CaCl or Ca gluc if giving IV Mg Consider postmortem cesarean delivery at 5min of resuscitation
49
Targeted Temp Management after ROSC
24 hours at 33-36C, consider 36 if arrhythmia or CV instability

RCE (18 decks)

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