Managing the ICU Patient Flashcards

Question

how to treat hypovolemic shock

Answer 1

* GIVE THE PATIENT FLUID! * Total body fluid: 80kg man (48L), 60kg woman (30L). * Blood volume: 80kg man (5.3L), 60kg woman (3.6L). * Can lose up to 15% of blood volume and compensate. * Start to get into trouble between 15 and 30%. * After 30%, will go into shock.

Answer 2

* Calculate fluid loss (% blood loss x total) * Give four (4) times the loss in IV crystalloid * Example: 35% x 5.3L = 1.9L, so replace with 7.5-8L * Target is CVP between 5-10mm Hg (12-15 can mean fluid overload) * Follow electrolytes and Hgb during replacement.

Answer 3

* ↑ Cardiac output * ↓↔ Central venous pressure * ↓ Systemic vascular resistance

Answer 4

* Dopamine (start 1.0mcg/kg/min, titrate to effect) * Dose dependent response. * Low dose (1-5mcg): specifically increases blood flow to renal, mesenteric, and cerebral regions, by increasing SVR in other regions. * Intermediate dose (5-10mcg): stimulates β receptors in heart, ↑ cardiac output. * High dose (\>10mcg): stimulates α receptors in systemic and pulmonary circulation, increasing SVR while preserving CO, thus helping to correct hypotension. * Complications: tachycardia at intermediate doses, and ischemic limb necrosis even at low doses (consider prompt α blocker, e.g., phentolamine).

Answer 5

* Give anti-hypertensives * Drips of nitroprusside/nicardipine/clevidipine/esmolol * PRN labetalol or hydralazine * Wean off and transition to longer-acting PO meds

Answer 6

* Invented in 1970, was the first device to measure hemodynamic phenomena in real time. * Several studies have shown there to be NO improved outcomes when using PA catheters. * Echocardiography and other measures are safer.

Answer 7

* Start with ABCs * Depending on injury, may need invasive monitoring to monitor intracranial pressures (ICP). * The problem is that trauma causes edema, which leads to ↑ ICPs, which leads to ↓ in oxygen delivery to brain tissue and/or herniation of brainstem through the foramen magnum (i.e., brain death). * If blood cant get into the brain, then the brain cant get oxygen and the brain begins to die – this can then cause the brain to push out through the foramen magnum – this will compress the brainstem against the skull and will prevent you from ever waking up again

Answer 8

* The goal is to keep oxygen flowing to brain so it can heal. * Need to maintain favorable pressure gradient, called cerebral perfusion pressure (CPP). * CPP = MAP - ICP * So, for critical head injuries, we need to be able to monitor (and control) both intracranial pressure AND blood pressure. * Goal CPP is often around 60mm Hg (may vary) * Goal ICP is generally \<22mm Hg * Thus, MAP should be maintained at ≥ 80mm Hg * To maintain CPP, we can lower ICP (preferable), or raise MAP (less preferable) * Other methods of lowering ICP include paralysis, mannitol, and surgical decompression (definitive) * You can also use hypertonic saline to decrease the pressure

Answer 9

* Camino Bolt * Threaded, is screwed into skull. * Rests just under dura * Provides real time ICP data

Answer 10

* Inserted like a Camino bolt * Measures O2 content of blood * Considered more useful than Camino, because it measures direct oxygenation, rather than perfusion pressures (which only correlate with oxygenation).

Answer 11

* A catheter inserted into the lateral ventricle * Provides real time ICP monitoring * Also provides means to drain CSF from brain, which can reduce ICP * May be used in conjunction with Licox * GOLD STANDARD FOR CRANIAL PRESSURE MONITORING

Answer 12

* Subarachnoid hemorrhage and aneurysms * “Worst headache of my life.” * May be traumatic, or due to an aneurysm. * Aneurysms are worse. * A weak point in a cerebral artery. * Often asymptomatic. * Usually devastating. * 50% never make it into the hospital. * 50% in hospital die. * Once in ICU, these patients are placed on a protocol. * Critical BP control, neuro checks, seizure prophylaxis, vasospasm prophylaxis. * The goal is to repair the aneurysm before it bleeds again. * Surgery (clipping) or interventional radiology (coiling) are the methods. * Once repaired, patient stays in ICU. * High risk for vasospasm, so gets neuro checks, HHH (hypervolemic-hypertensive-hemodilution) therapy, and nimodipine. * These patients get a lot of IV fluid, and are allowed to have SBP as high as 200, for a week or longer. * Vasospasm requires emergent transluminal balloon angioplasty.

Answer 13

* Respiratory insufficiency, cardiovascular insufficiency, and neurological injury. * Know your history. * Read the chart, especially the previous notes. * Sweat the “small stuff.”

Answer 14

* Just because they’re “small” doesn’t mean they’re not critical to keeping your patient moving rightward. * It does mean that they tend to kill your patient slowly, rather than quickly. * The “Small Five” * GI/nutrition, hematology, electrolytes, renal, infectious disease

Answer 15

* Most ICU patients are too obtunded to eat. They’re either NPO (on purpose) or they need nutrition. * Nutrition is critical to surviving a stay in the ICU. * Patients can be fed through NGT (at first), Dobhoff tubes (longer term), or G-tubes (longest term). * Tube feeds are recommended by our nutritionists. * Prophylaxis

Answer 16

* ICU patients tend to become anemic. * Hemorrhage, consumption, malnutrition, phlebotomy * We follow Hgb; if it falls below 8.0, we consider transfusion. * We also follow coags (INR), and correct as needed. * Prophylaxis

Answer 17

* Following I’s & O’s * In: IVF (including meds), TF, oral * Out: UOP, BM, drains, emesis, NG output, insensate * Insensate fluid loss in a healthy adult: 400ml H2O from lungs, 400ml H2O from skin * Follow over 24°, and over multiple days. We prefer that I’s & O’s (plus insensate losses) are balanced.

Answer 18

* For renal, we follow urine output, and blood urea nitrogen and creatine. Minimum UOP should be ≥20ml/hr. BUN/Cr should not be climbing. * Pre-renal: ↓ blood flow to kidney (hypovolemia, renal artery obstruction) * Intrinsic: damage to kidney (drugs, ischemia, infection) * Post-renal: obstruction of urinary tract (stones, catheter, BPH)

Answer 19

* May be chronic in ICU patients (125-130). Can be caused by malnutrition, drug side effects, fluid overload. * Best to treat the underlying problem first. * If really low (\<120) and symptomatic (nausea, malaise, headache → coma, seizures, arrest), replace sodium, with continuous infusion of 3% (hypertonic) NaCl IV. Start oral repletion.

Answer 20

* Hypernatremia (\>145) * Usually caused by hypovolemia, renal disease, or diabetes insipidus (DI). * Give more fluid, but NOT normal saline. * Slow correction is the general rule. * DDAVP is indicated some cases of DI (patients will have ↑ UOP, ↓ urine SG, and ↑ serum osmolality).

Answer 21

* Patients generally asymptomatic until ≤ 3.0 * Correct the underlying disorder, and give K+ * Oral is preferable (KCl tabs, or KCl elixir). IV is frequently necessary. 20-40mEq at a time. * Prophylaxis

Answer 22

* Mild (\<6.0): Give loop diuretic (40-80mg Lasix), and Kayexalate (30gm in 50ml of 20% sorbitol PO or PR) * Moderate (\<6.0-7.0): Sodium bicarb, insulin with D50, albuterol nebs) * Severe (\>7.0 or lower w/ EKG changes): CaCl or calcium gluconate IV, hemodialysis

Answer 23

* Normal range is 1.7-2.3 * Very low levels (≤ 0.7) can cause fatal arrhythmias * Seen in drinkers * Correct with MgSO4 1-2gm IV slow push * Prophylaxis

Answer 24

* Infection can be the cause of a patient’s critical condition, or a complication. Every ICU patient is at risk for a life-threatening infection. * Pay special attention to WBC and temp in writing your note. Also follow antibiotics: What are they on now? What have they been on? How long? * If patient has a new fever or ↑ WBC, then get “pan cultures” (blood, sputum, urine) and CXR to start.

Answer 25

* Feed patient as soon as you can. Give them a multivitamin to help prevent electrolyte problems. * Most, if not all, ICU patients need to be on a proton pump inhibitor (Nexium, Pepcid). Especially patients who are NPO, on steroids, or head injured. * Bowel regimen: stool softener (colace), stimulant laxative (senna), suppositories (dulcolax).

Answer 26

* Deep venous thrombosis and pulmonary embolism * Every patient should be wearing sequential compression devices (aka “pumpy leg things”). * Every patient should get prophylactic heparin or LMWH when hemodynamically stable. * Confirm this every day, even if already ordered.

Answer 27

* Review all medications every day. * Which meds can or should be removed? * Which should the patient be on? * Do any meds need to be renewed? * Do we need to check serum drug levels on anything?

Answer 28

* Does the patient have adequate sedation and pain control? * Is the patient over-sedated or over-narced? * Always document what meds are being used, and the usage history of these meds. * Some meds have toxic profiles when used for a long time (e.g., propofol, toradol); check labs accordingly.

Answer 29

* Skin breakdown is a huge concern among bedbound patients. * Is the patient being turned? Is there any sign of skin breakdown? * Do they need a special mattress (e.g., airflow mattress)? * Any new rashes or lesions?

Answer 30

1. Identify patient 2. Main problem (why admitted), new problems. 3. PMHx, ICU Hx 4. Current problems 5. Vitals, vent status, I’s & O’s, labs, meds, physical exam 6. Overall impressions * Respiratory * Cardiovascular * Neuro * GI/Nutrition * Heme * FEN/Renal * ID * Prophylaxis 7. General plan for the next 24 hours