Managing the ICU pt. Flashcards

Question

Whats the treatment?

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 ∼ 15mm Hg Follow electrolytes and Hgb during replacement.

Answer 3

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

Answer 4

Dopamine (vasopressure) (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 or nicardipine PRN labetalol or hydralazine Wean off and transition to longer-acting PO meds

Answer 6

Several studies have shown there to be NO improved outcomes when using PA catheters. Echocardiography and other measures are safer.

Answer 7

(Glasgow Coma Score, pupils, movement, reflexes)

Answer 8

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 The goal is to keep oxygen flowing to brain so it can heal. CPP = MAP - ICP

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

Answer 12

Goal CPP is often around 60mm Hg (may vary) Goal ICP is generally <20mm 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)

Answer 13

``` Aneurysm A weak point in a cerebral artery. Often asymptomatic. Usually devastating. 50% never make it into the hospital. 50% in hospital die ```

Answer 14

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.

Answer 15

Respiratory insufficiency, cardiovascular insufficiency, and neurological injury. Know your history. Read the chart, especially the previous notes.

Answer 16

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 17

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 18

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 19

In: IVF (including meds), TF, oral Out: UOP, BM, drains, emesis, NG output, insensible Insensible 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 insensible losses) are balanced.

Answer 20

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 21

Patient’s pathology (diagnosis, staging, etc.) | Patient’s overall health (i.e, are they going to be able to recover from the grave wounds we plan to inflict upon them?)

Answer 22

ICU — 2:1 (or even 1:1) SDU — 3:1(step down unit) Med/Surg — 5:1

Answer 23

Respiratory insufficiency Hemodynamic (cardiovascular) insufficiency Depressed consciousness or coma * or the threat of these conditions!

Answer 24

``` 1. Identify patient Name, age, days in ICU, primary team 2. Main problem (why admitted), new problems 3. Background information Medical history, ICU history ``` 4. Current problems 5. Physical findings (I’s & O’s, labs, vitals, exam) 6. Evaluation of patient by system Observation, intervention, impression (stable?) 7. Overall impression 8. Plan for the next 24 hours

Answer 25

1. Respiratory 2. Cardiovascular 3. Neurological 4. GI and Nutrition 5. Hematology 6. Electrolytes 7. Renal 8. Infectious Disease

Answer 26

The pt must be intubated...

Answer 27

Assist-control (AC) Intermittent Mandatory Ventilation (IMV/SIMV) Pressure Support Ventilation (Spontaneous)

Answer 28

Fixed respiratory rate and fixed tidal volume Patient can initiate breaths, and each gets full TV Required for patients in deep coma or sedation Deep coma/sedation is required for AC

Answer 29

Periodic breaths at set rate (minimum) Patient can initiate breaths above set rate Patient determines TV for spontaneous breaths, and breaths are supported by positive pressure. More comfortable for patients who are more awake.

Answer 30

Patient initiates every breath (no set rate) Breaths are supported by positive pressure Least invasive, most comfortable for awake patients Used when weaning from mechanical ventilation

Answer 31

``` When documenting (or ordering) mechanical ventilation, it’s written this way: Mode RR(actual) TV Fi02 PEEP PSV Example: SIMV 12(14) 400 50% PEEP=5 PSV=8 ```

Answer 32

AC IMV/SIMV Spontaneous (Spont)

Answer 33

Not just important for oxygenation. The rate controls how much CO2 is being expired. The higher the rate, the more CO2 is removed.you can control the ph of the pt.

Answer 34

Normally should be 10-12ml/kg. Higher volumes are associated with barotrauma. With critically ill patients, the general practice is low volume ventilation, with tidal volumes of 6-8ml/kg.

Answer 35

Expressed as a percentage. Start with 100% when beginning mechanical ventilation, and titrate down, monitoring O2 saturation. >60% for 48 hours can be toxic.

Answer 36

Residual positive pressure at the end of expiration. Keeps alveoli open. Useful in people with “stiff lungs” (e.g., ARDS). 5 cm H2O is helpful in promoting oxygenation and reducing barotrauma.

Answer 37

Used in IMV and Spontaneous ventilation. Positive pressure applied with patient-initiated breaths. Helps to overcome the resistance of the ventilator circuit (“sucking through a straw”).

Answer 38

tracheostomy

Answer 39

A functioning pump Sufficient fluid volume Regulated resistance When one or more of these are absent, it’s called....

Answer 40

``` Pump dysfunction Cardiogenic shock Volume depletion Hypovolemic shock Resistance dysfunction Septic/neurogenic/anaphylactic shock ```

Answer 41

Cardiac output (SV x HR) Central Venous Pressure (CVP) Systemic Vascular Resistance (SVR)

Answer 42

↓ Cardiac output ↑ Central venous pressure ↑ Systemic vascular resistance

Answer 43

Dobutamine Inotropic, so will ↑CO (by ↑ stroke volume) Patient will experience ↓ SVR, due to baroreceptor response Does not ↑ arterial BP, so may need additional drugs

Answer 44

↓ Cardiac output ↓ Central venous pressure ↑ Systemic vascular resistance

Answer 45

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 46

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 ∼ 15mm Hg Follow electrolytes and Hgb during replacement.

Answer 47

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

Answer 48

Dopamine (vasopressure) (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 49

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

Answer 50

Several studies have shown there to be NO improved outcomes when using PA catheters. Echocardiography and other measures are safer.

Answer 51

(Glasgow Coma Score, pupils, movement, reflexes)

Answer 52

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 The goal is to keep oxygen flowing to brain so it can heal. CPP = MAP - ICP

Answer 53

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

Answer 54

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 55

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

Answer 56

Goal CPP is often around 60mm Hg (may vary) Goal ICP is generally <20mm 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)

Answer 57

``` Aneurysm A weak point in a cerebral artery. Often asymptomatic. Usually devastating. 50% never make it into the hospital. 50% in hospital die ```

Answer 58

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.

Answer 59

Respiratory insufficiency, cardiovascular insufficiency, and neurological injury. Know your history. Read the chart, especially the previous notes.

Answer 60

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 61

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 62

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 63

In: IVF (including meds), TF, oral Out: UOP, BM, drains, emesis, NG output, insensible Insensible 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 insensible losses) are balanced.

Answer 64

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 65

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 100ml 3% NaCl IV at a time.

Answer 66

Usually caused by hypovolemia, renal disease, or diabetes insipidus (DI). Give more fluid, but NOT normal saline. Slow correction is the general rule.

Answer 67

Mild (7.0 or lower w/ EKG changes): CaCl or calcium gluconate IV, hemodialysis

Answer 68

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

Answer 69

GI/Nutrition 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 70

Hematology Deep venous thrombosis and pulmonary embolism Every patient should be wearing sequential compression devices (aka “pumpy leg things”). Every patient should get Lovenox (40mg SQ daily) when hemodynamically stable. Confirm this every day, even if already ordered.(must be re-ordered as it will stop after 72hrs)

Answer 71

``` 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 72

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 73

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 RespiratoryCardiovascularNeuroGI/NutritionHemeFEN/RenalIDProphylaxis 7. General plan for the next 24 hours