Papers and Guidelines Flashcards
Workup and management of postop a-fib that is acutely unstable. (Critical Care Net)
EKG confirms. Check and replace lytes.
Synchronized cardioversion if acute instability.
If the patient was already on pressors and requirements have not gone up, give amio bolus (300 over 1 hr) and start drip (1mg/min then wean over 24 hrs).
Management of postop a-fib that is stable. (Critical Care Net)
EKG confirms. Check and replace lytes. COPD or HF?
- No: metoprolol 5 q5 min x3, then amio if no NSR
- COPD: calcium channel blocker
- HF: amiodarone
What is HELLP syndrome? Incidence? Pathogenesis?
Hemolysis w/ microangiopathic features on blood smear, elevated liver enzymes, low platelets. It is possibly a severe form of pre-eclampsia. Can cause hepatic manifestations - infarction, hemorrhage, rupture.
0.1-0.2% of all pregnancies. 10-20% of pregnancies w/ pre-eclampsia.
Likely d/t abnormal placental placement.
Pregnant patient in 3rd trimester w/ abdominal pain/tenderness midepigastrum/RUQ/below sternum. Nausea/vomiting/malaise.
Sign/symptom Frequency, percent
- Proteinuria 86 to 100
- Hypertension 82 to 88
- RUQ/epigastric pain 40 to 90
- Nausea, vomiting 29 to 84
- Headache 33 to 61
- Visual changes 10 to 20
- Jaundice 5
HELLP Syndrome
Workup and Diagnosis of HELLP
(UpToDate)
- DDx: acute fatty liver of pregnancy , intra-abdominal acute dz, HUS/TTP
- CBC: PLT <100K
- peripheral smear showing microangiopathic features
- Bilirubin >1.2
- LFTs: AST >2x upper limit
- Chem 10 - check Cr
Management of HELLP
(UpToDate)
- stabilize mother
- assess fetal - possible prompt delivery w/ C-section
- tx HTN: labetalol, hydralazine, nifedipine; last resort nitroprusside
- tx preeclampsia: Mg IV 4g bolus then 2g/hr, monitor reflexes and serum Mg
- deliver the baby: >34 wks, <23 wks, fetal demise, MODS, DIC
- tx thrombocytopenia: transfuse platelets if bleeding
- manage elevated LFTs: CT/MRI to check for hematoma or infarct
In adult patients with severe trauma, should an MT/DCR protocol versus no MT/DCR protocol be used to decrease mortality or total blood products used?
What is the ABC score?
(EAST)
Rec the development and implementation of an MT/DCR protocol for the management of severely injured trauma patients.
ABC score: 2/4 activates MTP
- penetrating mechanism
- systolic <90
- HR > 120
- FAST positive
Some advocate if HR > SBP, then they will likely benefit from blood.
In adult patients with severe trauma, should a high ratio of PLAS:RBC and PLT:RBC versus a low ratio be administered to decrease mortality or total blood products used?
(EAST)
Preparing MT packs or pre-positioning blood products in the trauma resuscitation bay in a 1:1:1 ratio (e.g., 6 units PLAS, 1 unit apheresis PLT, and 6 units RBC) can help avoid a significant ratio imbalance during the early empiric resuscitation phase.
Management of AKI
- UA can help determine causes, likely d/t hypovolemia in postop pts; FENA; renal ultrasound
- ID life threatening conditions:
- volume - resuscitate MAP w/ non-K fluid
- lasix if overloaded and oliguric
- dialysis if cannot diurese (anuric) and overloaded
- hyperK - EKG; if >5.5 do C BIG K Di (if making urine)
- dialysis if >6.5
- metabolic acidosis - bicarb in non-gap acidosis (if no overload)
- dialysis if pH <7.1
- dialysis for uremia, neuropathy, AMS
- volume - resuscitate MAP w/ non-K fluid
- treat other conditions:
- hyperPh - phoslo if phos >6
- anuria may require CRRT
In patients with suspected BTAI (P), should CT of the chest with intravenous contrast (I) be used versus conventional catheter-based angiography (C) for the identification of clinically significant injury (O)?
(EAST)
CT chest w/ con is a useful diagnostic tool for both screening and diagnosis of BTAI
SCIP Protocols
- ppx abx within 1 hr
- ppx abx selection for surgical patients
- ppx abx DC within 24 hrs after end of surgery
- cardiac surgery pts w/ controlled 6am postop glucose
- appropriate hair removal
- catheter out POD1 or POD2
- perioperative temperature management
- beta blockers started on patients w/ home med
- VTE within 24 hrs prior and 24 hrs postop
SCIP 2 - perioperative abx ppx selection
- Ancef 2g q4h works for the following
- cardiac - S aureus, S epi
- gastroduodenal - GNB, GPC
- no need if low risk (no entry into lumen, not obese, no obs)
- biliary - GNB, enterococci, clostridia
- hernia - aerobic GPC
- Add metronidazole 500mg x1
- small intestine - GNB, GPC, anaerobes, enterococci
- appendectomy - GNB, anaerobes, enterococci
- colorectal - GNB, anaerobes, enterococci
- Genitourinary needs cipro or bactrim
- Gynecological needs ancef
- ENT needs ancef; clean-contaminated add metronidazole
- NSGY needs ancef
- Ortho needs ancef
- Thoracic needs ancef
- Vascular needs ancef
- Perc does not need abx
- Breast cancer procedures need ancef
How do you manage postoperative urinary retention?
- H&P - bladder fullness, low abd discomfort; inability to void 4-6 hours after removal of the Foley
- Bladder scan
- If <0.5 ml/kg/hr (or 600 ml) and asx - may be hypovolemic
- if >0.5 ml/kg/hr (or 600 ml) or discomfort - do I/O catheter
- I/O catheter
- >400 ml/15 min - leave catheter, start flomax, o/p urology f/u
- <400 ml/15 min - 6 hr spontaneous voiding trial
Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment
(JAMA 2018)
- Berlin criteria
- Berlin definition of 3 ARDS categories
- Prone positioning
- Vent management
- Berlin criteria: lung injury within 1 week, CXR w/ bilateral opacities not d/t CHF/overload
- ARDS categories (PaO2/FiO2): mild 200-300, moderate 100-200, severe <100; PEEP >5
- Management: TV 6 ml/kg predicted BW, increase PEEP for oxygenation
- PaO2/FiO2 <150 - deep sedation and prone positioning, NB blocker
- <80 - case by case - VV ECMO, HFOV
