SR 65 - Surgical Intensive Care Flashcards Preview

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Flashcards in SR 65 - Surgical Intensive Care Deck (103):
1

How is an ICU note written?

By systems:
- Neuro (GCS, MAE, pain control)
- Pulmonary (vent settings)
- CVS (pressors, swan numbers)
- GI (gastrointestinal)
- Heme (CBC)
- FEN (Chem10, nutrition)
- Renal (urine output, BUN, Cr)
- ID (Tmax, WBC, antibiotics)
Assessment/plan

2

Possible causes of fever in the ICU?

Central line infection
Pneumonia/atelectasis
UTI, urosepsis
Intra-abdominal abscess
Sinusitis
DVT
Thrombophlebitis
Drug fever
Fungal infection, meningitis, wound infection
Endocarditis

3

What sit he most common bacteria in ICU penumonia?

Gram-negative rods

4

Basic ICU care checklist?

FAST HUG
- Feeding
- Analgesia
- Sedation
- Trhomboembolic prophylaxis

- Head-of-bed elevation
- Ulcer prevention
- Glucose control

5

What is CO?

Cardiac output = HR X SV

6

What is normal CO?

4-8L/min

7

What factors increase CO?

Increased contractility, HR, preload
Decreased afterload

8

What is CI?

Cardiac index = CO/BSA

9

What is normal CI?

2.5-3.5L/min/M2

10

What is SV?

Stroke volume
Amount of blood pumpoed out of the ventricle each ebat
EDV-ESV or CO/HR

11

What is normal SV?

60-100cc

12

What is CVP?

Central venous pressure
Indirect measurement of intravascular voume status

13

What is normal CVP?

4-11

14

What is PCWP?

Pulmonary Capillary Wedge Pressure
Indirectly measures left atrial pressure, which is an estimate of intravascular volume (LV filling pressure)

15

What is the normal PCWP?

5-15

16

What is the anion gap?

Na - (Cl + HCO3)

17

What are the normal values for anion gap?

10-14

18

Why do you get an increased anion gap/

Unmeasured acids are unmeasured anions in teh equation that are part of the 'counterbalance' to the sodium cation

19

What are the causes of incrased anion gap acidosis in surgical patients?

Starvation
Alcohol (ethanol, methanol)
Lactic acidosis
Uremia (renal failure)
DKA

20

What is SVR?

Systemic vascular resistance
MAP - CVP / CO x 80

21

What is SVRI?

Systemic Vascular Resistance Index
SVR/BSA

22

What is normal SVRI?

1500-2400

23

What is MAP?

Mean arterla pressure
DBP + 1/3 SBP

(not the mean b/c diastole lasts longer)

24

What is PVR?

Pulmonary vascular resistance

PA (mean) - PCWP / CO X 80

25

What is the normal PVR value?

100 +/- 50

26

What is the formula for arterial oxygen content?

Hb X SaO2 x 1.34

27

What is the basic formula for oxygen delivery? Full formula?

CO x (oxygen content)

CO x (1.34 x Hg x SaO2) x 10

28

What factors can increase oxygen delivery?

Increased CO by increasing SV, HR or both
Increased O2 content by increasing Hb content, SaO2 or both

29

What is mixed venous oxygen saturation?

SvO2
The O2 saturation of teh blood in teh right ventricle or pulmonary artery
An indirect measure of peripehral oxygen suplly and demand

30

Which lab values help assess adequate oxygen delivery?

SvO2 - low with inadequate delivery
Lactic acid - elevated
pH - acidosis
Base deficit

31

What is FENa?

Fractional Excretion of Sodium

(Una x Pcr / Pna x Ucr) x 100

32

What is the prerenal FENa value?

33

How long das Lasix effect last?

Six hours

34

What is the formula for flow/pressure/resistance?

Pressure = Flow x Resistance

35

Effect of PaCO2 on acid-base status?

For every increase in PaCo2 by 10mmHg, pH falls by 0.08

36

One liter of O2 via nasal canula raises FiO2 by how much?

3%

37

SICU Drugs:
Dopamine

Site of action - dependant on doses
- Low dose (1-3ug/kg/min): Dopa agonist, renal vasodilation
- Intermediate dose (4-10): + a1, ++B1; positive ionotropy and some vasocontriction
- High dose (>10): +++a1 agonist; marked afterload increase from arteriolar vasoconstriction

38

Has 'renal dose' Dopamine been shown to decrease renal failure?

No

39

SICU Drugs:
Dobutamine

SOA: +++B1 agonist, ++B2
Effect: increased inotropy; increased chronotropy; decrase in SVR

40

SICU Drugs:
Isoproterenol

SOA: +++B1 and B2 agonist
Effect: Increase inotropy, increased chronotropy; vasodilation of skeletal and mesenteric vascular beds

41

SICU Drugs:
Epinephrine

SOA: ++ a1, a2, ++++B1/2 agonist
Effect: Increased inotropy, increased chronotropy

42

SICU Drugs:
Norepinephrine

SOA: +++a1, a2, +++B1/2 agonist
Effect: Increased inotropy, increased chronotropy, ++ increas in BP

43

What is the effect of Epinephrine at high doses?

Vasoconstriction

44

What is the effect of high dose Norepinephrine?

Severe vasoconstriction

45

SICU Drugs:
Vasopressin

Effect: Vasoconstriction, increases MAP, SVR
Indications: Hypotension, refractory to other vasoporessors

46

SICU Drugs:
Nitroglycerine

SOA: +++venodilation, +ateriolar dilation
Effect: Increased venous capacitance, decreased preload, coronary arteriole vasodilation

47

SICU Drugs:
Sodium nitroprusside

SOA: +++ venodilation, +++ arteriolar dilation
Effect: Decreased preload and afterload, allowing BP titration

48

What is the major toxicity of Sodium Nitroprusside?

Cyanide toxicity

49

Define Preload

Load on the heart msucle taht stretches it to EDV = intravascular volume

50

Define afterload

Load or resistance the heart must pump against = vascular tone = SVR

51

Define contractility

Fource of heart muscle contraction

52

Define compliance

Distensibility of heart by the preload

53

What is the Frank-Starling curve?

Cardiac output increases with increasing preload up to a point

54

What is the clinical significance of the steep slope of the Starling curve relating EDV to CO?

Demonstrates the importance of preload in determining CO

55

What factors influence the oxygen content of whole blood?

Hemoglobin concentration and the arterial oxygen saturation
Partial pressure of oxygen dissolved in plasma plays a minor role

56

What factors influence mixed venous oxygen saturation?

Oxygen delivery (Hb concentration, arterial O2 sat, CO) and oxygen extraction by the peripheral tissues

57

What lab test for tissue ischemia is absed on teh shift from aerobic to anaerobic metabolism?

Serum lactic acid levels

58

Define dead space

Part of inspired aire that does not participate in gas exchange

59

Define Shunt fraction

Fraction of pulmonary venous blood that does not participate in gas exchange

60

What causes increased dead space?

Overventilation (emphysema, excessive PEEP)
Underperfusion (PE, low CO, pulmonary artery vasoconstriction)

61

At high shunt fractions,w aht is the effect of increased FiO2 on arterial PO2?

Shunt fraction>50%, changes in FiO2 have NO effect on arterial PO2
You want to minimize FiO2 to prevent oxygen toxicity

62

Define ARDS

Acute respiratory distress syndrome
Lung inflammation causing respiratory failure

63

What is the ARDS diagnostic triad?

CXR:
- Capillary wedge pressure

64

What does the classic CXR look like with ARDS?

Bilateral fluffy infiltrates

65

At what concentration does O2 toxicity occur?

FiO2 >60% x 48hrs

66

What is the only ventilatory parameters that have been shown to decreased mortality in ARDS patients?

Low tidal volumes (

67

What are the main causes of CO2 retention?

Hypoventilation
Increased dead space ventilation
Increased CO2 production (hypermetabolic states)

68

Why are carbohydrates minimized in patient having difficulty with hypercapnia?

Respiratory Quotione is ration of Co2 production to O2 consumptoin
The RQ is highes for carbohydrates (1.0) and lowest for fats (0.7)

69

Why are indwelling arterial lines used for BP monitoring in critically ill patients?

Need for frequent measurments
Inaccuracy of repeated cuff measurements
Inacuraccy of cuff measurements in hypotension
Need for frequent ABGs

70

Which values are obtained from a SGC?

CVP, PA pressures
PCWP, CO, PVR, SVR
Mixed venous O2 sat

71

What is PCWP?

PCP after ballon occlusion of the PA, which eaquals elft atrial pressure
LAP is equal to LVP/EDP, left heart preload, and intravascular volume status

72

What is the primary use of PCWP?

Indirect measure of preload = intravascular volume

73

Has use of SGC been shown to decrease mortality in ICU patients?

No

74

Define ventilation

Air moving through the lungs
Monitored by PCO2

75

Define oxygenation

Oxygen delivery to the alveoli
Mesasured by O2Sat and PO2

76

What can increase ventilation to decrease PCO2?

Increased RR
Increased TV
(Increasing minute ventilation)

77

What is minute ventilation?

Volume of gas ventilated through the lungs
RR x TV

78

Define tital volume

Volume delived with each breath
6-8cc/kg on ventilator

79

Are ventilation and oxygenation related?

No - you can have an O2Sat of 100% and PCO2 of 150
O2Sat do NOT tell you anything abotu PCO2

80

What can increase PO2 in the ventilated patient?

Increased FiO2
Increased PEEP

81

Define IMV

Intermittent Mandatory Ventilation
Patient can breath on their own, but if they don't breath within a specific time, the machine breathes
Can breath above the mandatory rate without help from the ventilator

82

Define SIMV

Synchronous IMV
Delivers mandatory breath synchronously with patient's initiated effort. If no breath is initiated, breath will be initiated by machine.
Patient's breath triggers the machine to supplement the breath

83

Define A-C

Assist-Control venitlation
Ventilator delievers breath when patient initiates a breath
If the patient does not breath , ventilator takes control
All breaths are by the ventilator

84

Define CPAP

Continuous Positive Airway Pressure
Delieves continuous pressure during expiration and inspiration, but no volume breaths
Patient breaths on own

85

Define Pressure Support

Pressure is delieved with initiated breaths
Decreases work of breathing by overcoming the resistance in the venitlatory circuts
Patient breaths on own

86

Define APRV

Airway Pressure Release Ventilation
HIgh airway pressure intermittently released to a low airway pressure

87

Define HFV

High frequency ventilation
Rapid rates of venitlation with small tidal volumes

88

What is the effect of PP ventilation in patients with hypovolemia or low lung compliance?

Decreased VR
Decreased CO

89

Define PEEP

Positive end expiration pressure
Pressure maintained at the end of a breath - keeps alveoli open

90

What is 'physiologic PEEP'?

5cmH2O
Approximates normal pressure in normal non-intubated people caused by the closed glottis

91

What are the AE of increasing levels of PEEP?

Barotrauma (injury to airway = PTX)
Decreased CO from decreased preload

92

What are the typical initial vent settings?

IMV
TV = 6-8ml/kg
VR = 10bpm
FiO2 = 100% and wean down
PEEP = 5cmH2O

Then change based on ABGs

93

What is normal I:E?

1:2

94

When would you use an inverse I:E ratio?

Ex - 2:1, 3:1
To allow for longer inspiration inpatients with poor compliance
To allow for alveolar recruitment

95

When would you use a prolonged I:E ratio?

Ex. 1:4
COPD
To allow time for complete exhalation
Prevents 'breath stacking'

96

What clinical situations cause increased airway resistance?

Airway or endotracheal tube obstruction
Bronchospasm
ARDS
Mucous plug
CHF --> pulmonary edema

97

What are the presumed advantages of PEEP?

Prevention of alveolar collapse and atelectasis
Improved gas exchange
Increased pulmonary compliance
Decrease shunt fraction

98

What are the possible disadvantages of PEEP?

Decreased CO (esp in Hypovolemia)
Decreased gas exchange
Decreased compliance with high levels of PEEP
Fluid retention
Increased ICP
Barotrauma

99

What parameters must be evaluated in deciding if a patient is ready to be extubated?

Alert and able to protect airway
Gas exhange (PaO2 >70, PaCO2 5cc/kg)
Minute ventilation (

100

What is the Rapid-Shallow Breathing (AKA Tobin) Index?

RR:TV

101

What is the possible source of fever in a patient with an NG or nasal endotracheal tube?

Sinusitis
Diagnose by sinus films or CT

102

What medications can be delievered via an endotracheal tube?

Narcan
Atropine
Vasopressin
Epinephrine
Lidocaine
'NAVEL'

103

What conditions should you think of with increased peak airway pressure and decreased urine output?

Tension pneumonthorax
Abdominal compartment syndrome