Surgical- ICU

Question 1

two major reasons for admittance to the ICU

Answer 1

1. Organ failure affecting biologic homeostasis that cannot be appropriately managed on a regular floor
   Ex: Respiratory distress
2. Concern for progressive worsening of conditions that could need for close monitoring
   ex: Multiple rib fractures in a fragile patient

Question 2

3 mortality risk scoring systems. why do these matter for the ICU?

Answer 2

APACHE (Acute Physiology and Chronic Health Evaluation)
SAPS (Simplified Acute Physiologic Score)
MPM (Mortality Probability Model)
* The key is to transfer patients out of ICU as fast as possible once they have stabilized.

Question 3

central venous access is placed with the assistance of what? (KNOW)

Answer 3

visualization with US guidance

except sometimes not for subclavian placement- US through bone doesnt work

Question 4

central venous line: types of access? (4) KNOW

Answer 4

Femoral
Subclavian
IJ
PICC (periph. inserted central cath: like IV in the arm)

Question 5

what are the risks for each type of central line access? femoral, subclavian, IJ (KNOW)

Answer 5

1) . Femoral: “Dirty”: near the groin– should change to access site that is less likely to become infected ASAP
2) . Subclavian – increased risk of Pneumothorax
3) . IJ – close to carotid!! (don’t accidentally dilate this!)

Question 6

what is the benefit of the PICC central line? (KNOW)

Answer 6

allows for prolonged access in patients required to have prolonged IV therapy. They can go home with this

Question 7

2 types of central venous lines (KNOW)

Answer 7

MML (multi-med line)

Vascath (larger for more viscous fluid)

Question 8

what are 4 types of meds used for sedation in the ICU? (KNOW)

Answer 8

Benzos
Propofol (Diprivan)
Precedex (Dexmetomidine)
Haloperidol (Haldol)

Question 9

benefit of using Benzos (ex: versed or ativan) for sedation? Cons to using benzos? who do you not give them to? (KNOW)

Answer 9

• sedation + amnesia
• amnesia can prevent the PTSD assoc. with ICU stay
  Cons: overdose, withdrawal
  ** DONT give to elderly, heart failure or resp/hepatic insufficency

Question 10

what is the RASS score? (KNOW)

Answer 10

a scoring system used to measure the patient's sedation. 
\+4 combative
\+3 very agitated 
\+2 agitated
\+1 Restless
0 alert and calm
-1 drowsy
-2 light sedation
-3 mod sedation
-4 deep sedation
-5 unarousable sedation)

Question 11

don’t provide sedation without ________ (KNOW)

Answer 11

analgesia

Question 12

5 drugs used for analgesia (KNOW)

Answer 12

IV: morphine, fentanyl, PCA
epidural
Toradol (NSAID)
*PCA (patient- controlled-Analgesic)

Question 13

IV morphine vs IV fentanyl (KNOW)

Answer 13

*both need titrated dosing

Morphine: metabolites can accumulate in renal failure (dose reduction by 50%), increased vasodilation and hypotension due to stimulation of histamine release;

Fentanyl: faster acting, less likely to decrease BP, absorbed readily into CNS (quicker onset of action and shorter acting)

Question 14

SIRS criteria (KNOW)

Answer 14

*systemic inflammatory response syndrome*
At least 2 of the following
Temperature >38C or <36 C
Heart rate > 90 bpm
RR > 20 bpm or pCO2 < 32 mmHg
WBC >12,000 or < 4,000
Or >10% bands

Question 15

what is sepsis?

Answer 15

SIRS due to infection

Question 16

severe sepsis vs septic shock

Answer 16

Severe Sepsis: One or more vital organ dysfunction/failure

Septic Shock: Severe sepsis + hypotension refractory to volume resuscitation

Question 17

shock that causes hypovolemia, what order of fluids are you giving the pt?

Answer 17

two liters of crystalloid- switch to a colloid: if blood counts are low - give blood, if blood counts are normal and they need volume- give albumin

Question 18

MODS and MOF stand for what?

Answer 18

MODS (Multiorgan Dysfunction Syndrome) and MOF (Multiorgan Failure)

Question 19

what 4 organs are frequently injured in SIRS and sepsis?

Answer 19

1) Lungs: ARDS (Acute Respiratory Distress Syndrome) – see in about 40% of severe sepsis cases
2) . Kidneys
3) . CV system- volume probs
4) CNS- altered mental status (encephalopathy)

Question 20

what analgesia is good for rib fractures? (KNOW)

Answer 20

epidural

Question 21

4 step approach to SIRs/ Sepsis

Answer 21

1. Treat underlying cause
2. Do not cause further damage - take off meds that will further injury/damage
3. Address organ failure (encephalopathy and vol. status)
4. vasopressors (used if you can’t manage BP with vol. replacement)

Question 22

ABGs: what level is acidic vs alkalotic blood?

Answer 22

acidic < 7.35

alkalotic > 7.45

Question 23

What variable is typically changed, and in what direction, in a respiratory acidosis?
Metabolic acidosis?

Answer 23

increased CO2

decreased HCO3

Question 24

ICU monitoring: 3 ways to measure blood pressure?

Answer 24

CVP
pulm wedge pressure
EV1000

Question 25

when is EV1000 used over CVP?

Answer 25

EV 1000- most accurate for ventilator dependent and regular Heartbeat.

Question 26

what is EV1000?

Answer 26

Measure SV and SVV (Stroke Volume Variation)

-As SVV goes down, SV increases

Question 27

EV 1000: what is the target SVV?

Answer 27

Target SVV under 15% (ish) (ex/ if its 20%, they need volume)

Question 28

do we continue metformin in DM pt in the ICU?

Answer 28

NO, they are not in their normal state, they need more than what the meds usually provide
1st- SSI - sliding scale insulin
Strict glycemic control: keep around 120 <170
2nd- if SSI isn’t working after 2 doses, switch to insulin drip

Question 29

why do we use anticoagulation in ICU? when do we use each type?

Answer 29

ICU pts are in a hyperCoag state

• heparin: short acting (taking pt back and forth to OR)
• Lovenox: can reverse
• Aspirin: combat platelet aggregation, arterial injuries

Question 30

nutrition: when is TPN used?

Answer 30

TPN: total parental nutrition in greater than 7 days of NPO status-
—> bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs

Question 31

why do we need to check ABGs?

Answer 31

if on ventilator and needing to stabilize, calc. anion gap, etc.

Question 32

why do you want to manage use of Toradol? (KNOW)

Answer 32

inhibits platelet aggregation and impairs renal function (no more than 5 days)

Question 33

How do you manage someone’s pain with a RASS score of -1 to 0? (KNOW)

Answer 33

continuous infusion, once patients sedation level improves then the pain management can decrease

Question 34

what blood levels are checked to monitor lovenox dosing?

Answer 34

10A

Question 35

pros of using propofol for sedation? Cons? USES (2) KNOW

Answer 35

-Pros: rapid acting, short lasting, amnesia
-Cons: change diet bc a lot of fat in it
USES** those with head injury (dec cerebral O2 consumption), those withdrawing from alcohol (dec DT’s)

Question 36

what two levels do we check when a patient is on propofol sedation?

Answer 36

CK and LD (if elevated then we change sedation type)

Question 37

Pros of precedex sedation? Cons? USES (2) KNOW

Answer 37

-Pros: sedation WITHOUT resp depression, sed + anxiolytic + mild pain relief
-Cons: hypotension and bradycardia
USES** great for WEANING from sedation or those who withdrawal easily

Question 38

Pros of Haldol sedation? Cons? USE (know)

Answer 38

-Pros: sedation and anti psychotic
-Cons: 10-20 mins to take effect, extrapyramidal rxns, torsades, neuroleptic malignant syndrome
USE** patients with delirum

Question 39

shock types

Answer 39

1) . Hypovolemic: hemorrhagic vs non hemorrhagic
2) . distributive: neuro, septic, adrenal
3) . cardiogenic: AMI
4) . obstructive: tamponade, PE, tension pneumo