Critical Care

Front 1

How do you define septic shock

Back 1

High CI (2.5-4 normal)
Low PCWP (8-12)
Low SVR (800-1400)

High CO but with vasodilation and low SVR with leaky capillaries causing intravascular fluid to move to interstitial space. This causes low PCWP (low blood volume pumping)

Front 2

How do you define hypovolemic shock

Back 2

Low CI
Low PCWP
High SVR

Front 3

How do you define cardiogenic shock

Back 3

Low CI
High PCWP
High SVR

Heart failure, low CI. This causes increased volume (high PCWP) and high pressure.

Front 4

How do you treat hypovolemic shock

Back 4

Restore intravascular volume, use crystalloids and colloids

May need vasopressors if hypotension not controlled by fluid resuscitation

Use target CVP of 8-12 to guide fluid resuscitation

Front 5

How do you define general sepsis

Back 5

Temp greater than 38 or lower than 36

HR > 90

Tachypnea
Altered mental status
Hyperglycemia
WBC>12000 or<4000

Front 6

How do you differentiate severe sepsis

Back 6

Complicated by organ dysfunction or hypoperfusion

Front 7

What constitutes organ dysfunction by system

Back 7

CV: SBP >90 or MAP<70
Pulmonary: Need for mechanical ventilation
Kidney: UOP <30ml/hr
Hematologic: Decreased platelet or WBC or increase in INR

Front 8

How do you initially treat sepsis

Back 8

In 6 hours:

CVP 8-12
MAP > 65
UOP>0.5ML/KG/HR
SV02 > 70%

Front 9

Protocol for achieving sepsis goals

Back 9

1) Fluid resuscitation using 1000ml of crystalloids or 300-500ml of colloids
2) There is no evidence that colloids are superior to crystalloids
3) If SV02 target not met, consider fluid resuscitation, packed red blood cells and dobutamine
4) Vasopressors may be necessary to keep MAP > 65 if fluid challenge fails to restore BP
5) Norepi or dopamine are vasopressors of choice
6) Vasopressin efficacy similiar to norepi, but can be used together for vasopressor sparing effect
7) Inotropes (dobutamine, milrinone) may be needed to improve cardiac function with low CO

Front 10

What are the features of vasopressin

Back 10

Direct stimulation of smooth muscle receptors, peripheral vasoconstriction

Effective during acidosis and hypoxia because does not rely on adrenergic receptors

Not titrated

Front 11

What are some of the features of dobutamine

Back 11

Positive inotrope to increase CO

Can cause hypotension due to Beta 2 stimulation

Front 12

What are the indications of using corticosteroids in sepsis

Back 12

IV hydrocortisone can improve short term survival in adult patients who continue to have hypotension despite vasopressors or fluid resuscitation

Usually 50mg IV Q6hrs

Front 13

How do you use drotrecogin alfa?

Back 13

Can improve survival in adult patients with sepsis induced organ dysfuinction (at least 2 organs) who has APACHE score > 25

Do not use in internal bleeding, hemorrhagic stroke, recent intracranial or intraspinal surgery or head trauma, epidural catheter

Front 14

What is the dose of drotrecogin alfa?

Back 14

24mcg/kg/hr for 96 hours based on actual body weight

Started within 24 hours of onset of severe sepsis or septic shock.

Hold 2 hours before a procedure, resume 12 hours after surgery

Front 15

What route is preferred in cardiac arrest? Intraosseus or endotracheal?

Back 15

Intraosseous

Front 16

What drugs can be given endotracheal?

Back 16

NAVEL

N - Naloxone
A - Atropine
V - Vasopressin
E - Epinephrine
L - Lidocaine

Front 17

When do you consider hypothermia?

Back 17

12-24 HOURS BEGINNING AS SOON AS POSSIBLE AFTER CARDIAC ARREST TO IMPROVE MORTALITY AND NEUROLOGIC RECOVERY

For patients who have been resuscitated after cardiac arrest but are still comatose

Front 18

What complications can occur during hypothermia

Back 18

Shivering - causes excess heat production, excess oxygen consumption

Treat with BZD, meperidine, fentanyl, buspirone, magnesium 2gm

Front 19

What analgesic is not prolonged in hepatic or renal failure?

Back 19

Remifentanil (Ultiva)

Front 20

What abnalgesi has no effects on hypotension?

Back 20

Fentanyl

Front 21

What are the characteristics of propofol in sedation

Back 21

Avoid loading doses because of risk of hypotension

Use in intubated patients because of risk of respiratory depression

Propofol infusion syndrome is more likely to occur with prolonged infusions and is metabolic acidosis, cardiac failure, arrythmias

Front 22

What are the characteristics of dexmedetomidine

Back 22

Sedative and analgesic properties through alpha recept agonist activities

Does not cause respiratory depression or drug dependency

Rapid onset, short duration

Compared to BZD's, causes less ICU delirium

Front 23

How do you treat delirium in the ICU

Back 23

1) Haldol 1-10mg
Monitor for hypotension, QT interval, EPS effects, seizures
2) Atypical antipsychotics are potential alternatives

Front 24

When do you use therapeutic paralysis

Back 24

Only use for intubated patients with persistant hypoxia despite sedation and analgesia

Should be used with continuously infused sedative

Front 25

What are the duration of effects of the paralytic agents

Back 25

Atracurium - 0.25 to 0.5hrs
Vecuronium - 0.5 to 0.75 hrs
Cisatracurium - 0.5 to 1 hrs
Pancuronium - 0.75-1.5 hrs

Front 26

What paralytics are not prolonged in renal or hepatic failure

Back 26

Atracurium and cisatracurium

Front 27

What paralytics do not cause tachycardia or hypotension

Back 27

Vecuronium and cisatracurium

Front 28

Which risk factors are present for stress ulcers

Back 28

Respiratory failure requiring mechanical failure

Coagulopathy, platelets <50k, INR>1.5

Front 29

What drugs are normally used for stress ulcer prophylaxis

Back 29

Most evidence with H2 blockers, PPI also used