Fisher Absite. Ch 16. Critical Care.

Front 1

What is the normal range for CO?

Back 1

4-8 L/min

Front 2

What is the normal range for Cardiac Index?

Back 2

2.5-4

Front 3

What is the normal range for systemic vascular resistance? and systemic vascular resistance index?

Back 3

800-1400, 1500-2400

Front 4

What is the normal PCWP?

Back 4

11 +- 4

Front 5

What is the normal CVP?

Back 5

7 +- 2

Front 6

What is the normal pulmonary artery pressures?

Back 6

20-30/6-15

Front 7

What is the normal mixed venous oxygen saturation SvO2?

Back 7

75+-5

Front 8

What percentage of CO does the following organs get? kidney, brain, heart

Back 8

25, 15, 5 respectively

Front 9

What is the formula for MAP?

Back 9

CO x SVR

Front 10

What is the formula for ejection fraction?

Back 10

stroke volume/EDV

Front 11

Cardiac output increases with HR up to 120-150 bpm, then starts to go down, why?

Back 11

decreased diastolic filling time

Front 12

Atrial kick accounts for what % of LVEDV?

Back 12

15-30%

Front 13

Automatic increase in contractility secondary to increase in afterload. What is this effect called? What about automatic increase in contractility secondary to increased HR?

Back 13

Anrep effect

Bowditch effect

Front 14

What is the normal O2 delivery-to-consumption ratio? What increases to keep this ratio constant?

Back 14

5:1, CO

Front 15

What is the normal SvO2?

Back 15

75%

Front 16

What measurement can be thrown off by pulmonary htn, aortic regurg, mitral stenosis, mitral regurg, high PEEP, porr LV compliance?

Back 16

Wedge

Front 17

What is the only way to measure pulmonary vascular resistance?

Back 17

swan

Front 18

Which zone of the lung do you place a swan?

Back 18

zone III (lower lung)

Front 19

Hemoptysis after flushing Swan. Name three interventions.

Back 19

increase PEEP to tamponade the pulmonary artery bleed

mainstem intubate the nonaffected side,

try to place a Fogarty down the affected side,

may need thoracotomy and lobectomy

Front 20

Name two relative contraindications to a swan.

Back 20

previous pneumonectomy, LBBB

Front 21

In this pulmonary artery wedge tracing, wedge pressure is measured at end expiration. Which point is for spontaneous breathing pts and which is for pts undergoing positive pressure ventilation?

Back 21

A is for spontaneous, B is for vent

Front 22

What are the two primary determinants of myocardial O2 consumption -> can lead to myocardial ischemia?

Back 22

increased ventricular wall tension and HR

Front 23

Why is LV blood 5 mmHg of PO2 lower than pulmonary capillaries?

Back 23

unsaturated bronchial blood empties into pulmonary veins

Front 24

What is the normal alveolar-arterial gradient in a non ventilated pt?

Back 24

10-15 mmHg

Front 25

Where is blood with the lowest venous saturation located?

Back 25

coronary venous blood (30%)

Front 26

Cardiovascular collapse; characteristically unresponsive to fluids and pressors.

Back 26

Acute adrenal insufficiency

Front 27

hyperpigmentation, weakness, weight loss, GI sx, increased K, decreased Na, fever, hypotension.

Back 27

chronic adrenal insufficiency

Front 28

Steroid potency:

1x - cortisone, hydrocortisone
___ - prednisone, prednisolone, methylprednisolone
___ - dexamethasone

Back 28

5x
30x

Front 29

Neurogenic shock - loss of sympathetic tone. Usually have decreased HR, decreased BP, warm skin. Tx?

Back 29

give volume 1st, then phenylephrine after resuscitation; give steroids for blunt spinal trauma with deficit

Front 30

What is the initial alteration in hemorrhagic shock?

Back 30

increased diastolic pressure

Front 31

What is the tx for cardiac tamponade?

Back 31

fluid resuscitation initially; need pericardial window or pericardiocentesis

Front 32

What is the CO and SVRI in hemorrhagic shock (increased or decreased)? and septic shock?

Back 32

CO is decreased, SVRI is increased in hemorrhagic shock

CO is increased, SVRI is decreased in septic shock

Front 33

What is the triad of hyperventilation, confusion and respiratory alkalosis?

Back 33

early sepsis triad

Front 34

What is the insulin and glucose in early vs late gram-negative sepsis?

Back 34

Early is decreased insulin and increased glucose due to impaired utilization

Late is increased insulin and increased glucose due to insulin resistance

Front 35

When does hyperglycemia occur in sepsis?

Back 35

just before pt becomes clinically septic

Front 36

What is activated protein C (Xigris) used for and what is the mechanism?

Back 36

used for sepsis; mechanism is fibrinolysis

Front 37

What stain can be used to find fat in sputum in urine to help dx fat emboli?

Back 37

sudan red

Front 38

PA systolic pressures >40, decreased PO2 and PCO2, respiratory alkalosis, chest pain, cough, dyspnea, increased HR

Back 38

PE

Front 39

What is the tx for air emboli?

Back 39

place pt head down and roll to left to keep air in RV and RA then aspirate air out with central line or PA catheter to RA/RV

Front 40

When is IABP used? what is the contraindication? what does it improve?

Back 40

cardiogenic shock, aortic regurgitation, improves coronary perfusion

Front 41

Name the receptor:

vascular smooth muscle constriction; gluconeogenesis, glycogenolysis

Back 41

Alpha 1

Front 42

Name the receptor:

venous smooth muscle constriction

Back 42

Alpha 2

Front 43

Name the receptor:

mycocardial contraction and rate

Back 43

Beta 1

Front 44

Name the receptor:

relaxes bronchial smooth muscle, relaxes vascular smooth muscle; increases insulin, glucagon, rennin

Back 44

Beta 2

Front 45

Name the receptor:

relax renal and splanchnic smooth muscle

Back 45

dopamine

Front 46

Name the three receptors and associated effects for dopamine at low (0-5 ug/kg/min), medium (6-10), and high (>10) doses.

Back 46

low - dopamine receptors (renal)
medium - beta-adrenergic (heart contractility)
high - alpha-adrenergic (vasoconstriction and increased BP)

Front 47

What receptors and affects does dobutamine affect at low (5-15 ug/kg/min) and high (>15) doses.

Back 47

low - beta-1 (increased contractility)
high - beta 2 (vasodilation, increased HR)

Front 48

Name the drug that is a phosphodiesterase inhibitor (Increases cAMP). Results in increased Ca flux and increased myocardial contractility. Also causes vascular smooth muscle relaxation and vasodilation.

Back 48

Milrinone

Front 49

What receptor does Phenylephrine affect?

Back 49

alpha-1, vasoconstriction

Front 50

What receptors does Norepinepherine affect at low and high doses?

Back 50

Low - beta-1 (increased contractility)
High - alpha-1 and alpha-2

Front 51

What receptors does Epinephrine affect at low and high doses?

Back 51

Low - beta 1 and beta 2 (increased contractility and vasodilation). Can decrease BP at low doses.
High - alpha-1 and alpha-2 (vasoconstriction). Increased cardiac ectopic pacer activity and myocardial O2 demand.

Front 52

Name the drug that hits Beta-1 and beta-2 receptors, increasing HR and contractility, vasodilates. Side effects: extremely arrhythmogenic; increased heart metabolic demand (rarely used); may actually decrease BP.

Back 52

Isoproterenol

Front 53

Name the Vasopressin receptor:

vasoconstriction of vascular smooth muscle

Back 53

V-1

Front 54

Name the vasopressin receptor:

water reabsorption at collecting ducts

Back 54

V-2 (intrarenal)

Front 55

Name the vasopressin receptor:

mediate release of factor VIII and vWF

Back 55

V-2 (extrarenal)

Front 56

What is the concern with Nipride (arterial and venous dilator)?

Back 56

Cyanide toxicity at doses ?3 ug/kg/min for 72 hrs; check thiocyanate levels and signs of metabolic acidosis

Front 57

How does nitroglycerin decrease myocardial wall tension?

Back 57

decreasing preload

Front 58

What is the MOA of hydralazine?

Back 58

alpha blocker

Front 59

What is the formula for compliance? What does high compliance lungs mean?

Back 59

change in volume/change in pressure.

easy to ventilate

Front 60

Pts with ARDS, fibrotic lung disease, reperfusion injury, pulmonary edema all have reduce what?

Back 60

pulmonary compliance

Front 61

Which part of the lungs has the highest V/Q ratio? the lowest?

Back 61

highest in upper, lowest in lower

Front 62

On a ventilator what can be increased to improve oxygenation (alveoli recruitment) -> improves FRC

Back 62

increased PEEP

Front 63

On a ventilator what 2 things can be increased to decrease CO2?

Back 63

increased rate or volume

Front 64

Normal weaning parameters:

negative inspiratory force (NIF) > ___,
FiO2 < ___%
PEEP ___ (physiologic)
pressure support 5,
RR < ___
HR < ___
Po2 > ___
PCO2 < ___
pH 7.35-7.45
sats > 93%
off pressors,
follows commands,
can protect airway

Back 64

negative inspiratory force (NIF) > 20,
FiO2 < 35%
PEEP 5 (physiologic)
pressure support 5,
RR < 24
HR < 120
Po2 > 60
PCO2 < 50
pH 7.35-7.45
sats > 93%
off pressors,
follows commands,
can protect airway

Front 65

Barotrauma on vent - high risk if plateus >___ and peaks >___ -> consider prophylactic ___

Back 65

30,50, chest tubes

Front 66

What does pressure support on a vent do?

Back 66

decreases the work of breathing (inspiratory pressure is held constant until minimum volume is achieved)

Front 67

Excessive PEEP complications include decreased RA filling, decreased CO, decreased renal blood flow and decreased urine output and increased ___

Back 67

pulmonary vascular resistance

Front 68

What 3 types of pts where high frequency ventilation is used?

Back 68

kids, tacheoesophageal fistula, bronchopleural fistula

Front 69

Why is inverse ratio ventilation used? (normal 1:2 I:E phase; go to 2:1)

Back 69

helps reduce barotrauma

Front 70

What is the formula for minute ventilation?

Back 70

TV x RR

Front 71

What class of lung disease is represented by decreased TLC, decreased RV, decreased FVC, FEV1 can be normal or increased?

Back 71

restrictive lung disease

Front 72

What class of lung disease is represented by increased total lung capacity, increased residual volume and decreased FEV1?

Back 72

obstructive lung disease

Front 73

What is the most common cause of ARDS?

Back 73

sepsis

Front 74

Acute Lung Injury is defined by acute onset, bilateral pulmonary infiltrates, PaO2/FiO2 < 300, PAOP < 18 mmHg or no clinical evidence of LAH. What one additional criteria defines acute respiratory distress syndrome?

Back 74

PaO2/FiO2 < 200

Front 75

What two cytokines mediate SIRS?

Back 75

TNF-alpha and IL-1

Front 76

What are the 4 SIRS criteria?

Back 76

Temp >38 or <36
RR >20 or Pco2 < 32
WBC >12,000 or <4000
HR >90

Front 77

SIRS -> Sepsis -> Septic Shock -> ___

Back 77

MOD (Progressive but reversible dysfunction of 2 or more organs arising from an acute disruption of normal homeostasis)

Front 78

What is the name of the syndrome of chemical pneumonitis from aspiration of gastric secretions.

Back 78

Mendelson's

Front 79

Most common cause of fever in the first 48 hours after operation?

Back 79

atelectasis

Front 80

What effect does the following have on the lungs?

bradykinin, PGEi, prostacyclin (PGI2), nitric oxide

Back 80

pulmonary vasodilation

Front 81

What effect does the following have on the lungs?

histamine, serotonin, TXA2, epinephrine, norepinephrine, hypoxia, acidosis

Back 81

pulmonary vasoconstriction

Front 82

What effect does alkalosis have on pulmonary vasculature? and acidosis?

Back 82

alkalosis - pulmonary vasodilator

acidosis - pulmonary vasoconstrictor

Front 83

What does nitroprusside, nitroglycerine, and nifedipine do to the pulmonary vasculature?

Back 83

pulmonary shunting

Front 84

What is the most common cause of postoperative renal failure?

Back 84

hypotension

Front 85

What percentage of nephrons need to be damaged before renal dysfunction occurs?

Back 85

70%

Front 86

What is the best test for azotemia?

Back 86

FeNa

Front 87

What are the three steps to treating Oliguria?

Back 87

1st make sure pt is volume loaded (CVP 11-15 mmHg), 2nd try diuretic trial (Lasix or butanamide)
3rd dialysis if needed

Front 88

Renin is released in response to decreased pressure sensed by ___ in kidney. Also in response to increased Na concentrations sensed by ___

Back 88

juxtaglomerular apparatus, macula densa

Front 89

What does renin do?

Back 89

converts angiotensinogen to angiotensin I

Front 90

What converts angiotensin I to angiotensin II?

Back 90

angiotensin converting enzyme in the lung

Front 91

What structure releases aldosterone in response to angiotensin II?

Back 91

adrenal cortex

Front 92

What specifically does aldosterone do to the kidney?

Back 92

Acts on distal convoluted tubule ATPase to increase resorption of water and sodium and secretion of potassium.

Front 93

What does atrial natriuretic peptide do to the kidney? to the blood vessels?

Back 93

inhibits Na and water resorption at the collecting ducts

vasodilator

Front 94

What specifically does ADH do to the kidney? the blood vessels?

Back 94

Acts on the collecting ducts for water resorption

vasoconstrictor

Front 95

How do NSAIDs cause renal damage?

Back 95

Inhibit prostaglandin synthesis, resulting in renal arteriole vasoconstriction

Front 96

How do aminoglycosides cause renal damage?

Back 96

direct tubular injury and later renal vasoconstriction

Front 97

Myoglobin causes direct renal tubular injury. What is the tx?

Back 97

alkalinize urine

Front 98

Contrast dyes cause direct tubular injury. What is the tx?

Back 98

premedicate with N-acetylcysteine and volume

Front 99

The following things preclude what diagnosis?

uremia, temp <30, BP <70/40, desaturation with apnea test, drugs, metabolic derangements

Back 99

brain death

Front 100

How long must the following exist to declare brain death:

unresponsive to pain, absent caloric oculovestibular reflexes, absent oculocephalic reflex, positive apnea test, no corneal reflex, no gag reflex, fixed and dilated pupils.

Back 100

6-12 hours

Front 101

What two testing modalities can be used to prove absence of brain activity?

Back 101

EEG - electrical silence
MRA - will show no blood flow to brain

Front 102

Apnea test – disconnected from ventilation; CO2 >___ mm Hg or increase in CO2 by ___ is a positive test for apnea. If arterial pressure drops to <60 or patient desaturates, the test is terminated

Back 102

60, 20

Front 103

Can you still have deep tendon reflexes with brain death?

Back 103

yes

Front 104

What does carbon monoxide do to a pulse oximeter?

Back 104

Can falsely increase reading

Front 105

What does carbon monoxide do to hemoglobin?

Back 105

binds hemoglobin directly creating carboxyhemoglobin

Front 106

What is an abnormal carboxyhemoglobin level? and in smokers?

Back 106

>10%, >20%

Front 107

What is tx for carbon monoxide poisoning?

Back 107

100% O2 on a ventilator; may need hyperbaric O2 if really high

Front 108

Methemoglobinemia can occur from nitrites such as Hurricaine spray; nitrites bind Hgb. What is the O2 saturation? What is the tx?

Back 108

85%, methylene blue

Front 109

Critical illness polyneuropathy – motor > sensory neuropathy; occurs with ____; can lead to failure to wean from ventilation

Back 109

sepsis

Front 110

In endothelial cells, forms toxic oxygen radicals with reperfusion, involved in reperfusion injury. Also involved in the metabolism of purines and breakdown to uric acid

Back 110

Xanthine oxidase

Front 111

When do seizures occur with ETOH withdrawal?

Back 111

48 hrs

Front 112

ICU (or hospital) psychosis generally occurs after which postoperative day? What do you need to rule out?

Back 112

3rd, metabolic and organic causes