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87 Cards in this Set
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EXTUBATIONS guidlines/criteria
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Extubation
1. The decision to extubate is made by medical staff, in consultation with either the senior registrar, fellow or duty consultant. 2. Extubation is to be performed by medical or senior nursing staff, with airway competent medical staff immediately available. 3. Criteria to predict successful extubation are helpful, however, ongoing success should never be assumed: a) FiO2 < 0.5 with PEEP ≤ 5 cmH2O b) PaO2 > 70 mmHg ** lower values may be appropriate in SpO2 > 90% chronically hypoxaemic patients c) RR < 30 with PS ≤ 5cmH2O (Dräger) d) pH > 7.2 e) No respiratory distress (see over) f) Patient able to obey commands g) Patient able to protect airway and cough h) Patient able to cope with amount of secretions i) Reason for intubation resolved. *this may include checking for an air leak with the cuff deflated 4. Early extubation to NIV may be considered for some patients who present with hypercapnic exacerbation of COPD or pulmonary oedema: a) Performed with close supervision by senior medical staff. b) If no improvement after 1-2 hrs, the patient should be considered for reintubation. 5. Extubation protocol: a) Ensure equipment, monitoring and adequate assistance is available, as for intubation b) Plastic surgical and ENT patients with intermaxillary fixation/wiring require consultation with the Parent Clinic. i) A wire cutter must be present in the room at all times. ii) The parent clinic should be given opportunity to be present during extubation if the jaws are wired. c) All patients should receive supplemental oxygen pre/post-extubation |
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FAST HUGS IN BED Please
-add from BASIC BOOK FAT DOGS? |
Feeding/nutrition - requirements?
Analgesia - HR BP RR grimace Sedation - assessing agitation (delirium, anxiety, pain, withdrawal Treat the cause!) Ramsay sedation scale Thromboprophylaxis - Heparin 5000U Q 8hr Head up 30-45 degrees (ulcer & pneumonia prophylaxis, plus ICP) Ulcer prevention - ranitidine 150mg BD Glucose control - 6-10 Skin/eye care Indwelling catheter NGT Bowel cares Environment (temperature, surroundings in delirium) De-escalation Psycho/social FAT DOGS Fluids & feeding Analgesia and Sedation THromboprophylaxis DRug O2 & ventilation Glucose Sitout of bed |
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Basic ICU review/notes plan
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One liner - age, PLOF, length of stay, dx
Previous issues & Relevant PMHx INPUTs/infusions A B C D/Neuro GIT/METABOLIC GUT/fluid balance Haem/bloods Infection/lines FAST HUGS?FATDOGS Family Current Issues/IMP PLAN |
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Approach to weaning off MV
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EASY
SIMV, reduce rate ==> Pressure support ==>reduce pressure support to 5cm H2O ==> trial of extubation HARD -will fatigue with above approach. (usually lung or neuromeuscular dz) -recommend a regime based on incentive training using T piece trial via a tracheotomy *wean patient during the day 6am-10pm with full rest overnight and midday siesta 12-2pm *Place on T piece for 15 mins, observe for signs of deterioration and return to resting mode eg SIMV for 1hr *incrementally increase interval according to schedule *once 18hrs is achieved for continuous Tpiece |
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Benefits of tracheostomy
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Pt comfort/tube tolerance
==> less sedation Secretions access Expedite weaning Reduce laryngeal/vocal cord Cx |
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INdications for tracheostomy
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Prolonged MV
Upper airway obstruction Access to tracheobronchael secreations Faciliated HEad/neck surgery |
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Complications of tracheostomy procedure
Compications during use |
PROCEDURE Cx
-bleeding -Loss of airway ==>Hypoxia -Mis placement (RM bronchus or paratracheal) -pneumothorax - tracheal injury: laceration/transection -infection DURING USE Cx Bleed Dislodgement Blockage (secretions) Infection & wound breakdown Trachael ulcer/granuloma/stenosis IMpaired swallow/aspiration |
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Assessment of intravascular volume
How quickly to replace? What are some good endpoints to aim for How much maintenance fluids? |
INTRAVASCULAR
Basic Obs -HR -pulse pressure -BP/MAP -RR Examination -perfusion including mentation, CR, temp, -JVP - mucous membranes BLOODS lactate, pH, BE Other -UO -artline swing (systolic and pulse pressure variation -CVP fluid challenge OR PASSIVE LEG RAISING -Echo Aim to replace 50% Iin first 4 hrs and rest in 24hr ENDPOINTS HR <100 UO >0.5mg/kg/hr MAP>70 CVP >5 MAINTENANCE 4mg/kg 1st 10kg AND 2mg/kg 2nd 10kg AND 1mg/kg for remainder == 60 + wt-20 eg 80kg person == 60 +60 =120ml/hr and ~(Na ~140mmol & K ~70- mmol per day) |
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DIC
What is it? How do you differentiate from liver disease? Management? |
-massive systemic activation of coagulation cascade
==> generation & deposition of fibrin ==> microvascular thrombi ==> MOD AND Consumption of coag proteins and platelets can induce severe bleeding HENCE can present with simultaneous thrombotic and bleeding problems LIVER DISEASE Both can present with -decr platelets -decr fibrinogen incr FDP (fibrinogen degadation product) -incr INR, APPT BUT in DIC factor VIII reduced while in liver dz factor VIII increased MANAGEMENT -volume resus, haemostatic measures -platelet and factor replacement -heparin for those with evidence of extensive fibrin deposition and no extensive bleeding (usually used in chronic) -treat underlying disease |
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severe pneumonia
Common causes of severe? Other causes of severe? Mx (5 key areas) |
Common
-Strep Pneu -Staph A -Pseudomonas Other legionella viruses - adeno, RSV, influenza, parainfluenza mycobacterium fungi - aspergillus, cryptococcus, pneumocystis Mx -Risk assessment (sats, lactate) -Early fluid resus -Prompt oxygenation -Immediate combined Abx -Evaluation for ICU admission |
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What is ARDS?
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Acute respiratory distress syndrome
-acute -bilateral pulmonary infiltrates -severe hypoxaemia -absence of evidence for cardiogenic pulmonary oedema PaO2/FiO2 <200 |
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recommended CVP in sepsis
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8-12
12-15mmHg in mech ventilated ?the americans only |
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Massive transfusion
Definition? Suggested criteria for activation? Protocol? |
DEFINITION
replacement of >1blood volume in 24 hours or >50% blood volume in 4 hours (adult blood volume ~70ml/kg hence avg human 5L and 100kg person 7L) 1Unit blood ~470ml CRITERIA -Actual or anticipated 4U <4hrs +haemodynamically unstable +/- anticipated ongoing bleeding OR -Severe abdominal, thoracic, pelvic or multiple long bone trauma OR -Major obstetric, GIT or surgical bleeding PROTOCOL 1. ?meet criteria 2. baseline bloods: ABG FBC Coags biochem 3. notify lab,consider use of cell salvage 4. request 4U RBC, 2U FFP +/- 1U Platelets OR 1/1/1? 5. COnisder tranexamic acid in trauma 6. include cryoprecipitant if fibrinogen <1g/L |
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ICU PRESENTATION OUTLINE
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1 line into
-age & previous level of fxn/occupation, length of admission (ICU, hopital, ventilation), Dx PLUS any relevant history whilst admitted Include • Hospital Day # / Ventilator Day # (if vented) • Number of days on antibiotics • Presence, location, and duration of invasive lines/tubes • Presence or absence of GI/DVT/VAP prophylaxis • If febrile, date of last cultures (urine, sputum, blood) -Medications review • Family discussions and code status • Is patient ready to be extubated (if applicable)? • Does the patient need to remain in the ICU? Overnight events Pertinant +ves and -ves from exam and labs Systems based - ASSESSMENT & PLAN, thoughts -start with system with primary problem -then secondary etc -then systematic _____________________________________________________________ Presentations should be of a standard suitable for a fellowship examination: i) Should take no more than 5-8 minutes. ii) Emphasise the relevant and pertinent issues only: • Patient details and demographics. • State day of ICU admission (e.g. Day 6 ICU). • Diagnosis or major problems. • Relevant pre-morbid history pertinent to this admission. • Relevant progress and events in ICU (deterioration/improvement, procedures, investigations). • Current clinical status (system by system). • Outline features on daily pathology and radiology. • Current plan of management: a. Medications b. Further investigations / procedures c. Discharge planning & prognosis |
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http://musom.marshall.edu/students/senior-handbook/Documents/MED833_Guide.pdf
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http://meded.ucsd.edu/isp/2001/sicu/note.html
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ICU Examintion
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GCS
HEENT -pupils, ?icterus NECK -JVP, lines CHEST lungs-auscultation cardiac-apex, heart sounds ABDO -soft, distended, wounds, bowel sounds EXTREMETIES perfusion, pulse, temp, oedema, emboli NEURO reflexes, CN, motor stregth, sensation SKIN - lines, catheter, wounds/ulcers ?RECTAL/BACK |
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INdications for mechanical ventilation?
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-Respiratory failure - hypercarbic or hypoxic
-Ventilatory muscle fatigue -to stabilse the chest wall eg flail chest -surgery -airway protection NOTE: no specific threshold for respiratory failure -can they be supported by other means eg trial of Non-Invasive ventilation, |
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CPAP vs BIPAP uses? Why?
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CPAP - like PEEP, props open alveoli hence good for oxygenation: pulomary oedema, OSA
BIPAP - assists with ventilation, reduces ventilatory muscle fatigue: COPD, neuromuscular dz |
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Very basic factors that you can adjust to improve oxygen delivery?
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oxygen delivery
= cardiac output x [(Hb x1.31xSaO2) + 0.003xPaO2] So, can improve 1. cardiac output, 2. Hb 3. sats/PaO2 (1 & 2 can have a larger effect) |
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How do you assess if someone can be weened from MV?
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-Underlying process must be improving/resolved
-Must be able to maintain oxygenation on minimal support eg >80mmHg on 0.5 O2 and PEEP<8 -Must be able to maintain dequate acid base disturbance without large Minute volume (>12) -VItal capacity >10ml/kg TRIAL on CPAP/t piece or low level pressure support for 30-120minutes -ABG following with stable O2, no increasing CO2 -RR <25 -TV >5ml/kg -stable vitals ____________________________________________________________- Weaning Guidelines 1. Commencement of weaning is a medical decision. 2. Weaning is contraindicated with any of the following: a) Unstable ICP (abort weaning if ICP increases) b) Need for heavy sedation (e.g. upper airway obstruction) c) Haemodynamic instability d) Significant bronchospasm e) High work of breathing. 3. Trial pressure support daily if the patient meets both the following criteria: a) PaO2/FiO2 ratio > 150 b) Patient can take spontaneous breaths if SIMV resp-rate reduced. 4. Weaning protocol: a) See the flow diagram following page. b) Set initial pressure support to maintain adequate VT i) Start at 10 cmH2O and adjust to: VT ≤ 6 ml/kg IBW for patients recovering from ARDS. VT ≤ 8 ml/kg IBW for all others. IBW Males = 0.91 × (height [cm] – 152.4) + 50 IBW Females = 0.91 × (height [cm] – 152.4) + 45.5 ii) Alternatively, use target VT = 80-100% of set SIMV VT iii) Allowable PS range = 5-25 cmH2O If VT cannot be achieved with 25cmH2O, cease trial c) Assess at 15 and 30 minutes for “weaning success criteria” d) Assess each hour for suitability to wean PS e) Once PS has reached minimum (5cmH2O) then wean PEEP to 5cmH2O f) If PS & PEEP = 5cmH2O then assess for extubation. 5. Weaning Success Criteria: i) RR < 30/min ii) SpO2 > 90% May be set lower with COPD, e.g. >86-88% iii) FIO2 ≤ 0.5 iv) No respiratory distress as shown by 2 or more of the following: HR > 120% baseline Accessory muscle use Diaphoresis Paradoxical abdominal movements Marked dyspnoea |
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How do you assess if someone can be extubated?
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-Passed spontaneous breathing trial as per weening.
-Free of upper airway problems -Able to protect against aspiration/secretions...(strong cough &no need for frequent suctions) -inital problem is resolved/ing |
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DDx for sudden rise in airway pressure in MV patient
Approach? |
Machine
Tube Pt -PTX -MI -PE -bronchospasm -autopeep -inadequate sedation (ensure no other source of pain) APPROACH -DIsconnect from ventilator and assess -suction -Thorough Ax including exam, CXR, ECG bloods |
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DDX for hypotension post intubation
Approach |
-induction agent/analgesia induced
-PTX -bronchospasm -anaphylaxis -mechanical ventilation induced -esophageal intubation -mainstem bronchus intubation -pre-load dependant right hear (severe pHTN) -severe autopeep APPROACH LIsten to chest (PTX, bonchial intubatn, bronchospasm) Look at pt (?rash/oedema) Look at tube at teeth Confirm capnography Look at pressures, including expiratory hold ( ?cxr |
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What does a rise in the plateu pressure indicate?
What should you do? |
Complicance issue - ie lung, chest wall, abdomen
CXR = for APO, effusions, PTX, ARDS examine including abdo for distension If pt becomes haemdynamically unstable, high suspicious for tension PTX |
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Should a failed/ing extubation be given a trial on non-invasive before reintubation?
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No
FAIled extubations get reintubated at the same rate if trialled on non-invasive All the non-invasive ventilation appears to do in these cases is delay reintubation to a point when the patient may, in fact, be sicker and the intubation process may carry more risk. |
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DDx post extubation stridor?
Mx? Prevention? |
Laryngeal oedema- most likely
laryngospasm - nest most liekly dislocation of arytenoid structures bilateral vocal cord palsy (rare) NOTE usually develops immediatley post extubation but can take hours Mx depends on clinical appearance -if in extremis, reintubate immediately (be aware that may now be challenging due to oedema -otherwise, steroids, adrenaline, helium Oedema will usually resolve within 24-48hrs PREVENTION if concerned, can give steroid prior to extubation (?can try to assess via cuff deflation sounds) |
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differential diagnosis for a patient who cannot be liberated from the mechanical ventilator?
Diagnostic steps? |
DDX
-Primary process has not improved -NEUROLOGIC: insufficient/absent respiratory drive, excessive sedatives (lingering or ongoing anxiety), -NEUROMUSCULAR (ie too weak): critical illness polyneuropathy/myopathy, insufficient nutritional status, electrolyte abnormalities, hypothyroid, lingering paralytics WORK REQUIRED TOO HIGH DUE TO DZ: COPD, ARDS, pulmonary oedema, effusions, abdo distension, high minute ventilation requirements eg infxn. |
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Benefits of A TRACHE over intubation
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-decreased sedation needs,
-increased patient comfort, - increased chances for the patient to eat or speak, -ease of patient transfer -ease of taking the patient on and off the ventilator without the need for reintubation and its associated risks if they fail a period of spontaneous breathing. |
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NOrmal ICP?
How high is too high? DDx |
Normal 7-15mmHg
Too high - 20-25 DDX Swelling - post bleed, infarction, injury, hypoxia Mass effect (bleed, tumour, abcess) Hydrocephalus Increase in venous pressure - venous sinus thrombosis and many others |
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Definition of transfusion related acute lung injury
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-nil ALI prior to t/f
-within 6 hours of t/f -no other recent risk factor for ALI |
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INtraabdominal pressure
NORMAL? Pressure associated with end organ dysfunction? What abdominal perfusion pressure (APP) should you aim for? Define IAH? Define intraabdominal compartment syndrome (ACS)? The most common clinical findings in ACS? |
5-7mm
End organ dysfunction at >15mm APP=MAP-IAP =>60mm IAH = sustained/repeated >12 sustained >20mm associated with new organ dysfunction (irrespective of APP) ACS -hypotension -refractory metabolic acidosis, -persistant oliguria, - elevated peak airway pressures, -refractory hypercardbia, -hypoxaemia -raised intracranial pressure. |
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6 basic reasons people go to ICU
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1. intensive monitoring prior to likely aggressive interventions
- eg coronary care 2. extension of post op recovery - eg postop cardiac surgery 3. intense nursing care eg burns 4. need to control physiology -eg neurosurg 5. minimal reserve + acute reversible eg COPD + pneumonia 6. Massive disruption to physiology due to overwhelming stress response to injury or inadequate compensation -eg major trauma or sepsis |
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Multi Organ dysfunction syndrome
-most common organs effected -how common? -mortality Methods of assessing severity Clinical conditions most commonly leading to MODS/MOF Suggested mechanism/pathophys Mx |
lungs, kidney, liver, heart, brain, haemopoetic
15% of hospital admissions When 3 or more organs involved mortality~50% After 5 or more organs ~80% Assessing severity 2 scoring systems -MOD score -SOFA socre (sequential organ failure assessment) Usually due to sepsis/SIRS SIRS due to - Cardiac arrest, CCF, upper GI bleed, trauma, burns & surgery (Specifically - head trauma, AAA repair, aortic dissections/ruptures, cardiac valvular surgery, GIT surg. likely due to combination of -hypoperfusion/hypoxia -cytokines (capillary leakiness, impaired o2 extraction) Mx cause of SIRS - early! |
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specific reasons/scenarios for choosing a specific CVL route
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Bleeding issues
-not subclavian, as cannot compress Emphysema/someone unable to cope with PTX -not subclavian Trauma, neck immobilised -femoral or subclavian If transvenous cardiac pacing is required in an emergency -R IJ gives best access to RV |
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INOTROPE OPTIONS
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adrenaline
dobutamine dopamine noradrenaline isoprenaline digoxin insulin glucagon calcium |
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OSMOLAR GAP
NOrmallY? what is it? How is it used? |
Normally ~10
Difference between measured and calculated osmolality CAlculated = Na + glucose + bun If increased osmolar gap then aditional substance: ALCOHOLS - EtOH, Methanol, Acetone, Isopropyl SUGARS - mannitol, sorbitol LIPIDS - triglycerides PROTEINS - hypergammaglobinaemia |
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CONTRACTION ALKOLOSIS
What is it? Theorys as to mechanism? Mx? |
VOlume depletion leading to incr pH
THEORY 1 (short term) decr solvent, same bicarb THEORY 2 (longer term) renal compentsation ==> incr aldosterone ==> Na+-H+ exchange and incr bicar resorption (PLUS K+ secretion ==> hypokalaemia) THEORY 3 All due to Cl- depletion ==> failure of Cl- /HCO3 transporter in kidney Mx NaCl & K+ |
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Problems with pain & anxiety in ICU
Problems with sedation/analgesia |
i) Hypertension, tachycardia
ii) Increased myocardial and cerebral oxygen consumption iii) Gastric erosions iv) Intracranial hypertension v) Increased catabolism vi) Delirium Sedatives and analgesics are also associated with adverse effects: i) Respiratory depression ii) Prolonged ventilation and complications (e.g. nosocomial infections) iii) Delirium iv) Hypotension v) Gastroparesis, ileus and resultant feed intolerance vi) Increased cost & ventilator days |
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Delirium pharma options
"The Intensive Care Delirium Screening Checklist (ICDSC) should be used as the screening tool for ICU delirium (performed once per shift) " |
haloperidol 2.5-10mg IV Q2hr
olanzipine 50mg PO Q12hr (increase by 25mg every 24hrs as needed) clonadine quetiapine ?risperidone |
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indications for desmopression (DI)
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-persistant polyuria in the absence of diurectics >300ml/hr for 3hrs
-altered consiousness & inability to detect thirst or tak eoral fluids -low urinw osmolality with high plasma osmolality -acute perioperative mx od DI following pituitary surgery |
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INdications for TPN
complications of TPN |
Unable to be fed enterally AND
GIT failure >7-10days and expected duration of support >5-7 days -prolonged post operative ileus -Enteric fistulae Short GIT syndrome following major intestinal resection Cx -depression of immune function esp cancer pts -intestinal vilous atrophy -metabolic imbalance Electrolyte disturbances (K+, HPO4, Mg++) Glucose intolerance: hyperglycaemia and glycosuria Hyperosmolar dehydration syndrome Rebound hypoglycaemia on cessation of TPN Hyperbilirubinaemia CO2 production, esp. in COPD patients -central venous access cx |
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iNDUCED HYPOTHERMIA
whAT? Inclusion criteria? EXCLUSION CRITERIA? PROCEDURE? Cx? REVERSAL? |
to T core 32-34 to improve neurological outcome
INclusion criteria -Non traumatic arrest with ROSC -unconscious, intubated, ventilated -absence of immediately correctable cause for coma -Tcore >34.5 EXCLUSION CRITERIA -arrest related to trauma or head injury -ongoing CPR/persistant cardiovasc instability -need for acute cardio intervention -unable to give 40ml/kg cold hartmans eg pulm oed -Time from arrest to ED >12 hrs -pregnancy (relative) PROCEDURE -ECG, bloods, IV access -record core temp (rectal, oesoph or bladder) -document neuro function pupillary reactions gcs/painful stimuli reflexes (gag, conjuntival, lash, tendon, plantar) -hartmans 4degrees 40ml/kg bolus@100ml/min -maintain MAP, K Mg, -if T > 35 after 1 hour add surface cooling -if pt shivering midaz/propofol +/- paralytic THEN maintain 42-34 for 12-24 hrs (heated air blanket vs cold pack, cooling blankets, Cx -arrythmias -incr PVR, reduced CO -cardiovasc instabiilty may require cessation of cooling -hyperglycaemia REVERSAL after 24hr, cease active cooling ***passive rewarming -if temp <1 increase after 4 hrs then rewarm actively to 36 -once t>35 cease sedation etc |
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Non invasive ventilation
indications complicatins |
INDICATIONS
-acute COPD exac -cardiogenic pulmonary oedema -OSA/obesity -post extubation hypoxia (?) -febrile neutropenia with infiltrates COMPLICATIONS -inadequate ventilatin -mask leaks -intolerance/claustrophobia -aerophagia, gastric distention, vomting, aspiration -pressure necrosis of nasal bridge -dry secretions -barotrauma -reduced preload/hypotension -raised ICP, introcular |
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Objective measure that support intubation
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i) RR > 35 bpm, speech impariment due to dyspnoea
ii) VC < 15 ml/kg iii) SpO2 < 90% on 15L O2 iv) PaCO2 > 60 mmHg (with pH < 7.2) |
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complications of mechanical ventilation
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HAEMODYNAMIC (reduced preload, incr afterload)
RESP(VAP, barotrauma, dysynchrony) METABOLIC (SIADH, post hypercap metabolic alkalosis) ICP/INTRAOC raised SEDATION risk of DVT, weakness, sores, joint mvmnt LOCAL PRESSURE from masks, tubes etc |
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consequences/cx of acute renal failre?
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fluid overload
uraemia = encephalopathy, plt dysfxn, percarditis acidaemia electrolytesz(K PO4 bicarb) |
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Causes of ARF
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pre renal, renal, post renal, other
PRERENAL shock - cardio, distrib, hypovol renal vasoconstriction - nsaids renal artery obstruction - stenosis, embolus RENAL ATN- ischamia, nephrotoxic (drugs, contrast, myoglob) interstitial nephritis- infection, drugs vascular dz - renal vein occlusion, vasculitis, HUS glomerulonephritis POST RENAL Obstruction -drugs (opioid, anticholinergics) -neoplasm -retroperitoneal collections (blood, pus, fibrosis) -prostate -calculi -pregnancy OTHER increased IAP hepatorenal syndrome rhabdo ineffective plasma volume (HF, Liver failure, nephrotic) |
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INDICATIONS FOR RENAL REPLACEMENT THERAPY (DIALYSIS)
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Symptomatic/refractory
-acidosis -hyperkalaemia -fluid overload -uraemia (>35 or symptomatic) Severe sepsis & oliguric renal failure drug removal eg OD |
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Neurosurg pt management
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1 resus, homostasis
Ventilation, haemodynamics, osmotherapy, seizure prophylaxis, antibiotics, sedation, nutrition, thromboprophylaxis VENTILATION -normal O2 & CO2 HAEMODYNAMICS -euvolaemia (avoid dehydration due to polyuria: DI, mannitol) -maintain CPP 60-70 -MAP 80 in absence of ICP measurement -avoid cerebral venous return obstruction (head up, no ties) OSMOTHERAPY ICU consultant decision indications: - unequivacol signs intracranial HTN prior to imaging or evacuation - threatened herniation - progressive CNS deterioration not due to systemic SEIZURE PROPHYLAXIS Indicaitons - closed head injury with haematomas - penetrating head injury - depressed skull # - pre-existing epilepsy ANTIBIOTICS Indications -insertion of ICP catheter cephazolin -not indicated in base of skull unless meningism SEDATION -consider propofol where regular CNS r/v required -control large sympathetic swings with fentanyl, opioids can increase ICP and should not be used a sole therapy -paralytics relatively contraindicated NUTRITION -enteral feeding ASAP -maintain BGL, avoid hyper THROMBOPROPHYLAXIS -TEDS & SCUDS within 8hrs -Pharma relatively contraindicated in first 72hrs post op, may be commenced following discussion with surgeons |
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NORMAL ICP?
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7-15mmHg
upper limit of normal = 20-25mmHg |
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Cerebral Perfusion Pressure Algorithm
(INITIAL THERAPY) (THERAPY FAILURE) |
INITITIAL
euvolaemia sedation normocarbia/o2 inotropes if needed to maintain CPP THERAPY FAILURE =ICP >20 for 10mins or CPP <60 -ENsure accurate MAP, ICP -Correct hypovolaemia, hypoxia, ensure normocarbia -ensure adequate sedation -if possible consider drainage of 2-5mlCSF -exclude venous obstruction: neck position, head up -exclude fevers/seizures -notify ICU consultant, consider osmotherapy, short term hyperventilation, paralytics -urgent CT Head, notify neurosurg IF non-surgical lesion -attempt to maintain CPP with fluid/inotropes -consider additional therapies: propofol, hypothermia, decompressive craniotomy |
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Status epilepticus- Basic ICU considerations
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AIRWAY
IV ACCESS DRUGS -avoid paralytics LOOK FOR CAUSE EEG LOOK FOR COMPLICATIONS -hypovolaemia -rhabo & renal failure ==> Urine output -hyperthermia -dislocations/# |
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UTI in a catheterised pt?
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defined as:
> 10^5bacteria + positive culture of organisms, plus > 500 WBC **Treatment with antibiotics will not result in clearance of colonisation and is only indicated for systemic involvement - The only effective treatment is catheter removal. |
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Organisms to think of in immunosuppressed pneumonia?
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BACTERIAL - nocardia
VIRAL - HSV, CMV, varicella zoster FUNGAL - candida, cryptococcus PROTOZOAL - pneumocystis also consider non-infective: ARDS |
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DDX lung infiltrates
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pulmonary fibrosis
alveolar haemorrhage atelectasis pneumonia ARDS oedema |
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Catheter related bloodstream infection is defined as ?
what do do if suspected Mx |
infection where the same organism is grown from the blood and from the catheter tip
suspected culture from catheter and peripheral -if +ve remove after consulting team -send tip for culture Mx remove line ABx IF -high risk pt eg joint/endovasc prosthesis -virulent organism eg Staph A -signs of sepsis continue after removal (rpt bcs before starting) try to wait 24hrs before reinsertion of central access |
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necrotising soft tissue infections
Sx usual causes? Management basics? |
Sx
hallmark symptom of necrotizing fasciitis is -intense pain and tenderness over the involved skin and underlying muscle. -Over the next several hours to days, the local pain progresses to anesthesia. (The intensity of the pain often causes suspicion of a torn or ruptured muscle. This severe pain is frequently present before the patient develops fever, malaise, and myalgias.) Other indicative findings include -oedema extending beyond the area of erythema, -skin vesicles, and crepitus. -subcutaneous tissue demonstrates a wooden, hardened feel Causes -anaerobes: clostridium spp, bacteroides -Gram +ve: Group A Strep, staph -Gram -ve: enteric organisms -salt water variant - vibrio Mx -Prompt resus -Early, aggressive, and repeated surgical debridement -Prompt organism identification, early empiric & specific ABx -?IGG ?hyperbaric O2 |
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Procalcitonin
What is it? Where is it made? Why is it useful? |
precursor to calcitonin
Produced by C cells of thyroid & neuroendocrine cells of lung, intestine Rises significantly in bacterial infections and not in viral/non infectious inflammation Cochrane review- no change in mortality when basing decisions on procalcitonin |
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To do when a pt is admitted to ICU
(particularly trauma) |
ABC/primary survey
A - ETT/trache secured and adequately positioned B - ventilation both sides of chest -appropriate mode of ventilation -adequate minute ventilation, sats -ABG C -IV access adequate -appropriate monitoring -urine output -BP/CVP/exam D -GCS -limb movements -appropriate sedation/analgesia SECONDARY SURVEY Looked for missed injuries -spinal -traumatic aortic rupture -myocardial contusion (mechanism, ECG, ?echo) -diaphragmatic rupture -abdominal compartment syndrome PMHx Drug Hx PREVENT Cx -remove dirty canulas/unnecessary tubes -prevent hypothermia -prevent DVT PE |
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arterial line trouble shooting
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-check transducer position
-get rid of bubble (over damps), check and gently tap -should be zeroed once a day (midaxillary line) -ensure all connections are tight -periodically flush to remove air bubbles -"fast flush" or "square wave" test |
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HAEMODYNAMIC MONITORING TECHNIQUES
-invasive? -non invasive? |
INVASIVE
-Pulmonary artery catheter --bolus thermodultion --continuous thermodilution -Central venous O2 saturation -Arterial pulse contour analysis NONINVASIVE -ultrasound --Transthoracic --Trans oesophageal -Thoracic electrical bioimpedance -partial CO2 rebreathing |
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What is cardiac index?
Normal range? When is cardiogenic shock? |
= CO/BSA = HR*SV/BSA
body surface area NOrmal = 2.6-4.2 <1.8 may indicate cardiogenic shock |
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ANTIBIOTICS
Penicillin spectrum of activity order? Extended spectrum penicillins? Cephlasporin generations? (what do they not treat?) CArbapenums? FLUOROQUINOLONES ? AMINOGLYCOSIDES?(what is commonly mistaken for one?) VANCOMYCIN? What is BACTRIM? TETRACYCLINES? MACROLIDES? CLINDAMYCIN? METRONIDAZOLE? |
PENICILLIN SPECTRUM OF ACTIVITY
penicillin ==> ampicillin ==> ticarcillin ==> piperacillin N. meng ==> Ecoli, prot, HIB ==> kleb, pseudomon Extended spectrum penicillins (beta lactamase inhibitor = anaerobe coverage) Piptaz (pip + tazobactam) timentin (tic+clavulanic) CEPHALOSPORINS - do not treat enterococcus! higher generations become progressively more gram -ve and less gram +ve 3rd&4th have pseudomonas coverage 1st - cephalzolin 2nd - Cefotetan, Cefoxitin 3rd - Ceftriaxone, ceftazidime 4th - cefepime CArbapenems -cell wall synthesis inhibitors -broadest spectrum ABx available -4 drugs *penems eg meropenem FLUOROQUINOLONES eg cipro -anti pseudomonal agents -poor Staph A -AE include *CDiff and *QT prolongation AMINOGLYCOSIDES -gram -ve -not vancoycin, not clindamycin, not daptomycin VANCOMYCIN -cell wall synthesis inhibitor -gram +ve & C DIFF -not nephrotoxic but accumulates -red man syndrome BACTRIM -trimethoprim & sulfmethoxazole TETRACYCLINES (tetra, doxy, mino) -Gram +&- -atypicals -alternative for hpylori MACROLIDES (eryth, claryth, azith) -GRam +&- -Atypicals -use eryth for GIT motility CLINDAMYCIN -Gram +ve & anaerobes -excellent alternative for penicillin allergic METRONIDAZOLE -anaerobes -used for CDiff |
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what is adrenal insufficiency of critical illness?
Sx? Ix? |
Adrenal insufficiency and receptor insensitivity , inadequate for severe stress response
Sx -hypotension -hypoglycaemia -unresponsiveness to catecholamine infusions -ventilator dependence Random cortisol <20mcg/dL Mx -steroid replacement |
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when do steroids need weening?
how? |
>7 days
25-50% per day as tolerated |
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how long after a traumatic PTX can someone fly?
One thing that can be done if PTX on plane? |
14 days after radiographic resolution
-needs CXR immediately prior to air travel to confirm lower altitude |
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Fungal infections in ICU
CAndidaemia Mx? How long? CVL/IDC culture +ve for yeast? When should empiric antifungal treatment be initiated? |
All pt with candidaemia should have systemic antifungal
-14days post -ve BC If CVL/IDC culture positive they should be changed, if persistent candiduria follow IDC change indicates systemic antifungal EMpiric Rx when signs of systemic infection and 2 or more risk factors |
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Chest tube management
-amount draining prior to removal -do you need a CXR post removal? -if still bubbling after 24hrs what might you think? |
fluid-must be < 2ml/kg/day or <200ml/day (which ever is less) prior to removal
ptx - The air leak (bubbling) has ceased for 24 hours in the presence of tube patency. -The lung is fully inflated on x-ray. If in doubt as to whether the air-leak has ceased, some clinicians: clamp the chest tube, and re-x-ray in several hours to check for re-accumulation of air. -no post removal CXR required if non-ventilated -if ventilated CXR 1-3 hrs post removal Safety tip! Chest Tube Clamping Clamping to check whether a pneumothorax re-accumulates is generally unnecessary. (1) If the chest tube is clamped for any period of time, ensure that the patient knows they have to report any symptoms of chest tightness, shortness of breath or chest pain. These symptoms could indicate the recurrence of pneumothorax or development of a tension pneumothorax. A chest tube should only be clamped on a documented medical order and at a time when there is an adequate staff: patient ratio, for example during the day. Chest tubes should not be clamped overnight. bubbling >24hrs - ?bronchopleural fistula (sinus tract between bronchus & pleural space. -> necrotising pneumonia/empyema, neoplasm, trauma, iatrogenic |
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NUTRITION
-energy requirements? |
maintenance = 25Kcal/kg/day
stressed/trauma/general surgery/ICU = 30-35 burns = 25*wt +40* TBSA burned |
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indications for neuromuscular blockade in ICU
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-mx of raised IAP or ICP
-facilitation of mechanical ventilation with refractory hypoxia/hypercarbia -mx of muscle contractures associated with tetanus -mx of shivering during therapautic hypothermia -if able to tolerate, blockade should be interrupted daily to assess motor function and level of sedation -require physio & Eye care |
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LIVERPOOL PROTOCOL
-Cardiac surgery routine prophylaxis -ROutine blood tests on admission -c-spine precautions -?coroners case -death in the unit -thromboprphylaxis -Ulcer prophlyaxis |
cephazolin 1g TDS for 6 doses
(if valve replacement see vancomycin protocol) U&E FBC LFTs CMP BSL +/- coags ABG at least daily on ventilated morning bloods to be ordered by reg the day before following d/w SR/SS unconscious trauma pt - semi rigid collar until cleared & documented cleared -see spinal care form (and relevant section of trauma handbook) -to be complete within 24 hours of admission -discusse w SS/SR -Refer to coroners checklist (completed for all deaths) -Refer to the Coroners Act on Liverpool Hospital Intranet to check whether the coroner is to be notified. -if in any doubt ring the coroners office 85847777 death -Notify the ICU Consultant, physician/surgeon involved • Speak to the family. • Ask for a post mortem if Specialist considers it appropriate. Fill in request if they agree. • Is it a coroner’s case? See above. • Fill in the death certificate (confirm content with Specialist/SR) and cremation certificate. • Complete a discharge summary on Powerchart • Complete a death review form (Specialists/SRs) THROMBOPRPHYLAXIS 1. TEDS for all patients unless specified (PVD). Patients with pvd should not have TEDS. 2. All trauma patients, neurosurgical patients or patients with contraindications for heparin have calf compressors. 3. Decisions regarding the time of initiation of heparin in post-operative patient should be individualized based on type of surgery and patient risk factors. 4. Unless contraindicated, patients receive EITHER heparin 5000 units bd sc or enoxaparin 0.5 units per kg daily. 5. Pitfalls: enoxaparin in renal failure and obesity. Prophylaxis with ranitidine or pantoprazole should be given if feeding is not possible. |
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LIVERPOOL PROTOCOL CARDIOTHORACIC SURGERY
Guidelines & routine practice exists for? Common routine practices include: -prophylactic ABx? -GTN? -acute htn? -Thromboprophylaxis? -warfarin? -fluids? -anaglesia/sedation -criteria for extubation |
Guidelines & routine practice exists for:
1. Routine and bolus fluid orders 2. Electrolyte replacement 3. Management of Supra Ventricular Arrhythmias 4. Management of post operative bleeding 5. What conditions constitute a surgical emergency 6. Management of oliguria -prophylactic ABx? until the wound drains are removed, (including vanc for vavular surg) -GTN? infusion for first 24hrs -acute htn? sodium nitroprisside (supplemented with adjunct antihypertensives if on for a long time) -Thromboprophylaxis? aspirin 100mg daily S/c heparin day 2 all pts have TEDS -warfarin? for some valve surgery commenced on day1 on the advice of CTS team (if so aspirin should be withheld, no loading dose given) -fluids? 1mg/kg/hr and replace urine output -analgesia/sedation? regular paracetamol morphine infusion while intubated post op then regular oxycontin, PRN endone occasional pts may require PCA tolerance of prolonged intubation may require midazolam criteria for extubation? Criteria for extubation • Patient awake, co-operative and has adequate analgesia. • Bleeding less than 2 mls/kg/hr hour. • Stable cardiac rhythm. (Paced or un-paced) • Mean arterial pressure 60-100 mm Hg and/or minimal stable inotrope requirements. • IABP less than 1: 1 assist. • Oxygen saturation > 94% on Fi02 less than 50%. • Arterial blood gas Ph > 7.2 and/or PaC02 < 55 mm Hg. |
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MASSIVE TRANSFUSION PROTOCOL LIVERPOOL
Definition -10U 24hrs or 5u in 3hrs |
Senior clinician determines activation
if trauma, acutely bleeding & critically ill & <3hrs tranexamic acid(1g/10mins) recommended BAseline blood -Pink: Group Xmatch -BLue coags -Purple FBC Notify transfusion lab 85020 to ACTIVATE Nurse Manager to organise blood runner Will be provided with: 4U PRBC 4U FFP 5U cryoprecipitate (aim dose 3-4 g cryo, each unit 15ml, 350mg fibrinogen) 1 dose platelets (every 2nd MTP pack) ALSO Provide 30-60min rpt bloods( including ionised Ca and ABGs) Contact haematology for assistance Contact to advise of cessation of MTP NOTE Factor VIIa requires haematologist approval AIM for temp >35 - use blood warmer, warm pt pH >7.2 BE <6 Lactate <4 Ca2+ >1.1 platelets >50 PT/APTT <1.5xnormal INR<1.5 fibrinogen >1 Other measures to consider: Protamine sulphate as an antidote to standard unfractionated heparin if there is heparin activity. Vitamin K and prothrombin complex concentrate as antidotes to warfarin. The use of anti-fibrinolytic agents (tranexamic acid, aprotinin) if there is evidence of excessive fibrinolysis. The use of desmopressin 0.3 mcg/kg in 50msl NS over 30mins for patients with platelet dysfunction SPECIAL CLINICAL SITUATIONS Warfarin - add vit K, prothrombinex FFP Obstetric haemorrhage - often early DIC, consider cryoprecipitate Head injury - aim for platelets >100 - permissive hypotension contraindicated |
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starting TPN and ?refeeding syndrome?
complicatinos of TPN in general |
at risk if >10days without feeding
BEfore TPN -give thiamine and cernevit -replace potassium, Mg, phosphate then commence at 1/3 goal rate -monitor for falls in phosphate, potassium, Mg -monitor BSL COMPLICATIONS -electrolytes/fats/sugar derrangement -LFTs -fluid overload -infection |
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INTUBATION
Indications/contraindications? Preparations? Precautions? What to do if poor view? Options for predicted difficult intubation? Things to document? |
Indications/contraindications?
-airway obstruction -decr LOC -ventilation -enable tracheal suctioning contraindications -VALID NFR/do not intubate (no changes to condition since this was made) -better mx with surgical airway Preparations? Staff & plan - 2 operators experienced in intubation - roles: 1st intubator, 2nd, intubaing assistant, drug administer, cricoid person\ - who to contact if difficulty position preoxygenation 3-5mins monitoring (ETCO2, ECG, SAts) equipment(suction, bag valve mask, airways [ETT/ LMA] & adjuncts, laryng0s/CMAC, , resus trolley, difficult intubation trolley) Drugs (including vasopressor) Fluids/IV access Precautions ?cspine ?previous intubations hx ?last ate POOR VIEW? -BURP/adjust cricoid -bougie -reposition head -different blade eg CMAC, airtraq -change intubator Difficult intubation? -awake direct laryngoscopy -awake fibre optic -Gaseous induction maintaining spontaneous vent -AWake surgical airway Document - CXR - above carina position at teeth laryngeal grade complications EtCO2 wafeform confirmed |
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risks of FFP?
when may plt administration be considered approapriate in the absence of acute bleeding? |
ARDS & ALI
hence not recommended routinely in critically ill with coagulopathy - underlying cause should be identified then risk benefit analysis platlets <20 - can consider replacing |
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febrile neutropenia
-define -empiric therapy (after cultures) -duration of abx? -what if fevers >5 days |
defined as
- >38 degrees - neutrophil count <0.5 or <1 with predicted further decline Empiric therapy non -penicillin allergic -Tazocin (piptaz) 4.5g IV 8hrly (Adjust in severe renal impairment GFR < 20ml/min 4.5g IV every 12 hrs) Penicillin allergy - cefepime 2g IV BD (Adjustment for renal impairment: GFR <30ml/min use 1g IV BD GFR <10ml/min use 1g IV Daily) See guidline if betalactam anaphylaxis IF hypotensive or shocked add gentamicin 4-6mg/kg OD and vancomycin 1g IV BD (adjust for renal impairment) DURATION can be ceased when either -neutrophils >0.5 and afebrile 48hrs -neutrophils >0.5 4 days Prolonged fever, consider -fungal infection -CMV, mycobacterial -adverse drug reaction Consider -HRCT -PCR Bronchoalveolar lavage |
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SEPSIS antibiotics guidelines
Basic elscalation See full guideline as emailed |
2x Blood cultures FIRST!! (and other cultures)
NON PENCILLIN ALLERGIC piptaz (tazocin) then cipro & vanc PENCILLIN ALLERGIC if Severe reaction cipro & vanc else cefepime Add vanc if ?MRSA (known colonisation, CVL, recently inserted prosthesis) |
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what are the sepsis six?
MOst likely sources? |
1. O2 >95, ?ABG
2. culturesx2 (& bloods) 3. lactate 4. fluids (250 bolus, rpt if no APO. consider 20mg/kg if severe) 5. Abx within 60mins 6. monitoring Q30min for 2hrs, then hourly 4hours, urine output & consider IDC SOURCES resp urinary abdominal wound/cellulitis vascular device (heart, vein) neuro neutropenia |
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Blood products
Volumes of each unit of -whole blood? PRBC? platelets? Contraindications for platelets? INdicaqtions? What does prothrombinX contain? INdications? Contraindications? INdications for FFP? Who should get irradiated blood products? What gauge is recommended for blood products? Can a CVL be used? How often shoud obs be taken? Immediate transfusion reaction? |
whole = 450mls
PRBC = 250-300ml platelets = 300-350ml FFP = 300ml Cryoprecipiate = 25ml Unless pt has life threatening haemorrhage, Don;t use platelets in pt with desctruction eg -idiopathic thrombocytopaenic purpura (ITP) -thrombotic thrombocytopaenic purpura (TTP) -idiopathic thrombocytopaenic purpura (ITP) -heparin induced thrombocytopaenia (HIT) INdications -<10 wihtout RF, <20 with RF (fever, ABx, CV instability) -<50 before surgery -inherited or acquired platelet dysfunction in which platelet count is not a reliable indicator ProthrombinX -factors II IX X and low levels of VII Indications -immediate reversal of warfarin in combination with FFP (25-50IU/G PTX and 15ml/kg FFP every 2-4 hrs) Contraindications -do not use for pts showing signs of thrombosis or DIC (?) FFP -single factor deficiencies (use specific factors if available) -Warfarin (life threatening bleeding) -Acute DIC with bleeding and abnormal coags (not chronic DIC) -TTP -liver dz (with bleeding and abnormal coags) -massive transfusion (bleeding and abnormal coags Irradiated blood products for -all haematology/oncology pts -intrauterine transfusion -exchange transfusion 18-20gauge recommended (22-24 for paeds), CVL can be used basline just prior 1st hour: Q15mins 2nd hour Q30mins then hourly Immediate transfusion reaction -stop transfusion -supportive -check ID etc -If severe/more than just locaised urticaria, send purple, pink and white tubes from other arm & remaining blood with sets -fill out transfusion reaction paperwork -lab may require first post transfusion urine If simple reaction - antihistamines and restart slowly |
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Causes of ARF?
indications for CRRT Pros and cons of CRRT vs IHD vs PD What is Slow Continuous Ultrafiltration (SCUF)? Haemofiltration vs haemodialysis? Complications of CRRT types of dialysate available at liverpool and differnces? how do you improve diffusion? convection/ultrfiltrate? indications for discontinuing CRRT? monitoring required whilst on CRRT? |
PRERENAL
-hypotension -hypovolaemic shock -cardiogenic shock -septic shock -bilateral renal vascular obstruction/thrombosis INTRARENAL -glomerula: acute GN -vascular: vasulitis -tubular: ATN, -interstitium: AIN -acute pyelonephritis -acute cortical necrosis -malignant hypertension -Rhabdo (drugs, trauma) -Nephrotoxins(IV contrast, aminoglycosides POST RENAL -obstruction (BPH, calculi, tumour, blocked catheter) INDICATIONS FOR CRRT refractory -fluid overload -hyperkalaemia -acidosis -uraemia -drug OD CRRT -better for haemodynamic instablility -readily accessible, can be done by ICU staff Issues - pt mobilisation limited -anticoagulation -access issues -reduced blood flow rates IHD -quick, large amounts of fluid/solutes reomved over a short period Issues: -Access complications -requires specialised staff -may not be tolerated in haemodynamically unstable -fluid.electrolyte issues between treatments PD -cheaper -no anticoagulation -no haemodynamic instablity Issues: -high incidence peritonitis -slowe clearance -Access, formal access required (tenkhoff catheter) -required frequently hence limitations on pt SCUF - method used when fluid removal is the only aim Haemofiltration vs haemodialysis HF = convective clearance, replacement used, moderate solute removal HD = diffusion clearance using counter current, dialysate used, more aggressive solute removal (both have maximum removal of 1L/hr) Haemodiafiltration uses both methods, same removal rate, dialysate & replacement used -maxiumum fluid and solute removal COMPLICATIONS -hypotension -electrolyte imbalance -arrythmia -anaemia 2ndry to haemolysis -Thrombocytopenia 2ndry to platelet aggregation -hypothermia -coagulopathy 2ndry to heparinsation -infection -HIT Dialysates GAMBRO and HEMOSOL Hemosol is lactate free and hence needs bicarb added Gambro should not be used in liver dysfunction or severe acidosis as lactate cannot be converted to bicarb Both need potassium added if pts K <5.0 (gambro has some already) IMprove diffusion by -larger surface area filter -concentrations (ie don't add K to dialysate if hyperkalaemic) IMprove convection/ultrafilrate by -high flow rate can be done by predilution which reduces viscocity ( but worsens concentration gradient) -care & location of vascath DISCONTINUATION -indication resolved -return pressures elevated associated with filter clot -alarms indicate poor clearance -procedures in theatre or CT MONITORING -APPT 6hrly -U&E, CMP 6hrly -fluid balance hourly -temperature -vascath site for infection |
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INOTROPES
define shock 3 factors needed for tissues to be oxygenated? What is CO? normal CO? normal SV? What is MAP? Define preload, afterload very basic actions of alpha, B1, b2, dopamine receptors? |
shock
-inadequate tissue oxygenation (or imbalance between oxygen delivery and demand) tissue oxygenation requires: 1) O2 transfer across alveolar capillary membrane 2) O2 attachment to haemaglobin 3) Adequate CO to move to tissues CO = SVxHR, normally 4-8L/min SV ~70mls MAP = COxSVR (afterload) = HRxSVxSVR Also = (SBP-DBP)/3+DBP Preload the volume of blood in the ventricle at the end of diastole Afterload the resistance that the heart must pump against inorder to eject the blood alpha - vasoconstriction beta1 - incr HR & contractility beta 2 - bronchodilation, vasodilation of skeletal & coronary vessels dopamine - vasodilation of renal and mesenteric vessels |
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PACEMAKERS/PACING
indications? 3 Routes of pacing? what do the first 3 letters of a pacemakers name tell you? 5 pacing modalities? blargh SINGLE CHAMBER PACING when is atrial pacing used? when is ventricular pacing used? How often should the threshold be checked? Why? Causes of failure to capture? interventions? |
Indication:
-Unstable Bradyarrythmia refractory to Rx eg CHB, 2nd HB, SSS, Sinus brady, asystole -can also be used in tachyarrhytmias, overpacing -can be prophylactic post cardiac surgery 3 routes -transcutaneous -transvenous -epicardial FIrst 3 letters 1) cardiac chamber being paced: A,V or D (dual) 2) cardiac chamber being sensed: A,D,V or O(neither) 3) response to the sensed event: I (inhibited), T (triggered) or D (both possible) 5 pacing modalities DDD, DDD500, DVI, VDD, DOO 1) DDD: AV pacing, max HR 150, atrial refractory 400ms Both chambers paced and sensed Inhibit reponse to sensing ventricle, triggered response in atria 2) DDD500: AV pacing max HR 120 atrial refractory 500ms 3) DVI: blargh - look into all later SINGLE CHAMBER atrial - if AV nodal fxn preserved then atrial pacing preferred to maintain AV synchrony and preserve atrial kick ventricular-usuallu after cardiac surgery with AV nodal dysfxn or intraventricular dysfunction eg bifasicular block Threshold should be checked daily - can change due to -fibrosis around electrode tip -ischaemia/infarction around tip -electrolyte disturbance -antiarrhythmic drugs CAUSES OF FAILURE TO CAPTURE -electrode tip discplacement -oedema or scar tissue at electrode tip -output too low (abnorm electrolytes, hypoxia, iscahemia) -lead wire fracture, battery depletion, generator malfunction -loose connections in system -myocardial perforation INTERVENTIONS -if transveous roll pt on to left, check CXR -if epicardial consider alternate route -increase output until pacing achieved 100% -replace/change lead/wire/battery/generator/pulse generator/connections -correct electrolytes/hypoxia/ischaemia |
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guillian barre
what is it? prognosis? Presentation? Exam? ddx Dx? Mx? |
demyelinating neuropathy with ascending weakness
(post infectious, immune mediated) usually resp/GIT ?campylobacter jejuni, CMV PROGNOSIS mortality 2-12% (resp , sepsis, VTE, 85% full recovery within 6-12 months 7-15% permenant neurological sequalae PRESENTATION (2-4 weeks post benign resp/GIT infections) -finger dysesthesias and proximal muscle weakness LL -weakness progresses over hour/days, ascending, symetical -may present as pure motor or acute dysautonomia (HR, BP, skin, bladder) -meak time to peak is 12 days with 98% within 4weeks -then plateau phase followed days later by gradual symptom improvement -CN involvement in 45-75% -sensory symtoms often precede weakness but do not usually progress beyond wrsit/ankle -Loss of vibration, proprioception, touch, and pain distally may be present. CHECK Exam - confirm ABC (autonomic, resp paralysis, bulbar) -then full neuro -expect hypotonia, absent reflexes DDX transveremyelitis/vascular spinal cord compression/syndromes conversion tick parlaysis toxic neuropathies chronic inflammatory demyleinating polyneuropathy HIV paraneoplastic Dx nerve conduction studies = demyelination LP: incr protein, N WCC MRI - to exclude mechaincal cuases peripheral neuropathy bloods ?serum autoantiobodies, not routine Mx? admit (1/3 require ICU) Vigilant observation bowel/bladder care analgesia allied health Intravenous immunoglobulin and plasma exchange |
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danaparoid
-what is iT? |
anticoagulant, inhibits FActor X
"low molecular wt" Heparinoid substitute used in HITs peak plasma 2-5 hrs temrinal half life- 24hrs excretion via urine |
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sodium nitroprusside
what is it? indications starting dose, usual range, do not exceed? Warning? |
potent vasodilator (arterioles & venules) (including coronary)
indications -BP control -heart failure (off label) -cerbral vasospasm post subarachnoid -MI (off label) Starting-0.25-0.3mcg/kg/min (30mcg/min 100kg) Usual -3-4mcg/kg/min (300-400mcg/min 100kg) Starting-10mcg/kg/min (1000mcg/min 100kg) Half life 2mins (metabolite thicyanate 3 days) ONset<2mins duration 1-10mins excretion - urine Warning - cyanide toxicity, especially if hepatic dysfxn or prolonged infusion Cyanide toxicity symptoms: acidosis (decreased affinity of oxygen to hemoglobin resulting in anaerobic metabolism-increased lactic acid etc.), tachycardia, coma, convulsions, almond smell on breath. THerefore maxium rate of 10mcg/kg/min no longer than 10mins ? no infusion >24hrs |
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THoracic aorta surgery
-post op complications/consdierations |
-BP control as per surgeon to protect graft (SNP)
-bleeding -ischaemic organ injury -stroke/generalised cerebral dysfunction -infection, particularly of prosthetic valve |
