Week 09 - Intensive care

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mewinstanley@googlemail.com
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125333
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Week 09 - Intensive care
Updated:
2012-02-02 11:57:11
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intensive care glasgow medicine
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Week 9 lectures
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  1. Functions of ICU (3)
    • Pt requires advanced resp support
    • Pt req support of >2 organ sys
    • Chronic impair + acute organ failure
  2. Describe
    -APACHE II
    -SOFA
    • APACHE II
    • 12 physiological measurements
    • general measurement of severity
    • score 0-71, higher = worse

    • SOFA
    • sequential organ failure assesment
    • more failure, sicker Pt, ^score (1-4)
  3. SIRS
    -Criteria
    -Causes
    • Criteria
    • >2 of
    • T >38/ <36
    • HR >90bpm
    • RR >20/min
    • WWC >12/<4

    • Causes
    • infection
    • trauma
    • burns
    • pancreatitis, etc
  4. Define;
    -Sepsis
    -Severe Sepsis
    -Septic Shock
    • Sepsis
    • SIRS + presumed/confirmed infection

    • Severe Sepsis
    • Sepsis + organ dysfunction

    • Septic Shock
    • Severe Sepsis + hypotension (not resp to fluid challenge)
    • inadequate perfusion ^lactate
  5. Presentation of sepic shock
    -Early
    -Established
    -Late
    • Early (pre-shock)
    • hot, sweaty, flushed
    • Pt feels unwell
    • SIRS

    • Established
    • warm peripheries
    • pyrexial
    • ^CO
    • vasodilation
    • SIRS + infection + oragan failure + hypotension

    • Late
    • cool peripheries, mottled skin
    • low CO
    • ~cardiogenic shock
    • Mort >50%
  6. Describe the management of a septic Pt (ABCDE)
    • Airway
    • colour - cyanosed?
    • Pulse Ox
    • Talk ok?

    • Breathing
    • Tachypnoea
    • Talk Ok (whole sentences?)

    • CVS
    • peripheral perfusion
    • HHR & pulse vol
    • BP
    • Urine output (>0.5ml/kg/hr?)

    • Disability
    • GCS

    Examine Pt
  7. What are the sepsis 6?
    • High flow O2
    • Take B/C
    • Give IV antibiotics
    • Fluid resuscitation (Hartmanns solution/equivalent) 250ml fluid challenge
    • Chack [Lactate] & Hb
    • Monitor Urine output - >0.5ml/kg/hr
  8. Is Tx working?
    • MAP >65mmHg
    • Improving capillary refill
    • warming extremities
    • ^urine output
    • ^GCS
    • decreasing [Lactate]
  9. What are the normal plasma concentrations of the following?
    -Sodium
    -Potassium
    -Chloride
    -Bicarbonate
    • Sodium - 142mmol/L
    • Potassium - 4mmol/L
    • Chloride - 103mmol/L
    • Bicarbonate - 25mmol/L
  10. Give 3 crystalloids
    • 5% dextrose
    • Saline
    • Hartmanns Solution - most isotonic to blood
  11. Give 4 colloids
    • Albumin
    • Gelatins - LMW proteins, gelofusine & Haemaccel
    • Dextrans
    • Hydroxy-ethylated starches
  12. Compare Crystalloids & Colloids
  13. Describe a fluid challenge & the physiological observations involved
    • 250mls rapid
    • observe; HR, BP, GCS, Perfusion (capillary refill) UO, CVP
  14. Describe the pharmacology of;
    -Adrenaline
    -Dobutamine
    -Noradrenaline
    -Vasopressin
    • Adrenaline
    • Sympathomimetic (A1, B1 & B2)
    • ^^pulmonary vascular pressure
    • Beware necrosis @ injection site
    • t1/2 = 2mins

    • Dobutamine
    • Vasocostriction (A-ceptors)
    • ^myocardial O2 demands
    • Inotrope 15ug/kg/min
    • Synthetic Catecholamine - B1 &B2 adrenoceptors

    • Noradrenaline
    • A agonist, some B activity
    • ^BP
    • ^cardiac BF
    • vasoconstrictor, little chronotropy

    • Vasopressin
    • Synthetic ADH
    • ^water absorption by renal tubules
    • vasoconstriction
    • t1/2 = 10-20min
  15. Describe the CVS monitoring of a septic Pt
    (BP, CO, DO2)
    • BP
    • Persistant hypotension = bad
    • Target systolic 90mmHg, MAP 65mmHg

    • CO
    • Measured - invasive [Swan Ganz], Aortic blood flow [oesophageal doppler]
    • Target - normal [4.9-5.6L/min], supranormal [4.5L/min/m2]

    • Oxygen Delivery
    • Tissue oxygenation, measure via catheter
    • SvO2 [mixed venous oxygenation] target 70%
  16. What are the causes of AKI?
    (Pre-renal, renal & post-renal
    • Pre-renal
    • hypovolaemia/hypotension

    • Renal
    • vasculitis
    • glomerulitis
    • drugs [Cimetidine/Trimethoprim]

    • Post-renal
    • obstruction
    • clot
    • stones
    • prostate
  17. Define AKI using the RIFLE criteria
  18. What are the SCr levels for each stage of RIFLE?
    • Risk → SCr x1.5
    • Injury → SCr x 2
    • Failure → SCr x 3
    • Loss → persistant ARF >4w
    • ESKD → Persistang RF >3m
  19. Define
    -ALI
    -ARDS
    • ALI [Acute lung injury]
    • PaO2/FiO2 <40kpa, regardless of PEEP [Positive end expiratory pressure]
    • CXR → bilateral infiltrates
    • Pulmonary artery occlusion pressure < 18mmHg

    • ARDS [Acute respiratory distress syndrome]
    • All ALI +
    • PaO2/FiO2 <27kpa
  20. What are the causes of ALI?
    -Pulmonry
    -Extra-pulmonary
    • Pulmonary
    • Pneumonia
    • Aspiration
    • Contusion
    • Fat emboli
    • Inhalational injury

    • Extrapulmonary
    • Sepsis
    • Trauma
    • Transfusion related ALI [TRALI]
    • Drug overdose
  21. Outline the CF of ARDS
    • Refractory hypoxaemia
    • SOB
    • Exhausted
    • Sitting up [^^accessory muscles]
    • Usually tachypnoeic [if bradypneoic = V v v bad]
    • Hypoxaemic
    • RV strain
    • CV symptoms

    • O/E
    • Progressive severe dyspnoea
    • coarse basal crackles most RS = norm
    • Pulmonary hypertensin & RVF
    • ~SIRS
  22. What is the pathology of ARDS?
    Assoc w diffuse alveolar damage [DAD]

    • First phase = Exudative
    • ^ in permeability of alveolar-capillary memb → fluid into alveoli
    • Sepsis dam capillary side, inhalation = alveolar side
    • Dam to T1 pneumocytes ^ fluid into alveoli
    • Dam to T2 = decreased surfactant → alveolar collapse
    • Histology → capillary congestion, intra-alveolar haemorrhage & oedema, Fibrin w hyaline membranes

    • Regeneration
    • T2 proliferate & diferentiate into T1
    • regen under hyaline membranes

    • Repair
    • Fibrotic pattern
    • myofibroblasts → distort & shrink lung
    • Interstitial fibrosis [TNF-alpha]
  23. What Ix are useful for ARDS?
    • Bronchoalveolar Lavage → C+S
    • CXR → bilateral infiltrates
    • Transbronchial lung biopsy/open lung biopsy

    Mainly clinical Dx
  24. Explain how ARDS can impair respiration?
    • Hypoventilation
    • caused by Alveolar hypoventilation [filled w fluid] or ^^dead space [poor BF due to clots]

    • V/Q mismatch
    • Intrapulmonary shunts [good perf but poor ventilation]
    • Fluid filled alveoli

    • Diffusion deficit
    • Damage to alveolar-capillary membrane
  25. Outline the Tx of ARDS
    [ABCDEFG]
    • A = Airway
    • B = breathing [mechanicla ventilation]
    • C = circulation [BP - fluids & vasopressers as per]
    • D = Dx [Tx underlying cause]
    • E = Empirical antibiotic cover
    • FG = feed the gut → prevent villous atrophy & bacterial translocation

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