My Acute Medicine
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What is the significance of common obs measured in ICU?
- HR: Tachycardia related to poor outcome >120bpm
- RR: Tachypnoea in many acute diseases. >20r/min
- MAP: Lowers in sepsis/blood loss.
- GSC: Any effect suggests an effect on cell function
- O2 sat: Low = lung, airway or CVpathology
- Temp: Sign of metabolism. High = sepsis, drug reaction
What observations are performed in ICU, excluding general Obs? What is their significance?
- Urine output: Hypovolaemia, renal disease, overhydration, drugs. Normal = adequate perfusion
- Biochem: lactate, glucose, acid/base. Metabolic function and perfusion
- Pain: Associated with actual or potential tissue damage
- Size of Patients flaccid member?
- Presence of anal tage?
Outline the general observations used in the APACHE II score
- Rectal Temp, MAP, HR, RR
- Bio: Sodium, Potassium, pH, Creatinine, PaO2
- Haematocrit, WBC
Your patient is ill with oxygen FAIL, how much O2 do you prescribe?
- Give all the mmHg!!!!
Outline the full calculations of the APACHE II score
- Age (45-54=2, 64=3, 74=5, >75=6)
- Chronic health; liver, CV resp, renal, immune
Outline the SOFA scoring system
What does the APACHE 2 system predict?
The prognosis of a critically ill patient
What does the SOFA scoring system determine?
Used to determine the extent of a person's organ function, or failure (respiratory, renal, coagulation, CNS, CVS, liver)
What does MEWS predict?
- "Modified Early Warning Score"
- Guide used to quickly determine the degree of illness
- Four readings: SBP, HR, RR, tem and GCS
- The more the patient's diverse from the norm, the greater the score
Outline the pathological mechanisms leading to shock
- Micro-organisms invade blood stream
- Toxins (exo/endo) cause mediator release
- Profound vasodilation = acute renal failure + hypoxia
- Necessary mechanical ventilation can also cause infection, trauma and so ARDS
- What are the clinical manifestations of shock?
- What defines 'severe sepsis'?
- SIRS criteria + presumed/confirmed infection
- Sepsis, with at least one acute organ dysfunction
What is the definition of 'septic shock'?
- Confirmed severe sepsis
- Hypotension unaffected by IV fluid reconstitution
How is a septic patient resuscitated?
- 1. High flow O2 for <4 hours
- 2. Two blood cultures, at least one from each IV access
- 3. Other examinations (CSF, CXR, urine culture)
- 4. Antibiotics within 1st hour; 1+ in likely spectrum
- 5. Iv fluids; 250ml crystalloid and consider fluid challenge
- 6. Severe hypotension = vasopressors
- 7. Lactate, Hb and urine measured
What were the findings of the Rivers clinical trial?
Proved aggressive management of sepsis, including guidelines described, associated with better mortality
What is the significance of AKI in a clinical setting?
- Around 10% of patients in ospital are in the risk stages
- Directly related to mortality and other organ failures
- Around 20% of CCU patients require RRT
What are the classical causes of AKI?
- Pre renal: hypovolaemia, stenosis
- Renal: Vasculitis, glomerulonephritis, drugs
- Post-renal: obstruction, e.g. prostate, kidney stone
What are the multifactorial causes of AKI?
- No single cause contributes to renal ischaemia
- Vast majority are related to sepsis. Also poor haemodynamic or low cardiac output
- Cytokines, toxins and obstructionpart of the 'multifactorial' idea
How are RIFLE criteria measured?
- Outlines the measurements 'RIF' and outomes 'LE' of kidney injury
- R: Risk area - creatinine x1.5, urine <5ml/kg/h for 6hr
- I: Injury area- creatinine x 2, urine <5ml/kg/h for 12hr
- F: Failure - creatinine x 3, urine <3ml/kg/h for 24hr
- L: Persistent acute renal failure = complete loss of function >4 weeks
- ESRD: End stage renal disease
What are the problems with the measurements used in the RIFLE criteria?
- Several conditions can cause a drop in urine production unrelated to renal failure
- Creatinine can also be affected by other conditions (e.g. diabetes, muscle mass)
What are the indications for RRT?
- Increased urea, decreased urine, hyperkalaemia, acidosis, fluid overload etc. related to renal function
- Hypoxia/sepsis/obstruction ruled out as causes of the AKI
- Perfusion/BP unaffected by IV fluids
The withdrawal of desirable ions using concentration gradients across a semi-permeable membrane via countercurrent mechanisms
The withdrawal of desirable ions using concentration gradients, aided by hydrostatic pressure allowing for large solute removal. The fluid composition is then changed and reinfused
What are the contraindications of RRT?
- If the injury is not survivable
- There is no opportunity to stop RRT in the future
- The prognosis is poor (elderly, ESRD etc)
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