Surgical Recall (Surgical Intensive Care) Questions and Answers (Latest version).

Surgical Recall (Surgical Intensive Care) Questions and Answers (Latest version). How is an ICU note written? By systems: - Neuro (GCS, MAE, pain control) - Pulmonary (vent settings) - CVS (pressors, swan numbers) - GI (gastrointestinal) - Heme (CBC) - FEN (Chem10, nutrition) - Renal (urine output, BUN, Cr) - ID (Tmax, WBC, antibiotics) Assessment/plan what is the best way to report urine output in the ICU 24 hours/last shift/last 3 hourly rate = "urine output has been 2L over the last 24 hours, 350 last shift, and 45, 35, 40cc over the last 3 hours" Possible causes of fever in the ICU? Central line infection Pneumonia/atelectasis UTI, urosepsis Intra-abdominal abscess Sinusitis DVT Thrombophlebitis Drug fever Fungal infection, meningitis, wound infection Endocarditis What sit he most common bacteria in ICU penumonia? Gram-negative rods Basic ICU care checklist? FAST HUG - Feeding - Analgesia - Sedation - Trhomboembolic prophylaxis - Head-of-bed elevation - Ulcer prevention - Glucose control What is CO? Cardiac output = HR X SV What is normal CO? 4-8L/min What factors increase CO? Increased contractility, HR, preload Decreased afterload What is CI? Cardiac index = CO/BSA What is normal CI? 2.5-3.5L/min/M2 What is SV? Stroke volume Amount of blood pumpoed out of the ventricle each ebat EDV-ESV or CO/HR What is normal SV? 60-100cc What is CVP? Central venous pressure Indirect measurement of intravascular voume status What is normal CVP? 4-11 What is PCWP? Pulmonary Capillary Wedge Pressure Indirectly measures left atrial pressure, which is an estimate of intravascular volume (LV filling pressure) What is the normal PCWP? 5-15 What is the anion gap? Na - (Cl + HCO3) What are the normal values for anion gap? 10-14 Why do you get an increased anion gap/ Unmeasured acids are unmeasured anions in teh equation that are part of the "counterbalance" to the sodium cation What are the causes of incrased anion gap acidosis in surgical patients? SALUD Starvation Alcohol (ethanol, methanol) Lactic acidosis Uremia (renal failure) DKA what is MODS? multiple organ dysfunction syndrome What is SVR? Systemic vascular resistance MAP - CVP / CO x 80 What is SVRI? Systemic Vascular Resistance Index SVR/BSA What is normal SVRI? What is MAP? Mean arterial pressure DBP + 1/3 SBP (not the mean b/c diastole lasts longer) What is PVR? Pulmonary vascular resistance PA (mean) - PCWP / CO X 80 What is the normal PVR value? 100 +/- 50 What is the formula for arterial oxygen content? Hb X SaO2 x 1.34 What is the basic formula for oxygen delivery? Full formula? CO x (oxygen content) CO x (Hb X SaO2 x 1.34) x 10 What factors can increase oxygen delivery? Increased CO by increasing SV, HR or both Increased O2 content by increasing Hb content, SaO2 or both What is mixed venous oxygen saturation? SvO2 The O2 saturation of the blood in the right ventricle or pulmonary artery An indirect measure of peripheral oxygen supply and demand Which lab values help assess adequate oxygen delivery? SvO2 - low with inadequate delivery Lactic acid - elevated with inadequate deliver pH - acidosis with inadequate delivery Base deficit What is FENa? Fractional Excretion of Sodium (Una x Pcr / Pna x Ucr) x 100 "U Need to P Cretin!" What is the prerenal FENa value? 1.0 Renal failure from decreased renal blood flow what is the prerenal BUN-to-Cr ratio 20:1 what is the renal ATN BUN-to-Cr ratio 20:1 what is the prerenal FENa 1 what is the renal ATN FENa 1 what is prerenal urine osmolality 500 what is renal ATN urine osmolality 350 what is prerenal urine Na 20 what is renal ATN urine Na 40 what is prerenal urine specific gravitiy 1.020 How long does Lasix effect last? Six hours What is the formula for flow/pressure/resistance? Pressure = Flow x Resistance Push FoRward Effect of PaCO2 on acid-base status? For every increase in PaCo2 by 10mmHg, pH falls by 0.08 what is the "40, 50, 60 for 70, 80, 90 rule" for O2 sats? PaO2 of 40, 50, 60 corresponds to an O2 sat of 70, 80, 90 One liter of O2 via nasal canula raises FiO2 by how much? 3% what is pur respiratory acidosis? low pH, increased PaCO2, normal bicarbonate what is pure repsiratory alkalosis? high pH, decreased PaCO2, normal bicarbonate what is pure metabolic acidosis? low pH, low bicarbonate, normal PaCO2 what is pure metaoblic alkalosis? high pH, high bicarbonate, normal PaCO2 what does SIRS stand for systemic inflammatory response syndrome how does the body compensate for metabolic alkalosis increased PaCO2 what does MOF stand for multiple organ failure how does the body compensate for metabolic acidosis decreased PaCO2 how does the body compensate for respiratory alkalosis decreased bicarbonate how does the body compensate for respiratory acidosis increased bicarbonate SICU Drugs: Dopamine Site of action - dependant on doses - Low dose (1-3ug/kg/min): Dopa agonist, renal vasodilation - Intermediate dose (4-10): + a1, ++B1; positive ionotropy and some vasocontriction - High dose (10): +++a1 agonist; marked afterload increase from arteriolar vasoconstriction Has 'renal dose' Dopamine been shown to decrease renal failure? No SICU Drugs: Dobutamine SOA: +++B1 agonist, ++B2 Effect: increased inotropy; increased chronotropy; decrase in SVR SICU Drugs: Isoproterenol SOA: +++B1 and B2 agonist Effect: Increase inotropy, increased chronotropy; vasodilation of skeletal and mesenteric vascular beds SICU Drugs: Epinephrine SOA: ++ a1, a2, ++++B1/2 agonist Effect: Increased inotropy, increased chronotropy SICU Drugs: Norepinephrine SOA: +++a1, a2, +++B1/2 agonist Effect: Increased inotropy, increased chronotropy, ++ increase in BP What is the effect of Epinephrine at high doses? Vasoconstriction What is the effect of high dose Norepinephrine? Severe vasoconstriction SICU Drugs: Vasopressin Effect: Vasoconstriction, increases MAP, SVR Indications: Hypotension, refractory to other vasoporessors SICU Drugs: Sodium nitroprusside SOA: +++ venodilation, +++ arteriolar dilation Effect: Decreased preload and afterload, allowing BP titration What is the major toxicity of Sodium Nitroprusside? Cyanide toxicity Define Preload Load on the heart msucle taht stretches it to EDV = intravascular volume Define afterload Load or resistance the heart must pump against = vascular tone = SVR Define contractility Force of heart muscle contraction Define compliance Distensibility of heart by the preload What is the Frank-Starling curve? Cardiac output increases with increasing preload up to a point What factors influence mixed venous oxygen saturation? Oxygen delivery (Hb concentration, arterial O2 sat, CO) and oxygen extraction by the peripheral tissues What lab test for tissue ischemia is based on the shift from aerobic to anaerobic metabolism? Serum lactic acid levels Define dead space Part of inspired aire that does not participate in gas exchange Define Shunt fraction Fraction of pulmonary venous blood that does not participate in gas exchange What causes increased dead space? Overventilation (emphysema, excessive PEEP) Underperfusion (PE, low CO, pulmonary artery vasoconstriction) At high shunt fractions, what is the effect of increased FiO2 on arterial PO2? Shunt fraction50%, changes in FiO2 have NO effect on arterial PO2 why do you want to minimize FiO2 You want to minimize FiO2 to prevent oxygen toxicity Define ARDS Acute respiratory distress syndrome Lung inflammation causing respiratory failure What is the ARDS diagnostic triad? CXR: - Capillary wedge pressure 18 - XR of chest with bilateral infiltrates - Ratio of PaO2 to FiO2 200 what does the classic CXR look like with ARDS? bilateral fluffy infiltrates At what concentration does O2 toxicity occur? FiO2 60% x 48hrs What is the only ventilatory parameters that have been shown to decreased mortality in ARDS patients? Low tidal volumes (6cc/kg) Low plateau pressure (30) What are the main causes of CO2 retention? Hypoventilation Increased dead space ventilation Increased CO2 production (hypermetabolic states) Why are carbohydrates minimized in patient having difficulty with hypercapnia? Respiratory Quotione is ration of Co2 production to O2 consumptoin The RQ is highes for carbohydrates (1.0) and lowest for fats (0.7) Why are indwelling arterial lines used for BP monitoring in critically ill patients? Need for frequent measurments Inaccuracy of repeated cuff measurements Inacuraccy of cuff measurements in hypotension Need for frequent ABGs what is a swan-ganz catheter? pulmonary capillary pressure after balloon occlusion of the pulmonary artery, which is equal to left atrial pressure because tehre are no valves in the pulmonary system left atrial pressure is essentially equal to left venticualr end-diastolic pressure: left heart preload, and, thus, intravascular volume status what is the primary use of the PCWP? as an indirect measure of prelaod - intravasuclar volume Define ventilation Air moving through the lungs Monitored by PCO2 Define oxygenation Oxygen delivery to the alveoli Mesasured by O2Sat and PO2 What can increase ventilation to decrease PCO2? Increased RR Increased TV (Increasing minute ventilation) What is minute ventilation? Volume of gas ventilated through the lungs RR x TV Define tital volume Volume delived with each breath 6-8cc/kg on ventilator Are ventilation and oxygenation related? No - you can have an O2Sat of 100% and PCO2 of 150 O2Sat do NOT tell you anything abotu PCO2 What can increase PO2 in the ventilated patient? Increased FiO2 Increased PEEP what can decrease PCO2 in the ventilated patient increased RR increased tidal volume Define IMV Intermittent Mandatory Ventilation Patient can breath on their own, but if they don't breath within a specific time, the machine breathes Can breath above the mandatory rate without help from the ventilator Define SIMV Synchronous IMV Delivers mandatory breath synchronously with patient's initiated effort. If no breath is initiated, breath will be initiated by machine. Patient's breath triggers the machine to supplement the breath Define A-C Assist-Control venitlation Ventilator delievers breath when patient initiates a breath If the patient does not breath , ventilator takes control All breaths are by the ventilator Define CPAP Continuous Positive Airway Pressure Delieves continuous pressure during expiration and inspiration, but no volume breaths Patient breaths on own Define Pressure Support Pressure is delieved with initiated breaths Decreases work of breathing by overcoming the resistance in the venitlatory circuts Patient breaths on own Define APRV Airway Pressure Release Ventilation HIgh airway pressure intermittently released to a low airway pressure Define HFV High frequency ventilation Rapid rates of venitlation with small tidal volumes Define PEEP Positive end expiration pressure Pressure maintained at the end of a breath - keeps alveoli open What is "physiologic PEEP"? 5cmH2O Approximates normal pressure in normal non-intubated people caused by the closed glottis What are the typical initial vent settings? IMV TV = 6-8ml/kg VR = 10bpm FiO2 = 100% and wean down PEEP = 5cmH2O Then change based on ABGs What is normal I:E? 1:2 When would you use an inverse I:E ratio? Ex - 2:1, 3:1 To allow for longer inspiration inpatients with poor compliance To allow for alveolar recruitment When would you use a prolonged I:E ratio? Ex. 1:4 COPD To allow time for complete exhalation Prevents "breath stacking" What clinical situations cause increased airway resistance? Airway or endotracheal tube obstruction Bronchospasm ARDS Mucous plug CHF -- pulmonary edema What are the presumed advantages of PEEP? Prevention of alveolar collapse and atelectasis Improved gas exchange Increased pulmonary compliance Decrease shunt fraction What parameters must be evaluated in deciding if a patient is ready to be extubated? Alert and able to protect airway Gas exhange (PaO2 70, PaCO2 50) Tidal volume (5cc/kg) Minute ventilation (10L/min) Negative inspiratory pressure ( -20cmH2O or more negative) FiO2 40% PEEP 5 pH 7.25 RR 35 Tobin index 105 (shallow breathing index) What is the Rapid-Shallow Breathing (AKA Tobin) Index? RR:TV 105 asssociated with sucessful extubation What is the possible source of fever in a patient with an NG or nasal endotracheal tube? Sinusitis Diagnose by sinus films or CT what is the 35-45 rule of blood gas values? normal values - pH = 7.35-7.45 - PCO2 = 35-45 What medications can be delievered via an endotracheal tube? Narcan Atropine Vasopressin Epinephrine Lidocaine "NAVEL" What conditions should you think of with increased peak airway pressure and decreased urine output? Tension pneumonthorax Abdominal compartment syndrome what is the diagnosis 48-y/o male with pancreatitis now with acute onset of respiratory failure, PaO2 to FiO2 ratio of 89, normal heart echo, bilateral pulmonary edema on CXR severe ARDS what is the diagnosis 67-y/o female with severe diverticulitis now with acute onset of respiratory failure, PaO2-to-FiO2 ratio of 234, normal heart echo, bilateral pumlonary edema on CXR mild ARDS what is the diagnosis 22-y/o male s/p MCC 48-y/o now with bleeding through liver and pelvic packs; TEG reveals a progressive narrowing of the TEG tracing over time (small tail) hyperfibrinolysis what is the diagnosis 22-y/o fmeale s/p fall with severe TBI, urine output 30-50 , CVP 15, sodium of 128 SIADH what is the diagnosis 45-y/o with evere pancreatitis, now with increasing peak airway pressure, decreased urine output, and hypotension abdominal compartment syndrome what is the diagnosis 70-y/o male with severe sepsis on three pressors (vasopressors), antibiotics, refractory to fluid bolus and progressively increasing doses of pressors adrenal insufficiency what is the diagnosis 44-y/o male with pulmonary contusions s/p several infusions of KCl for hypokalemia but iwth no increase in post-infusion potassium level hypomagenesemia what is the diagnosis 44-y/o female with severe pancreatitis on ventilator ABG reveals pH of 7.2, PO2 of 100, PCO2 of 65, bicarbonate 26 respiratory acidosis (uncompensated) what is the diagnosis 65-y/o male s/p pulmonary contusion on a ventilator, ABG reveals pH 7.35, PO2 80, PCO2 of 60, bicarbonate of 35 compensated respiratory acidosis what is the diagnosis 34-y/o female s/p liver injury from an MVC on the ventilator, ABG reveals pH 7.23, PO2 105, PCO2 40, bicarbonate 17 metabolic acidosis what is the diagnosis 76-y/o male with severe diverticulitis on ventilator, pH 7.35, PO2 76, PCO2 25, bicarbonate 16 metabolic acidosis with respiratory compensation what is the diagnosis 45-y/o found down with pH of 7.17, PCO2 39, PO2 90, sodium 140, chloride 108, bicarbonate 26 normal anion gap metabolic acidosis what is the diagnosis 56-y/o female found down with pH of 7.19, sodium 140, bicarbonate 18, chloride 100 increased anion gap acidosis what is the treatment 34-y/o female s/p MVC with carotid dissection on CTA antiplatelet or anticoagulation therapy what is the treatment 25-y/o male s/p crush injury with CK of 45,000, dark urine myoglobinuria: IV fluid hydration +/- bicarbonate IV what is the treatment DVT prophylaxis for 34-y/o trauma patient with acute renal failure unfractioanted heparin what is the treatment 78-y/o male in ICU develops SVT and hypotensive 75/palp synchronized cardioversion what is the treatment 80-y/o male s/p Hartmann's procedure for severe fecal diverticulitis, now with urine output of 10ccs per hour, FENA 1%, creatinine 1.7, BUN-to-Cr ratio of 20, urine sodium of 8 prerenal acute renal failure, treat with IV volume