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Functions of ICU (3)
- Pt requires advanced resp support
- Pt req support of >2 organ sys
- Chronic impair + acute organ failure
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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)
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SIRS
-Criteria
-Causes
- Criteria
- >2 of
- T >38/ <36
- HR >90bpm
- RR >20/min
- WWC >12/<4
- Causes
- infection
- trauma
- burns
- pancreatitis, etc
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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
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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%
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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?)
Examine Pt
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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
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Is Tx working?
- MAP >65mmHg
- Improving capillary refill
- warming extremities
- ^urine output
- ^GCS
- decreasing [Lactate]
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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
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Give 3 crystalloids
- 5% dextrose
- Saline
- Hartmanns Solution - most isotonic to blood
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Give 4 colloids
- Albumin
- Gelatins - LMW proteins, gelofusine & Haemaccel
- Dextrans
- Hydroxy-ethylated starches
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Compare Crystalloids & Colloids
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Describe a fluid challenge & the physiological observations involved
- 250mls rapid
- observe; HR, BP, GCS, Perfusion (capillary refill) UO, CVP
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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
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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%
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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
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Define AKI using the RIFLE criteria
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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
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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
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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
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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
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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]
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What Ix are useful for ARDS?
- Bronchoalveolar Lavage → C+S
- CXR → bilateral infiltrates
- Transbronchial lung biopsy/open lung biopsy
Mainly clinical Dx
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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
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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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