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Critical Care

Critical Care. A 56 year old wm , s/p AAA repair, in the ICU on the vent,with the following. persistent hypotension despite fluids and pressors PCWP - 20 CVP15 hyponatremia hypoglycemia. Dx and management?. Adrenal Insufficiency. Random cortisol level of less than 20µg/dl is suggestive

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Critical Care

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  1. Critical Care

  2. A 56 year old wm , s/p AAA repair, in the ICU on the vent,with the following • persistent hypotension despite fluids and pressors • PCWP - 20 • CVP15 • hyponatremia • hypoglycemia Dx and management?

  3. Adrenal Insufficiency Random cortisol level of less than 20µg/dl is suggestive Cosyntropin test - 250 µg of cosyntropin Check cortisol level at 30 minutes Failure to increase greater than 9 µg is diagnostic Administer Dexamethasone - it does not affect cosyntropin test

  4. Label the axis on the following graph Delivery dependent Delivery independent Y X

  5. CaO2 = 1.34 x Hgb x SaO2 + ( 0.0032 x PaO2 ) DO2 = CaO2 x C.O VO2 = C(a-v)O2 x C.O

  6. Oxygen-hemoglobin disociation curve Factors that shift curve to the right ? What is P50 ?

  7. Oxygen-hemoglobin disociation curve P50 - the partial pressure of oxygen at which hemoglobin is 50% saturated with oxygen

  8. AVP( ADH) is secreted in response to what?

  9. AVP( ADH) is secreted in response to what? ADH increases water permeability and passive sodium transport to the distaltubule , allowing increased water reabsorption Increased serum osmolality and hypovolemia

  10. Which of the following precludes a diagnosis of brain death? • Uremia • Hypothermia below 32.2 C • Systemic blood pressure of 70/40 mmHg • Hypercarbia with a PaCO2 greater than 60mm Hg with no respiratory response Answer: A, B, C

  11. Brain death • Def – Irreversible cessation of all functions of the brain, including brain stem • 1st – Exclude reversible causes of coma, i.e. sedation, hypothermia, neuromuscular blockage, shock • 2nd – Clinically unresposive to pain, absent brainstem reflexes and positive apnea test • Or flow study of blood to brain

  12. A 45 year old female presents to the emergency room with nausea and vomiting and severe headache. She has been having these episodes frequently which last about an hour. A CT scan of the abd pelvis is obtained. You suspect it is a pheochromocytoma. What is your work up?

  13. Differential Diagnosis Primary Aldosteronism Carcinoid Malignant Hypertension Thyrotoxicosis Menopause Panic Disorder Medication withdrawal (e.g. Clonidine ) Labs: Best studies • Plasma Free Metanephrines • Test Sensitivity: 99% • Test Specificity: 89% • Urine Metanephrines (24 hour collections) • Test Sensitivity: 76% • Test Specificity: 94% • Tests with lower efficacy (rarely used now) • Urinary VMA • Imprecise test • Plasma Catecholamines (Norepinephrine, Epinephrine) • Test Sensitivity: 85% • Test Specificity: 80% Stop any interfering medications Labetalol Tricyclic Antidepressant Levodopa or Methyldopa Benzodiazepines

  14. Preoperative • IV Fluids • Alpha Blocker • Phenoxybenzamine • start - 20mg per day • then increase by 10mg every 3 days • until pt has postural hypotension • Prazosin - 1mg QID • BetaBlocker • most pts do not need B-blocker • reserved for tachyarrhytmias • can exacerbate hypertensive crisis

  15. What is your most likely diagnosis and management of this patient? You are about to do a laparoscopic cholecystectomy on a 25 year old female. The nurse anesthesist calls you into the room. She states that the patient has a temperature of 104.5 deg ,HR of 132 and high ETCO2 This came on right after induction.

  16. Malignant Hyperthermia Active Cooling Monitoring Signs and Symptoms • Ice packs• Cooling blankets• Fans• Cold intravenous fluids• Intragastric, intracystic cooling• Peritoneal dialysis using cold diasylate• Extracorporeal cooling if equipment is available • Core temperature• Arterial line and CVP line• Urinary catheter• ECG• Pulse oximetry & capnography• Blood gases• Serum glucose• Serum potassium• Blood for CPK• Urine for myoglobin • ↑ End tidal CO2 • Tachycardia• Fever 2°C per hour• Cyanosis• Mottling of skin• Tachypnoea• Arrhythmias• Rigidity• Sweating• Hypercarbia• Labile blood pressure• Intense masseter spasm Terminate anaesthesia and surgery as soon as possible Hyperventilate with 100% oxygen Give Dantrolene Transfer to ICU as soon as possible

  17. Malignant Hyperthermia DANTROLENE 2.5 mg/kg IV Repeat as required at 5.10 min intervals to a maximum cumulative dose of 10 mg/kg. Favorable response indicated by: (a) fall in heart rate(b) abolition of arrhythmia(c) decline in body temperature(d) reduced muscle tone • ARRHYTHMIASIf these persist despite Dantrolene give:PROCAINAMIDE 1 mg/kg/ml IVMaximum dose: 15 mg/kg • HYPERKALAEMIAControl if necessary using glucose and INSULIN 0.1 units/kg in 2 ml/kg 50% dextrose IV • ACIDOSISCorrection withSODIUIM BICARBONATE0.5 - 1.0 mmol/kg/dose IVRepeated as necessary • URINE OUTPUTMANNITOL 0.5 - 1.0 g/kg(2.5 - 5ml/kg of 20% solution) and/orFUROSEMIDE 1 mg/kg IVto maintain urine output (> 1 ml/kg/hr)

  18. You are called to see a pt post-op in the ICU, this is the tracing on the monitor. Case 1. BP 70, HR160 Case 2.BP125/67 , HR86

  19. Atrial Fibrillation Irregular P waves > 300/min, irregular ventricular rhythm Associated Conditions: MI.HTN,hypoxia,Hyperthyroidism,electrolyte imbalance, pulmonary embolus If Unstable ( Case 1) Cardioversion – 200 – 360 J Initial Therapy Diltiazem 0.25mg/kg , then 10-15mg/hr Digoxin 0.5mg , then 0.25mg Q2hrs Esmolol, procainamide, amiodarone Subsequent therapy Procainamide, Digoxin, anticoagulation

  20. A 45 year old male with gastric outlet obstruction, has had an NG tube in for six days. His avg daily out put is 1500cc per day. On the sixth day you realize that the intern has not been replacing the NG output. Inadequate or no replacement of nasogastric suctioning would result in what disturbance?

  21. Hypokalemic,hypochloremic metabolic alkalosis PARADOXICAL ACIDURIA

  22. Match the treatment Adequate volume status and hypotension refractory to inotropic agents Distended neck veins, distant heart sounds, and hypotension Hypotension, appropriate volume, atrial fibrillation with a HR of 40 Hypotension and low right and left atrial pressures Adequate volume, no mechanical defects, hypotension Inotropic agents Cardiac pacing Fluid administration Pericardiocentesis Intraaortic balloon pump E D B C A

  23. TNICU – PTD #2, Ex-lap, GradeII liver injury & splenectomy. R2 called at 0100 to see pt. RN states abdomen is tight. How do you work this up?

  24. Abdominal Compartment Syndrome should be suspected and sought for in any multiple trauma patient who has undergone a period of profound shock and aggressive ressuscitation . Clinically • fall in urine output • elevated central venous pressure. • Increase peak airway pressure • Decrease pulm compliance • The diagnosis confirmed by measurement of intra-abdominal pressure.

  25. Pt with long cardiac history, PAC placed pre-op for large ventral hernia repair. 1st – CI 1.4 SVR 880 PWP 9 CVP 6 2nd – CI 1.6 SVR 1000 PWP 15 CVP11 Vitals: BP 110/55, HR 128 Which Inotropic agent do you want to use and why?

  26. Milrinone Dobutamine

  27. 55 year old on trauma service with severe watery , foul smelling diarrhea, WBC 40,000, 15 bands. Colonoscopy showed the following.

  28. Pseudomembranous Colitis Pseudomembranes compromised of fibrin, mucus and necrotic epithelial cells Mostly in rectosigmoid Accessible to sig-scope C.diff toxinis agent responsible found in 90 -100% of Pts with Pseudomembranous colitis Mortality 20% - if untreated Progression – perforation, toxic megacolon TREATMENT: Flagyl – 250mg PO/IV Q 6 hrs – 7 – 10days If unsuccessful Vancomycin – 125 mg Q6 hrs ( PO only )

  29. A 17 year old male, multiple GSW, Blood loss ~ 2000cc, rapid respiration, weak pulse, confused, skin is cold and clammy and pale . What Class of hemorrhagic shock ?

  30. Stage Blood Loss Vasocon-striction Pulse Rate Pulse Pressure/ Strength BP Resp. Rate Resp. Volume 1 <15%       2 15-25%       3 25-35%       4 >35%      Classes of Hemorrhage • Average Blood Volume = 5 L

  31. 65 year old male , restrained driver in MVC, Vitals :BP 90/40, HR 110

  32. A B C D

  33. What is the significance of SvO2?

  34. An SvO2 of 75% is usually quoted as the normal value. A range of 63-77% is acceptable under normal conditions, tissues extract 25% of the oxygen delivered Mixed Venous Oxygen Saturation % - Condition77% - Sepsis, shunting, hypothermia, cell poisoning, wedged catheter 66-77% - Normal range 60% - Cardiac decompensation 55% - Lactic acidosis 32% - Unconsciousness 20% - Permanent cell damage Causes for an increase in SvO2 decreased peripheral oxygen consumption increased peripheral shunting ( e.g sepsis. cyanide toxicity , hypothermia. (the balloon at the end of the pulmonary artery catheter is inflated, the blood distal to the balloon stagnates, absorbs oxygen from the surrounding ventilated alveoli and becomes closer in saturation to arterial blood )

  35. Dietary protein – (UNN + 4gm) 6.25 What equation is this? What does the 6.25 and 4 stand for?

  36. Nitrogen balance grams protein = 6.25(grams N) 4 = factor for skin and GI losses

  37. Copius irrigation and immediate application of 2.5% calcium gluconate gel.

  38. Hydrofluoric acid

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