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ITU and Ward Rounds What am I looking for

ITU and Ward Rounds What am I looking for. Look at the patient DO THEY LOOK WELL ?. ITU. Temperature Blood pressure. Pulse Bleeding Urine output Balance GASES. Temperature. Temp. 37 o C. Time. Gases Not pO 2 or pCO 2. Blood gas slip. Data. Blood gases Electrolytes

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ITU and Ward Rounds What am I looking for

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  1. ITU and Ward RoundsWhat am I looking for

  2. Look at the patient DO THEY LOOK WELL ?

  3. ITU • Temperature • Blood pressure. • Pulse • Bleeding • Urine output • Balance • GASES

  4. Temperature Temp 37oC Time

  5. GasesNot pO2 or pCO2

  6. Blood gas slip

  7. Data • Blood gases • Electrolytes • Haemoglobin • Calculations • Glucose • “Balance”

  8. Glucose metabolism I Glucose Rest of body Muscle Liver Insulin

  9. Glucose metabolism II • Glucose uptake depends on • Serum glucose • Blood flow • Insulin availability • Glucose doesn’t always cause acidosis

  10. Lactic acid I Glucose No oxygen Lactic acid Pyruvate TCA cycle Oxygen ATP Energy

  11. Lactic acid II - Lactic acidosis • Increased production • Tissue Hypoxia • Circulatory shock • Decreased utilisation • Liver failure • Circulatory shock • Acidosis dangerous, Lactate harmless • BE as surrogate marker

  12. Calcium • Total calcium = free Ca2+ and Protein bound Ca2+ • Active form is free Ca2 • Myocardial contraction and vasoconstriction • NOT with radial artery • Calcium chloride and gluconate

  13. Hct and haemoglobin • Bleeding • revealed • concealed • Chest • GIT • Retro peritoneum (IABP, recent angio)

  14. Balance I • Most are 500mL to 2.0 L +Ve by am • Depend on • fluids/loses in theatre • pre op dehydration • An aid to diagnosing internal bleeding and excessive vasodilatation

  15. Balance II • Always think (especially if CVP low) • Cold & 1.5L+Ve > CXR • Warm & 2.0 to 2.5L+Ve > CXR • Intra thoracic bleeding can occur regardless of chest tube drainage

  16. CXR

  17. Acid - Base balance • Metabolic “HCO3/other acid problem” • Produce / loose acid / alkali • Respiratory “CO2” problem • Produce / retain CO2

  18. Base excess (BE)orHow much extra alkali • Meaning • Observation • Treatment

  19. BE I - meaning • Normal ~ 0 • If –Ve acidosis of any cause is present • Circulatory insufficiency • Cardiac • Circulatory volume • Renal failure • Liver failure • Ischaemic limb eg IABP • Ischaemic bowel • Respiratory • If +Ve alkalosis • Chronic hypokalaemia

  20. BE II - observation • A guide that patient is ok • If increasing negative monitor continuously • Can change from hour to hour

  21. BE III - treatment • If BE < -6.0 to –8.0 negatively inotropic • Acknowledge there is a problem, give bicarb, monitor BE frequently to reassess

  22. Blood gases I acid base balance • Uncompensated • No respiratory compensation when fully ventilated • Compensated • Most extreme value is usually primary problem • pO2 “unimportant” • CO2 + H2O > H2CO3 > H+ + HCO3- • Carbon dioxide + water > carbonic acid > acid + bicarbonate

  23. Blood gases II acid base balance Uncompensated

  24. Blood gases III acid base balance Compensated

  25. Anion gap • What you can’t measure • (Na+ + K +) - (Cl - + HCO3 -) • Causes “KUSMAL” • Ketones • Uraemia • Salicylates • Methyl alcohol • Acid poisoning • Lactate

  26. Frequency of blood gases? ½ Hr, 1 Hr, 2 Hr • Recent admission • Unstable • Bleeding • Oliguria/ renal failure • Liver failure • “just unwell” or “just not right” • Previously abnormal result • Change in ventilation • Good lungs 5 minutes poor lungs 20 to 25 minutes

  27. Juniors and Fio2

  28. ABG verses pulse oximetry • CO2 • Carbon monoxide

  29. Calculated verses Measured oxygen • Different types of Haemoglobin • Oxyhaemoglobin • Reduced (Normal, but no oxygen bound) • Carboxyhaemoglobin (CO poisoning) • Methemoglobin • DPG, blood transfusions • Haemoglobinopathies

  30. Ward • Temperature especially valves • Blood Pressure High / low ?medication • Pulse • AF, BETA BLOCKERS, BRADY, PACEMAKER • Weight TAMPONADE, wound healing • Urine output • In / out • Drains <200ml/24hr if nor bubbling

  31. Thank you

  32. Next week30th NovemberITU and Ward, ward roundsLecture Theatre

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