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Saturday January 28th

A Practical Introduction to Intensive Care. Saturday January 28th. 2012 . A one day ‘basics’ of intensive care course. A Practical Introduction to Intensive Care ICU Housekeeping. How did your 1 st day on the ICU go?. Where do you start?. Does it matter?. A Practical Solution …

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Saturday January 28th

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  1. A Practical Introduction to Intensive Care SaturdayJanuary 28th 2012 A one day ‘basics’ of intensive care course

  2. A Practical Introduction to Intensive CareICU Housekeeping

  3. How did your 1st day on the ICU go?

  4. Where do you start?

  5. Does it matter?

  6. A Practical Solution … the Handover Sheet

  7. Don’t forget the Diagnosis!

  8. Problem Lists: A Solution

  9. P1: VAP? A1: Start Ceftazidime Airway Breathing (Ventilatory Mode) PaO2:FiO2 Ratio Positive End Expiratory Pressure RR:TV Ratio Peak Airway Pressure Secretions Chest X-Ray Respiratory & Ventilation

  10. P:F Ratios PaO2 10 on 21% ≠ PaO2 10 on FiO2 100% P:F = PaO2 / FiO2

  11. Everything’s fine, doc

  12. Weaning Pressure Sup port Ventilation RR/TV

  13. Rate and Rhythm MAP Inotrope / Vasopressor No. 1 Inotrope / Vasopressor No. 2 Steroids Hb Markers of Perfusion Clinical – Warm Well Perfused Central Venous Oxygen Saturation Lactate Base Deficit Cardiovascular

  14. Cardiovascular Numbers MAP 65 mmHg is OK 0.5 mcg/kg/min (Adr / NAd) is A LOT ScvO2 <70% is TOO LOW Lactate >2 mmol/l is TOO HIGH Base deficit < -2 is TOO MUCH

  15. Steroids in Sepsis Controversial Previously shown to reduce mortality amongst those unable to mount a steroid stress response (Synacthen) CORTICUS study (2008): • No effect on mortality but faster time to resolution of shock (i.e. reduced inotrope/vasopressor duration). • Same for responders and non-responders thus synacthen test no longer indicated

  16. Target Fluid Balance Achieved Fluid Balance Urine Output in 24hrs (= hourly urine output) Oedema Biochemistry Na K Urea Creatinine Magnesium Phosphate Renal

  17. Fluid Balance Colloids for Filling Crystalloids for Maintenance +500ml / day is normal Add if febrile / diarrhoea Subtract if oedema / bad lungs Controversial Crispy or Bloated?

  18. Renal Numbers Normal Mg2+ >0.8 Give 10mmol over 1 hour Normal PO43- > 0.8 <0.5 mmol / kg over 6 hours

  19. Target Nutrition In Achieved Nutrition In Nutrition Out Ulcer prophylaxis BM - Glycaemia Bilirubin GI / Liver

  20. Nutrition Controversial Starvation is bad (eventually) 30ml/kg/day TNIN ≠ ANIN? Metoclopramide

  21. Gastric Protection Controversial Ranitidine / Sucralfate Ventilator Associated Pneumonia

  22. Glycaemic Control NICE-SUGAR (2009) Tight (4.5-6 mmol/L) vs conventional (4.5-10mmol/L) glycaemic control ---------------------------------------------------Increased mortality and hypoglycaemic episodes for tight control. Conventional range recommended

  23. Bilirubin

  24. Haemoglobin Platelets Clotting DVT Prophylaxis Haematology

  25. Blood in Critical Care Controversial TRICC Exceptions

  26. DVT Prophylaxis Don’t forget

  27. Sedation Scores Hypnotic Dose Opiate Dose Sedation Holidays CNS Intact? PNS Intact? Neuro & Sedation

  28. Temperature White Cell Count C-Reactive Protein Organism Site of infection Antibiotic 1 Day Antibiotic 2 Day ║(Lines ) Central Arterial Vascath Micro & Sepsis

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