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significance of lactic acid levels in critical care
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BCPS study guide
Critical care - shock, sedation, respiratory support etc.
| Question | Answer |
|---|---|
| normal MAP | 70-100 mmHg |
| significance of lactic acid levels in critical care | indicates hypoperfusion and the resultant anerobic metabolism. |
| SVR in sepsis vs hypovolemic shock | will be low in sepsis and high in hypovolemic shock (compensatory mechanism) |
| normal pH | 7.4 (7.35-7.45) |
| normal pCO2 | 35-45mmHg |
| normal pO2 | 80-100 mmHg |
| normal HCO3- | 22-26 mEq/L |
| Normal SaO2 | 95-100% |
| metabolic acid base disorders are illustrated by changes in what blood gas measurement | HCO3- |
| respiratory acid base disorders are illustrated by changes in what blood gas measurement | pCO2 - elevated when acidiv, decreased in alkalosis |
| what is the compensatory mechanism for metabolic acid base disorders | respiratory acid base via slowing or increasing respiratory rate to alter pCO2. blow off CO2 to increase pH. or decrease pCO2. alternate is true to decreasing pH |
| how does metabolic acid base compensate for underlying respiratory acid base | in kidneys by regulating excretion and reabsorption of HCO3 or excretion. |
| MUDPILES | causes of anion gap metabolic acidosis: Methanol, Uremia, DKA, Propylene glycol, Intoxication/Infection, Lactic acidosis, Ethylene glycol, Salycilates/Sepsis |
| F-USED CARS | causes of non-anion gap metabolic acidosis: Fistula, Uteroenteric conduits, saline excess, Endocrine, diarrhea, carbonic anhydrase inhibitors, arginine/lysine/chlorine, renal tubular acidosis, spironolactone |
| Hypovolemic shock - first line treatment | fluid resucitation. either blood, colloids or crystalloids. if still hypotensive may need pressor support but this wont work without adequate fluid replacement. |
| protocol to achieve goals in pts with sepsis | fluid resuscitation to achieve HR, MAP and CVP goals. if SvO2 still not at goal may give more fluid. vasopressors to achieve MAP of 65+ if needed. place ART line rather than BP cuff for monitoring. if cardiac dysfunction may need inotropes |
| Options other than phentolamine for extravasation. | nitroglycerin paste Q6H. or SQ terbutaline |
| preferred vasopressors for septic shock | norepi is first line. can add vasopressin to achieve a pressor sparing effect. both are equivalent efficacy. phenylephrine if need BP support or tachyarrhythmias. dopamine no better than norepi and can cause arrhythmias. |
| preferred inotropes for septic shock | milrinone and dobutamine but only if cardiac function is compromised or persistently low CO or MAP after adequate fluid resucitation. |
| monitoring for propofol | triglycerides, BP, calories from IV lipid 10% 1 kcal/ml. S/sx of PRIS |
| What is PRIS? what causes it and what are the symptoms. | Propofol related infusion syndrome. associated with infusion rates of >50mcg/kg/min. results in metabolic acidosis, rhabdomyolysis, hyperkalemia, kidney failure, cardiac arrest, bradycardia |
| What sedatives should you avoid loading doses with | propofol and precedex. Precedex can use load in surgery though. |
| infusion rate for precedex. | 0.2-0.7 mcg/kg/hr but some evidence supports going up to 1.5 |
| what withdrawal symptoms are associated with precedex and when would they be likely to present? | nausea, vomiting, agitation. occur after prolonged use, 1 wk |
| what tools can be used to assess patients for delerium | CAM-ICU and ICDSC |
| drugs associated with delerium | benzos, opioids, anticholinergics |
| drug used to treat delerium | haloperidol - but no evidence to support |
| uses for paralytics in icu | intubated pts with persistent hypoxia despite adequate sedation and analgesia. control intracranial hypertension in pts with neurological injury from TBI |
| risks with paralysis | bed sores and corneal ulcers, critical illness polyneuropathy, masks inadequate sedation and analgesia, masks seizure, inc risk for VTE |
| critical illness polyneuropathy | prolonged muscle weakness or paralysis once paralytic is removed |
| Train of four | a peripheral nerve stimulation tool. an awake and alert pt should have a TOF (4/4) and should get a baseline. |
| electrolyte disorders that potentiate nerve blockers | hypermag, hypo calcemia, hypokalemia |
| electrolyte disorders that antagonize nerve blockers | hypercalcemia, hyperkalemia |
| drugs that potentiate nerve blockers | aminoglycosides, corticosteroids, clinda, tetracyclines, CCBs, Type Ia antiarrhythmics, lasix, Lithium |
| drugs that antagonize nerve blockers | aminophylline and theophylline, CBZ, phenytoin. |
| treatment target for glucose in the ICU | <180 |
| risk factors for stress ulcers that ALONE warranting drug therapy | respiratory failure with mechanical ventilation >48 hours, coagulopathy (plt<50,000; INR>1.5; aPTT>2xcontrol; ) |
| risk factors for stress ulcers that if two+ present warrants drugs | head or spinal cord injury, 35%+ burn, hypoperfusion, acute organ dysfunction, GI bleed in last year, high dose corticosteroid, liver failure with associated coagulopathy, postop transplant, AKI, major surgery, multiple trauma |
| hypertensive urgency - time to controlled blood pressure | decrease BP over days |
| key difference between hypertensive urgency and emergency | end organ damage |
| what are the end organ complications that can occur with hypertensive emergency | encephalopathy, ICH, unstable angina/MI, acute decompensated heart failure, pulmonary edema, aortic dissection, retinopathy/papilledema, decreased urine output or acute renal failure, eclampsia |
| goal BP drop and timing in hypertensive emergency | decrease DBP to 100-110 or decrease MAP by 25% within 30-60 minutes |
| drugs of choice for hypertensive emergency - tailored by disease state | CHF - NTG or ACEi with diuretics; intracranial hemorrhage - labetalol or nicardipine; MI - beta blocker and nitrate; acute renal failure - nicardipine, clevidipine or fenoldopam; ecclampsia - hydralazine, labetalol or nicardipine. |
| warfarin INR goal in patients with PAH for precention of catheter thrombosis and VTE | 1.5-2.5 |
Created by:
mjuhlin
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