2) Organ Support Flashcards

Question

What would you do if the patient lost cardiac output on being turned into the prone position?

Answer 1

Recognise, declare cardiac arrest, call for help Commence CPR - Mid-thoracic level between scapulae, effective if good EtCO2 and arterial trace Place defib pads biaxillary or over left mid-axillary line and right scapula Check for equipment malfunction or disconnection If ineffective turn patient supine

Answer 2

Bleeding - platelet consumption by device Tamponade RV failure Fluid overload Vasoplegia - SIRS or phospodiesterase inhibitor induced Haemodynamic instability - septum deviation with underfilled ventricles GI/ Liver dysfunction Infection

Answer 3

Intrinsic: Idiopathic, Ischaemia, Cardiomyopathy, Genetic, Infiltrative (sarcoid, amyloid, haemochromatosis), Collagen/ Vascular (RA, Scleroderma, SLE, Storage diseases, Neuromuscular), Infection (Lyme, Toxoplasmosis), Congential heart disease, Surgery (CABG, transplant, valves etc) Extrinsic: Physical training, Vagal reflex, drug effects, electrolyte disturbances, hypothyroid, anorexia, hypoxia, acidosis, cushings reflex, OSA Reversible: Ischaemia, Infection, Post-op, electrolytes, drugs

Answer 4

Prevention is ideal (minimise NMB, avoid benzos) Rehab should start ASAP on the ICU Short risk assessment as soon as able, followed by more comprehensive risk assessment in those at risk. Rehab goals should be set and reviewed. Many tools exist to assess patients' physical and non-physical status. E.g. Post-ICU Presentation Screen (PICUPS), domains include medical stability, basic care and safety, cough/ secretions, transfers, communication, mental health and family distress. A rehab prescription is then completed. Further assessment and management can also be coordinated through attendance at a follow-up clinic once discharged from critical care.

Answer 5

Difficult and prolonged weaning account for 20% of patients on adult ICU Associated with increased LOS, VAP, ICU weakness and mortality Failure to extubate can be due to various causes, reintubation rate is 10-15% Causes of failure to wean: Unresolved airway problem Increased work of breathing - Bad ventilator settings, excessive secretions, pulmonary oedema, poor compliance etc Increased cardiac work - High metabolic demand, unresolved cardiac failure, flluid overload, anaemia Poor neuro status Other issues - Burns/ DKA/ Acidaemia etc

Answer 6

Normothermia, aim central temp of 36-37 Therapeutic hypothermia used occasionally but largely fallen out of favour

Answer 7

Drop and Stretch Reduce FiO2 Reduce Phigh by 2 every 2-6 hours Once Phigh is 20, increase Thigh by 1-2s every time Phigh reduced This will leave you on CPAP

Answer 8

Used to substitute kidney function in acute and chronic disease. It can provide solute/water removal, electrolyte correction and acid-base correction Classified as follows: Short/ Long term Continuous/ Intermittent Vascular/ Peritoneal Modalities: Peritoneal dialysis Intermittent haemodialysis CVVH - Continuous veno-venous haemofiltration CVVHDF - Continuous veno-venous haemodiafiltration CVVHD - Continuous veno-venous haemodialysis SCUF - Slow continuous ultrafiltration SLEDD - Slow low-efficiency daily dialysis

Answer 9

Could be withdrawing from alcohol, benzos, opioids soon after admission to the ICU. This may be easier to anticipate and appropriate withdrawal regimes may be tailored with the assistance of pharmacy/ substance misuse liaison services. Iatrogenic withdrawal symptoms post cessation of sedation will tend to be Opioid/ Benzos. Opioid - Characterised by adrenergic excitation and exaggerated nociception, Prevent by titrating analgesia/ perform sedation holds, can use Clonidine to blunt symptoms, wean slowly Benzos - Acute withdrawal can last 1-2 weeks, presents with psychiatric sypmtoms, paraesthesia, tremors, seizures, ataxia. Wean slowly, lorazepam is better than diazepam as it accumulates less

Answer 10

Stress-related mucosal injury can be caused by critical illness and may increase morbidity. Its incidence has declined with effective prophylaxis. Pathophysiology is unclear but contributing factors may include hypoxia, hypoperfusion and coagulopathy. Initial erosions may progress to deeper ulcers which may haemorrhage or cause GI perforation

Answer 11

NAVA = Neurally assisted ventilatory assist. It is a form of proportional assist ventilation. It utilises electronic activity from the diaphragm which is monitored using a specialised NG tube. Support is based on lung dynamics and patient effort.

Answer 12

Increased: Burns, CRRT, open abdomen, trauma, nec. fasc., BMI >30 Decreased: Hepatic Encephalopathy

Answer 13

Adults requiring critical care for more than 4 days with risk of morbidity should be followed up face-to-face 2-3 months post-discharge from critical care. The purpose of the review includes: Assessment of new physical or non-physical issues Assessment of rate of recovery as per goals Assessment of social care or equipment needs Arranging of support as needed All patients should be able to self refer for reassessment at any time

Answer 14

EN delivered past the pylorus i.e. via NJ tube. Reduces risk of aspiration, however more complex to than NG insertion. No evidence to suggest it is superior to NG.

Answer 15

Chatter is rapid movement of the drainage line in response to venous drainage occlusion. The pump will be unable to spin at the desired rate and flows will decrease. Chattering also causes haemolysis. Contributing factors include inadequate circulating volume, patient position, cannula position, kinked tubing and thrombosis.

Answer 16

Sedation is indicated in specific circumstances and should be individualised. Assess for analgesia before increasing sedation. Specific: Facilitate tracheal intubation Obtund laryngeal reflexes and maintain tracheal intubation Increase tolerance of invasive procedures Facilitate ventilator synchrony Reduce O2 demand and prevent secondary injury (TBI, Seizures, Serotonin syndrome, MH, Severe metabolic disturbances) Withdrawal from sedative agents Severe hyperactive delirium

Answer 17

Surgically implanted mechanical system that provides flow in order to maintain cardiac output whilst reducing work of the heart LVAD, RVAD, BiVAD, TAH (totally artificial heart), Minimally invasive catheter based assist devices (Impella) Devices range from short term to large external circuits to compact wearable consoles for longer term therapy

Answer 18

Cannula related Bio incompatibility - inflammatory response, prolonged AKI Fluid shifts - hypovolaemia, instability Altered drug metabolism Anticoag - HIT, Lactic acidosis Loss of circulating blood volume, anaemia Failure to meet RRT (filter down time) Increased nursing workload

Answer 19

Electrical impulse to the myocardium to achieve a wave of depolarisation. If successful this is termed electrical capture. If this causes contraction of appropriate chambers of the heart, this is mechanical capture. Requires intact myocardium and electrical/ conducting tissues. Therefore can be unsuccessful.

Answer 20

Troubleshooting on ECMO will involve complex diagnosis and may trace back to problems with the circuit, monitoring, or patient. Technical complications should be ruled out and addressed if found. Hypercarbia should prompt consideration of increased metabolic state in the patient or may be the first presentation of sepsis/ other pathology. The sweep gas flow rate can be increased to further remove CO2

Answer 21

HFOV is a mode that achieve alveolar ventilation using low Vt at below dead space volumes (1-2ml/kg) and supra-normal frequencies 3-15/s The inspiratory limb is connected to an electromagnetic piston that moves a flexible diaphragm to create pressure oscillation. Settings: Mean airway pressure (mPaw), deltaP (power), %ti and f (frequency) EtCO2 cannot be monitored, 'Wobble' describes how far oscillations propagate i.e. to mid thigh Oxygenation is controlled by mPaw, CO2 controlled by deltaP, %ti and 1/f Physiological principles: Bulk convection - gas entrained when vacuum left in alveoli as oxygen absorbed into capillaries Pendelluft - gas exchanged between lung units with different time constants Taylor dispersion - gas exchanged between central column and peripheral airways Coaxial flow - bidirectional flow, central rapid inspiratory column and outer slow expiratory sleeve Augmented molecular diffusion - force of oscillation pushes molecules to enhance Brownian motion Not a recommended mode post OSCILLATE and OSCAR, potential harms are barotrauma/ hypotension/ oxygenation failure

Answer 22

OSCILLATE 2013: New onset moderate-severe ARDS Intervention = HFOV vs Conventional PCV Primary = In-hospital mortality - significantly higher, trial stopped earlier (may overestimate harm as p value not reached) Secondary = refractory hypoxaemia lower HFOV patients received more NMB, midazolam and vasoactive drugs OSCAR 2013 ARDS Intervention = HFOV vs Local practice Primary = 30 day mortality - no difference Secondary = Oxygenation improved

Answer 23

ROSE R - Resuscitation: patient rescue, early adequate fluid management, life-saving (boluses) O - Optimisation: organ rescue, avoiding fluid overload or creep S - Stabilisation: organ support (homeostasis), late conservative fluid management E - Evacuation: organ recovery, resolving fluid overload, active late goal directed fluid removal

Answer 24

Subject of research scandal. Numerous studies withdrawn on the use of HES after the author found guilty of research misconduct. Subsequent RCTs examining HES suggest they cause significant harm including increase need for RRT and mortality. CHEST 2012: Critically ill patients requiring fluid resus HES vs NaCl Found renal failure significantly higher with HES, no difference in mortality 6S 2012: Critically ill adults with severe sepsis HES vs Ringers Death/ Dialysis dependence at 90 days - sig. higher. RRT use sig. higher

Answer 25

Cranial bolt/ fibre-optic device: Transduction of sensed pressures, placed ipsilaterally to maximal pathology to optimise tissue physiology in at-risk areas and should not be placed in lesion. External ventricular device: Intraventricular catheter connected to an external pressure transducer via fluid-filled tubing Optic nerve sheath diameter (ONSD): US used to measure the optic nerve diameter 3mm posterior to the globe ONSD >5-6mm is associated with ICP >20mmHg Pupillometry: Measures reactivity and calculated the Neurologic Pupil Index (NPi) NPi <3 associated with ICP >20mmgHg

Answer 26

Sum of internal heat produced and external work. Critical illness is associated with increased catabolism and a significant energy deficit. In theory calculating the EE is essential to minimise this deficit. The TICACOS trial examined this but it was limited by design: TICACOS 2011: Critically ill patients Resting EE used to determine energy goal vs weight-based goal Primary - hospital mortality - no difference Measurements/ estimations: Indirect calorimetry using VO2 and VCO2 - difficult to achieve in clinical practice Derived values - VCO2 from vent, VO2 from pulmonary artery catheter - EE = 8.2 x VCO2 Feeding equations - e.g. Harris-Benedict Calculations on IBW - Simplest and easiest to use

Answer 27

May be acute (vascath) or long-standing (fistula) Successful RRT needs adequate flow so location and position is important. KDIGO recommends (in order of site preference): Right IJV 15cm Femoral vein 25cm Left IJV 20cm Dominant hand SCV Non-dominant hand SCV

Answer 28

Cerebral microdialysis is a form of cerebral metabolism monitoring. A catheter containing a semi-permeable membrane is placed into the white matter. It is constantly perfused with microdialysate. Small molecules are able to diffuse. Measured substrates: Glucose - Low glucose is associated with poor outcome, Reduced in hypoxaemia/ischaemia, reduced cerebral glucose supply and cerebral hyperglycolysis Lactate & Pyruvate - Lactate to pyruvate ratio (LPR) >25 is associated with metabolic distress Glutamate - Excitatory neurotransmitter associated with neuro-injury and neuro-inflammatory response cascade Glycerol - Lipid-rich component of neurones and marker of neurological breakdown and cell death

Answer 29

Refers to a variety of non-invasive and invasive techniques used to observe neurophysiological and systemic parameters. These should be used in conjunction with clinical examination and traditional haemodynamic monitoring to guide treatment before irreversible damage has occurred. Focuses on the following domains: Clinical Neurological Examination ICP and CPP Cerebral blood flow Cerebral oxygenation Cerebral metabolism Electrophysiological activity

Answer 30

Airway Support - Impaired airway reflexes and risk of aspiration, Airway patency threatened Respiratory Support - Need for increased oxygen delivery, guarantees high FiO2 delivery and helps with recruitment of alveoli thus improving oxygenation Ventilatory Support - Regulation of ventilation to control PaCO2 or to support deep sedations (i.e. need to reduce oxygen demand, peri-procedural, imaging)

Answer 31

Hypnotics - Propofol, Ketamine, Thiopentone, etomidate Opioids Benzos Alpha agonsits - Clonidine, Dexmedetomidine Neuroleptics - Haloperidol, Olanzapine Volatile anaesthetics - Sevo/ Isoflurane Other - Chlroral hydrate in kids

Answer 32

Its complicated Key principles: Low protein binding - More readily removed by RRT High volume of distribution - lower clearance by RRT Example of adaptations: Vancomycin - Infusion due to narrow therapeutic index Antifungals - greater clearance so increased dosing Beta-Lactams - more frequently/ normal dosing

Answer 33

Medical nutrition therapy comprises oral supplements, enteral nutrition and parenteral nutrition. Considered for patients who have: Increased risk of malnutrition Little/no diet for 5 days, likely to continue for another 5 days Poor absorptive capacity High nutritional loss High nutritional demand

Answer 34

Ideally should go to VAD centre, this will depend on pre-hospital networks. Contact a VAD centre for advice. Ask patient/ family as they are likely to be very knowledgeable about their device. Information may also be located on an ID card/ bracelet/ in the controller bag/ on the controller or in an emergency bag with the patient. Key differences in resuscitation: LVAD Failure: Check for signs of life with responsiveness and breathing (Pulseless) If no signs of life, auscultate the heart for humming sound If no humming sound or loud alarm from device: LVAD failure Ventilate but do not start chest compressions Try to restart LVAD Expose components to ensure connections attached Ensure power source working and secure Replace controller if unsccessful in restarting LVAD Consider cable fracture - try manipulating driveline and taping if successful Ventricular arrhythmias - Defib/ cardioversion as indicated and consider CPR if fails Hypovolaemia likely to cause failure - replace it

Answer 35

Involves delivery of stimuli at high frequencies to convert a tachyarrhythmia to sinus rhythm. Can be uses acutely or for prevention. Risk of VT/ VF if done. Indications: Diagnostic - VT or SVT Recurrent arrhythmia Failure of drug therapy Contraindication of cardioversion

Answer 36

ESPEN recommends clinical assessment over scoring systems due to lack of validity or demonstration of improvement in mortality All patients admitted to the ICU > 48 hrs should be considered at high risk of malnutrition Hx - Pre-ICU weight loss, pre-ICU decline in physical performance Exam - Muscle mass, body composition, strength

Answer 37

The ALBIOS study showed no difference in mortality with albumin supplementation to maintain a normal serum concentration in the context of sepsis. Most clinicians would not aim to correct hypoalbuminamia to a target threshold in critical care. ALBIOS 2014: Adults with severe septic shock HAS and crystalloid to target albumin above 30 vs crystalloid alone No differences in mortality Under-powered study

Answer 38

MUST - Malnutrition universal screening tool BMI Note % unplanned weight loss Establish acute disease effect and score Add scores from above to obtain overall risk Apply guidelines to develop care plan Score of 0 = low risk, 1 = medium risk, >2 = high risk Other scores - Nutrition risk in critically ill, Nutrition risk screening

Answer 39

Summary of stay including diagnosis and management Monitoring and investigation plan Plan for ongoing treatment Individualised structure rehab plan Specific communication needs

Answer 40

Improved VQ matching More homogenous ventilation of dorsal and ventral lung units Less lung deformation - heart no longer compressing lungs Increased FRC Improved drainage of respiratory secretions Improved response to recruitment manourvres Improved chest wall mechanics in fat people

Answer 41

ECMO is a form of extracorporeal life support in which a modified heart-lung machine provides respiratory or circulatory (or both) support for refractory hypoxaemia. Types of ECLS: VV ECMO, VA ECMO, AV ECMO (rarely used), Extracorporeal CO2 removal (ECCO2R), Cardiopulmonary Bypass, VAD with oxygenator Introduced in the 1970s, became popular during the H1N1 pandemic of 2009. ECMO is not a benign process and patients need significant physiological reserves to withstand the demans and sequelae of an ECMO admission. In the UK, VV ECMO is provided by a network of tertiary centres. VA ECMO is not commissioned but is used in selective cases.

Answer 42

Improved patient comfort Reduced need for sedation Reduced pressure on tongue, mouth, oral structures Improved mouth care Ability for vocal cords to move (phonation and reduced aspiration) Improved ability to swallow Reduced nursing dependency

Answer 43

LVAD Failure Ventricular arrhythmias Hypovolaemia Pump thrombosis Embolic stroke Anticoag related Can also be unrelated to VAD

Answer 44

Decreased CMR Decreased cerebral oxygen demand Decreased production of neurotransmitters (e.g. glutamate) Reduced free radical exposure/ oxidative stress from reperfusion injury

Answer 45

Energy - 25-35 kcal/kg Carbs - 2g/kg Protein - 0.8-1.5 g/kg Lipid - 1-1.5 g/kg Water - 30ml/kg Consider single high dose Vit D if low after 1 week of admission

Answer 46

General: Age >65 with biventricular failure B - Severe dysfunction, fixed pulmonary hypertension C - Severe valvular lesions D - Recent stroke, severe psychological disease E - AAA, metastatic cancer, long term RRT, Cirrhosis, Faaat, unable to be anticoagulated, immunodeficiency

Answer 47

Indications: Critical care - Moderate to Severe ARDS (FiO2 >0.6, P/F <20), Early in disease (<48 hrs and after 12-24 hrs of optimisation of ventilator settings). Supported by PROSEVA trial Surgery - For surgical access Contraindications: Absolute - Open chest, <24 hrs post-cardiac surgery, Central cannulation for BiVAD/ ECMO, Spinal instability Relative - Previous poor tolerance of proning, recent tracheostomy, refractory CVS instability, raised ICP/ occular pressures, frequent seizures, facial fractures, significant trauma, pregnancy, morbid obesity

Answer 48

Difficult of weaning is described in terms of time to extubation: Simple - Liberation from ventilator on first attempt (70%) Difficult - Extubation 2-7 days after initial assessment of readiness for extubation Prolonged - >7 days after initial assessment

Answer 49

Citrate overload - Occurs when the quantity of citrate exceeds the body's alkalotic requirements, resulting in metabolic alkalosis (due to raised sodium availability). This is not dangerous and is easily managed. Citrate toxicity - Occurs when body cannot metabolise CCCs and acidic citrate impacts on the metabolism. Causes raised gap metabolic acidosis, hypokalaemia and hypomagnesaemia. Hypocalcaemia results from decreased systemic ionised calcium. Suspect toxicity if: Post-filter calcium substitution requirement continuing to rise, Total:Ionised Ca ration >2.5, HAGMA Management - Reduce/ Stop citrate, optimise hepatic clearance (improve cardiac output), treat hypocalcaemia.

Answer 50

Bilirubin Bile acids Prostacylcins Nitric oxide Fatty acids Ammonia Lactate

Answer 51

Goals can be subdivided into short, medium and long term May change throughout recovery process Must be achievable Regular assessment required throughout recovery MDT input essential

Answer 52

Acute, severe, potentially reversible respiratory failure. Inclusion criteria: Potentially reversible severe respiratory failure Murray Lung score of 3 or more Uncompensated hypercapnia with a pH <7.2 (despite RR >35 or due to life threatening airway disease) Additional considerations: Failed trial of ventilation in prone position for >6 hours unless contraindicated Failed optimal respiratory management with lung-protective ventilation after discussion with national centre Exclusion criteria: Refractory or established multi-organ failure Evidence of severe neurological injury Prolonged (>15 min) cardiac arrest 2 ECMO centres must agree if there is indication of low potential to recover (RESP score 3 or less) or invasive mechanical ventilation has been received for >7 days

Answer 53

Medications used to get gastric pH >3.5. This reduces incidence of stress ulceration but no mortality benefit has been shown. PPI - 1st line H2 antagonist - 2nd line Sucralfate - not widely used due to difficult in administration of sticky compound Antacids Pharmacological prophylaxis is recommended in those in the 'Highest' and 'High' risk groups

Answer 54

Inflow cannula to the pump Outflow cannula Pump Electrical controller/ console Driveline (Cable connecting device to controller) Power supply

Answer 55

Pressure control ventilation: Operator sets Pinsp, PEEP and inspiratory time Vt is dependent on compliance and Pinsp Pressure rapidly delivered and held at constant level leading to square wave pattern Flow delivered in decelerating pattern Allows time for gas to equilibrate between fast and slow recruiting alveoli Pressure rapidly released in expiration (elastic recoil of lung allows expiration against PEEP) Volume control ventilation: Operator sets Vt, PEEP, RR, Flow pattern (Constant/ decelerating) Constant inspiratory flow - gradual rise in Pinsp Decelerating flow - longer inspiratory time may be used, improvement in alveolar time constants Pressure support: Operator sets Pinsp, PEEP and expiratory flow trigger Commonly used to aid weaning

Answer 56

Efficacy of anticoagulation - Post filter ionised calcium - aim - 0.2-0.35 Adequacy of calcium replacement - Systemic ionised caclium - aim - 1.1-1.2 Avoidance of citrate accumulation - Total/ (Patient) ionised calcium ration - aim - <2.5

Answer 57

Staff injury Instability - Airway displacement, haemodynamic instability, increased abdominal pressures, line issues, reflux & aspiration, brief period without monitoring Patient injury - Pressure sores, periorbital oedema & chemosis, ocular injury, brachial plexus injury, other nerve injuries

Answer 58

Physical: Longer LOS Sig. physical or neurological injury Inability to ventilate on FiO2 <0.35 Premorbid respiratory or mobility issues Risk/ presentation of nutritional issues Inability to mobilise independently over short distances/ out of bed Non-Physical: Recurrent nightmares Intrusive memories Acute stress reactions Hallucinations/ delusions Expressing wish not to discuss illness Lack of cognitive function

Answer 59

SLEDD employs features of intermittent haemodialysis and CRRT. It utilises slow dialysis to remove solutes and ultrafiltration to remove fluid Key advantage is that it is relatively cheap. It takes 6-12 hours daily and is most often done overnight allowing patient to be active and mobile during the day. It requires no anticoagulation or frequent handling of biohazardous effluent bags. The slower solute removal avoids solute disequilibrium that can be seen in IRRT.

Answer 60

Output failure Failure to capture Undersensing Oversensing Cross-talk Endless loop tachycardia

Answer 61

Scoring systems such as RASS: 1 to 4 increasingly agitated/ restless 0 - Alert and calm -1 to -5 increasingly unresponsive

Answer 62

First exclude common patient causes - Sepsis, then address equipement Increase blood flow, Reduced pre-dilution, Improve vascular access, Increase effluent dose, Minimise interruptions

Answer 63

CRRT needs prescription of the following: RRT dose - effluent rate suggested = 25-30 ml/kg/hr Fluid removal Target 24 hr fluid balance Replacement fluid Potassium supplementation Anticoagulation ATN 2008/ RENAL 2009/ IVOIRE 2013 - All 3 studies looked at various high vs low doses of RRT, no significant differences to lower/ normal doses

Answer 64

Trophic feeding is the minimal administration of nutrients via EN, typically between 10-20 ml/hr of feed. It is used to preserve gut integrity rather than provide nutrition Benefits - Preserves intestinal epithelium, Stimulates secretion of brush border enzymes, enhances immune function, preserves epithelial tight cell junctions, prevents bacterial translocation Hypocaloric or permissive underfeeding is the deliberate energy administration below 70% of target. Caloric amount will be lower, lipid/ protein targets may be the same as expected. PermiT study showed it amde no difference to mortality vs standard feeding

Answer 65

Resuscitation - rapidly restoring circulating volume Replacement - mimic fluid being lost Maintenance - deliver basic electrolytes & glucose for metabolism

Answer 66

Ventilator cycling can depend on the trigger to deliver a breath as well as how inspiration and expiriation are defined Things that can determine ventilatory cycling: Time - Inspiration and expiration determined by time, RR = 60/ freq, This results in less patient interaction with the ventilator, used in mandatory modes Flow - Inspiration and expiration commenced after sensing change in circuit flow, flow changes as patients attempt to breath Pressure - Changes in pressure in ventilator circuit sensed (pressure decrease triggers inspiratory cycle)

Answer 67

Pacemaker response is inhibited by spontaneous ventricular activity.

Answer 68

Involves cooling a patient to subnormal temperatures for specific indications (usually to prevent brain injury). Now limited to very specific circumstances as it is not without complication. Indication: Neuroprotection in neonatal hypoxic ischaemic brain injury Deep hypothermic circulatory arrest to facilitate neuroprotection in aortic surgery Previous used in TBI and post ROSC

Answer 69

Pros: Avoidance of systemic anticoagulation Safe in HIT Prolongs circuit lifespan Well-established practice Clear safety protocols Cons: Risk of citrate overload/ toxicity Electrolyte imbalance (low Ca/ Mg, high Na)

Answer 70

Optimisation of fluid status and electrolytes Judicious use of vasopressors Enteral feeding Pharmacological prophylaxis

Answer 71

Extracorporeal carbon dioxide removal (ECCO2R) is a low flow technique that selectively removes CO2 and is indicated in ARDS. It may be carried out through an ECMO circuit, stand alone device or adaptation of an existing circuit (haemofilter) Currently it is being evaluated for ARDS, COPD and as a bridge to lung transplant. 2 recent studies: SUPERNOVA (2019): ARDS Evaluation of 3 different ECCO2R systems Primary: Patients achieving Vt 4ml/kg with PaCO2 <20% baseline an pH >7.3 Results: 78% at 8hrs and 82% at 24hrs Adverse events: 39% of cases, 14% membrane clots, 13% thrombocytopaenia, 12% haemolysis etc. 6 severe events (Massive ICH, SVC thrombus, Death, PTX, Severe hypoxia, haematemesis) REST (2021): Acute hypoxaemic respiratory failure Intervention: ECCO2R vs mechanical ventilation Primary: 90 day all cause mortality - no difference Secondary: 28 day mortality/ ICU or Hospital LOS - No difference. Ventilator free days - Lower.

Answer 72

BMR is the amount of energy expended per unit time during periods of rest. Normal BMR is around 40 cal/m2/h. Hypothalamus has the greatest influence on BMR as it regulates adrenal and thyroid function

Answer 73

We can support failing kidneys in solute and fluid removal. However RRT cannot replace the cardiovascular or endocrine functions of the kidney.

Answer 74

Hepatocytes (human or porcine) are incorporated into plasmapheresis or other extracorporeal systems

Answer 75

May be useful for patients with severe bronchospasm due to bronchodilating properties or in patients who are difficult to sedate on multiple infusions (Paeds) Sevo or Iso can be administered through a dedicated anaestehtic machine on the critical care unit or through a stand alone device incorporated into the ventilator circuit (AnaConDa). The desired MAC is targeted and measured through a gas sampling line in both contexts. Methoxyflurane (penthrox) can be used pre-hospitally/ in ED. Difficulty can arise if there is limited diffusion across membranes (excessive secretions). Knowledge of contraindications such as MH susceptibility/ planes of anaesthesia is essential for safe use.

Answer 76

Citrate - First lane Heparin - Second line Prstacyclin Argatroban Danaparoid

Answer 77

Gastric fundus most commonly affected compared to gastric antrum/ duodenum in peptic disease. Presentation is often painless.

Answer 78

General: Minimise time on RRT Haemodialysis requires less anticoagulation than filtration Trial of no anticoagulation Optimisation of circuit lifespan: Access: Optimise for good flow Choice of anticoag: Longer lifespan with citrate Equipment - Prompt response to filter alarms, reduce blood-air contact in bubble trap, minimise interruptions, built in safety devices Viscosity - maintain filtration fraction <25% (using pre-dilution and high blood flow rate), diffusion better than filtration, regular rinsing of membrane with saline flushes

Answer 79

PICS was brought to the forefront during the Covid-19 pandemic as reporting of long term morbidity increased. Respiratory - Laryngeal injuries, stenosis, pulmonary deconditioning/ fibrosis/ embolism/ hypertension, PTX, prolonged wean, long term trachy Renal - AKI with ongoing RRT need Neuro - Seizures, disordered consciousnesses, hypoxic brain injury, focal deficit, sleep disordered breathing, cognitive deficit CVS - LV/ RV dysfunction Nutritional - Anosmia, appetite loss, dysphagia, altered bowel habit Physical - ICUAW, positioning injuries, pressure sores, joint stiffness, incontinence, sexual dysfunction Communication difficulties - weakness and intubation related pathology Psychosocial - 50% suffer sig. symptoms during stay and 50% of all patients have anxiety/ depression/ PTSD post-discharge Fatigue/ chronic pain in 70% of survivors

Answer 80

Oversedation: Increased ventilator days Increased ICU LOS Delirium Masking of significant haemodynamic responses Undersedation: Hypercatabolism Immunosuppression Hypercoagulability Increased sympathetic activity Risk of patient self harm

Answer 81

Brain parenchymal oxygen tension (PbtO2): Provides a regional measurement of the balance between oxygen supply and demand via a bolt Normal = 23-35 mmHg, <20 may indicate ischaemic secondary injury Near-infrared spectroscopy (NIRS): Measures regional cerebral o2 saturation A near-infrared light source and receiver is placed with the amount of light attenuation between the 2 measured Light spectra absorption between oxyhaem and deoxyhaem compared Jugular bulb venous oxygen saturation (SjvO2): Fibre-optic catheter is placed in the IJV ipsilateral to the injury and advanced superiorly to the jugular bulb SjvO2 provides a global measure of the balance between oxygen supply and demand Normal = 55-75% <55% - may indicate poor O2 supply or increased O2 demand and may indicate ischaemia >75% - may indicate increased O2 supply or poor O2 demand and may indicate hyperaemia or cell death

Answer 82

Dilutional coagulopathy (Fibrinogen monitoring needed) Drug dose alteration - especially if albumin bound or continuous infusion Recirculation Bradykinin-induced histamine release Hypovolaemia Allergy to replacement fluid Access related Anticoagulation related

Answer 83

Anticoagulation Cannulation Volume shifts Electrolyte derangements Trajectory of disease and perceived benefits

Answer 84

Used to screen readiness to wean Can be paired with sedation hold 30 min trial on T-piece or minimal CPAP +/- pressure support Assessment of success or failure If well tolerated consider extubation +/- NIV Failure: B - RR >35, Sats <90 or high wob/ minimal effort C - HR >140, Hyper/Hypotensive, Sweating D - Agitation/ anxiety

Answer 85

Should be checked every day/ shift, providing the patient is not unstable due to another reason. 1 - Underlying rhythm - reduce rate and allow native rhythm to appear (better than reducing energy and risking loss of capture) 2 - Sensitivity (Minimum current that the pacemaker can sense, a low number corresponds with greater sensitivity) - Should be around half the pacing threshold (the sensitivity at which the sense indicator flashes during each endogenous depolarisation when tested) 3 - Capture threshold (Minimum output needed to stimulate an action potential in the myocardium) - Don't check if no underlying rhythm, output should be twice the capture threshold 4 - Rate - should be around 80-90

Answer 86

Clinical assessment: Underlying condition resolved Patient condition optimised A - Satisfactory reflexes, secretions not problematic, cuff leak present B - Spontaneous breathing, strength adequate, FiO2 <0.4, minimal PEEP C - CVS stable on minimal vasoactive drugs D - Obeying commands Objective measures: RR <30, Vt >5ml/kg Rapid shallow breathing index (f/ Vt in litres) = <105 P0.1/ PImax of >0.3 - this ratio correlates to central respiratory drive

Answer 87

If caloric requirements are not met within 48-72 hrs, suplementation/ replacement with PN should be considered. Late initiation of PN has been associated with improved survival, shorter duration of ventilation and lower requirement for RRT. EPaNIC 2011: Critically ill adults Late PN (D8) vs Early PN (D3) Primary - ICU LOS sig. lower, discharge alive from ICU sig. higher, mortality no difference, hypoglycaemia sig. higher Secondary - New infection, Duration of ventilation, duration of RRT, hospital LOS and health care cost sig. lower, functional status on discharge no difference

Answer 88

RESP score - Respiratory ECMO Survival Prediction: Patient characteristics: Age, Immunocompromise, History of CNS dysfunction, Acute associated non-pulmonary infection Acute respiratory diagnosis group: Viral Pneumonia, Bacterial Pneumonia, Asthma, Trauma/ Burn, Aspiration pneumonitis, Other acute respiratory diagnosis, Non-respiratory and chronic respiratory diagnosis Status/ Management prior to ECMO: Duration of ventilation, NMB, iNO, Bicarbonate infusion, Cardiac arrest, PaCO2 >10, PIP >42 Risk class determined from score of -22 to 15 Risk classes 1-5 with survival decreasing as class increases

Answer 89

Utilisation of prone position in coscious patients with respiratory failure in order to improve oxygenation. Increased use during Covid Pandemic. ICS recommends its use if requiring FiO2 >28% or basic respiratory support if patient can communicate/ cooperate/ adjust their own position, without airway concerns. Contraindications - Respiratory distress, need for intubation, CVS instability, altered mental status, spinal injury, abdo surgery recently Stop proning if no improvement after 15min or deterioration

Answer 90

Acute liver failure: Severe alcoholic steatohepatitis Primary graft dysfunction following liver transplant Posthepatectomy liver failure Intrahepatic cholestasis with intractable pruritus Overdose/ intoxication with protein bound substance Progressive intrahepatic cholestasis associated with HF/ graft vs host disease Acute-on-chronic liver failure: Progessive jaundice Hepatic encephalopathy (grade 3-4) Renal dysfunction Combination of above

Answer 91

Transcranial Doppler: US of intracranial arteries to evaluate CBF velocities - can help to identify emboli, stenosis or vasospasm in SAH Pulsatile index is associated with elevated ICP Parenchymal thermal diffusion flowmetry: Probe with 2 thermistors set at different temps, rate of temp dissipation is calculated to estimate blood flow Transcranial colour coded duplex sonography Laser doppler flowmetry

Answer 92

Suxamethonium: Hyperkalaemia risk in burns >24 hrs and spinal cord injury >72 hrs (extrajunctional ACh receptor development) Muscle fasciculations may be undesirable (Rhabdo) Contraindicated in MH susceptibility Contraindicated in GBS (up-regulated ACh receptors so risk of severe hyperkalaemia) Relative resistance in MG Rocuronium: Highest risk of anaphylaxis Prolonged duration of action in hepatic and renal failure May be ineffective if sugammadex used Atracurium - Bronchospasm due to histamine release Cisatracurium - Most haemodynamically stable but expensive

Answer 93

Positive end-expiratory pressure - Pressure present in the airway that exists at the end of expiration It is used to improve alveolar recruitment and therefore oxygenation. It also reduces the work of breathing by preventing airway collapse at the end of expiration (reduces work of re-opening during inspiration)

Answer 94

Airway pressure release ventilation is an open-lung mode of ventilation. It is indicated in patients who are felt to have a recruitable lung disease and have shown a poor response to conventional ventilator modes. The patient is encouraged to breath spontaneously over time-cycling alternation in pressure. High pressure (Phigh) is maintained for a longer time (Thigh) through an inverse ratio, only allowing a short time (Tlow) at low pressure (Plow) for CO2 clearance. Pros - Promotion of alveolar recruitment, improvement in lung homogeneity, Increased FRC, Reduction in cyclical opening/ closing of lung units (atelectotrauma) Cons - Potential to aggravate lung injury (High local transpulmonary pressures, Potential for RV dysfunction, tachypnoea can causes patient self-inflicted lung injury), May not be useful if patient is paralysed by NMB Initial settings - Phigh = current PPlat, Plow = 0, Thigh = 5s, Tlow = 0.5s. Reduced Tlow until expiratory flow terminates at 75% peak expiratory flow.

Answer 95

Risk of prophylaxis may outweigh benefit in lower risk groups. Pharmacological prophylaxis can increase risk of bacterial overgrowth and thus increase the risk of HAP SUP-ICU 2018: ICU patients at risk of GI bleeding Pantoprazole vs Placebo Primary - Mortality - no difference Secondary - Sig. Lower rate of clinically important GI bleeding

Answer 96

Timing is multifactorial TracMan study showed no significant difference in 30 day mortality in early vs late trachy, early trachy patients had more tracheostomies than late trachy group. Secondary endpoint showed my reduce amount of sedation to do early

Answer 97

Sickle cell - acute chest syndrome, acute stroke, severe sepsis Severe malaria Polycythaemia rubra vera Hereditary haemochromatosis

Answer 98

Cannulation: Haemorrhage Failure - vessels may be inadequate Death Damage to local structures Lower limb ischaemia Stroke General: Bleeding Death Line infection Circuit colonisation Thrombus Haemolysis Pain Progression of underlying disease Medication under/over-dosing Sequelae of lengthy ICU stay Circuit failure: Oxygenator thrombosis Recirculation Pump failure Gas embolism Unintentional decannulation Hypothermia Interventions: Reconfiguration - Instability, cannulation related Circuit change-out - gas embolism, instability Proning - Chemosis, GI reflux, decannulation High-dose sedatives - withdrawl Anticoagulation - HIT Sequelae of repeated transfusions Transfer - decannulation, instability, circuit failure

Answer 99

Severe ARDS Intervention - Prone for >16hrs for 28 days or until improvement vs supine Primary = 28 day all cause mortality significantly lower with proning Proning stopped once P/F >150 with PEEP <10 and FiO2 <0.6 Trial may have shown such a good result as proning started early (within 36 hrs), a significant amount of time was spent prone (73%) and care was protocolised

Answer 100

Refers to the process of liberation of the patient from organ support. Weaning mechanical ventilation involves the reduction of ventilatory support, increase in spontaneous effort and extubation.

Answer 101

Patient: Varied population, age range, extremes of prior health, increasing frailty Active disease: Acute gut injury, sepsis, major trauma/ surgery, organ failure Interventions: Ventilation, RRT, Body temperatures, sedation, rehabilitation

Answer 102

ICP Bolt: Pros: Continuous monitoring, Infection <1% Cons: Poor positioning affects values, Cannot be recalibrated (drift > day 5), Local not global measurement, Some not MR compatible EVD: Pros: Diagnostic and therapeutic, CSF sampling, Intrathecal medication, Recalibration possible Cons: Infection up to 10%, Intermittent ICP monitoring when system closed, Difficult to place in distorted anatomy ONSD: Pros: Non-invasive, Serial measurements at bedside Cons: May not be possible in orbital trauma, Operator dependent, Intermittent Pupillometry: Pros: Non-invasive, Serially measurable Cons: May be difficult in orbital trauma, Operator dependent, intermittent TCD: Pros: Non-invasive, Serially measurable Cons: Difficult if poor windows, Operator dependent, Poor assessment of posterior circulation Parenchymal thermal diffusion flowmetry: Pros: Continuous Cons: Poor positioning affects values, Local not global, poor reliability if hypothermic PbtO2: Pros: Early detection of cerebral hypoxia Cons: Poor positioning affects values, Local not global, Some not MR compatible NIRS: Pros: Non-invasive, Serially measurable Cons: Difficult if scalp oedema/ thick clot, operator dependent SjvO2: Pros: Continuous Cons: Requires calibration, CVC related complications, Thrombosis risk Cerebral microdialysis: Pros: Early detection of secondary injury Cons: Poor positioning affects values, Delay in results EEG: Pros: Non-invasive, Continuous Cons: Operator dependent SSEPs: Pros: Non invasive, serially measurable Cons: Operator dependent

Answer 103

Synchronised intermittent mandatory ventilation. SIMV is a time cycled mode involving mandatory breaths which may be machine or patient triggered. SIMV can be pressure or volume controlled and the patient receives at least the set pressure of Vt (guarantee) Spontaneous ventilation is permitted at varying parts of the cycle, if the patient effort is insufficient a machine triggered breath is applied.

Answer 104

Apheresis - Process of removing a component of a patients blood using and extracorporeal device, often used in the donation of blood products. Plasmapheresis - A form of the above in which blood plasma is removed Plasma exchange - Involves plasmapheresis and replacement with a substitute. Usually used to remove a high molecular weight substance from plasma that is causing pathology

Answer 105

Types of NIV: HFNO CPAP BIPAP HFNO: Provides heated, humidified oxygen at adjustable flows of gas and FiO2 Pros - Humidification of inspire gas (Improves secretion clearance/ prevents epithelial injury and decreases wob) - Reduction of entrained atmospheric gas (Increases FiO2 delivered) - Reduced CO2 dead space through a washout effect - Delivery of PEEP (when closed mouth breathing) CPAP: Continuous application of positive pressure to the upper airway throughout the respiratory cycle Delivery - Nasal cushions, face mask, hood Increases oxygen delivery by aiding alveolar recruitment and improving VQ matching Pros - Cheap, Easily delivered, Usually well tolerated, Can help with LVF and subsequent pulmonary oedema BiPAP: Provides ventilatory support through the driving pressure created by the difference between IPAP and EPAP Delivered via face mask Pros - Clearance of CO2 and helps to reduce wob, helps to prevent post-extubation respiratory failure

Answer 106

Both involve blood passing through and extracorporeal circuit via a wide bore cannula. The circuit will contain a blood pump and inflow/outflow of another substance depending on the modality used. Haemofiltration: Convection - hydrostatic pressure gradient across membrane Ultrafiltration - 'solute drag' pulls molecules (<5000 Da) along with mass movement of water, the resultant fluid is termed ultrafiltrate Transport determined by transmembrane pressure gradient and direction Ultrafiltrate is discarded as effluent Volume is lost by this process so replacement fluid can be added after the filter (buffered electrolyte fluid) Haemodialysis: Diffusion - Solutes equilibrate down the concentration gradient across the membrane Counter- current flow of dialysate against blood The choice between modes may depend on stability of the patient, available resources and vascular access. CRRT is slow, more haemodynamically stable with better fluid balance manipulation/ enhanced inflammatory mediator removal/ preservation of CPP. IRRT is faster, removes smaller non protein bound agents quicker (methanol, ethylene glycol, Li)

Answer 107

Anaemia Thrombocytopaenia Lose blood in filter Interruptions Increased LOS Disrupts pharmacokinetics and pharmacodynamics of RRT drug dosing

Answer 108

Bypass upper airway obstruction Allow tracheal toilet Decrease airway resistance Facilitate weaning and liberation from the ventilator Long-term airway support

Answer 109

Indications are classified as first line (Cat 1), second line (Cat 2), role not established (Cat 3) or ineffective/ harmful (Cat 4). Cat 1: Acute inflammatory demyelinating polyneuropathy (e.g. GBS) Acute MG NMDA antibody encephalitis Anti GBM disease ANCA vasculitis TTP Catastrophic antiphospholipid syndrome Acute liver failure (high volume plasma exchange) Cat 2: ADEM Lambert eaton MS - Acute/ relapse Hashimotos encephalopathy Voltage-gated potassium channel diseases Renal transplant - antibody mediated rejection Thyroid storm Lots of others in these categories

Answer 110

Highest risk: Mechanical ventilation without EN Chronic Liver disease High risk: Concerning coagulopathy 2 or more moderate risk factors Moderate risk: Mechanical ventilation with EN AKI Sepsis Shock Low risk: Critically ill no other risk factor Acute hepatic failure Steroids/ immune suppression Anticoags Cancer Male

Answer 111

Absolute: Adequate oral intakes Gut dysfunction Generalised peritonitis Uncontrolled severe shock states Relative: Expected period of fast <5 days Gastric aspirate volumes above 500ml for 6 hrs Localised peritonitis/ intra-abdominal abscess/ active upper GI bleed High risk pulmonary aspiration High output intestinal fistula Abdominal compartment syndrome Dementia/ Agitation/ Confusion

Answer 112

Improving trajectory with rehab Consistent approach with MDT involvement important No single weaning method superior to another Establish ability to tolerate cuff down, ability to clear secretions and cough - Aiming for 24 hours with cuff down and no support Can downsize trachys or cap off Fenestrated tubes may also help

Answer 113

A term used to describe the discrepancy between predicted and administered fluid (drug diluent, flushes or fluids to maintain catheter patency).

Answer 114

Adaptive support ventilation uses a feedback loop to adjust support based on patient requirements. Support is delivered in response to RR and effort to achieve the required MV.

Answer 115

PICS encompasses a group of disorders that arises as sequelae of life-threatening illness and the therapies used to manage it. Subdivided into problems with: Physical function - Weakness, pain, breathlessness and difficulty with movement/ exercise Mental health - Anxiety, irritability, depression, sleep disturbance, PTSD Cognitive function - Memory loss, difficulty thinking/ concentrating

Answer 116

No demonstrable survival benefit from SLEDD. CRRT is familiar with well established training and equipment. Since CRRT is continuous it will allow for more stable fluid removal. CRRT also results in more continuous drug removal in comparison to SLEDD which can complicated drug dosing with SLEDD.

Answer 117

Propofol - 1 kcal/ml Dextrose containing infusions

Answer 118

A sedation hold is the temporary cessation of sedative infusions in critical care. This allows the patient to wake and facilitates washout of drugs preventing accumulation Sedation holds are thought to reduce the duration of mechanical ventilation and ICU LOS when indicated, this was not replicated in the SLEAP trial which found light sedation increases amount used and nursing work load. ABC trial showed higher ventilator free days, lower LOS and lower mortality in those who had sedation holds but higher rates of self extubation SLEAP showed no difference in days to extubation but significantly lower days to extubation in trauma/ surgical patients

Answer 119

Bridge to recovery - Cardiogenic shock (e.g. post-MI, viral cardiomyopathy, primary graft failure post-transplant) Bridge to candidacy Bridge to transplantation - limited organ availability and long waiting times Destination therapy - emerging internationally as outcomes become comparable to those of heart transplantation Long term therapy is usually via LVAD support as RV failure from pulmonary hypertension often improves concurrently.

Answer 120

Percussion Transcutaneous Endocardial (leads implanted into myocardium) Epicardial (during thoracotomy) CRT - Pacemaker

Answer 121

Fluid bolus (Albumin vs NaCl) vs no fluid boluses in children with severe febrile illness in resource-limited setting Significantly higher mortality in those without preceeding hypotension Mortality at 4 weeks - significantly higher Difficult to apply to ICU setting (setting difference, patients not on ICU, high incidence of malaria)

Answer 122

Actual/ Total - Measured by weight at time Lean - Excludes body fat IBW - Related to height Adjusted - Applicable to obese patients

Answer 123

ESPEC recommend EN via NG tube to the stomach first line. This should start within 48 hrs of ICU admission once haemodynamically stable. Feed should start at 50% of estimated target and increased to 70% of EE over 48 hrs. Early EN is recommended in ECMO, TBI, Stroke, Spinal cord injury , severe acute pancreatitis, GI surgery, abdominal aortic surgery, on NMB, prone, open abdomen, abdominal trauma with GI continuity

Answer 124

Staff - Minimum of 5 (1 airway, 2 each side), more needed if ECMO/ Chest drains etc Monitoring - Airway trolley, ECG electrodes, Caps for disconnected lines Protecting patient - Tracheal tube tapes, eye ointment and patches, NG syringe, absorbent pads, nipple patches Moving and handling - Low air loss mattress, Slide sheets, Pillows and bed sheets

Answer 125

Pre-Procedure: MDT decision Proning team introductions, briefing (including emergency deproning), checklist Choice of appropriate time Complete tasks best suited when supine Systems review (A-E) to check and prep lines/ tubes etc Procedure: Neutral position on slide sheet and tuck arm nearest ventilator under buttocks Pillow over chest, iliac crests and knees Wrap patient with sheet over the top keeping head and neck exposed, roll sheet edges to make pasty Move: Horizontal, turn 90 degrees, complete proning Post-procedure: Immediate systems review and pressure area check Swimmers position, 30 degree trendelenberg Debrief Document Swim patient to other side ever 2-4 hrs Change support as needed i.e. low volume feed

Answer 126

Generations: 1 - Pneumatic, hydraulic or mechanical pusher plate (pulsatile) 2 - Continuous non-pulsatile flow - rotor suspended by contact bearings spins within a pipe and generates flow within the bloodstream 3 - Non-contact bearings - centrifugal flow through magnet/ hydrodyamic levitation of an internal impeller Mechanism: Pulsatile vs Continuous

Answer 127

Molecular adsorbent recirculation system A type of extracorporeal albumin dialysis. It involves exposing ultrafiltrate to albumin rich solution across a membrane to allow albumin bound substances to move down a concentration gradient. The ultrafiltrate then undergoes conventional dialysis.

Answer 128

Ration of CO2 released to O2 absorbed during respiration. Varies on dietary intake: Carbs - 1.0, Protein - 0.8, Fat - 0.7 Can be applied to patients with CO2 - CO2 can be driven down by increasing the proportion of dietary fats

Answer 129

SPLIT 2015: ICU Patients needing crystalloid fluid therapy (mostly postop) PlasmaLyte vs NACL Primary: Proportion of patients with AKI at 90 days - No difference Secondary: AKI, RRT need, readmission, LOS, mortality - no difference Small amount of fluid on average given (2L) SMART 2018: Critically ill patients Balanced crystalloid vs nacl Primary: Composite of major adverse kidney events at 30 days - significantly lower in cystalloid group Secondary: Mortality, new RRT and persistent renal dysfunction - no difference BaSICS 2021: Adult ITU patients Plasmalyte vs NaCL. Slow vs rapid bolus if required Primary: 90 day mortality - no difference Secondary: day 7 SOFA score - significantly lower PLUS 2022: Adult ITU patients Plasmalyte vs nacl Primary: 90 day mortality - no difference Secondary: new RRT - no difference

Answer 130

Indications: Post-operative support Acute MI Cardiogenic shock Acute MR VSD Refractory ventricular arrhythmias Cardiomyopathy Structural heart disease and sepsis Contraindications: AR Aortic dissection Aortic stents End-stage heart disease Complications: Limb ischaemia Thromboembolism Compartment syndrome Aortic dissection Local vascular injury Gas embolus from balloon rupture Balloon entrapment Malpositioning - renal/ cerebral compromise Tamponade Low platelets, haemolysis

Answer 131

A - May hlep to maintain patency (e.g. prevents pharyngeal collapse in OA) B - Alveolar recruitment, reduced shunt fraction, reduced overdistention and ventilator-induced lung injury C - Initial increase then decrease in systemic venous return, increased afterload (SVR), increased PVR, Raised RV pressure and reduced SV (increased interventricular dependance) D - Raised ICP E - Increased ANP, ADH and catecholamines

Answer 132

Targeted temperatue management superseded therapeutic hypothermia. In TTM a constant targeted temperature was maintained. It has also been superseded by 'Temperature Control' strategies. Previous used post ROSC if unconscious Contraindication was severe systemic infection and pre-existing coagulopathy

Answer 133

Facilitation of airway procedures Severe hypoxaemic respiratory failure - reduces oxygen consumption Specific vent. modes - High pressures/ Inverse I:E ratios Suppression of high respiratory drive Raised ICP unresponsive to sedation Abdominal compartment syndrome Risk of instability during some transfers

Answer 134

Hybrid method of CRRT, it takes advantage of the ability of dialysis to effectively remove small molecules and the ability of ultra-filtration to remove medium/ larger molecules

Answer 135

Equivalence to 0.9% NaCl (SAFE) - Volume resuscitation, ARDS with hypoalbuminaemia, Septic shock Supported - SBP - Lower mortality Not supported - TBI (SAFE) SAFE 2004: ICU patients HAS vs NaCl for resuscitation Primary - 28 day mortality - no difference Secondary - No differences Mortality in TBI - significantly higher with albumin

Answer 136

Immediate: Loss of airway, Bleeding, Subcut emphysema, derecruitment, aspiration, bronchospasm, injury to local structures, death Short-term: Infection, bleeding, tracheo-innominate artery fistula, accidental cannulation, inadequate sputum clearance, change in smell/ taste Long-term: Tracheal stenosis Tracheomalacia Change in voice Scarring

Answer 137

Name given to systems that may be used to prevent further toxic injury in the failing liver. There are various mechanisms by which it can be provided. Use is restricted to specialist centres and in clinical trial settings. Not much evidence relating to their efficacy at present. Examples include cell based (Bioartifical liver support systems) and non-cell based (Haemodialysis, haemofiltration, plasmapheresis etc)

Answer 138

Dependent on functional GI tract Recognised cause of diarrhoea Risk of NG tube misplacement and lung feeding Discomfort from NG Increased VAP risk

Answer 139

Cat 4: Amyotrophic lateral sclerosis Dermato/ Polymyositis Inclusion body myositis POEMS syndrome Rheumatoid arthritis Schizophrenia

Answer 140

2 methods that can be used: Filtration - Blood passes through filter to separate components (ICU/ Renal patients) Centrifugation - Blood spins to separate components by density (donation) Filtration uses a similar extracorporeal set-up to RRT with the addition of a specialised filter. The circuit may be adapted for plasma exchange by allowing replacement fluid to be given back to the bloodstream.

2) Organ Support Flashcards

(164 cards)