Critical Care

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Critical Care
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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?
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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

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Label the axis on the following graph
Delivery dependent
Delivery independent
Y
X
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CaO2 1.34 x Hgb x SaO2 ( 0.0032 x PaO2 ) DO2
CaO2 x C.O VO2 C(a-v)O2 x C.O
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Oxygen-hemoglobin disociation curve
Factors that shift curve to the right ?
What is P50 ?
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Oxygen-hemoglobin disociation curve

• P50 - the partial pressure of oxygen at which
  hemoglobin is 50 saturated with oxygen

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

• Increased serum osmolality and hypovolemia

ADH increases water permeability and passive
sodium transport to the distaltubule , allowing
increased water reabsorption
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Which of the following precludes a diagnosis of
brain death?

1. Uremia
2. Hypothermia below 32.2 C
3. Systemic blood pressure of 70/40 mmHg
4. Hypercarbia with a PaCO2 greater than 60mm Hg
   with no respiratory response

Answer A, B, C
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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

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• 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?
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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
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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

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• 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.

What is your most likely diagnosis and
management of this patient?
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Malignant Hyperthermia
Active Cooling
Signs and Symptoms
Monitoring
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 2C 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
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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
  givePROCAINAMIDE 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 (gt 1 ml/kg/hr)

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• 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
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• Atrial Fibrillation
• Irregular P waves gt 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

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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?

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Hypokalemic,hypochloremic metabolic alkalosis
PARADOXICAL ACIDURIA
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Match the treatment

1. Adequate volume status and hypotension refractory
   to inotropic agents
2. Distended neck veins, distant heart sounds, and
   hypotension
3. Hypotension, appropriate volume, atrial
   fibrillation with a HR of 40
4. Hypotension and low right and left atrial
   pressures
5. Adequate volume, no mechanical defects,
   hypotension

• Inotropic agents
• Cardiac pacing
• Fluid administration
• Pericardiocentesis
• Intraaortic balloon pump

1. E
2. D
3. B
4. C
5. A

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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?
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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.

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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?
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Milrinone
Dobutamine
Dose 0.3 0.75ug/kg/min 2.0 20ug/kg/min
Mechanism Phosphodiesterase inhibitor B1,2,a
Cardiac contractility
Heart rate No change
Preload
SVR
Oxygen delivery
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55 year old on trauma service with severe watery
, foul smelling diarrhea, WBC 40,000, 15 bands.
Colonoscopy showed the following.
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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 )

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• 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 ?

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Classes of Hemorrhage

• Average Blood Volume 5 L

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65 year old male , restrained driver in MVC,
Vitals BP 90/40, HR 110
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(No Transcript)
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A
B
C
D
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(No Transcript)
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• What is the significance of SvO2?

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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

• Causes for an increase in SvO2
• decreased peripheral oxygen consumption
• increased peripheral shunting ( e.g sepsis.
  cyanide toxicity , hypothermia.

Mixed Venous Oxygen Saturation - Condition 77
- Sepsis, shunting, hypothermia, cell poisoning,
wedged catheter 66-77 - Normal range 60 -
Cardiac decompensation 55 - Lactic acidosis
32 - Unconsciousness 20 - Permanent cell
damage
(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 )
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Dietary protein (UNN 4gm)
6.25
What equation is this? What does the 6.25 and 4
stand for?
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• Nitrogen balance
• grams protein 6.25(grams N)
• 4 factor for skin and GI losses

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Copius irrigation and immediate application of
2.5 calcium gluconate gel.
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Hydrofluoric acid