02 ICU

Misc

Admission Criteria

• Q1 monitoring

• Bipap

• Drips: cardine

• Intubation

Presentation

• Patient

  • fever

  • pain

  • any problems

• Medications

  • Pressors and how much

• VS

  • I/O: even or negatives are better

  • Other VS

• PE

• Labs

  • ABG, vent settings, interpretation

  • Chest Xray

  • Others

• Assessment/Plan

Chest Xray

• Airway

  • Carina, distance ET tube from carina in cm (2-3 cm normal)

  • Any lines

• Bones

• C: everything else

  • Cardiac shadow

  • Lung parenchyma

  • Costophrenic angles

Ventilation

Extubation

• FiO2 < 0.4

• PO2 > 60

• P/F ratio > 100

• Off sedation

• Spontaneous breathing

• ABG good

• Neuro status good

• Rapid shallow breathing index: fraction of respiratory rate to tidal volume.

  • <65 is good for extubating

  • less than 105: 85% chance of extubating

  • more than 105: can't wean

Ventilation modes

• Bipap: help with hypercapnia

• CPAP: help with O2

Tidal Volume

• ARDS: 4-6 mm/kg ideal body weight

• Others: 6-8 mm/kg ideal body weight

Septic Shock

• Sepsis: 2 or more:

  • Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)

  • Heart rate of more than 90 beats per minute

  • Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32 mm Hg

  • Abnormal white blood cell count (>12,000/µL or <4,000/µL or >10% immature [band] forms)

• Severe sepsis: with acute organ damage

• septic shock: sepsis refractory to fluid or high lactic acid

EGDT

• EGDT protocols:

  • 1: early sepsis detection, culture, abx

  • 2: risk stratification via lactate levels and fluid response

  • 3: protocol

The protocol was as follows. A 500-ml bolus of crystalloid was given every 30 minutes to achieve a central venous pressure of 8 to 12 mm Hg. If the mean arterial pressure was less than 65 mm Hg, vasopressors were given to maintain a mean arterial pressure of at least 65 mm Hg. If the mean arterial pressure was greater than 90 mm Hg, vasodilators were given until it was 90 mm Hg or below. If the central venous oxygen saturation was less than 70 percent, red cells were transfused to achieve a hematocrit of at least 30 percent. After the central venous pressure, mean arterial pressure, and hematocrit were thus optimized, if the central venous oxygen saturation was less than 70 percent, dobutamine administration was started at a dose of 2.5 μg per kilogram of body weight per minute, a dose that was increased by 2.5 μg per kilogram per minute every 30 minutes until the central venous oxygen saturation was 70 percent or higher or until a maximal dose of 20 μg per kilogram per minute was given. Dobutamine was decreased in dose or discontinued if the mean arterial pressure was less than 65 mm Hg or if the heart rate was above 120 beats per minute. To decrease oxygen consumption, patients in whom hemodynamic optimization could not be achieved received mechanical ventilation and sedatives.

ARDS

Vent

• TV:

Fluid Management