critical care essentials don h. van boerum, md, facs · critical care essentials . don h. van...

Critical Care Essentials

Don H. Van Boerum, MD, FACS Trauma Surgeon, Director of Surgical Critical Care,

Co-Director of Shock Trauma ICU, Intermountain Medical Center, Intermountain Healthcare; Salt Lake City, Utah

Aaron A. Pugh, PA-C Physician Assistant, Trauma and Critical Care,

Intermountain Medical Center, Intemrountain Healthcare; Salt Lake Cityy, Utah

Objectives: • Assess adequate signs of fluid status and apply management strategies

in both emergent and non-emergent settings • Describe and compare and contrast various ventilator management

modes and match modes to particular critical care situations. Demonstrate safe and reliable extubation strategies

• Identify, differentiate, and organize treatment plans for various types of shock and their differing treatment modalities.

• Identify various Acid/Base derangements and develop strategies for their correction and management

• Recognize various work-up strategies for different infectious disease states in the ICU. Understand the use of MIC and trough based dosing. Develop a working list of usable medicines and recognize local resistance patterns in their own facilities

• Identify current concepts in nutrition both enteral and parenteral, summarize updates in early feeding strategies and describe various testing available for assessing adequate or over feeding

• Assess early Identification of frequent complicating and confounding comorbidity in the critically ill patient. Provide examples of strategies to mitigate and minimize impact and sequelae of them

Critical Care EssentialsDon Van Boerum MD FACS; Aaron A Pugh PA-C Excellence in Trauma Critical Care Conference

#ETCCC14 @IMCTRAUMA

Topic ObjectivesDrinking from a fire hose

• Assess adequate signs of fluid status and apply management strategies in both emergent and non-emergent settings

• Describe and compare and contrast various ventilator management modes and match modes to particular critical care situations. Demonstrate safe and reliable extubation strategies

• Identify, differentiate, and organize treatment plans for various types of shock and their differing treatment modalities.

• Identify various Acid/Base derangements and develop strategies for their correction and management

• Recognize various work-up strategies for different infectious disease states in the ICU. Understand the use of MIC and trough based dosing. Develop a working list of usable medicines and recognize local resistance patterns in their own facilities.

• Identify current concepts in nutrition both enteral and parenteral, summarize updates in early feeding strategies and describe various testing available for assessing adequate or over feeding.

• Assess early Identification of frequent complicating and confounding comorbidity in the critically ill patient. Provide examples of strategies to mitigate and minimize impact and sequelae of them.

Topic Objectives3 years in 90 minutes

• fluid status up/down/ok• intubate or not non invasive non-invasive• steps to extubation• hypoxia workup ie. PE Shunt CO poisoning, ARDS• Persistent Shock

• fluids, inotropes, ACS, bleeding, ingestion OD• ACS who how when to treat• ICH Persistent Cerebral Edema; Vasospasm• Sympathetic Storm• Acid Base Disorders • Coagulopathy• Thrombosis HIT DIC hyperFibrinolysis• Fever Unknown Causes Infxn, Drugs, Central• VTE Prophylaxis Chemical, Mechanical

Topic Objectives CONTLAST ONE I SWEAR• Common Comorbids, Coumadin, Newer DTIs,

DM, COPD, Psych, Obesity, Withdrawal, age• Ventilator Barotrauma Peep, PAo2 Pco2 goals• Vent Modes changes• ARDS, 6ml/kg gospel?• Sedation: approaches, too much too little unique

patients, complications of• propofol infusuion syndrome• malignant hypothermia • seratonin syndrome• alternatives to propofol (they all suck)

• Infection: source control, empiric treatment, narrowing treatment, cxs,

Topic Objectives CONTJust Kidding. This is the last one.

• Bailouts/Kitchen Sink: calcium, turn up o2, try not to just do the thing you know

• airway obstruction, trach troubleshooting, mucus plugging, kink, circuit clogged

• tamponade in general, lungs, pericardium, hematoma• Ultrasound Cheap Fast Harmless• Look four days ahead think of possible problems before they occur

what did this look like the last time i took care of it• standard ordersets: checklists• hypothermia how to warm a patient• treating with hypothermia cool guard arctic sun, old fashioned cooling• long term stay early trach, peg• trach and peg complications• line complications: wire un coiled, ptx, infxn, • nutrition refeeding, over/under• icu psychosios and delirium• bedsores, skin• Politics: bitchy providers, nurses, alienating people, getting ham

stringed• AND MANY MANY MORE!

Patient Scenario 80 year old male, Alta Skier all his life ($49 Season Pass), crashes into a tree

Injuries from Physical Exam, CTs, & PMHX• Rib fractures• Ptx• Spleen• Pelvic fractures• SAH• Skull Fx• Femur• Delayed Calcaneus• AFIB on Coumadin• DM• ETOH USE “OCCASIONAL”

Nobody Cares You Ski Alta

“The pulse fades away, the color is extremely pallid, cold and malodorous sweats break out of the body as if the body has been wetted by dew, the extremities become cold and death quickly follows.”

Celsus 20 AD

“The bullet-thrown from the gunpowder acquires such rapid force that the whole animal participates in the jarring (shock and agitation).”

LeDran 1743

Shock

Inadequate perfusion of tissues with oxygen and nutrients to support cellular function

Shock

Inadequate perfusion of tissues with oxygen and nutrients to support cellular function

“A state of tissue dysoxia in which energy (ATP) production is inadequate to meet metabolic needs”

Types of Shock

HypovolemicCardiogenicDistributiveObstructive

Hypovolemic Shock

Hemorrhage!!!BloodlossOngoing Bleeding

Fluid LossDiarrheaDKAVomitting

Cardiogenic Shock

Chronic Cardiac DysfunctionPrevious MIValve ProblemsSystolic/Diastolic DysfunctionArrhythmias

Acute Cardiac DysfunctionAcute MICardiac ContusionCardiac “Stun” – Sepsis, Drug AbuseArrhythmias

Distributive Shock

Sepsis ShockMost CommonWidespread VasodilatationBacterial or FungalCardiogenic Component

Distributive Shock

Anaphylactic ShockMassive Histamine ReleaseWidespread Vasodilatation

Neurogenic ShockLoss Sympathetic Tone Below InjuryBradycardia – No Cardiac Sympathetics

Obstructive Shock

Cardiac TamponadeImpaired Venous Return

Tension PneumothoraxElevated Intra-thoracic PressureObstructed Venous Return

Pulmonary EmbolismObstructed Right Heart OutflowDecreased Left Heart Inflow

Recognition of Shock

History


HistoryVital Signs


HistoryVital SignsExam


HistoryVital SignsExamLaboratory Tests

Resuscitation

“The timely, systematic, goal-directed reversal of shock”

Treatment of Shock

Compensated ShockUncompensated ShockIrreversible Shock

Oxygen Debt

Resuscitation

“The timely, systematic, goal-directed reversal of shock”

Oxygen Delivery (DO2)

DO2=Cardiac Output x Arterial Oxygen Content

DO2=CO x [(Hgb x 1.34 x SaO2) + PaO2 x 0.003]

DO2=CO x (Hgb x 1.34 x SaO2)

Oxygen Consumption (VO2)VO2 = Cardiac Output x Arterial / Venous O2 Diff

VO2 = CO x ( CaO2 – CvO2)

Delivery Dependent Oxygen Consumption

Oxygen Content

Raise the O2 Saturation• Depends on starting point• FIO2• PEEP

Oxyhemoglobin Curve

Oxygen Content

Raise the O2 Saturation• Depends on starting point• FIO2• PEEP

Increase the Amount of Hemoglobin?• Depends on starting point• Upper limits

Cardiac Output

CO = Stroke Volume x Heart Rate

CO = SV x HR

Frank-Starling Curve

Pressure Volume Relationship

6hrsScvO2 ≥70CVP 8-12MAP 65-90UOP >0.5

Measuring Degree of Shock

Traditional “Upstream” Targets• Blood Pressure• Heart Rate• CVP• PAOP(Wedge)• Ejection Fraction• Cardiac Output

Measuring Degree of Shock

“Downstream” Targets• Urine Output• Lactic Acid• Base Deficit• SCVO2

Lactic Acidosis

Tissue Hypoxia – Excessive production of lactate as byproduct of anaerobic metabolism

Insufficient Hepatic Metabolism of Lactate• Liver dysfunction• Pharmacologic

Base Deficit

Normal Range -2 to +2Correlates with degree of shockBicarbonate as a substitutePotential for misinterpretation

• Hyperchlormia – non anion gap• Administration of bicarbonate

~1,300 Trauma Admits

Admission lactate and BD equally effective in predicting mortality

During ICU course, lactate more sensitive

If BD normal, lactate still sensitive

If lactate normal, BD does not remain sensitive

Mixed Venous Saturation - SCVO2

Measurement of Oxygen Content of Blood Returning to Heart

Low Levels Correlate With Increased Peripheral Extraction = Shock

Trended Over TimeNormal ~70%

Shock Resuscitation

Stop the bleedingIdentify shock & establish severityMaximize oxygen deliveryReassess effectiveness

Overaggressive FluidResuscitation

Too much fluid comes at a price, much more than the cost of a $1 bag of saline

Passive Leg Raise Test


Increase of 150-300 ml of blood to circulationTransientMaximum response @ 60 secondsNon-invasiveIndependent of breathing mode or cardiac

rhythm> 15% improvement = fluid responsive


Limitations• Positioning Issues

• Head Injuries• Sympathetic Discharge

• Most accurate with continuous cardiac output monitoring• PPV Pulse Pressure Variation• SVV Stroke Volume Variation

NICOM

BioreactanceNon InvasiveWorks w ArrythmiasControlled or Spontaneous BreathingPassive Leg Raise OR 250 mL Challenge> 10% Change in SVI is Positive Test for FR

FloTrac Vigileo

Pulse Wave ContourControlled Vent OnlyNeeds NSRWorks off A-LineContinuous MeasurementStroke Volume Variation SVV> 10-15% SVV is Positive Test for FR

Echocardiography

Real-time evaluation of:• Preload Volume• Ejection Fraction• Stroke Volume• Cardiac Output• Wall Motion Abnormalities

Echocardiography

Limitations• Special Training• Usually Episodic

What Else?More Doping

• INOTROPIC SUPPORT

SummaryStandard hemodynamic parameters do not

adequately quantify the degree of physiologic derangement in trauma patients.

Downstream markers, such as initial base deficit and lactate level should be used to stratify patients with regard to the need for ongoing resuscitation.

SummaryOxygen delivery parameters should be observed.

Ability to obtain supranormal levels correlates with improved chance of survival

Time to normalization of base deficit and lactate is predictive of survival.

Persisting base deficit or lactate may be early indicator of complications, ie bleeding or abdominal compartment syndrome

SummaryEffects of EtOH, seizures, sepsis, hyperchlormia,

pre-existing metabolic acidosis, or administration of bicarb, on base deficit levels should be considered when using this as an endpoint.

CVP is not a reliable measurement for preload or fluid responsiveness.

Dynamic assessment of fluid responsiveness is preferred over static measurements ie passive leg raise or ECHO

Summary

During resuscitation, oxygen delivery should be increased to normalize downstream targets, such as lactate and base deficits, within the first 24 hours.

Abdominal Compartment SyndromeDiagnosis

Repeated Measurements Bladder PressureAbd HTN with Resultant End-Organ DysfunctionBladder Pressure 20-25 mm HgAPP Abd Perfusion Pressure < 55 (MAP-IAP)

TreatmentPositioning – Spine StraightSedation (Paralytics?)Decompression – NGT, Drain CollectionsDecompression – Surgical w Loose VAC Dress.

Fluid Choice – Colliod vs Crystalloid

No Difference at 28 Day Mortality

Fluid Choice – Colloid vs Crystalloid

Cochrane Review 2013There is no evidence from randomized controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery.

Persistant Shock

Despite Treatment – Shock PersistsStart Over – ABC’sSource Control

Bleeding? Infection? Obstruction?FluidsOxygen ContentCardiac OutputDrugs

Nutrition

Feeding is a good thingCritical Illness is Very Energy IntensiveIncreasing Calorie Debt has Consequence

Longer ICUMore Vent DaysMore ComplicationsIncreased Mortality

Nutrition

What Method of Nutrition is Best?Enteral > Parenteral

More PhysiologicImmune Enhancing

Gastric vs Small Bowel Feeding TubeIs the Jury Out?

What if I Can’t Feed Enterally?WaitParenteral in Select Patients

Nutrition

How Much Do I Feed?Harris-Benedict Equation(BMR)

Correction Factor(Stress Factor)TablesIndirect Calorimetry(IDC)

UnderfedOverfed

Nutrition

What to FeedProtein – 1-2g/kgCarbsFats

Special FormulasImmune ModulatingRenal FormulasHepatic FormulasPulmonary Formulas

Airway

adjuncts/hacks• Oral Airway: yes always in pt’s with no gag

• Nasal Trumpet: meh. maybe prehospital/or drunk

• Bougie: yes always

• Glide-scope/McGrath: perhaps the death rattle of DL; not without pitfalls though

• Small Bronchoscope/Difficult Airway Cart: know how to use it and have fresh batteries

Airwaynoninvasive measures

• CPAP and OSA: OSA, if they look like they have it, they probably have it. Have a low threshold, also a great way to preoxygentate while you are getting stuff together

• BiPap: not super helpful in patients where their problem is secretion related, but can be very helpful in restoring mechanics, and also a good DNI alt

• PREVENTION! I/S Saves Lives: in the awake pt, this should be on the short list of things you bring up on rounds with the pt everyday.

• EZ Pap/IPV/Vest: Q6 with A&A

AirwayIntubation “the pre-emptive strike”• yes. do it.• if they need it. do it. • RSI. But “take your time”

• Pre-oxygenate: use it as an excuse to:• Take a good long look at the room, the staff in it, the

equipment, and finally the patient• look at their chin, neck, teeth, and mouth

• Induce and Paralyze• etomidate 20mg i.e. 10ml of 2mg/ml• succcinylcholine* 100-120mg i.e. 1.1mg/kg

• Have your back up solution ready: DL, Smaller tube, Trach, another clinician

• Have a bougie, suction, end tidal, an RT

AirwayIntubation, Emergent “The Knocked Out or Air Hungry” ALOC, Aspiration, persistently hypoxic

• no choice. there is a good chance you will only get one look

• the importance of having your backup ready is that much more important.

• you may not need an induction agent

• bagging a patient and controlling the pace of the room is very helpful, telling everyone in the room including the patient to take a deep slow breath

• this can go crash quickly so be ready to convert

AirwayIntubation, Crash “THE GURGLER”Bronchospasm, Laryngospasm, angioedema, facial trauma, secretory

• assume you aren’t going to be successful

• already have someone getting trach supplies ready

• you may not need an induction or a paralytic but give them where possible.

• preoxygenation often loses out to need for definitive airway

• speed.

AirwayVent and trach troubleshootquestions to ask

• size, how long has it been in, other factors• turn o2 up• look listen feel clear secretions• false passage?• have a back up, suction, and RT• don’t change a trach without the above

questions answered• don’t change out a fresh trach• if it is bleeding, IDENTIFY SOURCE immediately • is the circuit nasty?• time to convert to trach?

AirwayExtubation

• Ideally pt is an GCS 11t

• CPAP (implies no extra PS)

• The Maximal Inspiratory Px/Negative Inspiratory force [MIP/NIF] • at least 1.5 seconds; normal is -60cm/H2O, below -20 is

indication for help needed

• Tobin Index or the Rapid Shallow Breathing Index [RSBI]• normal is 40-50/L; less than 105/L were 80% successful; greater

than 105/L were unsuccessful

• a Cuff Leak

• Vital Capacity greater than a 1L

• Secretions managed

• CXR volume status is in check

BreathingThe “Thoraxes”

• Hemo; Pneumo; Chylo; Tension; Other• ultrasound and CXR• big versus small tube• Thal technique• tension is a clinical diagnosis• chylo thorax sent for TGS• propofol thorax• feeds

Breathing

Shunt• Qs/Qt = (Cco2- Cao2)/(Cco2- Cvo2)• this word gets thrown around a lot• a couple of varieties

• pulmonary (equation above) is perfusion without ventilation that causes local constriction and moves blood elsewhere for effective gas exchange

• vascular or dead space no ventilation is possible due to decreased perfusion

• if you can grasp this concept most pulmonary problems and their solutions will make sense to you

BreathingPneumonia

• dx is based on 3/5 criteria• WBC; Fever; Secretions; CXR; CX

• ventilated greater than 3 days is a coins flip• CX first!• start broad and cover P. aeruginosa if

ventilated• treat with MIC and trough guiding your RX• narrow as soon as prudent• know your local resistance patterns• fancy labs like CRP, and Pro-Calcitonin

available but not awesome yet

BreathingPulmonary Embolus

• vascular shunt or dead space• hypoxia especially in

presence of adequate SaO2• right heart strain• chest pain• echo/helpful but not dx• clinically relevant vs. lethal

vs. dx• tachycardia that is

unexplained is always present but often confounded or in conjunction with other things

BreathingFat Emboli Syndrome

• recent long bone repair

• petechiae, neuro sxs

• and SOB, Hypoxia• tx is supportive• lasts for a few days• is a nidus for

pneumonia/ARDS & and prolongs stay

BreathingARDS and the Gospel According to 6mls/kg

• Since World War I, patients with nonthoracic injuries, pancreatitis, transfusions, sepsis, and other conditions develop respiratory distress, diffuse lung infiltrates, and respiratory failure,after a delay of hours to days.

• ARDS is a NUMBER before it is anything else.• ARDS is defined by the ratio of the partial

pressure of oxygen(PaO2) over fraction of oxygen in the inspired air (FIO2).

• ARDS, the PaO2/FIO2 ratio is less than 200, and in ALI, it is less than 300.


• caused by damage to the epithelial tissues either pulmonary or vascular with a particular focus on Type II Alveolar cells leading to increased permeability and alveolar distention, which then causes pro-inflammatory release which can cause further damage

damage distention & inflammation

permeability


• SO LET IT BE WRITTEN! SO LET IT BE DONE.

• (NIH) ARDS Network, several large well-controlled trials of ARDS therapies have been completed. Thus far, the only treatment found to improve survival in ARDS is a mechanical ventilation strategy using low tidal volumes (6 mL/kg based upon ideal body weight).

• (and maybe judicious fluid control)


• treatment approaches• high dose statins; simvastatin 80mg (maybe)• maybe Nitric Oxide (disproved)• drotrecogin alfa (withdrawn)• no other current drugs• definitely NOT steroids

• supportive cares and treat underlying cause• with supportive care• ventilation using low tidal volumes, • judicious fluid management (very important). • infection • eliminate mitigating factors


• fluid and ventilation approaches• keeping people euvolemic • PEEP avoid barotrauma higher not shown beneficial,

possibly harmful• work toward wean slowly

• PRONE positioning 5-7 days worth usually • shown to help with postural recruitment of

dependent lung volumes• no change in primary outcomes however (we do it

anyway)• Trach

• regional variation and again not great primary outcomes data, but our answer is early and often.


• treatment in the meantime• early recognition of potential complications the

including pneumothorax, • line infections, • skin breakdown, • inadequate nutrition, • arterial occlusion at the site of intra-arterial

monitoring devices, • DVT and PE • GI bleed, iatrogenes and misadventures • myopathies of critical illness

• BASICALLY ALL THE OTHER STUFF IN THIS LECTURE

BreathingBarotrauma/Blast Injuries

• Product of overpressure on sensitive tissues• Pulmonary contusion• Systemic air embolism, which most commonly

occlude blood vessels in the brain or spinal cord• Free radical–associated injuries such as

thrombosis, lipoxygenation, and DIC• Impaired pulmonary performance lasting hours

to days• ARDS may be a result of direct lung injury or of

shock from other body injuries• Treatments similarly is based on ARDS and

prevention of ARDS

NeuroTBI: Inter-cranial Hemorrhage

• Subdural• Epidural• Sub Arachanoid

• prevent elevated ICP• minimize cerebral metabolic rate of oxygen

consumption usually by slight compensation• avoid hypotension• maintenance of eucapnia PaCo2 35-39mm hg• maintenance of PaO2 80-90mm hg• maintenance of euthermia 37.8-38.5 Cº• proper positioning almost “bolt” upright if

possible/tolerated• clearance of c-spine if possible

NeuroEdema and Secondary Injury

• monitor for seizure activity low threshold for dx and empiric tx

• neuromuscular blockade• sedation• analgesia• premptive tx prior to studies and

manipulation• careful but early initiation of feeds• judicious stabilization of other injuries

NeuroHyperOsmolar therapy

• 3%, 23%, and Mannitol• increases serum osmolality, causing the shift of

water from intracellular compartments to the intravascular space, and a subsequent decrease in cellular edema

• other theoretical benefits include improved vasoregulation, cardiac output, immune modulation, and plasma volume expansion

• dose is completely ICP driven and is weighed by the cost benefit ratio • potential for renal insufficiency when serum

Osm greater than 320 mOsm/L (RED LINE is 360)

• theoretical central pontine myelinolysis with rapidly increase (esp in the HypoNa+ pt)

NeuroICP Monitoring

• most important in the first 7 days• normal is 7-12 mmhg • 20-25 mmhg for greater than 8-15 minutes should

cause you to decide on a way to fix it• sometimes as simple as telling nursing to stop

touching the patient or repositioning the patient• magic number is used to maintain a minimum CPP

[MAP-ICP] threshold of 45-50 mmhg• several tools

• Camino• Licox• EVD

• Use it as a trend; be sure to keep an eye out for physiologic ICP changes (can be a good sign)

Neuro

Prolonged Swelling• Swelling lasting more than 6-7 days

• refractory ICPs• no improvement• concomitant seizure phenomenon common

• pentabarbatol and cistacurium• takes 7-10 days of tx.

Neuro

Herniation Imminent Swelling• refractory ICPs• hyperventilation

• very short term can be harmful• decompressive hemicraniectomy

• still controversial and center dependent on method and evaluation of helpful vs prolong the dying/terrible QOL picture.

NeuroDAI/Shear/Anoxic Brain Injury

• Sudden deceleration injuries• drownings• hangings

• therapeutic hypothermia• based on s/p CPR data• ideal temperature range 35-36 Cº• midazolam for shivering• 24 hours and then slowly rewarm

• Suspect DAI/Shear in patients without significant improvement all other things being equal.

• additional dx studies MRI/A

Neuro

Sympathetic Storm• hypothalamic dysregulation• fever• tachycardia• hypertension

• important to rule out other causes• treatment with b-blockade• fever

NeuroVasospasm

• common in SAH and diffuse injury patterns• should be expected when you have a worsening

clinical exam but a stable or even improved CT• should be looking for pseudo-aneurysm • treatment

• is daily trans-cranial dopplers • Triple H Therapy

• Hypertension• Hypervolemia• Hemodilution

• interventional radiology on standby for intervention

• involve neuro critical care consult• can last weeks.

ICU Systems

foresight and a sense of urgency• visualize where you want to see

the patient 4 days from now• build a mental checklist: “what did

this look like the last time?”• as the provider, whether you want

to or not, you are guiding the pace of the patient’s care.

• how you behave, speak, and your body language will distinguish you as a leader

ICU SystemsChecklists, Standard Ordersets, Bundles, and

Protocols• Rounding; a sort of wrap up time-out should include:

• infection• VTE• Lines• Skin• WB status • Consult and Team communication• family communication

• Standard Admit, Transfer, and Procedural Ordersets• Protocols for just about everything; always

changing; always open for improvement• NOT COMMANDMENTS don’t let anybody tell you

“well that’s not what the protocol says.” especially if you were the one that wrote it

ICU SystemsbailoutsHave a toolbox of go to things that are both helpful in problem solving and buy you time.

• Ca++• Oxygen• stopping meds• paralytics• increasing meds• Ultrasounds• Fluids/Colloids• inotropes• ABG, CXR

ICU SystemsAlienating Behaviors

• DON’T BE RIGHT. BE HELPFUL.• WORK HARD. BE NICE.• nothing can make your job harder than a team of

nurses, colleagues that don’t like you or trust you• difficult consults and “bitchy” staff members

• “don’t start none and there won’t be none.”• learn to work around them if not with them• give them what they want• don’t get sucked into the reindeer games• don’t take it personal

• work aversion and entitlement are rampant• going it alone kills people• consensus and help saves them

ICU SystemsCultivating an espirit de corps

• DON’T BE RIGHT. BE HELPFUL.• WORK HARD. BE NICE.• Know your ABC’s. Both sets. “Always.

Be. Cool.”• one of the main things people/patients

remember is your teamwork and how willing you were to listen

• if it feels like fun, it probably is. • conscious leadership; all things

deliberate• peace begins with you

ICU Systemsdifficult families and managing expectations

• you aren’t just taking care of the person in the bed

• remind them of the schedule and the culture• remind them to write things down• no such thing as false hope• skepticism and pessimism are harmful• involve risk management early if needed• it is okay to let people know what behaviors

are not tolerated and a minimum level of expectation of them as patients and families

ICU SystemsDNR/DNI and Code Status

• legal definition: important to delineate with families what these two things really mean and how often they are ineffective or only prolong things

• QOL this is different for everybody; define this early with families

• meaningful recovery again comparative but most people have similar views as to what this means which is why it shouldn't be assumed and can be a pitfall.

ICU Systemsdeath and dying

• legal definition and the brain death exam • apnea testing• cold colonics• dolls eyes

• organ donation and DCD• have a low threshold for a Palliative Care

Consult• if there is any question obtain an Ethics

Consult• involve risk management early if needed

ComplicationsCommon Comorbidities

• afib • DM• RF/Renal insuff• COPD• psych• age• obesity• addiction• REMEMBER OUR 80yo ALTA Skier? He

could have, except for maybe obesity, every one of these things.

ComplicationsCoumadin and Other Rat Poisons

• Warfarin; Eloquis; Plavix; ASA; the “bans” apixaban, rivaroxiban, • make almost all things in trauma exacerbated• reversal precautions• partial vs full reversal• in the meantime• when to restart them• TEG directed therapy and reversal

ComplicationsICU Psychosis

• low dose seroquel 12.5-25mg QHS in high risk populations at the time of admission reduces incidence significantly

• multifactorial causes• neuro-transmitter dysregulation, depletion• metabolic and catecholamine exhaustion • drug related

• circadian rhythm and sleep hygiene protocols very useful• minimize night time interruptions• stress diurnal cycle • a sleeper if prudent• spa voices ay night• binaural beats sound• no light at night

• can last for days• can be layered on top of withdrawal• growing body of data regarding PTSD and initiation SSRIs prior

to discharge

ComplicationsPropofol Infusion Syndrome

• characterized by cardiac dysrhythmia, and collapse, metabolic acidosis, acute renal failure, and rhabdomyolysis

• much higher likelihood at doses that exceed .05 mg/kg/min for multiple days and without sedation vacations

• as a result, important to check daily: CK, BMP, and PRN 12 Lead ECG in any patient on more than a moderate dose for more than 3 days.

• CKs greater than 5000 that are not explained elsewhere should be switched

• also worth noting that proposal adds a fair amount of fat to a patients’ metabolism and should be accounted for in their nutrition workup

ComplicationsMalignant Hyperthermia

• NOT an allergy; inherited and has over 30 mutations with little prediction if reaction will occur

• ryanodine RYR-1 receptor dysfunction causes a massive calcium buildup in muscles that leads to catastrophic hyper metabolism

• associated with administration of succinylcholine• early signs are rising end tidal PCo2 despite

increase in Ve• muscle rigidity, tachycardia, hyperthermia,

rhabdo, mods, DIC, and acidosis• dantrolene sodium and aggressive symptom

treatment/support

ComplicationsRefeeding Syndrome

• Any pt who has had little intake for more than 5 consecutive days is at risk of refeeding syndrome.

• hallmark is hypophosphatemia after starting feeds but can be other electrolytes too

• sxs are neurologic, cardiac (most common), neuromuscular, hematologic, and pulmonary (most deadly)

• think of process as a depletion of ATP• TX is don’t get it in the first place by going slow

in anybody at risk; AND replacing it and all other lytes as fast as it is being taken up

Complications

Skin Breakdown• look under dressings• take sutures out• roll the patient• listen to your nursing staff• involve wound care early• include it in the discussions of new WBC, or fever

Bibliography and References

critical care essentials don h. van boerum, md, facs · critical care essentials . don h. van...

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