ICU Lecture:Common Problems in the ICU

Christian Sonnier MDLSU-FP Alexandria

6/23/15

Learning objectives

• Discuss common problems in the ICU and how to manage them– Hypotension– Hypertension– Hypoxemia– Arrhythmias– Electrolyte abnormalities especially hyperkalemia– Sepsis-not going to cover as it has been covered extensively– Altered mental status/agitation– Aki– Pain-see ICU lecture 1 daily care– Fever-work up for sepsis if fever presents, also look at meds– Cardiac arrest: ACLS and induced hypothermia

Hypotension• Definition

– Map <60mmHg, SBP <90 mmHg or decrease in SBP by more than 40mmHg from baseline.

– MAP=COxSVR• Causes

– Decrease CO• Hypervolemia, hemorrhage, third spacing, poor venous return, excessive PEEP

– Decreased contractility• MI, myocarditis, cardiomyopathy, valve issue, CHF, arrhythmia, drugs,

electrolytes

– Obstruction• PE, tension pneumo, tampanode

– Decrease in SVR• Sepsis, anaphylaxis, neurogenic shock, vasodilators, adrenal insufficiency.

Hypotension

• Work up– Based largely on ddx:• labs and imaging if needed• The previous slide listed multiple causes which are very

broad in scope therefore cast a large net and use your clinical judgment to investigate the cause• Consider

– Cbc, cmp, pt/ptt, abg, lactic acid ect

Hypotension

• Management– Hemodynamic monitoring

• Cvc, art line, echo ect

– Fluid resuscitation should be attempted first• 500ml-1L boluses of ns or LR then reassess

– Review medications and labs– If fluid resuscitation fails then pressors should be

considered• See presentation from Dr. Atkins on the wiki about pressors

– Continue to assess response to tx as well as investigate/re-examine

Hypertension

• Definition– Hypertensive emergency/urgency• Profound elevations in sbp over 200• Profound elevation sin dbp over 100

• Causes– Missing home meds– Stress both physical and emotional– pain

Hypertension

• Work up– Ct head, echo, ekg, cxr, cbc, cmp– Look for any neurovascular compromise ie stroke

Hypertension

• Management– There are many different options, ones we use

most commonly• Hydralazine IV push q4-6 hrs prn• Labetalol IV push q4-6hrs prn or drip• Nitroglycerine or other nitrate• Cardene (nicardipine) drip

Hypoxemia/respiratory failure

• Definition: PaO2 <60 mmHg, or SpO2 <90%– Hypoxia refers to clinical exam and pox– Hypoxemia refers to the blood ie ABG

– We covered this in the respiratory failure lecture and mechanical ventilation lecture.

– Please review those powerpoints and presentations

Electrolyte abnormalities

• Sodium: abnormalities can be due to multiple things

• Dehydration, iv fluid dilution, meds, neurovascular injuries, renal injuries

– Hypernatremia: calculate free water deficit and correct using equations or calculator• Lower no faster than 0.5meq/hr and recheck often (q4)

– Hyponatremia: calculate correction using calculator or equations• Raise no faster than 0.5meq/hr and recheck often (q4)

Electrolyte Abnormalties

• Potassium:• Disturbances can be due to many things. *• Remember to always correct mag and phos

– Hyperkalemia• Serum K over 5.0 and over 6.0 is severe• Monitor for EKG changes • Means of lowering

– Albuterol 15-20mg neb over 10 min intracellular shift– Regular insulin 10U IV push with 25g dextrose IV push (intracellular shift)– Sodium bicarb 50mmol IV push or 150mmol IV at varied rate (intracellular shift)– Lasix 40-80mg IV push to eliminate from body– Kayexylate (not if recent gi surgery or risk of perf/obstruction)– HD-if hyperkalemia is unresponsive– If pt unstable need to stabilize cardiac membrane with calcium gluconate (10%)

10ml IV push over 2-3 min, repeat q5min

Potassium

• Hypokalemia:– Can correct via iv or po• IV: run is a concentrated form that is best via central

line as it will burn the veins• IV: large volume fluids can handle less concentrated

potassium and be given peripherally• General rule is 10meq K increases serum K by 0.1meq• Need to be careful with how many meq can go in a

certain volume of fluid. If in doubt ask pharmacy.• Correct mag and phos as the patient will not correct K if

these are low

Arrhythmias: Bradyarrhythmia

• Definition: HR <60• Causes– Sa node dysfunction• Sinus arrest, SA conduction block, sick sinus syndrome

– Av node dysfunction• AV blocks any type

– Junctional escape rhythm– Ventricular escape rhythm– Sinus brady

Arrhythmias: Brady

• Work up/management– Stat EKG, cmp, CE– May need to begin ACLS– Consider:

• Atropine 0.5mg IV bolus q5minutes max of 3mg• Dopamine IV drip• Epi IV drip• Transcutaneous pacing especially for 3rd degree AV and

mobitz type II 2nd degree• Transvenous pacing• Treat any discovered underlying causes

Acls bradycardia with a pulse

Arrhythmia: Tachycardia

• Causes: need to determine if narrow or wide complex tachycardia. Changes tx– Narrow

• Sinus tachycardia• Focal atrial tachycardia• Afib• Multifocal atrial tachycardia• Av node reentry tachycardia

– Wide• Monomorphic V-tach• Polymorphic V-tach• SVT with aberrancy or pvc’s• Wolf parkinson white (pre-excitement tachycardia)

Narrow complex tachycardia

• Stat 12 lead ekg• If thermodynamically unstable may need synchronized

cardioversion– Narrow regular: 50-100 J biphasic– Narrow irregular: 120-200 J Biphasic or 200 J monophasic

• B-Blockers such as metoprolol IV (2.5-5mg IV)• Calcium channel blockers such as diltalizem IV bolus and drip

(0.25mg/kg IV)• Amiodarone: 150mg IV over 10 min then 1mg/min for 6hrs then

0.5mg/min • Obtain cbc, cmp, abg, mag, phos, ce ect and treat any

abnormalities or underlying cause

Wide complex tachycardia

• Stat ekg• If thermodynamically unstable: sync cardioversion

– Wide regular: 100 J biphasic, increase J instep wise fashion if ineffective

– Wide irregular: defibrillation non-sync such as in ACLS• Vagal maneuvers for svt• Adenosine 6mg IV push for SVT• B-blockers, calcium channel blockers or amiodarone as

in previous slide• Obtain stat labs and treat any abnormalities

Acls adult tachycardia

AFIB

• Definition: irregularly irregular arrhythmia with no p-waves• Causes

– Alcohol– Autonomic deregulation– Cardiac or thoracic surgery– Chf or cardiomyopathy– Electrolytes– Hyperthyroidism– MI– Pericarditis– Lung disease– Valvular disease

AFIB

• Management– Stat ekg, cbc, cmp, mag, phos, ce– If unstable and new (less than 48 hrs old)• Sync cardioversion 120-200 J biphasic

– If stable and new (less than 48 hrs old)• Sync cardioversion or pharmacologic cardioversion

– Amiodarone, sotalol, ibutilide, flecainide

AFIB

• Management– If stable and old• Rate control and anticoagulants

– Metoprolol 5mg IV q5min total of 15mg– Diltiazem 0.25mg/kg IV then drip– Digoxin 0.25mg IV q2hr for 1.5mg loading dose– Amiodarone 150mg IV over 10 min, then 1mg/min for 6 hrs

then 0.5mg/min after. Can repeat 150mg iv loading dose if unresponsive after first dose.

Always get labs and treat any underlying cause

Sepsis:

• We have discussed this extensively.• Strive for EGDT and be on the look out for

sepsis constantly.• If patient develops sirs look for a source and

re-culture

AMS/agitation

• Definition/spectrum– Confusiondeliriumobtundedstuporcoma

• Causes– Neurovascular• Stroke, seizure, encephaltis, meningitis

– Metabolic• Electrolytes, drugs, alcohol w/d, thiamine, adrenal

insufficiency, hepatitis, hyper/hypoglycemia, resp failure

AMS/Agitation

• Diagnostic approach:– Vitals– Ct head/cta, mri, cta head– Echo, carotid us– Labs: cbc, cmp, ammonia, abg, ua, LP– EEG for seizures– Review medications for causes as well as try to

establish a pattern if wax/waning

AMS/agitation

• Management:– Watch ABC’s– Thiamine if alcoholic– Dextrose or insulin if glycemic issue– Narcan or fluazenil if overdose suspected– Avoid benzodiazepines for agitation as these can make it

worse. Try atypical antipsychotics like haldol, geodon if needed and no contraindications

– Can be related to sleep disturbances/disorientation of time/place• Have family bring familiar items or stay with family. • Have blinds up and use daylight to orient patient

AKI

• Definition– Acute elevation in bun/cr

• Causes– Dehydration, medications, infections

• Work up:– Cmp, urine studies to calculate FeNa, FeUrea, FeCr

AKI

• Treatment– Treat underlying cause such as dehydration and

remove nephrotoxic medications

Cardiac arrest

• Definition– Sudden electrical and muscular failure of the heart causing

complete cessation of perfusion and blood pressure systemically

– Asystole vs PEA vs V fib ect– Trigger for ACLS

• Management (in this case before and during workup)– ACLS– Induced hypothermia

• Should ACLS be successful, inclusion criteria are met and family consents

ACLS (cardiac arrest)

Cardiac Arrest

• Work up:– Ideally performed simultaneously to ACLS– H’s and T’s

• Hypoxia• Hypoglycemia• Hypothermia• H+ (acidosis)• Hypovolemia• Hypo/hyperkalemia (hypo/hypernatremia also)• Tamponade• Tension pneumo• Thrombosis (MI or PE)• Toxins• trauma

Cardiac Arrest

• So you have successfully revived the patient and have made it to the MICU or SICU…what do you do now?– Talk to the family– Follow up labs– Consider induced hypothermia (if patient meets

indications and family consents to it)• How and why?

Induced hypothermia

• Rational–  Neurologic injury is the most common cause of death in patients after cardiac arrest 

– Standard post cardiac arrest care + induced hypothermia (88-92 degrees) has been shown to improved neurologic outcome. Based on 2012 article by Arrich J, Holzer M

– Hyperthermia must be avoided following cardiac arrest. Failure to control a patient’s core temperature is associated with the development of fever and worse neurologic outcome

Induced Hypothermia

• Indications– Witnessed cardiac arrest/event

• Preferably in the hospital setting as this is when the research was done

– Better outcomes have been shown when used in situations in which ACLS involves “shockable” rhythm such as V-Fib• However it has been studied (limited) in PEA and asystole

– Patient remains comatose for at least 6 hours after event• Technically yes however one of the goals is cooling within 6-12

hours after start of the code so it is better to start immediately than to wait as time is neurons

Induced Hypothermia

• Timing and duration:– Best results have been shown when goal

temperature is reached with in 12 hours after the event and maintained for 48 hours.

Induced Hypothermia

• Goals– Reach 88-92 degrees F by 12 hours after the event– Maintain temperature in this range for a maximum of 48

hours– Do not allow temperature to increase more than 0.25-0.5

degrees an hour (doing so will negate all benefit)– Rewarm at rate of 0.25 to 0.5 degrees an hour until

normal body temperature is reached• Again more than 0.5 degrees in an hour and you lose all benifit

– Avoid fevers after procedure is complete as this can cause increased ICP and cerebral edema

Induced Hypothermia

• Methods and tools to reach goals– External

• Ice packs• Cooling blankets• Thermal suits-only one is in the ER and it is still a prototype

– Internal• Ice water gastric lavage• Ice water bladder lavage• Iced IV normal saline

– Medications• Sedation: propofol, midazolam, ect

– Sedation first

• Paralytics: cisatracurium, vecuronium, ect – Goal is to reduce shivering…most patients end up on a paralytic

Induced hypothermia RRMC protocol

Inclusion criteria– Non- Traumatic witnessed arrest with return of

spontaneous circulation• Less than 15 minutes between arrest and start of ACLS• Less than 60 minutes from event to ROSC• Core body temp over 95 degrees• Good pre-arrest condition (can fxn independently)• Heat stroke

• Exclusion Criteria– Arrest to start of cooling over 6 hours– VF, VT, or PEA for over 1 hour– Asystole for more than 15 minutes– Major traumatic bleeding injury– Patient is awake with normal Mental status within 15-

30 minutes of ROSC– If DNR– If in multi-organ system failure pre-arrest– If family refuses

• Steps– Move to MICU– Stat CBC, CMP, Pt/PTT, CE, ABG, EKG– Repeat all of above q8hrs x3– 2 large bore IV and or CVC– Place on thermosuit if in ER– Place esophageal probe and or rectal probe for temperature

monitoring. Call MD immediately if temperature is out of range – Medication options

• Magnesium sulfate 30mg/kg IVP over 2 minutes • Propofol 20mg IVP to prevent shivering and start drip between

10mcg/kg/min to 50mcg/kg/min• Vecuronium 5mg IVP for shivering per MD only if pt is adequately sedated

• Pre-cooling– Insert NG tube on low intermittent suction– Insert foley– Place protective dressings– Insure AED is in room– Maintain airway with ambu-bag or place on vent– CVC:  pt will be receiving many meds and fluids– Arterial line: hypotension is a major risk and patients

have a high likelihood of ending up on pressors.

• Cooling (goal of 88-92 degrees)– Place cooling mechanism on patient• Ice blanket, ice packs, cool water and air mist

– Provide iced IV saline– contact MD if not at goal temperature in one hour this is the time when you move on to medications• Sedation maxed out first then paralytics if needed

• Re-warming:– Rewarm at less than 0.3 degrees C per hour• No faster than 0.5 F an hour

– Warming blankets– Bair hugger– Continually monitor temperature and use cooling

techniques if patient appears to be warming too quickly

sources

• Pocket ICU• Blue Marino’s ICU Book• Uptodate.com• RRMC e-demand