saturday january 28th
DESCRIPTION
A Practical Introduction to Intensive Care. Saturday January 28th. 2012. A one day ‘basics’ of intensive care course. A Practical Introduction to Intensive Care ICU Housekeeping. How did your 1 st day on the ICU go?. Where do you start?. Does it matter?. A Practical Solution … - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/1.jpg)
A one day ‘basics’ of intensive care course
![Page 2: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/2.jpg)
A Practical Introduction to Intensive Care
ICU Housekeeping
![Page 3: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/3.jpg)
How did your 1st day on the ICU go?
![Page 4: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/4.jpg)
![Page 5: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/5.jpg)
Where do you start?
![Page 6: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/6.jpg)
Does it matter?Topic Author Outcome Recommendation
Steroids in septic shock
Spring, 2008 No effect on 28d or 1 year mortalityFaster time to resoultion of shock
Steroids for those on CV support (inotropes/pressors) may reduce duration of support
Semi-recumbent positioning
Drakulovic, 1999 Reduced ventiator associated pneumonia
All mechanically ventilated patients should be 45 head up
Tight Glycaemic control
NICE-sugar investigators, 2009
Increased hypoglycaemia and mortality with tight control
Keep BM 4-10 but tight control (BM4.5-6) not recommended
Sedation holidays Kress, 2000 Reduced duration of mech ventilationReduced LOS on ICU
Daily sedation holds recommended
![Page 7: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/7.jpg)
Topic Author Outcome Recommendations
Low tidal Volume ventilation(6mls/Kg v 12mls/Kg)
ARDSnet, 2000 Low VT associated with lower in-hospital mortality(NNT 11)
Aim for VT no greater than 6mls/Kg keeping Pplat<30 cmH2O
Transfusion Triggers Herbert, 1999 Restrictive v liberal(<7 vs <10)
Restrictive stratergy is probably better in non-cardiac patients
DVT prophylaxis(Enoxaparin 20/40mg)
Samama, 1999 Reduced DVT incidence
Prophylactic LMWH should be administered unless contraindicated
![Page 8: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/8.jpg)
A Practical Solution …the Handover Sheet
![Page 9: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/9.jpg)
![Page 10: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/10.jpg)
Problem Lists: A Solution
![Page 11: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/11.jpg)
Airway
Breathing (Ventilatory Mode)
PaO2:FiO2 Ratio
Positive End Expiratory Pressure
RR:TV Ratio
Peak Airway Pressure
Secretions
Chest X-Ray
Respiratory & Ventilation
P1: VAP? A1: Start Ceftazidime
![Page 12: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/12.jpg)
Acute Lung Injury Acute Respiratory Distress Syndrome
ALI ARDS
<300 (mmHg) <200 (mmHg)
<40 (kPa) <27 (kPa)
P:F Ratios
PaO2 10 on 21%
≠
PaO2 10 on FiO2 100%
P:F = PaO2 / FiO2
![Page 13: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/13.jpg)
Everything’s fine, doc
![Page 14: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/14.jpg)
“Weanable” Not “Weanable”
RR/TV <80 RR/TV >100
Spontaneous Breathing Trial
Pressure Sup port Ventilation
RR/TV
Weaning
![Page 15: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/15.jpg)
Cardiovascular
Rate and Rhythm
MAP
Inotrope / Vasopressor No. 1
Inotrope / Vasopressor No. 2
Steroids
Hb
Markers of PerfusionClinical – Warm Well PerfusedCentral Venous Oxygen SaturationLactateBase Deficit
![Page 16: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/16.jpg)
Cardiovascular Numbers
MAP 65 mmHg is OK
0.5 mcg/kg/min (Adr / NAd) is A LOT
ScvO2 <70% is TOO LOW
Lactate >2 mmol/l is TOO HIGH
Base deficit < -2 is TOO MUCH
![Page 17: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/17.jpg)
Steroids in Sepsis
ControversialPreviously shown to reduce mortality amongst
those unable to mount a steroid stress response (Synacthen)
CORTICUS study (2008): No effect on mortality but faster time to
resolution of shock (i.e. reduced inotrope/vasopressor duration).
Same for responders and non-responders thus synacthen test no longer indicated
![Page 18: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/18.jpg)
Renal
Target Fluid Balance
Achieved Fluid Balance
Urine Output in 24hrs(= hourly urine output)
Oedema
BiochemistryNaKUreaCreatinineMagnesiumPhosphate
![Page 19: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/19.jpg)
Fluid Balance
ControversialCrispy or Bloated?
Colloids for FillingCrystalloids for Maintenance
+500ml / day is normalAdd if febrile / diarrhoea
Subtract if oedema / bad lungs
![Page 20: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/20.jpg)
Renal Numbers
Normal Mg2+ >0.8Give 10mmol over 1 hour
Normal PO43- > 0.8
<0.5 mmol / kg over 6 hours
![Page 21: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/21.jpg)
Target Nutrition In
Achieved Nutrition In
Nutrition Out
Ulcer prophylaxis
BM - Glycaemia
Bilirubin
GI / Liver
![Page 22: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/22.jpg)
Nutrition
Controversial
Starvation is bad (eventually)30ml/kg/day
TNIN ≠ ANIN?Metoclopramide
![Page 23: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/23.jpg)
Gastric Protection
Controversial
Ranitidine / Sucralfate
Ventilator Associated Pneumonia
![Page 24: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/24.jpg)
Glycaemic Control
NICE-SUGAR (2009)Tight (4.5-6 mmol/L) vs conventional
(4.5-10mmol/L) glycaemic control---------------------------------------------------Increased mortality and hypoglycaemic
episodes for tight control. Conventional range recommended
![Page 25: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/25.jpg)
Bilirubin
![Page 26: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/26.jpg)
Haemoglobin
Platelets
Clotting
DVT Prophylaxis
Haematology
![Page 27: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/27.jpg)
Blood in Critical Care
Controversial
TRICC
Exceptions
![Page 28: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/28.jpg)
DVT Prophylaxis
Don’t forget
![Page 29: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/29.jpg)
Sedation Scores
Hypnotic DoseOpiate Dose
Sedation Holidays
CNS Intact?
PNS Intact?
Neuro & Sedation
![Page 30: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/30.jpg)
Temperature
White Cell CountC-Reactive Protein
Organism Site of infection
Antibiotic 1 DayAntibiotic 2 Day
║(Lines ) Central Arterial Vascath
Micro & Sepsis
![Page 31: Saturday January 28th](https://reader035.vdocuments.us/reader035/viewer/2022062301/56814799550346895db4cd8d/html5/thumbnails/31.jpg)