CRITICAL CARE FINAL EXAM REVIEW

Ethics has its origins in philosophy

the love of wisdom and the pursuit of knowledge

Ethics is primarily concerned with the question?

how should we act?

Ethics represents commitment to the principle

respect humanity in persons

Autonomy

• principle acknowledges patients personal liberty and their right to decide their own course of treatment

• basis for “ informed consent”

Under this principle, any use of deceit to get to reverse decision to refuse treatment is considered unethical

the principle of autonomy

Veracity

• principle binds health care provider and patient to be truthful

• problems with veracity center around issues with benevolent deception ( withholding truth from patient for his or her own good )

• in most cases telling truth is best policy

Nonmaleficence

• principle obligates health care providers to avoid harming patient and to actively prevent harm when possible

• problems occur when treatment has serious side effects or double effect

• pain caused due to blood draw for diagnostic test

Confidentially

• requires health care workers to respect patients right to privacy

• qualified rather than absolute ethical principle

• in certain situations health care workers are permitted to share patients medical history with others

• risks of inadvertent disclosure of patients protected health information ( PHI ) has increased exponentially with advent of social networking sites

Justice

• involves fair distribution of care

• balance must be found between health care expenses and ability to pay

• rationing of health care services calls for distributive justice

• compensatory justice calls for recovery of damages incurred from medical practice

• less than 2% of health care costs are related to medical malpractices or negligence lawsuits

• costs represent little if any impact on cost of health care

Role Duty

• practitioners have duty to understand limits of role and to practice with fidelity

• respiratory therapists must not perform duties outside defined role

Role fidelity

never divulge information regarding patient condition when asked by the patient/ family member. It’s not our job kindly refer them to the Dr.

Formalism

• view point relies on rules and principles

• rules function apart from consequences of a particular act

• ACT: justifiable if it upholds applied rules or principles

Consequentialism

• ACT: judged to be right or wrong based on consequences

• commonly uses principle of utility— aims to promote greatest general good

• example- withdrawing life support because “ it would be best for all involved”

Virtue ethics

• founded not in rules or consequences but in personal attributes of character or virtue

• allows established practices of profession to give guidance

• ask, “ how should I carry out my life if I am to live well?”

• calls for behavior based on whats goof practitioners would do un similar circumstances

Example of virtue ethics

performing duty for free bc patient is poor

Intuitionism

• Ethical viewpoint holds there are certain self evident truths, usually based on moral maxims

• “ treat others fairly”

• when decision making tool is unhelpful in certain situations, it will depend on intuitional abilities of any specific caregiver

1. Ethical Decision Making Model

identify the problem or issue

2. Ethical Decision Making model

identify the individuals involved

3. Ethical Decision Making Model

identify the ethical principle or principles that apply

4. Ethical Decision Making Model

identify who should make the decision

5. Ethical Decision Making Model

identify the role of the practitioner

6. Ethical Decision Making Model

Consider the alternatives ( long term and short term consequences )

7. Ethical Decision Making Model

Make the decision ( including the decision not to act )

8. Ethical Decision Making Model

follow the decision to observe its consequences

Criminal Law Malpractice

a physician participating in active euthanasia

Civil Law Malpractice

a respiratory therapist who practices below a reasonable standard of care

Civil Court

Made up of juries that decide between two parties

• how wrong was it

• how much reparation

Category of Civil Law best related to resp care

• tort

Tort Law

a civil wrong committed against individual or property for which court provides remedy

1. element of negligence

the practitioner owes a duty to the patient

2. elements of negligence

the practitioner breaches that duty

3, elements of negligence

the breach of duty was the cause of damages

4. Elements of negligence

damage or harm came to the patient

Negligence

failure to perform ones duties competently

Three classifications of malpractice

• criminal malpractice

• assult

• battery

Assult

threatening ( swing a bat and miss )

Battery

physical contact without consent ( swing a bat and connect )

rt example- bronchoscopy without informed consent

Three classification of malpractice

Civil malpractice ( negligence )

Three classification of malpractice

ethical malpractice ( violations of professional ethics, possibly resulting in censure )

Medical supervision

• RT’s required by scope of practice to work under competent medical supervision

• RTs employer either physician or hospital is liable for RT’s actions

• in some states supervising physician may still be liable even if therapist is employed by hospital

• legal theory of failure to supervise

Respondeat superior

let the master answer

Phase one

• gas exhaled from conducting airways/anatomical dead space

• contains no CO2

Phase Two

Represents mixture of anatomical and alveolar gas

Phase three

• exhaled alveolar gas

• alveolar plateau: ETCO2 reading at the end of exhalation

Phase four

• switch between exhalation and inhalation

• sudden drop in waveform to zero

Hypoventilation Waveform

• RR decreased

• VE decreased

Causes of Hypoventilation

• OD

• CNS dysfunction

• sedation

Hyperventilation waveform

• RR increased

• VE increased

Causes of hyperventilation

• Anxiety

• DKA

• PE

Apnea Waveform

• no spontaneous breaths

Causes of Apnea waveform

• cardiac arrest

• respiratory arrest

• equipment failure

• displaced airway adjunct

• ETT totally blocked

Asthma Waveform

• shark fin

• no plateau

• bronchoconstriction

• foreign body in upper airway

• partially kinked/ occulded airway

ROSC Waveform

• CO low/ absent

• pulmonary blood flow is low/absent, then return of spontaneous circulation

Cardiac Oscillation

• heart contracting and relaxing

• seen as notches or oscillations

Curare Cleft

• muscle relaxant wearing off

• diaphragm contraction

• external force on thoracic cavity

SBCO2 is

produced by integration of airway flow and CO2 concentration

Volumetric Capnometry is

presented on a breath to breath basis

X=

CO2 exhaled in one breath

Y=

CO2 not exhaled

• alveolar dead space

• poor or no perfusion

Z=

CO2 not exhaled

• anatomical dead space

Exhaled Nitric Oxide Monitoring

• currently used as a marker for airway inflammation associated with asthma

• exhaled NO ( eNO) quantified using chemiluminescence

Electrochemical sensors normal values:

7.8 to 44.1 ppb

Conditions when NO is reduced

• systemic hypertension

• pulmonary hypertension

• cystic fibrosis

• sickle cell anemia

• ciliary dyskinesia

Conditions when NO is elevated

• asthma

• bronchiectasis

• airway viral infection

• alveolitis

• allergic rhinitis

• pulmonary sarcoidosis

• chronic bronchitis

• systemic sclerosis

• pneumonia

Transcutaneous monitoring

• monitored via electrodes

• O2 and CO2 measured at the skin surface

• heated to 42-45 degrees celsius

Transcutaneous monitoring produces

• capillary vasodilation

• increased blood flow

• temp greater than 41 degrees melts lipid layer

• improves diffusion of gases across the skin

Transcutaneous Monitoring

PtcO2

servo controlled heated clark polarographic electrode

Transcutaenous Monitoring

PtcCO2

Stow- Severinghaus gas electrode

Transcutaneous monitoring limitations

• improper calibration

• trapped air bubbles

• damaged membranes

• the presence of hyperoxemia or a hypoperfused state can increase the difference between PtcO2 and PaO2

Considerations for transcutaneous monitoring

• burns: reposition sensor every 4 to 6 hours

• leak: room air= higher PtcO2 and lower PtcCO2

VCO2 and VO2

% of total energy contributed by substrates

Ketosis RQ=

<0.7

Fat oxidation RQ =

0.7

Protein Oxidation RQ =

0.8

Carbohydrate oxidation RQ=

1.0

Lipogenesis RQ =

>1.0

RQ> 1 ….

introduce high fat low carb diet

diets with a high % of carbs will….

raise the amount of carbon dioxide ( CO2 ) a patient produces.

the added CO2 is greater than the patients ventilatory capacity and when attempting to maintain spontaneous breathing the patient will fail to wean

Hypercapnic Resp Failure

• result of ventilatory pump failure

• resp muscles, thoracic cage and nerves that are controlled by resp centers in the brainstem

Acute hypercapnic Resp failure

pH- LOW

CO2- HIGH

O2- LOW

HCO3- NORMAL

Chronic Hypercapnic Resp Failure

pH-LOW

CO2- HIGH

O2- LOW

HCO3- HIGH

Normal PaO2 mmHg

80-100

Critical PaO2 value

<70 ( FIO2 > 0.6 )

Normal P ( A-a) O2 ( mmHg)

5-20

Critical P( A-a) O2

> 450 ( on O2)

Normal PaO2/PAO2

0.75

Critical PaO2/PAO2

<0.15

Normal PAO2/FiO2

475

Critical PaO2/ FiO2

<200

Maximum Inspiratory pressure MIP Normal Adult Range

-100 to -50

MIP Critical Value

-20 to 0

Vital Capacity VC normal range

65 to 75

VC critical value

<10 to 15

Tidal volume normal range

5 to 8

Tidal volume critical value

<5

Normal RR

12-20 bpm

Normal minute ventilation

5-6 L/min

Minute ventilation above

10 is a concern

• the pt may not be able to sustain the WOB to maintain a stable PaCO2

NIV reduces

the need for intubation and related complications

• reduces mortality rates

• shortnes hospital stay for patients requiring ventilatory assistance

NIPPV advantages

• avoid intubation

• helps avoid risk and complications related to intubation, sedation and lower risk of VAP

• allows pt to maintain normal function ( speak and eat )

NIPPV disadvantages

• lower airway pressure is tolerated

• airway not protected

• not able to suction airway

• not tolerated by some groups of patients

• pressure sores on face