UPDATED SESATS critical care

What are the specifics of the Mini-Cog?

The Mini-Cog test can be used as a tool to assess cognition.

Three unrelated words are spoken to the patient to remember. The patient is then asked to draw the face of a clock with the hands on a specific time. The patient is then instructed to recall the 3 words.

For each word recalled, 1 point is given. Drawing a normal clock gets 2 points, and an abnormal clock receives 0 points.

Mini-Cog scores range from 0 (worst score) to 5 (best score). A patient with a score ≤ 3 is considered to have cognitive impairment and additional testing is warranted.

Effects of glucose control (125-200 mg/dL) compared to glucose control target of <250 mg/dL.

- lower incidence of atrial fibrillation

- decreased episodes of recurrent ischemia

- fewer recurrent wound infections

*tighter control is better but elevated is ok during these times.

General guideline for chest tube output at 1, 2, and 4 hours warranting re-exploration.

>400mL/hour for 1 hour

>300mL/hour for 2 hours

>200 mL/hour for 4 hours

When to give preoperative glucocorticoids?

Patients receiving the equivalent of 20 mg or more of prednisone per day for more than 3 weeks.

Patients taking 5-20 mg of prednisone per day and those that have discontinued the use of steroids over the previous year should undergo preoperative evaluation of the HPA axis if possible or, alternatively, should have prophylactic perioperative administration of steroids.

Topical and inhaled glucocorticoids (such as fluticasone) also have the potential to suppress the HPA axis.

Indicators for successful weaning from vent for extubation.

RSBI: When the rapid shallow breathing index (RSBI) exceeds 105 breaths/(L*min) up to 95% of the attempts to discontinue mechanical ventilation will fail.

RR: 40 breaths/min or more being an indicator of increased work of breathing.

MIP: The strength of the diaphragm and respiratory muscles can be evaluated by having a patient exhale to a residual lung volume and then inhale as forcefully as possible. This pressure generated is called a maximum inspiratory pressure (MIP) or negative inspiratory force (NIF). When this value -30 cm H20 or less the likelihood of successful extubation is great; when it is greater than -20 cm H20, it implies poor reserve and a high likelihood of reintubation.

TV: tidal volumes >5 L/min or >6 mL/kg of ideal body weight.

Total ventilation: 5-6 L/min is normal for an adult patient, and if after a spontaneous breathing trial the total ventilation remains <10 L/min, a positive outcome is more likely.

Meds contraindicated in treatment for MG crisis

Atropine, an anticholinergic medication, may be used to support patients with cholinergic crisis (eg, pyridostigmine overdose), and is contraindicated in myasthenic crisis.

Pyridostigmine bromide (Mestinon), acetylcholinesterase inhibitor is usually ineffective during a crisis because the acetylcholinesterase is already maximally inhibited by ongoing (preoperative) use. Because it and other anticholinesterase inhibitors promote oral and bronchopulmonary secretions it is best to withhold them until the crisis is resolved.

HOCM patients that require ICD placement:

In high-risk patients, ICD placement is recommended.

High-risk patients include those with an

- extremely thick (>3 cm) interventricular septum

- evidence of non-sustained ventricular tachycardia

- a family history of sudden death

- a history of syncope.

Surgical septal myomectomy may reduce the risk of sudden death but it does not eliminate it.

How many calories per day

25 kcal/kg per day

How much protein per day

1.2-2.0 grams per kg

Correction rate for acute and chronic hypernatremia

Acute: 12 mmol/(Lxday)

Chronic: 8-10 mmol/ (Lxday)

*it is hyponatremia correction NOT hypernatremia correction that leads to osmotic demyelination syndrome.

Correction rate of hyponatremia

0.5 mEq/hr: no more that 8-10 mEq per day.

Using 3%Na

4T score for HIT

Independent predictive factors for MG crisis post-anesthesia

chances of MG crisis peri-op 12-18%.

- pyridostigmine 360 mg/day

- woman <55, 4:1 likelihood over men

- bulbar symptoms or chronic lung disease

- hx of previous crisis

- post-op pulmonary infection

When do you see Native Lung Hyperinflation

known complication with single lung transplant patients (most commonly done with COPD patient's).

can present acutely with hemodynamic instability and respiratory distress but more commonly presents progressively.

Treatment for native lung hyperinflation

Lung volume reduction surgery of hyperinflated native lung, can improve ventilation of the transplanted lung.

Must to bronchoscopy and transbronchial biopsy first to rule out acute or chronic rejection.

Adverse effect of IABP

thomocytopenia. Occurs in 47-82% of people. Max percent reduction from baseline platelet count usually 30-35%.

Severity of c-diff and treatment (mild/moderate vs severe)

generally oral option preferred when patient is functioning enterally.

Mild/moderate: metronidazole

Severe: vanc

When to use and how much of a dose of methylene blue?

used for treatment of methemoglobinemia. Acts by giving electron to NADPH methemoglobin reductase which converts methemoglobin to hemoglobin again.

1-2 mg/kg.

Adverse effect of certain topical anesthetics

conversion of hemoglobin to methhemoglobin

Treatment for cyanide poisoning

Ferrous state has more affinity for cyanide and can be used as a treatment option for cyanide poisoning by intentionally converting hemoglobin to methemoglobin which binds to cyanide and then is excreted from the body by treating with thiosulfate which binds to methemoglobin cyanide complex forming thiocyanate which is a complex that is excreted.

Nitrites and dapson can lead to ferrous state

TEVAR prevention of intraoperative spinal cord ischemia

Lumbar drain reduces risk of injury by 4-7% according to literature.

Not well validated but practiced, keeping hematocrit above 12 and maintaining elevated BP.

Strongest indicator for stress ulcer prophylaxis

mechanical ventilation 48 hours.

What are lung protective settings on a vent

low tidal volume (6 ml/kg) and plateau pressure <30.

With low tidal volume, minute ventilation and alveolar ventilation are lower which results in a tolerable mild hypercarbia.

ARDS Severity (P/F ratio) and positioning

if moderate to severe severity, mortality benefit seen in early prone positioning.

TRALI what is it, how does it present and how to treat?

transfusion related lung injury. Thought to be due to neutrophil activation in response to blood products.

Can occur up to 6 hours after transfusion. Presents with sudden onset hypoxia and dyspnea with pulmonary opacities on CXR. May have fever and hypotension.

Treatment is supportive.

Signs of cyanide poisoning and anectdote

headache, nausea, vomiting, seizures, flushing, confusion, obtundation.

Treatment, stop nitroprusside (or nitrate or depo causing it) and if bad, can give nitthiosulfate which binds the cyanide methemoglobin complex.

IABP timing issues graphed

sharp V that you want with appropriately times IABP

Fick principle formula

CO = rate of O2 consumption / 10 (1.36x hemoglobin x arterial O2 content - pulmonary artery O2 content)

O2 consumption= 125xBSA

old standard for calculation CI for patients when swan is likely to be inaccurate.

Likely to be inaccurate when tricuspid regurgitation, intracardiac shunts, irregular rhythms, low cardiac output.

Massive, submassive and limited PE definitions

Massive: PE wit hypotension <90

Submassive: PE without hypotension but wit cardiac alterations (wall stress on eco, troponins, elevated BNP)

Limited: PE wit low risk and treated wit anticoagulation.

What to be aware of for vasopleia in patients on SSRI treatment algorithm

beware of giving methylene blue because it is also a MAO inhibitor which leads to serotonin syndrome and can be deadly.

Treatment for serotonin syndrome

Cyrproeptadine is treatment for serotonin syndrome.

Myasthenic Crisis: preoperative prevention and management

If higher risk, can give preoperative plasmapheresis to reduce risk.

If have crisis, intubate, IVIG or plasmapheresis, stop anticholinesterase inhibitor b/c increases secretions while intubated and give high dose steroids.

Factors that put patient at higher risk for MG crisis

if have bulbar symptoms

preoperative expiratory weakness

preoperative vital capacity <2L

hx of MG crisis

antiacetylcholine receptor antibody >100 nmol/L

intraoperative blood loss >1L

Drug used to wean off iNO by helping with pulmonary hypertension after cardiac surgery

sildenafil.

phosphodiesterase inhibitor oral medication

predictors of poor outcome when placed on VA ECMO

diabetes

low EF

SBP <90

prolonged CPB times during prior operation

persistent metabolic acidosis after being on ECMO

increased age

hypoxemia after pulmonary contusions management strategies on ventilator

1st increase PEEP

2nd: prone position with neuromuscular block has had survival benefit in these patients.

VV or VA ecmo help with survival as well.

Dementia in ICU (haldol, Seroquel, precedex, Benzos)

haldol: not recommended for delirium other than that associated with alcohol withdrawal

Seroquel: only for delirium associated with danger to the staff or patient themselves.

precedex: improves duration of delirium when used.

Benzos: worsen delirium.

most common organisms for sternal infection

MSSA then MRSA then GNB then coag neg staph then strep.

pulmonary vascular resistance is increased by :

hypercarbia, acidosis. hypoxemia.

most common cause for readmission after lobectomy

infection post op: pneumonia, empyema, wound infection.

major bleeding on warfarin reversal technique

PCC with vitamin K

only if no PCC do you give FFP (plasma)

Idrarucizumab

reversal agent for dabigatran (direct thrombin inhibitor).

Subsegmental PE treatment guidelines

if low risk of VTE and no DVT in LE's then clinical surveillance recommended over anticoagulant.

if high risk of VTE and/or have DVT in LE's then anticoagulation over clinical surveillance is recommended.

Initial treatment for actinomyces lung abscess

IV penicillin 4-6 wks followed by 6-12 months oral penicillin.

Mechanism in which ARDS causes cor pulmonale (right heart failure)

hypoxia induced pulmonary hypertension

first therapy is to fix oxygenation/optimize the vent settings.

Initial treatment for severe hypercalcemia

IV fluids that do not have calcium and loop diuretics for intravascular balance.

Nissen, Dor, Toupet

Nissen 360 back wrap

Dor: 180 front

Toupet: 270 back