ICU topics for Final FRCA


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ICU topics for Final FRCA

  1. 1. Intensive Care MedicineTopics for the Final FRCA<br />Dr. Andrew Ferguson<br />
  2. 2. Why ICU matters for the FRCA…<br />20 specific questions in MCQ<br />Helps with medicine/surgery MCQs<br />SAQs - 1 or 2 questions for sure…maybe more<br />SOE 1 - potential topic/part of topic<br />SOE 2 - 10 minutes of pure fun!<br />
  3. 3. Be calm…<br />The examiners are human (honestly!!!)<br />The questions are (mostly) mainstream<br />You will have seen many of the cases<br />Guillain-Barre / Myasthenic crisis / weakness<br />Brainstem death <br />Status epilepticus and asthmaticus<br />Trauma<br />Septic shock<br />ARDS<br />Acute pancreatitis<br />Burns<br />Some questions just won’t lie down and die e.g. PAC<br />
  4. 4. But don’t be complacent…<br />People still fail the exam! 10/17 passed in 2008<br />Don’t assume you know enough…make sure you do<br />Structure…structure…structure!<br />Don’t waffle - answer the actual question, not the one you wanted to be asked!!<br />
  5. 5. Other potentials…<br /><ul><li>Acute hepatic failure
  6. 6. Sedation
  7. 7. Fluid balance and outcome
  8. 8. Nutritional therapy
  9. 9. Tissue oxygenation and oxygen delivery
  10. 10. Abdominal compartment syndrome
  11. 11. Cardiogenic shock
  12. 12. Clostridium difficile
  13. 13. Scoring systems</li></li></ul><li>Examples…<br />In the question on the brain-stem dead patient, too many candidates included detail of brain stem testing in their answers, which was not required. Candidates are reminded to answer the question as written; no credit will be given for irrelevant information<br />It cannot be emphasised enough that the answer provided to the  examiners is  less than a page and is focused completely to the question.<br />
  14. 14.
  15. 15.
  16. 16. Case scenario 1<br />49 year old female, history of depression & anxiety found unconscious in apartment having failed to turn up for work<br />On arrival A&E GCS 5-6, BM = 0.4<br />After 50ml 50% glucose BM = 14.5 and GCS 12-14<br />Bruising left buttock and thigh<br />Tender abdomen, jaundiced, BP 75/45, HR 104, Temp 34.1<br />CT brain NAD, CT abdo - mild hepatomegaly, ? fatty<br />Labs: Lactate 10.2, Bili 27, AST 4465, ALT 1945, INR 4, Paracetamol 25, tox negative, K 1.9, Ca 0.8, PO40.4, Hb 10.4, WBC 15.9, Plts 102, CK 595<br />
  17. 17. Questions for discussion<br />What are the main differential diagnoses?<br />What other information/tests would you like?<br />Why is the GCS abnormal?<br />How do you assess fluid status and responsiveness?<br />What does the lactate level tell you?<br />Why is the B low and how will you tackle it?<br />How do you assess the adequacy of oxygen delivery?<br />Does this patient need antibiotics?<br />What problems are likely in the next 24-48 hours?<br />
  18. 18. INFO<br />Acute hepatic failure<br />“Life-threatening multi-system illness resulting from massive liver injury. The defining clinical symptoms are coagulopathy and encephalopathy occurring within days or weeks of the primary insult in patients without pre-existing liver injury”<br />Auzinger G, Wendon J. Curr Opin Crit Care 2008; 14: 179-188<br />Early death despite support<br />Survival with supportive therapy (liver regeneration)<br />Unlikely to survive with supportive therapy alone<br />candidate for emergency transplant<br />NOT candidate for emergency transplant<br />
  19. 19. INFO<br />Aetiology based therapy<br />
  20. 20. INFO<br />Paracetamol toxicity<br />Major paths<br />Enhanced risk<br />Excessalcohol<br />Enzyme-inducing drugs<br />carbamazepine<br /> phenytoin, <br /> phenobarbitone<br /> St John's Wort<br /> rifampicin<br />3. Glutathione depletion<br /> malnutrition<br /> eating disorders <br /> malabsorption<br /> HIV<br />Minor path<br />NAPQI<br />
  21. 21. N-acetylcysteine<br />INFO<br />(1) Initially 150mg/kg in 200mL glucose 5% given over 15 minutes, then<br />(2) 50mg/kg in 500mL glucose 5% given over 4 hours, then<br />(3) 100mg/kg in 1000mL glucose 5% given over 16 hours<br />
  22. 22. INFO<br />Paracetamol<br />Referral criteria<br />Non-paracetamol<br />
  23. 23. INFO<br />Non-paracetamol<br />Paracetamol<br />Referral criteria - Kings College Hospital<br />
  24. 24. Clinical Issues in ALF<br />INFO<br />CNS<br />Encephalopathy - ammonia => glutamate<br />Intracranial hypertension - oedema<br />Cardiovascular<br />Intravascular volume depletion<br />Vasodilatation<br />Subclinical myocardial damage (Tn > 0.1 in 66%)<br />Respiratory<br />Hypoxia - effusions, atelectasis, shunting, splinting, ALI<br />
  25. 25. Clinical Issues in ALF<br />INFO<br />Renal<br />Oliguria<br />Acute renal impairment - drugs, hepatorenal, pre-renal, ATN, intra-abdominal hypertension<br />Haematological<br />Thrombocytopaenia and coagulopathy <br />Procedural bleeding possible<br />Spontaneous bleeding rare<br />Infection <br />Monocyte (HLA-DR), complement, Kupffer cell failure<br />Responsible for most deaths!<br />
  26. 26. INFO<br />Useful references<br /> Kramer DJ, Canabal JM, Arasi LC. Application of Intensive Care Medicine Principles in the Management of the Acute Liver Failure Patient. Liver Transplantation 2008; 14: S85-89.<br /> Auzinger G, Wendon J. Intensive Care Management of Acute Liver Failure. Current Opinion in Critical Care 2008; 14: 179-188.<br /> Stravitz T. Critical Management Decisions in Patients with Acute Liver Failure. Chest 2008; 134: 1092-1102.<br />
  27. 27. Case scenario 2<br />56 year old male, history of IHD/PVD/smoker/MI/EF 35%<br />Admitted to ICU following emergent leaking AAA repair…complicated by intraoperative ST depression and hypotension<br />On arrival ICU BP = 90/45, HR 121 SR, NA @ 0.5 mg/kg/min, lactate 5<br />CVP 14, pO2 11 on 70% O2with PEEP 5, creps bilaterally<br />ECG: infero-lateral ST depression<br />In theatre 4 L crystalloid, 2 L tetraspan, 6 packed cells, 2 FFP<br />Abdomen distended and tense, skin clammy<br />Over next 4 hours: NA increasing, lactate 8, U/O poor<br />Labs: Hb 9.5, Plts 85, WBC 7.9, Na 141, K 5.3, U 10.5 Creat 168, APTT 47, PT 18, fibrinogen 0.95<br />
  28. 28. Questions for discussion<br />List the main clinical issues in this case<br />How would you approach the respiratory failure?<br />What factors contribute to the hypotension/malperfusion?<br />What is your strategy to improve haemodynamics?<br />What is your target for fluid balance in the next 24 hours?<br />How does PPV assist the left ventricle?<br />What other monitors/investigations might assist you?<br />When would you involve the surgeons?<br />
  29. 29. INFO<br />Cardiogenic Shock<br /><ul><li>Definition
  30. 30. Incidence
  31. 31. Aetiology
  32. 32. Pathophysiology
  33. 33. Therapy</li></ul>Clinical:<br /><ul><li> Hypotension i.e. SBP below 90 mmHg
  34. 34. Impaired tissue perfusion
  35. 35. After correction of non-cardiac factors</li></ul>Haemodynamic:<br /><ul><li>Cardiac index < 2.2 litres/min/m2
  36. 36. Systolic blood pressure < 90 mm Hg
  37. 37. LAP/RAP > 18 mm Hg or PCWP > 16
  38. 38. Urine output < 20 ml/hr
  39. 39. SVR > 2100 dynes-sec·cm–5</li></li></ul><li>INFO<br />Incidence & Mortality<br />[1] The CREATE-ECLA Trial Group. Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction: the CREATE-ECLA Randomized Controlled Trial. JAMA 2005; 293: 437–446.<br />[2] Babaev A, Frederick PD, Pasta DJ, et al. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA 2005; 294:448–454.<br />[3] Jeger RV, Harkness SM, Ramanathan K, et al. Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry. Eur Heart J 2006; 27:664–670.<br />[4] Chen ZM, Pan HC, Chen YP, et al. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomized placebo controlled trial. Lancet 2005; 366:1622–1632.<br />
  40. 40. INFO<br />Echo indicators of mortality<br />
  41. 41. INFO<br />Pathophysiology<br />
  42. 42. INFO<br />Cardiogenic Shock<br /><ul><li>Definition
  43. 43. Incidence
  44. 44. Aetiology
  45. 45. Pathophysiology
  46. 46. Therapy</li></li></ul><li>INFO<br />Pathophysiology<br />Target for therapy?<br />At least 20% of CS patients have SIRS and low SVR<br />
  47. 47. INFO<br />Therapy- Reducing iNOS<br />Effect of Tilarginine Acetate in Patients With Acute Myocardial Infarction and <br />Cardiogenic Shock - The TRIUMPH Randomized Controlled Trial. JAMA 2007; 297: 1657-1666<br /> “Excessive NOS results in high levels of nitric oxide that, in turn, lead to inappropriate systemic vasodilatation, progressive systemic and coronary hypoperfusion, and myocardial depression”<br />
  48. 48. INFO<br />Cardiogenic Shock: Therapy<br /><ul><li>Optimise volume / oxygenation / rhythm
  49. 49. Inotropic agents & vasopressors
  50. 50. b agonists
  51. 51. a agonists
  52. 52. PDE III inhibitors
  54. 54. sensitizes myocardial contractile proteins to calcium
  55. 55. independent of sympathetic NS and so NO increase in MVO2
  56. 56. Prolonged action beyond infusion duration
  57. 57. IABP
  58. 58. PCI</li></li></ul><li>INFO<br />Abdominal compartment syndrome<br />Increasingly recognised problem<br />LOOK for it! - don’t forget “medical” ICU patients<br />Thinks about screening if<br />Large volume resuscitation > 3.5 L in 24 hours<br />Abdominal Surgery/Primary Fascial Closure<br />Coagulopathy or polytransfusion<br />Pulmonary, renal or hepatic dysfunction<br />Acidosis<br />Hypothermia<br />Ileus<br />Physical exam is NOT accurate<br />
  59. 59. INFO<br />Intra-abdominal pressure<br />Abdominal perfusion pressure = MAP - IAP (aim > 60 mmHg)<br />
  60. 60. INFO<br />Abdominal CompartmentSyndrome<br />ACS = sustained IAP > 20 mmHg (with or without APP < 60 mmHg) that is associated with new organ dysfunction/failure<br />World Society of the Abdominal Compartment Syndrome (<br />
  61. 61. INFO<br />
  62. 62. INFO<br />
  63. 63. Case scenario 3<br />25 year old female, “fit and well”<br />Admitted to ICU after 6 day prodromal illness (fever, aches) followed by confusion, shortness of breath and now fluid-resistant hypotension<br />Intubated in A&E as hypoxic and combative, received 3 L saline<br />On arrival ICU BP = 75/40, HR 135 SR, NA @ 0.7 mg/kg/min, lactate 7, CVP 9, pO2 9 on 100% O2with PEEP 7, creps bilaterally<br />Temperature 39.7, flushed<br />Over next 2 hours: NA increasing, lactate 9, U/O poor<br />Labs: Hb 10.5, Plts 65, WBC 27.9, Na 137, K 3.3, U 12.5 Creat 138, APTT 47, PT 19, fibrinogen 1.0, CK 290<br />
  64. 64. Q: Comments on Xray appearance?<br />
  65. 65. Questions for discussion<br />What is the differential diagnosis?<br />What are the possible sources?<br />What are the principles of management?<br />Describe your haemodynamic targets and approach<br />How do you make the diagnosis of ARDS?<br />What ventilator settings will you choose?<br />What principles guide your ventilation strategy?<br />What are your ventilator targets?<br />
  66. 66. Sepsis: Know what you mean…<br />INFO<br />SIRS - 2 or more of the following<br />Temperature > 38 or < 36 oC<br />Heart rate > 90 bpm<br />Respiratory rate > 20/min or pCO2 < 4.2 kPa<br />WBC > 12000/mm3 or < 4000/mm3 or > 10% bands <br />Sepsis<br />Systemic response to infection<br />SIRS + infection<br />Severe sepsis<br />Sepsis + organ dysfunction, hypotension or hypoperfusion<br />May be oliguria, encephalopathy or lactate rise<br />Septic shock<br />Sepsis induced SBP < 90 mmHg or SBP fall > 40 mmHg<br />PLUS hypoperfusion despite adequate fluid resuscitation<br />i.e. sepsis-induced hypotension requiring vasopressors<br />
  67. 67. Principles of septic shock management<br />INFO<br />Initial resuscitation<br />Fluid resuscitation - ? EGDT (Rivers)<br />Diagnosis<br />Antibiotic therapy<br />Source identification and control<br />Haemodynamic and adjunctive therapy<br />Vasopressors and/or inotropes (know characteristics & pros and cons)<br />Steroids (know relative adrenal insufficiency principles)<br />rhAPC (know trials and controversies)<br />Other support<br />Blood products<br />Safe ventilation in ALI/ARDS (know ARDSNet etc.)<br />Sedation (know sedation breaks)<br />Glucose control (know controversies medical v surgical pts)<br />RRT<br />DVT prophylaxis<br />Stress ulcer prophylaxis (relationship to Cdiff?)<br />Limitation of therapy?<br />
  68. 68. When septic shock isn’t just septic…<br />INFO<br />TOXIC SHOCK SYNDROME<br />Toxins act as “superantigens”<br />Activate up to 30% of neutrophils (normal <0.1%)<br />Cytokine storm => MSOF<br />Differences in treatment from “simple” septic shock<br />Prodromal illness…source can be subtle => LOOK HARD<br />Remember vaginal infections<br />Predominant organisms<br />S. aureus (often blood culture negative)<br />Menstrual and non-menstrual forms<br />May not have protective antibodies<br />Group A strep (majority blood culture positive)<br />Therapeutic principles<br />As for septic shock BUT<br />Toxin suppressing antimicrobial: clindamycin or linezolid<br />Immunoglobulin 1g/kg then 0.5 g/kg for 4-5 days<br />
  69. 69. Q: Nutrition - how and why?<br />Your patient stabilises over the next 18-24 hours<br />She weighs 60 kg at baseline<br />She hasn’t eaten at home for 5 days<br />How are you going to support her nutrition?<br />What are her requirements?<br />How much do you give her today?<br />How do you manage “intolerance”<br />Why is nutrition important?<br />
  70. 70. INFO<br />Nutrition Support/Therapy<br />When to feed = EARLY (< 36 hours) if possible<br />Support EN with TPN but EN preferred<br />Early nutrition decreases infection, hospital LOS and may decrease mortality<br />CUMULATIVE ENERGY DEFICIT KILLS!!!!<br />> 10000 kcal deficit correlates with poor outcome<br />= 5 days off food in sepsis!!<br />every day in ICU without feeding is a day closer to death!<br />
  71. 71. INFO<br />Nutrition Support/Therapy<br />Nutrition modulates stress response<br />Nutrition modulates systemic immunity<br />Gut surface area = tennis court!!<br />Exposure to and in harmony with trillions of organisms<br />GALT = gut associated lymphoid tissue - appropriate exposure enhances systemic immunity<br />
  72. 72. INFO<br />Nutrition Support/Therapy<br />No feeding + systemic illness = leaky gut (BAD)<br />Antibiotics = higher pH and less anaerobic flora (BAD)<br />Anaerobes produce substances which enhance immune response (GOOD)<br />Fewer anaerobes = poor WBC function and more systemic infection (BAD)<br />Leaky gut = bugs and cytokines (BAD)<br />GUT-LUNG conduit: bugs/cytokines via thoracic duct and heart to pulmonary capillary bed => lung inflammation (BAD)<br />
  73. 73. INFO<br />Nutrition Support/Therapy<br /><ul><li>Short-chain fatty acids related to anaerobe levels
  74. 74. Short-chain fatty acids are colonocyte fuel
  75. 75. WBCs have receptors for SCFA = imprived function!
  76. 76. Attention to nutrition/antibiotics and pre/probiotics</li></li></ul><li>INFO<br />What and how much?<br />Energy (kcal)<br />generally 25 kcal, up to 35 kcal/kg<br />start at 25-35% of requirement if refeeding syndrome risk<br />Protein<br />generally 1.25 g/kg<br />no need for < 1g/kg in acute liver disease<br />Lipids<br />? omega-3 FA’s in ARDS (favour anti-inflammatory eicosanoids)<br />Trace elements<br />selenium in sepsis?<br />Amino acids<br />arginine (vasodilatory)<br />glutamine (enterocyte fuel and ? better WBC function in trauma)<br />
  77. 77. INFO<br />
  78. 78. INFO<br />
  79. 79. INFO<br />
  80. 80. INFO<br />
  81. 81. INFO<br />
  82. 82. INFO<br />
  83. 83. INFO<br />
  84. 84.<br />
  85. 85. Fluid Balance & OutcomeIt’s not IF they should be dry... it’s WHEN<br />