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PC mode 2
This document discusses mechanical ventilation and the weaning process. It outlines the 7 stages of weaning and indicators for readiness to wean, including parameters like respiratory rate, tidal volume, rapid shallow breathing index, and maximum inspiratory pressure. It describes methods for spontaneous breathing trials and criteria for weaning failure. Difficult weaning can be caused by respiratory, cardiac, psychological, ventilator or nutritional factors. Daily assessment is important to evaluate readiness and avoid complications from prolonged mechanical ventilation.
PC mode 1
PC mode uses pressure control ventilation where the ventilator controls the inspiratory pressure and the patient controls the respiratory rate and inspiratory time. The tidal volume depends on the inspiratory pressure set, lung compliance, and airway resistance. Key settings include inspiratory pressure, respiratory rate, inspiratory time, and PEEP. Plateau pressure and driving pressure should be monitored to avoid overinflation and volutrauma. PEEP is used to prevent alveolar collapse and improve oxygenation but can impact hemodynamics at higher levels by decreasing venous return and cardiac output.
Nutrition in critically ill patients
This document discusses nutrition guidelines for critically ill patients. It recommends starting enteral nutrition within 24-48 hours of admission to provide 25 kcal/kg/day and over 1.2 g/kg/day of protein. Enteral nutrition is preferred over parenteral nutrition when possible. Guidelines suggest not stopping nutrition without a definite medical cause and consulting nutrition support teams.
Review 1 nutrition_case
1. The patient is a 75-year-old male admitted to the EICU for septic shock due to pneumonia and colitis. He received TPN for nutrition support from admission until signs of bowel recovery were seen.
2. Enteral nutrition was started with 500 kcal/day of tube feeding once bowel sounds returned, but was reduced due to distension. IV fluids were given initially until TPN was started providing over 1300 kcal per day.
3. Laboratory findings and the patient's clinical status including hemodynamics, mottling, and ventilator settings are discussed to determine the adequacy and progression of nutrition support and management of septic shock. Further suggestions may be considered.
Mechanical ventilation 1
This document discusses different types of mechanical ventilation and ventilation modes. It begins by outlining four types of respiratory failure that may require mechanical ventilation. It then discusses goals of mechanical ventilation related to oxygenation and ventilation. The document goes on to explain various ventilation modes including volume control, pressure control, pressure support, and APRV. It provides details on settings for tidal volume, minute ventilation, and initial mechanical ventilation settings. Overall, the document provides an overview of mechanical ventilation types, goals, modes, and initial settings.
Mechanical ventilation 2
1. Mechanical ventilation settings like PEEP aim to reduce ventilator-induced lung injuries from atelectrauma and overdistension while improving oxygenation.
2. The optimal PEEP level can be determined through methods like the ARDSnet table, transpulmonary pressure measurements, lung compliance curves, and stress indexes. Higher PEEP recruits more alveoli but may affect hemodynamics.
3. Pressure-volume curves can help identify the lower inflection point and lower deflection point to guide PEEP setting, along with recruitment maneuvers. Slow-flow curves more accurately detect inflection points.
Mechanical ventilation 3
1. Mechanical ventilation can be associated with significant morbidity and mortality if prolonged. Weaning patients from mechanical ventilation in a timely manner is important.
2. There are seven stages of weaning which include assessing patient readiness, conducting spontaneous breathing trials, and using various ventilator modes like pressure support to gradually reduce support.
3. Spontaneous breathing trials for 30 minutes to 2 hours are generally preferred for weaning but gradual reduction over days may be better in some cases. Daily assessment of readiness and trials are recommended with prompt reintubation if trials fail.
Mv trouble shooting
1. Mechanical ventilation troubleshooting involves identifying the cause of a patient's sudden respiratory distress by analyzing monitor alarms, physical signs, and ventilator graphs.
2. Common causes include ventilator issues like leaks, circuit blocks, or setting errors as well as patient issues such as pneumonia or pneumothorax.
3. The document outlines steps for troubleshooting including disconnecting the patient to manually bag and assess response, then treating the most likely problem by procedures like suctioning, adjusting settings, or emergency thoracostomy.
Electrolytes
This document provides an overview of electrolyte disorders including hypernatremia, hyponatremia, hyperkalemia, hypokalemia, and hyperglycemia. It discusses the etiology, clinical effects, and approaches to management. Specifically, it covers how these disorders disrupt osmotic balance and cell volume, outlines factors that influence electrolyte concentrations, and provides guidelines for treatment including shifting electrolytes between intra and extracellular compartments or removing excess amounts. The document compares US and European guidelines for hyponatremia and concludes by thanking the reader.
20201202 cardiogenic shock
Cardiogenic shock is a serious condition where the heart cannot pump enough blood to vital organs, causing hypotension and end-organ damage. The most common cause is acute myocardial infarction with left ventricular dysfunction. In-hospital mortality from cardiogenic shock is high, around 27-51%. Treatment involves stabilization, vasopressor support, mechanical circulatory support if needed, and identifying and treating the underlying cardiac cause, such as through coronary angiography and PCI. Despite aggressive treatment, cardiogenic shock remains a medical emergency with high mortality.
20201118 sepsis and septic shock
1. The document discusses definitions of sepsis, severe sepsis, septic shock from 1992, 2001, and 2016. It describes the criteria for systemic inflammatory response syndrome, sepsis, and septic shock.
2. Guidelines for management of sepsis from the Surviving Sepsis Campaign are summarized, including early goal directed therapy, resuscitation bundles, and antimicrobial therapy recommendations.
3. Key aspects of the updated 2018 Surviving Sepsis Campaign guidelines are highlighted, such as initial fluid resuscitation, hemodynamic support, antimicrobial administration, and duration of therapy.
20201021 pcas care
This document discusses post-cardiac arrest syndrome (PCAS), which refers to the pathology caused by complete whole body ischemia and reperfusion following cardiac arrest. PCAS involves (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischemia/reperfusion response, and (4) persistent precipitating pathology. The document outlines recommendations for targeted temperature management, hemodynamic goals, prognostication of outcome, and organ donation for patients experiencing PCAS.
20200624 aki
This document discusses acute kidney injury (AKI). It notes that AKI is common in ICU patients and associated with increased mortality. Sepsis and postoperative/toxic causes are common. It defines AKI and discusses causes including prerenal, postrenal, and intrarenal. For intrarenal causes, it mentions glomerulonephritis, vasculitis, interstitial nephritis, acute tubular necrosis, and sepsis-induced AKI. It reviews diagnosis and novel biomarkers. Prevention and treatment sections discuss volume expansion, diuretics, vasopressors, vasodilators, sedation, hormonal manipulation, metabolic interventions, statins, and renal replacement therapy.
[03] 20200708 acid base
This document provides an overview of acid-base principles and disorders. It discusses the normal ranges for pH, PCO2, and HCO3 and defines acid-base disorders. Primary acid-base disorders are classified as respiratory or metabolic based on changes in PCO2 or HCO3. Secondary responses to primary disorders and mixed acid-base disorders are also covered. Evaluation of acid-base disorders follows a stepwise approach identifying the primary disorder and any secondary responses. Metabolic acidosis is further evaluated using anion gap, delta gap, and urine anion gap. Causes and treatments of various acid-base disorders are outlined.
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More from GBKwak
PC mode 2
This document discusses mechanical ventilation and the weaning process. It outlines the 7 stages of weaning and indicators for readiness to wean, including parameters like respiratory rate, tidal volume, rapid shallow breathing index, and maximum inspiratory pressure. It describes methods for spontaneous breathing trials and criteria for weaning failure. Difficult weaning can be caused by respiratory, cardiac, psychological, ventilator or nutritional factors. Daily assessment is important to evaluate readiness and avoid complications from prolonged mechanical ventilation.
PC mode 1
PC mode uses pressure control ventilation where the ventilator controls the inspiratory pressure and the patient controls the respiratory rate and inspiratory time. The tidal volume depends on the inspiratory pressure set, lung compliance, and airway resistance. Key settings include inspiratory pressure, respiratory rate, inspiratory time, and PEEP. Plateau pressure and driving pressure should be monitored to avoid overinflation and volutrauma. PEEP is used to prevent alveolar collapse and improve oxygenation but can impact hemodynamics at higher levels by decreasing venous return and cardiac output.
Nutrition in critically ill patients
This document discusses nutrition guidelines for critically ill patients. It recommends starting enteral nutrition within 24-48 hours of admission to provide 25 kcal/kg/day and over 1.2 g/kg/day of protein. Enteral nutrition is preferred over parenteral nutrition when possible. Guidelines suggest not stopping nutrition without a definite medical cause and consulting nutrition support teams.
Review 1 nutrition_case
1. The patient is a 75-year-old male admitted to the EICU for septic shock due to pneumonia and colitis. He received TPN for nutrition support from admission until signs of bowel recovery were seen.
2. Enteral nutrition was started with 500 kcal/day of tube feeding once bowel sounds returned, but was reduced due to distension. IV fluids were given initially until TPN was started providing over 1300 kcal per day.
3. Laboratory findings and the patient's clinical status including hemodynamics, mottling, and ventilator settings are discussed to determine the adequacy and progression of nutrition support and management of septic shock. Further suggestions may be considered.
Mechanical ventilation 1
This document discusses different types of mechanical ventilation and ventilation modes. It begins by outlining four types of respiratory failure that may require mechanical ventilation. It then discusses goals of mechanical ventilation related to oxygenation and ventilation. The document goes on to explain various ventilation modes including volume control, pressure control, pressure support, and APRV. It provides details on settings for tidal volume, minute ventilation, and initial mechanical ventilation settings. Overall, the document provides an overview of mechanical ventilation types, goals, modes, and initial settings.
Mechanical ventilation 2
1. Mechanical ventilation settings like PEEP aim to reduce ventilator-induced lung injuries from atelectrauma and overdistension while improving oxygenation.
2. The optimal PEEP level can be determined through methods like the ARDSnet table, transpulmonary pressure measurements, lung compliance curves, and stress indexes. Higher PEEP recruits more alveoli but may affect hemodynamics.
3. Pressure-volume curves can help identify the lower inflection point and lower deflection point to guide PEEP setting, along with recruitment maneuvers. Slow-flow curves more accurately detect inflection points.
Mechanical ventilation 3
1. Mechanical ventilation can be associated with significant morbidity and mortality if prolonged. Weaning patients from mechanical ventilation in a timely manner is important.
2. There are seven stages of weaning which include assessing patient readiness, conducting spontaneous breathing trials, and using various ventilator modes like pressure support to gradually reduce support.
3. Spontaneous breathing trials for 30 minutes to 2 hours are generally preferred for weaning but gradual reduction over days may be better in some cases. Daily assessment of readiness and trials are recommended with prompt reintubation if trials fail.
Mv trouble shooting
1. Mechanical ventilation troubleshooting involves identifying the cause of a patient's sudden respiratory distress by analyzing monitor alarms, physical signs, and ventilator graphs.
2. Common causes include ventilator issues like leaks, circuit blocks, or setting errors as well as patient issues such as pneumonia or pneumothorax.
3. The document outlines steps for troubleshooting including disconnecting the patient to manually bag and assess response, then treating the most likely problem by procedures like suctioning, adjusting settings, or emergency thoracostomy.
Electrolytes
This document provides an overview of electrolyte disorders including hypernatremia, hyponatremia, hyperkalemia, hypokalemia, and hyperglycemia. It discusses the etiology, clinical effects, and approaches to management. Specifically, it covers how these disorders disrupt osmotic balance and cell volume, outlines factors that influence electrolyte concentrations, and provides guidelines for treatment including shifting electrolytes between intra and extracellular compartments or removing excess amounts. The document compares US and European guidelines for hyponatremia and concludes by thanking the reader.
20201202 cardiogenic shock
Cardiogenic shock is a serious condition where the heart cannot pump enough blood to vital organs, causing hypotension and end-organ damage. The most common cause is acute myocardial infarction with left ventricular dysfunction. In-hospital mortality from cardiogenic shock is high, around 27-51%. Treatment involves stabilization, vasopressor support, mechanical circulatory support if needed, and identifying and treating the underlying cardiac cause, such as through coronary angiography and PCI. Despite aggressive treatment, cardiogenic shock remains a medical emergency with high mortality.
20201118 sepsis and septic shock
1. The document discusses definitions of sepsis, severe sepsis, septic shock from 1992, 2001, and 2016. It describes the criteria for systemic inflammatory response syndrome, sepsis, and septic shock.
2. Guidelines for management of sepsis from the Surviving Sepsis Campaign are summarized, including early goal directed therapy, resuscitation bundles, and antimicrobial therapy recommendations.
3. Key aspects of the updated 2018 Surviving Sepsis Campaign guidelines are highlighted, such as initial fluid resuscitation, hemodynamic support, antimicrobial administration, and duration of therapy.
20201021 pcas care
This document discusses post-cardiac arrest syndrome (PCAS), which refers to the pathology caused by complete whole body ischemia and reperfusion following cardiac arrest. PCAS involves (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischemia/reperfusion response, and (4) persistent precipitating pathology. The document outlines recommendations for targeted temperature management, hemodynamic goals, prognostication of outcome, and organ donation for patients experiencing PCAS.
20200624 aki
This document discusses acute kidney injury (AKI). It notes that AKI is common in ICU patients and associated with increased mortality. Sepsis and postoperative/toxic causes are common. It defines AKI and discusses causes including prerenal, postrenal, and intrarenal. For intrarenal causes, it mentions glomerulonephritis, vasculitis, interstitial nephritis, acute tubular necrosis, and sepsis-induced AKI. It reviews diagnosis and novel biomarkers. Prevention and treatment sections discuss volume expansion, diuretics, vasopressors, vasodilators, sedation, hormonal manipulation, metabolic interventions, statins, and renal replacement therapy.
[03] 20200708 acid base
This document provides an overview of acid-base principles and disorders. It discusses the normal ranges for pH, PCO2, and HCO3 and defines acid-base disorders. Primary acid-base disorders are classified as respiratory or metabolic based on changes in PCO2 or HCO3. Secondary responses to primary disorders and mixed acid-base disorders are also covered. Evaluation of acid-base disorders follows a stepwise approach identifying the primary disorder and any secondary responses. Metabolic acidosis is further evaluated using anion gap, delta gap, and urine anion gap. Causes and treatments of various acid-base disorders are outlined.
More from GBKwak (20)
Imr
- 1. 당직 전담의를 위한 호흡기내과 TIP ★ 암센터에서 호흡기 관련 환자로 call을 받는 경우는 - 암 검사를 위하여 입원한 환자들의 검사 후 합병증 - 암 치료 중 폐 합병증으로 입원한 환자들의 call이다. 호흡곤란이나 산소 포화도가 떨어지는 경우가 많아 반드시 직접 가서 보아 야 하는 경우가 많다. ★ 검사 후 합병증 - PCN시행하고 나서 Pneumothorax를 확인해 달라는 call이 온다. CPA를 봐서 검사 전후로 Pneumothorax 여부를 확인하고, O2를 5L정도 준 다. F/U 하면서 Pneumothorax가 점차 증가 할 경우에는 PCD나 Chest tube 를 넣어야 하며 당직 시에는 TS를 contact 하여 시행한다. 요새는 PCNB를 오전에 시행하여 보통은 주치의가 낮시간동안 F/U하여 영상 에 PCD를 미리 Arrange하는 경우가 더 많은 편이다. - Bronchoscopy/EBUS/BAL 시행하고 당일 열이 나는 경우가 있다. 보통은 post procedure fever이나, 실제 infection일 가능성이 있어, 발열이 지속되거나 하는 경우는 culture시행하고 empirical anti ceftriaxone을 걸어두 어도 밤사이에는 무방하다. ★치료 받으면서 입원중인 환자 밤사이 호흡곤란이나 산소포화도가 떨어지는 전화가 오면 일단 직접 가서 봐야한다. 가는 동안 전화로 O2를 주라하여 산소 포화도는 90%전후로 유지 시키자. <원인 감별> 숨이 찬 원인은 수도 없이 많다. 모르겠으면 적극 검사를 시행하여라. 1) V/S확인, I/O balance, ABGA, CXR, ECG, BNP, D-dimer, 발열시는 CBC, CRP -> 필요시 Chest CT를 시행하여라 - CT arrange시 NPO여부 및 Creatinine level확인 – 필요시 noncon CT
- 2. 2) ABGA확인 후 O2 supplement, Target SaO2 90% - COPD환자의 경우 CO2 retention에 각별히 주의 - 산소 공급시에 O2 6L까지는 Nasal prong으로 주면 되고 그 이상 시에는 Facial mask로 변경하여 유지를 한다. ; Facial mask 6L전후부터는 밤사이 나빠질 가능성이 높기 때문에, 미리 ICU 당직에게 Contact을 하여 향후 나빠질 상황에 미리 대처를 하자. <원인별 management> - Pleural effusion : 이전 Chest PA비교하여 Effusion 양이 많다면 Bedside thoracentesis를 하면 좋으나, 요새는 sono-guided로 시행하는 경향이 있고 pneumothorax주의가 필요하여 v/s이 괜찮다면 PCD consultation을 하고 O2로 유지해본다. V/S이 불안하면 ICU contact하여 ICU 당직 도움을 받는다. - Pneumothorax : O2 therapy 5L/min 유지하여도 악화시에는 30%이상시 흉부외과 contact후 CTD insertion Tension pneumothorax시 emergency thoracostomy(내공부재시) - Pul. Edema : 갑자기 chest PA가 악화가 있거나, 최근 몸무게가 늘거나 I/O +인 경우에 해당된다. BP, renal Fx. 괜찮을 시 Lasix 1@를 투약해보고 소변이 나오는지 확인한다. - Pneumonia : 열이나고 LAB상에 leukocytosis가 있고 crp가 높은데 anti를 안쓰고 있다며 빨리 culture하고 anti tazocin 4.5g iv tid로 시작을 한다. 보통은 주치의가 manage를 하는 부분이라, anti 바꾼지 3일 이내면 그냥 밤사이에는 유지하고 다음날 바꿀수 있게 culture만 잘 해두고, 상태가 좀 안좋다 싶으면 기존에 anti를 쓰던 상태라면 anti step up을 하는데 ceftriaxone -> tazocin -> cefepime -> meropenem으로 올리면 되겠다. - Pericardial effusion : CT상 Pericardial effusion이 이전 CT와 비교하여 양이 늘었거나 혹은 1cm 이상 확인시 심장클리닉 contact하여 PCC insertion 고려한다. - AE-COPD : O2 supplement 주의, nebulizer (ventoline, aventro qid하세요) - Sudden onset의 경우 PTE 의심, d-dimer올라가 있고, 밤사이 Angio CT 확인시 Fragmin start를 한다. 호흡곤란 환자는 상태 변화가 빠를 수 있어, 보다 어려움이 있으면 지체 없 이 ICU당직을 contact 하세요.