Specific organ support in icu
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This document summarizes specific organ support considerations in the ICU, including the brain, heart, lungs, kidneys, liver, hematology/coagulation, skin/soft tissue, and endocrine system. Key points covered include oxygenation and ventilation strategies for respiratory support, indications for renal replacement therapy, transfusion thresholds for blood products, and general measures to prevent complications like bed sores.
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- Dry surface
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CRRT is a continuous renal replacement therapy that provides a gentler form of dialysis for critically ill patients. It works through slow, continuous removal of waste and fluid over multiple days rather than the typical 4 hour sessions of hemodialysis. This puts less stress on the heart. CRRT can be delivered through various modes including continuous venovenous hemofiltration, hemodialysis, or hemodiafiltration that utilize diffusion, convection, or both to clean the blood. Anticoagulation is required to prevent clotting of the dialysis circuit and can include regional citrate or low-dose heparin.
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Stage-based management of acute kidney injury (AKI) involves monitoring for progression from risk to injury to failure. For stage 1 (risk), monitoring to prevent progression is recommended. For stage 2 (injury), conservative therapy is recommended due to high risk of mortality/morbidity. For stage 3 (failure), renal replacement therapy (RRT) should be considered due to highest risk of death. Continuous renal replacement therapy (CRRT) is preferred for hemodynamically unstable patients and allows for slow correction while maintaining hemodynamic stability. Higher CRRT doses of 35 ml/kg/hr may improve survival compared to lower doses, though optimal dosing remains controversial.
Central venous catheterization
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renal replacement therapies
Renal replacement therapies like dialysis and continuous renal replacement therapies are used to replace kidney function in patients with kidney failure. Dialysis involves diffusion of toxins out of the bloodstream across a semipermeable membrane. The main types of dialysis are hemodialysis, which uses an external dialysis machine, and peritoneal dialysis, which uses the patient's peritoneum. Hemodialysis requires vascular access via an arteriovenous fistula or graft and occurs several times per week. Peritoneal dialysis involves infusing dialysate into the peritoneal cavity daily to remove waste through the peritoneum. Continuous renal replacement therapies continuously filter blood using convection and diffusion.
Defibrillation & Cardioversion
- Ensure safety of area
- Check rhythm post shock
- Continue compressions if needed
Patient Safety
- Dry chest
- Oxygen removed
- Pads placement
- Minimize number of shocks
Equipment Safety
- Check pads/battery
- Connect properly
- Replace pads regularly
Environment Safety
- Dry surface
- Away from fluids/gas
- Clear working space
Abg presentation
An arterial blood gas (ABG) analysis measures pH, carbon dioxide, oxygen, bicarbonate and oxygen saturation levels to aid in diagnosis and treatment. Key components include pH, PaCO2, PaO2, HCO3, O2 saturation and base excess. ABGs help evaluate acid-base balance, guide ventilator management and monitor for electrolyte abnormalities. Conditions like respiratory acidosis or alkalosis and metabolic acidosis or alkalosis can be diagnosed based on patterns of pH, PaCO2 and bicarbonate levels. Mixed disorders may involve two or more concurrent acid-base imbalances.
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ACUTE RENAL INJURY
Acute renal injury, also known as acute renal failure, can develop suddenly in hospitalized patients and is classified as prerenal, intrarenal, or postrenal. Prerenal failure results from decreased blood flow to the kidneys, intrarenal failure damages the kidneys directly, and postrenal failure involves urine outflow blockage. Treatment focuses on identifying and reversing causes, maintaining fluid and electrolyte balance, and initiating dialysis for severe cases. Nursing care monitors for complications and educates patients on diet, medications, symptom reporting and managing the condition.
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Shock is a life-threatening condition caused by inadequate tissue perfusion. It has several stages from initial to irreversible. The main types are hypovolemic, cardiogenic, obstructive, distributive, and neurogenic. Hypovolemic shock results from a loss of intravascular volume and is the most common type. Diagnosis involves assessing vital signs and fluid status. Treatment focuses on restoring volume with fluids and blood products, addressing the underlying cause, and supporting organ function. Close monitoring for complications is important during resuscitation.
Dialysis
Hemodialysis and peritoneal dialysis are two types of dialysis used to replicate kidney function for patients with kidney failure. Hemodialysis uses a machine to filter waste from the blood outside of the body through a semipermeable membrane, while peritoneal dialysis introduces fluid into the abdomen to draw waste from the blood vessels within. Both aim to control fluid balance and remove toxins when the kidneys are unable to do so, helping to correct conditions like fluid overload, electrolyte imbalances, and metabolic acidosis. Key differences between the two include that hemodialysis requires vascular access while peritoneal dialysis uses a permanent catheter, and that hemodialysis is done at a center several times a week
HYPERTENSIVE CRISIS
A 76-year-old male is admitted to the ICU for recovery after lung surgery. His BP is 168/96 mmHg without end-organ damage, so this represents a hypertensive urgency rather than emergency. Fundoscopic exam is not needed for this transient postoperative hypertension. Starting IV antihypertensives or consulting a hypertension specialist are not necessary actions at this time. The patient should be reassessed later since there is no end-organ damage currently.
Hypertensive crisis
A 76-year-old male is admitted to the ICU for recovery after lung surgery. His BP is 168/96 mmHg without end-organ damage, so this represents a hypertensive urgency rather than emergency. Fundoscopic exam is not needed for this transient postoperative hypertension. Starting IV antihypertensives or consulting a hypertension specialist are not necessary actions at this time. The patient should be reassessed later since there is no end-organ damage currently.
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AKI & CKD for DCM-converted.pdf
This document provides an overview of acute kidney injury (AKI). It defines AKI and discusses its causes, diagnosis, staging, management principles, and outcomes. The main points are:
- AKI is defined as a rapid reduction in kidney function over hours to days. Common causes include low blood flow, toxins, infections, and ischemia.
- Diagnosis involves blood and urine tests to assess kidney function and rule out other issues. Staging of AKI severity is based on changes in creatinine and urine output.
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Shock is caused by inadequate systemic oxygen delivery that activates autonomic responses to maintain circulation. The main types of shock are hypovolemic, septic, cardiogenic, anaphylactic, neurogenic, and obstructive. Treatment focuses on airway control, oxygen delivery, circulation optimization through fluid resuscitation, and achieving hemodynamic goals to restore tissue perfusion. Early goal directed therapy for septic shock involving aggressive fluid administration and inotropes improves outcomes.
Shock
Shock is characterized by a systemic reduction in tissue perfusion resulting in decreased oxygen delivery. There are four main types of shock: hypovolemic, cardiogenic, obstructive, and distributive. The goals of resuscitation are to increase oxygen delivery and decrease demand. Treatment involves establishing IV access, fluid resuscitation, vasopressors, inotropes, antibiotics for infection, and treating the underlying cause. Endpoints of resuscitation include restoration of blood pressure, normalization of heart rate, urine output, lactate levels, and mental status.
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2) Management involves fluid resuscitation and monitoring for warning signs of severe disease like abdominal pain, vomiting and bleeding. Patients requiring emergency treatment have severe plasma leakage, hemorrhage or organ dysfunction.
3) Complications include fluid overload, shock, bleeding, and organ impairment of the liver, brain or kidneys which require intensive monitoring and organ-specific treatment.
Heart failure
This presentation provides an overview of heart failure, including:
1. It defines heart failure as when the heart is unable to pump sufficiently to meet the body's needs, which can result from systolic or diastolic dysfunction.
2. Some key statistics on the incidence and prevalence of heart failure worldwide and in India are presented.
3. Heart failure is classified in different ways such as whether it affects the left or right side of the heart, and whether it involves forward or backward failure.
4. The etiology, clinical presentation, diagnostic assessment, medical management including medications, and surgical options for treatment are discussed at a high level.
Blood pressure changes during
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2. Blood pressure fluctuates significantly during hemodialysis due to changes in vascular volume, cardiac output, and systemic vascular resistance. Both hypotension and hypertension are common complications.
3. Preventing intradialytic blood pressure issues involves accurate dry weight determination and gradual, steady ultrafiltration. Treatment of issues focuses on fluid balance, vasoactive medications, and optimizing dialysis prescription elements like sodium and temperature.
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Shock
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Responsibilities of respiratory therapist
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ABCDEF bundle: ICU Liberation Bundle
A – Assess, Prevent and Manage Pain
B – Both SATs and SBTs
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D – Delirium: Assess, Prevent and Manage
E – Early Mobility and Exercise
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3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
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Specific organ support in icu
- 1. Specific Organ Support in ICU Fakhir Raza SIUT
- 2. Specific Organ Support • We need to support following organs • Brain • Heart • Lungs • Kidneys • Liver • Hematology & Coagulation • Skin and soft tissue • Endocrine
- 3. Brain • No parenteral non-ionic fluid must be given • Keep plasma sodium concentration >140 mmol/l. A fall produces an osmotic gradient across the blood-brain barrier and aggravates cerebral oedema • Avoid hyperglycaemia and hypoglycaemia. Hyperglycaemia may aggravate ischaemic brain injury by increasing cerebral lactic acidosis. Blood glucose levels >11 mmol/l should be treated • Feed through an orogastric tube. Gastric motility drugs can be given as required • Anti-thromboembolism stockings; avoid low dose heparin • 15-30° head up tilt with the head kept in a neutral position may improve cerebral perfusion pressure
- 4. ICP management • Hypertonic saline • Mannitol • Hyperventilation • Sedation and paralysis • EVD • Craniectomy • Non invasive and invasive monitoring of ICP
- 5. Brain Perfusion • Perfusion pressure depends upon ICP and MAP • Increasing Mean Arterial pressure or decreasing Intracranial pressure
- 6. Heart support • Hemodynamic support – Already discussed in general organ support • Arrythmias • Myocardial infarction • Pericardial tamponade
- 7. Arrythmias • All unstable tachyarrythmias should be treated with shock • Broad complex tachycardia with shock should be treated as ventricular fibrillation • Amiodarone is drug of choice in ICU in most supraventricular and ventricular tachyarrythmias • Electrolytes should be corrected to prevent recurrent arrythmias • Potassium, Magnesium and calcium are important
- 8. Myocardial infarction • Mostly in ICU, MI is due to systemic illness and can’t be treated with PCI or thrombolysis • Supportive treatment and anticoagulation is indicated along with antiplatelet therapy (if no contraindications exist)
- 9. Pericardial temponade • It is treated with symptomatic and causing right heart dysfunction
- 10. Respiratory support • Mechanical Ventilation • Oxygenation • How much oxygen to be given • Ventilation
- 11. Respiratory Support • Oxygenation: • Nasal canulla • Venturi mask • Non rebreathing mask • Mechanical ventilation • PEEP • I:E ratio • FiO2 • Proning • ECMO /ELS
- 12. Liver Support • Portal Hypertension • Hepatorenal syndrome • Hepatic encephlopathy • SBP • GI bleeding • https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/lt.24815
- 13. Liver support • ABC • Maintaining sugar • Making sure that patient moves bowel • Medicines for decreasing portal hypertension • Antibiotics for SBP • Terlipressin when indicated • GI clearance • Coagulopathy
- 14. Kidney Support • Fluid balance • Electrolyte balance • Acid base balance • Solute balance (urea) • Renal replacement therapy
- 15. Indication of RRT in ICU • Acute kidney failure • Acute on chronic kidney failure • On going dialysis for End stage kidney failure patients admitted for any other reason
- 16. Indications of dialysis • Without RRT mortality from the complications of fluid overload, refractory hyperkalaemia, and metabolic derangement would be far higher
- 17. Hematologic support • Packed RBC transfusion • Platelet transfusion • FFP transfusion • Clotting factors replacement • Plasmapheresis
- 18. Transfusion of blood products • Most critically ill patients do not need RBC transfusions when Hgb is greater than 7 g/dL • Hb target may be above 8 g/dL for those with non-STEMIs and perhaps as high as 10 g/dL for patients with STEMIs • Although FFP often is transfused to correct coagulopathy and prevent bleeding in a nonbleeding coagulopathic critically ill patient, there is no evidence to support its use • little evidence exists to support the prophylactic transfusion of platelet concentrates in nonbleeding thrombocytopenic patients
- 19. Skin and soft tissue • Turning the patient with care is the best way of preventing bed sores in ICU patients • Soft tissue infections and DVT should be actively searched with the help of ultrasound and treated promptly • These two conditions are confusing and may be overlapping • Any breach in skin should be taken seriously as it can progress quickly • General measures like good nutrition, moisturizing the skin and regular washing can prevent bed sores
- 20. Endocrine • Blood sugar control is important as a general measure in all ICU patients • The target is less then 10 mmoles or less then 180mg% in all patients • IV insulin infusion is needed in ICU patients especially in the presence of shock • Hydrocortisone is indicated in refractory septic shock patients (need of vasopressors despite of adequate fluid resuscitation) • Thyroid disease should be suspected in unexplained hyponatremia, somnolence and hypothermia
- 21. Blood components • Function of RBC _______________________ • Function of Platelet ____________________ • Function of Plasma ____________________
- 22. What precautions should be taken while transferring patient from one bed to another • A team should take care of patient • Airway should be protected • All lines should be secured • Monitoring should be continued