Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
.pdf
MCQ #2 –2023
• What is the next best step?
a) Give methylprednisolone 125 mg daily – no guideline based indication to
give steroids for ARDS secondary to acute inhalation.
b) Reduce PEEP to 10 and repeat an ABG – to optimize oxygenation you
would want to INCREASE PEEP based on the FiO2/PEEP tables.
c) Diurese with Lasix 40 mg IV BID – while we try to keep the lungs ‘dry’, this
has not been shown to have a mortality benefit.
d) Place patient in prone positioning for 16 hrs – based on the PROSEVA trials,
there is a mortality benefit to proning patients if the P/F ratio is less than 150
despite optimizing deep sedation and ventilator settings (ie. PEEP, FiO2).
39
https://t.me/medicina_free
OUTLINE
• Shock and Sepsis
• Respiratory failure
• Weaning from Mechanical Ventilation
• ICU Delirium, Sedation, Analgesia,
Sleep
• Targeted temperature management,
neuroprognostication, DNC, neuro
ICU
• Toxicology
• Extra slides for your reference:
– Acute hypoxia in the ICU
– Gas trapping
– Maternal cardiac arrest
– Liver failure guidelines
– Hyperthermia & Hypothermia
– Toxic ol og y Bo nus Sl id es
– Bonus MCQs
https://t.me/medicina_free
Sedation
SCCM 2018 Guidelines:
• Target RASS -2 to +1 (light sedation)
• Daily sedation interruptions and nurse
titrated protocols can help achieve this
• Propofol or dexmedetomidine are
preferable to benzodiazepines
– Reduced LOS, duration of IMV, delirium
– Beware of bradycardia and hypotension
• Do not use dexmedetomidine if deep
sedation is required
41
4+
Combative,
Violent, Dangerous
3+
Pulls/removes tubes
or catheter,
aggressive
2+
Frequent non
-purposeful mvmt,
dysynchronous
1+
Anxious,
apprehensive, but not
aggressive
0
Alert
and calm
-1
Awakens to voice, eyes open > 10
seconds
-2
Lid sedation, briefly awakens < 10
seconds
-3
Moderate
sedation, moves/eyes open
-4
Deep sedation,
no response to voice,
moves with physical stimulus
-5
Unrousable
, no response to voice or
stimulus
1
. Devlin et al., Crit Care Med 2018; 46:e825–e873
https://t.me/medicina_free
A Note on Dexmedetomidine
• Alpha-2 agonist – acts on CNS receptors
• Recent meta-analysis compared to Propofol and Benzodiazepines
:
– ↓risk of delirium (RR 0.67, 95% CI 0.55 to 0.81; moderate certainty)
– ↓ duration of mechanical ventilation (MD - 1.8 h, 95% CI - 2.89 to - 0.71;
low certainty)
– ↓ ICU length of stay (MD - 0.32 days, 95% CI - 0.42 to - 0.22; low certainty)
– Increased risk of bradycardia (RR 2.39, 95% CI 1.82 to 3.13; moderate
certainty) and hypotension (RR 1.32, 95% CI 1.07 to 1.63; low certainty)
42
Lewis et al. Intensive Care Med 2022; 48(7): 811-840
BONUS
Read on own
https://t.me/medicina_free
Delirium (2018 SCCM Guidelines)
• Treatment of delirium in the ICU
– Nonpharmacologic therapy:
• Optimize mobility, sleep, hearing, vision
• Frequent orientation
• Minimize modifiable risk factors – medications,
transfusions
– Pharmacologic therapy
• Pharmacological agents (statin, anti-
psychotics) should not be used to
prevent
delirium in ICU patients
• Do not routinely use Haldol, atypical
antipsychotic or statin to treat
delirium except
if significant hallucinations, distress, agitation
• Consider dexmedetomidine for intubated
patients with delirium to help facilitate
extubation/weaning
Risk factors:
– “modifiable”—benzodiazepine use and blood
transfusions
– “nonmodifiable”—greater age, dementia,
prior coma, pre-ICU emergency surgery or
trauma, and increasing Acute Physiology and
Chronic Health Evaluation (APACHE) and ASA
scores
• Screen with CAM-ICU
• ICU-Delirium in ICU is associated with:
– cognitive impairment at 3 & 12 months
– longer ICU stay
43
AID-ICU NEJM 2023 Anderson-Randberg
- Haloperidol vs placebo for delirium in ICU
- Number of days alive/out of hospital no different at 90d
- Number of rescue medications for agitation the same in
both groups
https://t.me/medicina_free
Pain in the ICU (2018 SCCM Guidelines)
Multimodal approach to pain management
• Opioids are mainstay, especially post-op, but associated with side
effects (respiratory depression, delirium, dependence)
• Adjuncts should be used to reduce opioid requirements
– Acetaminophen, NSAIDS (where appropriate)
– Low dose ketamine (0.5 mg mg/kg bolus then 1-2 mcg/kg/min infusion) in
post-operative patients
– Gabapentin, pregabalin, carbamazepine for neuropathic pain
– Do not
routinely use lidocaine, local anesthetics or inhaled volatiles for pain
adjuncts (may be effective for special circumstances – postoperative, trauma)
• Others recommended: cold therapy, relaxation techniques, music,
massage
44
https://t.me/medicina_free
Sleep (2018 SCCM Guidelines)
• Use non-pharmacologic component to improve sleep
– Limit noise (ear plugs)
– Light reduction (eye shades)
– Avoid sleep disruption
• Do not use Propofol to promote sleep
– Unable to make recommendations for dexmedetomidine or melatonin
to promote sleep
• Consider assist-control over pressure support at night to
improve sleep in appropriate (ventilated) patients
45
https://t.me/medicina_free
OUTLINE
• Shock and Sepsis
• Respiratory failure
• Weaning from Mechanical Ventilation
• ICU Delirium, Sedation, Analgesia,
Sleep
• Targeted temperature management,
neuroprognostication, DNC, neuro
ICU
• Toxicology
• Extra slides for your reference:
– Acute hypoxia in the ICU
– Gas trapping
– Maternal cardiac arrest
– Liver failure guidelines
– Hyperthermia & Hypothermia
– Toxic ol og y Bo nus Sl id es
– Bonus MCQs
NEW!
• 2 new guidelines
• Canadian journal of Cardiology
• Neurocritical Care Society (American)
*Slides will focus on Canadian guidelines*
https://t.me/medicina_free
MCQ 3 -2024
75 year old patient is admitted to the ICU after an out-of-hospital cardiac arrest. The patient was found
by bystanders. No CPR was initiated before paramedic arrival. The initial rhythm was ventricular
fibrillation, they required multiple shocks for Vfib/VT, with a total downtime of approximately 20
minutes.
In the ER: Intubated and diagnosed with a STEMI. They underwent PCI with angioplasty to the LAD. Postcardiac arrest management included therapeutic hypothermia targeting 35-36 degrees C. It is now 96 hrs
since the arrest and the following information is available:
Examination shows absent pupillary reflexes bilaterally, absent corneal reflexes bilaterally, M1 on motor
examination. CT head shows subtle reduced grey-white matter differentiation with a ratio of 1.5.
When considering neuroprognostication for this patient, which of the following results best predicts a
poor neurological outcome (cerebroperformance categories 3-5)?
1. Initial rhythm during cardiac arrest
2. Duration of cardiac arrest
3. Absent pupillary light reflexes at 72h
4. CT head results
5. Motor examination findings
47
https://t.me/medicina_free
Post Arrest Targeted Temperature Management
1. Continuous monitoring of core temperature in comatose
patients after ROSC.
2. Actively prevent fever (T < 37.7
o
C) with antipyretics and
cooling blankets set to 37.5
o
C.
3. Actively prevent fever for at least 72 hours.
4. Do not actively rewarm patients with mild hypothermia to
achieve normothermia after ROSC.
48
2022 ERC-ESICM Guidelines
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана