Chapter 41

Critical Care Medicine

Weaning off Vent:

-SBT daily – 30 to 120 min trial of breathing w/o assistance from ventilator (or pressure support
trial). Perform daily.
 Daily SBT shortens duration of mechanical ventilation and improve mortality
-for extubation – pt must have adequate airway reflexes to handle secretion, avoid upper
airway obstruction. No signs of inc work of breathing. HDS stability. Adequate oxygenation.
PEEP <8, GiO2 <.5. Normal acid-abse. Vital capacity >10cc/kg. Neg inspiratory force >30cm H2O.

VTE:
-hypercoagulability, venous stasis, vascular endothelial damage – almost all should receive
LMWH
-IVC filters (not routine) or SCDs in pts with contraindicated to drugs

Nutrition:
-caloric needs predicted based on ideal body weight, 15-20% protein
-feeding tube if pt can’t take nutrition. If >7d, then do total pareneteral nutrition (TPN) – inc
infection complications.

Glucose Control:
-hyperglycemia – common, a/w inc risk infection, poorer outcomes in stroke/TBI/MI pts. 140-
180.
-stress ulcer ppx not routine, but used in intubated pts, high risk pts, etc

Transfusion:
-Hb <7 – transfuse except in cases of acute MI, unstable angina, acute blood loss, neuro injury.

Common Diagnoses in ICU:

-nosocomial infection: common include ventilator associated pneumonia, central line
associated blood stream infection, catheter associated UTI, cdiff infection
-ventilator associated pneumonia: dec with SBT. Bugs include hemophilus influenza, strep
pneumo, MSSA. Nonsensitive – staph MRSA, pseudomonas, Acinetobacter. 8d tx for sensitive,
14 for nonsensitive.
-UTI: try to remove bladder, aseptic technique during placement

ARDS: hypoxemic respiratory failure, diffuse alveolar damage, noncardiogenic edema, reduce
thoracic compliance, inc dead space and shunt
-result of injury to lung (aspiration, pneumonia), extra pulm infection (Sespsis), injury (Trauma)
-supportive tx
-lung protective strategy: TV <6 ml/kg, static airway pressure of <30cm h2o. Can lead to
permissive hypercapnia and respiratory acidosis.
 If not for pairing with HIGHER PEEP, could lead to atelectasis/inc shunt.
-prone positioning shows mortality benefit in severe ARDS for rescue technique. NO inhaled
nad inhaled prostacyclines can improve oxygen in ARDS. Also extracorporeal lfie support.

-in sepsis, norepinephrine is first line pressor

-consider adding vasopressin at fixed rate as adjunct
-consider dobutamine if low CO persists despite fluid resuscitation
-dopamine and phenylephrine not recommended

-steroids: stress dose steroids in pts who are hypotensive despite adequate volume
resuscitation and vasopressor therapy