Vent Settings & Supplemental O2

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General Vent Concepts
-oxygenation: PEEP, FiO2
-ventilation: TV, RR

-PEEP = alveolar recruitment (oxygenation)
-RR = time to exhale (ventilation)
-TV = 6-8mL/kg IBW (ideal body weight) — titrate to protect alveoli (baby lungs)

NIV
-IPAP/EPAP = 10/5
-EPAP = PEEP (recruitment/oxygenation)
-IPAP = pressure control (PC) over PEEP (PC minus PEEP = TV) – increasing IPAP (PC) without changing PEEP increases TV (ventilation)

 

Initial Vent Settings

Nonobstructive process:
-PEEP 5
-RR 16 or higher if metabolic acidosis…..MICU: after paralyze, initially ventilate at RR 25-30 to blow off acid accumulated during apneic period

Obstructive (asthma/COPD):
-ZEEP (zero or minimal PEEP/EPAP) with high IPAP (promote air movement for fatigued respiratory muscles)
-low RR (10)

ARDS (baby lung):
-400-450 mL males; 350-400 mL females (4-6 mL/kg IBW)

 

Post Intubation
-bring initial RR to 25-30 – to blow off CO2 accumulated during apneic period
-fentanyl drip, then assess for further need for sedation if tachycardic or diaphoretic (neuromuscular blockade only affects nicotinic/motor receptors)

Check for autoPEEP: hold “expiratory hold”
Check plateau pressure: hold “inspiratory hold”

 

FYI
-prior to intubation of severely acidotic pt, consider giving several bicarb pushes OR bagging pt during apneic period – to prevent pt from coding during apneic period from severe acidosis

Hepatobiliary Disease

Pancreatitis
simple pancreatitis presents with fever ~70% of the time (does NOT mean it’s infected)
-use BISAP score to risk stratify (predicts mortality in ED)
-hyperTG is not that uncommon => when diagnose, send lipid panel

Necrotizing Pancreatitis
-diagnosed by CT (emulsified, infected pancreatic tissue, often gas/emphesematous changes)
-ONLY time you give abx in pancreatitis per EBM
-give carbipenams (meropenam) + flagyl for best penetration into pancreatic tissue

 

FYI
-get tylenol level (and salicylate) in jaundiced pt

 

VP Shunt Patients

Vomiting or altered/drowsy: evaluate for shunt malfunction
-look for hydrocephalus
—get rapid sequence MRI instead of CT head (these pts get many, many CTs)
—either may require sedation (etomidate)

-look for kinks in the shunt
—-shunt series (skull xray, cxr, kub)

Fever + irritability: consider shunt infection
-erythema of skin overlying hardware
-other causes: ears, throat, lungs, abd
-labs, blood culture, UA and culture +/- rapid strep and culture

Shunt taps:
1. Does the shunt need to be tapped?
2. Call NSG (at MMC) vs do it yourself?

Push Dose Pressors (Epi)

Cardiac/Code Epi
-alpha & beta effects (inotropy, chronotropy)
-one ampule = 10 mL syringe = contains 1mg total
-thus 1mg / 10 mL = 1000 mcg / 10 mL ==> 100 mcg / 1mL

Push Dose Epi
-never give cardiac doses (1mg) to pt with a pulse
-use a 10mL saline flush: waste 1mL, draw up 1mL epi (contains 100 mcg) from cardiac ampule
-you now have 100 mcg / 10 mL = 10 mcg per mL in this flush

Dirty Epi Drip
-take the entire ampule (10mL syringe) of cardiac epi and inject into 1L NS bag
-you’ve put 1mg epi into 1000mL NS = 1000 mcg / 1000 mL = 1mcg/mL epi drip
-run wide open in anaphylaxis

 

Phenylephrine
-pure alpha, so all inotropy and no chronotropy
-https://emcrit.org/wp-content/uploads/push-dose-pressors.pdf

 

DKA/HONK Management

DKA
-3 components: Diabetes (BG >250), Ketones (serum/urine BHB*, acetone, acetoacetate), Acidosis (pH<7.3, bicarb <18)
(1) Fluid resuscitate: 15-20 cc/kg NS bolus within first hour
(2) Supplement K if <4 (No benefit for supplementing phosphate)
(3) Give insulin regular/Humalog 0.1 U/kg gtt

Continue until Anion Gap closes. Repeat blood gases q1h.

If glucose drops <150, start D5 0.45NS alongside insulin.

Evaluate for precipitants.

-Note: it is possible for the anion gap to be low/closed at diagnosis/???
-Note: if acidosis is worsening, look for concomitant hyperchloremic metabolic acidosis

*BHB is most sensitive. (BHB comprises ~78%. Acetoacetate ~20%, but is unstable and breaks down into CO2 and acetone, which comprises the remaining 2%.)

 

Euglycemic DKA =  metabolic derangement (low insulin / high glucagon) causing excess ketone production without hyperglycemia
– vomiting is most common symptom
– look for elevated AG and acidosis without high BGM – send urine and serum ketones!
– still require iv hydration and lyte replacement
– require iv insulin to close the gap – however will need to start D5-containing fluids concomitantly
– associated with sodium-glucose co-transporter 2 inhibitors (SGLT-2 inhibitors, or the “zins”)

 

HONK
-Glucose usually very high (600-1000), no/minimal ketones, pH>7.3
-HONK is managed the same way, except the fluid deficit is much greater (the dehydration is chronic). No established guidelines.

Tamponade & Pericardiocentesis

-CXR not sensitive – minimum 200-250cc (large) pericardial fluid produces cardiomegaly

-TEMPORIZE by pushing fluids to increase preload and Trendelenburg

-APPROACHES include subX vs parasternal: choose based on whichever view you see the largest pocket of fluid

-may use central line kit

-Place needle just inferior and lateral to the right of the subX process. Aim at pt’s left shoulder. Numb the tract. Try to visualize needle on US but if pt is in extremis, it’s ok not to (basically blind procedure) as long as you advance cautiously. Take off as much fluid as you can.

-GOAL: Take off enough fluid to stabilize the patient. If tamponade recurs, repeat pericardiocentesis and consider placing a catheter/drain (Rosen’s)

-COMPLICATIONS: myocardial perforation, pneumothorax, laceration of LIMA (esp parasternal approach) or coronaries, dysrhythmias, liver lac (expected as part of subX approach)

5.8.17