Anaesthesiology & Intensive Care
💉 Types of anesthesia
- 😴 General anesthesia
- 💉 Local & Regional anesthesia
- 👾 Special patients
🔩 ICU Management
- 💥 Pain
- 🫁 Respiratory insufficiency & Ventilation
- 🚰 Fluid Resuscitation, Blood Transfusion & Acid-Base
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Mismatch betw. O2 demand and supply of tissues + organs
Disorder of circulatory system → inadequate organ perfusion + tissue hypoxia → metabolic disturb. → irreversible organ damage
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1) Hypotension
2) Signs of end-organ hypoperfusion:
🧠brain : altered conciousness or other mental disturbance, weakness, dizziness, nausea
🥐kidney ⇒ 🚱 oliguria
💪skin ⇒ 🧊 cold, mottled, clammy/diaphoretic+ ↓recap time
→ exception: distributive⇒ 🥵 might be warm+flushed+ normal recap
3) Specific signs depending on type of shock (see below)
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The following stages may not occur in cases of sudden severe cardiovascular collapse, and the progression between stages in septic shock can be indistinct.
Pre-Shock
compensated, non-progressive shock
appears IMMEDIATELY after triggering event
Compensatory mechanisms only:
- Peripheral vasoconstriction
- 💪 🧊 cold + clammy + ↓recap
- may be absent in distributive shock ❗
- ❤️ ↑HR
- 🥐 Oliguria
Shock
decompensated, progressive shock
- ✨ ↓BP
- Hypoperfusion →🍼 Lactic acidosis (high AG metabolic acidosis)
⇒ 🧠 Altert mental stage
⇒ DIC
⇒ worsening tachypnea
End-organ dysfunction
irreversible shock
ORGAN FAILURE due to ISCHEMIA, INFLAMM. MEDIATOR + REPERFUSION INJURY
- 🧠 - autonomic dysfunction
- 🧠 - ↓/↑ activity
- ⇒ ❤️ - ↓↓output
- ⇒ 🫁 ⇒ ARDS ⇒ micro-thrombi
- ⇒ 🥐 ⇒ ischemia, oliguria, ↑↑RAAS + tubular necrosis
- ⇒ 🍑 ⇒ ischemia ⇒ ↑transaminases
- ⇒ 🍤 ⇒ ischemia ⇒ translocation of gut bacteria ⇒ septic shock
- ⇒ 🩸 (coagulation) ⇒ DIC + Thrombocytopenia
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- Volume
- Shift ⇒ DISTRIBUTIVE shock
- Capillary leakage ⇒ SEPTIC shock
- Vascular tone dysregulation
- Loss ⇒ HYPOVOLEMIC shock
- Blood ⇒ HEMORRHAGIC shock
- Body fluids (i.e. GI) ⇒ NON-HEMORRHAGIC NON-TRAUMATIC shock
- Plasma (i.e. burns) ⇒ NON-HEMORRHAGIC TRAUMATIC shock
- Output
- Cardiac ⇒ CARDIOGENIC shock
- Myocardium (i.e. MI)
- Conduction system → arrhythmias
- valves
- Extracardiac ⇒ OBSTRUCTIVE shock
- Impaired filling ⇒ TAMPONADE
- ↑after-load ⇒ (massive) PE
- Obstruction of venous retunr ⇒ TENSION PNEU
⇒ ANAPHYLACTIC shock
⇒ NEUROGENIC shock
TYPE | CAUSES |
💧 HYPOVOLEMIC | - fluid loss (GI, burns)
- hemorrhage (esp TRAUMA) |
❤️ CARDIOGENIC | - cardiac ischemia
- arrhythmias
- valvulopathies
- cardiotoxic substances (see toxins) |
🚧 OBSTRUCTIVE | - cardiac tamponade
- PE
- tension pneu |
🔥 SEPTIC | - infection
- bacteremia |
🤧 ANAPHYLACTIC | - exposure to allergens
(food, sting, drug) |
🧠NEUROGENIC | CNS injury:
- traumatic brain injury
- intracerebral hemorrh.
- spinal cord injury |
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- hypodynamic shock = all shocks, except distributive
- hyperdynamic shock = distributive
→ ↓ CO
→ ↑ SVR
→ ↑O2 extraction + lactic acidosis
→ variable CO (see next question)
→ ↓ SVR
→ normal O2 extraction
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TYPE | OUTPUT | PRE-LOAD (PCWP or JVP) | AFTER-LOAD
(SVR) |
💧 HYPOVOLEMIC | ↓ | ↓ | ↑ |
❤️ CARDIOGENIC | ↓↓ | ↑ | ↑ |
🚧 OBSTRUCTIVE | ↓↓ | ↑ or ↓ | ↑ |
🔥🤧🧠 DISTRIBUTIVE | 🧠 ↓
🔥 🤧 early:↑ ; late: ↓ | ↓ | ↓↓ |
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AFTER-LOAD:
↑ due to compensatory ↑ in vascular resistance (vasoconstriction)
in distributive shock: ↓↓ due to vasodilation
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Gap between systolic + diastolic BP
⇒ wide in distributive
⇒ narrow in cardiogenic (+others)
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Sytolic BP = marker for Cardiac Output
Diastolic BP = marker for SVR
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All have usually ↓BP + ↑HR (except: neurogenic = ↓HR)
+ SIGNS OF SPECIFIC ETIOLOGY
💪 skin perfusion | 🚹 jugular v. | ⭐ specific | |
💧 HYPOVOLEMIC | 🧊 cold + diaphoretic + ↑recap
↓tugor+dry membranes
| Ødistended | -signs of cause (bleeding, diarrhea)
-Shock index (HR/BP) > 0.9 |
❤️ CARDIOGENIC | 🧊 cold + diaphoretic + ↑recap | distended + ↑JVP | -HF signs (i.e. dyspnea)
-signs of cause (chest pain, palpitations, murmor)
-mechanical complication (mitral insuff, septal/free wall rupture + taponade, aneurysm) |
🚧 OBSTRUCTIVE | 🧊 cold + diaphoretic + ↑recap | distended + ↑JVP | -signs of cause (chest pain, ↓breath sounds, tracheal deviation, muffled heart sounds, DVT signs) |
🔥 SEPTIC | early: 🥵 warm + flushed
late: 🧊 cold + pale + ↑recap | -🤒 sepsis signs (fever, SIRS criteria)
Source signs(signs of pneumonia, UTI, menigitis) | |
🤧 ANAPHYLACTIC | 👹 rash + flushed + edematous | 🫁 - stridor, wheezing, cough
💩 - vomiting + diarrhea | |
🧠NEUROGENIC | 🥵 warm + flushed | ↓❤️ BRADYCARDIA
neurological-deficits |
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👉🏽
The patient is placed in supine position with the torso elevated to 45 degrees and the head rotated away from the examiner. Tangential lighting can help elicit the finding. Determine the vertical distance between the upper limit of visible distention of the internal jugular vein and the sternal angle. A distance > 4 cm is considered elevated.
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- Systemic inflammatory response syndrome (SIRS):
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LAB:
- ↑Lactate ⇒ Metabolic acidosis
- CBC, inflammatory lab → hemorrhage, sepsis?
- cultures (BEFORE AB tx)
- troponin → cardiac?
OTHER
- EKG + Echo→ cardiac? obstructive?
- FAST → hemorrhage?
- CT Brain, Abdomen → neurogenic? septic? 3rd space fluid loss (pancreas, obstruction)?
- Chest Xray → obstructive? cardiac? sepsis (pneumonia)?
- other exams depending on etiology
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⇒ BUT: clinical dgx!
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Parameter | Class I | Class II | Class III | Class IV |
Blood loss (mL) | Up to 750 | 750–1500 | 1500–2000 | > 2000 |
Blood loss (% blood volume) | Up to 15% | 15–30% | 30–40% | > 40% |
Pulse rate | < 100 | 100–120 | 120–140 | > 140 |
Blood pressure | Normal | Normal | Decreased | Decreased |
Pulse pressure (mm Hg) | Normal or increased | Decreased | Decreased | Decreased |
Respiratory rate | 14–20 | 20–30 | 30–40 | > 35 |
Urine output (mL/h) | > 30 | 20–30 | 5–15 | Negligible |
CNS/mental status | Slightly anxious | Mildly anxious | Anxious, confused | Confused, lethargic |
Fluid replacement | Crystalloid | Crystalloid | Crystalloid and blood | Crystalloid and blood |
Stage 1 (+2) ⇒ 🌊fluids
Stage (2+) 3 ⇒ 🌊fluids + 🩸blood
Stage 4 ⇒ 🌊fluid + 🩸blood + 🔪surgery (hemostasis)
Normal volume:
- adults: 7% of ideal body weight (approximately 5 I / kg for 70)
- children: 8% of ideal weight (approx. 80 mL / kg)
Q. 4th stage of hemorrhagic shock is defined by:
(A) Low systolic blood pressure
(B) Normal diastolic blood pressure
(C) Diuresis 5-15 ml/h
(D) Heart rate > 140 /min
(E) Heart rate <100 /min
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AD
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primary evaluation! (first ABCDE)
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Type of shock | Treatment |
💦 Hypovolemic: | 1. 🌊Fluids
(i.v. location depending on injury or CV catheter)
2. 🩸 hemorrhage
-Blood transfusion
-Hemostatic control (emergency surgery🔪) |
❤️ Cardiogenic: | 1. ⚠️ check fluid responsiveness
(dry = output problem vs. wet = congestion problem)
2. Output maintenance (preload, afterload, contractility)
- 🏵️ Inotropes (Dobutamin, Milrinone)
-🔺 Vasopressors (NE)
-⚠️ Diuretics (only if sysBP >90)
3. Definite tx: PCTA, stents, thrombolysis
4. OTHERS
(oxygen, AB +electroly. correction, arrythmia correction, Mechanical assistant devices) |
🚧 Obstructive: | 1. 🌊 Fluids
2. 🪡 Relieving intervention
-Pericardiocentesis
-Thoracostomy
-Thrombolysis |
🔥 Septic shock: | 1. 🌊 Fluids
2. 🔺 Vasopressors (NE, vasopressin, ØE!)
3. 🧫 infection
-AB
-Infectious source control
4. OTHERS
(consider FFP or Platelets if DIC; steroid if adrenal dysfunction, ventilation in ARDS, sedation, analgesia, glycemic control, bicarb if acidosis, ulcer. + DVT prophylaxis) |
🤧 Anaphylactic: | Initial:
1. 🌊Fluids
2. 🫀 Epinephrine bolus (if refract. other vasopressor)
3. Stop the exposure + airway maintanance
LATER:
- 🐝 Anti-histamines, 🌝steroids, 🎺 bronchodilators
- 🔺vasopressor (NE, vasopressin) |
🧠 Neurogenic: | 1. 🌊 Fluid
2. 🔺 Vasopressors (NE, vasopressin)
3. 🥀 Atropine (for bradycardia) |
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- ⬇️ Injury below the diaphragm:
- 1 above: At least 1 i.v. line should be placed in a tributary of the superior vena cava.
- ⬆️ Thoracoabdominal damage:
- 1 above: At least one i.v. access site should be above the diaphragm.
- 1 below: One access below the diaphragm.
→ Never i.v. access in injured limb
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The content of Na Osmolarity pH The amount of water provided Glucose requirements (calories) Anticipated rate of administration
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Ringer Lactate
- large quantities + prolonged
- lactic acidosis
- Ø in RF, high need of free water, in transfusion line + hyperK
Saline solution
- RF
- hyponatremia , hyper
- transfusion line
- !! → hyperchloremic acidosis + hypokalemia
emergency:
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- unnoticed loss of fluids (i.e. hemorrage after fracture)
- ventilation problem
- wrong Dgx
- other type of shock
- Addison crisis + DKA
- Hypothermia
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mainly clinically!
- 🧠mental status
- 🩸 perfusion
- Vitals (RR, HR, Resp-rate)
- Diuresis
- Periph perfusion: recap-time
- CVP
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- Start primary evaluation - ABC(DE)
- Start Tx during primary evaluation
- Evalulate FLUID LOSS
- Figure out TYPE of shock
- Assess RESPONSE to Tx
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- Vitals
- HR
- BP invasive → Ø good indicator of tissue perfusions
- CVC
- Pulmonary artery catheter
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- SvO2 = mixed venous saturation
- Lactate (arterial)
- VO2 = O2 consumption
- DO2 = O2 delivery
- CO2 clearance
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- SvO2 (Mixed Venous Saturation): It is a measure of the oxygen saturation of venous blood returning to the heart. It indicates the balance between oxygen delivery and consumption in the tissues.
- Lactate (Arterial): Lactate is a byproduct of anaerobic metabolism and is measured in arterial blood. Elevated levels of lactate can indicate tissue hypoxia or inadequate oxygen delivery.
- VO2 (O2 Consumption): VO2 represents the amount of oxygen consumed by the body per unit of time. It reflects the metabolic needs of the tissues and is an important parameter to monitor during anesthesia.
- DO2 (O2 Delivery): DO2 is a measure of the amount of oxygen delivered to the tissues per unit of time. It depends on cardiac output, hemoglobin concentration, and arterial oxygen content.
- CO2 Clearance: CO2 clearance refers to the removal of carbon dioxide from the body. It is an important parameter to monitor during anesthesia as elevated levels of CO2 can indicate inadequate ventilation.
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