Tag Archives: cardiac

5th East Midlands Critical Care Conference – take home notes

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Leadership & Management – Merrill & Reid Social behaviour types/personalities. Know who you are and who you are dealing with.

http://www.ucd.ie/t4cms/Personality%20Categories.pdf

https://www.gotoquiz.com/your_personality_1

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Anaesthesia for PH/protecting RV – Goldilocks. Not overloaded, not undefiled, must be just right.

Pulmonary Hypertension: sPAP>40mmHg, mPAP>25. sPAP = RAP + 4x[TRVmax]^2

Mort 5%

ECG: strain pattern. RAD. ST depression V1- V4

On echo: TR Vmax = underestimate.

RHS: TAPSE<15mm, RV thickness >5mm (in diastole)

Tips: Open, not laparoscopic surgery. A-line + CVC. Avoid ketamine/des/N2O (as they increase PVR). fiO2 0.6, PEEP 5-8. PaCo2 4-4.5. Warm everything. Post-op HDU/ICU. Phone a friend – local/own PH unit. Should they be for full MOS? What is disease trajectory? Beware NYHA Class 3-4.

Signs of problems: High CVP + low BP, low SpO2, reduced end organ perfusion. Consider cautious fluid bolus 150-200ml OR diuretic. Optimise ventilation, Keep in SR (Amiodarone +/- DCCV), avoid b-blocker. Start norad +/- vasopressin. Then adrenaline. Then milrinone. Then iNO, epoprostenol

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Liver failure.

Think: Is it the culprit or a bystander? Is it treatable? What further investigations (imaging, bloods, bx) will help?

Mortality: encephalopathy > ascites + bleed > other

Citrate RRT seems to be safe. However need to consider low Ca2+:Ca2+ ratio. Monitor for accumulation + toxicity

Use albumin for high volume replacement. Evidence only for paracentesis.

Adrenal dysfunction, so consider steroid (hydrocortisone 50mg qds) if increasing vasoconstrictor.

In GI bleeed -> start NG feed early (despite ‘protein load’ )

Prophylaxis antibiotics

Early TIPS

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Obesity

BM ventilation usually is biggest challenge. DL usually is ok – though increased difficult predicted in neck circ > 40 cm (especially > 50cm) + MP3. Apples worse than pears.

Proposed induction strategy:

Pre-O2 in ramped position, fiO2 0.8, PEEP 5-10

Early iGel instead of BMV

Muscle relaxant

Video laryngoscopy

If predicted difficult DL/VL + can’t access neck think AFOI

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Need patient centred (not doctor centred) outcome measures. Ideally standardised.

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On fatigue. Samn Perelli scoring system.

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Vitamin D

In UK all population at risk of Vit D def which increases mortality which can be treated/reversed with treatment. Jury is out on ICU treatment of Vit D, however screening and treatment may be prudent/pragmatic.

VITDAL – ?

Currently in progress VITALISE, VIOLET

Vit D3 better than cholicalciferol.

Should we screen pre-op?

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Frailty.

Consider having electronic frailty index (based on Rockwood method). Works with EMIS and SystemOne.

Assessment methods: Gait speed, Clinical Frailty Score, Edmonton Frailty Score

 

Pulmonary hypertension

mean PAP > 25 mm Hg

Classification:

  1. Pulmonary arterial e.g. IPAH, systemic sclerosis, congenital heart disease
  2. Secondary to left heart disease
  3. Secondary to chronic lung disease
  4. Chronic thromobo-embolic
  5. Multifactorial/unknown

ECHO features:

  • Estimation of sPAP in Apical 4-Chamber view. PH likely if estimated sPAP>50 mm Hg
  • Other features of PH: dilated right side chambers, reduced RV function, RVH, enlarged PA, abnormal inter-ventricular septum motion

Management:

  • Ca-channel blockade
  • Prostacyclin
  • Endothelin receptor antagonists
  • NO
  • PDE-5 inhibitor
  • TREAT PRIMARY CAUSE
  • consider (CTPA) +/- treat VTE
  • diuretics

http://www.escardio.org/guidelines-surveys/esc-guidelines/guidelinesdocuments/guidelines-ph-ft.pdf