COMMON TREATMENT ORDER AND PRACTICAL  Practical knowledge in ICU

KNOWLEDGE FOR ICU - Cardiovascular

- Respiratory

REFERENCES - GI system/nutrition

 Hospital docs - Neurology/neurosurgery

- PMH ICU Department protocols, orientation tutorials - Renal, fluids and electrolytes

- PWH ICU Department protocols - Microbiology/sepsis/infectious diseases

- QMH Infection Control Notes to new interns/residents - Trauma

(1/2014) - Endocrinology
rd
- Handbook of Internal Medicine (HA, 2011, 3 Ed) - Radiology

- HA guidelines - Miscellaneous

 Lectures/tutorials/training sessions/clinical experience  Medications

- Central Commissioned Training Program 2014 - Emergency - Analgesics

Bedside ECHO (12/12/2014) - Antimicrobials

- HA ECMO Simulation Training (22/10/2014) - Antiseptic

- Lecture on intubation (Dr Rita So, AC, PMH Anaes) - Electrolyte disturbance

(19/9/2014) - Inotropes

- Residency @ PMH ICU (7-12/2014) - Muscle relaxant

- Beyond BASIC Course – Airway Management (20-21/1/2015) - Sedative

 Books - Nutrition

- The ICU Book (4th Ed, 2014) - Miscellaneous

 Online resources (including journals)  Short forms

- CRRT (JPMA, 2012)

- Ventilatory mx (Michael N. Cocchi, 2011) BACKGROUND

- Cardiovascular complications of brain injury (Continuing

Education in Anaesthesia, Critical Care & Pain, 2011) Organ failure

- Airway management.ppt (Dr CHAN King Chung Kenny, 2006)  Shock (“CHOD” – cardiogenic, hypovolemic, obstructive,
- Critical Care Medicine Tutorials distributive)
(http://www.ccmtutorials.com/)  CNS: GCS, confusion, coma
- Deranged Physiology (http://www.derangedphysiology.com/)  Lungs: ALI / ARDS
- Critical Care Drug Manual | Life in the Fast Lane  Cardiovascular: heart failure (systolic vs. diastolic, right vs. left)
(http://lifeinthefastlane.com/book/critical-care-drugs/)  Kidneys: AKI (anuria, met acidosis, hyperK, fluid overload)
- ICU web | CUHK (http://aic-server4.aic.cuhk.edu.hk/web8/)  Liver: liver failure and its asso complications
- Google, YouTube  GI: ileus
*Please refer to the notes of BASIC and Beyond BASIC courses  Coagulopathy: DIC

CONTENT Organ support a/v in ICU

 Background  CVS: inotropes (NA, adrenaline, dobutamine)
 Common bedside procedures / investigations / scoring scales in ICU  Resp: stepwise approach
- Line insertion 1. MV +/- sedate and paralyse
- CNS 2. Lung recruitment (PEEP)
- Respi  Indx: refractory hypoxaemia ie. PaO2 <50mmHg
- Cardi (6.7kPa) on FiO2 1.0
- Abd 3. Positional change ie. prone ventilation (**evidence-based)
- Miscellaneous
 4. Advanced ventilator modalities e.g. APRV, HFOV (rarely used  Keep good documentation.

here in PMH ICU)  Don’t hesitate to ask for help from the 2nd call (during call) and your

5. ECMO seniors. ICU is team work, not one man show.

 Renal: CRRT

 Sepsis: anti-microbial

 Haemat: blood products

 Nutrition: TPN (parenteral), RT feeding (enteral)

*N.B.: need for intubation (i.e. MV) can be easily determined by clinical

assessment (e.g. resp distress), but that of CRRT often relies on lab results

(RFT, ABG)

Procedures commonly performed in ICU  *know the indx, contraindx,

potential risks/cx, weaning

 Line insertion: A line, central line, hemocath

 USG or echo, +/- tapping (pleural, abdomen)

 Bronchoscopy

 Airway: intubation, bedside tracheostomy

ROS (charts/labs/exam, problem list, mx plan)

 CVS, resp, GIT, neuro

 Nutrition/BGA, renal, sepsis/microbiology, haemat/clotting

Examinations (head to toe)

 Monitors/infusions/ventilator

 Patient: GC, head to toe, lines/drains

- Review indications
- Look for cx

- Plan to remove/wean

Ward round

 Review clinical progress

- Active problem

- Organ function

- Any need to start organ support vs. weaning/titration

 FU plan by parent team e.g. OT, scope, rescan

 Specific blood test, imaging, consultation, bedside procedure

Tips

 Always JUSTIFY your mx plan and clinical decision.

 Patient first. Documentation next.

 Facilitate the weaning (hence early discharge) of the patient e.g.

fast 6am for possible extubation that day

 Treat the patient. Don’t solely treat the lab results/monitor

values/nurses’ comments without a good explanation.

COMMON BEDSIDE PROCEDURES / INVESTIGATIONS / SCORING - Respiratory variation (in fluid depleted state)

SCALES IN ICU  Transverse vs. longitudinal view

- Needle puncture

Line insertion  Once entering the skin, look at the USG mon

A line  Approach

 Siting: radial x2, dorsalis pedis x2 = 4 - Transverse: fan the probe to look for needle

 If fails, insertion of single lumen catheter using Seldinger technique tip every time you advance it, aspirate as you

and aseptic procedure at femoral arteries advance the needle (睇下抽得順唔順), avoid
to-and-fro movement which may cause

Central line (7Fr) unintended puncture

 Types: single vs triple lumen - Longitudinal: bevel towards feet, L-and-R

- Single: for femoral artery catheterization if difficult A line movement to position the needle tip under

- Triple: almost always used for central venous access the probe window, observe the needle tip on

 Siting real-time as you advance, no need to aspirate

- USG guided: IJ x2, axillary x2, femoral x2 = 6  Off syringe to observe blood flow + blood colour

- Blindly: IJ x2, subclavian x2, femoral x2 [no anatomical (venous vs. arterial)

landmark for axillary approach] - Seldinger technique

- Rarely do subclavian nowadays as difficult hemostasis  Thread guidewire into needle, gauze over, needle out

- According to preference: axillary > IJ > femoral  Dilator in, dilator out

 Axillary approach: - Never use scalpel unless thick skin (reduce

- : easier hemostasis by external compression bleeding), stretch the skin for easier entry

- : highest risk of PTX (must be supervised for  Thread CVC along guidewire, guidewire out

beginners) - Ensure guidewire intact after out

 USG guided - 20ml blood x cst (skipped if prolonged manipulation and

- Use USG to locate site of needle puncture multiple attempts of needle puncture  take peripheral

- Gown up, prepare equipment (e.g. prime CVC) blood culture instead)

- Skin prep, drape (窿窿布: tear off the tape cover, note the - Flush the lumens with NS

figure for proper direction 公仔個頭對住 patient 個頭) - Connect to pressure transducer

- 包 probe  Confirm nil waveform (r/o arterial puncture)

 Expose the arrow sign  Measure CVP

 Avoid stretching the tegaderm too much (risk of tear) - Anchor with instrumental tie (using 3O vicryl, not 4O or 5O)

 Put “gel + tegaderm + gel” to enhance the - Marking (confirmed by CXR; okay as long as no arrhythmia)

echogenicity  IJ: R 12-13cm, L 14-15cm

- Head down NOW to avoid air embolism (not too early   Axillary: R 14-15cm, L entire length

excessive venous return  may provoke cardiac arrest if pre-  Femoral: entire length

existing heart failure)  Blindly

- +/- LA - IJ/femoral

- USG probe

 Note the left-right direction Approach Insertion Pt towards Remarks

 Probe hand applies minimal pressure (avoid Upper Midpt between Sternal Useful for pts

compressing the vein) mastoid process and notch with short neck

 Locate vein (vs. artery) angle of jaw

- Compressible (only seen on transverse view) Middle Palpate for carotid Ipsilateral
- Non-pulsatile pulse  lateral to it nipple
Lower Apex of triangle Almost always reflect R atrial pressure (hence fail to guide fluid resus)

formed by clavicular succeed, but  Removal of CVC: head down to avoid air embolism

head + sterna head narrow safety

of SCM + clavicle margin  PTX Hemo cath (double lumen = 12Fr; triple lumen = 11Fr)

Femoral 1cm medial to Abduct and  Types

femoral pulse (midpt hyper-extend hip - 150mm for neck access

between ASIS and joint (put a pillow - 200mm for groin access

pubic symphysis), 2- underneath).  Design

3cm below inguinal Must be below - Double lumen (usually needs central line for extra ports of

ligament inguinal ligament venous access)

to avoid - Triple lumen (with side port e.g. for inotropes – if not many

retroperitoneal IV drugs/infusions required)

bleeding (difficult  : prone to mechanical blockage (side holes against

hemostasis) vessel wall)  twist the catheter, A/V exchange

*N.B.: In short, draw a line from mastoid process to sternal notch,

puncture at its mid point (99.99% success rate) # Lumen Access Design

Double A/V Lumen ends x2

Triple A/V Side holes

Side port (e.g. drug infusion) Lumen end x1

 Siting

- IJ x2, femoral x2 = 4

- Never subclavian due to risk of subclavian stenosis

 Insertion

- Similar to that of central line except

 Much thick caliber  always make a small cut using

the blade before dilating the track (high bleeding risk

 ensure hemostasis by compressing the puncture

site using gauzes)

 Gel the lumens with heparin 5000u/ml before capping

 Marking: whole length

 Caution: never replace hemocath with central line since the latter

has a much smaller caliber and may cause breakage  catheter

embolism under high pressure of CRRT

CNS
N.B.: Further about central line

 Change a new one or remove: 1. whenever fever arises, 2. Q1/52 Lumbar puncture
(theoretically only, in practice the line can be kept as long as there  Choice of spinocath
are no signs of infection) - 22G (black)**
 CVP (representing R atrial pressure) can be accurately measured - 20G (yellow)
using femoral central line in supine position (common ililac vein   Send CSF for
IVC c.f. IJV  SVC) - Cell count
 However in the presence of TR, CVP reading cannot accurately - Biochem: glucose (+ serum RG), protein
 - Gram stain, CST, bacterial antigens (latex agglutination) - Preparation (-10min)

- Viral studies  *Assess for difficult airway (“LEMON”)

- Look externally

EEG  Micrognathia

 Interpretation of abnormal pattern  Macroglossia

- Non-epileptiform  Protruding teeth

 Slow wave: focal vs. diffuse  Short neck

- Continuous focal: localized structural lesion  Obese

e.g. tumour, stroke, abscess  H&N injury

- Intermittent focal: nonspecific e.g. migraine, - Evaluate 3-3-2

trauma, postictal dysfunction  Mouth opening 3fingers

- Diffuse slowing: note the state (e.g. alertness)  Hyoid-mental distance 3fingers

and meds used, could indicate diffuse  Thyro-hyoid distance 2fingers

dysfunction e.g. encephalopathies - Obstruction

 Asymmetry  Foreign body

- Amplitude wise  Peritonsillar abscess

- Frequency wise  Epiglottitis

- Epileptiform: spike, sharp waves  Upper airway tumour

 Neck infection

Richmond Agitation Sedation Score (RASS)  Goitre

 Haematoma

- Mallampati score

 I: faucial pillars

 II: uvula

 III: soft palate

 IV: hard palate

- Neck motility
 Sternomental distance 15cm (difficult

<12.5cm)

 Patient

Respi - Vitals, proper IV access (!!!)

 Stabilize BP before RSI  otherwise may

Rapid sequence intubation (RSI) arrest due to hypotensive effect of

 Definition: virtually simultaneous administration after induction agents

preoxygenation of a potent sedative agent and a rapidly acting NMB - Positioning: 成床高, elevate head (use 橫單/
to facilitate rapid tracheal intubation without interposed MV [c.f. no 細枕頭 below occiput, not nape i.e. sniffing
meds/sedation only/nasal] position)  avoid bending

 Your first try should always be your best try. Good preparation is  Female 5cm

MUCH MUCH MORE important than ETT placement itself and  Male 7cm

ensures high success rate  Equipments

 Procedures: 7”P”s - E trolley

- MUST bring the intubation kit box (with tools for difficult - OP airway (male orange, female green)

airway) + drugs (etomidate, propofol, sux, rocuronium) - Bag valve mask, O2

from ICU before attending a consultation for airway mx - Laryngoscope + blade (size 3-4)

- Cap, N95 respirator, face shield, PPE  Macintosh (curved blade) or MacCoy
 (hinged tip)  CXR

 See body size - Near-fail-save signs

 Check the light source  EtCO2 (N 35-45mmHg, 4-6kPa)

- ETT (九男八婆, male #9, female #8, prepare - False –ve: poor circulation, severe

one smaller size) [see body size] bronchospasm

- Bougie, stylet - False +ve: carbonated drinks

 Bougie: curved end = head  enter  Esophageal detector

mouth - Fail-save signs

- Yankauer, suction (make sure it works!!)  Fiberoptic visualization of bronchial tree

 Drugs  Visualization of tube between cords

- Sedative  Off cricoid pressure only AFTER ETT position confirmed

- Paralyzing agent - Postintubation mx

- NS flush / pump set IVF  Secure tube

- Preoxygenation (-5min)  Set ventilator

 Hold mask, bag with 100% O2 for 5min  Sedation +/- paralysis

- Pretreatment  CXR

 +/- Fentanil  Documentation

 Sedate  DL to assess airway, avoid paralysis if

difficult airway (maintain spontaneous breathing

effort)

- Etomidate / propofol / dormicum

- Paralysis with induction (0s)

 Paralyse

- Sux: after fasciculation

- Rocuronium: after counted for 60s

- Protection and positioning (+30s)

 Head tilt
 Cricoid pressure (Sellick’s maneuver), BURP

- Placement with proof (+45s)

 DL, +/- bougie or stylet, ETT placement, bag

 Bag only if SpO2 <90% (avoid aspiration)

 Confirm position

- Non-fail-save signs

 Feeling of cartilage on bougie

 Resistance upon passing bougie/suction

catheter

 Chest movement

 Moisture condensation on tube in

expiration

 BS on chest (symmetrical, if not, suspect

one lung intubation  shift out), no BS

on stomach Mallampati score + thyromental distance (N 6cm ~3finger breadths) more

 Hearing air exit from tube on accurate than Mallampati score alone to predict Cormack-Lehane score

compression

 “Normal” compliance on bagging N.B.: Premeds

 Sympathetic antagonists  Design: reinforced with Nitinol (nickel-titanium shape-

- Fentanil 100mcg  (-) sympathetic response e.g. avoid high memory alloy)

BP if known AAA [rarely used in RSI]  : avoid kinking for prolonged proning e.g. spinal OT

 Sedate / sedatives  : once patient wakes up from GA, may be agitated 

- Etomidate 2mg per ml  BW ÷ 10 = ?ml [generally more bite the tube  narrowed caliber (with shape

preferred than propofol except severe sepsis due to memory)  tube blockage  hypoxia

hypoadrenalism]  Mx

- Propofol 10mg per ml  2mg/kg (1.5mg/kg if small body Sedate +/- paralyse for emergent situations

size e.g. elderly) - Change to conventional ETT, or

- Dormicum 15mg per 3ml  2mg i.e. 0.4ml (up to 5mg i.e. - Insert a bite block (OP airway) +/- early

1ml if large body size) extubation

 Paralyse / muscle relaxant

- Suxamethonium 50mg per ml  100mg (2ml 比晒)

- Rocuronium 1mg/kg (onset time 1min vs. 0.5mg/kg)

*propofol + sux = RSI

*propofol + rocuronium (high dose 1mg/kg) = modified RSI  LMA

insertion for temporary ventilation before rocuronium offsets in case 1st

attempt unsuccessful

N.B.: Airway mx equipment

- Double lumen tube (DLT)

 Indx (absolute)

- Isolation of each lung to prevent soiling of

contralateral healthy lung

 Massive hemoptysis

 Infection (pus)
- Control of distribution of ventilation to only

one lung or differential lung ventilation

 Anatomy  Bronchopleural or bronchopleural-

- Trachea (D-shaped) cutaneous fistula, surgical opening of a

 Inner diameter: 2.5cm (1 inch) major conducting airway  low airflow

 Length: 10-15cm (4-6 inches) resistance, to prevent air vol loss through

- From: cricoid cartilage (C6) the fistula

- To: carina (T4/5)  Giant unilateral bulla or cyst  easily

- ETT rupture under PEEP

 Inner diameter: ETT size (in mm)  Major bronchial trauma/disruption

 Outer diameter: ~1cm  Severe unilateral lung disease

 Types of ETT - Unilateral BAL for pulmonary alveolar

- PVC >> latex proteinosis

- Cuffed vs. uncuffed - Video assisted thoracoscopic technique (VATS)

 Uncuffed: used in children <8yo  narrow subglottic  Contraindx

areas already serves the functions of a cuff (prevents - Difficult airway

slipping of ETT and aspiration) - Small patients

- Wire reinforced - Airway lesion or tumour

 Determining factors of size increment each time

- Main bronchial diameter (CT scan)  Cx

- Estimated body height - False side intubation

 Choice of size  Need to weigh the pros and cons of

- Female: (29, 32), 35, 37Fr remaining in-situ vs. reattempting

- Male: 37, 39Fr - Patient’ respiratory reserve

 Design - Expertise a/v

- Tracheal lumen + cuff - May still achieve differential

- Bronchial lumen + cuff (blue) ventilation

 L or R (labeled) - Whether RUL can be sacrificed

 L always preferred since R needs (collapse with L DLT intubating R

apposition of distal side hole (ventilation main bronchi)

slot) to RUL which could be technically - Too deep (rare): unilateral breath

difficult sounds/chest rise upon bagging tracheal

- Two curvatures lumen

 Method of insertion - Too proximal: bilateral breath sounds/chest

- Choose left or right double lumen ETT of the rise upon bagging bronchial lumen

appropriate size, stylet in-situ - Bronchial cuff sitting over carina  asphyxia

- Blue cuff passes through the vocal cords, turn (complete sealing of bil lungs)

the curvature to the targeted size, stylet out, - Individual lumens too small  easily blocked

tube in, connect to Y piece

- Marking ~30cm

- Confirm position

 Inflate tracheal cuff with 5ml air  bag

 check for etCO2, bil breath

sounds/chest rise ∴ ensure tracheal (vs.

esophageal) intubation
 Inflate bronchial cuff with 0.5-1ml air 

clamp the tracheal limb of Y piece and

uncap  bag  check for breath

sounds/chest rise of L side ∴ ensure L

main bronchus intubation (and vice

versa)

 Clamp the bronchial limb of Y piece and

uncap  bag  check for breath

sounds/chest rise of R side

 Fibreoptic bronchoscope via tracheal

lumen (blue cuff at L main bronchus)

- Confirm complete sealing of main bronchus

(i.e. complete separation of bil vent system)

 Deflate tracheal cuff

 Put a paper at the outlet of tracheal

lumen  bag through bronchial lumen 

if paper moves, incomplete seal  inflate

bronchial cuff further with 0.5ml

 - DL 2oc  12oc, displace tongue to L side, tip

at vallecula, use 陰力 to elevate at ~45deg to

align oral-pharyngeal-tracheal axis (3 parts)

- ETT on R side (vs. central  obstructs view)

- Must intubate in a CONTROLLED manner

 LOOK AT the VCs

- Other anatomical landmarks

 Behind epiglottis

 In front of arytenoids

 Bougie:

- Differentiate its head (curved)

from end (straight)

 Methods of intubation: oral vs. nasal  Hold nearer to its head for

- Direct laryngoscopy better pivoting

 Cormack-Lehane score - Once below the VCs, feel the

- I: full VCs resistance from passing through

- II: partial VCs the tracheal cartilaginous rings for

- III: no VCs, epiglottis only 2-3x (not too much  reach

- IV: no epiglottis beyond carina and cause airway

trauma)

- 套喉: YOU should always hold the

bougie, no matter wt problem

others are having with the ETT

 Position the ETT

- 1 mark: VCs at this mark

- 2 marks: VCs in between them

 N marking at incisor: male 24cm, female

22cm

 Cx

- Too deep

 One lung intubation

- Too superficial

 Anatomy  Risk of dislodgement

- Sites which cause significant sympathetic - Sx: bubbling of OP secretions 

response (i.e. tachycardia when passed either leakage or dislodgement,

through) reintubate if not sure

 DL  Patient discomfort (cuff against vocal

 Vocal cords cords)

 Touching carina (too deep e.g. while

passing bougie  trigger tracheal reflex)

 Technique

- Linen underneath occiput (not nape), open

mouth widely + extend neck by pressing your

middle finger against pt’s hard palate and

pushing the mandible with you index finger

  :

- Blind procedure

- No guarantee of airway protection, may not

be perfect seal of glottic opening

- Intubating LMA e.g. Fastrach

 Requires skillful manipulation (hence not

recommended for first-time users)

 Feature: almost 90deg angulation

 Compatible size of ETT

- iLMA size 4: ETT size 7

- iLMA size 3: ETT size 6

 Procedure of iLMA insertion:

- Metal bar at same horizontal level as patient’s

chest, insert with a circular motion against

hard palate until resistance is felt

- Inflate cuff, ensure endotracheal intubation by

etCO2 and auscultation/chest rise

 Procedure of intubation (without fiberoptic guidance):

- Insert wire –reinforced ETT (preferred to

conventional ETT due to the exaggerated

angulation of iLMA easy kinking)

- Video laryngoscope  15cm / transverse line = epiglottic

 With preformed track / loaded / guided: Airtraq elevator bar

 Without preformed track / non-loaded / non-guided:  Further in = either tracheal or esophageal

Cmac*, McGrath*, glidescope  Confirm position with etCO2

- : requires minimal manipulation e.g. - May leave iLMA in-situ or remove

suspected C-spine injury  Remove ETT connector piece

- : diff technique c.f. DL  Stabilizing rod in

 * = Macintosh blade  sit on the mouth floor, displace  Hold the ETT when seen in distal opening

and compress the tongue like usual DL (c.f. sit in the of iLMA in the oral cavity

midline on the dorsum of tongue, do NOT compress  Stabilizing rod and iLMA out

submandibular tissues, usually needs the use of stylet)  Procedure of intubation (with fiberoptic):

 Remark: direct view grading from DL does NOT apply - Bronchoscope loaded with ETT

to screen view grading from video laryngoscope - Bronchoscope in, see epiglottic elevating bar

- Classical LMA - ETT in, open up epiglottic elevating bar

 Size: 3 (female), 4 (male) - Bronchoscope in, see carina

 Procedure: - ETT in, bronchoscope out

- Hold the LMA like holding a pen - Remove ETT connector piece…

- +/- use of DL, airway maneuver e.g. jaw thrust - Awake fiberoptic intubation (AFOI)

- Insert the LMA using your index finger as a  About fiberoptic bronchoscope

guide against the hard palate until resistance - Up or down: lever

is felt - R or L: either you turn your body, or twist the

- Inflate cuff, ensure endotracheal intubation by bronchoscope (while straightened)

etCO2 and auscultation/chest rise - Always keep the bronchoscope as straight as

 possible to avoid overbending of in-built fibers  Risk: barotrauma

 otherwise black dots on screen  Contraindx: UAWO

- Suctioning channel (after sucking patient’s  Tracheostomy

oropharygeal secretions/mucus, always suck  Connection

water to avoid blockage of the channel) - ETT  T-piece connector (with suction catheter)  HME

- Delivery channel: NS, gas, drugs (heat and moisture exchange) filter  etCO2 sensor 

 Awake vs. asleep ventilator circuit

- Asleep: loss of muscle tone, difficulty - ETT  T-piece connector  bacterial filter  etCO2 sensor

 Approach  oxylog

- Sitting vs. supine - *Caution: avoid connecting etCO2 sensor directly to patient’s

 Sitting: more preferred in patient with side otherwise easily wetted by the condensed moisture

upper airway obstruction

- Nasal vs. oral

 Nasal: ETT size 6

 Oral: more preferred if patient can

tolerate the Berman airway

 Procedure:

- Patient preparation: lignocaine (4-5mg/kg)

 Nebulized

 Spray to throat and nose

 Jelly to front part of bronchoscope

 Spay as you go

- Bronchoscope (loaded with ETT) in

- See vocal cords, topicalization

- See carina, ETT in

- (Berman airway out)

- Bronchoscope out  Cuff pressure measurement

 Contraindx: bleeding from OP (血係 fiber 既天敵)

- Surgical airway

 Cricothyrotomy  would need revision tracheostomy

- Dilational

- Scalpel-bougie

 Size 10 scalpel, horizontal cut, turn 90deg

 Bougie in, scalpel out

 Size 6 ETT in, bougie out, inflate cuff, bag

- Cannula

 14G

 Ventilation methods

- 2.5ml syringe with plunge out, ETT

size 7.5 connector piece, bag

- 20ml syringe with plunge out, ETT

size 6-6.5 with cuff inflated, bag

- Manual jet

 Exhalation via upper airway,

3s each cycle
 Chest tapping

 Must be USG guided (NEVER EVER do it by percussion alone)

- Sliding pleurae = r/o PTX

 Ix

- Pleural fluid x

 Cell count

 Gram stain, CST

 AFB smear+PCR

 Fungal culture

 ADA, pH (3ml syringe), LDH, total protein

 Cyto (one large bottle)

- Blood x LDH, LFT (total protein)

 Results:

- Transudate vs. exudate (Light’s criteria)

 Transudate: may try medical tx e.g. diuretic

 Exudate: physical drainage

- ADA >=30  TB

Template

 Intubation x (indication) +/- under supervision of (name)

 PreO2, RSI, cricoid pressure

 Propofol/etomidate/dormicum (dose) +

suxamethonium/rocuronium (dose)

 DL (grade), (laryngeal findings e.g. oedematous epiglottis)

 Successful on (order) attempt +/- using MacCoy blade/ bougie

 Position confirmed by auscultation and etCO2

 ETT (size) , marking (cm)

 Mx: ventilator as charted, CXR, ABG after 1hr

Example. A 50kg man with C spine injury failed 1st extubation Chest drain insertion

 PreO2, RSI, manual in-line immobilization with neck collar  Types: CD vs. rocket (Seldinger technique)

temporarily removed  Size

 Fentanil 100mcg IV + etomidate 8mg IV + sux 75mg IV - For PTX

 DL grdae I, swollen arytenoids and cords, normal epiglottis  Stable: 16-22Fr

 ETT #7.5 passed with mild resistance, fixed at 22cm  Chronic lung ds, on MV, risk of large air leak: 24-28Fr

 AE symmetrical and good - Commonly: 20Fr (gas), 24Fr (fluid/pus)

 BP/pO2 maintained throughout  Indx

- PTX: ventilated pts, tension, persistent/recurrent, large 2ry

spontaneous in age >50yo

 - Malignant/complicated parapneumonic pleural effusion, - Trachea/carina

empyema  C-shaped cartilage rings  anterior (hence L and R)

- Traumatic hemopneumothorax  Longitudinal muscles  posterior

- Postop: thoracotomy, oesophagectomy, cardiac surgery - Bronchi

 Procedures  Circumferential cartilaginous rings

- Safety triangle  R main bronchus: wider, shorter (2.5cm), more vertical

 Avoid puncture through diaphragm (liver) or back  L main bronchus: narrower, longer (5cm)

muscles (e.g. latissimus dorsi)  More medial, upper lobe

- Surface wound  More lateral, lower lobe

 Avoid too small  air tracks through SC space created  Mnemonics: 1/2/3 + 4/5 + 6/7/8/9/10

with blunt dissection  surgical emphysema  Types: narrow 幼鏡 vs. thick caliber 粗鏡 (for spt suction)
- Direction: apically for PTX, basally for pus/fluid  Indx

- +/- Apply suction 10-20cmH2O - Check VC mobility, airway edema, etc

- Aim <1-1.5L output within 30min - Lung collapse  sputum clearance, facilitate lung

 Removal reexpansion

- Indx - Look for endobronchial lesion

 No bubbling / output <200mlx24hrs - BAL (lower respiratory tract sample  better representation

 CXR resolved PTX/pleural effusion of causative pathogen)

 MV weaned - +/- lung biopsy

- Done while holding breath/end exp on MV  Use

- CXR stat and 24-48hrs post removal - Disinfect with cidex OPA (glutaraldehyde) x 15min (浸鏡)
 : occupational hazard

- sensitization by repeated skin contact

- inhalation of vapour may cause asthma-like sx

 Remark: use of cidex OPA in PMH ICU is gradually

phasing out and in the future disinfection of

endoscopies would be centralized in designated

hospital areas e.g. OT

Template

 Fast, preO2, sedate/LA spray, paralyse

 Findings:

- Erythema over trachea/bronchi/bronchioles

- Endobronchial lesion  bx

- Sputum (amount, thickness, colour) from (lobe)  BAL

 Post CXR (esp if bx taken)

Flexible (fiberoptic) bronchoscopy

 Anatomy
N.B.: Not to confuse with rigid bronchscopy

 Done under GA with total intravenous anesthesia (TIVA) by CTS with

Anaes support (nearest a/v in QEH, not PMH)

 Indx

- Removal of foreign body aspiration

- Massive hemoptysis >600ml/24hrs  electrocautery

Tracheostomy

 Indication of tracheostomy: prolonged weaning +

- Patient comfort for prolonged ventilation

 sedation requirement, communication

 work of breathing  allows gradual weaning of

ventilatory support

- Sputum clearance (tracheal toilet)  prevent VAP

 nursing care (mouth care and mobility)

 Ease of replacement of TT

- Protection from aspiration

- Bypass glottis or subglottic stenosis/obstruction

 Method: perQ vs. surgical

- Surgical

 Better hemostasis with diathermy (e.g. bleeding

tendency – thrombocytopenia)

 Better dissection (e.g. goiter)

 Cx

- Loss of airway control

- Bleeding

- False passage

- Infection

N.B.: TT

 Types

Types Remark

Cuffed To obtain a closed circuit for ventilation

Non-cuffed/cuffless For those ready for decannulation - Subcostal

Fenestrated For those with difficulty using speaking valve; high  Look for

risk of granuloma formation at site of fenestration - RWMA, global HK vs. hyperdynamic (mention any inotropes)

and aspiration  RWMA only indicate underlying ischemia, be it acute

Inner cannula Either disposable or reusable or chronic  take into account the clinical context

- Valvular lesion, vegetation

Exchange of tracheostomy tube (TT) - EF (quantification of LV vol  Simpson’s method)

 Procedures  >55% normal

- Tracheostomy tube (check balloon), suction catheter (cut  45-55% mild impairment

away the connection  use as railroading), syringe, bag valve  35-45% moderate

mask, intubation kits, check DL grade (anticipate if difficult  <35% severe

airway) - Diastolic and systolic pressure

- Fasted x 2-4hrs, preO2 with FiO2 1.0, +/- sedation and SIMV  Whenever there is blood flow (systole with valves

- Cut tie, off ventilator, deflate, off old TT, insert new TT (45deg open, regurgitant, shunt), the jet velocity – and in turn,

angulation), inflate, to ventilator pressure gradient – can be calculated as follows:

 Trouble shooting - Pressure gradient = 4 x peak velocity2

- Within 1-2weeks  dislodged TT  desat  (a+b)2 = a2 + 2ab + b2

 Off TT (not to reinsert since track not yet formed   E.g. 3.52 = (3 + 0.5)2 = 32 + 3 + 0.25

prone to fistula and malplacement  surgical  Systole = diastole + pressure gradient

emphysema) - IVC size, respiratory variation  estimate fluid state

 BVM @ nose/mouth + O2 mask @ trach  IVC @ subcostal view

 Oral intubation - Ddx: abdominal aorta, subhepatic vein (**most important is

 To OT for revision tracheostomy to visualize the merging of IVC to RA)

- Unsuccessful exchange - Measurement of diameter

 BVM @ nose/mouth + O2 mask @ trach  At 2-3cm from IVC/RA junction

 Oral intubation, cover tracheostomy  Largest wrt respiratory variation

- Exp in SBT: pressure in RA

CAUTION - Insp in IPPV: predictive response to fluid

 For any procedures that involves airway e.g. bronchoscopy, ETT challenge

exchange, perQ tracheostomy, “fast + preO2 + sedate +/- SIMV  +/- M mode

mode” then “post CXR”

- Fast x 2-4hrs, aspirate from NG tube

- preO2 with FiO2 1.0

- Sedate with propofol / midazolam bolus

Cardi

Echocardiography

 Views

- Parasternal long axis (from L 2nd ICS downwards along L

sterna border, point to R shoulder)

- Short axis (L shoulder)

- Apical (short axis down, no need change direction)

 Papillary muscles @ 3-4oc, 7-9oc

  Metastatic cancer

 Hx of mediastinal radiation

 ESRF

 TB

 Traumatic injury

 Recent cardiac surgery

 Cardiac arrest with PEA

- S/s: pulsus paradoxus (SBP >10mmHg)

 Inflate then deflate cuff  Korotkoff sound

- 1st reading: only at expiration

- 2nd reading: throughout resp cycle

- Ix: ECHO

 Sonographic signs of tamponade

IVC % Collapse during inspiration^ CVP - Pericardial collection

<1.5cm >50% 0-5  Fluid = black

1.5-2.5cm >50% 5-10  Clot = white

1.5-2.5cm <50% 10-15 - RA systolic collapse

>2.5cm Little phasicity 15-20 - RV diastolic collapse

- Dilated IVC

Emergency pericardiocentesis - Equivalents of pulsus paradoxus – incr

 Indx: tamponade (≠ pericardial effusion alone) respiratory variation of

- S/s  Mitral inflow velocities

 Dypsnea, tachypnea (**most common presenting sx)  Tricuspid inflow velocities

 Beck’s triad = jugular venous distention, distant heart  L ventricular outflow velocities

sounds, hypotension  usually only 1 of them,  Differentiate from pleural fluid:

simultaneously occur briefly before arrest [spec but

not sen] Type of collection Position in relation to descending aorta

 Pulsus paradoxus >10mmHg Pericardial Anterior

 Low voltage QRS Pleural Posterior/lateral

 Electrical alternans

 Enlarged cardiac silhouette on CXR - Tx

- Risk factors  Pericardiocentesis

  Pericardial window - Size

 Thoracotomy + pericardiotomy - Cortimedullary differentiation (CMD): clear?

 Contraindx - Renal cyst, obstructive lesion, hydronephrosis

- Stable vitals  consider medical therapy +/- elective  IVC, aorta

pericardiocentesis

- Traumatic pericardial effusion + unstable vitals  for Abdominal tapping / paracentesis

emergency thoracotomy due to rapid reaccumulation of  Tx:

blood within pericardium - Yield <4-5L: no need to replace alb

- Myocardial rupture - Yield >5L: 6-8g albumin (~50ml) per L of ascitic fluid removed

- Aortic dissection  20% albumin 50/100ml IV over 30min (20g/100ml)

- Severe bleeding disorder

 Procedure Intra-abdominal pressure (IAP)

- Elevate head of bed 35-45deg (if possible)  Measuring methods

- Gown up, aseptic preparation - Direct: intra-peritoneal catheter connected to a pressure

- 20ml syringe + 3-way stopcock + 18G needle transducer

- Approach - Indirect

 Subxiphoid  IVC pressure: transfemoral

th
 Parasternal: 5 ICS, next to sternum  Intra-gastric pressure: water manometer via an NG or

- Needle insertion gastrostomy tube

 USG guidance, confirm position by injected agitated  Transgastral technique

saline (with bubbles)  Urinary bladder pressure (**PMH ICU)

 ECG monitor - Supine position

- STE = too deep (touches myocardium)  - Inject 50-100ml sterile saline into empty

withdraw the needle until STE resolves bladder through Foley (Bladder behaves as a

 Blind approach (if neither USG or ECG not immediately passive diaphragm when its vol is 50-100ml)

a/v; inevitably high risk, mortality 10%, morbidity 50%) - Connect to a water manometer / pressure

- 45deg, towards L shoulder transducer via a T-piece / three-way stopcock

 Cx - Zero reference point = pubic symphysis

- Arrhythmias

- Cardiac puncture

- Coronary vessel injury

- Pleural effusion, PTX

- Peritoneal puncture

- Liver/stomach/diaphragmatic/internal thoracic artery injury

- Death

Abd

USG Miscellaneous

 Liver

- Overall echogenicity, any intrahepatic lesion Off A sheath

- Gallbladder (wall thickness, any pericholecystic fluid), CBD,  Check for any coagulopathy/significant thrombocytopenia

intrahepatic ducts  C clamp standby

- Morrison pouch  Press proximal to the entrance point, gauze underneath

 Kidneys  Retrieve A sheath, check intact

 Manual compression x10min

 Consider C clamp x 15-30min if bleeding not controlled, check distal

pulse, review regularly, off when hemostasis achieved

Electrophysiological studies

 EEG: mention any sedative use

 Echo: mention any inotrope use

Point-of-care tests (POCT)

 Thromboelastogram (TEG)

- Clinical use: assess global visco-elastic properties of whole

blood clot formation

 Differentiate coagulopathy due to low fibrinogen vs.

thrombocytopenia

 Alternative: rotational thromboelastogram (ROTEM)

- Duration: 30min

- Indx: predict need for transfusion, guide transfusion strategy

(e.g. trauma, liver transplant, cardiac surgery, obstetrics,

early detection of dilutional coagulopathy)

- : cost effectiveness, reduction in blood products

- Interpretation

Parameter Meaning Represents N value Tx

R Time of latency Coagulation 5-10min FFP

(reaction) from start of test factors

time to initial fibrin

formation (2mm)

K (kinetic) Time taken to Fibrinogen 1-3min Cryoppt

time achieve a certain

level of clot

strength (20mm)

Alpha Slope between R Fibrinogen 53-72deg Cryoppt Setting up an infusion set

angle and K; rate of clot  Close infusion rate clamp +/- clamp the tubing leading to

formation contralateral spike

(thrombin burst)  Spikes

MA (max Ultimate strength Platelet 50-70mm Plt conc - Vented: non-collapsible bottle

amplitude) of fibrin clot - Non-vented: collapsible bags

LY30 (lysis % decrease in Fibrinolysis 0-8% Antifibri  Remove cover of spike and bottle/bag (above wrist level)

at 30min) amplitude at nolytic  Insert the spike into the bottle/bag ASEPTICALLY

30min post MA - No twisting action to avoid perforation

 (Invert, passively fill, squeeze and release pump chamber  fully

fluid filled, no air)

 Squeeze and release drip chamber  air + fluid level ~2/3

 Open the clamp, prime the tubing and remove any bubbles

 Set the infusion rate

Catheter scale

 C = d x pi  Fr = external d (in mm) x 3

PRACTICAL KNOWLEDGE IN ICU

Cardiovascular

Shock

 Types

- Hemorrhagic/hypovolaemic

- Cardiogenic

 Must be left (**) heat failure

- Systolic >> diastolic

- Distributive: septic, neurogenic, adrenal insufficiency

- Obstructive: tamponade, PE

 PE

- Peripheries: warm (septic) vs. cold  Non-shockable: PEA, asystole

- CVP: high (obstructive- tamponade, PE) vs. low - S/s:

 Ix  which type of shock  PEA: 有 ECG 無 A line/SpO2

- CBC: Hb drop (hemorrhagic), high WBC (septic) - Ax

- Echo: pericardial effusion (tamponade), dilated RV (PE),  5Hs

RWMA/hypokinesia/poor EF (cardiogenic), size of IVC (assess - HyperK

for further fluid replacement) - Hypoxia

- Hypovolemia (dehydrated state)

Arrest - HyperH2 (severe acidosis)

 Min pressure of palpable arterial pulse: - Hypothermia (bradycardia)

- Carotid 30mmHg  5Ts

- Femoral 60-70mmHg - Tamponade

- Radial 90mmHg - Tension PTX

 Shockable: VF, VT - Thrombosis @ coronary (AMI)

- Mx: - Thrombosis @ pulmonary (PE)

 Defibrillation - Tablets (drug)

- Almost all defibrillators in the wards nowadays - Mx

are biphasic  Find out underlying cause

 Adrenaline 1:10,000 10ml (=1mg) IV stat Q3-5min - Hx: ppt factors for hypovool (excessive blood

- Alternative: vasopressin loss)/hyperK and severe acidosis

 Amiodarone 300+150+150mg IV bolus then (ARF)/tamponade (malignant effusion,

maintenance infusion pTB)/DVT and PE, drugs

- Alternative: lignocaine - PE: hydration status (hypovol), temp

(hypothermia), auscultation (tension PTX)

Indx Monophasic Biphasic - Echo: collapsed IVC (hypovolemia), pericardial

Atrial rhythm 50-100-200-300-360 30-50-75-120 effusion (tampaonde), RWMA (AMI), dilated

VT 100-200-300-360 75-120-150-200 RV (PE)

Pulseless VT/VF 360 150-200 - iSTAT/RFT/ABG: saturation (hypoxia), e-

(hyperK), BE (acidosis)

Post-cardiac arrest

 Tx: Therapeutic hypothermia

 - Rationale: brain protection - Active [less commonly done in PMH ICU]

- Indx  IVF at 4oC

 Out of hospital VF/VT arrest  CRRT

 <15min from collapse to ambulance  Bladder irrigation, chest drain insertion for instillation

 Comatose of cold fluid, cold water immersion (paed) …

 Intended for ICU admission  Difficult cooling

- Contraindx (Relative) - Heavy sedation

 Cardiogenic shock (despite fluids / vasopressor) - Pethidine 50/25mg IV stat

 Primary coagulopathy  By unknown mechanism, not analgesic/opiate effect

 Uncontrolled sepsis - Atracurium 30mg IV stat

 GCS >8/15 (no need TH if fully conscious)  Ms relaxant stat dose only, avoid infusion as far as

 Pregnant possible (cx: critical illness polyneuropathy)

- Procedures  Can certify death at min. 36oC

 Aim core temp (usually Rectal temp) 32-34oC asap

- Methods Arrhythmia

 Surface cooling: polar air, ice packs a) Tachyarrhythmia >=150bpm

 Active cooling: IVF at 4oC  Tx

- Duration - [Rhythm + rate control] Amiodarone 150mg in 100ml D5

 24hrs from cooling; or (not NS) over 30min IV  600mg in 500ml D5 over 24hrs

 12hrs from target temp  : BP drop (stop if BP<90/60 P<60), prolonged QTc

 Sedate and paralyse to prevent shivering - [Rate control only] Digoxin 0.5mg (0.25mg in elderly) in

 Passive rewarming x ~6-8hrs 100ml NS over 30min IV  0.25mg PO Q8H x2

 Stop sedation when temp >=36oC  Caution: therapeutic range varies for diff indication

- Cx (CHF < AF control)

 During TH / cooling - [SVT]

- Hypertension (vasoconstriction)  Vagal maneuvers

- Bradycardia, arrhythmia  ATP 10+20+20mg IV stat

- Cold diuresis  BB, CCB (verapamil, diltiazem)

- Increased risk of infection - [Stable VT] Procainamide, sotalol, amiodarone

- Lactic acidosis  ABG Q4H

- Bleeding tendency  clotting profile Q6H b) Bradyarrhythmia <=50bpm

 Post TH / rewarming  Ppt: hypothermia, hypoglyc, drugs (precedex, digoxin)

- Hypotension (vasodilatation)  Tx:

- Diuresis, e- imbalance, malignant arrhythmia - Atropine 0.6mg IV Q3-5min [max 3mg, 1.2mg/vial]

- Dopamine 2-10microgram/kg/min [6-30mg/hr for a 50kg pt

*N.B.: - i.e. 3-15ml/hr using 200mg in 100ml NS]

 According to new guideline (NEJM, 2013) - Adrenaline 2-10microgram/min [0.12-0.6mg/hr i.e. 1.5-
o
- Target temp 34-36 C already enough 7.5ml/hr using 4mg in 50ml D5]

- Most important is to keep normothermic for a total of 72hrs - Transcutaneous pacing (TCP)

(including period of TH) post arrest (!!!)  Principle: smallest energy able to produce persistent

 Cooling methods: capture

- Surface  Indx: 3rd degree +/- 2nd degree type II HB with unstable

 Coolant blanket(**) hemodynamics

 Ice pads (neck, groin, axillae  near great vessels)  Contraindx

 Fans, cooling helmet… - Chest trauma, flail chest

 - C spine injury - 50mg in 50ml D5 i.e. 1mg per ml

- Body weight <30kg - 100mg in 50ml D5 i.e. 2mg per ml

- HR >40bpm unless cardiac output severely - Undiluted i.e. 5mg per ml

depressed  Intermittent bolus

 Procedure - 5mg over 2min Q15min if SBP >160

- Consent (if GCS full)  Mech: alpha and beta blocker

- Attach pacing electrodes and connect to pulse  : bradycardia

generator  Caution:

 Anterior (-ve): L 4th ICS, MCL - Labetalol, being an acidic drug, should not be

 Posterior (+ve): between spine and L co-administered with an alkaline drug (e.g.

scapula at level of the heart frusemide) or diluted in sodium bicarbonate

- Sedation, analgesics lest precipitation occurs.

- Turn to pace mode, ensure sensing of QRS - Also avoid labetalol if pt is in alkalosis

complex - Nitroglycerin (nitrocine®) IV [glyceryl trinitrate, TNG]

 Pacing rate: faster than QRS rate of the  Continuous infusion: 50mg in 50ml NS i.e. 1mg per ml

patient [0.6-12ml/hr]

 Output/current threshold: 20-100mA  : vasodilatory effect  reflex tachycardia, ICP;

- Ideally <40mA tachyphylaxis

- 40-90mA causes chest discomfort  Remark: less used in practice esp old pts with stroke

- >90mA results in pain and chest - Nitroprusside IV

contractions interfering with  Continuous infusion: 50mg in 500ml D5

respiration  Caution: protect from light (photosensitive)

- High threshold if  : fast onset and offset

 Dilated CMP  : possible cyanide and thiocyanate toxicity

 COPD - PK: Nitroprusside (NTP) is rapidly metabolized

 Obesity to cyanide radicals, which are then converted,

 Hypoxia, met acidosis in the presence of a sulfur donor, to

- Initiate pacing, output until 100% electrical thiocyanate in the liver via the enzyme

+ mechanical capture rhodanase. Thiocyanate is then excreted

 A line waveform, palpate carotid/femoral almost entirely in the urine.

pulse - Mx:

 Limit infusion to =<24hrs

c) Other  Start with 0.3mcg/kg/min, then slowly

 Prolonged QTc (>500ms) titrate to max 10mcg/kg/min

- Tx: 49.3% MgSO4 10ml in 100ml NS over 1hr IV (4mcg/kg/min recommended max safe)

- Avoid amiodarone, macrolide, antifungal

 TCA anticholinergic toxicity (myocardial Na channel blockade)  Toxicity Cyanide Thiocyanate

widened QRS (>100ms) Risk factor Hepatic dysfunction, Renal dysfunction when
- Tx: NaHCO3 50ml IV Q15min till arrhythmia resolves or pH hypoalbuminemia, infusion too rapid
>=7.45 hypothermia (15mcg/kg/min),

prolonged infusion
Hypertension (>48hrs)
 Tx Clinical Can occur as soon as Slower onset but occurs
- Labetalol IV 35min more frequently
 Continuous infusion [max 4mg/kg/hr]
S/s Lactic acidosis (decr O2 Confusion, hyperreflexia,  Poor cardiopulmonary reserve:

affinity to Hb  anaerobic ms cramps, seizures,  Rx

mech), shallow respiration tinnitus - [Thromolytic] Alteplase 100mg over 2hrs IV

(almond small breath), - [Anticoagulant]

tachyphylaxis to  Enoxaparin 1mg/kg Q12H SC, or 1.5mg/kg Q24H SC

hypotensive effect / - Prophylactic dose: 40mg Q24H SC

hypotension / bradycardia,  Heparin 5000units in 100ml NS i.e. 50units/ml [10-

change in mental status / 20ml/hr] (max 1000units/hr) [aim APTT 1.5-2x

coma / convulsion, normal]

vomiting - Or 5000units in 50ml NS i.e. 100units per ml

Tx Thiosulfate, cyanide Dialysis - 2500units in 50ml NS in gen ward setting

antidote kits (amyl nitrate - dose if liver ds, renal ds, bleeding tendency,

+ sodium nitrate) preg or hemorrhagic ds

- Indx

- Hydralazine IV  Persistent hypotension

 Indx: pregnant  Increased risk of bleeding

 : effect quite weak and usually inadequate  Potential abn SC absorption (e.g. morbid

- Nonsympatholytic vasodilatory antihypertensive obesity)

 Renal impairment (CrCl <=30ml/min)

Arteriolar Arteriolar + venule  Warfarin [aim INR 2-3]

Nitrovaso NO / Nitroprusside - SC/IV heparin + warfarin x 5days  INR >2 for

dilator N Hydralazine / >=24hrs  warfarin only

Others K channel opener: /

minoxidil, diazoxide Heart failure

CCB  IABP

- Indx:

Pulmonary embolism  Cardiogenic shock

 Tx - Classic catch-22 of tx

- Cautious fluid resus (preload) +/- inotropes  Inotropic support: myocardial work

- Supp O2 +/- NIV +/- MV  Afterload reduction: coronary

 Airway mx: avoid RSI (vasodilatory  BP crash), call perfusion pressure

Anaes for awake fiberoptic intubation  Intractable angina

- Definitive  Septic shock  cardiomyopathy

 Stable (without RV strain): LWMH  Cardiac contusion

 Intermediate (with RV strain): LMWH +/- rtPA  Mechanical cx of ischemic e.g. VSD, MR

 Unstable (SBP <90mmHg for 15min): heparin + rtPA  High risk surgery (prophylactic, wean from cardiac

- Surgical embolectomy / suctioning bypass)

thrombectomy @ IR  Bridging device

 Contraindx to thrombolytic - Design:

 Remained unstable: s  Tip @2nd ant ICS

- IVC filter  40cc helium (density  viscosity)

 Contraindx to anticoagulation  Triggering

 Recurrent PE despite therapeutic - Surface ECG

intervention - Aortic pressure wave

- Mech:
  Inflation during diastole (80-85% occlusion)

 Deflation during systole

- Outcome

 end diastolic vol and pressure

 L ventricular work

 stroke vol

 O2 demand-supply balance

- Cx

 Bleeding

 Vascular damage, aortic injury Respiratory

 Infection (*) = evidence based (randomized controlled trial)  in fact few trials are

 Thromboembolism (clotted), gas embolism convincing in ICU, and so, for those which are truly evidence based, you

 Vascular obstruction should go read up (frequently examined)

 Timing errors

- Inflation too early, deflation too late: (-) Stridor (large/upper airway obstruction)

cardiac fx  Tx

- Inflation too late, deflation too early: limited - Nebulized adrenaline 1:1000 4-5ml Q10min

effect  Watch out for rebound after 1-2hrs when adrenaline

effect wears off

- Dexamethasone 4mg Q6H IV x 3/7

- Methylprednisolone 20mg Q4H IV x4 (last dose immediately

prior to extubation), or 40mg IV stat (prior to extubation)

Bronchospasm (small/lower airway obstruction)

 Status asthmaticus

- Tx (**frequent reassessment)

 Ventolin® (salbutamol) 4/6/8puffs Q5/15/30min inh

- PO 2/4mg stat

- IV if refractory

 Atrovent® (ipratropium) 4-6puffs Q4H inh if acute

severe or life threatening asthma, or those with poor

initial response to SABA

 Hydrocortisone 100mg Q8H IV  prednisolone 30mg

daily PO  resume inhaled steroid once stabilized

 MgSO4 [sympatholytic] 0.1ml/kg at 5ml/hr IV in

refractory cases regardless of serum Mg level

 Aminophylline IV only after discussion with senior

(narrow therapeutic range with significant SE)

 Antibiotics should NOT be routinely given

 Caution: hypercapnia drives sympathetic response. If pCO2 is

corrected too rapidly, may hamper sympathetic drive  BP crash

(*permissive hypercapnia esp in chronic T2RF)

CAP

 Ix:
 - CAP profile

 NPA

- Flu A/B rapid test, flu A PCR

- + respiratory viruses panel

 Sputum/ETA x

- Urgent Gram stain, C/ST

- AFB smear and C/ST x3

- Flu rapid test and PCR

 Urine x legionella, pneumococcus Ag N.B.: For metabolic acidosis with compensatory tachypnea (i.e. acidotic

 Blood x breathing), may delay intubation as the compensation often suffices

- C/ST, atypical pneumonia titre

- Viral C/ST  Intubation

 Consider the following if deranged LFT - Indx x4

- Widal  typhoid fever  Aspiration

- Rickettsial Ab (rarely Weil Felix nowadays)  Obstruction

- Dengue Ab  Assisted ventilation

- Leptospira Ab - Apnea, impending resp arrest

- Sputum x PCP; BAL x histo (silver stain) - Poor mental status/central drive

- CXR - Hemodynamic instability

- Save ETA if: spt/thickness, change in colour, clinical  Resp muscle ischemia  prone to fatigue

deterioration (e.g. paradoxical breathing)  work of

breathing

- AECOPD + type 2 RF + unresponsive i.e. CO2

narcosis/contraindx to NIV

- Neuromuscular weakness + type 2 RF

- Mx of ICP

 Sputum clearance
- Most of the time, one fails to intubate not b/c of his skills

but IMPROPER POSITIOING of the patient.

- Your first try should always be your best try.

 Ventilation

- Ventilation (hence. OXYGENATION) is much more important

than intubation itself!!

 Fail to intubate but can ventilate = 無限復活

- Airway maneuvers

 Head tilt, chin lift

 Jaw thrust

 Modified jaw thrust (for C spine injury)

- Airway adjucts: Guedel OP/NP airway

 OP airway: female = green, male = orange

- Cx: gastric distention, aspiration, pressure injury (eyes, nose,

lips), facial nerve palsy

 Difficult airway

- Anticipated vs. unanticipated

Airway mx - Predictors of difficult ventilation (“MOANS”)

  Mask seal (beard, facial injury)

 Obese (BMI>26)/obstruction

 Age >55

 No teeth

 Stiff lungs

- Scenarios

 Morbidly obese

 Pregnant women (low respiratory reserve, desat

within 1-2min once off mask ventilation, high risk of

aspiration)

 RA with atlantoaxial instability

 C spine injury with immobilization

 NPC with RT done  very stiff neck

 Recent H&N surgery

 Acute epiglottitis: awake fiberoptic (LA to VC) in OT

with standby tracheostomy

 Bleeding from OP

- Types

 Can’t intubate, can ventilate by bag-mask

- Repositioning, different blade size/type,

BURP  repeat DL

- Video laryngoscopy

- iLMA

- Optical stylet

- Awake fiberoptic intubation (AFOI)

 Can’t intubate, can’t ventilate

- LMA, iLMA  intubate via LMA/iLMA, or

video laryngoscopy

- AFOI, , gas induction, LA tracheostomy

- Surgical airway

 Can’t intubate, can’t oxygenate despite adequate

ventilation

- One more attempt to intubate (iLMA, video

laryngoscopy, optical stylet)

- Surgical airway
  Inadequate inspired O2: altitude

 Alveolar hypoventilation

- Type II (hypercapnic): PaCO2 > 55mmHg + rising, pH<7.25

 Alveolar hypoventilation = (Vt-Vd) x RR

- Dead space

 Hypovolaemia, poor cardiac output

 Pulmonary embolism

- RR

 Resp ms fatigue

- Obstructed airway: COPD, asthma

- Restricted ribcage: flail chest,

inra-abdominal pressure

 Resp ms dysfunction

 Decreased central drive

- Mixed

SB = spontaneous breathing

NMBA = neuromuscular blocking agent

DMV = difficult mask ventilation

DI = difficult intubation

Mechanical ventilation

 Indx  Modes

- pO2: APO, ARDS, pneumonia - Continuous mandatory ventilation (CMV) aka assist control

 APO: cardiac cause  Pressure control  fixed pressure

 ARDS: non-cardiac cause (a spectrum of disease) - Determining factors for uptitration: RR, TV

- Acute onset - Parameters for weaning: FiO2, PEEP, (**)PS

- Bil lung infiltrates on CXR  Volume control  fixed TV and flow

- No cardiac failure (clinical / PCWP >18cmH2O) - Commonly used in gen ward (?old habit ?

- Hypoxemia  pO2/FiO2 avoid barotraumas)

 <200: ARDS - : upper limit of pressure fixed  lung

 <300: ALI compliance  pressure exceeding upper

 >450: normal limit  premature termination of breath cycle

- pCO2: airway obstruction, asthma, COPD  frequent apnea

 Acute respiratory failure - Parameters for weaning: FiO2, PEEP, (**) SIMV

- Type I (hypoxaemic): PaO2 <70mmHg on FiO2 0.6, or rate (look for patient trigger) (PEEP usually set

PaO2/FiO2 ratio <200 at physiological level ~4-5) (TV kept at ~6-

 VQ mismatch 8ml/kg)

 Diffusion barrier: pul edema, IPF - Intermittent mandatory ventilation (IMV)

  Supported breath (extra breaths > SIMV rate) in  Cx:

between mandatory breath - VAP

- Pressure support (PSV) - Ventilator asso lung injuries

 Patient dependent: rate, insp time  Barotrauma

 Back to SIMV if fatigued/CO2 retention  Volutrauma

- Pressure regulated volume controlled (PRVC)  Atelectrauma (aka shear injury)

 Indx  Biomarkers (?ALI ?ARDS)

- ARDS: very poor lung compliance  Weaning ventilator

- COPD: very high airway resistance (好難揼) - Determining factors

 Setting  Regain of GCS (off sedatives), obeys commands

- PEEP: incr if T1RF (i.e. oxygenation problem)  Good cough effort/muscle power, absence of

- I:E ratio, breath cycle: 1 to 2 bronchospasm, spt clearance (consider vigorous chest

 in practice, only the insp time is fixed, exp time would physio pre and post extubation)

depend on self recoil of pt’s lungs hence varies from  Low ventilator requirement

person to person - SIMV mode  PS mode of low support

- Lung protective strategy (*): TV kept ~6ml/kg of ideal BW (vs. - If fatigued, back to SIMV mode for rest

traditional concept of 12ml/kg) - Pleural effusion  consider tapping

- Asthma, COPD: RR, TV  allow longer exp phase  - Control of (lung) sepsis

permissive hypercapnia (pH >7.2) - Endotracheal tube (ETT)  extubation

 Caution: beware of autoPEEP (gas trapping) esp if BP  Fast >=4hrs (e.g. fast 7am mane)

drop or desaturation  +/- 6-8L O2 oxyvent (depends on FiO2 requirement) x

 Troubleshooting 0.5-2hrs (not too long otherwise fatigued)

- Desat: “DOPE” - Any RR, lethargy, +/- ABG

 Dislodged ETT - Indx: previously intubated for reps

 Obstruction e.g. sputum, crusts failure/UAWO/difficult airway (vs. elective

 Pneumothorax intubation for OT under GA)

 Equipment failure  +/- cuff leak test

- Resistance (connector tubings, ETT, airway) vs. compliance - -ve (diff between insp and exp TV <110ml):

(chest wall, parenchyma) problem larynx still edematous  not fit

 Pplat unchanged: airway obstruction (problems of ETT, - +ve (diff between insp and exp TV >=110ml,

secretions, bronchospasm) thrill felt over neck): larynx spacious  fit

- Confirm patency of ETT - Done only when indicated (risk of spt

- Suction aspiration causing VAP)

- Bronchodilators  +/- Cook’s catheter

 Pplat : compliance (pul edema, auto-PEEP, PTX, - : jet ventilation (without cuff for airway

atelectasis, vent dysynchrony, abd distention) protection), railroading for reintubation

- Needle decompression (PTX) - Off after 2hrs if well

- Disconnect from vent (auto-PEEP)  Extubate

- Check bladder pressure  +/- NIV (or standby) (esp if PEEP needed)

- CXR  +/- NRM

- Sedate/paralyze ONLY AFTER excluding all  0-6L O2 via NC

other causes - Tracheostomy tube (TT)  SBT

- etCO2  (Oxyvent)

 CO2 retention / T2RF  Trach mask (with humidifier  loosen spt  lower risk

 Tube biting  sedation or consider extubation of spt blockage of TT)

  SOOB as part of rehab

Lung recruitment

 Various methods a/v

- “40/40”: PEEP 40 for 40s

- Dept protocol

 “C” dynamics = compliance

Management Strategy of ARDS  Critical closing pressure/optimal PEEP  keep slightly

 Methods known to improve oxygenation: Lung recruitment, Prone above

ventilation as a rescue therapy etc. are NOT shown to have direct  Cx

significance on Survival - Lung barotrauma

 The primary determining factor of survival is the presence of - Incr ICP (decr cerebral venous outflow)

Ventilator Associated Lung Injury (VALI)

 EARLY prevention of VALI is key Proning, aka prone ventilation (*)

- Lung protective ventilation strategies e.g. low TV [ARDSnet]  Indx: severe ARDS

- Early Prone ventilation [PROSEVA trial]  Start early to have any significant impact on the long term survival

 E.g. when patient is on FiO2 >0.6 and PEEP >10 - Preventing VALI is the key

- Early ECMO if not a responder to Prone ventilation - In PROSEVA trial, the mortality is halved from 32% to 16%

with early prone ventilation in ARDS, very significant

 Contraindx

- High ICP

- Unstable spine

- Abd compartment syndrome, pregnancy, extreme obesity

 :

- ventilation-perfusion mismatch (improves oxygenation)

 less hydrostatic collapse of posterior lung segments

 less compression of lung parenchyma from the heart /

abd contents
 leading to more homogenous distribution of ventilated

alveoli, matching with the homogenous distribution of

blood flow

-  ventilator support and hence VALI

 :

- Pressure sore, blindness, cartilaginous damage to ears

- Difficult IV access (esp central line and hemocath), delayed

resus in arrest

 Procedure

- Adequate sedation and stable hemodynamics

- Move the pt AWAY from the ventilator, turn supine  lateral

(facing ventilator) prone (doctor: secure ETT and support

head)

N.B.: Conclusion from ARDSnet- lung protective ventilation strategies - Check proper position to prevent pressure injuries

 Low TV (6ml/kg)  Head donut

 Use PEEP - Ears free from pressure (esp down-side)

 Pplat <30 - Eyes tapped and free from pressure (esp

 Allow permissive hypercapnia (pH ~7.25) down-side)

 - Neck NOT hyperextended

 3 transverse pillows

- Under 1. chest/across shoulder and 2. pelvis

 abd freed (diaphragmatic ventilation)

- Under 3. shins  keep feet ~30-45deg to legs,

toes off from bed

 Upper arms abducted + extended, elbows flexed

 Breasts / male genitalia free from pressure

- Each time at least 16hrs e.g. 4pm-8am

 Order

- Turn head and check eyes Q2H

 Remark:

- Turn supine/prone only during A or P session, avoid N session

(not enough manpower)

- Responder should be evident (decr FiO2) within hrs - Contraindx (all are relative, risks vs benefits)

- Once a responder, forever a responder  Intracranial bleeding (current/recent)

 Other contraindx to heparinization

ECMO (extracorporeal membrane oxygenation)  High pressure (peak insp pressure >30cmH2O) and/or

 Background high FiO2 (>0.8) ventilation for >7days

- Organ support only, not a definitive tx by itself - HA guideline

- Underlying cause should be reversible  VV ECMO

- Absence of contraindications (progressive and - Rapid progressive respiratory failure pts who

nonreversible / terminal disease, intolerance to are refractory to conventional mechanical

anticoagulation) ventilation, with FiO2 >=0.9 + one of

 Criteria [CESAR study]  P/F ratio <100mmHg (13.3kPa) and pCO2

- Indx >80mmHg (10.7kPa) for 1hr

 Age >=16yo  P/F ratio <80mmHg (10.7kPa) and Murray

 Potentially reversible severe acute resp failure score 3-4

 No limitation to on-going life-sustaining tx  P/F ratio <60mmHg (8kPa)

 Murray score >=3  VA ECMO

 Determinants of survival on ECMO - One of

- Etiology of underlying pneumonitis e.g. viral  Acute STEMI, undergone primary PCI with

- Age profound cardiogenic shock with SBP

- Days of MV before ECMO <75mmHg despite IV inotropes and/or

- SOFA score IABP, asso with altered mental status,

oliguria, and resp failure requiring

mechanical ventilation

 Acute fulminant myocarditis, with SBP

<80mmHg and oliguria <0.5ml/kg/hr

while on inotropes equivalent

>40mcg/kg/min (dopamine x1 +

dobutamine x1 + adrenaline x100 +

noradrenaline x100 + isoproterenol x10 +

milrinone x15)

 Heart transplant candidate, with

 refractory cardiogenic shock despite ~10cmH2O
medical and IABP, as a bridge to Prevent ventilator induced lung injury
ventricular assist device or heart Heart tissue perfusion inotropes, myocardial work
transplant

 Lung or heart lung transplant candidate,  Model (from oldest to newest): Terumo, Rotaflow, Cardiohelp
with severe respiratory failure +  Principle: main goal is to achieve enough blood flow esp drainage
concomitant R heart failure (+/- pHT) cannula (<=8L/min) which determines the system efficacy for
 Refractory VT/VF storm oxygenation (NOT sweep gas or FiO2)  drainage cannula should
 Circulatory collapse due to potentially be at least 23Fr
reversible causes (thyrotoxicosis, drug  Components
OD, during PCI despite IV inotropes - Cannulae (VV ECMO: 1. RIJ, 2. R femoral and 3. L femoral)
and/or IABP)  Drainage
 Failed wean off bypass in post- - Design: side + end holes (blood flow)
cardiotomy pt with unstable circulatory - Sites: femoral x2 (if 2 drainage catheters
condition required due to inadequate drainage, 2nd
 Types catheter at RIJ targeting SVC, return catheter
- V-V: for lungs [PMH ICU] placed at femoral)
 Examples of resp failure: - Size: 23Fr (5L/min), 25Fr (6L/min)
- Viral pneumonitis (better mortality outcome - Length: 55cm
c.f. bacterial pneumonia) - Target: proximal IVC (intrahepatic portion 
- ARDS prevent vascular collapse under high –ve
- Trauma i.e. pulmonary contusion pressure)
- Post-lung transplant e.g. primary graft failure  Return
- V-A: for heart +/- lungs [PMH CCU] - Design: end only
 Central (sternotomy) vs. **peripheral (common - Sites: femoral x2, RIJ (not LIJ)
femoral a)  return cannula in aorta - Length: 20cm
 Examples of cardiac failure: - Size: 17 / 19Fr
- Severe cardiac failure - Length: 20cm
 Decompensated CMP, myocarditis - Target: RA
 AMI cx e.g. cardiogenic shock / refractory  Bi-caval dual-lumen catheter
VF or VT refractory to conventional tx - dual lumen catheter at RIJ, Return side-hole
 Profound cardiac depression due to drug targeting RA while Drainage side/end hole
overdose/sepsis targeting SVC and IVC
- Post-cardiotomy e.g. unable to wean from - : Only one catheter, easier nursing, more
cardiopulmonary bypass following cardiac OT patient comfort
- Post-heart transplant e.g. primary graft failure - : requires TEE for placement, technical
- VV-A: drainage of deO2 blood (to achieve blood flow) difficulty
- V-AV: return of O2 blood (in case of differential hypoxia) - Not a/v in PMH ICU

 Cautions
Organ Support Rest - 10-15cm between the ends of drainage and
Lungs O2 supply ventilator setting (FiO2, Vt) at the return cannulae to avoid recirculation
CO2 removal same time avoiding atelectasis: FiO2 - Always insert under ECHO guidance (TEE more
<0.4, RR <10, Vt <6ml per kg, plateau preferred if equipment and expertise allows)
airway pressure <25cmH2O, PEEP - Once inserted, 只可出不可入 for length
 adjustment (outside part no longer sterile)  2. Hb >=10 (12 at QEH ICU) or Hct >40%

- Usually only drainage catheter adjusted  3. cardiac output (not measured)

 Shifting the Return catheter away from - SvO2 ~70%**  measures system efficacy of the ECMO

the RA into SVC actually results in more  SvO2 <50%: not enough oxygen delivery to tissues

recirculation  SvO2 too high: recirculation of oxygenated blood back

 Take into account that shifting drainage into ECMO

catheter away from the intra-hepatic - CNS status: sedated and paralysed in acute phase

portion of IVC reduces drainage adequacy  AVOID propofol, which is largely sequestered in the

- Balance risks and benefits of adjusting circuit

catheter positions, to tolerate small degree of - Hemolysis: any hematuria, serum free Hb (>10mg/L =

recirculation hemolysis significant)(not a/v in PMH, to sent out to QEH

- Tubing (heparin coated) every morning), haptoglobin

- Pump - Heparin 10-15units/kg/hr  APTT 1.5-2x normal i.e. ~50-60s

 Mech: centrifugal effect (vs. roller) or activated clotting time (ACT) 220-260s (patient

- In-coming: -ve pressure (max nearest pump)

- Out-going: +ve pressure (max nearest pump)

- : hemolysis

- Oxygenator

 Pre-oxygenator chamber

 Membrane

 Post-oxygenator chamber

- Central unit controller (CUC) heparinized), platelet >100  INR Q6H

- Heat exchanger (water bath 水煲) - Cannulation site: bleeding, oozing, hematoma, unsecured

dressing

*N.B.: For concomitant CRRT - Extracorporeal circuit

 Blood drainage = labeled as arterial; blood return = labeled as  Cannulae/lines

venous (OPPOSITE to ECMO circuit) - placement, stability

- Think of CRRT as an extracorporeal kidney (renal artery in, - Drainage catheter “Kicking” = difficulty in

renal vein out) c.f. ECMO as an extracorporeal heart-lung maintaining drainage, check patient / catheter

system (SVC/IVC in, aorta out) - colour differentiation (i.e. colour difference of

 Set up as either 1 of the following: blood in access and return lines)

- Insert a hemocath for a separate system, or  both bright red  recirculation

- Connected to ECMO circuit (180ml/min in CRRT c.f. 3-4L/min  both dull red  oxygenator failure

in ECMO  minimal disturbance to circuit blood flow,  Circuit

recirculation in both circuit also not significant) - Any bubbles

 Any part of the circuit (e.g. post-oxygenator  Pump

chamber) CRRT  pre-oxygenator chamber(!!) for - Speed (~3000rpm, titrate against blood flow),

air/clot trapping - Blood flow (begin with 70ml/kg/min  ~3-

4lpm, titrate according to systemic arterial

 Monitoring saturation ~85%)**  determines system

- O2 delivery capacity (DO2): factors include efficacy

 1. **SaO2 >=85% (max ~90% in reality, due to mixing - Pven (-60mmHg  always -ve)

of oxygenated return blood with normal venous - Pint [between pump and oxygenator]

return, unless native lung oxygenation is somehow - Part (<300mmHg  always +ve)

maintained) - △P [between Pint and Part, i.e. pressure across

 oxygenator  any clots  oxygenator failure]  Clots within circuit

(<50mmHg, usually 10+)  Inappropriate pump speed setting

- Noise (air trap) - S/s

 Oxygenator  Hematuria

- Any blood clot (shine the light over pre and  HyperK

post membrane  dark red dots)  Haptoglobin; free Hb (daily send-out

- Pre and post oxygenator iSTAT test to QEH in heparin tube) (>10mg/L =

 Post pO2 ~40kPa on FiO2 1.0 hemolysis significant), LDH

 Sweep gas - Mx

- Gas flow (initially set as equivalent to blood  Fluid bolus to venous return (if

flow i.e. 4lpm, titrate according to pCO2 i.e.  excessive fluid -> worsen ARDS and

if CO2 retention) recovery)

- FiO2  2nd access cannula (target SVC)

- Securement of O2 tubing  Review pump speed (<3000rpm)

 Emergency preparation  Clot present: change circuit, reset

- 4 pairs of strong artery (Kocher) forceps accessible and kept anticoagulation targets

close to the machine  Acute desat

- Emergency drive with hand crank attached - Ax

- Emergency ventilator setting  O2 supply disconnection, accidental turn-

- Ensure T&S a/v at all time off

 Complications and troubleshooting: 1. patient, 2. machine (3  Oxygenator failure/thrombosis  check

circuits to check: blood, O2, water bath) for clot, colour of blood in tubings,

- Patient pressure gradient / PaCO2, hemolysis

 Bleeding (coagulopathy/thrombocytopaenia): basically  Recirculation  check for colour of blood

anywhere e.g. lungs, brain, surgical sites… in tubings

- ICH 5%  New/deteriorated lung patho

 unproportionately high, as patient on  (VA peripheral) Recovery of cardiac

heparin infusion + increased jugular output but not lung function 

venous pressure due to presence of large Deoxygenated output from LV  Blood at

bore cannulae in IJV/SVC proximal aorta become less oxygenated

 inevitably lethal ( SaO2 at RUL< LUL) (differential hypoxia)

- Mx for bleeding: - Mx

 Blood transfusion, fluid replacement  Emergency ventilator setting +/- pump

 Correct bleeding tendency blood flow

- Stop heparin (resume >=12hrs  Look for underlying cause

after a major bleeding) - Thrombosis: blood flow (if

- Plt conc  plt >100 minimal clots), review level of

- FFP  INR <1.3 anticoagulation +/- heparin bolus,

- Cryoprecipitate  fibrinogen >1.5 may change oxygenator

 Transamin loading + maintenance - Differential hypoxia: change to V-

 Others: surgical intervention, factor VIIa, AV ECMO (return of oxygenated

protamine, palliation blood)

 Hemolysis  Consider transfusion (as oxygen delivery

- Ax is affected by both Hb level and Spo2)

 Access insufficiency  For differential hypoxia in VA peripheral

 ecmo:  Pump head disengagement / airlocked /

- Switch to VV ECMO clot inside

- Increase Pump speed - S/s: support, BP, SpO2, +/- alarms

 Arrhythmia - Cx: stopped support, back flow (esp VA), fatal

- Ax - Mx

 Cannulation position, e- disturbance  Emergency ventilator setting

 PEA, asystole: look for 5Hs, 5Ts  Manual cranking

- Mx:  Pump head disengagement: re-engage

 VV ECMO  treat asap  Airlocked / clot inside: change circuit

 VA ECMO  acceptable if full support  Oxygenator failure

- VT, VF: defib - S/s: circuit colour (dark red), SpO2, +/-

- Asystole/bradycardia: observe or alarms

increase ECMO support - Cx: hypoxemia, fatal

- Tachycardia: cardioversion/meds - Mx:

 Limb ischemia  Check O2 supply circuit/oxygenator

- Ax: in VA peripheral ECMO with return cannula  Inotropic and ventilator support

in common femoral a  cannulation obstructs  May change to a new oxygenator/circuit

blood flow to lower limb  Reduced blood flow

- Mx - Ax:

 Prophylactic perfusion cannula  Clot in pump head / cannulae / tubings /

(branching from arterial cannula) with oxygenator

adequate heparinization (long line with  Access insufficiency (agitated pt,

low blood flow  prone to thrombosis) hypovolemia, circuit kinking, postural

 Wean VA peripheral ECMO asap related, intra-thoracic or abdominal

 Renal failure pressure)

- Ax: kidney perfusion, non-pulsatile flow, - Mx:

dehydration  Pump speed to allow blood refill

- Mx: CRRT (to pre-oxygenator chamber  central vein

minimize thromboembolism), medical therapy  Agitated pt: sedation

 Infection / sepsis  Hypovol: fluid bolus

- Machine  Circuit kinking: release kinking

 Tubing rupture  Postural related: change posture

- Cx: massive blood loss, air in circuit,  Intra-thoracic or abdominal pressure:

hypoxaemia and haemodynamic collapse release pressure

- Prevention: no contact with alcohol containing  Bubbles in circuit/air embolism

substance - Ax:

- Mx  Accidental decannulation

 Call for help  Cracked tubing / cannula / circuit /

 Emergency ventilator setting connection on inlet side of pump

 Clamp circuit  Introduced through drainage line

 Vol resus - S/s: noise from centrifugal pump head, flow,

 Pump failure +/- alarms

- Ax: - Mx:

 Battery and power failure  Call for help

 Electrical motor failure  Emergency ventilator setting

  De-airing port (small amt of bubbles mx Emergency ventilator setting +/- inotropic support
inside venous circuit) Before clamping, pump speed to 1500rpm
 Clamp the circuit, turn off the pump Clamp return cannula before drainage cannula
 May change to a new circuit Always have a contingency plan for machine failure i.e.
 Accidental decannulation where to borrow a new one
- Ax: extreme tension on tubing / cannulae / Air Head down, left lateral
cannulation site embolism Clamp-clamp
- Cx: massive blood loss, air in circuit, Deair port, aspirate (either release clamp at drainage
hypoxemia and hemodynamic collapse cannula, or infuse NS into the circuit via a pigtail, otherwise
- Prevention: monitor cannulation site, anchor draw air from oxygenator and creates even more bubbles)
the cannulae to pt properly Prime another circuit (~10-15min) if bubbles at return
- Mx cannula (無得救)
 Call for help Arrest VV vs. VA ECMO
 Emergency ventilator setting 5Hs and 5Ts at patient and machine sides
 Clamp circuit proximal to the Patient Two O2 cylinders + adaptor 孖頭 to wall O2 (one for
disconnection site transfer ventilator, another for ECMO) (*if not enough O2, ensure
 Vol resus supply to ECMO rather than ventilator)
 Apply direct pressure to cannulation site Leave the water bath behind (should be able to maintain

temp even for whole body CT)

ECMO Rotaflow Cardiohelp One person holds ETT + look at cardiac mon
Design Pump (with ultrasonic gel) Pump + oxygenator Two persons hold drainage and return cannulae + look at
connected to the impacted into one piece  ECMO mon
oxygenator via a visible facilitates transportation, Always keep ECMO close to patient rather than ventilator,
circuit  can see both pre but cannot see pre- avoid dislodgement/overstretching of tubings
and post-oxygenator oxygenator chamber

chambers, iSTAT a/v, (where blood clots easily  Weaning

oxygenator always above formed) - Indx
pump head  VV

-  FiO2 requirement (<0.3)

-  Fresh gas flow rate into the circuit

(<2L/min)

- Improved lung compliance

- Improved serial CXRs

Drainage + return cannulae  VA
Gas blender, sweep gas supply - ECHO assessment
Water bath (connected to oxygenator)  Improved LV contraction
AC vs. DC (inbuilt battery) power supply  Size of LV and RV
Hand crank + 2 Kocher forceps accessible  Opening of aortic valve during systole
Monitor Pump speed, blood flow More measurement  Resolved myocardium edema
parameters a/v: -  Arterial pulsation (A line waveform)
Pump speed, blood flow, -  BP and tissue perfusion / end organ fx
Part, Pven, Pint, △P, temp, -  CKMB, TnI
bubble alarm, Hb, Hct, SvO2 - Method

General Call for help (ECMO team)  Turn off gas flow (but maintain blood flow)
  Adjust ventilator setting (as if off ECMO) - BiPAP (= EPAP + IPAP): type 2 RF

 Observe for tolerance x 1-4hrs  Mode: spontaneous/timed (S/T)

- BP, UO, SaO2 - CPAP (=EPAP): type 1 RF

- ABG: any CO2 retention  Mechanisms

- Echo: LV poor contraction - EPAP = PEEP

 When decide to off ECMO - IPAP = PS + PEEP (*varies among different models)

- Stop heparin infusion  Indx

- Remove circuit after 6hr (decr pump speed to - More efficacious

1000rpm, clamp lines, stop machine, no need  AECOPD, early weaning of COPD

to return blood to pt, remove cannulae)  APO

- Manual pressure over wound site +/- C clamp  Acute resp failure in immunosuppressed state

(for femoral site) for >=20min to achieve  Postop hypoxemia (except UGI surgery)

hemostasis  Prevent post extubation resp failure (esp COPD)

 Evidence - Less efficacious or even harmful

- Good quality RCTs of ECMO outcomes in adult patients are  Acute severe asthma

lacking e.g. CESAR trial for VV ECMO (2009)  ALI/ARDS

 Pneumonia

Oxygen delivery methods  Established post extubation resp failure

 T1RF of mixed causes

O2 delivery device L/min FiO2  Contraindx

Nasal cannula 0-6 21+3% per L/min - Poor GCS / absence of spontaneous resp drive / apnea /

Simple mask 6-10 35-50% unable to protect airway / excessive secretions / risk of

Non-rebreathing mask (NRM) 12-15 80-100% (in reality aspiration

~70-80% at most)* - Arrest/ haemodynamic instability / shock

*c.f. methods which ensure 100% FiO2: 1. NIV, 2. bag mask, 3. mechanical - Acute sinusitis / otitis media / epistaxis / facial, oral and skull

ventilation surgery or trauma

- UGIB / recent upper airway, esophageal or gastric OT

 High flow nasal cannula oxygen therapy (HFNC) - Pre-existing pneumothorax/pneumomediastinum

- Examples: - Allergy or sensitivity to mask materials / mask poor fit

 Vapotherm and Flowrest devices  Cx

 Optiflow and AIRVO devices - Skin breakdown and discomfort from mask

- : - Pulmonary barotrauma

 Pharyngeal dead space washout, reduction of - Cardiovascular compromise

nasopharyngeal resistance - Gastric distention

 PEEP - Incr ICP

 Alveolar recruitment  Alternative: Airvo esp if high O2 requirement (>=6L)

 Better control of FiO2 - :

 Greater humidification  better patient comfort and  Close to 100% relative humidity at body temp (37C) 

tolerance, mucociliary clearance ensure mucous clearance (e.g. bronchiectasis, COPD,

- : cystic fibrosis), additional patient comfort

 Limited experience of HFNC in adults (vs. neonates)  Precise, convenient FiO2 delivery (up to 0.9) with

considerable amt of PEEP

NIV  Easy to set up and use

 Types
Oxylog
 1000/2000 (pneumatic driven)

 3000 (requires prior charging  check the battery) Feeding

- Mode  NG tube

 SIMV/PS = VCPS  adjust Vt - Materials

 PCV/PS = PCPS(**)  PVC  x2wks

 PSV - : rigid  easy insertion

- Operating data (for PCPS) - : soft tissue trauma

 PEEP  Silicone or polyurethane  x4wks

 △ABS = PS above PEEP [for supported breath] - : too soft  difficult insertion

 Pinsp = PC + PS [for mandatory breath]  Entriflex

- Pmax 40mbar (not 30) - Design

- Freq (RR): accordingly  Removable stiff stylet

- O2 (%): accordingly  Only tip of the tube is densely

 Air mix (50%) vs. no air mix (100%) radioopaque

- O2 cylinder (size E in general cases): total 400L  suppose - Indx: difficult insertion

O2 flow rate ~10L/min  40min if full - : incr risk of tracheal misplacement +/-

visceral pleura perforation

Chest physio - Insertion

 Sputum clearance  Head flexion

- Hyperinflation  May insert using DL and MaGill forceps if difficult

 Caution: NOT the same as recruitment (PEEP)  Confirm position

 Outcomes - Aspirate  stomach fluid

- Open up atelectasis - Inject air  gurgling sound at epigastrium

- Clear secretions - **Must order CXR (+/- AXR if not clear)

 Principles - Write “start RT feeding as per protocol”

- Slow inspiration up to Pmax 40cmH2O  Continuous infusion: 30  50  70ml/hr (max)

 Slow: create lamellar flow to allow entry  If >200ml RT aspirate Q4H

into those airways with high resistance - W/H RT feeding for 4hrs and morphine

- Inspiratory hold infusion (if any)

- Quick expiration - Maxolon 10mg Q8H IV x 2-3/7

 Method  NJ tube

- Manual - Indx: high risk of aspiration (e.g. acute pancreatitis 

 : repeated vomiting)

- Disconnect from ventilator  - Must be inserted by OGD guidance (consult Surg)

derecruitment  OG tube

- Ventilator - Inserted by doctor (under sedation +/- DL)

 Indx  If tube feeding fails, consider TPN

- High PEEP ~10-15cmH2O - Temporary  peripheral

- High FiO2 requirement

 Cx Hyperglycemia

- PTX, surgical emphysema  On continual RT feed:

- Unstable hemodynamics - Write on infusion chart: Actrapid HM 1unit/ml of NS IV (NCI)

- Incr ICP  NCI = “nurse controlled insulin”

 Not on continual RT feed:

GI system / nutrition - Insulin bolus

 - Sliding scale with IV (or SC) insulin - C: 2 large bore IVC for fluid resus, +/- CVC for vasopressor,

- Insulin infusion (in effect “doctor controlled insulin”) aim MAP >70mmHg to maintain CPP

- Hypoglyc- 100mg thiamine, 40ml D50

- IV benzo (ativan > valium) [c.f. IM dormicum]

 Ativan 2-4mg over 2min, Q10min, up to 8mg (4x)

 Valium 5-10mg over 1-2min, Q5min, up to 20mg (4x)

- IV long-acting AED [simultaneous]

BGA (mmol/l) Actrapid HM 1unit/ml NS IV prn  Phenytoin

<=10 0 - Loading: 15mg/kg (elderly) or 20mg/kg

10.1-14 4 (adult), infuse at 50mg/min (very safe if in

14.1-18 6 500ml NS over 30min to 1hr)

18.1-22 8 - Maintenance: 100mg Q8H IV  to PO 300mg

>=22.1 10 + inform nocte if clinically stable, other AED up to

advice by Neuro team

Overfeeding  2nd line (i.e. for refractory SE)  bolus + maintenance

 Risk factors - Midazolam 0.2mg/kg, then 0.05-2mg/kg/hr

- Very small/large (10ml, then 2.5ml/hr)

- Very old - Propofol 20mcg/kg/min, then

 Cx 30-200mcg/kg/hr

- CHO3: hyperglycemia, hypertriglyceridemia / lipogenesis, - Thiopental 2-7mg/kg, then 0.5-5mg/kg/hr

hepatic steatosis, hypercapnia - Epilim/keppra with EEG monitoring

- Fat: hypertriglyceridemia, fat-overload syndrome - Regular AED

- Protein: azotemia, metabolic acidosis, hypertonic  Lacosamide, valproate (epilim®), levetiracetam

dehydration (keppra®), topiramate (topamax®), phenobarbital

- Refeeding syndrome - EEG control x 1-2days, then gradual withdrawal of IV AED

 Ix

Neurology/neurosurgery - CBC, LRFT, INR, ABG, Ca/iCa, Mg, RG, AED level, toxi
- CTB, LP, EEG

Status epilepticus - Others: MRI brain, anti-NMDA, workup for IEM etc

 Definition

- >=5min of continuous clinical and/or electrographic seizure N.B.: Ativan® = lorazepam, valium® = diazepam, dormicum® = midazolam

activity; or

- Recurrent seizure activity without recovery to baseline in Meds SE

between seizures IV benzo (ativan, valium) hypoBP, resp depression

 Terminology IV midazolam hypoBP, resp depression, tachyphylaxis

- Impending: at least 5min IV phenytoin hypoBP, arrhythmia (bradycardia, high deg

- Convulsive: rhythmic jerking of extremities AV block, sinus arrest), purple glove

- Non-convulsive: EEG seizure activity without clinical syndrome

manifestations IV propofol hypoBP, cardiac/resp depression, propofol

- Refractory: unresponsive to standard tx for SE i.e. adequate infusion syndrome (AKI, met acidosis,

dose of benzo followed by 2 AED nd

rhabdo, cardiac failure)

 Tx IV thiopental hypoBP, cardiac/resp depression

- A: intubate prn

- B: MV prn Ischaemic stroke  for IV thrombolytic (rtPA)

[*Refer to the department guideline and flow chart on IV rtPA therapy] Prednisolone 1 mg/kg/day if not tolerating Mestinon (can

 Indx: sx onset within 3hrs (if 3-4.5hrs, decide on case basis) cause early steroid-induced deterioration)

- IA thrombolytic rare in practice

 Hx: NIHSS (?/42), BW, onset time, needle time Guillain-Barre Syndrome

 Tx:  Subacute progressive ascending flaccid paralysis with generalized

- Actilyse 0.9mg/kg (max 90mg) arreflexia +/- sensory involvement

 10% bolus  clinical plateau by about 4weeks

 90% infusion over 1hr  Miller-Fisher Syndrome: bilateral ophthalmoparesis, ataxia, areflexia

- NPO except meds  Dx: NCV, LP , Anti-GQ1b

- Bed rest  Can cause respiratory failure

- Neuro obs Q30min x 6hrs, then Q1H x 16hrs - Intubate / MV PRN

- 2-6L/min O2 NC, keep SpO2 >=95% - IVIg 0.4 g/kg/day for 5 days OR

- Aim BGA 4-11 Plasmapharesis (Negates effect of IVIg previously given!)

- Labetalol 5mg IV if BP > 180/105 for 2 consecutive readings  alternative days for total 5 times

measured 5-10min apart

- No need A line / central line

- Avoid Foley and RT insertion for 24hrs Increased intracranial pressure (ICP)

- Avoid antiplatelets and anticoagulants for 24hrs  Reducing ICP has two purposes

- If ICH is suspected (e.g. incr weakness, decr GCS, severe - Maintaining CPP (CPP = MAP – ICP)

headache +/- signs of incr ICP) - Prevention of herniation (usually when ICP>20mmHg)

 Urgent CTB +/- consult NS  Prevention of herniation is more important in determining

 Transfuse 4u FFP and plt conc treatment threshold, as CPP can be maintained to a great extent by

increasing MAP

Myasthenia Crisis  Aim CPP >60mmHg (at least >50)

 Definition  Changes in intracranial volume will markedly affect the intracranial

- weakness from acquired myasthenia gravis that is severe pressure when the intracranial volume is high

enough to necessitate intubation or to delay extubation  So decreasing volume of blood/CSF/SOL will decrease ICP
 Tx:  Methods to decrease ICP

- Intubate / MV - Hyperventilation (Reduce cerebral blood volume)

- Check Anti-AChR / NCV / +- Tensilon test if not yet done  Aim low normal 4-4.5kPa

- Review drug chart, avoid certain antibiotics (aminoglycosides,  Only temporary effect

fluoroquinolones, marcrolides), cardiac drugs (beta-  For preventing herniation only

blockers, procainamide, and quinidine) and magnesium  Not so useful for maintaining CPP as it reduces

- IVIg 0.4 g/kg/day for 5 days OR cerebral blood flow

Plasmapharesis - Mannitol (osmofundin) (Reduce cerebral volume)

 (Negates effect of IVIg previously given!)  Tx: 20% mannitol 50ml Q6H IV (20g per 100ml)

 Removes acetylcholine receptor antibodies  Mech: serum osmolarity to 310-320 mOsm/kg H2O

 Usual regime: On alternative days for total 5 times  Draws brain ECF by osmosis

- Mestinon 30-180mg Q8H R/T to improve limb power for  Indx: impending herniation, progressive neurologic

weaning ventilator deterioration, (not prophylactic)

S/E: GI upset, increase in bronchial secretions  airway  Contraindx: renal failure (risk of pulmonary edema,

blockage (causes airway collapse especially with decrease in heart failure), serum osmo >320 mOsm/kg H2O

respiratory effort, Tx: bronchoscopy for sputum removal)  Dosage: 0.25-1g/kg IV over 15-20min

(hence Mestinon should be considered off if not ready to try  Cx: dehydration due to osmotic diuresis, hypoBP,

wean off ventilator) prerenal azotemia/renal failure, hypoK, hemolysis

  Weaning: - IV 1microgram stat

- Q6H  Q8H  Q12H  Q24H

- Rebound in incr ICP  taper off (not stop Delirium/psychosis

abruptly), limit use to 48-72hrs  Ddx

- External ventricular drainage (EVD) (Reduce intracranial CSF - Metabolic

volume )  HyperNa, hyperCa, hypogly, hyperosmolar, uremia

 Indication (uremic encephalopathy)

- Monitor ICP  CPP  Hypogly

- Control ICP by free drainage of CSF  Liver failure (hepatic encephalopathy)

 Prophylactic rocephin against line sepsis - Infectious

 Troubleshooting - CNS

- Blocked (no waveform)  urokinase (by  Alcohol withdrawal (delirium tremens) – very agitated

neurosurgeon, not by ICU doctor)  Barbiturate/benzodiazepine withdrawal (rare)

 Weaning:  Postictal state

- Elevate EVD ~cm above ears level (AEL)  see  ICP

if any more output via free drainage  Head trauma

- Keep sedation (indx: OT findings, cerebral edema ++ on CTB)  Encephalititis/meningitis

 +/- paralysis: Reduce oxygen demand, prevent  Vasculitis

coughing and straining which increase ICP - Drug induced

 Propofol  Anticholinergics

 Midazolam + morphine  Psychotropics (chlorpromazine, thioridazine,

 Thiopental 1.5g in 60ml WFI (2.5%) IV i.e. 25mg per benzodiazepine, TCA, paroxetine)

ml  Narcotics

- Bolus 100-250mg (4-10ml) slow IV over  Li toxicity

20seconds (3-5mg/kg)  Steroids

- Infusion 4-10ml/hr (3-5mg/kg/hr)  Haloperidol 3mg PO stat/ 5mg IM stat (0.5-10mg, max 100mg)

- Class: phenobarbitone (GA agent)  - 5mg in 1ml solution; Serenace® 0.5mg/tab (green),
“thiopental coma” 1.5mg/tab (white), 5mg/tab (red)

- : deepest sedation - Caution: IV not allowed   risk of prolonged QTc

- : hemodynamic instability (may need

inotropic support), slow neurological recovery Neurogenic cardiac injury / brain injury-related cardiovascular dysfx

(including brainstem death test), resp

depression (keep ventilated)

- Prop up patient by 30 degrees

- Other points to note:

 Avoid hyperthermia which increase cerebral oxygen

demand

 Avoid hyperglycemia which compounds neurological

injury

Diabetes insipidus (DI)

 Ix:

- serum Na, UO

- Urine osmo <200

 Tx: desmopressin (DDAVP)

- PO 100microgram tds and titrate up accordingly

 Dx by exclusion  Px: often transient; severe QTc prolongation probably

- Suggestive of neurogenic cause explains sudden cardiac death after brain injury

 No hx of cardiac problems - (**) Arrhythmia: sinus tachy, AF, PAC/PVC, 3rd deg HB (AV

 Temporal relationship between brain injury and dissociation)

cardiovascular abn  Remark: severe rhythm disturbance rare and asso with

 ECG changes in isolation, modest elevation in trop I, biomarkers of cardiac injury e.g. TdP, VF

new onset LV dysfunction, RWMA that does not  Px: mostly benign

correspond to coronary vascular territories,  Tx: mx of the underlying intracranial pathology is the

inconsistency between echo and ECG findings, most effective way to prevent and treat the

inconsistency between trop I (<2.8ug/l) and LVEF arrhythmia, avoid drugs that prolong QTc

(<40%) - (**) LV dysfunction: impaired LV contractility / EF (mild and

 Spontaneous, early resolution transient), hypokinesia, RWMA (basal and middle portions of

- Could have coincidental coronary artery disease anteroseptal and ant ventricular wall with apical sparing 

 Types distribution of sympathetic nerves)

- Neurogenic cardiac injury - (**) Release of biomarkes of cardiac injury

 Mech: brain injury-induced catecholamine and  Trop I

inflammatory storm (neuroinflammation)  - Peak within 24-36hr (<threshold for dx of AMI)

afterload, myocardial workload, O2 demand, - Proportional to severity of brain injury

myocardial vasoconstriction  ventricular arrhythmia, - 100% sen and 86% spec for LV dysfunction

myocardial dysfunction, cell death  CK-MB

- Neurogenic stunned myocardium (NSM) syndrome(**) - 29% sen and 100% spec

 Mech: local release of NA into myocardial interstitium - Cardiogenic shock

from sympathetic nerve terminals (independent of  Px: most resolve spontaneously, not necessarily fatal although asso

serum catecholamine level)  rapid depletion of ATP with mortality/morbidity and poor outcome

 mitochondrial dysfunction  myocardial  Mx:

contraction band necrosis (cell death) - Tx of underlying brain injury

 Other triggering factors: pheochromocytoma, near - General supportive critical care

drowning, severe emotional stress

 S/s: Brainstem death test

- Asymptomatic  Diagnosis and confirmation of death

- Hypotension - Irreversible cessation of brainstem function, or

 Tx: fluid resus, standard vasopressors/inotropes - Cessation of cardiorespiraotry function

- (**)ECG changes (esp SAH): ST segment changes, flat or  The concept that brainstem death is equivalent to death is accepted

inverted T wave, prominent U wave, prolonged QTc [~hypoK] legally and within the medical community in HK

 Ddx:  Who can certify brain death?

- NSM - Intensivist / critical care physician

- Acute coronary ischemic event - Neurologist

- Propofol infusion syndrome - Neurosurgeon

 Mech: high dose or long term propofol  Observation: 2 separate exams are performed by 2 separate

infusion  impaired utilization of fatty medical practitioners within the observation period

acids within mitochondria - 1st: after exclusion of reversible causes of apneic coma, and

 Cx: cardiac myocytolysis, rhabdomyolysis, min of 4hrs observation during which pt has been comatose

acute renal failure  CK, metabolic (24hrs after cardiorespiratory arrest)

acidosis, widespread ECG changes  Depressant drugs or poisons

 Precaution: <4mg/kg/hr - Peripheral nerve stimulator should always be

 used to confirm intact neuromuscular - Types of ix

conduction if muscle relaxants have been used  4 vessel radio-contrast angiography by digital

- Sedation off x 24hrs subtraction  absent intracranial blood flow

 Primary hypothermia  Radionuclide examination: SPECT, 99m Tc-HMPAO or

 Metabolic and endocrine disturbance 99m Tc ECD  agents that cross BBB and retained by

- May give steroid replacement for potentially brain parenchyma, demonstrates absent brainstem

brainstem dead patients and cerebral blood flow

 Arterial hypertension  Time of death: 2nd set test or ix completed

- 2nd: can be done any time after the 1st exam

- Can be compatible with brainstem death Renal, fluids and electrolytes

 Movement of limbs in response to stimulus outside

distribution of cranial nerves Electrolytes

 Sweating, blushing, tachycardia  K: muscle contraction (including myocyte), nerve conduction

 Normal BP without pharmacological support  Mg, Ca: co-factors for muscle contraction

 Absence of DI - Mg (+) intracellular shift of K

 Deep tendon reflexes - Ca (+) nerve cell excitability

 Extensor plantar reflex  Na:

NOT compatible with brainstem death - hyperNa

 Decerebrate or decorticate posturing  ax: mostly dehydration

 Seizure  tx: rehydration!

 Response to verbal / noxious stimuli administered  PO4: energy production, production of nucleotides

through a cranial nerve path way  Indx of blood x e- (uncommon presentations c.f. gen ward setting):

 Presence of cranial nerve reflexes - Delirium

 Clinical testing - Frequent ventricular ectopics

- Diagnosis of severe brain injury which is consistent with

progression to brain death Fluid balance

- Assessment of brainstem reflexes  -ve fluid balance

 Absence of pupillary light reflex, corneal reflex, - Indx

vestibulo-ocular reflex, gag reflex, oculocephalic reflex  Fluid overload e.g. APO, pleural effusion, ascites 

- Apneic patient on a ventilator difficult weaning of ventilator, resp distress

 Performed last - Tx

 pCO2 >8, pH <7.3  Lasix

 Disconnect when PaCO2 close to normal - Determining factors: diuresis response, Na

 Prevent hypoxemia trend, CVP (bodily fluid status)

 Confirmatory ix  CRRT

- Indx

 No clear cause of coma Renal failure

 Possible metabolic or drug effect  Ax: prerenal, intrarenal, postrenal

 Cranial nerves cannot be adequately tested - Anuria  postrenal until proven otherwise

 Cervical vertebral or cord injury - Oliguria  prerenal until proven otherwise

 Cardiovascular instability precluding apnea test  Pathophysio: renal autoregulation / renal medullary

 Severe hypoxemic respiratory failure precluding apnea hypoxia / tubuloglomerular feedback

test  Ix/monitoring: UO, CVP, cardiac function (ECHO, PA

- Prerequisite: 4hr period of observation and brainstem catheter  stoke vol if high suspicion)

reflexes which can be tested should always precede ix - Intrarenal

  Rhabdomyolysis membrane by being carried along with the solvent (water)

- Pathophysio: flow (i.e. requires Ultrafiltration) (medium sized molecules)

 Nephrotoxic free Fe  free radicals 3. Ultrafiltration: passage of water through a membrane under

 Myoglobin + renal excretory protein a pressure gradient ~normal physiology of glomeruli (most

(Tamm-Horsfall) in acidic urine  cast effective for fluids)

- Tx: 4. Adsorption: binding of molecules to any surface

 UO 100ml/hr (e.g. fluid resus, mannitol,  Components

not loop diuretic  urine acidification) - Access line

 Alkaline diuresis: 50ml 8.4% NaHCO3 in - Hemofilter 骨 = 2 compartments (*filaments  SA)

500ml 1/2:1/2 solution  100-150ml/hr  Patient’s blood

(as maintenance fluid)  Fluid

 CRRT / HD - Replacement fluids: predilution vs. postdilution

 Acute interstitial nephritis  Predilution (vice versa for postdilution) @ PMH ICU

- Ax: drugs e.g. penicillins  allergy - : filter less easily clotted  UF rate

 Paradoxical retention of fluid despite fluid resus - : less effective plasma solute loss

- Pathophysio: inappropriate secretion of anti- - Pumps: control blood flow and fluid removal rate

diuretic hormone (ADH) and anti-natriuretic - Return line

hormone (ANH)  Types

 ADH: surgery, pain, IPPV 1. Slow continuous ultrafiltration (SCUF)

 ANH: steroids (cortisol, aldosterone)  Mechanisms: UF only

- Tx: diuretics  Features: no dialysate or replacement fluid, only

- Remark: this explains why most critically ill pts solvent(water) removed

have diuresis during their recovery stage  Effluent: ultrafiltrate

 Indx: severe hypervolaemia

Continuous Renal Replacement Therapy (CRRT)  Procedures: over 8-12hrs, then switch to another

 Indx appropriate therapy

- **Acute/absolute (esp in ICU setting) x3: 2. Continuous veno-venous hemofiltration (CVVH)

 Severe hyperK > 6.5 (+/- ECG changes)  Mechanisms: convection, UF

 Severe metabolic acidosis pH <7.1, BE <= -10  Features

 Fluid overload causing APO and resp distress - Blood flow rate: ~150ml/min [fixed  does

- Chronic/relative: not affect fluid removal]

 Anuria / oliguria (UO 200ml/12hrs) - Predilution rate: +2L/hr [fixed]

 Azotaemia - UF rate: -2L/hr [*variable- adjusted by system]

 Uraemic encephalopathy / pericarditis / neuropathy /  Determinant of solute clearance rate/system

myopathy effectiveness/dose of CRRT: UF rate

 Hyperthermia  Effluent: ultrafiltrate, replacement fluid (predilution)

 Drug overdose with a dialyzable product  Fluid balance: either neg or zero 洗渣 (no positive)
 Categories - Fluid removal: 50/100/150/200 (max) ml/hr

- Continuous (C) [over 24hrs] vs. intermittent (I)  Types

- Hemodialysis (HD) vs. hemofiltration (HF) - Citrated (prismocitrate® 5L/pack)

- Veno-venous (VV) vs. arterio-venous (AV) [obsolete]  Content:

 Mechanisms of solute removal - Only Citrate/citric acid, Sodium

1. Diffusion (= dialysis): movement of solute down a and Chloride

concentration gradient (small molecules) - NO K, PO4 (ppt CaPO4), Ca (form

2. Convection (= solvent drag): transfer of solutes across a Ca-citrate), Mg

  Contraindx x2: NS over >=2hrs IV

- Liver failure (bili >80)  Mg (for citrated)

- Massive transfusion: 10u PC, or - 49.3% MgSO4 10ml in 100ml NS

>50% total blood vol (no exact over 1hr Q24H during CRRT (D2

definition) onwards)

 Citrate toxicity  Anticoagulation: regional (citrate) vs. systemic (LMWH)

- Unexplained worsening of met - Citrate  bind serum Ca to form Ca-citrate 

acidosis 越洗越酸 metabolized by liver into iCa and HCO3

- Incr total Ca/iCa ratio >2.5  Heparin 5000units/ml 10vials stat for both citrate and

 : more durable filter which is expensive non-citrate CRRT (to cap the line)

and due by 72hrs (less likely to clot) 3. Continuous veno-venous hemodialysis (CVVHD)

 : fluid more expensive  Less expensive than CVVH

 New regime (Plasmocitrate 18/0)  Mechanisms: Diffusion

- More concentrated in terms of  Features: no replacement fluid  UF rate

citrate  Effluent: ultrafiltrate, dialysate

- Can give lower rate pre-filter to  Dose of CRRT: dialysate flow rate

achieve same regional  Blood flow rate: ~150ml/min (same as CVVH)

anticoagulation  Dialysate flow: 1000-2000 ml/hr

- Post-filter run Hemosol BO / 4. Continuous veno-venous hemodiafiltration (CVVHDF)

Phoxillium  Mechanisms: Diffusion, convection, UF

- Overall having the benefits of  Effluent: ultrafiltrate, dialysate, predilution

citrate anticoagulation, while replacement fluid

having more balanced electrolytes  Features

- Non-citrated (haemosol B0® / Phoxillium - Diffusion  small MW solutes (e-,

5L/pack) metabolites)

 haemosol B0® contains no K, PO4 - Convection  middle/large MW solutes (TNF,

vs Phoxillium contains K and PO4 IL-1, cytokines, inflammatory mediators)

 : fluid less expensive  Dose of CRRT: UF rate + dialysate rate

 : less durable filter  add systemic  Compared to

heparin (e.g. tinzaparin 2000units Q6H) - Intermittent hemodialysis (IHD)

(usually add to arterial side of circuit)  Mechanisms: Diffusion, UF (some degree of UF due to

bleeding tendency  better for short higher pressure gradient than CVVHD)

term use  Features

 Replace essential e- - Blood flow rate : 200-500ml/min

- At system - High solute clearance over short duration

 KCl (Phoxillium already contains K)  Dose of IHD: size of membrane, duration of therapy

- 0/10/20/30 (max) mmol/5L  :

 10% Ca gluconate via central line or - Quicker, cost effective

injected post filter (for citrated) - Cheaper (training expenditure, resource mx)

- 18 (min)/20/22…ml/hr  titrate  :

according to iCa - Greater BP drop

- Outside system - Disequilibrium syndrome (cerebral oedema)

 PO4 (Phoxillium already contains PO4) - Desaturation (WBC sequestration in lungs,

- Phosphate mixture 10ml tds RT (*) pCO2  breathing drive 

- KH2PO4 + K2HPO4 10ml in 100ml hypoventilation)

  Parameters preset/info filled in by Doctors

- HBsAg, (anti-HBc), anti-HCV status

- Desired BW loss (in kg) e.g. 0.5-1, 1-2

- Length 2-4hrs (standard)

- KCl 20mmol if normal (expect decr K after

RRT), incr to 40 or more accordingly to RFT

- Na acetate (avoid too rapid correction

resulting in CNS lesion) 125/135/145

- HCO3 25-30 (avoid effect on breathing)

- Ca 18-20

 20% mannitol 10ml Q0.5hr throughout HD due to 1st

time user

- Advantages of CRRT

 Better control of e- and acid/base balance

- Slower solute removal  abrupt change in

serum osmo  cerebral oedema,  surges

in ICP asso with intermittent therapies

 Better haemodynamic stability

- Composition of replacement fluid and

dialysate easily altered

- Blood flow rate

- Ensure adequate mean arterial pressure

- Exception: initial 1/2hr when the system just

started (circuit primed with 300-400ml NS)

 Tx: fluid bolus, NA, start with blood

flow then step up gradually

 Ensure adequate nutrion

 Clear inflammatory mediators

- Disadvantages of CRRT

 High PO4 clearance + simultaneous initiation of

nutritional support  hypophosphataemia

 Systemic anticoagulation  bleeding cx

 Administration of large vol fluid of room temp 

hypothermia (*fluids with HCO3 cannot be warmed 

convert HCO3 into CO2 bubbles)

- Fever trend unreliable

 Risk of infection

 Risk of embolism

 No evidence of improved mortality or better recovery

of renal function
  Serum markers

- Procalcitonin [expensive and not a/v in other hsp]: bacterial

 <0.5 sepsis unlikely

 0.5-<2 sepsis possible

 >=2-10 sepsis likely

 >=10 SIR  severe sepsis

- 1,3-beta-D glucan: invasive fungal infection (not specific to

candida)

- Galactomannan (Aspergillus) Ag: invasive aspergillosis

 Bacteria

- 1st line tx

 Anaerobe: augmentin, unasyn

 MSSA: cloxacillin, augmentin, unasyn, cefotaxime,

ceftriaxone

 MRSA: vancomycin (contraindx: renal impairment),

linezolid (contraindx: myelosuppression; NOT for

bacteremia since bacteriostatic), ceftaroline (if cst

polymicrobial)

 Paer: cipro, levo, tazo, timentin, sulperazon

- Other common choices/combinations

 Hospital-acquired infection e.g. pneumonia: beta

lactam i.e. tazocin, meronem (to cover Gram-ve

bacteria)

 CAP: augmentin + klacid + tamiflu [if allergic to

augmentin, use rocephin i.e. 2nd or 3rd gen

cephalosporin]

 HCAP: sulperazon + klacid + tamiflu

 Paer: tazocin, fortum (ceftazidime) or sulperazon

(cefoperazone) [3rd gen], meronem, levofloxacin,

amikacin

 PMAL: levofloxacin, sulperazon, (NOT meronem)

 ICBL strain: quinolone (e.g. levofloxacin), cefepime [4th

gen] >> meronem

 ESBL strain: meronem >> augmentin, quinolone,

nitrofurantoin

 Acute pancreatitis: carbapenem group (tienam,

meronem) > zinacef + flagyl [biliary cause]

 終極 anti-microbial combination for severe sepsis x6:

- Meronem

Microbiology/sepsis/infectious diseases - Levofloxacin

 Possible sites of infection - Minocycline [atypical organism]

- CNS (meningitis, encephalitis) - Tamiflu [influenza virus]

- Pneumonia, IE - PO flagyl [anaerobic organisms]

- Cholangitis/cholecystitis, GE, UTI - Anidulafungin [fungi]

- Soft tissue (abscess, necrotizing fasciitis) - ESKAPE pathogens  high rate of abx resistance, responsible
 for most nosocomial infections  According to ST results

 ESBL strain

Pathogen Resistant Resistant abx Abx of - Severe infection e.g. bacteremia

strain choice  Meronem

Enterococcus faecium VRE Vancomycin Linezolid, - Mild and uncomplicated UTI – alternatives of meronem

daptomycin  Augmentin (with beta lactamase inhibitor cover)

Staphylococcus aureus MRSA, Methicillin Vanco, - : good bioavailaility, high urine conc,

/ epidermidis MRSE (cloxacillin) linezolid anaerobic coverage (for polymicrobial

Klebisella pneumoniae CRE Carbapenem Colistin IV infections e.g. bite wound, diabetic foot

(Enterobacteriaceae) +/- inh infection)

Acinetobacter CRAB, Carbapenem,  Fluoroquinolone

baumanii MDRA multi drug - : good bioavailability, high urine conc, good

resistant tissue penetration (bactermemia, pneumonia)

Pseudomonas CRPA Carbapenem  Nitrofurantoin

aeruginosa - : E coli highly susceptible, good bioavailaility

Enterobacter spp ICBL ENTS Inducible Quinolone, - Contraindx: impaired renal function (decr urine

chromosomal B- cefepime, conc)

lactamase* meronem

(resistance may *N.B.:

develop after 1. Recommended choice of empirical abx in PMH ICU

exposure to

penicillins, 1st-3rd Disease entity Empirical abx

generation Meningitis Rocephin

cephalosporin, SBE Ampicillin + genta

and cephamycin IVDU  MSSA Cloxacillin + genta

for >3-4days) CAP Augmentin + klacid

Stenotrophomonas Intrinsic Carbapenem, HAP <4/7 Augmentin

(Gram –ve aerobe) resistance aminoglycoside (VAP) > 4/7 Sulperazon

Streptococcus PRSP Penicillin Bronchiectasis Tazo

pneumoniae Intra-abd sepsis Zinacef + flagyl; augmentin +/- aminoglycoside

Escherichia coli ESBL All penicillins, Meronem* Acute pyelonephritis Augmentin

narrow spectrum Neck abscess Augmentin; clindamycin

cephalosporins, Necrotizing fasciitis Augmentin + levo
aztrenonam Aspiration No abx initially
*N.B.:

 ICBL strain 2. Fever / central line / ANC

- High bacterial load (abscess), requires long duration of tx

(>1wk), serious or invasive infections Neutropeni Normal ANC

 Non beta lactam: quinolone, aminoglycoside, septrin, c Without G+ve bact on G+ve bact
nitrofurantoin, tetracycline mibi results smear/cult with ST
th
 4 gen cephalosporin: cefepime Central Vancomycin Pending Vancomycin Vancomycin
 Carbapenem line+, mibi results
- Non serious or non-invasive infections requiring short inflamed+
duration of tx only e.g. uncomplicated UTI Central Pending Pending Pending ST Vancomycin
line+, not mibi results mibi results results (but 2010

inflamed vancomycin - Guideline

Central for ICU pts)  Surviving Sepsis Campaign (SSC)

line-  Early Goal Directed Therapy (EGDT)

*To vancomycin if seriously ill and deteriorating - Targets

 BP (N Engl J Med 2014;370:1583-93.)

3. CAPD pts with turbid PD fluid - MAP 70-80mmHg if pre-existing HT  CRRT

 st
1 line: cefazolin + aminoglycoside but no difference in overall mortality

 G+ve cocci on smear: continue cefazolin + aminoglycoside - Otherwise MAP 65-70mmHg

 Culture results a/v:  Infection control

- MSSA: cloxacillin + aminoglyoside - Standard precaution

- MRSA: vancomycin  Principle: BLOOD and ALL body fluids of ALL patients

- Enterococcus spp: ampicillin + aminoglycoside should be considered potentially infectious

 If turbidity not improved or worsened after 3/7, repeat C/ST  Applicable to:

- Blood

 Fungi - Deep body fluids (semen/vaginal, peritoneal,

- Candidaemia pericardial, pleural, amniotic, cerebrospinal,

 Tx synovial, etc)

- Candida rules: >=3 predicts greater risk of - Excretion and secretion

invasive candidiasis in pts >=7days of ICU stay - Any body fluid visibly contaminated with bld

colonized with candida  Measures:

 Severe sepsis = 2 - Wear gloves, mask, eye shield, and gown

 Colonization of multiple sites = 1 - No recapping, handle sharps carefully

 Parenteral nutrition = 1 - Hand hygiene

 Postop = 1 - Contact precaution

- Remove all lines if possible - Droplet precaution

- Antifungal x >=2/52* - Airborne precaution

 Critically ill: echinocandin e.g.  Aerosol generating procedures: BiPAP, bronchoscopy,

anidulafungin 100mg Q24H IV (no need sputum induction, intubation and extubation, open

for renal/hepatic adjustment, remarkably suctioning of airways

non-toxic)**  Hand hygiene

 Less severely ill, non-neutropenic: - 5 moments:

fluconazole  Before: touching a pt; clean aseptic technique

- Refer Ophthalm x screen for Candida  After: body fluid exposure; touching a pt; touching pt’s

enophthalmitis within 1/52 of therapy surroundings

*Types: 1. echinocandin (~fungin), 2. lipid formulation amphotericin B

(Ambisome®), 3. voriaconazole (~azole) Trauma

st
**As a matter of fact, fluconazole is used as 1 line @ PMH ICU  Trimodal peak of death

- Min to hrs: on scene  injury to brain / heart / great vessels

 Tx of sepsis - Hrs to days (“golden 48hrs”): ICU care  head to toe (**early

- Trials proper resus can reduce mortality in 3rd peak)

 REVERSE study - Days to weeks: post ICU care  sepsis, multi organ failure

 PROMISE  Trauma team (ad hoc, depends on call list)

 Australasian resuscitation of sepsis evaluation (ARISE)

 Specialty Injury Procedures/role  Fluid resus: WHOLE blood > PC + FFP + plt (**simultaneous

ICU ABC Intubation (call Anaes if difficult transfusion, not sequential) > crystalloids (NS / Hartmann). Never

airway), escort to CT suite/ICU colloid.

Surg Thorax + abd injury FAST scan, PR for anal tone, - Massive transfusion protocol = 任攞唔嬲 (PC/FFP/PLT), 唔駛

chest drain (if indicated), decide 逐包逐包响 CMS order

for CT thorax + abd + pelvis - Transamine protocol

Ortho Long bones, spine Splints, pelvic binder, decide for  Indx

(neck, logroll), pelvis CT C spine - Age >16

NS Brain Ask for any HI, check scalp - Significant hemorrhage (SBP <90, HR >110), or

wounds, GCS + pupils, decide stable but at risk of significant hemorrhage

for CTB - <=3hrs of injury

AED / Activate trauma call,  Contraindx

coordination between teams - >3hrs of injury

N.B.: - DIC

 In reality, anyone who is confident enough can intubate, not just ICU - Allergy to transamin

doctors (c.f. chest drains must be inserted by surgeon).  Rx (500mg/ampoule)

 The leader role is historically dedicated to Surg but in most cases - 1g transamin in 100ml NS over 10min IV, then

each doctor will just do their own parts spontaneously - 1g transamin in 500ml NS over 8hrs IV

 Your notes should include: - Order “WARM saline”

- Age/gender  Lethal triad: coagulopathy, hypothermia, acidosis

- PMH - Pathophysio: acute traumatic coagulopathy /

- HPI anaemic coagulopathy (not DIC)

- PE: vitals (BP/P, GCS, PEARL, SpO2), chest, HS I+II, abd, power,  Common traumatic injuries

external wounds/lacerations/abrasions, limb deformity, - TBI

logroll (spine tenderness/stepping/wound, anal tone)  Preferably keep sedated (vs. stroke)

- FAST scan [ask Surg]  Cx

- Trauma series (CXR, XR C spine, XR pelvis) - Neurological

- Mx: proceed to CT, admit to C2/D2 [ask nurse IC]  Diffuse axonal injury: disruption of

 At the end of the CT Ortho shall order: brainstem centre for hemodynamic

- Keep neck collar / logroll / in-line traction / sandbags control  neurogenic hypotension

- Off spinal board in ICU  SDH, SAH, ICH

 For nursing convenience, may need to consult Ortho later to clear - Cardiovascular (see “Neurogenic cardiac

neck collar. injury” under “Neurology/Neurosurgery”)

- C-spine injury  difficult airway

 1ry survey (ABCDE for life threatening injuries)  1ry resus  2ry  Manual in-line immobilization (downward pressure

survey (head to toe exam, AMPLE hx)  2ry resus upon the mastoid processes to counterforce the

 Destinations upward pressure of DL during intubation)

- OT  ICU  Prepare gadgets

- CT  OT  ICU - Bougie, MacCoy blade

- CT  ICU - Video laryngoscope with (Airtraq) or without

 For all trauma cases – whether major or minor – an OT (C-mac) preformed track

room will be reserved automatically. If, after initial - Rib fractures

assessment, there is no need for EOT, contact the staff  s/s: surgical emphysema

in OT to step down the reservation. - suspect PTX +/- rib # esp if no open wound

- Cx: airway edema  blockage, difficult

 intubation, asphyxia Type of fracture Columns affected Stability
- Tx: subcutaneous cut x3 bil, needle aspiration Wedge Anterior only Stable
- Spinal fracture Burst Anterior + middle Unstable
 “Three-column” concept Fracture/dislocation Anterior + middle + posterior Unstable
- Anterior / middle / posterior columns Seat belt Anterior + middle + posterior Unstable
- Involvement >2 columns = unstable

 Types: wedge, burst, dislocation, seat belt - Pelvic fracture

 Mechanisms: compression, distraction, rotation, shear  Foley insertion: must consult Uro (risk of urethral

injury  may need flex cystoscopy guidance)

 Pelvic binder application (aka trauma pelvic orthotic

device, T-POD)

- Indication: pelvic fracture + unstable BP

- Contraindx: nil

- Position: centered over great trochanters

- Max duration: 24hrs

 Standard mx x3

- Ext fixation

- Packing

- Embolisation

- Internal organ injury

 Grading of severity: The American Association for the

Surgery of Trauma (ASST) (from least to most severe)

- Liver: grade 1 to 4 (hepatic avulsion)

- Spleen: grade 1 to 5 (shattered, hilar vascular

injury with devascularized spleen)

- Kidney: grade 1 to 5 (shattered, avulsion of

 renal hilum, devascularization of kidney due to

hilar injury)

- Burns

 Fluid resus within first 24hrs

- Indx: 2nd and 3rd deg burn

- Parkland’s formula = 4 x BW x %BSA

 First half: 8hrs

 Second half: 16hrs

- %BSA: rule of 9s

- Choice of IVF: Hartmann’s solution

 Other

- Information Services Department (政府新聞處)

 Question: How is the condition of the trauma patient?

 almost always asked for trauma cases

 Answer:

- Intubated  critical

- Extubated  severe

- Discharged  stable

Endocrinology

 Sick euthyroid syndrome (aka low T3 syndrome or nonthyroidal

illness syndrome)

- Definition: low serum levels of thyroid hormones in clinically

euthyroid patients with non-thyroidal illness (~2ry

hypothyroidism but N pituitary function in other axes)

- Pathophysio:

 peripheral deiodination of T4 to T3 is impaired, largely

secondary to decr activity of type 1 deiodinase enzyme - Risk factors (could be acute or chronic)

 decr production of T3, but same clearance  same  Critical illness: pneumonia, sepsis, myocardial

production of rT3, but decr clearance infarction, cardiopulmonary bypass, DKA, trauma

 Previously thought as euthyroid. Latest: may represent  Chronic renal failure, cirrhosis, heart failure,

genuine acquired transient central hypothyroidism  malignancy

prevent excess tissue catabolism  Starvation, anorexia nervosa

- Ix

 Total and unbound (or free) T3, reverse T3

 Variable TSH and fT4 (most commonly “normal”)

- Mx: Repeat TFT >=6wks after recovery

 Thyroid storm

- Definition: life-threatening exacerbation of thyrotoxicosis 

decompensation and failure of multiple organ systems

- Ppt: 4”I”s

 Infection

 Infarction: myocardial, CVA, GI, vascular

 Insufficient thyroid tx

 Intercurrent illness e.g. surgery, RAI therapy

- Dx: clinical (the distinction of severe thyrotoxicosis and - Tx

thyroid storm is merely a matter of clinical judgment   Resuscitation

proactive tx) - O2, aggressive fluid replacement

 S/s of hyperthyroidism  Supportive

 Fever, and tachycardia out of proportion to fever - Temp control (external cooling, panadol)

 CNS/GI/CVS dysfunction  Aovid aspirin  displace T4 from

 Burch and Wartofsky score: 1. thermoregulatory, 2. binding protein

CNS, 3. GI, 4. CVS - Treat AF and heart failure

- >45: suggestive of thyroid storm  Digoxin 0.5mg in 100ml NS over 30min V

- 25-44: impending thyroid storm  Lasix, nitrate

- <25: unlikely to represent thyroid storm - Agitation

 Chlorpromazine 50-100mg IM

 Diazepam 5-20mg PO/IV

 Specific + treat ppt:

- Antithyroid + antiadrenergic

 PTU 200mg QID PO/NG x 1hr, then

- PTU: (-) synthesis**, release, and

peripheral conversion of T4 to T3

 Iodide (Li if allergic)

- NaI 1g IV then KI 60mg QID PO, or

- 6drops of saturated solution of

potassium iodide (SSKI)

- Iodine: (-) release of prestored

thyroid hormone, and peripheral

conversion of T4 to T3

 Must be used AFTER PTU,

otherwise paradoxical 
intrathyroid hormone by 

substrate for hormone

 Propranolol 1mg over 5min IV Q 10min

to a total of 10mg, then 80mg tds PO

- Contraindx: heart failure (may

need Swan Ganz), bronchospasm

- Steroid

 Hydrocortisone 100mg Q6H IV, or

 Dexamethasone 2mg Q6H IV

- Further clinical deterioration: removal of

thyroid hormone from circulation

- Px: ~10% mortality despite tx  Exchange transfusion

- Ix  Plasma transfusion

 TFT: TSH, fT4 and T3  Plasmapheresis

 Sepsis workup  Charcoal plasma perfusion

 ECG: sinus tachy/AF, ST-T changes - Remarks

 CXR: consolidation, APO  Avoid amiodarone

 CBC, RFT, RG, Ca (~10% hyperCa)  Switch PTU to CMZ if deranged LFT
  Definitive tx with RAI and surgery should  15-20: 3

be postponed until euthyroid  >20: inform

 Admit ICU x close monitoring - Maintenance IVF with half half

 DKA solution Q6H + 20mmol KCl

- Pathophysio: fluid deficit = 6L  Mane

 3L from intracellular  3L from extracellular (clinical - Humulin N 8units om SC + Actrapid

signs of dehydration) HM 4uints tds SC (30min before

- Dx meals)

 RG >14 - + backup Actrapid HM 4units tds

 Heavy ketonuria SC prn if Hstix >=15

 Venous pH <7.3, and/or HCO3 <15 - Stop IV insulin infusion 30min after

 >=5% dehydration (malaise, drowsy, vomiting) or administration of SC insulin (to tide

features of infection over period of delayed onset of

- Serum Na (hyperglycaemia induced hypoNa) action) and change maintenance

(despite dehydrated state) IVF from half half solution to NS

- Total body K (serum K may be //N) 500ml Q8H

- Tx  Blood x HbA1c, anti-islet cell Ab, TFT

 Aggressive fluid replacement with NS  See dietitian x DM diet

- 1L over 30min  1L over next 1hr  1L over  See DM nurse x insulin advice

next 2hrs  1L Q4H (depending on degree of  Continue to tx underlying ppt cause

dehydration, <10% BW in first 12hrs) - Cx:

- Hstix may fall substantially during first 60-  Shock

90min of initial rehydration even without  Cerebral edema (1% DKA) (20% fatal)

insulin tx - Usually at 4-12hr from tx onset (but can

- Insulin should not be started until shock present on presentation or up to 24hrs later)

successfully reversed by resus and saline/K - Risk factors:

rehydration regime  Young age, new onset of DM, longer

- Change to D5 when Hstix <=14 duration of symptoms

 Insulin infusion (Actrapid 30units in 30ml NS)  pH, initial pCO2, tx with HCO3; initial

- Start with 0.1unit/kg/hr serum urea;  serum Na despite tx

- by half when Hstix <=14 - Warning features: headache / bradycardia /

- Aim at Hstix by 3-4mmol/L per hr BP / desat, recurrent vomiting, change in

- Target Hstix 8-12mmol/L neurologic state / neuro signs, convulsion /

 Replace K papilloedema / resp arrest (late signs)

 NaHCO3 only when pH <7.0 - Tx

 Transition to SC insulin and oral feeding  R/o hypogly

- Start oral DM diet when clinically stable +  Head elevation, mannitol infusion

without nausea or vomiting  +/- Intubation, CTB when stable

- Change to SC insulin when diet resumed  Consult NS

 Over night  Hyperosmolar non-ketotic state/coma (HONK)

- IV insulin infusion (sliding scale) - Epid: middle-aged/elderly pts with T2DM

 <4: 0 ml/hr - Ppt factors

 4-8: 0.5  Consumption of large amt of sugary drinks

 8-11: 1  Infection

 11-15: 2  Thiazide diuretic / steroids

  Myocardial infarction (may be silent in diabetic) Start infusion at 3ml/kg/hr 1 hour before the

- S/s: polydipsia, polyuria, evidence of precipitating disorder examination

- Ix Followed by 1ml/kg/hr for 6 hours after the

 plasma osmo, blood glucose >50mmol/l procedure

 HyperNa (sometimes falsely low i.e. pseudohypoNa

due to presence of excess lipids) O&G

 Usually normal pH (or mild acidosis)  Pre-eclampsia

 Sepsis workup, MI screen - HT occurring after 20 weeks of gestation in a woman whose

- Mx BP has previously been normal; + Proteinuria, >= 0.3 g /24-

 Rehydration with NS (or half half solution if hyperNa hour urine

>150) - Pathogenesis: abnormal placenta perfusion -> production of

 Insulin infusion 1-3units/hr (careful titration as HONK angiogenic and anti-angiogenic factors -> vasoconstriction

more sensitive to insulin infusion than DKA) and end organ ischemia

 DVT prophylaxis  Severe Preeclampsia

 NO bicarbonate infusion - SBP >=160 mm Hg or DBP>= 110 mm Hg on two occasions in

 Recommencement of OHA after acute state a pregnant woman who is on bed rest;

- Aim - Proteinuria>= 5 g / 24-hour urine specimen or >= 3+ on two

 plasma osmo of 3mOsm/hr random samples collected

- Cx: cerebral edema - Oliguria, Pulmonary edema, impairment of liver function,

Visual or cerebral disturbances, Epigastric / RUQ pain,

Radiology Decreased platelet count, IUGR

 CT with contrast  Mx of pre-eclampsia

- Identification of arterial bleeder - For BP control:

 Phase: arterial IV labetalol Infusion of 5mg/ml, start at 5ml/h OR

 Criteria: peripheral line a/v, cannot use central line IV hydralazine 5mg every 15-20 mins (max 40mg) (onset

(central line  manual contrast injection  limited later than IV labetalol)

infusion rate  cannot capture arterial phase) - Prophylactic Anticonvulsant therapy:

- +ve allergic history  steroid cover MgSO4

 Hydrocortisone 200mg IV on call to CT, then Q4H till Loading: 10ml 49.3% MgSO4 in 100ml NS over 30 mins

12hrs after CT (x3); or Maintenance: 10ml 49.3% MgSO4 in 100ml NS at

 Prednisolone 40mg PO 12hrs before CT, and 2hrs 20-60ml/hr (1-3g/hr)

before CT Reduce dose in renal impairment

- Anaphylaxis - Check Mg Q8H, target Mg level 2.5-3 mmol/L

 Adrenaline 0.5mg (0.5ml of 1:1000) IM stat - Check tendon reflex Q1H (by nurse)

- Renal cover for renal failure - Signs of Mg toxicity: arreflexia, increased PR/QT/QRS

 Oral - Treatment for Mg toxicity: boluses of IV Ca Gluconate

- Fluimucil (=N-acetylcysteine) 600mg Q12H PO - Careful fluid replacement: high risk of pulmonary / cerebral

x 2 doses before and 2 doses after CT, or edema

 IV  Eclampsia (Pre-eclampsia + seizure)

- Fluimucil 1.2g in 250ml D5 over 1hr before +/- - Consult Anaesthetist for airway management

after contrast study - IV diazepam for seizures

- Fluimucil 600mg in 500ml D5 Q12H over 2hrs - Start MgSO4 as above (loading + maintenance)

IV (withhold IVF) - IV dilantin if refractory

- Bicarbonate infusion (75ml 8.4% NaHCO3 in - May require CT Brain to rule out intra-cranial pathology

500ml D5)  Discuss with Obstetric team for delivery of fetus: the definitive
 management for both Pre-eclampsia / Eclampsia 2-6L/min O2 (should not be less than 2L)

- Placenta is essential in the pathogensis  removal of  Do-not-resuscitate (DNR) order

placenta during delivery - Team decision (or after discussion w/ 2nd call)

- Balancing maternal and fetal risks - Indx: terminal malignancy, end stage organ failure, profound

 Continue MgSO4 till 24-48 hours after delivery brain damage, no response to maximal therapy

 Terminally ill not for CPR and for comfort care

- Stop blood taking/restrict to daily blood taking only

Miscellaneous - Cap inotropes

 ADL - Titrate morphine for comfort

- Bathing > toileting > dressing (LL > UL) > grooming > feeding  Massive blood transfusion

- Walking aids: stick, tripod, quadripod, frame, rollator - Cx: hypofibrinogenemia, coagulation defects

 Assessment of fitness for anaesthesia and surgery - Mx: consider transfusing the following besides FFP

- American Society of Anaesthesiologists (ASA) grading  Cryoprecipitate

 Factor II (Thrombin)

ASA grade Definition Mortality (%)  Factor VIIa (Novo7®)

I Normal healthy individual (50% of 0.05 - No direct comparisons to other coagulation

elective OT) products have been conducted, therefore no

II Mild systemic disease that does not 0.4 conclusions regarding the comparative safety

limit activity or efficacy can be made

III Severe systemic disease that limits 4.5  DVT prophylaxis

activity but is not incapacitating - For all

IV Incapacitating systemic disease which 25  Keep hydrated

is constantly life-threatening  Early mobilization

V Moribund, not expected to survive 50  Do not regard aspirin or other antiplatelet agents as

24hrs with or without surgery 做又死 adequate prophylaxis for VTE

唔做又死 - Mechanical

 TED stockings (thigh or knee lengths)

 Postop  Foot impulse devices

- Hx  Intermittent pneumatic compression device

 Elective vs. emergent (thigh/knee lengths)

 What OT, indication - Pharmacological

 Findings  Fondaparinux (i.e. factor Xa inhibitor)

 Intraop BP, any use of vasopressor  LMWH: enoxaparin 40mg SC daily

 OT duration  UFH [for renal pts]

 Blood loss, any blood products given - Other

 Reversed vs. not reversed (e.g. blood loss >2L) to ICU  IVC filter for high risk pts if mech/pharma contraindx

- Mx:

 NPO +/- except meds, RT Risk Examples DVT risk without Prophylactic

 1/2 : 1/2 solution 70ml/hr (adjust accordingly) groups prophylaxis options

 BGA Q4H, keep 4-10, NCI prn Low Minor OT <10 Mobilization

 Routine bloods +/- iCa, CK, Trop I Fully mobile

 CXR, ECG Medium GA 10-40 Mechanical +

 Meds as charted Uro/gyn pts pharma (unless

 Ventilator as charted / (PCA for pain control) Bed rest high bleeding
 risk/contraindx) Neurological LMWH/UFH: ? 5-7days

High Ortho (HFS) >40 Mechanical + (cranial/spinal) (~1wk)

Neurological (major phama (unless Elective hip Dabigatran: 1- 28-35days

trauma, SCI) high bleeding replacement 4hrs postop (~4-5wks)

risk/contraindx) Elective knee Fondaparinux: 10-14days

SCI: spinal cord injury replacement 6hrs postop (~2wks)

HFS: hip fracture surgery Rivaroxaban: 6-

10hrs postop

*N.B.: Contraindx to mechanical prophylaxis LMWH/UFH: 6-

 PVD 12hrs postop

 Peripheral neuropathy Hip fracture Fondaparinux 28-35days

 Severe leg edema/cardiac failure [not (~4-5wks)

 Wound/dermatitis/fracture LL recommended]:

stopped 24hrs

**N.B.: High bleeding risk / contraindix to pharma prophylaxis preop, restarted

 Absolute 6hrs postop

- Uncorrected bleeding diathesis LMWH/UFH:

 INR > 1.5 started on

 APTT > 48s admission,

 Plt <70 stopped 12hrs

 Hemophilia/other bleeding ds preop, restarted

 Oral anticoagulants 6-12hrs postop

- Bleeding/potentially leading lesions Other Ortho LMWH/UFH: 6- ~1wk

 Active peptic/stress ulcer OT 12hrs postop
 Recent ICH/severe GIB (w/i 3mths) Vascular LMWH/UFH: ?
 Esophageal varices Day OT Fondaparinux
 Intracranial aneurysm/angioma LMWH/UFH: ?
 Clinically apparent bleeding Other OT LMWH/UFH: ?
- Allergy to heparin UL Ortho OT No routine DVT prophylaxis
- Heparin associated thrombocytopenia or thrombosis

 Relative  Temp lowering techniques

- Severe liver impairment, alcoholism - Non-pharma
- Severe renal impairment  Ice packs
- Major trauma/surgery to brain, eye or spinal cord  Coolant blanket 寒冰牀
- Spinal/epidural block

- Anaemia Hb <10  Plasmapharesis (plasma exchange)

- (Negates effect of IVIg previously given!)

Surgical pts Mechanical Pharmacological - Usual regime: On alternative days for total 5 times
GI, gyn, On Until pt Fondaparinux ~1wk / - By Prismaflex machine (same as CRRT) via Hemocath / AVF /
thoracic or admission no long (GI pts only) postop AVG
urological has sig LMWH/UFH: ? 4wks for - Indications for plasmapheresis
reduced major  MG crisis
mobility cancer in  GBS
(5-7days) abd/pelvis  TTP
  Others: Drug intoxication / HELLP / hyperviscosity

syndromes / autoimmune diseases

- Amount of plasma removed = 1 to 1.5 x Plasma Volume

(plasma volume = total blood volume x [1-HCT], and total

blood volume is estimated from height and weight)

- Replaced by same volume of Albumin / FFP / gelofusin / NS:

ideally all by albumin / FFP, but due to limited resources,

usually partially replaced by gelofusin / NS

- E.g. 2.5L plasma removed, replaced by 1L 5% albumin + 1.5L

NS

- Arbitary in terms of ratio of replacement with albumin / FFP

vs NS/Gelofusin, usually half / half , consider more FFP for

coagulopathy e.g. TTP

MEDICATIONS - B-lactam resistant G+ve bacteria ie. MRSA,

MRSE

Remarks  Confirmed by culture

 In case of fluid restriction, increase dilution ratio i.e. NA 4mg in  Suspected IE affecting prosthetic device,

50ml D5  8mg in 50ml D5 (2x strength) pending culture results

- Serious infection due to G+ve bacteria with

Analgesic allergy to B-lactam antimicrobials

 Morphine IV 30mg in 30ml NS  1mg per ml NS [0-20mg/hr] / - Prophylaxis

bolus 1-5mg Q30min to Q1H IV  Pts susceptible to IE + exposed to

- 10mg/ml per ampoule potentially bacteraemic

- Analgesic + sedative (+ side effects e.g. GI upset  not procedures/episodes with

tolerate RT feed  W/H RT feed, morphine, add maxolon) - Recent exposure or hypersen to

 Fentanyl [0-100mcg/hr] / bolus 50mcg Q30min IV penicillin

- 100mcg in 2ml  either diluted or undiluted by IV push - Prosthetic heart valves, vascular

- Analgesic effect only shunts or other devices or prior hx

 Tramadol 50mg Q6-8H IM/IV of IE

 Gabapentin 300mg tds PO  Pts undergoing OT with prior hx of MRSA

 Patient controlled analgesia (PCA) infection or colonization

- Criteria: GCS full (vs. confused) - Wound infection in

 Cardiovascular surgery

Antimicrobials  Major OT for insertion of

 Abx groups prosthetic device (artificial

- Penicillin heart valve, hip)

 Ampicillin + cloxacillin (synergistic)  cellulitis - Shunt infection

 Tazocin  PAER, better G+ve coverage than  Cerebrospinal shunt

sulperazon (e.g. enterococci), **anaerobes placement

- Narrow coverage of coliform bacteria c.f. - Empirical tx

augmentin, unasyn  not for empirical use  Fever in Neutropenic or ICU pts with

 Timentin  PAER, PMAL, ACIS, coliform bacteria with - Central line inflammation

confirmed sensitivity - Mucositis

- Not for empirical use - Septic shock

- Cephalosporin - G+ve cocci on blood/specimen

 Ceftaroline [research drug, 5th gen cephalosporin]  smear (pus, deep wound swab,

hitherto the only beta lactam that can cover MRSA tissue)

- Macrolide - Prior hx of MRSA infection or

 Klacid  atypical pneumonia colonization

- Amionglycoside - Prior prophylactic use of quinolone

 Amikacin  resistant G-ve bacteria (e.g. Paer, ACIS,  Fever in pts on chronic HD or PD with

ENTS) - Unclear site of infection, pending

- Carbapenem culture results

 Meronam  ESBL-producing bacteria - Prior hx of MRSA or MR pathogens

- Glycopeptides causing infection or colonization

 Vancomycin / teicoplanin (glycopeptides) ?max 2g  Presumed pneumococcal meningitis (as

Q12H (dilution ratio: 500mg in 100ml NS over 1hr)  an additional abx)

- Initial tx for an infected prosthetic HD access,

 pending culture results of adequate 1st line tx
- Tx of abx associated colitis Invasive infection = bacteraemia / infection of a normally sterile sites (CSF,
 Unresponsive to metronidazole pericardial, pleural, peritoneal, synovial, tissue, pus) / lower RTI colonized
 Life threatening or severe infection due with Paer or ESBL
to toxigenic strain of C diff a
+/- aminoglycoside or macrolide [CAP] for synergistic activity
- Presence of endoscopic

confirmation of  Serum level monitoring

pseudomembranous colitis, or ICU - Vancomycin trough level
admission  Vancomycin peak level has no clinical significance
- AND one of the following  Indx:
 Age >60 - Therapy >4/7
 T >38.3 - Severe/life-threatening infection
 WCC >15 - Concomitant nephrotoxic drugs (cyclosporine,
 Serum alb (?) <25 amphotericin B, aminoglycoside)
- NOT poor clinical response of MSSA towards - On continuous or intermittent dialysis
cloxacillin - High vol of distribution (obese, burns, sig
- Other edema)
 Colistin  MDRA [G-ve] e.g. CRAB - High therapeutic level i.e. 15-20mg/l needed
- 2MU Q8-12H IV (CNS infection, endocarditis, VAP, bacteremia,
- 2MU in 4ml NS Q6-8H inh osteomyelitis) as poor penetration into
 Not via BIPAP lung/bone (large molecular size)
 Linezolid  resistant G+ve bacteria (e.g. MRSA),  NOT indx: therapy <4/7, oral admin (min. absorption)
contraindicated to VAN (deteriorated RFT)  Procedure: within 30min before 4th dose
 Big guns  fill in “PMH antibiotic audit form”  Aim: 5-15mcg/ml (up to 20 in selected, severe
- Anti-pseudomonal penicillin: piperacillin + tazobactam infections where drug penetration may be
(tazocin®) compromised)
- Carbapenem: imipenem + cilastatin (tienam®), meropenem  Tx option
rd
- 3 gen cephalosporin: ceftazidime (fortum®), cefoperazone + - Empirical
sulbactam (sulperazon®), cefotaxime (claforan®) - Specific: refer to latest cst +ve results
th
- 4 gen cephalosporin: cefepime  Without ST: Gram +ve vs. –ve
- Glycopeptides: vancomycin, teicoplanin  With ST: “I to SUL but this is the only IV that is sen 

high dose”
Abx Tx of invasive infection Empirical txa  If clinically no response/septic deterioration (e.g. unstable
(known or suspected haemodynamics, desat, incr ventilator requirement, incr WBC/PCT)
pathogen) - Review previous culture results, any organisms not covered

Imipenem Atypical mycobact - Neutropenic fever - Trace new culture results, any new organisms found

ESBL or ampC B- (quantitative or qualitative - Repeat sepsis workup

Meropenem
lactamase producing ie. blast cells on PBS) - Step up empirically
Cefepime
- Organ transplant
Ceftazidime Paera
recipients on high level of Antiseptic
Burkholderia
immunosuppressants  Chlorhexidine
pseudomallei
- Severe clinical sepsis - Preparation
(melioidosis)
- Def deterioration or  0.2%  as mouthwash
Tazocin Paera
persistent fever despite 72rs  2% in alcohol (“pink solution”)  for skin disinfection
 e.g. aseptic procedure

e- disturbance

Preparation Amount of e- Compatible fluid  hypoPO4

14.9% KCl 2mmol K+ per ml (i.e. NS, D5/10/20, half - KH2PO4 + K2HPO4 10ml in 100/250/500ml NS IV over

20mmol per 10ml in each half, Hartmann 1/2/4hrs etc

ampoule)  Beware of hyperK

10% Ca gluconate 0.23mmol Ca2+ per ml (i.e. NS, D5, half half, - Phosphate mixture 10ml tds PO/RT for 3days

2.2mmol or 1g per 10ml) Hartmann  hyoMg

10% Ca chloride 0.68mmol Ca2+ per ml (i.e. - 49.3% MgSO4 10ml (5g) or 5ml in…

6.8mmol or 1g per 10ml) - [torsades de pointes] 5ml direct IV injection via central line

49.3% MgSO4 2mmol Mg2+ per ml NS, D5/10, half half,  Metabolic acidosis (pH <7.1) [*NOT resp acidosis  NIV/IPPV]

Hartmann - 8.4% NaHCO3 50/100ml IV over 30/60min

8.4% NaHCO3 1mmol HCO3- per ml (50 NS, D5, half half  Hypoalb for regular albumin replacement

and 100ml glass bottles) - 20% albumin 50ml Q24H IV x 5/7days

KH2PO4 + K2HPO4 ? ?
Inotropes/vasopressors

 hypoK [if AKI or Cr trend, no need to replace K]

- 10/20mmol KCl in 100/250/500ml NS over 1/2/4hrs etc

 Same as below

- Max rate for peripheral line: 500ml over 4hrs

- Specify “via central line”: 100ml over 1hr

 Specify “withhold IVF”

- Add 20/30/40mmol KCl…to IVF/CVVH/TPN

- syrup KCl 2g (20ml) Q2H x 1-3 PO/RT

 hypoCa
- Ca content: chloride = 3x gluconate

- Calculate adjused Ca +/- check iCa if clinically indicated

- Indx:

 Massive transfusion (citrated), CVVH

 [Ca chloride  rapid Ca replenishment] arrhythmia,

severe Ca depletion

- 10% Ca gluconate 10ml in…

 “Slow IV push”  Only dopamine can be infused peripherally. All other inotropes, at

- Ca gluconate: not exceeding 2ml/min high dose, should be infused along the central line (thus wide need

- Ca chloride: not exceeding 0.5-1ml/min of central line insertion for vasopressor support in ICU).

- But technically difficult and high risk of - Conversion of infusion rate: dopamine ÷ 2 = NA

medication error  give diluted solution by  The most common (or routine) choice of inotrope/vasopressor in

intermittent infusion ICU is NA(**) esp in septic shock. This is not based on improved

- Both preferably given via central line outcome but rather because it has fewer side effects than

 Or according to CVVH protocol adrenaline or dopamine.

- Noradrenaline 4mg in 50ml D5 [no upper limit, each time

escalate by 20-30%]

 2x strength = 8mg in 50ml D5

  4x strength = 16mg in 50ml D5 Fluid replacement

 PD: Less physiological disturbance (e.g. less  Crystalloid:

tachycardia) and proven benefit in survival of critically - Hypotonic: D5  evenly distributed as free water

ill including septic pts, incr diastolic BP thus coronary - Isotonic: NS  interstitial (extracellular), Hartmann

perfusion  Colloid: gelofusine  intravascular

- Adrenaline 1:1,000 4mg in 50ml D5 [1-3ml/hr] / bolus 0.5ml  Common choice and rate of fluid maintenance

(40mcg) each time - half half solution 60-70ml/hr (vs. NS in stroke or HI)

 1:1,000 = 1mg per ml vs. 1:10,000 = 0.1mg per ml

 4mg in 50ml = 0.08mg per ml *N.B.:

 PD: quickly reestablish circulation but risk gut  Crystalloids preferred in sepsis shock/trauma pts

hypoperfusion and lactic acidosis  Infusion rate:

- Dopamine 200mg in 50ml NS [1-7ml/hr] - 40ml/hr ~Q12H per pint (~1L/day)

 200mg in 100ml NS in gen ward setting [<=30ml/hr] - 60ml/hr ~Q8H per pint (~1.5L/day)

- If beyond 30ml/hr, consider consulting ICU for - 80ml/hr ~Q6H per pint (~2L/day)

NA support via central line

 PD: additional beta adrenergic activity on top of NA; Muscle relaxant

chronotropic  (+) HR; (-) intestinal mucosal blood Depolarizing

flow  Suxamethonium, aka succinylcholine (1mg/kg; 1.5mg/kg for

- Dobutamine 250mg in 50ml NS [1-6ml/hr] nondepolarizing pretreatment)

 50mg in 50ml NS in gen ward setting (max conc - 100mg/2ml

5mg/ml) - : fast onset (45s) and offset (3-4min)

 Action: vasodilator (**)  use only in combination - : bradycardia, apnoea, hyperK, hyperthermia

with a vasopressor - Contraindx: hyperK (renal failure, burn 24-48hrs [okay if

 PD: additional beta adrenergic activity on top of NA  <24hs]), upper motor neuron lesion/incr ICP, malignant

(+) cardiac contractility, improve peripheral circulation hyperthermia

 Indx: poor circulation **with dusky peripheries - Intubate after transient muscle spasm

 Contraindx / : tachycardia or AF (atrioventricular - For short term use only e.g. intubation, not for maintenance
conduction), arrhythmia (including fatal)

 Inotropes wouldn’t be effective unless intravascular vol is Non-depolarizing

adequately replaced  fluid resus before further escalation of NA a) Amino-steroidal compounds  antidote: sugammadex (modified

- 水位  depends on SpO2, not CVP/clinical fluid status gamma-cyclodextrin)*

 If lungs are still not congested and oxygenation good,  Rocuronium

can allow further fluid resus (despite overt - 50mg/5ml

subcutaneous oedema 外濕內乾) - Indx: if contraindx to sux (see above)

 However there is always a limit as to the point fluid - :

resus takes place, even in a mechanically ventilated pt.  High risk of anaphylaxis

- Over replaced  alveoli congested  incr V/Q  Slow offset (30-45min)  if cannot intubate, hv to bag

mismatch  difficult ventilation 好難揼得起 by yourself for 30-45min before effect wears off

 frothy sputum, filter easily wetted  Renal elimination  unreliable offset time in renal

- Assessable outcomes: 1. pulse, 2. BP, 3. urine output (may lag failure pts

behind), 4. limb perfusion (limited by use of high dose - Intubate after you have counted enough time (0.6mg/kg 

vasopressor) 3min, 0.9mg/kg  1min)

 Intra-aortic balloon pump (IABP): (+) brain and coronary perfusion - Bolus: 50mg very safe in most situations

during diastole  Elective 0.6mg/kg

 RSI (high dose) 0.9 ?1 ?1.2mg/kg  onset time 1min

 - Infusion: 500mg in 50ml NS i.e. 10mg/ml [2ml/hr] - Usually no more than 10-12ml/hr (max 120ml/hr for status

 Vecuronium epilepticus)

b) Benzyliso-quinolinium compounds - Can separate or combine morphine + midazolam infusion

 Atracurium  Midazolam 30mg in 30ml NS  1mg per ml NS

- : BP drop (histamine release) - : analgesic effect (morphine) besides sedative (midazolam),

- : not renal dependent but temp/pH less BP drop

- Maintenance infusion 10mg per ml NS: same as rocuronium - : reliant on hepatic/renal excretion, accumulation,

 Cis-atracurium (0.1mg/kg  5x as potent as other NMB) tolerance/withdrawal

- : more expensive  Propofol 10mg per ml [2-3ml/hr placebo, 5-8ml/hr sedative effect,

- : no BP drop, not renal dependent but temp/pH (reliable 10-13ml/hr minor procedure, <20ml/hr] / bolus 10-20mg

offset time within 30-45min) - 200mg in 20ml / 500mg in 50ml

- Can be used as maintenance (best choice among all) - Max 20ml/hr to avoid infusion syndrome (children > adults)

- : fast onset (<1min) and offset (3-10min)  easily titrated,

~ acting Class Structure Drug Elimination not reliant on hepatic/renal excretion, limited accumulation,

Ultra- Depolarizing / Sux Plasma no tolerance/withdrawal

short cholinesterase - : greater BP drop (vasodilation)  fluid resus +/- inotrope,

Interme Non- Amino- Rocuronium Primarily no analgesic effect, propofol infusion syndrome (>20ml/hr for

diate depolarizing steroidal Vecuronium biliary, some >24hrs), bradycardia

renal  Precedex® (dexmedetomidine) 200mcg in 50ml NS i.e. 4mcg per ml

Benzyliso- Atracurium Ester [5-10ml/hr i.e. 0.4-0.7mcg/kg/hr]

quinolinium Cis- hydrolysis, - 200mcg in 2ml per vial

atracurium Hofmann - Central acting alpha2 agonist ~clonidine  ~sleeping

elimination - : bradycardia (tx: atropine), no evidence for use in Paed pts

N.B.:  Etomidate / bolus 8-10mg (0.3mg/kg undiluted slow IV but in

 *Currently a/v cholinesterase inhibitors are not capable of reversing reality body weight ÷ 10 = ? ml)

profound blockade, even in higher dose, without potential cardiac - 20mg in 10ml per ampoule

and autonomic side effects. - : less BP drop, generally more preferred than propofol

- Edrophonium +/- atropine (anticholinergic) - : hypoadrenalism (avoid in severe sepsis)

- Neostigmine, pyridostigmine (revsersible)  Thiopentone 500mg in 20ml WFI i.e. 25mg per ml / bolus 70mg (2-

 **Only rocuronium and atracurium are a/v in PMH for maintenance 5mg/kg ~1.5mg/kg)  assess effect on BP and conscious state

infusion (vs. best choice being cisatracurium) before next dose

 Ester hydrolysis: catalysis by nonspecific esterases - 500mg per vial

 Hofmann elimination: spontaneous degradation in plasma and  Ketamine 50mg in 50ml NS or D5 [5ml/hr] / bolus 1-2ml

tissue at normal body pH and temperature - 200mg/2ml per vial

- : counteracts bronchospasm

Sedative (NOT the same as analgesic/ms relaxant)

 Definition *N.B.:

- Does not have analgesic/muscle relaxant effect  Proper sequence: analgesia > sedation > paralysis (avoid post-

- GA agents = 1 arm-brain circulation (effective within 10s) traumatic stress syn)

 Propofol, etomidate, thiopentone >> ketamine  Induction premeds

 Avoid infusion if plan to “wake and wean” (change to prn e.g. - Pretreatment

morphine)  Atropine 0.01mg/kg: age <10

 Morphine 1mg + midazolam 1mg per ml of NS [1-2ml/hr if old, 4-  Fentanil 1-3mcg/kg: incr ICP, CAD

5ml/hr if young, increment by 0.5-1mg each time] / bolus 1-2mg  Lidocaine 1.5mg/kg: incr ICP, bronchospasm

 Rocuronium 0.06mg/kg (10% paralysis dose): incr ICP,

 fasciculation encephalopathy (e.g. pts with liver

- Sedative failure)

 Etomidate 0.3mg/kg (often ~2/3 in reality): stable BP, - Oliclinomel

adrenal suppression  avoid in septic shock  20% soybean oil, 80% olive oil

 Ketamine 1mg/kg: hyperBP  Peripheral

 Midazolam 0.1mg/kg: less clear endpt of induction - Kabvien peripheral

 Propofol 2-3mg/kg: hypoBP - Choice

 Thiopentone 1.5mg/kg: standard for NS pts  Energy: 25-35kcal/kg/day

- Ms relaxant/paralyzing agents  Avoid fish oil in thrombocytopenia

 Sux 1.5mg/kg (onset 30-45s, offset 10min): hyperK, - Incorporate into cell membranes of platelets

incr ICP and endothelial cells  (-) platelet function,

 Rocuronium 1mg/kg (onset 60s, offset 1hr) alter platelet and vascular interaction

- If UAWO, do NOT use muscle relaxant  cannot intubate and - Duration (for all TPN): over 24hrs (no need rest time)

cannot ventilate. Instead, do awake fiberoptic (urgent consult  Other

Anaes) - Aminoleban

 Bolus to reach plateau level: midazolam, propofol  Indx: HE due to acute on chronic liver disease

 Monitoring system  Content: 41% branched chain amino acids, vitamins

- Sedation: Richmond Agitation Sedation Score (RASS) A/D/E/K, zinc, macronutrients

 Prefer lighter than deeper sedation  Route: IV or PO

- Paralysis: Train of four (TOF) monitoring

 Ulnar / facial / sural (posterior tibial) nerve Miscellaneous

 Ventilated pts  (-) aspiration of contaminated oral

secretions/gastric contents  (-) VAP

- 0.2% chlorhexidine 30ml Q8H MW

- Ranitidine 50mg Q8H IV/NG (Q12H if renal failure) [omitted

if already on PPI]

 Pantoloc 40mg Q24H V [hx of bleeding ulcer or PPU]

 Pantoloc 40mg in 100ml NS [20ml/hr i.e. 8mg per hr]

for 72hrs [acute bleeding ulcer, not PPU]

- Prop up 30deg

 Aspirin + viral illness esp URTI/GE (in children) = Reye syndrome i.e.

Nutrition rash, encephalopathy, fatty liver

 Total parenteral nutrition (TPN)  Amoxicillin + EBV = infectious mononucleosis i.e. nonallergic

- Approach amoxicillin rash

 Central: both central and peripheral TPN formulae  [GI decontamination within 1hr of ingestion of toxic substance]

 Peripheral: only peripheral TPN formula Activated charcoal 50g RT x1 stat

- Formula  [Elevated INR] Phytomenadione (vitamin K1) 10mg daily IV

 Central: main difference is the lipid content  [Premeds for allergy] piriton 10mg Q4H IV, hydrocortisone 50mg

- Nutriflex Lipid special or plus (N1 or N2) Q4H IV

 50% soybean oil, 50% MCT

 N1: usual choice to start with

- Kabiven (K2)

- Hepatic (H1 or H2)

 Contains branched amino acids for

prophylaxis and therapy of hepatic

SHORT FORMS

 ACIS: Acinetobacter spp

 BGA: blood glucose assessment = Hstix

 CAP: community acquired pneumonia

 CVC: central venous catheter

 CVVH: continuous veno-venous hemofiltration

 ENTS: Enterobacter spp

 HAP: hospital acquired pneumonia (after 48hrs of hospital stay)

 HCAP: healthcare associated pneumonia (recent hospitalization

lasting for >=2days within 90days of current admission)

 HOB: head of bed

 M&M: morphine + midazolam

 MV: mechanical ventilation

 MW: mouthwash

 NA: noradrenaline

 NC: nasal cannula

 NIV: non-invasive ventilation (BiPAP, CPAP)

 NRM: non-rebreathing mask

 Paer: Pseudomonas aeruginosa

 PCT: procalcitonin

 PMAL: Stenotrophomonas (previously classified as Pseudomonas)

maltophilia

 ROS: review of system

 RSI: rapid sequence induction

 SBT: spontaneous breathing trial

 SOOB: sit out of bed

 TBL: total blood loss

 TM: tracheal mask

 UAWO: upper airway obstruction

 UPO: until proven otherwise

 VAP: ventilator associated pneumonia (after 48hrs of intubation)

- THE END –