Dexmedetomidine (Precedex)
- Sedation without respiratory depression
- Ideal for use in the Intensive Care Unit.
- Can be used for managing extubations.
- No absolute contraindications
- Compared to Versed (Midazolam), Precedex is associated with less delirium, tachycardia, and hypotension, but had more bradycardia
- Agonist of alpha 2 adrenergic receptors in the brain
- FDA reports that infusions greater than 24 hours in duration include ARDS, respiratory failure, and agitation
Skin and Soft Tissue – Surgical Issues
- Various classification systems for necrotizing skin and soft tissue infections help in the study of the disease, doesn’t necessarily help in the care of the patient.
- Dish water exudates and grey necrotic tissue are macroscopic findings of necrotizing soft tissue infection.
- Along with early debridement, very broad spectrum IV antibiotics is the mainstay of necrotizing soft tissue infection.
- Hyperbaric oxygen is not a proven therapy of necrotizing soft tissue infection.
- Switching from castille soap to a once daily 2% chlorhexidine body wash reduces MRSA colonization rates of Surgical ICU patients.
- MRSA (Methicillin Resistant Staphylococcus Aureus) is currently the leading pathogen of surgical site infection
- Chloraprep (contains alcohol) use must be selective – beware of starting a fire on the surgical site.
- After fasciotomies, negative wound therapy could be helpful for getting rid of edema and keeping wound clean and dry.
- Negative pressure wound systems have been associated with complications of death and injuries.
- Measuring compartment pressures, position of the head and trunk relative to the extremities is important when zeroing the transducer
- When performing a Fasciiotomy – one approach anterolateral incision and then posteromedial incision
- Calciphylaxis is associated with high calcium phosphorus product (Ca x P).
- Infected Calciphylaxis lesions must be completely excised which is associated with a high mortality rate.
- Pressure sores is a “never” event.
- Smoking cessation is a mainstay of managing hidradenitis supperativa
- Carbon dioxide laser excision is now being tried to treat moderate infections of hidradenitis supperativa (not severe enough for hospitalization).
- Biopsy of complex skin lesions is important for diagnosis
- Pyoderma Gangrenosum – 50-70% will have systemic disease (like inflammatory bowel disease (UC / Crohn’s Disease).
Perioperative ICU Topics
Transfusion related acute lung injury must be distinguished from cardiogenic and non cardiogenic pulmonary edema and pulmonary contusion.
- TRALI – acute onset of non-cardiogenic pulmonary edema after transfusion of blood products.
- Leading cause of transfusion related fatalities in the US
- Occurs within first 6 hours following transfusion
- Due to leukocyte antibodies in transfused plasma
- Incidence 1:5000
Transfusion related circulatory overload – diurese early
- Furosemide is a loop diuretic
Intubated patients should be transported in Semi fowler recumbent position, 30 degree head of bead to help prevent ventilator associated pneumonia
- Semi fowler – knees bent, head of bed not as high as fowler position
Hydration of the patient is an important measure to prevent contrast induced nephropathy
With ICU patients with Renal insufficiency, aggressive dialysis does not lead to significant improvements in renal recovery and 30 day mortality rates
Analgesics and sedatives may blunt ACTH stimulation test for adrenal insufficiency
- ACTH stim test for asessing the functioning of adrenal glands.
- ACTH is made by the anterior pituitary gland which stimulates the adrenal glands to release cortisol, DHEAS, and aldosterone.
- Adrenal insufficiency is a potentially life threatening problem
- ACTH stimulation test is primarily used to deterine the presence of Addison’s diaseas and pituitary impairment
- Addison’s disease: Adrenal glands do not produce sufficient steroid hormones. Also known as primary adrenal insufficiency.
- The test is extremely sensitive to primary adrenal insufficiency but less so to secondary adrenal insufficiency. Secondary adrenal insufficiency is caused by deficiency of ACTH.
Precedex: use less than 24-48 hours.
- Dexmedetomidine – a sedative used in ICU which does not cause respiratory depression
Outcomes protonics vs. H2 blockers not that different in stress gastritis prophylaxis
Advanced directives in ICU – pastoral care staff to bring up on initial contact
Family like ICU rounds – transparency
Refeeding syndrome – low phosphate levels is a hallmark. Happens in 10 days or more of not feeding. When feeding resumes: hyperglycemia – creates even lower levels by moving phosphate and potassium into cells.
Abdominal Compartment Syndrome – open abdomen immediately with elevated intra-abdominal pressure and renal failure, hypotension, or high pulmonary ventilation pressures.
Use of diuretics in ACS (Abdominal Compartment Syndrome) is controversial. Some surgeons diurese early to decrease bowel edema and to get the abdomen closed.
ICU central lines to be assessed daily and document need for it daily
Trauma patients, erythropoetin may predispose to DVT
- Liver production of erythropoetin predominates in the fetal and perinatal period
- Renal production is dominant during adulthood
Induced coma clouds the issue of brain death in regards to organ donation.
Elderly ICU with hyperactive delirium have better outcomes than those with hypoactive delirium.
Elevated CK levels hallmark in propofol infusion syndrome.
- Potentially and often fatal
- cardiac failure, rhabdomyolysis, renal failure, hyperkalemia, hypertriglycerdemia, hepatomegaly.
- Maybe caused by impaired mitochondrial function
- CK = creatine kinase = present in all muscles
- Elevated CK levels indicated muscle damage/strain – could be from heart attack or muscles being overworked (ie. weight lifting).
- Propofol infusion syndrome is at higher risk when patients are already on catecholamines or corticosteroids.
Inhaled PGE2, selectively vasodiates the pulmonary vasculature, it improves VQ mismatch in severe hypoxemia
- An area with no ventilation (V/Q = zero) = shunt
- The area with no perfusion = dead space
- PGE2 = prostaglandin E2
- PGE2 softens cervix and causes uterine contraction, causes fever, direct vasodilator, relaxes smooth muscles.
In sepsis, norepinephrine raises heart rate less than dopamine.
- Vasoactive drug use in septic shock
- Used to increase blood pressure
- Dopamine is the immediate precursor of norepinephrine and epinephrine
- Less tachycardic reaction with NorEpinephrine compared to Dopamine.
