Common Conditions – Special Employees and Conditions in the ICU

by Brian Warriner, MD, FRCPC

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    00:00 So let's talk about some fairly common diagnoses in the Intensive Care Unit.

    00:07 So Infection is a major reason to admit patients to the ICU.

    00:13 Failing organ systems is a second reason for admitting patients. Heart failure, renal failure, respiratory failure. And medical conditions with high mortality such as vasculitis, overdoses, toxic syndromes. Patients in need for ventilation.

    00:31 Respiratory failure, pulmonary edema, closed head injuries, diabetic ketoacidosis, renal failure again, and other system, major system disease. SIRS, which we'll talk about briefly in a moment, is Systemic Inflammatory Response Syndrome, and requires intensive care treatment. And any time a patient requires complex equipment, such as a ventilator, or a left ventricular assist or right ventricular assist device, which we'll talk about in a minute, continuous renal dialysis or as it's more properly called, continuous renal replacement therapy, CRRT, or extra corporeal membrane oxygenation, ECMO.

    01:13 So the modern ICU ventilator is a highly sophisticated piece of equipment which can deliver different modes of ventilation according to the patient's needs. It tends to be a little higher quality than the ones we use in the operating room, although that's changing. The ones we're using in the operating room are increasingly being used for critical care patients who were transferred from the ICU to the OR. So we basically need the same equipment in both places. Volume control ventilation is the commonest mode of ventilation control in which we set the volume and the minute ventilation or the ventilatory rate that we want the patient to receive. And we usually adjust this according to the patient's arterial oxygen saturation and carbon dioxide levels. And we can do either blood gases, or we can do end-tidal CO2, or just use saturation continuously on these patients.

    02:07 Pressure-Controlled ventilation is used for patients with high airway pressures, who are at risk of barotrauma or damage to the lungs from high pressure, from volume-controlled ventilation. And in this situation, instead of setting the volume, the maximum inspiratory pressure is set. And the ventilator rate is set according to blood gases, or saturations, or end-tidal CO2. Pressure assistant ventilation is a situation in which the ventilator assists the patient's own ventilatory efforts by providing a boost in pressure with each breath to assure adequate ventilation. So, the ventilator can sense when a patient is trying to breathe and quickly intervene to make sure that they get a breath, and that they get an adequate breath.

    02:55 We can easily add Positive End-Expiratory Pressure which is, basically applying pressure that is maintained in the lungs even at end expiration. So, normally when you expire fully, there's very little pressure in your lungs. But when we're healthy, there's still a lot of gas in our lungs that continue to supply oxygenation to the body. In sick people that can be a problem. So PEEP is added, usually in fairly low levels, just to maintain lung volume in sick people, so oxygenation is supported.

    03:31 If ventilation is prolonged and the patient cannot be weaned, tracheostomy is often provided and the patient may be ventilated through the tracheostomy, or in a better situation, they start to breathe spontaneously through their tracheostomy. Other organ systems are also extremely important, such as kidney. And renal failure in the ICU is now treated primarily with Continuous Renal Replacement Therapy or CRRT. The reason this is used is, it's a slow gradual technique rather than the more rapid dynamically dramatic changes that occur with hemodialysis. So when you put a person on hemodialysis, you tend to push their blood pressure down, their volume's changed very rapidly. And normally people can tolerate that, but they can't when they're critically ill. So continuous renal replacement therapy has replaced that. Acute Lung Injury or ALI, used to be called ARDS or Adult Respiratory Distress Syndrome. And has been revolutionized, the treatment of this disorder, by changes in ventilatory mode that have only been introduced in the last 5 years or so. And these have included using much smaller tidal volumes than we used to, and more rapid respiratory rates that's creating good minute ventilations, but low pressures in the lungs. This has reduced ventilator associated lung trauma dramatically and has improved outcomes. ECMO or Extra-Corporeal Membrane Oxygenation, is used more frequently and more effectively than it once was and we'll talk about this in a minute. Cardiac failure. We work by using Left-Ventricular Cardiac Assist Devices at a much earlier state than we used to. And these devices, and we'll discuss this in more detail in a moment, can act as a bridge to heart transplant, or more appropriately as a treatment from which the patient will recover from their heart failure and the left-ventricular assist device can be removed. So, infection that is often difficult to treat is a very common problem in the ICU. And ventilatory Associated Pneumonia, VAP, is a common problem. And intensive care units now use what's known as a VAP Pack, which reduces the incidence of VAP and improves the treatment of VAP.

    About the Lecture

    The lecture Common Conditions – Special Employees and Conditions in the ICU by Brian Warriner, MD, FRCPC is from the course The ICU.

    Included Quiz Questions

    1. Volume-controlled ventilation
    2. Pressure-controlled ventilation
    3. Pressure-assisted ventilation
    4. Positive end-expiratory pressure
    5. Airway pressure release ventilation
    1. Positive end-expiratory pressure
    2. Volume-controlled ventilation
    3. Pressure-controlled ventilation
    4. Pressure-assisted ventilation
    5. Airway pressure release ventilation
    1. Continuous renal replacement therapy
    2. Peritoneal dialysis
    3. Sustained low-efficiency dialysis
    4. Sustained low-efficiency daily dialysis
    5. Intermittent hemodialysis
    1. Early LVAD use
    2. Early CRRT
    3. Early ECMO
    4. Early HD
    5. Early SLEDD

    Author of lecture Common Conditions – Special Employees and Conditions in the ICU

     Brian Warriner, MD, FRCPC

    Brian Warriner, MD, FRCPC

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