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
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.