REBEL EM Useful Critical Care/ICU Stuff

I have started to split my time between the ED and ICU.  Obviously these two areas of clinical care have their similarities, but also have their differences. So I decided to create this post to put things that I have found useful and recurrently coming back to when on my critical care time.  This is not meant to be an EBM based post, but rather a clinical post of useful critical care/ICU information.  I will continue to add to this post as I spend more time in the ICU and hopefully this becomes a nice repository of information for others.

Vaso/InoPressors

• Milrinone 0.125-0.75 mcg/kg/min
• Isoproteronol 2-10 mcg/min
• Dobutamine 2-20 mcg/kg/min
• Epinephrine 0.01-0.1 mcg/kg/min
• Norepinephrine 0.01-1 mcg/kg/min
• Phenylephrine 0.1-1.0 mcg/kg/min
• Vasopressin 0.01-0.06 U/min

Antiarrhythmics

• Amiodarone 150mg bolus followed by 1mg/min x6hrs, then 0.5mg/min x18hrs
• Digoxin 250mcg IV q2hrs x3, then 125 to 375mcg qday
• Esmolol 500mcg/kg IV bolus, then 50mcg/kg/min (titrate by 50mcg/kg/min q5min)(Max dose 200mcg/kg/min)
• Procainamide 10 – 20mg/kg IV bolus over 20min, then 1 to 4mg/min
• Lidocaine 1mg/kg (50 to 100mg) IV over 2 – 4 min, then 1 – 4mg/min

Sedation:

• Ketamine 0.5 – 2mg/kg IV bolus, then 0.05 – 0.4mg/kg/hr
• Dexmedetomidine 0.2 – 1.4mcg/kg/hr
• Propofol 0.5 – 1mg/kg IV bolus, then 5 to 80mcg/kg/min

Paralytic Infusions

• Vecuronium
  • Bolus: 0.1mg/kg
  • Infusion: 1mcg/kg/min adjust dose by 0.3 mcg/kg/min q15 minutes (MAX Dose 1.7mcg/kg/min)
• Cisatracurium
  • Bolus: 0.2mg/kg
  • Infusion: 1 mcg/kg/min, adjust dose by 0.5 mcg/kg/min q 15 minutes (MAX Dose 10mcg/kg/min)

Options to Reduce Pulmonary Vascular Resistance in RV Failure

• Esoprostenol 0.05mcg/kg/min
• iNO 20 – 40ppm
• Alternative Options
  • Inhaled Milrinone (1mg/1mL) 5mg over 15min
  • Inhaled NTG (1mg/1mL) 5mg over 15min

Things to Consider Prior to Extubation

• RSBI <100 = RR/TV (Liters)
• MV <10 = RR x TV
• Pick up Head
• PEEP <8
• FiO2 <50%
• PaO2 >60
• Cough
  Follow Commands
• Low Secretions
• Cuff Leak

Anticoagulation

• Bivalirudin
  • Half-Life = 25min (with normal renal function)
  • Mechanism of Action = Direct Thrombin Inhibition
  • Protein Binding = None
  • Metabolism/Excretion = Combo of proteolytic cleavage + Renal
  • Monitor with PTT level
  • No Antidote BUT short half life (back to baseline coagulation at ≈1hr)
  • No risk of HIT
• Argatroban
  • Half-Life = 45min (with normal liver function)
  • Mechanism of Action = Direct Thrombin Inhibition
  • Protein Binding = 20% albumin/30% alpha-acid glycoprotein
  • Metabolism/Excretion = Liver
  • Monitor with PTT level
  • No Antidote BUT back to baseline coagulation at 2 – 4hrs
  • No risk of HIT

Cardiac Indices:

• NORMAL
  • CO = 4 – 8L/min
  • CI = 2.5 – 4.2L/min/m2
  • SVR = 900 – 1600 dynes/sec/cm-5
  • PCWP = 6 – 12mmHg
• HYPOVOLEMIC
  • Decreased CO + PWP + CVP
  • Increased SVR
• CARDIOGENIC
  • Increased SVR + PWP + CVP
  • Decreased CO
• DISTRIBUTIVE
  • Decreased SVR + PWP + CVP
  • Increased CO

Invasive Mechanical Ventilation

ExtraVentricular Drains (EVDs)

SETUP:
Laser Beam —> Level with tragus
Proximal Stop Cock —> Clearance of blood products/infection
Collecting Chamber —> Up or down to set desired pressure
Distal Stop Cock —>
-“Off” to the right – Allows Drainage
-“Off” to the floor – Zeroing
-“Off” to the ceiling – Clamped
-20cmH20 ≈ 15mmHg
-20mmHg ≈ 27cmH20
Clamp EVD (“Off” to ceiling) for ICP pressure

Image from EMCrit Site (Link is HERE)

WAVEFORMS:
P2>P1 = Decreased Compliance

Image from EMCrit Site (Link is HERE)

CEREBRAL PERFUSION PRESSURE (CPP):
CPP = MAP – ICP
MAP from A-Line
ICP from EVD

COMPLICATIONS:
Ventriculitis —> Send CSF
Bleeding —> Head CT
Overdrainage —>
-CSF Made = 600cc/day or 20cc/hr
->350cc/day can lead to this
Catheter Occlusion —> Talk to Neurosurg

MONITORING:
ICP Value Range
ICP Waveform
CSF Color
Daily/Hourly Output
Coagulation Status

2 Options for Elevated ICP in Severe TBI

• Mannitol
  • Bolus Only
  • Onset 30min
  • Lasts 6hrs
  • Causes Osmotic Diuresis
  • Dose 0.25 – 2g/kg over 30 to 60min
• HTS (3%)
  • Bolus or Drip
  • Onset 5min
  • Lasts 12hrs
  • No Diuretic Effect
  • Dose 300mL over 1hr