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Critical Care Medicine Information Sheet 2003

Respiratory Critical Care
1. Measurement of Hypoxemia
a. Alveolar-arterial oxygen difference (A-a gradient)
i. A-a gradient = PAO
2
- PaO
2

ii. A-a gradient = [(PB - PH
2
0) (FIO
2
) - PCO
2
/ R] - PaO
2

iii. A-a gradient = [713 (FIO
2
) - PCO
2
/ 0.8] - PaO
2

iv. A-a gradient = [713 (FIO
2
) - 1.25 (PCO
2
)] - PaO
2

v. A-a gradient:
1. On room air normal always < 25
2. On 100% FIO
2
on mechanical ventilation normal 100
3. Formula for determining normal A-a gradient based on
age:
4. Normal A-a gradient = [Patient age + 4] / 4

b. PaO
2
/FIO
2
ratio
i. PaO
2
off blood gas / FIO
2

ii. Normal > 200
iii. Useful trend to follow when patient on mechanical ventilation;
results affected less by changes in FIO
2
then when using A-a
difference to monitor hypoxemia.

c. PAO
2
: PaO
2
ratio (A.K.A. A/a ratio)
i. Same as for B.3
ii. PaO
2
off ABG
iii. PAO
2
calculated from known FIO
2
and measured PCO
2
off ABG
where, PAO
2
= 713 (FIO
2
) - 1.25 (PCO
2
)
iv. Normal PaO
2
/ PAO
2
0.8

d. Normal PaO
2
corrected for age in patients with normal Lungs:
i. Arterial PaO
2
= 100 - (0.4 X age in years)

2. Oxygen Saturation (Oxygen Dissociation Curve Determinants)

Shift Right ( affinity, P50, delivery) Shift Left ( Affinity, P50, delivery)
Acidosis Alkalosis
Hypercapnea Hypocapnea
Hyperthermia Hypothermia
Elevated RBC MCHC Reduced RBC MCHC
2,3 DPG 2,3 DPG
Abnl Hgb (ss) Abnl Hgb (fetal, meth, sulf)
Exercise Carbon monoxide
Propranolol
2


3. Ventilator Equations and Adjustments:
a. Minute ventilation = tidal volume (liters) X respiratory rate (# per
minute) (normal < 10 liters/min)

b. Adjusting ventilator rate:
i. Desired f = [(actual f) (actual PaCO
2
)] / desired PaCO
2


c. Adjusting tidal volume:
i. Desired V
T
= [(actual PaCO
2
) (actual V
T
)] / desired PaCO
2


d. Adjusting FIO
2
:
i. Desired FIO
2
= [(actual FIO
2
) (desired PaO
2
)] / actual PaO
2


e. Static pulmonary compliance (Cst):
i. C
stat
= V
T exhaled
/ P
plat
- PEEP
ii. Normal = 50-100 cm H
2
O
iii. Stiff noncompliant lung < 50 cm H
2
O (example ARDS)
iv. Highly compliant non-stiff lung > 100 cm H
2
O (example COPD)

f. Pressure generated to overcome airway resistance:
i. P
aw
= PIP - P
plat


g. Mean airway pressure:
i. Mean P
aw
= K (PIP - PEEP) (T
1
/ TCT) + PEEP
1. This equation shows the relationship of PIP, PEEP and
time on mean airway pressure.

h. Bohr Equation (V
D
/ V
T
):
i. V
D
/ V
T
= PaCO
2
- P
E
CO
2
/ PaCO
2


4. Strategies to reduce auto-PEEP in bronchospastic patients on mechanical
ventilation.
a. Controlled ventilation: sedation paralysis as needed.
b. -agonist, Ipatropium, steroids, magnesium sulfate, aersolized
lidocaine.
c. Increase peak inspiratory flow rate (70-120 Liters / min).
d. Reduce tidal volumes (5-8-ml/kg)--[permissive hypercapnea].
e. Reduce respiratory rate [permissive hypercapnea].
i. Permissive hypercapneaadd sodium bicarbonate drip if
arterial pH < 7.20 and titrate the drip to maintain arterial pH >
7.20.
ii. Add extrinsic PEEP (never more than 10 cm H
2
0) to counteract
intrinsic PEEP (auto-PEEP).

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5. Protocol for Mechanical Ventilation in patients with early ARDS.
a. Controlled ventilation: sedation paralysis as needed.
b. Use lower tidal volumes for the baby lung seen in ARDS (e.g., 5 - 8
ml/kg of ideal body weight and maintain plateau pressure 35 cm
H
2
O). This is a lung protective strategy designed to prevent over
distention of normal alveoli and to reduce pulmonary and systemic
inflammation caused by volume and/or pressure induced over
distention of the alveoli (alveolar volume/pressure trauma). [JAMA.
1999; 282:54-61; Amato NEJM 1998; 338:347-354; ARDS Network
Trial NEJM 5/00]. Studies show that in large groups of ARDS patients,
the lower inflexion point on the pressure volume curve ranges from
(mean) 12.6-13.6 2.8-3.9 (SD). For this reason, initially set PEEP at
12-15 cm H
2
O or set PEEP at 2-3 cm H
2
O higher than the lower
inflection point on the pressure volume curve. This is a lung protective
strategy to prevent repetitive opening and closure of alveolar units
sheer trauma. [JAMA. 1999; 282:54-61, Amato NEJM 1998;338:347-
354; ARDS Network Trial NEJM 5/00].
c. Respiratory rate is adjusted to < 10 -15/min.
d. Permissive hypercapnea- add bicarbonate drip if arterial pH < 7.20 and
titrate drip to maintain arterial pH > 7.20.
e. The standard inspiratory to expiratory ratio of 1:2 should be used;
however, in some cases Pressure Control Ventilation with inverse ratio
ventilation [I:E ratios of 1:1; 1.5:1; or 2:1] may be required. Be aware
that hemodynamic instability may occur during inverse ratio ventilation
especially in patients with pre-existing heart disease. A reduction in
preload caused by high intrathoracic pressure occurs. Therefore, a
physician must always be present at the bedside during initiation of
PCV or when making a change to inverse ratio ventilation.
f. Any patient on mechanical ventilation who develops a pneumothorax
should have a chest tube placed. Prophylactic chest tubes may be
justified in some patients.
g. Be aware that the development of pneumomediastinum or
subcutaneous air signals that the patient is at high risk for developing a
pneumothorax. A standard CXR does not always show the
pneumothorax (it may be located anteriorly). If a patient is
hemodynamically stable, a CT scan of the chest will demonstrate a
pneumothorax. Rule of thumb: In unstable patients, if in doubt as to
whether or not a pneumothorax is present, place a chest tube.
h. Calculation of idea body weight (Kg) for use in determining tidal
volume settings:
i. Ideal body weight (kg) males = 50 + 0.91[Height (cm) 152.4]
ii. Ideal body weight (kg) females = 45.5 + 0.91[Height (cm)
152.4]

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6. Differential Diagnosis for Failure to Wean From Mechanical Ventilation
a. WEANS NOW:
i. W - Work of breathing = NIF, VC, Tobin Index (frequency / TV),
BICORE machine
ii. E - Endotracheal or tracheotomy tube size.
1. Note: Airway resistance is related to diameter and length
of the breathing tube. Airway resistance may be
decreased by using a larger diameter tube and/or a
shorter breathing tube.
iii. A - Acid/base; abdominal distention; atelectasis;
anxious/agitated; alkalosis.
1. Note: metabolic alkalosis shifts oxygen hemoglobin
dissociation curve to the left and impairs the CNS
respiratory drive.
iv. N - Nutrition and electrolytes (Mg
2+
, PO
4
, K
+
)
v. S - Secretions due to sinusitis; bronchitis; pneumonia;
aspiration; CHF (systolic or diastolic dysfunction); TE fistula; GE
reflux; aspiration.
vi. N - Neuromuscular status. Neuromuscular disease;
neuromuscular blockers; steroids; aminoglycosides; endocrine
(hypothyroid).
vii. O - Occult obstruction (bronchospasm)
1. Consider: -agonist; ipatropium, steriods, leukotriene
inhibitors, theophyline
viii. W - Wakefulness. Is the patient over sedated? Is the patient
able to follow commands and participate in his/her care?

Cardiovascular Critical Care
1. Hemodynamic monitoring
a. Normal Values:
i. Cardiac output = 4-8 liters / minute
ii. Cardiac Index = CO / BSA = 2.2 - 4.0 l / m
2
/ min
iii. Stroke Volume = CO / heart rate
iv. Cardiac Output = Heart rate X stroke volume (1/min)
v. Right atrium pressure = 0-8 mmHg
vi. Central venous pressure (CVP) = 0-8 mmHg
vii. Pulmonary artery systolic (PAS) = 15-30 mmHg
viii. Pulmonary artery diastolic (PAD) = 5-12 mmHg
ix. Mean pulmonary artery pressure (MPAP) < 20 mmHg
x. Pulmonary artery wedge pressure (PAOP or PCWP):
1. < 6 = dehydrated
2. 6-15 = normal
3. 18-20 = mild congestion
4. 20-25 = moderate congestion
5. 25 = severe congestion
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xi. Body surface area (m
2
) = [(height (cm) x weight (kg)) /
3600] Where means take the square root of the number in
brackets

b. Essential Formulae:
i. Mean arterial pressure (MAP):
1. MAP = 1/3 (AP
systolic
- AP
diastolic
) + AP
diastolic

2. MAP = normal > 70
3. MAP < 70 = shock in the majority of patients.

ii. Mean pulmonary artery pressure:
1. PAP
mean
= 1/3 (PA
systolic
- PA
diastolic
) + PA
diastolic


iii. Systemic vascular resistance (SVR)
1. SVR = [MAP CVP / CO] x 80 (nl = 700 - 1400 dynes
- sec - cm-
5
)
a. Where MAP = mean arterial pressure
b. CVP = central venous pressure
c. CO = cardiac output
d. 80 = Conversion factor used to convert wood
units to dynes - sec - cm-
5


iv. Pulmonary vascular resistance (PVR)
1. PVR = [PAP
mean
- PCWP / CO] x 80 (nl < 200 dynes -
sec - cm-
5
)
a. Where PAP
mean
= mean pulmonary artery
pressure
b. PCWP = pulmonary capillary wedge pressure
c. CO = cardiac output
d. 80 = conversion factor used to convert wood
units to dynes - sec - cm-
5


c. Hemodynamic monitoring (short form) calculation
i. Theoretical, calculated, end-pulmonary capillary oxygen
content (CcO
2
), assuming 100% hemoglobin saturation with
oxygen:
1. CcO
2
= 1.39 (Hgb)

ii. Total arterial oxygen content (CaO
2
):
1. CaO
2
= 1.39 (Hgb) (SaO
2
)

iii. Total venous oxygen content (CvO
2
)
1. CvO
2
= 1.39 (Hgb) (SvO
2
)

iv. Arterial venous oxygen content difference (AVDO
2
)
1. AVDO
2
= CaO
2
- CvO
2
(nl < 5)
6

v. Oxygen delivery (DO
2
in ml/min)
1. DO
2
= CO (CaO
2
) (10)

vi. Oxygen consumption (VO
2
in ml/min)
1. VO
2
= CO (AVDO
2
) (10)

vii. Intrapulmonary shunt fraction (Q
S
/Q
T
). AKA: arterial-venous
admixture (nl < 10%)
1. Qs/Q
T
= CcO
2
- CaO
2
/ CcO
2
- CvO
2


viii. Extraction ratio (nl 22 32%)
1. VO
2
/ DO
2


ix. Caloric requirements (kcal/24 hours):
1. 7.1 (VO
2
)

x. Crude method of estimating intrapulmonary shunt fraction in
patients on mechanical ventilation who are on 100% FIO
2
:
1. Normal PaO
2
~600-650 mmHg
2. For every drop in PaO
2
of 100 mmHg from the normal
corresponds to a 5% shunt.
3. Example: PaO
2
= 230 mmHg on 100% FIO2
corresponds to an estimated 20% intrapulmonary
shunt.

2. Adverse consequences of PEEP
a. Elevation in airway pressure; increased risk of barotrauma.
b. Decreased venous return to right heart decreased right
ventricular preload decreased cardiac output.
c. Decreased left ventricular filling (preload) decreased cardiac
output (due to increased PA, PVR, and RV afterload).
d. Direct compression of heart by overextended lungs thus limiting LV
filling decreased cardiac output.
e. Decreased LV output due to PEEP i nduction of increased RV
afterload with subsequent RV distention and bulging of
intraventricular septum into LV cavity (causes LV diastolic
dysfuntion).

3. Beneficial effects of PEEP:
a. Increases FRC improves / prevents atelectasis.
b. Decreases work of breathi ng by reducing hypoxemia.
c. Reduces LV preload and afterload.
d. Improves hypoxemia by:
i. Recruiting atelectatic alveoli and increasing FRC
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ii. Redistribution of lung H
2
O from alveolar space into the
interstitium
iii. Improving static lung compliance
iv. Decreasing intrapulmonary shunting.
e. May be used to counter the effects of intrinsic (auto) PEEP.
f. Peep at or above the lower inflection point on the pressure volume
curve has a protective effect on the lungs in patients with ARDS.
g. Special note: PEEP does not prevent the development of ARDS.

4. Nitroprusside Information
a. Thiocyanate toxicity
i. Most common in patients with renal failure.
ii. Thiocyanate level < 10 mg/dl considered safe.
iii. Manifest as: fatigue, muscle weakness, nausea, vomiting,
confusion, seizures, coma.
iv. Treatment: hemodialysis
b. Cyanide toxicity
i. Use of nitroprusside for > 3 days.
ii. Most common with severe liver failure.
iii. Manifest as severe lactic acidosis.
iv. Treatment:
1. IV sodium nitrate
2. IV thiosulfate
3. IV vitamin B
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Critical Care Acid-Base:
2. Stepwise approach:
a. Determine electrolyte and ABG values concomitantly.
b. Compare the calculated and measured plasma HCO
3
concentration
to rule out laboratory error using H
+
= 24 (PaCO
2
/ HCO
3
) where
normal H
+
= 40 and corresponds to a normal pH = 7.40. An
increase in H
+
results in a lower pH and vise versa.
c. Compute anion gap (Na (Cl + HCO3).
d. Calculate degree of compensation (see below).
e. Compare the change in plasma sodium and chloride concentration;
anion gap and bicarbonate concentration; chloride and bicarbonate
concentration.

3. Determinants of compensation:
a. Metabolic acidosis:
i. PaCO
2
= 1.5 (HCO
3
) + 8
ii. PaCO
2
= last two digits of pH
iii. PaCO
2
= 1.0 1.5 per 1 mEq/L HCO
3




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b. Metabolic alkalosis:
i. PaCO
2
= 0.9 (HCO
3
) + 9
ii. PaCO
2
= 0.5 1.0 mm per 1 mEq/L HCO
3


c. Respiratory acidosis and alkalosis (acute acid-base changes based
on PCO
2
and HCO
3
):
i. H
+
=0.8 (PaCO
2
)
ii. For every or of PCO
2
by 1 = pH by 0.008
iii. For every or of HCO
3
by 1 = pH by 0.015

d. Estimate of baseline PCO
2
in patients with Acute Respiratory
Acidosis:
i. Estimated baseline PCO
2
= 2.4 (admission measured HCO
3

22)

4. Increased anion gap metabolic acidosis
a. Anion gap = Na
+
- [Cl
-
+ HCO
3
-
] = Normal < 15
i. Differential Diagnosis (MUD PIES):
1. M - Methanol
2. U - Uremia
3. D - DKA
4. P - Paraldehyde
5. I - Ischemia (lactic acidosis); INH
6. E - Ethanol; ethylene glycol
7. S - Salicylates

5. Normal anion gap metabolic acidosis
a. Differential diagnosis (HARD UP):
i. H - Hyperalimentation
ii. A - Acid Ingestion; Addisons; hypoaldosteronism;
acetazolamide, aldactone
iii. R - RTA; early renal failure
iv. D - Diarrhea; diuretics (e.g., spironolactone, diamox)
v. U - Uretosigmoidostomy
vi. P - Posthypocapnea; pancreatitis

6. Differentiating acidosis in alcohol ingestion:

Substance Target
Osm
Gap
Ketones Breath Acidosis Urine
Ethanol Liver +++ 0
Methanol Eyes 0 --- +++
Ethylene glycol Kidney 0 --- +++
Oxalate
crystals
Isopropyl + 0
Alcoholic ketoacidosis N + +
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7. Osmolar Gap:
a. Osmolar gap = [measured osmolality] [calculated osmolality]
b. Osmolar gap = normal < 10
c. Calculated osmolality = 2 [Na
+
] + [glucose / 18] + [BUN / 2.8]
d. Differential Diagnosis of increased osmolar gap:
i. Lactic acid
ii. Ethylene glycol
iii. Ethanol
iv. Isopropanol
v. Methanol
e. If osmolar gap > 25 think ethylene glycol and methanol.
f. You will generally see an anion gap > 20 and an osmolar gap > 25
in ethylene glycol and methanol poisoning.

8. Osmolar gap and ingestion of an unknown alcohol-glycol:

Osm Normal pH No acetone Ethanol
acetone Isopropanol
Acidosis Methanol
Ethylene glycol
9. Calcium relationship to albumin
a. Corrected calcium = observed calcium + 0.8 (4.0 - albumin)

10. Water/salt balance:
a. Fractional excretion of Na
+

i. FENA = [(Urine Na
+
) (Plasma Cr) / (Plasma Na
+
) (Urine Cr)]
X 100

b. Water deficit (L) = [(0.6) (wt in kg) ((Observed Na
+
/ 140) 1)]
i. Infuse of deficit over 24 hours then the remainder over the
next 2-3 days.

Critical Care Nutrition
1. Energy (kcal/gram)
a. Lipid = 9.1 kcal/gram
b. Protein = 4.0 kcal/gram
c. Glucose = 3.75 kcal/gram

2. Ideal body weight (kg) males = 50 + 0.91 [Height (cm) 152.4]
3. Ideal body weight (kg) females = 45.5 + 0.91 [Height (cm) 152.4]
4. Short form basal energy expenditure (BEE) equation:
a. BEE (kcal/day) = 25 x wt (kg)
b. Stress factors
i. Burns:
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1. 1-20% TBSA 1.2 - 1.5
2. 20-40% TBSA 1.5-2.0
3. 40% TBSA 1.8-25
a. Sepsis 1.2-1.7
b. Trauma 1.1-1.5
c. Fever 1.0 x each degree C of fever above
38 C
c. Rule of thumb calculation of caloric needs:
i. 25-30 kcal/kg/day for most patients is sufficient.

d. Swan-Ganz guided measurement of energy expenditure.
i. kcal/24 hours = VO
2
x 7.1
5. Protein
a. In general need one gram protein / kg / day
i. Nitrogen intake (grams) = protein intake (grams) / 6.25
ii. Nitrogen balance (grams) = [protein intake (grams) / 6.25]
[24 hour urine nitrogen (grams) + 4]