The Anesthesia & ICU Insights

Approach to Hypothyroidism

Approach to Elevated PT/PTT

Sepsis definitions over time

🔸️Reference: UpToDate2024

IVF comparison

Status epileptics

🛑Absence seizures

✅Absence seizures (petit mal) are a form of generalised epilepsy that is mostly seen in children.

✅The typical age of onset of 3-10 years old and girls are affected twice as commonly as boys.

✅Absence seizures - good prognosis: 90-95% become seizure free in adolescence

✅Ethosuximide has much better safety profile than valproic aci considered first-line treatment

#Not and Note

🛑What is the likelihood of being seizure-free after a second or third antiepileptic is added?

✅ A study of patients with previously untreated epilepsy demonstrated that 47% achieved control of seizures with the use of their first single drug
✅ 14 % became seizure-free during treatment with a second or third drug.

🛑when we start antiepileptics in patient with epileptic seizure ?

✅Most neurologists now start antiepileptics following a second epileptic seizure.
✅ NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present:
✅ the patient has a neurological deficit
✅ brain imaging shows a structural abnormality
✅ the EEG shows unequivocal epileptic activity
✅ the patient or their family or carers consider the risk of having a further seizure unacceptable
✅Sodium valproate is considered the first line treatment for patients with generalised seizures with carbamazepine used for partial seizures

#Not and Note

Lentiform Fork Sign caused by Metabolic acidosis mainly due to metabolic acidosis

It is reversible sign with improvement of the pt condition if there's no stroke associated

🔸️ Recurrent laryngeal nerve palsy due to endotracheal tube pressure is usually temporary

🅰️Partial injury lead to midline position due to unopposed adductors
1️⃣Unilateral lead to horsiness of voice
2️⃣Bilateral lead to complete airway obstruction


🅱️ complete RLN lead to cadaveric position
1️⃣ unilateral complete lead to reduced in phonation
2️⃣ bilateral lead to aspiration

🔸️right recurrent laryngeal nerve is more susceptible to damage during thyroid surgery

🔸️left RLN has a longer course in the thoracic region compared to the right RLN, which makes the former vulnerable to injury due to trauma

➡️ SLN is responsible for sensory input to the vocal folds.

✴️ most recurrent laryngeal nerve injuries are temporary and can recover within 6 months, with no impact on long-term survival

➡️ RLN is responsible for motor input to the vocal folds.

Postintubation recurrent laryngeal nerve palsy ⬆️

🔴 role of informed consent is very important in all such procedures.
Simple preventive measures should be followed as outlined below:
➡️ Use of endotracheal tubes with high volume low-pressure cuffs
➡️ Avoiding the use of reprocessed endotracheal tube. ➡️If ethylene oxide-sterilized endotracheal tube is to be used, it should be aerated for 10 days after sterilization
➡️Regular monitoring of cuff pressures, cuff position
➡️Adequate patient sedation to prevent excessive movement while endotracheal tube is in situ
➡️Avoiding overextension of neck during surgical procedures
Proper positioning of the tube while suctioning
➡️Better training of staff so as to decrease the incidence of multiple intubations, or traumatic intubation, which may be caused due to lack of skill

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Indications for RRT

OP poisoning

RSI

✅ Gastrointestinal loss using K+ -binding drugs:

🛜 For > 50 years👉 the main drug utilized to promote gastrointestinal K+ loss👉 was sodium polystyrene sulfonate usually👉 in combination with a cathartic such as sorbitol.

✅ The drug contains 4 mEq of Na+ per gram and binds K+ in exchange for Na+ primarily in the colon.

✅ An oral dose of 30 g of the drug can be expected to remove up to 36 mEq of K+ in association with a Na+ load of 6090 mEq.

✅ The drug reaches the site of action:

🔶 after 2 h
🔶 and has a peak effect at 4–6 h

🔶 and may continue for 24 h.

✅ When given as a retention enema👉 the drug binds about half as much K+ per gram dose as compared with oral administration.

❌🚨 With the advent of new K+ -binding drugs and the risk of gastrointestinal toxicity, such as colonic necrosis🚷✖️ the use of sodium polystyrene sulfonate both as an 🔛®acute and chronic therapy has fallen out of favor

β-adrenergic receptor agonists (also known as salbutamol):

✔️ The onset of action is usually within 30 min, with a peak effect occurring at 90–120 min.

✔️ The reduction in plasma K+ ranges from 0.6 to 1.0 mEq/l; however👉the response rate is much lower ( ≈40–50%) in patients with end-stage-kidney disease.


❌ Potential complications:

✖️ include tachyarrhythmias
✖️ and myocardial ischemia in patients with coronary artery dis- ease.

❎ Inhaled albuterol should not be used as monotherapy

🔛 given the inconsistent effect of the drug🟰 but may provide additional lowering of plasma K+ when coadministered with insulin

✅ IV sodium bicarbonate:

✔️ Sodium bicarbonate therapy can be considered as an additional treatment for hyperkalemia in the presence of concomitant metabolic acidosis

👉 although data on its effectiveness are conflicting.

✅ In the absence of metabolic acidosis, any lowering effect of bicarbonate is largely explained by dilution secondary to expansion of extracellular fluid volume.

❌🚫 Potential complications include:

❗️ volume overload development of hypernatremia

‼️ reductions in ionized calcium concentration

⁉️and carbon dioxide retention

✳️ As an example, administration of sodium bicarbonate as an isotonic solution is useful in a hyperkalemic patient with volume depletion and metabolic acidosis.

🅰 Patiromer is an oral polymer that binds K+ in exchange for calcium👉 creating a favorable gradient for K+ movement from blood👉 into the gastrointestinal tract.

🆎 A single oral dose of 8.4 grams low- ers plasma K+ by 0.23 mEq/l within👉👉 7 hours of administration

✅ Sodium zirconium cyclosilicate (SZC) has a high-capacity👉 crystalline lattice structure that binds K+ in exchange for sodium and hydrogen.

✅ The drug lowers K+ by:

⏱ 0.4 mEq/l at👉 1 h

⏱ and 0.7 mEq/L at 4 h

👉following administration of a 10-g dose.

✅ Both drugs have been proven to be:

💎 safe
💎 and effective in patients with hy- perkalemia

👉👉 however current labeling indicates the drugs✖️ should not be used as an emergent treatment of life-threatening hyper- kalemia

🔜 because of the delayed onset of action.

⬆️ While not a replacement for:

® calcium
® insulin and glucose
® or β2 -receptor agonists

©© the National Institute for Health and Care Excellence (NICE) has 🔝 approved both drugs as an option in the treatment of acute life-threatening hyperkalemia when used 🔛🔛 as an adjunct along with the standard of care

Hemodialysis (HD):

Dialytic K+ removal is lower in patients treated👉 with nebulized albuterol prior to the procedure 👉due to a shift of K+ into cells and a reduced concentration of K+ in the extracellular 👈space.

✅ A Kidney Disease: Improving Global Outcomes (KDIGO) controversies conference recommends 5 units of IV regular insulin.

🆔 The 2020 UK Renal Association Guidelines recommend:

✔️ 10 units of IV regular insulin with 25 g of IV glucose

👉 followed by an IV infusion of 10% glucose at 50 ml/h for 5 h 👈in patients with a pretreatment 👉blood glucose < 126 mg/dl to👈👉 prevent hypoglycemia.

Hyperkalemia treatment standard:

✔️ Emergent treatment of hyperkalemia::

✅ It should be emphasized that the electrocardiogram (ECG) is not a reliable indicator of hyperkalemia in that the ECG may remain😳👉 normal with severe degrees of hyperkalemia even when interpreted by a cardiologist 👈😜.

✅ In addition, a hyperkalemic patient can rapidly evolve from a normal ECG to manifestations of cardiac:

🔶 hyperexitability (ventricular tachycardia and/or fibrillation)

🔶 or depression (atrioventricular block, asystole).

✅ For these reasons👉any patient with ECG abnormalities related 👉to hyperkalemia should undergo emergent treatment.

✅ In addition👉 strong consideration for emergent therapy should be given to patients with👉 a plasma K+ value > 6.0 mEq/l👉👉 even in the absence of ECG changes.

Lowering plasma K+ concentration by promoting cellular uptake:

✅ Insulin therapy:

☑️ Insulin binds to cell surface receptors and triggers an increase in activity of the Na+ -K+ -ATPase🔉 facilitating the movement of K+ from the ex- tracellular to the intracellular space.

🟠 IV regular insulin exhibits an:

🔸 onset of action within 15 min
🔺 peaks at 30–60 min
🔺and has a duration of approximately 4 h.

🔴 In contrast subcutaneous regular insulin shows an:

🔶 onset at ≈30 min
🔸 a peak at 3 h
🔸 and a duration of 8 h.

☑️ The IV route of administration is preferred due to the shorter onset of action.

🟤 IV glucose in the form of dextrose in water (50 ml of 50% dextrose solution) is given with IV regular insulin in patients who are not hyperglycemic (blood glucose level < 250 mg/dl) to assist in preventing hypoglycemic events.

🟤 Studies utilizing a regimen of 10 units of IV regular insulin and 25 g of IV dextrose report a reduction in plasma K+ ranging from 0.65 to 1.14 mEq/l accompanied by hypoglycemia rates ranging from 11 to 75%.

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Adjuvant treatments for acute ischemic stroke are therapies that complement the primary intervention (often thrombolysis or mechanical thrombectomy) to improve outcomes. These treatments aim to reduce damage, enhance recovery, and manage complications. Here are some adjuvant approaches:

1. Antiplatelet Therapy: Aspirin is typically given within 24 to 48 hours after the onset of ischemic stroke to prevent further clot formation. In some cases, dual antiplatelet therapy (DAPT) with aspirin and clopidogrel may be used, especially in minor strokes or high-risk transient ischemic attacks (TIAs).


2. Anticoagulation: While not typically used acutely in stroke (due to the risk of hemorrhage), anticoagulants like heparin or direct oral anticoagulants (DOACs) may be introduced later for stroke patients with atrial fibrillation or other cardioembolic sources.


3. Neuroprotective Agents: Although no neuroprotective agent is yet fully established for clinical use, agents like magnesium sulfate, NMDA receptor antagonists, and free radical scavengers are being studied to limit neuronal damage during the acute phase of ischemia.


4. Blood Pressure Management: Careful management of blood pressure is crucial, as overly aggressive lowering can reduce cerebral perfusion. Medications such as labetalol or nicardipine are commonly used to maintain appropriate levels.


5. Blood Sugar Control: Hyperglycemia is associated with worse outcomes in stroke. Tight control of blood sugar (but avoiding hypoglycemia) through insulin therapy may help reduce ischemic damage.


6. Lipid-lowering Therapy (Statins): Statins may be started acutely to stabilize atherosclerotic plaques, reduce inflammation, and lower the risk of recurrent stroke, regardless of initial cholesterol levels.


7. Cerebral Edema Management: For patients with significant brain swelling, treatments such as osmotic agents (mannitol, hypertonic saline) and sometimes surgical interventions like decompressive craniectomy may be required to reduce intracranial pressure.


8. Rehabilitation: Early mobilization and rehabilitation, including physical, occupational, and speech therapy, are critical in maximizing recovery and preventing long-term disability.



Each of these treatments is used based on individual patient characteristics, stroke severity, and timing of intervention.

✅ Calcium is available as:

✔️ IV calcium gluconate
✔️or calcium chloride

👉 but the former👉 is preferred since👉 it can be:

🔶 administered through a peripheral vein

🔶 and is less irritating to the vasculature and surrounding tissues in case of extravasation

Hyperkalemia treatment standard:

✔️ Inhaled albuterol (also known as salbutamol)👉 is given as a 10–20 mg dose in 4 ml of saline delivered 👉⏱by nebulizer, a dose 👉several-fold higher than that used in the treatment of reactive😳 airway disease.

Stabilization of the cardiac membrane with administration of calcium salts:

✅ Intravenous (IV) calcium is the initial treatment of choice in cases of:

✔️👉 severe hyperkalemia with👈 or 👉without ECG changes
مش شرط يعني يكون في تغير في ECG😳

✔️ or symptoms of muscle weakness.

✅ Calcium does not alter the plasma K+ concentration but antagonizes 👈👉the destabilizing electrical effects of hyperkalemia on the heart

The usual dose is 10 ml of a 10% calcium gluconate solution (93 mg of elemental calcium).

✔️Hemoglobin is responsible for delivering oxygen to organs

O2 delivery = CO x [1.39 x hemoglobin x SaO2 + (0.003 x

✔️ 1998 showed that they could tolerate reduction of hemoglobin to 5 g/dL without evidence of inadequate oxygenation or abnormal lactate at rest

Transfusion Thresholds and the MINT Trial:


✅ Blood is a limited resource, costly, and not without harms, which include:
✔️ Transfusion reactions
✔️ Volume overload
✔️ Infection 
✔️ Iron overload
✔️ Venous thromboembolism 


✅ Guidelines:

✔️ Historically, clinicians followed the 10/30 rule, which was to transfuse when hemoglobin:

🔶 dropped <10
🔶 or hematocrit <30

✅ Most recent guidelines have recommended a more restrictive transfusion threshold of 7g/dL, but up to 👉8 g/dL for patients with cardiovascular disease

Special patient groups: possible applications of viscoelastic tests. VET: viscoelastic test; MOH: major obstetric haemorrhage.

Practical considerations of setting up a viscoelastic point of care service on intensive care units. IR: international radiology; von Willebrand Factor.

Potential benefits of using viscoelastic tests on intensive care units. VET: viscoelastic test; CCT: conventional coagulation test; DOAC: direct oral anti-coagulants.

Updated until May 2024

Meningitis

Pneumonia

Acid base status algorithm

Adrenal insufficiency