PICUPrimerI - PICU Primer I Kevin M. Creamer M.D. Pediatric...

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PICU Primer I Kevin M. Creamer M.D. Pediatric Critical Care Walter Reed AMC
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The Primer Outline Physiology Hypoxia / Hypoxemia ABG’s and Acidosis – Sodium and H 2 O metabolism Hemodynamics and Cardiopulmonary interactions ICU Care & Common Problems Head trauma Toxicology Postoperative issues Mechanical Ventilation
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Can you have hypoxia without hypoxemia? Can you have hypoxemia without hypoxia?
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Oxygen and Hypoxemia Define Hypoxemia Hypoxia
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Hypoxemia Ventilation/Perfusion mismatch Hypoventilation Shunt Diffusion Decreased Ambient O 2
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Oxyhemoglobin Curve >> low pH, high Temp
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Shunt / Dead Space Spectrum Shunt Dead Space V/Q = 0 V/Q = infinity No amount of O 2 difference will fix between EtCO 2 and PaCO 2
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Ventilation / Perfusion mismatch Blood Pus Air Water Atalectasis Quantitate using A – a Gradient V Q >>>
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A – a Gradient (P b -P H2O ) x FIO 2 - (PCO 2 /.8) - PaO 2 Other useful equations – Dead Space = 1 - (EtCO 2 /PaCO 2 ) OI = (P aw x FIO 2 x 100)/ PaO 2 Positive vs. negative pressure
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Cause for desaturations Anesthesia – hypoventilation Atalectasis – V/Q mismatch Edema - V/Q mismatch Asthma– dead space/ V/Q mismatch Dysfunctional Hemoglobin You may need a CXR and or ABG in addition to H+P to answer the question
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Non respiratory Physiologic causes of a low PaO 2 Causes Effect on P(A-a)O 2 Nonrespiratory Right-to-left intracardiac shunt Decreased PIO 2 Low barometric pressure Low FIO 2 Decreased R value Low mixed venous oxygen content* Artifact Very high white blood cell count Patient hyperthermia Increased Normal Normal Increased Increased Increased *Only in presence of increased venous admixture
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Hypoxia Hypoxic - ex. pulmonary disease Anemic – ex. low CaO 2 , CO poisoning Distributive - ex. sepsis, emboli Histotoxic – ex. cyanide
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Oxygen Debt/ Oxygen Deficit 0 5 10 15 20 25 30 35 40 45 O2 in ml 10 20 30 40 50 60 Time (minutes) O2 Deficit O2 Debt MODS > Death >? Inadequate Resuscitation
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Oxygen Content Which has the biggest impact on O 2 delivery to the tissues? – Hemoglobin, Sat, Cardiac Output, or PaO 2 Which patient has more oxygen in the blood? – Patient A, PaO 2 89, Sat% 97%, Hg 9.8 – Patient B, PaO 2 60, Sat% 85%, Hg 13.1
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Hb 15 Hb 10 Hb 7.5 Hb 0 A V O 2 c o n t e / d l 20 15 10 PO2 25 50 75 100 150 600 Sat% 50 75 90 99 100 // // // //
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DO 2 CaO 2 CO Sat % PaO 2 Hg HR SV Preload Contractility Afterload
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“Normal” Values CaO 2 = (Hg X 1.34 X Sat%) + (PaO 2 X 0.003) –17-20cc O 2 /dL DO 2 = CI X CaO 2 400-600 ml X min / M 2 VO 2 = CI X avDo 2 140-160 ml X min / M 2 Arterial sat 100% minus Consumption = Venous sat
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PICUPrimerI - PICU Primer I Kevin M. Creamer M.D. Pediatric...

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