critically ill patient - definitionukb.lf1.cuni.cz/ppt/monit_int_care.pdfcritically ill patient -...
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Critically ill patient - definitionDecompensation of the status ofthe patient leading withouttherapeutic intervention to themultiorganic failure and to thedeath
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Basal vital function
Central nervous systemRespirationBlood circulation (optimalaerobic metabolism) Renal, hepatic function, immunesystém, hemocoagulation andfibrinolysis, thermoregulation, barrier function of the gut
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Main clinical diagnosis of intensive medicineTraumatology: polytrauma, crush sy, craniocerebral , contusion of the chest, burnsShock of various clinical causes, cardiac impairmentSepsis, acute hemorrhagia, pulmonal embolia
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Diagnosis of critically ill patients
Clinical data klinická dataMonitoring of basic function(blood pressure, heart rate…) Imaging methods (X-ray, Computer tomography)BacteriologyHematology, ImunologyBiochemistry
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The possibilities of biochemical monitoring
On-line monitoring (Hearthsurgery – pH, minerals (K) bed side monitoring (point ofcare testing – glycaemia, urine, O2 saturation, acidobasis)Biochemical analysis (vitalindication, statim ,normal)
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Blood sample
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Biochemical parameters – basalNa,K,Cl,Ca,P,Mg - blood, urine Acidobasis, lactateurea, creatinin, creatinin clearence, Nitrogen balancebilirubine, ALT, AST, GMT, LD, amylase, lipase cholesterol, triglycerides, glucose – blood, urine CK, CK-MB, Troponin T,I, myoglobine, CK-MBmassTotal protein, albumine, prealbumine,CHECRP, procalcitonineTSH, b-HCG.
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The other biochemical parametersTrace elements /Zn,Se../VitaminsDrugs /methotrexate, antiepileptics, antibiotics.../Drogs /amfetamine, methadon, opioids../
Aminogram /glutamin../Interleucins,TNF…Small bowel permeability /Lactulose/mannitol/Hormones /cortisol, glucagone, adrenaline../.
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Na, K, Cl, Ca, P, Mg – serum levelsHypernatremia – over 150 mmol/lSec. hyperaldosteronism(intravenous hypovolemia)Hypothalamic impairmentHypertonic hyperhydrationDiabetes insipidusBrain death
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Na, K, Cl, Ca, P, Mg – serum levelsHyponatremia – under 130 mmol/lNa in the third space - ascites, hydrothoraxCardiac failure – increase ofextracellular volume Application of solutions withoutelectrolytesHypersecretion of ADH – waterretention
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Na, K, Cl, Ca, P, Mg – serum levelsHyperkalemia – over 5,0 - 5,5 mmol/l – pH dependent(acidosis increases K level)Acute renal failureCytostatics, tumorsAcute metabolic acidosisInfusion with K
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Na, K, Cl, Ca, P, Mg – serum levelsHypokalemia – under 3,5mmol/lEmesis, diarrhoeDiureticsChemotherapy, antimycoticsAnabolic phasisHyperaldosteronismAcute metabolic alcalosis
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Na, K, Cl, Ca, P, Mg – serum levelsCa – total, ionic – together withtotal protein Hypophosphataemia – under0,6 mmol/lOverfeeding sy, anabolismHyperphosphataemia – over1,9 mmol/lRenal failureCell damage
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Na, K, Cl, Ca, P, Mg – serum levelsMg – together with potassiumHypomagnesaemia – under 0,6 mmol/lPreventive application duringcardiac surgery (metabolicresuscitation of myocardial cells– K, P, Mg, glucose
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Na, K, Cl, Ca, P, Mg – urine levelsHypernatriuria – over 200 mmol/lHigh input of Na (food, drugs) Na mobilisation from the 3rd spaceduring anabolic phaseHyponatriuria – under 20 mmol/lHyperaldosteronism, HypovolemiaDiferential diagnosis between prerenaland renal failure
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Na, K, Cl, Ca, P, Mg – urine levelsHyperkaliuria – hyperaldosteronismNa – K changeHypokaliuriaHypocorticoidismThe risk of hypokalemia
Metabolic balance of electrolytes/24 hours – monitoring of parenteralnutritionClearence Na,K, fraction
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Acidobasis, lactate
Together with electrolytes, totalprotein, albumine, Hemoglobine, respiration functions, hepatic and renalfunction, hydration, emesisMetabolic acidosis – cardiopulmonalresuscitation, Diabetes mellitus, renalinsuficiency, hypoxia, hypoperfusisMetabolic alcalosis – bloodtransfusions, hyperaldosteronism, stomach output
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Acidobasis, lactateRespiratory acidosis – Chronicobstructive bronchopulmonarydisease, hydrothorax, malnutrition, high intake ofglucose in parenteral nutritionRespiratory alcalosis – hypoxia, microembolisation intopulmonary arteria, shock, craniocerebral trauma
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ABR, lactateHyperlactataemia – over 2,2 mmol/l /1,0/Hypoxia – cardiopulmonalresuscitationMetabolic failure – diabeticcoma, intoxication, hepatopathy, leucaemia, low level of B1…
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Urea, creatinine, creatinine clearence, N-balance, uratic acid
The level of urea – together withnutritional status, age andgenderSerum level of urea High level of urea – renal failure, high input od N, GIT bleedingLow level – malnutrition, hepaticfailure, pregnancy
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Urea, creatinine, creatinine clearence, N-balance, uratic acid
Urea in urine Increase – catabolism, prerenalfailureDecrease – chronic malnutrition, acute renal failure
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Urea, kreatinin, clearence kreatininu, N-balance, uratic acid
Serum levels of creatininetogether with muscle massIncrease – renal failureCreatinine clearence, excretionfraction -renal functionN-balance – catabolism – theneed of nitrogenUratic acid – cell damagearthritis uratica
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bilirubin, ALT, AST, GMT, ALP, LD, amonium, amylase, lipase
Bilirubine direct, indirectHigh level – neonatalhyperbilirubinaemia, massiveblood transfusion, hepatocellulardamage /drugs, hepatitis, hypoperfusion, necrosis, obstruction – extra-, intrahepatic
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bilirubine, ALT, AST, GMT, ALP, LD, amoniak, amylase, lipase
ALT – high level –hypoperfusion, hepatitis, cell necrosis, drugsAST – high level –hypoperfusion, hepatitis, cell necrosis, drugsboth aminotransferasesincrease during damage ofmuscles, heart muscle
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bilirubine, ALT, AST, GMT, ALP, LD, amoniak, amylase, lipase
ALP – increase – extrahepatalobstruction, isoenzymes –intestinal, bone, placentalGMT – increase – obstructionintra, extrahepatal, intoxication –ethanol, amanita..Both enzymes during parenteralnutrition