Critically ill patient - definitionukb.lf1.cuni.cz/ppt/monit_int_care.pdfCritically ill patient -...

Critically ill patient - definitionDecompensation of the status ofthe patient leading withouttherapeutic intervention to themultiorganic failure and to thedeath

Basal vital function

Central nervous systemRespirationBlood circulation (optimalaerobic metabolism) Renal, hepatic function, immunesystém, hemocoagulation andfibrinolysis, thermoregulation, barrier function of the gut

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

Diagnosis of critically ill patients

Clinical data klinická dataMonitoring of basic function(blood pressure, heart rate…) Imaging methods (X-ray, Computer tomography)BacteriologyHematology, ImunologyBiochemistry

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)

Blood sample

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.

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../.

Na, K, Cl, Ca, P, Mg – serum levelsHypernatremia – over 150 mmol/lSec. hyperaldosteronism(intravenous hypovolemia)Hypothalamic impairmentHypertonic hyperhydrationDiabetes insipidusBrain death

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

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

Na, K, Cl, Ca, P, Mg – serum levelsHypokalemia – under 3,5mmol/lEmesis, diarrhoeDiureticsChemotherapy, antimycoticsAnabolic phasisHyperaldosteronismAcute metabolic alcalosis

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

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

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

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

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

Acidobasis, lactateRespiratory acidosis – Chronicobstructive bronchopulmonarydisease, hydrothorax, malnutrition, high intake ofglucose in parenteral nutritionRespiratory alcalosis – hypoxia, microembolisation intopulmonary arteria, shock, craniocerebral trauma

ABR, lactateHyperlactataemia – over 2,2 mmol/l /1,0/Hypoxia – cardiopulmonalresuscitationMetabolic failure – diabeticcoma, intoxication, hepatopathy, leucaemia, low level of B1…

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

Urea, creatinine, creatinine clearence, N-balance, uratic acid

Urea in urine Increase – catabolism, prerenalfailureDecrease – chronic malnutrition, acute renal failure

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

bilirubin, ALT, AST, GMT, ALP, LD, amonium, amylase, lipase

Bilirubine direct, indirectHigh level – neonatalhyperbilirubinaemia, massiveblood transfusion, hepatocellulardamage /drugs, hepatitis, hypoperfusion, necrosis, obstruction – extra-, intrahepatic

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

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