ICU Tutorial

Medical Residents 2011

A 67-year-old is admi0ed to a MICU with ARDS. BS = 135 mg/dl. Intensive insulin therapy was started. An outcome about intensive glucose control includes which of the following. Increased risk of hypoglycemia Reduced mortality independent of the target glucose level Reduced mortality only if the paKents could be maintained with a BS 110 mg/dl Short hospital LOS

A. B. C.

D.

How hyperglycemia is harm?

BS > 140 mg/dl + HbA1C > 6.5% suspected preexisKng DM. Intensive glucose control 80-110 mg/dl. RR mortality 0.93 (95%CI 0.83-1.04) Small RR mortality benet in SICU 0.63 (95%CI 0.44-0.91) RR hypoglycemia 6.0 (95%CI 4.5-8.0) Last trial NICE-SUGAR study

Intensive glucose control increased absolute risk of death at 90 days Number needed to harm 38

NICE-SUGAR Study InvesKgators NEJM 2009;360:1283-97.

Daily SBTs in paKents supported by MV with stable and improving cardiorespiratory funcKon have been shown to facilitate the venKlator withdrawal process. In addiKon to monitoring RR, gas exchange, hemodynamics, and comfort during the SBT, what other strategy will be helpful in this process? A. Use of mode that automaKcally reduces pressure support in between daily SBT a0empts B. Required all paKents to have a f/VT < 105 before iniKaKng SBT C. Requiring P0.1 < 8 cmH2O before iniKaKng SBT D. Using pressure support of 5-8 cmH2O during SBT.

Readiness to wean
Clinical assessment Adequate cough Absence of excessive tracheobronchial secreKon ResoluKon of disease acute phase for which the paKents was intubated Clinical stability - Stable cardiovascular status (HR < 140, SBP 90-160 mmHg, no or minimal vasopressor) - Stable metabolic status Adequate oxygenaKon - SaO2 >90% on FiO2 0.4 (orPaO2/FiO2 150 mmHg) - PEEP 8 cmH2O Adequate pulmonary funcKon - RR < 35/min - MIP -20 - -25 cmH2O - VT > 5 ml/kg - VC > 10 ml/kg - f/VT < 105 - No signicant respiratory acidosis Adequate mentaKon - No sedaKon or adequate mentaKon on sedaKon)

ObjecKve measurements

Weaning Predictors
Measurements of oxygena4on and dead space PaO2/FiO2 PaO2/PAO2 Dead space (VD/VT) Simple tests of respiratory load and muscular capacity NIP (MIP) Respiratory system compliance and resistance MV MVV VC RR VT Test that integrate more than one measurement f/VT CROP index (compliance, RR, oxygena4on, pressure) = Cdyn x PImax x [PaO2/PAO2])/rate Complex measurements Airway occlusion pressure P0.1/MIP Esophageal pressurements Oxygen cost of breathing, WOB Gastric mucosal pH

Yang KL, Tobin MJ. NEJM 1991;324:1445-50.

SBTs
T-piece Low level pressure support (reduce resisKve work)

7-8 cmH2O in adult 10 cmH2O in pediatric

AutomaKc Tube CompensaKon DuraKon of SBT = 120 min (In general) Ideal duraKon of SBT (30 min VS 120 min) depend on duraKon of venKlaKon and underlying cause for respiratory failure

Poten4al causes of weaning failure

Auto PEEP pneumonia pulmonary edema Atelectasis PTX Pleural effusion Abdominal distension Secretions Bronchoconstriction ET-problems Dead space VCO2 Metabolic acidosis Anxiety Pain Oversedation Metabolic alkalosis CNS process OHS

Cardiac disease Psychological disease

Mg, Ca, K, PO4 Steroids Malnutrition Sepsis Medications Hypothyroidism Phrenic nerve injury CIP, CIM

A 43-yr-old man was admi0ed to ICU with seizure and mental status changes. He was BT 38.5 C. He had history of HIV and non- compliant ART. His CD4 count = 130/L. CT brain shown diuse brain atrophy and no focal mass lesion. LP was done and CSF protein=72 mg/dL, glucose 68 mg/dL, WBC 78/ L (85% L), RBC 3.6x106/ L. He began vancomycin, ampicillin, ceoazidime, amphotericin B and acyclovir. Day2 aoer admission his Cr 1.32.7 mg/dL. Urine is shown in Fig. Which one of the following is the most likely cause of AKI? A. Amphotericin B B. Acyclovir C. Contrast induced nephropathy D. Acute intersKKal nephriKs

Crystal induced AKI

Sulfonamide

Needle shape

Acyclovir

Sulfadiazine

Indinavir

Needle like birefringent

Shock of wheat Dumbbell

Starbursts Fan shapes

Acyclovir nephrotoxicity
Rapid excreted in urine and low urine solubility Risk factors

PrevenKon

High dose Rapid infusion Volume depleKon Renal impairment Isotonic saline before acyclovir infusion High urine ow rate Slow infusion in 1-2 hr

A 73 year old man presented with severe chest pain for 2 hr. ECG showed STEMI at inferior wall. He was given alteplase over 90 min and admi0ed to ICU. Next 48 hr severe dyspnea developed. Following intubaKon, furosemide, and inserted PAC. Pulmonary artery pressure waveform tracing are captured during balloon inaKon in Fig. Which of the following best explains why the waveform changes shape as the balloon is inated? A. Balloon has wedged in PA B. Catheter is malpositioned and overwedged. C. Catheter is malpositioned and migrated back to RA D. Balloon has failed to inflate due to balloon rupture.

PAC posi4on
Normally PA diastolic > PCWP ~ 1-4 mmHg PA diastolic PCWP > 5 mmHg: PVR

Giant V waves

Overwedging

Limita4on of PAOP

5
A variety of drugs may be used for inducKon of sedaKon during RSI. For which one of the following paKents would you preferably c h o o s e e t o m i d a t e i n s t e a d o f k e t a m i n e f o r R S I ? A. A 6 5 - y e a r - o l d m a n w i t h s e p K c s h o c k . B. A 45-year-old man who is hypertensive and has an acute MI C. A 25-year-old woman with asthma who is 8 weeks pregnant D. A 30-year-old woman with thoracic and abdominal injuries f r o m v e h i c l e s a c c i d e n t w h o i s h y p o t e n s i v e .

Etomidate
Minimal hemodynamic eects. 85% Dose dependent, temporary, and reversible inhibiKon of steroid synthesis aoer single dose or infusion. By inhibiKon of 11- hydroxylase, which converts 11-deoxycorKsol to corKsol N/V, pain on injecKon, supercial thrombophlebiKs, myoclonus Metabolized by liver and metabolites are inacKve Not used in repeated dose or infusion

Ketamine
0.1-0.5 mg/kg Analgesia + Amnesia Not necessarily cause a loss of consciousness but not aware. Amnesia, altered short term memory, decreased ability to concentrate, altered cogniKve performance, nightmares, N/V CombinaKon with small doses of BDZ does prolong recovery from ketamine, but eliminates these adverse eects Direct sKmuli ANS, tachycardia and increases BP Bronchodilator eect.

Propofol
Dose 2 mg/kg. Containing 10% soybean oil, 2.25% glycerol, 1.2% egg phosphaKde. Most frequently contaminated by bacteria. No analgesia HepaKc clearance + extrahepaKc sites eliminaKon Rapid recovery even aoer prolong infusion Dose dependent hypotension, respiratory depression Adjusted dose by volume status and cardiac funcKon Bronchodilator eect

Propofol related infusion syndrome

Metabolic acidosis, Cardiac dysfuncKon, Hyperkalemia, hypertriglyceridemia, Rhabdomyolysis AKI Trigger dose toxicity 5 mg/kg/hr x 48 hr

6
In which of the following paKent scenarios would therapeuKc hypothermia be most clearly indicated? A. A 55-year-old man in a coma following an in-hospital cardiac arrest with PEA due to massive pulmonary embolism. B. A 60-year-old man in a coma following an out-of-hospital VF C. A 59-year-old man transferred from an outlying hospital for conKnued care following a VF arrest 1 week ago with anoxic encephalopathy D. A 30-year-old man in a coma following a motor vehicle accident with head trauma

Comatose adult paKents with ROSC aoer out-of-hospital VF cardiac arrest (class I, LOE B) Comatose adult paKents with ROSC aoer in-hospital cardiac arrest of any iniKal rhythm or aoer out-of-hospital cardiac arrest with an iniKal rhythm of PEA or asystole (Class IIb, LOE B). Cooled to 32C to 34C for 12 to 24 hours Mechanisms

Slow down cerebral metabolic rate InhibiKon deleterious biochemical or cerebral events between reperfusion free radical producKon & excitatory amino acid release Promote neuronal recovery ICP

1. Induc4on phase Aim core BT < 34 C Down to target BT as quickly as possible Side eects are hypovolemia, electrolyte disorders, hyperglycemia 2. Maintenance phase Tightly control core BT, minor or no uctuaKon (max 0.2-0.5 C) 3. Rewarming phase 0.2-0.5 C/hour Electrolyte disorders (hyperkalemia, hyperphosphatemia) Beware rebound hyperthermia 4. Maintenance normothermic phase

1.Arrhythmias, hemodynamic changes and CVS eects

Cardiac output 25-40% CVP , SVR , BP Hypovolemia (cold diuresis) Core BT < 35.5C sinus bradycardia Core BT ~ 32C HR ~ 40-45 bpm Core BT < 28-30C VF or VT Drug level and/or enhance eect

2. Drug clearance 3. Electrolytes disorder Hypomagnesaemia

Hyperkalemia in rewarming phase

5. Hyperglycemia 6. CoagulaKon parameter

BT < 35C platelet funcKon BT < 33C coagulaKon factor Normal standard coagulaKon test because warm blood prior test

7. InfecKon 8. Shivering NMBA (++++)

Meperidine (++++)

7
A 46-year-old man is rescued from his home following a hurricane with regional power outages; he is found to be confused and disoriented. He lived there for 3 days with light and heat provided by a portable generator . His pulse is 130/min, BP 140/90 mmHg, RR 28/min, SpO2 98%. The remainder PE normal. Which of the following should be done immediately. A. A d m i n i s t e r 1 0 0 % o x y g e n B. U r i n e t o x i c o l o g y s c r e e n C. C T s c a n o f h e a d D. L u m b a r p u n c t u r e

Carbon monoxide (CO)

CO is a colorless, odorless, tasteless and nonirritant gas ProducKon in variety of ways

Incomplete combusKon of res Faulty heaKng systems Internal combusKon engines Wood stoves Charcoal grills Volcanic erupKons

In vivo hepaKc producKon

Methylene chloride poisoning: paint thinners

Accidental: automobile exhaust and smoke inhalaKon

Pathophysiology
CO easily diuses across alveolar-capillary membranes Rapidly taken up by RBCs Bind to iron of Hb with anity 240 Kmes > O2 Summary 4 mechanisms of CO intoxicaKon

Decrease in the O2 carrying capacity of blood Decreased O2 delivery to peripheral Kssue as a result of the leo shio in the oxyhemoglobin dissociaKon curve Mitochondrial dysfuncKon and impairment of cellular respiraKon by inhibiKon of cytochrome oxidase acKvity Lipid peroxidaKon of brain during reoxygenaKon

Clinical presenta4on
Headache, dizziness, sore throat, nausea, SOB and faKgue EnKre family is aected related to a faulty home heaKng system during the winter months Loss of consciousness Severity correlate be0er with duraKon of exposure Brain and heart are very sensiKve to CO intoxicaKon CVS disorder preexisKng CVS disease LacKc acidosis, rhabdomyolysis, ARF level > 60%

Signs and symptoms of CO intoxica4on

COHb level (%) 5-10 11-20 21-30 31-40 41-50 50 and above Clinical manifesta4ons Mild headache, confusion Throbbing headache, blurred vision Flushing of skin DisorientaKon, nausea, impaired manual dexterity Irritability, dizziness, vomiKng, syncope Tachypnea, tachycardia Coma, seizures, respiratory failure, death

Clinical presenta4on
Fetal Hb anity CO > adult Hb pregnancy CO intoxicaKon COHb clearance 4-5 Delay neuropsychiatric syndrome (3 days to 4 months)

10-30% CogniKve impairment, personality change, parkinsonism, inconKnence, focal neuro decits, demenKa, psychosis Aected at globus pallidus and deep white ma0er 50-70% recovery within 1 year

Diagnosis
Cherry-red lips, cyanosis, reKnal hemorrhage (infrequent) Increased level of COHb Dx CoHb co oximeter ABG: PaO2 normal Electrolyte (AG), CK, lactate EKG, cardiac enzymes Chest X-ray: non cardiogenic pulmonary edema Blood and urine cyanide Suicide: drug screen

Eect of COHb on measured O2 satura4on by pulse oximetry

Treatment
Removal from source of exposure 100% O2 T COHb 4-6 hr. 40-80 min IntubaKon indicaKons O2 COHb return to normal except pregnancy HBOT: 1.5-3 ATM half-life COHb 5-6 hr 20 min IndicaKon of HBOT

8
A paKent with ARDS is supported by MV with the mode depicted in Fig. What descripKon best ts this mode?

A. B. C. D.

Pressure support venKlaKon Airway pressure release venKlaKon Volume assisted control venKlaKon VC-SIMV

Ven4latory management of ARDS

OxygenaKon index (OI) = (FiO2 x mPaw x 100)/PaO2

Predictor of poor outcome High OI 12 to 24 h aoer onset of ARDS and rising are independent risk factors for mortality OI > 30 represent failure of convenKonal venKlaKon

Majority of paKents with ARDS die from mulKorgan failure

ARDSnet Low-VT protocol

Variables VenKlator mode VT Plateau airway pressure VenKlaKon rate/pH goal Inspiratory ow OxygenaKon CombinaKon of FiO2 and PEEP (cmH2O) Protocol Volume assist control 6 ml/kg predicted BW 30 cmH2O 6-35/min, adjusted to achieve arterial pH of > 7.30 if possible Adjust for I:E=1:1-1:3 PaO2 55 and 80 mmHg or SaO2 88% and 95% 0.3/5, 0.4/5, 0.4/8, 0.5/8, 0.5/10, 0.6/10, 0.7/10, 0.7/12, 0.7/14, 0.8/14, 0.9/14, 0.9/16, 0.9/18, 1.0/18, 1.0/22 and 1.0/24 A0empt by PS when FiO2/PEEP combinaKon is < 0.4/8

Weaning

Therapeu4c strategy for ARDS with refractory hypoxemia

Heavy sedaKon and NMBA High PEEP and recruitment maneuvers PCV with inverse I:E raKo Airway pressure release venKlaKon Prone posiKoning HFOV Inhaled NO ECMO

MulKcenter RCT, placebo-controlled trial PopulaKon: severe ARDS PaO2/FiO2 < 150 (PEEP 5 cmH2O) Cisatracurium 15 mg bolus then 37.5 mg/h for 48 h Open label, rapid 20 mg cisatracurium if plateau pressure > 32 cmH2O

Probability of survival through Day 90

PEEP in refractory hypoxemia

Three RCTs for modest VS high levels of PEEP
ALEOLI (NEJM 2004;351:327-36) LOVS (JAMA 2008;299:637-45) EXPRESS (JAMA 2008;299:646-55) SystemaKc review and meta-analysis JAMA 2010;303:865-73 (March)

Characteris4cs of included trials

PEEP strategies (ALEOLI)

PEEP strategies (LOVS)

PEEP strategies (EXPRESS)

Respiratory variables in rst week

Clinical outcomes

Summary
In hospital mortality
All paKents: higher PEEP = lower PEEP ARDS: higher PEEP > lower PEEP
RelaKve mortality reducKon 10% NNT 25

ALI: higher PEEP = lower PEEP (high < low)

VenKlator free days

All paKents: higher PEEP = lower PEEP ARDS: higher PEEP > lower PEEP ALI: higher PEEP = lower PEEP (high < low)

Lung recruitment maneuvers

Transient increase in transpulmonary pressure Reopening of collapsed alveoli. Use In refractory hypoxemia Variety of techniques

Sustained inaKon maneuvers High PCV Incremental PEEP Intermi0ent sigh Extended sigh

Sustained ina4on technique

CPAP 40 cmH20 for up to 60 sec. Advantages

Reducing lung atelectasis Improving oxygenaKon and respiratory mechanics PrevenKng ET sucKoning-induced alveolar derecruitment

Disadvantages

IneecKve Short-lived Circulatory impairment Increased risk of baro/volutrauma Reduced net alveolar uid clearance Worsened oxygenaKon

Stepwise maximum RM
PaO2 + PaCO2 400 mmHg as an indicator of maximum RM Decremental PEEP KtraKon

Start 25 cmH2O for 4 min 2 cmH2O Lowest PEEP maintain PaO2 + PaCO2 400 mmHg (opKmal PEEP) RM at last step again PEEP at opKmal PEEP

Borges JB et al. Am J Respir Crit Care Med 2006;174:26878.

Recruitment Maneuvers for ALI A Systemic Review

40 arKcles analyzed: mean sample size 30, total 1185 pts Study designs

4 RCT 32 prospecKve cohort 4 retrospecKve cohort

Type of RMs
Sustained inaKon 18 High PCV 9 Incremental PEEP 8 High VT/sigh 4 Other 1

Fan et al. Am J Respir Crit Care Med 2008;178:1156-63.

PCV inverse-ra4o ven4la4on

Inspiratory Kme > expiratory Kme No benet or marginal benet of PCIRV Li0le improvement in oxygenaKon Elevated mean airway pressure + autoPEEP Adverse eect to hemodynamics Required sedaKon and paralysis

Airway pressure release ven4la4on

APRV sebng
Phigh

Desired Ppla (typically 20-35 cmH2O) Phigh > 35 cmH2O when

thoracic & amdominal compliance or morbid obesity : 0 cmH2O

Plow

Thigh : 4-6 secs (80-95% of total cycle Kme) Tlow : 0.2-0.8 secs (end expiratory ow = 50-75%

of PEFR)

Prone Posi4on

Problem inuencing dierent responses to prone posi4oning

20% no response 50% response + maintain oxygenaKon when reposiKon to supine 30% response + cant maintain oxygenaKon when supine

Mortality

PaO2/FiO2

Prone posi4oning
Reduce mortality in severe by PaO2/FiO2 < 100 mmHg (p=0.01;RR 0.84;95%CI 0.74-0.96) Mean prone duraKon 14 hr/day Not reduce mortality in overall paKents Improve oxygenaKon 27-39% VAP No eect on venKlator free day or duraKon of MV Adverse eects: pressure ulcers, ET obstrucKon, tracheostomy tube dislodgement

HFOV

HFOV ini4al sebng

Gas-Transport Mechanisms during HFV

The major gas-transport mechanisms that are operaKve under physiologic condiKons in each region (convec4on, convec4on and diusion, and diusion alone) are shown. There are seven potenKal mechanisms: turbulence in the large airways, causing enhanced mixing; direct ven4la4on of close alveoli; turbulent ow with lateral convecKve mixing; pendellud (asynchronous ow among alveoli due to asymmetries in airow impedance); gas mixing due to velocity proles that are axially asymmetric (leading to the streaming of fresh gas toward the alveoli along the inner wall of the airway and the streaming of alveolar gas away from the alveoli along the outer wall); laminar ow with lateral transport by diusion (Tayor dispersion); and collateral ven4la4on through nonairway connecKons

HFOV
Safe and eecKve in improve oxygenaKon No lower mortality May improve mortality in paKents with high OI

NO inhala4on

Griths et al. NEJM 2005;353:268395.

Physiologic eect of iNO

Administra4on of iNO in adult

Major toxicity

Dose treatment in PHT > ARDS Maximum dose 40 ppm

Improved V/Q mismatch Be0er oxygenaKon No survival benet

MetHb: uncommon in usual dose, measure q 6 hr NO2 : rapid covert to nitric acid in aqueous soluKon that toxic to respiratory tract

Required 20% rise in PaO2 on FiO2 1.0

No reducKon in venKlator free days

9
Which of the following best describes the monitoring of glucose control in ICU? A. A laboratory glucose measurement is preferred over a POCT. B. A central or peripheral blood sample is preferred to capillary sample C. A single morning (eg. 6.00 am) glucose level is preferred over a mean morning glucose level D. A mean morning glucose level is preferred over a mean daily glucose level

Sampling Blood (vascular catheter) Danger of contaminaKon with IV uid FingersKck (not recommended) Inaccurate in paKents with edema or anemia

Measurement Glucometer Blood gas machine Laboratory analysis Fastest, least accurate Fast (if in ICU), accurate Slowest, most accurate

10

A 37 year old woman with history of asthma is admi0ed to ICU with acute respiratory failure. She is intubated. Over next 24 hr. she conKnues to have progressive hypoxemia. She is on assist-control mode with RR 22, VT 350 ml, PEEP 10 cmH2O and FiO2 0.6. She is transported to radiology and return, her peak pressure alarm. On examinaKon, the paKent is calm and sedate. Her Ppeak is now 53 cmH2O, Pplat 46 cmH2O. Prior to transport , her Ppeak 32 cmH2O and Pplat 24 cmH2O What is the most likely cause of her Ppeak alarm? A. H M E m a l f u n c K o n B. B r o n c h o s p a s m C. E T t u b e o b s t r u c K o n D. R i g h t m a i n s t e m i n t u b a K o n

Acute respiratory deterioraKon Peak inspiratory pressure Decreased Air leak HypervenKlaKon No change
AIRWAY OBSTRUCTION AspiraKon Bronchospasm SecreKons Tracheal tube ObstrucKon

Increased Plateau pressure

No change Pulmonary embolism Extrathoracic Process Increase

DECREASED COMPLIANCE Abdominal distension Asynchronous breathing Atelectasis Auto PEEP Pneumothorax Pulmonary edema

Proximal airway pressures

End-inspiratory peak pressure
Ppeak (Resistance + Elastance)
Peak pressure

Plateau pressure

End-inspiratory plateau pressure

Occlude the expiratory tubing at the end of inspiraKon Proximal airway pressure decreases and then reaches a steady level

InaKon

InaKon Hold

ExhalaKon

Pplau Elastance (Ppeak- Pplau) Airways resistance

11
A 28 year old woman is admi0ed to ICU for fever, hypotension, and mild lower middle abdominal pain, dysuria. She underwent a C/S 9 months ago and intraoperaKve bleeding required PRC transfusion. Review of system, she has some intermi0ent headaches and faKgue. She had noted a decrease in milk producKon aoer 4 weeks and not had a menstrual period since the delivery On examinaKon BT 38.5 C, BP 80/50 mmHg, PR 100/min, RR 15/min. Despite infusion of NSS and anKbioKcs, she remains hypotensive. Which of the following should next be added to her regimen? A. HydrocorKsone B. Dopamine C. Norepinephrine D. Drotrecogin alfa

Ini4al resuscita4on
CVP 8-12 mmHg MAP 65 mmHg

Goal 6 hrs
Urine output ScVO2 70 mmHg 0.5 ml/kg/hr SVO2 65 mmHg

Higher target CVP

Mechanical venKlaKon Decreased ventricular compliance IAH Diastolic dysfuncKon Pulmonary artery hypertension

Indices of uid responsiveness

Pulse pressure variaKon Passive leg raising CVP variaKon in spontaneous breathing

Respiratory changes in pulse pressure

PP (%) = 100 x (PPmax - PPmin) (PPmax - PPmin)/2

PPmax PPmin

Dened as responder

Threshold > 13% SensiKvity 94% Specicity 96%

More reliable than SPV

Early goal directed therapy

Diagnosis
Obtain appropriate cultures before starKng

anKbioKcs

2 BCs (percutaneous and vascular access) Culture other sites as clinically indicated

Imaging to conrm and sample any source of

infecKon

An4bio4c therapy
Start as early as possible and within 1 hr. Broad spectrum and good penetraKon Reassess daily for opKmize ecacy, prevent

resistance, avoid toxicity and minimize costs Bolus VS prolong infusion

An4bio4c dosage
Cefepime Ceoazidime Ceoriaxone Imipenem Meropenem Piperacillin/tazobactam Gentamicin Amikacin Vancomycin Linezolid Ciprooxacin Levooxacin 1-2 g q8-12h 2 g q8h 2 g q24h 1 g q8h or 500 mg q6h 1 g q6-8h 4.5 g q6h 7 mg/kg/d 20 mg/kg/d 15 mg/kg q12h 600 mg q12h 400 mg q8h 750 mg q24h

Source control
Clinical (suspected) diagnosis Pneumonia 2 peritoniKs PancreaKKs UTI Bacteremia SSI PyelonephriKs MediasKniKs SinusisKs Acalculous cholecysKKs PericardiKs consider Empyema Ongoing contaminaKon Infected pancreaKc necrosis Catheter-related Catheter-related NF Urinary tract lithiasis Esophageal perforaKon Abscess Abscess, hydrops Drainage ExteriorizaKon of leaking GI tract, drainage of peritoneal uid Debridement of pancreaKc Kssue Remove catheter Remove catheter ResecKon of necroKc Kssue explore when suspected on clinical grounds Debridement lithiasis removal Surgical drainage AspiraKon and drainage remove NG tube Percutaneous drainage chlecystectomy Drainage Source control

Fluid therapy
Crystalloid = colloid Fluid challenge
Crystalloid 1000 ml over 30 min Colloid 300-500 ml over 30 min

Vasopressors
MAP 65 mmHg: too low in paKents with severe

uncontrolled HT NE or dopamineas the 1st choice Epinephrine: poorly responsive to NE or dopamine

Inotropic therapy
Dobutamine for myocardial dysfuncKon (elevated

cardiac lling pressure or low cardiac output) No use of strategy to increase CI to supranormal level

Cor4costeroids
HydrocorKsone: BP poorly response to uid

therapy and vasopressor Not prefer dexamethasone FludrocorKsone is opKonal

12
Which of the following intervenKons, if used rouKnely, would be expected to reduce the incidence of VAP? A. Oral applicaKon of anKsepKcs B. Frequent respiratory circuit changes C. Standard electric toothbrushing D. Early tracheostomy among paKents expected to require prolonged mechanical support

VAP preven4on

VAP preven4on
Source of VAP Pathogen Aerodigestive colonization Prevention Goal Prevent colonization by exogenous routes Specific Measures Hand hygiene Microbial surveillance and targeted barrier isolation Preemptive barriers: Routine gloving & gowning Dedicated equipment Oral decontamination with chlorhexidine SDD Aerosolized antimicrobials Sucralfate instead of H2-blockers NIV Semirecumbant positioning Novel endotracheal tube permitting continuous subglottic suctioning

Suppress oropharyngeal mucosal colonization

Prevent aspiration

VAP preven4on
Source of VAP Pathogen Prevention Goal Specific Measures Procedures for reprocessing bronchoscopes and reused respiratory therapy equipment Training and education of reprocessing staff and respiratory therapists Procedures for use of aerosolized medications Heat-and-moisture exchanger Periodically drain condensate from circuit Sterile water for bubble-through humidifiers Aseptic procedures for suctioning of ventilated patients Contaminated Safe equipment and respiratory therapy medical aerosols equipment and medical aerosols

Reducing contamination of ventilator circuit

VAP preven4on
Source of VAP Pathogen Contaminated tap water (Legionella species, Pseudomonas aeruginosa) Prevention Goal Safe water Specific Measures Sterile water for: Cleaning respiratory therapy equipment Rinsing bronchoscopes Aerosolized medications Hospital surveillance for cases of nosocomial legionellosis Microbial surveillance of hospital water for contamination by legionellae Engineering controls for contaminated water: Superheat and flush Ultraviolet light Hyperchlorination Silver-copper ionization Ozonation

VAP preven4on
Source of VAP Pathogen Prevention Goal Specific Measures Procedures for minimizing communicable airborne infections: Disease recognition Administrative controls Engineering controls Procedures for minimizing risk to immunocompromised patients: High-efficiency particulate arrester (HEPA)-filtered rooms N95 masks for intrahospital transports Policies and procedures for management during periods of construction and renovation

Contaminated Safe air ambient air (filamentous fungi, Mycobacterium tuberculosis, SARS coronavirus)

13

A 53-year-old woman presented with severe ank pain and fever 40 C. A right sided ureteral stone and hydronephrosis is found. Hemodynamic and lab on iniKal ICU admission and following 24 hr of aniKbioKc are listed in Table. Oxygen consumpKon is m e a s u r e d b y m e t a b o l i c c a r t .
Ini4al HR (bpm) MAP (mmHg) RAP (mmHg) SaO2 (%) Hb (g/dL) VO2 (ml/min) SvO2 (%) CO (L/min) 130 63 2 95 15 278 50 3.0 24 h 105 78 8 97 10 277 75 ?

Which of the following is closest to her CO measured at 24 h? A. 12 L/min B. 9 L/min C. 6 L/min D. 3 L/min

Oxygen Delivery (DO2)

DO2= CaO2 x CO x 10

DO2 = CaO2 x CO x 10 CaO2 = [1.34 x Hb x SaO2] + [PaO2 x 0.0031] Normal DO2 = 900-1200 ml/min

Oxygen consumption (VO2)

VO2 = [CaO2-CvO2] x CO x 10
CaO2 CvO2 = A-V content difference CvO2 = [1.34 x Hb x SvO2] + [PaO2 x 0.0031]

277 = [1.34 x 10 x (0.97-0.75)] x CO x10 CO = 9.39 L/min

14
Endotracheal intubaKon in a young, hemodynamically stable paKent with 30% third-degree burns and sepsis would best be accomplished with the following IV drug combinaKon. A. Propofol and succinylcholine B. Ketamine and rocuronium C. Etomidate and succinylcholine D. Etomidate and rocuronium

Succinylcholine
Depolarized NMBA, binding to the ACh receptor and depolarizaKon of the muscle ber Metabolized by serum (pseudo-) cholinesterase. Most rapid onset of acKon (60 to 90 seconds) Adverse eects

Hypertension, arrhythmias, increased ICP and IOP, hyperkalemia, malignant hyperthermia, myalgias, and prolonged paralysis Major thermal burns, signicant crush injuries, spinal cord transecKon, malignant hyperthermia, and upper or lower motor neuron lesions

ContraindicaKons

Nondepolarized NMBA
CompeKKve antagonists and inhibit ACh binding to postsynapKc nAChRs Benzylisoquinolinium

mivacurium, atracurium, cisatracurium, and doxacurium vecuronium, rocuronium, pancuronium, and pipecuronium.

Aminosteroid

15
Which of the following factors is the best predictor of success of NIV in paKents with COPD with AE of their disease? A. Decrease in RR from 33 to 28/min aoer 1 h of NIV B. GCS < 9 at base line C. RR > 40/min at baseline D. pH < 7.2 at baseline

NIV
Recommended indicaKons 1. COPD exacerbaKons 2. Acute cardiogenic pulmonary edema 3. FacilitaKng extubaKon in COPD PaKents 4. Immunocompromised PaKents

Guidelines NIV in acute sebng

Appropriate diagnosis with poten4al reversibility Establish need for ven4latory assistance
Moderate-to-severe respiratory distress and Tachypnea (respiratory rate > 24/min for COPD, > 30/min for CHF); accessory muscle use or abdominal paradox Blood gas derangement (pH <7.35, Paco2 >45 mm Hg, or PaO2/FiO2 <200) Respiratory or cardiac arrest Medical instability (hypotensive shock, myocardial infarcKon requiring intervenKon, uncontrolled ischemia or arrhythmias) Unable to protect airway Unable to t mask Untreated pneumothorax Recent upper airway or esophageal surgery Excessive secreKons* UncooperaKve or agitated*

Exclude pa4ents with contraindica4ons to NIV

Factors associated NIV success

Synchronous breathing with venKlator Dentate Less air leaking Fewer secreKons Good tolerance Respiratory rate < 30/min* Lower APACHE II score ( <29)* pH > 7.30* Glasgow coma score 15* PaO2/FiO2 > 146 aoer rst hour if hypoxemic respiratory failure COPD, CPE No pneumonia, ARDS Best predictor of success is a good response to NPPV within 1 to 2 h: ReducKon in respiratory rate Improvement in pH Improvement in oxygenaKon ReducKon in PaCO2

16

A 50-year-old woman with severe bronchioliKs obliterans is receiving mechanical venKlaKon support. She has developed hypotension. The graphic display is pictured in Fig. Which combinaKon of the following manipulaKons of the MV can be performed to conrm the diagnosis and to ameliorate the c o n d i K o n ? A. Perform an inspiratory pause, increase inspiratory pressure B. Perform an expiratory pause, increase inspiratory pressure C. Perform an inspiratory pause, reduce the set rate D. Perform an expiratory pause, reduce the set rate

AutoPEEP

Hemodynamic eect of auto-PEEP

Highly compliant lung High fracKon of increase

alveolar pressure transmit to intrathoracic vessels Decrease venous return Decrease LV compliance Increase RV aoerload

Measurement of autoPEEP

Obstruc4ve lung disease

Mode FiO2 VT External PEEP RR I:E Any modes (CMV, PCV, PSV) COPD : SpO2 88-92% Asthma : SpO2 92-95% 6-8 ml/kg IBW prevent auto-PEEP 80% of auto-PEEP for decrease WOB 8-12 bpm Prolong expiratory Kme CMV : Increased peak inspiratory ow, square wave form ( Ppeak ) PCV : I:E PSV : E-sen > 25 %

17

In addiKon to hand hygiene, strict adherence to asepKc technique with maximal sterile barrier precauKons, skin anKsepKc with CHX, preferenKal use of subclavian inserKon, and prompt removal of unnecessary catheters, which of the following pracKces is associated with a reduced incidence of C R B S I i n I C U ? A. Heparin-coated catheters compared with uncoated catheters B. Transparent occlusive dressings compared with gauze C. Dressing with CHX-impregnated sponge compared with no a n K s e p K c D. Changing transparent dressings every 3 days compared with e v e r y 7 d a y s

Preven4on CVC related infec4on

1.

Set & use catheter care protocols

EducaKonal programs with hygiene training Catheter inserKon: prepare, skin anKsepKc, inserKon technique Catheter manipulaKon: hand hygiene, manipulaKon of taps Catheter care: catheter replacement modaliKes, type & frequency of dressing EvaluaKon incidence of CRBSI and feedback

2. 3.

Sta educaKonal / Quality improvement program Type of catheter

Polyurethane catheter Catheters coated with aniKmicrobial/anKsepKc (CHX/ silversulfadiazine, minocycline/rifampicin) CVCs with mulK lumen no increase risk of CRBSI

Preven4on CVC related infec4on

4.

Catheter inserKon site

Subclavian is rst BMI < 24.2 femoral vein BMI > 28.4 internal jugular vein

6. 7.

Ultrasound guided placement InserKon technique

Maximal sterile barrier precauKon CHX-based soluKon CHX based soluKon > aqueous povidone iodine > alcoholic povidone iodine

10.

Skin anKsepKc

Preven4on CVC related infec4on

8.

AnKbioKc prophylaxis

AnKbioKc lock with vancomycin CRBSI and risk of VRE Decrease risk colonizaKon 39% and BSI 44% when compared with non tunneling Recommend: subclavian access not possible and expected CVC > 7 d CHX gluconate impregnated sponge dressings CRBSI Frequency every 7 days

10.

Tunneling

12.

Dressing

Preven4on CVC related infec4on

11.

Venous line maintenance

Change IV set q 3 days Blood product, lipid emulsion (parenteral + propofol) change q 1 day or immediately be nished Hand hygiene before catheter manipulaKon Habs and sampling ports cleaning with CHX based anKsepKc before access No change catheter following by scheduled Change catheter via guidewire CRBSI AnKbioKc or anKsepKc ointments risk of fungal colonizaKon ProphylacKc heparin g thrombosis g nidus formaKon g colonizaKon

18

A 56-year-old alcoholic man with ARDS from massive aspiraKon is requiring MV. He is transferred to you with seng VT 12 ml/ kg, RR 20/min, PEEP 10 cmH2O, FiO2 0.5 and Pplat 36 cmH2O. His PaO2 93 mmHg, PaCO2 39 mmHg and pH7.41. You reduce his VT to 6 ml/kg and increase RR to 30/min. with these changes, his Pplat falls to 23 cmH2O, PaO2 65 mmHg, PaCO2 56 mmHg and p H 7 . 3 1 You wish to follow the ARDS net protocol, at this point y o u s h o u l d A. Increase VT to 9 ml/kg to improve both PaO2 and PaCO2 B. S w i t c h t o A P R V C. Increase PEEP to improve PaO2 and leave VT seng alone D. R e m a i n o n c u r r e n t s e n g s

19

A 68 year old man is admi0ed with sepKc shock and ARDS due to severe CAP. He is sedated and placed on MV with set RR 34/min. He appears comfortable and passive. On VT 6 ml/IBW, Pplat 29 cmH2O and PaCO2 43 mmHg. With FiO2 0.7 and PEEP 12 cmH2O, SaO2 88%. Appropriated anKbioKc have been iniKated. Aoer 12 h and following 4 L uid resuscitaKon, MAP 58 mmHg on NE 8 g/min, HR 112/min. Urine output 20 ml since ICU admission. You are considering giving uid bolus. Which of the following measures will most accurately predict whether a uid bolus will increase perfusion? A. The respiratory variaKon in PP aoer VT is increased to 10 ml/kg B. T h e P A O P m e a s u r e d a t e n d - e x p i r a K o n C. The CVP referenced to the phlebostaKc axis with supine posiKon D. T h e S c V O 2 m e a s u r e d f r o m a C V C

Respiratory changes in LV stroke volume in MV patients

RV preload Pleural pressure Transpulmonary pressure RV ejection RV afterload LV afterload LV ejection LV preload

Blood pulmonary transit time LV preload LV ejection

Pulse pressure variation

PP (%) = 100 x (PPmax - PPmin) (PPmax - PPmin)/2

Dened as responder
Threshold > 13% SensiKvity 94% Specicity 96%

More reliable than SPV

MICHARD F and et al. AJRCCM 2000;162:1348.

Pulse pressure variation

Limitation
Spontaneous breathing and any

spontaneous ventilatory efforts VT < 8 ml/kg HR/RR < 3.6 (false negative) Open chest Arrhythmia Increase IAP

Passive leg raising test (PLR)

Self volume challenge 300 ml Measures aorKc blood ow or pulse pressure 30-90 sec

AorKc blood ow > 10% (sensiKvity 97%, specicity 94%) Pulse pressure increased > 12% (sensiKvity 60%, specicity 85%)
Monnet X and et al. Crit Care Med 2006

20
A 50 year old paKent with severe ARDS from sepsis is supported by assist control venKlaKon. He is requiring an FiO2 of 0.8 and a PEEP of 12 cmH2O to produce a PaO2 57 mmHg. You elect to try to improve gas exchange and lower the FiO2 exposure by using a RM of 40 cmH2O for 40 sec. At end of maneuver, the PaO2 has risen to 106 mmHg. The duraKon if this improvement depends most importantly on: A. Whether addiKonal PEEP is added B. Performing repeated 40 cmH2O RMs every 1-2 h C. Performing repeated 40 cmH2O RMs every 3-6 h D. Immediately repeaKng the RM with 50 cmH2O and repeaKng RMs every hour if the SpO2 falls