Whats New in the SICU

Douglas JE Schuerer, MD FACS

Director of Trauma
General Surgery
Acute and Critical Care Surgery
Department of Surgery
Section of Acute and Critical care Surgery
Disclosures
I have no disclosures.
Department of Surgery
Section of Acute and Critical care Surgery
Intensive Care
SICU patient care is a
complex network of
overlapping conditions.
SICU research is exploding in
amounts, if not quality.
SICU research is truly
continuously changing.
Outcomes seem to change as
well.

I hope to review some the
most recent literature on
several topics.

Department of Surgery
Section of Acute and Critical care Surgery
Objectives
Review controversial subjects in ICU care.

Understand the literature associated with those topics.

Give my opinion of the best way to interoperate often
disparate results.

You thus get my opinion, for what that is worth.
Department of Surgery
Section of Acute and Critical care Surgery
Beta-Blockers
Topic: Perioperative
beta blockade helps
outcomes in those
undergoing
operations.
Initial studies done on
vascular patients
showed improved
mortality by fully BB
patients.

Department of Surgery
Section of Acute and Critical care Surgery
Beta Blockers
Recently, it has been
determined those initial
studies used faulty data
and have been retracted.
So what do we have now?

Most studies have shown
no improvement if not
high risk or not on BB
prior to surgery.

Perioperative Beta-Blocker Therapy
and Mortality after Major Noncardiac
Surgery
Peter K. Lindenauer, M.D., Penelope
Pekow, Ph.D., Kaijun Wang, M.S.,
Dheeresh K. Mamidi, M.B., B.S.,
M.P.H., Benjamin Gutierrez, Ph.D.,
Department of Surgery
Section of Acute and Critical care Surgery
Beta Blockers
Take home:

If patients are on BB prior to surgery, keep them on or
they will do worse.

If patients are not on BB, and are healthy, keep them off,
they will likely do worse with them.

Be judicious on starting new BB on high risk patients, it is
unclear if there is any benefit.
Department of Surgery
Section of Acute and Critical care Surgery
Resuscitation Fluid
Topic: For Trauma and/or
Sepsis, what is the best
resuscitation fluid?

Not a discussion of LR versus
NS.

Salt water vs. Albumin vs
starch
Department of Surgery
Section of Acute and Critical care Surgery
Resuscitation Fluid
First Starch:
Is a very good volume
expander.
However, consistently has
been proven to be a poor
resuscitation fluid in terms of
outcomes and cost.
This NEJM article for
example, showed more death
and renal replacement with
starch.


Hydroxyethyl Starch 130/0.4 versus
Ringers Acetate in Severe Sepsis, 2012
Department of Surgery
Section of Acute and Critical care Surgery
Resuscitation Fluid
Albumin vs Saline:

Three papers all from the
SAFE trial.
1
st
showed no differences
between saline and
albumin in ICU patients.
2
nd
showed increased
mortality of brain injured
patients with albumin.
3
rd
showed possible slight
benefit of albumin in those
with sepsis.

A Comparison of Albumin and Saline for Fluid
Resuscitation in the Intensive Care Unit
The SAFE Study Investigators*
Saline or Albumin for Fluid Resuscitation
in Patients with Traumatic Brain Injury
The SAFE Study Investigators*
Impact of albumin compared to saline
on organ function and mortality of patients
with severe sepsis
Department of Surgery
Section of Acute and Critical care Surgery
Resuscitation Fluid
Take home:
In most patients there is no benefit and potential harm
from albumin.
Cochrane review also favors this viewpoint.
In those with sepsis, Albumin may be helpful, but not
statistically so.
Albumin is 40 times more expensive than saline.

There are physiologic reasons to explain why it is worse.
This is not a comment on replacement (like after
paracentesis)
Department of Surgery
Section of Acute and Critical care Surgery
Glucose Control
Topic: Tight glucose control
improves survival in ICU
patients.

First approached in cardiac
surgery patients.
Other studies seemed to
concur, however.
Department of Surgery
Section of Acute and Critical care Surgery
Glucose Control
In real practice, without
study nurses always
present, tight glucose
control leads to many
hypogylcemic episodes
and mortality.
In this 2009 study, aiming
for 180 instead of 80-180
showed improved
mortality.
Most other studies have
backed this up.
Intensive versus Conventional Glucose
Control
in Critically Ill Patients
The NICE-SUGAR Study Investigators*
Department of Surgery
Section of Acute and Critical care Surgery
Glucose control
Take Home:
Keeping patient from hyperglycemia has certainly
improved survival.

If that is taken to extreme, risks of low sugars outweigh
good control.

We aim 120 -200 range in our unit.
Department of Surgery
Section of Acute and Critical care Surgery
Enteral Nutrition
Topic:
1) Immune modulating nutrients improve survival
2) Tube feeds should not be given with pressors on.
Department of Surgery
Section of Acute and Critical care Surgery
Enteral Nutrition
Tube feeds in general are protective against pneumonia
and other ICU infections.



Many studies have tried to show that immune modulating
feeds with things like glutamine, and antioxidants improve
outcome. Few have and have not been reproducible.
Department of Surgery
Section of Acute and Critical care Surgery
Enteral Nutrition
Problems with pressors and enteral nutrition are do too
poor bowel perfusion.
Recognized complications are intolerance to feeds, and at time a
disastrous bowel ischemia, especially with jejunal feeding.

More recent literature shows some of those concerns are
overweighted.


Department of Surgery
Section of Acute and Critical care Surgery
Enteral Nutrition
Take Home:

Use the gut instead of the IV

Fancy expensive tube feeds just make for more expensive
poop.

Be cautious with tube feeds on high dose pressors,
especially if patient had abdominal surgery. May slowly
start feeds when out of shock, even if on low dose
pressors.
Department of Surgery
Section of Acute and Critical care Surgery
Kidney Protection
Topic: IV contrast dye and other agents cause renal failure
and we can do something to prevent that.
Department of Surgery
Section of Acute and Critical care Surgery
Kidney protection
Multiple studies have
looked into renal failure
and using either bicarb or
other agents for
protection.
What is not clear is how
often dyes cause renal
failure.
The 2013 study is one
such that showed no
benefit.
Prophylactic Perioperative Sodium
Bicarbonate to Prevent Acute Kidney
Injury Following Open Heart Surgery: A
Multicenter Double-Blinded Randomized
Controlled Trial
Department of Surgery
Section of Acute and Critical care Surgery
Kidney Protection
Take Home:
The rise we see in Cr after a dye load is often not indicative
of renal failure and the incidence is much lower than
generally quoted.
Give dye if you think it will help save someone's life no
matter the Cr.
NAC and Bicarb have not consistently been shown to have
an effect on developing renal failure.

Department of Surgery
Section of Acute and Critical care Surgery
Very High Intracranial Pressure
In general, we have not been
able to show many adjuncts
work for elevated ICP.
However, outcomes are
better with a standardized
approach.

Topic: What to do with
intractable ICPs?
Department of Surgery
Section of Acute and Critical care Surgery
Very High Intracranial Pressure
2011 study in NEJM
between decompressive
craniectomy and standard
care.
Showed decreased ICU
LOS, but more unfavorable
outcomes for recovery.

Decompressive Craniectomy in Diffuse Traumatic Brain Injury
D. James Cooper, M.D., Jeffrey V. Rosenfeld, M.D., Lynnette Murray, B.App.Sci., Yaseen M. Arabi, M.D.,
Andrew R. Davies, M.B., B.S., Paul DUrso, Ph.D., Thomas Kossmann, M.D., Jennie Ponsford, Ph.D.,
Ian Seppelt, M.B., B.S., Peter Reilly, M.D., and Rory Wolfe, Ph.D., for the DECRA Trial Investigators
and the Australian and New Zealand Intensive Care Society Clinical Trials Group*
Department of Surgery
Section of Acute and Critical care Surgery
Very High Intracranial Pressure
The concern with the study is the varied population
enrolled and that some centers were not as facile at the
surgeries as others.

Take Home:
Decompressive craniectomy (for swelling not lesions) is not
beneficial.
Young patients may have better recoveries and should be
evaluated on a case by case basis.
Department of Surgery
Section of Acute and Critical care Surgery
Cooling Traumatic Brain Injury
Topic: Cooling after head injury will help outcomes as n
anoxic injury after cardiac arrest.
Department of Surgery
Section of Acute and Critical care Surgery
Cooling Traumatic Brain Injury


This 2010 study attempted
once again to show
differences in cooling head
injured patients.
It showed no
improvement.

Very early hypothermia induction in
patients with severe brain injury (the
National Acute Brain Injury Study:
Hypothermia II): a randomised trial
Department of Surgery
Section of Acute and Critical care Surgery
Cooling Traumatic Brain Injury
Take Home:
Cooling traumatic head injury to 35 or below does not
improve outcomes.
Unknown if keeping head injured patients from having high
neurogenic fevers is helpful.
If not infected, I will cool a head injured patient who gets
over 39.
Further use of cooling should only be done in studies.

Department of Surgery
Section of Acute and Critical care Surgery
Aggressive Modes of Ventilation
Pressure Control
Pressure Control- Inverse Ratio Ventilation
BiLevel Ventilation
Airway Pressure Release Ventilation (APRV)
High Frequency Ventilation
Department of Surgery
Section of Acute and Critical care Surgery
PC-IRV
Often next step up from pressure control.

Patient usually requires heavy sedation or even paralysis.

Good at recruitment in ARDS.
Department of Surgery
Section of Acute and Critical care Surgery
BiLevel / APRV
These two are basically related to each other.

Both are based on pressure control ventilation at two levels
with PSV at both.

If the I:E ratio is extremely reversed then it is APRV with a
low time less than 1.5 sec.
Department of Surgery
Section of Acute and Critical care Surgery
BiLevel
Pressure control breathing at all plateau portions of the
respiratory cycle.

Time cycled switching between the two pressure levels.
This varies if spontaneously breathing.

A fully sedated and paralyzed patient is effectively on
normal PC ventilation.
Department of Surgery
Section of Acute and Critical care Surgery
BiLevel
Department of Surgery
Section of Acute and Critical care Surgery
BiLevel Why?
Usually less sedation required as patient can better sync
with the vent.
Less alveolar collapse with spontaneous breathing.
Improve the distribution of ventilation.
Improve ventilation/perfusion mismatches.
Department of Surgery
Section of Acute and Critical care Surgery
BiLevel Why?
Protects the lung with pressure limited ventilation
(protective lung strategies.)
Better venous return to the heart with BiLevel over PC
ventilation.
Probably better abdominal organ blood flow, both bowel
and kidneys.
Spontaneous breathing decreases work of breathing.
Department of Surgery
Section of Acute and Critical care Surgery
BiLevel Why not?
Knowledge base in the ICU

All of the problems associated with PC ventilation.
Air trapping can occur.
Tidal volumes may be lost acutely.
Department of Surgery
Section of Acute and Critical care Surgery
APRV
Confusing nomenclature in the literature exists
Lung injury is non uniform/heterogenous
a. In etiology
b. In pathoanatomy and distribution
c. In response to mechanical ventilation
APRV allows higher mean airway pressure with lower
VT and peak
Literature and physiology points to better
oxygenation, lower airway pressures, less dead space
and shunt
Whether these surrogate outcomes will translate into
better patient outcomes remains to be determined
Department of Surgery
Section of Acute and Critical care Surgery
P high
P low Spontaneous
T low
Department of Surgery
Section of Acute and Critical care Surgery
Department of Surgery
Section of Acute and Critical care Surgery
Common Mistakes
1. Using APRV in patients with expiratory flow limitation
2. Setting Plow to > 0 cm H20
3. Cant use it if not spontaneously breathing
4. Checking ABG too soon
5. Be careful when setting in TBI patients and use your ICP monitor
and EtCO2 detector
Department of Surgery
Section of Acute and Critical care Surgery
High Frequency Ventilation
High Frequency Oscillatory Ventilation (HFOV)

Department of Surgery
Section of Acute and Critical care Surgery
HFOV
Department of Surgery
Section of Acute and Critical care Surgery
HFOV
The study below in 2013 showed increased mortality in
ARDS.
May have benefit in isolated cases of lung bleeding or
pulmonary contusion as a temporary method of ventilation.
High-Frequency Oscillation in Early Acute Respiratory
Distress Syndrome
Niall D. Ferguson, M.D., Deborah J. Cook, M.D., Gordon H. Guyatt, M.D., Sangeeta Mehta, M.D., Lori
Hand, R.R.T.,
Peggy Austin, C.C.R.A., Qi Zhou, Ph.D., Andrea Matte, R.R.T., Stephen D. Walter, Ph.D., Francois
Lamontagne, M.D.,
John T. Granton, M.D., Yaseen M. Arabi, M.D., Alejandro C. Arroliga, M.D., Thomas E. Stewart, M.D.,
Arthur S. Slutsky, M.D., and Maureen O. Meade, M.D., for the OSCILLATE Trial Investigators
and the Canadian Critical Care Trials Group*
Department of Surgery
Section of Acute and Critical care Surgery
Prone Positioning
Gattinoni L, et al. Body position changes redistribute
lung computed tomographic density in patients with
acute respiratory failure. Anesthesiology 1991;74:15-29
Department of Surgery
Section of Acute and Critical care Surgery
Prone Positioning
Recent (2013) article in NEJM showed a benefit with prone
positioning in ARDS.
Why finally positive?
Duration of proning
Standardized vent wean
Take home: I use it routinely when patient are stuck on
high settings .

Prone Positioning in Severe Acute Respiratory Distress
Syndrome
Claude Gurin, M.D., Ph.D., Jean Reignier, M.D., Ph.D., Jean-Christophe Richard, M.D., Ph.D., Pascal
Beuret, M.D.,
Arnaud Gacouin, M.D., Thierry Boulain, M.D., Emmanuelle Mercier, M.D., Michel Badet, M.D.,
Alain Mercat, M.D., Ph.D., Olivier Baudin, M.D., Marc Clavel, M.D., Delphine Chatellier, M.D., Samir
Jaber, M.D., Ph.D.,
Sylvne Rosselli, M.D., Jordi Mancebo, M.D., Ph.D., Michel Sirodot, M.D., Gilles Hilbert, M.D., Ph.D.,
Christian Bengler, M.D., Jack Richecoeur, M.D., Marc Gainnier, M.D., Ph.D., Frdrique Bayle, M.D.,
Gael Bourdin, M.D., Vronique Leray, M.D., Raphaele Girard, M.D., Loredana Baboi, Ph.D., and Louis
Ayzac, M.D.,
for the PROSEVA Study Group*
Department of Surgery
Section of Acute and Critical care Surgery
ECMO
CESAR trial showed improved mortality in patients treated
in ECMO centers.


Take Home: Consider strongly in patient with unresolving
respiratory failure. Earlier is better than later.
Department of Surgery
Section of Acute and Critical care Surgery
HIT
Occurs in 1-3% of patients exposed to unfractionated heparin
Occurs in 0-0.8% of patients exposed to LMWH

HIT antibodies against complexes of platelet factor 4 (PF4)
Found in 20% of patients treated with UFH
Found in 8% of patients treated with LMWH

HIT Ab react with PF4/heparin complexes leading to:
Strong platelet activation
Degranulation with release of procoagulant substances
Activate endothelial cells to further generate thrombin

Hypercoaguable state with thromboembolic complications


Chest. 2009 J une; 135
Department of Surgery
Section of Acute and Critical care Surgery
2 1 0
Thrombocytopen
ia
>50% plt fall or
nadir >20-
100,000
30-50% plt fall
or nadir 10-
19,000
<30% plt fall or
nadir <10,000
Timing of onset
Days 5-10 or
<day 1 with
recent exposure
(30 days)
>day 10 or
timing unclear,
or <day 1 with
recent exposure
(31-100 days)
<day 4, no recent
heparin
Thrombosis or
other sequelae
Proven new
thrombosis, skin
necrosis or
acute systemic
reaction
Progressive or
recurrent
thrombosis,
erythematous
skin lesions,
suspected
thrombosis
None
oTher causes of
platelet fall
None evident Possible Definite
HIT
The 4 Ts
Chest. 2009 J une; 135
Department of Surgery
Section of Acute and Critical care Surgery
Diagnosis of HIT




Serotonin Release Assay (SRA)
- Platelet activation test
- Detection of donor platelet activation in the presence of patient
plasma/serum and heparin
- Anti-PF4 antibodies present in patient plasma/serum activate platelets
in vitro
- High specificity
- Gold Standard

ELISA
- Detect HIT antibodies by incubating patient plasma/serum in wells
coated with PF4 and heparin
- Detects clinically relevant and irrelevant antibodies
- High sensitivity with excellent negative predictive value

Both tests often used in conjunction SRA results usually more reliable
Chest. 2009 J une; 135
Department of Surgery
Section of Acute and Critical care Surgery
HIT Overview
Crit Care Med. 2006, 34
Department of Surgery
Section of Acute and Critical care Surgery
Management of HIT
First and foremost: DISCONTINUE HEPARIN

Anticoagulate:
Argatroban
- synthetic direct thrombin inhibitor (DTI)

- reversibly binds thrombin active site rapid onset of
action

- plasma t = 45 minutes

- predominant hepatobiliary elimination

- continuous iv infusion keep PTT 1.5-3 x baseline


Chest. 2009 J une; 135
Department of Surgery
Section of Acute and Critical care Surgery
Bivalirudin
- synthetic DTI metabolized by proteolytic degradation

- plasma t = 25 minutes

- continuous iv infusion keep PTT 1.5-2.5 x baseline


Management of HIT
Chest. 2009 J une; 135
Department of Surgery
Section of Acute and Critical care Surgery
Management of HIT
Anticoagulation continued:
Anti Factor Xa agents have been used in the treatment of
HIT
- Danaparoid no longer on US market due to lack of
availability

- Fondaparinux recent case reports linking its use to
HIT
still a viable agent for DVT prophylaxis

IIb/IIIa inhibitors are not sufficient therapy for HIT




Chest. 2009 J une; 135
Department of Surgery
Section of Acute and Critical care Surgery
Management of HIT
Other Considerations:
HIT-associated thrombotic events should be treated with
warfarin
- postpone warfarin therapy until platelets reach 150,000

- continue alternative anticoagulation when initiating
warfarin

- 4-5 day overlap of DTI with stable INR before
discontinuing DTI

- continue warfarin for 3-6 months

Do NOT give platelet transfusions during active HIT
- akin to dumping gasoline on a fire
Chest. 2009 J une; 135
Department of Surgery
Section of Acute and Critical care Surgery
Questions?