ICU Tutorial 2011

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ICU Tutorial

Medical Residents 2011

A67-year-oldisadmi0edtoaMICUwithARDS.BS=135mg/dl.

Intensive insulin therapy was started. An outcome about

intensiveglucosecontrolincludeswhichofthefollowing.

A. Increasedriskofhypoglycemia

B. Reducedmortalityindependentofthetargetglucoselevel

C. Reduced mortality only if the paKents could be maintainedwithaBS≤11mg/dl

D. ShorthospitalLOS

How hyperglycemia is harm?

• BS>14mg/dl+HbA1C>6.5%suspectedpreexisKngDM.• Intensiveglucosecontrol8-11mg/dl.

• RRmortality.93(95%CI.83-1.4)

• SmallRRmortalitybenefitinSICU.63(95%CI.44-.91)

• RRhypoglycemia6.(95%CI4.5-8.)• LasttrialNICE-SUGARstudy

• Intensiveglucosecontrolincreasedabsoluteriskofdeathat9days

• Numberneededtoharm38

NICE-SUGARStudyInvesKgatorsNEJM29;36:1283-97.

Daily SBTs in paKents supported by MV with stable andimprovingcardiorespiratoryfuncKonhavebeenshowntofacilitate

thevenKlatorwithdrawalprocess.InaddiKontomonitoringRR,gasexchange,hemodynamics,and

comfortduringtheSBT,whatotherstrategywillbehelpfulinthisprocess?

A. UseofmodethatautomaKcallyreducespressuresupportinbetweendailySBTa0empts

B. RequiredallpaKentstohaveaf/VT<15beforeiniKaKngSBT

C. RequiringP.1<8cmH2ObeforeiniKaKngSBT

D. Usingpressuresupportof5-8cmH2OduringSBT.

Clinicalassessment • Adequatecough

• AbsenceofexcessivetracheobronchialsecreKon

• ResoluKonofdiseaseacutephaseforwhichthepaKentswasintubated

ObjecKve

measurements Clinicalstability

-Stablecardiovascularstatus(HR<14,SBP9-16mmHg,noor

minimalvasopressor)

-StablemetabolicstatusAdequateoxygenaKon-SaO2>9%onFiO2≤.4(orPaO2/FiO2≥15mmHg)

-PEEP≤8cmH2OAdequatepulmonaryfuncKon

-RR<35/min

-MIP≤-2--25cmH2O

-VT>5ml/kg-VC>1ml/kg

-f/VT<15

-NosignificantrespiratoryacidosisAdequatementaKon

-NosedaKonoradequatementaKononsedaKon)

Readinesstowean

Measurementsofoxygena4onanddeadspace

PaO2/FiO2

PaO2/PAO

2Deadspace(VD/VT)Simpletestsofrespiratoryloadandmuscularcapacity

NIP(MIP)

Respiratorysystemcomplianceandresistance

VTTestthatintegratemorethanonemeasurement

f/VTCROPindex(compliance,RR,oxygena4on,pressure)=CdynxPImaxx[PaO2/PAO2])/rate

Complexmeasurements

Airwayocclusionpressure

P0.1/MIP

Esophagealpressurements

Oxygencostofbreathing,WOB

GastricmucosalpH

WeaningPredictors

YangL,TobinMJ.NEJM1991;324:1445-5.

• T-piece

• Lowlevelpressuresupport(reduceresisKvework)

• 7-8cmH2Oinadult

• 1cmH2Oinpediatric

• AutomaKcTubeCompensaKon

• DuraKonofSBT=12min(Ingeneral)

• IdealduraKonofSBT(3minVS12min)dependonduraKonofvenKlaKonandunderlyingcauseforrespiratoryfailure

Poten4alcausesofweaningfailure Auto PEEP

pneumoniapulmonary edema

Atelectasis

Pleural effusion

Abdominal distensionSecretions

Bronchoconstriction

ET-problemsDead space

Metabolic acidosis

Anxiety

Oversedation

Metabolic alkalosis

CNS process

↓Mg, Ca, K, PO4

Steroids

Malnutrition

Sepsis

Medications

HypothyroidismPhrenic nerve injury

CIP, CIMCardiac disease

Psychological disease

A 43-yr-old man was admi0ed to ICU with seizure and mentalstatuschanges.HewasBT38.5

๐C.HehadhistoryofHIVandnon-

compliantART.HisCD4count=13/µL.CTbrainshowndiffusebrain atrophy and no focal mass lesion. LP was done and CSFprotein=72mg/dL,glucose68mg/dL,WBC78/ µL(85%L),RBC3.6x16/ µL. He began vancomycin, ampicillin, ceazidime,amphotericin B and acyclovir. Day2 aer admission his Cr

1.3→2.7mg/dL.UrineisshowninFig.

Whichoneofthefollowingisthe

mostlikelycauseofAI?

A. AmphotericinB

B. AcyclovirC. Contrastinducednephropathy

D. AcuteintersKKalnephriKs

Acyclovir

CrystalinducedAKI

Needlelikebirefringent

Sulfonamide

Sulfadiazine

Needleshape

Shockofwheat

Dumbbell

Indinavir

Starbursts

Fanshapes

• Rapidexcretedinurineandlowurinesolubility

• Riskfactors• Highdose

• Rapidinfusion

• VolumedepleKon• Renalimpairment

• PrevenKon

• Isotonicsalinebeforeacyclovirinfusion

• Highurineflowrate• Slowinfusionin1-2hr

Acyclovirnephrotoxicity

A73yearoldmanpresentedwithseverechestpainfor2hr.ECGshowedSTEMIatinferiorwall.Hewasgivenalteplaseover

9 min and admi0ed to ICU. Next 48 hr severe dyspneadeveloped.FollowingintubaKon,furosemide,andinsertedPAC.

Pulmonary artery pressure waveform tracing are capturedduring balloon inflaKon in Fig. Which of the following bestexplains why the waveform changes shape as the balloon is

inflated? 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.

PACposi4on • NormallyPAdiastolic>PCWP~1-4mmHg

• PAdiastolic–PCWP>5mmHg:éPVR

GiantVwaves

Overwedging

Limita4onofPAOP

Avarietyofdrugsmaybe used forinducKon of sedaKonduringRSI.ForwhichoneofthefollowingpaKentswouldyoupreferably

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. A45-year-oldmanwhoishypertensiveand hasanacuteMI

C. A25-year-oldwomanwithasthmawhois8weekspregnantD. A 3-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 .

• .1-.5mg/kg

• Analgesia+Amnesia

• Notnecessarilycausealossofconsciousnessbutnotaware.

• Amnesia,alteredshorttermmemory,decreasedabilitytoconcentrate,alteredcogniKveperformance,nightmares,N/V

• CombinaKonwithsmalldosesofBDZdoesprolongrecoveryfromketamine,buteliminatestheseadverseeffects

• DirectsKmuliANS,tachycardiaandincreasesBP

• Bronchodilatoreffect.

Ketamine

• Dose2mg/kg.

• Containing1%soybeanoil,2.25%glycerol,1.2%eggphosphaKde.

• Mostfrequentlycontaminatedbybacteria.

• Noanalgesia

• HepaKcclearance+extrahepaKcsiteseliminaKon

• Rapidrecoveryevenaerprolonginfusion

• Dosedependenthypotension,respiratorydepression

• AdjusteddosebyvolumestatusandcardiacfuncKon

• Bronchodilatoreffect

Propofol

• Metabolicacidosis,

• CardiacdysfuncKon,

• Hyperkalemia,hypertriglyceridemia,

• Rhabdomyolysis

• AI

• Triggerdosetoxicity≥5mg/kg/hrx48hr

Propofolrelatedinfusionsyndrome

InwhichofthefollowingpaKentscenarioswouldtherapeuKchypothermiabemostclearlyindicated?

A. A55-year-oldmaninacomafollowinganin-hospitalcardiacarrestwithPEAduetomassivepulmonaryembolism.

B. A6-year-oldmaninacomafollowinganout-of-hospitalVF

C. A59-year-oldmantransferredfromanoutlyinghospitalforconKnuedcarefollowingaVFarrest1weekagowithanoxicencephalopathy

D. A3-year-oldmaninacomafollowingamotorvehicleaccidentwithheadtrauma

• ComatoseadultpaKentswithROSCaerout-of-hospitalVF

cardiacarrest(classI,LOEB)• ComatoseadultpaKentswithROSCaerin-hospitalcardiacarrest

ofanyiniKalrhythmoraerout-of-hospitalcardiacarrestwithaniniKalrhythmofPEAorasystole(ClassIIb,LOEB).

• Cooledto32°Cto34°Cfor12to24hours

• Mechanisms

• Slowdowncerebralmetabolicrate

• InhibiKondeleteriousbiochemicalorcerebraleventsbetweenreperfusion

• ↓freeradicalproducKon&excitatoryaminoacidrelease

• Promoteneuronalrecovery

• ↓ICP

1.Induc4onphase• AimcoreBT<34

• DowntotargetBTasquicklyaspossible

• Sideeffectsarehypovolemia,electrolytedisorders,hyperglycemia

2.Maintenancephase• TightlycontrolcoreBT,minorornofluctuaKon(max.2-.5

3.Rewarmingphase

• .2-.5๐

C/hour

• Electrolytedisorders(hyperkalemia,hyperphosphatemia)

• Bewarereboundhyperthermia

.Maintenancenormothermicphase

1. Arrhythmias,hemodynamicchangesandCVSeffects

• Cardiacoutput↓25-4%

• CVP↑,SVR↑,BP↑

• Hypovolemia(colddiuresis)

• CoreBT<35.5๐

C→sinusbradycardia

• CoreBT~32๐

C→HR~4-45bpm

• CoreBT<28-3๐

C→VForVT

2.Drugclearance

• ↑Drugleveland/orenhanceeffect

3.Electrolytesdisorder

• Hypomagnesaemia

• Hyperkalemiainrewarmingphase

5.Hyperglycemia6.CoagulaKonparameter

• BT<35๐

C→plateletfuncKon

• BT<33๐

C→coagulaKonfactor

• NormalstandardcoagulaKontestbecausewarmbloodpriortest

7.InfecKon

8.Shivering

• NMBA(++++)

• Meperidine(++++)

A 46-year-old man is rescued from his home following ahurricane with regional power outages; he is found to be

confusedanddisoriented.Helivedtherefor3dayswithlightandheatprovidedbyaportablegenerator.Hispulseis13/min,BP14/9mmHg,RR28/min,SpO 298%.TheremainderPEnormal.Which of the following should be done immediately.

A. A d m i n i s t e r 1 % 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

Carbonmonoxide(CO) • COisacolorless,odorless,tastelessandnonirritantgas

• ProducKoninvarietyofways

• IncompletecombusKonoffires

• FaultyheaKngsystems

• InternalcombusKonengines• Woodstoves

• Charcoalgrills

• VolcanicerupKons

• InvivohepaKcproducKon• Methylenechloridepoisoning:paintthinners

• Accidental:automobileexhaustandsmokeinhalaKon

Pathophysiology

• COeasilydiffusesacrossalveolar-capillarymembranes

• RapidlytakenupbyRBCs

• BindtoironofHbwithaffinity24Kmes>O2

• Summary4mechanismsofCOintoxicaKon

• DecreaseintheO2carryingcapacityofblood

• DecreasedO2deliverytoperipheralKssueasaresultoftheleshiin

theoxyhemoglobindissociaKoncurve

• MitochondrialdysfuncKonandimpairmentofcellularrespiraKonby

inhibiKonofcytochromeoxidaseacKvity

• LipidperoxidaKonofbrainduringreoxygenaKon

Clinicalpresenta4on • Headache,dizziness,sorethroat,nausea,SOBandfaKgue

• EnKrefamilyisaffectedrelatedtoafaultyhomeheaKng

systemduringthewintermonths

• Lossofconsciousness

• Severitycorrelatebe0erwithduraKonofexposure

• BrainandheartareverysensiKvetoCOintoxicaKon

• CVSdisorderเกดไดเรวถาผ ปวยม preexisKngCVSdisease

• LacKcacidosis,rhabdomyolysis,ARF

• ตายแนถา level>6%

Diagnosis • Cherry-redlips,cyanosis,reKnalhemorrhage(infrequent)

• IncreasedlevelofCOHbèDx

• CoHbตองวดโดย cooximeter

• ABG:PaO2normal

• Electrolyte(AG),C,lactate• EG,cardiacenzymes

• ChestX-ray:noncardiogenicpulmonaryedema

• Bloodandurinecyanide

• Suicide:drugscreen

Eff f COHb d O 4 b

EffectofCOHbonmeasuredO2satura4onby

pulseoximetry

Treatment • Removalfromsourceofexposure

• 1%O2สามารถลด T½ ของ COHbจาก 4-6 hr. เปน 40-80

• IntubaKonตาม indicaKons

• O2ควรใหจน

COHbreturntonormalexceptpregnancy

• HBOT:1.5-3ATMลด half-lifeของ COHbจาก 5-6hrเปน 2min

• IndicaKonofHBOTหนาตอไป

ApaKentwithARDSissupportedbyMVwiththemodedepictedinFig.WhatdescripKonbestfitsthismode?

A. PressuresupportvenKlaKon

B. AirwaypressurereleasevenKlaKon

C. VolumeassistedcontrolvenKlaKon

D. VC-SIMV

• OxygenaKonindex(OI)=(FiO2xmPawx1)/PaO

2• Predictorofpooroutcome

• HighOI12to24haeronsetofARDSandrisingareindependentrisk

factorsformortality

• OI>3representfailureofconvenKonalvenKlaKon

• MajorityofpaKentswithARDSdiefrommulKorganfailure

Ven4latorymanagementofARDS

Variables ProtocolVenKlatormode Volumeassistcontrol VT ≤6ml/kgpredictedBW Plateauairwaypressure ≤3cmH2OVenKlaKonrate/pHgoal 6-35/min,adjustedtoachievearterialpHof

>7.3ifpossibleInspiratoryflow AdjustforI:E=1:1-1:3 OxygenaKon PaO2≥55and≤8mmHgorSaO2≥88%

and≤95%CombinaKonofFiO2andPEEP(cmH2O) .3/5,.4/5,.4/8,.5/8,.5/1,.6/1,

.7/1,.7/12,.7/14,.8/14,.9/14,.9/16,.9/18,1./18,1./22and1./24

Weaning A0emptbyPSwhenFiO2/PEEPcombinaKon

is<.4/8

ARDSnetLow-VTprotocol

P b bili f i l h h D 90

ProbabilityofsurvivalthroughDay90

PEEP i f h i

PEEPinrefractoryhypoxemia • ThreeRCTsformodestVShighlevelsofPEEP

• ALEOLI(NEJM24;351:327-36)

• LOVS(JAMA28;299:637-45)

• EXPRESS(JAMA28;299:646-55)

• SystemaKcreviewandmeta-analysis

• JAMA21;33:865-73(March)

Ch t i 4 f i l d d t i l

Characteris4csofincludedtrials

PEEP t t i (LOVS)

PEEPstrategies(LOVS)

R i t i bl i fi t k

Respiratoryvariablesinfirstweek

Summary

Summary • Inhospitalmortality

• AllpaKents:higherPEEP=lowerPEEP• ARDS:higherPEEP>lowerPEEP

• RelaKvemortalityreducKon1%

• NNT25

• ALI:higherPEEP=lowerPEEP(high<low)

• VenKlatorfreedays

• AllpaKents:higherPEEP=lowerPEEP

• ARDS:higherPEEP>lowerPEEP

• ALI:higherPEEP=lowerPEEP(high<low)

Lung recruitment maneuvers

• Transientincreaseintranspulmonarypressure

• Reopeningofcollapsedalveoli.

• UseInrefractoryhypoxemia

• Varietyoftechniques

• SustainedinflaKonmaneuvers

• HighPCV

• IncrementalPEEP

• Intermi0entsigh

• Extendedsigh

Lungrecruitmentmaneuvers

Sustained infla4on technique

Sustainedinfla4ontechnique • CPAP4cmH2forupto6sec.

• Advantages• Reducinglungatelectasis

• ImprovingoxygenaKonandrespiratorymechanics

• PrevenKngETsucKoning-inducedalveolarderecruitment

• Disadvantages

• IneffecKve

• Short-lived

• Circulatoryimpairment• Increasedriskofbaro/volutrauma

• Reducednetalveolarfluidclearance

• WorsenedoxygenaKon

Stepwise maximum RM

StepwisemaximumRM • PaO2+PaCO2≥4mmHgasan

indicatorofmaximumRM

• DecrementalPEEPKtraKon

• Start25cmH2Ofor4min

↓ 2 cmH2O

• LowestPEEPmaintainPaO2+

PaCO2≥4mmHg(opKmalPEEP)

• RMatlaststepagain• PEEPatopKmalPEEP

BorgesJBetal.AmJRespirCritCareMed26;174:268–78.

Recruitment Maneuvers for ALI

RecruitmentManeuversforALI

ASystemicReview • 4arKclesanalyzed:meansamplesize3,total1185pts• Studydesigns

• 4RCT

• 32prospecKvecohort

• 4retrospecKvecohort

• TypeofRMs

• SustainedinflaKon18

• HighPCV9

• IncrementalPEEP8

• HighVT/sigh4

• Other1

Fanetal.AmJRespirCritCareMed28;178:1156-63.

PCV inverse ra4o ven4la4on

PCVinverse-ra4oven4la4on •

InspiratoryKme>expiratoryKme• NobenefitormarginalbenefitofPCIRV

• Li0leimprovementinoxygenaKon

• Elevatedmeanairwaypressure+autoPEEP• Adverseeffecttohemodynamics

• RequiredsedaKonandparalysis

Airway pressure release ven4la4on

Airwaypressurereleaseven4la4on

APRV seng

APRVseng • Phigh

• DesiredPpla(typically2-35cmH2O)

• Phigh>35cmH2Owhen ↓ thoracic&amdominal

complianceormorbidobesity

• Plow :cmH2O

• Thigh :4-6secs(8-95%oftotalcycleKme)

• Tlow :.2-.8secs(endexpiratoryflow=5-75%

ofPEFR)

Mortality

Prone posi4oning

Proneposi4oning • ReducemortalityinseverebyPaO2/FiO2<1mmHg

(p=.1;RR.84;95%CI.74-.96)

• MeanproneduraKon14hr/day

• NotreducemortalityinoverallpaKents

• ImproveoxygenaKon27-39%

• âVAP

• NoeffectonvenKlatorfreedayorduraKonofMV

• Adverseeffects:pressureulcers,ETobstrucKon,tracheostomytubedislodgement

G T t M h i d i HFV

The major gas-transport mechanisms that are operaKve under physiologic condiKons in each region (convec4on, convec4on anddiffusion,anddiffusionalone) areshown.Thereare sevenpotenKalmechanisms:turbulenceinthelargeairways,causingenhanced

mixing;directven4la4onofclosealveoli;turbulentflowwithlateralconvecKvemixing;pendellu(asynchronousflowamongalveolidue

toasymmetriesinairflowimpedance);gasmixingduetovelocityprofilesthatareaxiallyasymmetric(leadingtothestreamingof“fresh”

gastowardthealveolialongtheinnerwalloftheairwayandthestreamingof“alveolar”gasawayfromthealveolialongtheouterwall);

laminarflowwithlateraltransportbydiffusion(Tayordispersion);andcollateralven4la4onthroughnonairwayconnecKons

Gas-TransportMechanismsduringHFV

HFOV • SafeandeffecKveinimproveoxygenaKon

• Nolowermortality

• MayimprovemortalityinpaKentswithhighOI

NO inhala4on

NOinhala4on

Griffithsetal.NEJM25;353:2683–95.

Administra4onofiNOinadult

• Majortoxicity

• MetHb:uncommoninusualdose,measureq6hr

• NO2:rapidcoverttonitricacidinaqueoussoluKonthattoxictorespiratorytract

• DosetreatmentinPHT>ARDS

• Maximumdose4ppm• Required2%riseinPaO2onFiO21.

• ImprovedV/Qmismatch

• Be0eroxygenaKon

• Nosurvivalbenefit

• NoreducKoninvenKlatorfreedays

WhichofthefollowingbestdescribesthemonitoringofglucosecontrolinICU?

A. AlaboratoryglucosemeasurementispreferredoveraPOCT.

B. Acentralorperipheralbloodsampleispreferredtocapillarysample

C. Asinglemorning(eg.6.am)glucoselevelispreferredoverameanmorningglucoselevel

D. Ameanmorningglucoselevelispreferredoverameandailyglucoselevel

SamplingBlood(vascularcatheter) DangerofcontaminaKonwithIVfluidFingersKck(notrecommended) InaccurateinpaKentswithedemaoranemia

MeasurementGlucometer Fastest,leastaccurateBloodgasmachine Fast(ifinICU),accurateLaboratoryanalysis Slowest,mostaccurate

Acuterespiratory

d t i K

deterioraKonPeakinspiratorypressure

Decreased Increased NochangePlateaupressure• Airleak

• HypervenKlaKon• Pulmonaryembolism

• ExtrathoracicProcessNochange Increase

AIRWAYOBSTRUCTION• AspiraKon

• Bronchospasm

• SecreKons

• Trachealtube

• ObstrucKon

DECREASEDCOMPLIANCE• Abdominaldistension

• Asynchronousbreathing

• Atelectasis

• AutoPEEP

• Pneumothorax

• Pulmonaryedema

A28 yearoldwoman is admi0edtoICUforfever, hypotension,andmildlowermiddleabdominalpain,dysuria.Sheunderwenta

C/S 9 months ago and intraoperaKve bleeding required PRCtransfusion. Review of system, she has some intermi0entheadaches and faKgue. She had noted a decrease in milkproducKonaer4weeksandnothadamenstrualperiodsincethedelivery

OnexaminaKonBT38.5C,BP8/5mmHg,PR1/min,RR15/min.DespiteinfusionofNSSandanKbioKcs,sheremainshypotensive.Whichofthefollowingshouldnextbeaddedtoherregimen?

A. HydrocorKsone

B. Dopamine

C. Norepinephrine

D. Drotrecoginalfa

Ini4al resuscita4on

Ini4alresuscita4on CVP8-12mmHg MAP≥65mmHg

Urineoutput≥0.5ml/kg/hr ScVO2≥70mmHgSVO2≥65mmHg

Goal6hrs

Higher target CVP

HighertargetCVP • MechanicalvenKlaKon• Decreasedventricularcompliance

• IAH

• DiastolicdysfuncKon

• Pulmonaryarteryhypertension

Indices of fluid responsiveness

Indicesoffluidresponsiveness • PulsepressurevariaKon• Passivelegraising

• CVPvariaKoninspontaneousbreathing

•Respiratory changes in pulse pressure

• Respiratorychangesinpulsepressure

• Definedasresponder

• Threshold>13%

• SensiKvity94%

• Specificity96%

• MorereliablethanSPV

PPmaxPPmin

∆PP(%)=1x(PPmax-PPmin)(PPmax-PPmin)/2

Early goal directed therapy

Earlygoaldirectedtherapy

Diagnosis

Diagnosis • ObtainappropriateculturesbeforestarKng

anKbioKcs

• ≥2BCs(percutaneousandvascularaccess)

• Cultureothersitesasclinicallyindicated• Imagingtoconfirmandsampleanysourceof

infecKon

Source control

Sourcecontrol Clinical(suspected)

diagnosis consider SourcecontrolPneumonia Empyema Drainage2๐ peritoniKs OngoingcontaminaKon ExteriorizaKonofleakingGItract,drainageof

peritonealfluidPancreaKKs InfectedpancreaKc

necrosis DebridementofpancreaKcKssueUTI Catheter-related RemovecatheterBacteremia Catheter-related RemovecatheterSSI NF ResecKonofnecroKcKssue–explorewhen

suspectedonclinicalgroundsPyelonephriKs Urinarytractlithiasis Debridement–lithiasisremovalMediasKniKs EsophagealperforaKon SurgicaldrainageSinusisKs Abscess AspiraKonanddrainage–removeNGtubeAcalculous

cholecysKKs Abscess,hydrops Percutaneousdrainage–chlecystectomyPericardiKs Drainage

Fluid therapy

Fluidtherapy • Crystalloid=colloid• Fluidchallenge

• Crystalloid≥1mlover3min

• Colloid≥3-5mlover3min

Vasopressors

Vasopressors • MAP≥65mmHg:toolowinpaKentswithsevere

uncontrolledHT

• NEordopamineasthe1stchoice

• Epinephrine:poorlyresponsivetoNEordopamine

Inotropic therapy

Inotropictherapy • DobutamineformyocardialdysfuncKon(elevated

cardiacfillingpressureorlowcardiacoutput)

• NouseofstrategytoincreaseCItosupranormal

Cor4costeroids

Cor4costeroids • HydrocorKsone:BPpoorlyresponsetofluid

therapyandvasopressor

• Notpreferdexamethasone

• FludrocorKsoneisopKonal

WhichofthefollowingintervenKons,ifusedrouKnely,wouldbe

expectedtoreducetheincidenceofVAP?

A. OralapplicaKonofanKsepKcs

B. Frequentrespiratorycircuitchanges

C. Standardelectrictoothbrushing

D. Early tracheostomy among paKents expected to require

prolongedmechanicalsupport

VAPpreven4on

Source of VAP

Pathogen Prevention Goal Specific MeasuresAerodigestive

colonization Prevent colonization by

exogenous routes • Hand hygiene

• Microbial surveillance and targeted

barrier isolation

• Preemptive barriers: Routine gloving &

gowning Dedicated equipmentSuppress oropharyngealmucosal colonization • Oral decontamination with

chlorhexidine

• SDD

• Aerosolized antimicrobials

• Sucralfate instead of H2-blockersPrevent aspiration • NIV

• Semirecumbant positioning

• Novel endotracheal tube permitting

continuous subglottic suctioning

VAPpreven4on

Source of VAP

Pathogen Prevention Goal Specific MeasuresContaminated

respiratory therapy

equipment and

medical aerosols

Safe equipment and

medical aerosols • Procedures for reprocessing

bronchoscopes and reused

respiratory therapy equipment

• Training and education of reprocessing

staff and respiratory therapists

• Procedures for use of aerosolized

medicationsReducing contamination

of ventilator circuit • Heat-and-moisture exchanger

• Periodically drain condensate from

circuit

• Sterile water for bubble-through

humidifiers• Aseptic procedures for suctioning of

ventilated patients

VAPpreven4on

Source of VAP

Pathogen Prevention Goal Specific MeasuresContaminated tap

( Legionella

species,

Pseudomonas

aeruginosa)

Safe water • 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

HyperchlorinationSilver-copper ionization

Ozonation

VAPpreven4on

Source of VAP

Pathogen Prevention Goal Specific MeasuresContaminated

ambient air

(filamentous fungi,

Mycobacterium

tuberculosis,SARS

coronavirus)

Safe air • 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 managementduring periods of construction and renovation

Endotracheal intubaKon in a young hemodynamically stable

Endotracheal intubaKon in a young, hemodynamically stable

paKent with 3% third-degree burns and sepsis would best be

accomplishedwiththefollowingIVdrugcombinaKon.

A. Propofolandsuccinylcholine

B. etamineandrocuronium

C. EtomidateandsuccinylcholineD. Etomidateandrocuronium

NondepolarizedNMBA

• CompeKKveantagonistsandinhibitAChbindingtopostsynapKc

nAChRs• Benzylisoquinolinium

• mivacurium,atracurium,cisatracurium,anddoxacurium

• Aminosteroid

• vecuronium,rocuronium,pancuronium,andpipecuronium.

RecommendedindicaKons

1. COPDexacerbaKons

2. Acutecardiogenicpulmonaryedema

FacilitaKngextubaKoninCOPDPaKents4. ImmunocompromisedPaKents

FactorsassociatedNIVsuccess Synchronous breathing with venKlator

SynchronousbreathingwithvenKlatorDentateLessairleakingFewersecreKonsGoodtoleranceRespiratoryrate<3/min*LowerAPACHEIIscore(<29)*pH>7.3*Glasgowcomascore15*PaO2/FiO2>146aerfirsthourifhypoxemicrespiratoryfailureCOPD,CPENopneumonia,ARDSBestpredictorofsuccessisagoodresponsetoNPPVwithin1to2h:ReducKoninrespiratoryrate

ImprovementinpH

ImprovementinoxygenaKon

ReducKoninPaCO2

A 5-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 beperformed to confirm the diagnosis and to ameliorate the

c o n d i K o n ?

A. Performaninspiratorypause,increaseinspiratorypressure

B. Performanexpiratorypause,

increaseinspiratorypressure

C. Performaninspiratorypause,

reducethesetrate

D. Performanexpiratorypause,

reducethesetrate

AutoPEEP

MeasurementofautoPEEP

In addiKon to hand hygiene, strict adherence to asepKc

yg , ptechnique with maximal sterile barrier precauKons, skinanKsepKcwithCHX,preferenKaluseofsubclavianinserKon,and

prompt removal of unnecessary catheters, which of thefollowing pracKces is associated with a reduced incidence ofC R B S I i n I C U ?

A. Heparin-coatedcatheterscomparedwithuncoatedcathetersB. Transparent occlusive dressings compared with gauze

C. Dressing with CHX-impregnated sponge compared with noa n K s e p K c

D. Changingtransparentdressingsevery3dayscomparedwithe v e r y 7 d a y s

Preven4onCVCrelatedinfec4on

1. Set&usecathetercareprotocols

• EducaKonalprogramswithhygienetraining

• CatheterinserKon:prepare,skinanKsepKc,inserKontechnique

• CathetermanipulaKon:handhygiene,manipulaKonoftaps

• Cathetercare:catheterreplacementmodaliKes,type&frequencyof

dressing

• EvaluaKonincidenceofCRBSIandfeedback

2. StaffeducaKonal/Qualityimprovementprogram

3. Typeofcatheter

• Polyurethanecatheter

• CatheterscoatedwithaniKmicrobial/anKsepKc(CHX/

silversulfadiazine,minocycline/rifampicin)

• CVCswithmulKlumen→noincreaseriskofCRBSI

Preven4onCVCrelatedinfec4on

11. Venouslinemaintenance

• ChangeIVsetq3days• Bloodproduct,lipidemulsion(parenteral+propofol)changeq1dayor

immediatelybefinished

• HandhygienebeforecathetermanipulaKon

• HabsandsamplingportscleaningwithCHXbasedanKsepKcbefore

access

• Nochangecatheterfollowingbyscheduled

• Changecatheterviaguidewire→↑CRBSI

• AnKbioKcoranKsepKcointments→↑ riskof fungalcolonizaKon

• ProphylacKcheparing↓ thrombosisg↓ nidus formaKong↓ colonizaKon

A56-year-oldalcoholicmanwithARDSfrommassiveaspiraKoni i i MV H i f d i h € V 12 l/

is requiringMV.He is transferredto you with se€ngVT12ml/kg,RR2/min,PEEP1cmH2O,FiO2.5andPplat36cmH2O.His

PaO293mmHg,PaCO239mmHgandpH7.41.YoureducehisVTto6ml/kgandincreaseRRto3/min.withthesechanges,hisPplat falls to 23 cmH2O, PaO2 65 mmHg, PaCO2 56 mmHg andp 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 se€ng alone

D. R e m a i n o n c u r r e n t s e € n g s

A68yearoldmanisadmi0edwithsepKcshockandARDSduetoCAP H i d d d l d MV i h RR 34/ i H

severeCAP.HeissedatedandplacedonMVwithsetRR34/min.Heappearscomfortableandpassive.OnVT6ml/IBW,Pplat29cmH2O

andPaCO243mmHg.WithFiO2.7andPEEP12cmH2O,SaO288%.AppropriatedanKbioKchavebeeniniKated.Aer12handfollowing4LfluidresuscitaKon,MAP58mmHgonNE8µg/min,HR112/min.Urineoutput2mlsinceICUadmission.Youareconsideringgivingfluid bolus. Which of the following measures will most accurately

predict whether a fluid bolus will increase perfusion?

A. TherespiratoryvariaKoninPPaerVTisincreasedto1ml/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. TheCVPreferencedtothephlebostaKcaxiswithsupineposiKonD. T h e S c V O 2 m e a s u r e d f r o m a C V C

Pulsepressurevariation

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

Definedasresponder

• Threshold>13%• SensiKvity94%

• Specificity96%

MorereliablethanSPV

MICHARDFandetal.AJRCCM2000;162:13–8.

Passivelegraisingtest(PLR)

• Selfvolumechallenge3ml

• MeasuresaorKcbloodfloworpulsepressure

• 3-9sec• AorKcbloodflow> 1%(sensiKvity97%,specificity94%)

• Pulsepressureincreased>12%(sensiKvity6%,specificity85%)

MonnetXandetal.CritCareMed26

A5yearoldpaKentwithsevereARDSfromsepsisissupportedby

y p p pp yassistcontrolvenKlaKon.HeisrequiringanFiO2of.8andaPEEPof12cmH2OtoproduceaPaO257mmHg.Youelecttotrytoimprove

gas exchange and lower the FiO2 exposure by using a RM of 4cmH2Ofor4sec.Atendofmaneuver,thePaO2hasrisento16mmHg.

TheduraKonifthisimprovementdependsmostimportantlyon:

A. WhetheraddiKonalPEEPisadded

B. Performingrepeated4cmH2ORMsevery1-2h

C. Performingrepeated4cmH2ORMsevery3-6h

D. ImmediatelyrepeaKngtheRMwith5cmH2OandrepeaKngRMseveryhouriftheSpO2falls

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