Approach to Critically Ill Patient with Acute Respiratory Failure Ognjen Gajic M.D. Professor of Medicine Attending Intensivist Mayo Clinic Rochester MN, USA Multidisciplinary Epidemiology and Translational Research in Intensive Care and Perioperative Medicine (METRIC - PM) @ [email protected]
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Approach to Critically Ill Patient with Acute Respiratory ... · Approach to Critically Ill Patient with Acute Respiratory Failure Ognjen Gajic M.D. Professor of Medicine Attending
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Approach to Critically Ill Patient with Acute Respiratory Failure
Ognjen Gajic M.D.
Professor of Medicine
Attending Intensivist
Mayo Clinic
Rochester MN, USA
Multidisciplinary Epidemiology and Translational Research in
Intensive Care and Perioperative Medicine (METRIC - PM)
Whalen FX, Gajic O, Thompson GB, Kendrick ML, Que FL, Williams BA, Joyner MJ, Hubmayr RD, Warner DO, Sprung J. The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. AnesthAnalg. 2006 Jan;102(1):298-305
The effect of recruitment maneuver
Brower RG, Morris A, MacIntyre N, et al.. Crit Care Med 2003;31:2592-2597.
PEEP selected during deflation to prevent both overdistension and derecruitment
(according to compliance, stress index, esophageal balloon?)
• Recruitability: Response to RM/decremental PEEP trial
• Step 3 customized management:
• Bronchoscopy for lobar atelectasis
• Inhaled vasodilators (iNO) for pulmonary hypertension
• Shock treatment based on type of shock
• Prone position or HFO for recruitable lungs without shock
• Consideration of PFO closure for intracardiac shunt
• ECMO for refractory cardiopulmonary dysfunction
Resuscitation Aphorisms
• Trust no one, assume nothing
• “Golden hour”
• When in doubt, treat as sepsis.
• Get as many lines and tubes in as fast as possible.
• Anyone with a heart rate consistently over 130 is being grossly mismanaged.
• If they have ischemic heart disease, the number is 110
• Laboratory tests are rarely useful• Most negative tests are false negatives
• Most positive tests are false positives
Day to day management in the ICU
• Get as many lines and tubes out as fast as possible.
• Listen to the nurses religiously: they are the citizens; you are the visitor
• Sit the patient up, dammit!
• Even if God herself says that small tidal volumes are good, everyone will still be ventilated at 10ml/kg. The knobs adjust themselves!
• Any ritually administered drug (be it dopamine, digoxin or whatever) will cause more harm than good. In fact, avoid all drugs that begin with the letter "D“
• Above all else, keep your patient out of the hands of someone who doesn't obey these rules
“And actually it does not matter what is the source of the patient’s
gasping. You simply have to bring his breathing back in order”
Ultrasound: hyperdynamic LV/RV, collapsing IVC; B lines
RUL, no effusion
Temperature : 38.4 C
Lung Injury Prediction Score (LIPS)
Shock (2) + Pneumonia (1.5) +
Sepsis (1) +Tachypnea (1.5) +
Acidosis (1.5) = 7.5
CLIP Element Clinically Supported Practices
Adequate empiric antimicrobial treatment and source control
According to suspected site of infection, health care exposure, and immune suppression
Lung protective mechanical ventilation Tidal volume <6-8 mL/kg predicted body weight and plateau pressure <25 cm H2O; PEEP≥5 cm H2O, minimize FIO2 (target O2sat 88-92% after early shock)
Aspiration precautions Rapid sequence intubation supervised by experienced providers, elevated head of the bed, oral care with chlorhexidine, gastric acid neutralization
Fluid management:
- Early fluid administration in septic shock
-Limiting fluid overload after resuscitation
- Resuscitation according to institutional protocol and IHI sepsis bundle
- Modified ARDSnet FACCT protocol after early shock
Restrictive transfusion Hemoglobin target >7 g/dL in the absence of active bleeding and/or ischemia; avoid FFP and platelet transfusion in the absence of active bleeding
Appropriate handoff of patients at risk Structured handoff such as SBAR
Checklist for Lung Injury Prevention: CLIP
Rapid sequence intubation
Lung protective ventilation
Goal directed fluid resuscitation
Blood and sputum culture
Cefepime 2 gr IV
Levofloxacine 750 mg IV
Hydrocortisone 50 mg IV
Furosemide
Spontaneous awakening and breathing trial
Short monitoring after extubation
De-escalation to oral antibiotics, steroid taper and transfer
50 year old with shortness of breath and tachycardia
• Chief Complaint:• 50 year old with two days history
of cough, hemoptysis, worsening shortness of breath and markedly elevated heart rate
• Past History:• Hepatitis C
• Previous substance abuse on Methadone
• Seizure disorder
• Paroxysmal A fib, s/p ablation, on chronic Coumadin
Anxious, Increased work of breathing with accessory
Ultrasound: hyperdynamic LV/RV, collapsing IVC; B lines
RUL, no effusion
Temperature : 38.4 C
Lung Injury Prediction Score (LIPS)
Shock (2) + Pneumonia (1.5) +
Sepsis (1) +Tachypnea (1.5) +
Acidosis (1.5) = 7.5
CLIP Element Clinically Supported Practices
Adequate empiric antimicrobial treatment and source control
According to suspected site of infection, health care exposure, and immune suppression
Lung protective mechanical ventilation Tidal volume <6-8 mL/kg predicted body weight and plateau pressure <25 cm H2O; PEEP≥5 cm H2O, minimize FIO2 (target O2sat 88-92% after early shock)
Aspiration precautions Rapid sequence intubation supervised by experienced providers, elevated head of the bed, oral care with chlorhexidine, gastric acid neutralization
Fluid management:
- Early fluid administration in septic shock
-Limiting fluid overload after resuscitation
- Resuscitation according to institutional protocol and IHI sepsis bundle
- Modified ARDSnet FACCT protocol after early shock
Restrictive transfusion Hemoglobin target >7 g/dL in the absence of active bleeding and/or ischemia; avoid FFP and platelet transfusion in the absence of active bleeding
Appropriate handoff of patients at risk Structured handoff such as SBAR
Checklist for Lung Injury Prevention: CLIP
Rapid sequence intubation
Lung protective ventilation
Goal directed fluid resuscitation
Blood and sputum culture
Cefepime 2 gr IV
Levofloxacine 750 mg IV
Hydrocortisone 50 mg IV
Furosemide
Spontaneous awakening and breathing trial
Short monitoring after extubation
De-escalation to oral antibiotics, steroid taper and transfer