A case of complicated “cold”

1. A case of complicated “cold”

2. Warning signs

3. Recognizing the sick patient • The most commonly disturbed variables prior to cardiac arrest are signs of respiratory distress and alterations in mental state. • Deterioration in respiratory function is the best warning sign prior to ICU admission from the general wards.

4. Recognizing the sick patient • One can rely on four criteria to identify ‘at risk’ patients: • the patient complains of feeling ‘not right’ • the patient’s colour has changed • the patient is agitated • there is marginal deterioration in nursing observations

5. Role of ABG • Any sick patient should have arterial blood gases measured as a routine. This simple test provides information about both gas exchange and the metabolic state of the patient • Always obtain an arterial blood gas sample on admission if oxygen saturation is less than 92%.

6. Base excess • A base excess of less than –4 mmol/l on admission to the ICU is associated with an in-hospital mortality of 57%, which increases to 70% if it has not corrected to less than –2 mmol/l within the next 24 hours • The base excess has been shown to be superior to pH in the evaluation of metabolic acidosis and in the prediction of subsequent complications, but its importance appears to be less clearly appreciated by many junior doctors.

7. NIV • Contraindicated in facial trauma and burns, • Fixed upper-airway obstruction • Haemodynamic instability, • Limitations in the presence of copious respiratory secretions • Altered consciousness • Agitation • Undrainedpneumothorax • Bowel obstruction

8. Severe sepsis Rx - Goals • Central venous pressure: 8-12 mm Hg (In mechanically ventilated patients, a higher target central venous pressure of 12–15 mm Hg is recommended to account for the increased intrathoracic pressure.) • Mean arterial pressure more than 65 mm Hg • Urine output more than 0.5 ml per kg per hour • Central venous or mixed venous oxygen saturation more than 70%.

9. Role of central line • Establishing vascular access and initiating aggressive fluid resuscitation is the first priority when managing patients with severe sepsis or septic shock.

10. Vasopressor choice SSCG • Either norepinephrine or dopamine (through a central catheter as soon as available) is the first-choice vasopressor agent to correct hypotension in septic shock.

11. Comparison of Dopamine and Norepinephrinein the Treatment of Shock (NEJM March 4, 2010) • Although there was no significant difference in the rate of death between patients with shock who were treated with dopamine as the first-line vasopressor agent and those who were treated with norepinephrine, the use of dopamine was associated with a greater number of adverse events (specifically more arrhythmias)

12. Timing of A line SSCG • All patients requiring vasopressors should have an arterial catheter placed as soon as practical if resources are available

13. CAP in ICU Tests • BCx • Sputum Cx • Legionella UTA • Pneumococcal UAT • ET aspirate if intubated, bronchoscopic or nonbronchoscopic BAL • ? HIV

14. Timing of 1st dose of ABX • Intravenous antibiotic therapy should be started within the first hour of recognition of severe sepsis, after appropriate cultures have been obtained • Within 6 hours – for CAP

15. Linezolid+Zosyn+Azithromycin+Tamiflu • CAP – Ceftriaxone + Azithromycin • Post influenzea – Peumococcus and Staph. aureus including MRSA – Vancomycin/Linezolid • Severe PNA – must cover for MRSA – Vanco but Linezolid preferred due to better tissue penetration • Hemorrhagic PNA – Staph. aureus, HSV • H1N1 – Tamiflu • Neutropenia - Zosyn

16. MRSA RF • Prior MRSA carriage • Severe CAP • Postinfluenzae PNA • Presence of HCAP

17. PRBC in the first 6 hours • During the first 6 hrs of resuscitation of severe sepsis or septic shock, if central venous oxygen saturation or mixed venous oxygen saturation of 70% is not achieved with fluid resuscitation to a central venous pressure of 8–12 mm Hg, then transfuse packed red blood cells to achieve a hematocrit of 30% and/or administer a dobutamine infusion (up to a maximum of 20 g·kg1·min1) to achieve this goal

18. PRBC in ICU • Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as significant coronary artery disease, acute hemorrhage, or lactic acidosis (see recommendations for initial resuscitation), red blood cell transfusion should occur only when hemoglobin decreases to 7.0 g/dL (70 g/L) to target a hemoglobin of 7.0–9.0 g/dL

19. Thresholds for platelets transfusion - SSCG • In patients with severe sepsis, platelets should be administered when counts are <5000/mm3 regardless of apparent bleeding. • Platelet transfusion may be considered when counts are 5000–30,000/mm3 and there is a significant risk of bleeding. • Higher platelet counts (50,000/mm3) are typically required for surgery or invasive procedures.

20. Enteralnutrition: Indications ESPEN Guidelines on Enteral Nutrition: Intensive care 2006 • EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days • It should have begun during the first 24 h using a standard high-protein formula

21. Parenteral nutrition: indications • Patients should be fed because starvation or underfeeding in ICU patients is associated with increased morbidity and mortality • All patients who are not expected to be on normal nutrition within 3 days should receive PN within 24 to 48 h if EN is contraindicated or if they cannot tolerate EN.

22. SupplementaryPN with EN • All patients receiving less than their targeted enteral feeding after 2 days should be considered for supplementary PN

23. TPN • (a) TPN should be initiated through a new catheter inserted via a clean stick, not a catheter changed over a wire • (b) TPN catheters should be inserted via subclavian (preferably) or internal jugular veins, not via femoral veins • (c) TPN should have its own dedicated lumen used for nothing else • (d) a team dedicated to TPN central-line care should be assembled

24. Refeeding syndrome • To avoid refeeding syndrome requires a slow start to feeding, as low as 5–10 kcal/kg/day in the most severely malnourished, and very careful monitoring and correction of electrolyte imbalance (K, Mg, Phos)

25. Glucose control

26. Glycemic Control in the ICU NEJM Dec 23, 2010 • “In consideration of these moderate target levels, we recommend that nutritional support be introduced gradually, preferably by the enteral route, and that infusion of substantial quantities of intravenous dextrose be avoided”

27. Sodium bicarbonate SSCG • Bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor requirements is not ecommended for treatment of hypoperfusion induced lactic acidemia with pH >7.15

28. Dalteparin versus Unfractionated Heparin in Critically Ill Patients NEJM April 7, 2010 • “Although no trials have directly compared the use of unfractionated heparin in twice-daily and thrice-daily regimens, an indirect comparison suggests an increased rate of major bleeding with the thricedaily regimen. • In a recent meta-analysis of studies in which twice-daily unfractionated heparin, thrice-daily unfractionated heparin, and low-molecular-weight heparin were compared with one another or with an inactive control, both twice-daily and thrice-daily regimens of unfractionated heparin had similar effects on the rates of deep-vein thrombosis, pulmonary embolism, major bleeding, and death”

29. A comparison of early versus late initiation of renal replacementtherapy in critically ill patients with acute kidney injury: asystematic review and meta-analysis Crit Care. 2011 Feb 25 • Earlier institution of RRT in critically ill patients with AKI may have a beneficial impact on survival. • Early, compared with late therapy, was associated with a significant improvement in 28-day mortality (odds ratio (OR) 0.45; 95% confidence interval (CI), 0.28 to 0.72).

30. Call renal early • However, this conclusion is based on heterogeneous studies of variable quality and only two randomized trials. In the absence of new evidence from suitably-designed randomized trials, a definitive treatment recommendation cannot be made

31. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome - Intensive Care Med (2007) • If you don’t check a temperature, you can’t find a fever • If you don’t check a bladder pressure you can’t find ACS