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Critical Care Medicine

2/19/14. Critical Care Medicine. Medicine In-Service Topics . General: Honk Fluids in ARDS ARDS – vent settings, manage vent, gas exchange. (6) TRALI Hemoptysis – positioning Pulmonary shunt as cause of hypoxemia – causes of hypoxemia HIT Cause of Resp failure PE with shock

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Critical Care Medicine

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  1. 2/19/14 Critical Care Medicine

  2. Medicine In-Service Topics General: Honk Fluids in ARDS ARDS – vent settings, manage vent, gas exchange. (6) TRALI Hemoptysis – positioning Pulmonary shunt as cause of hypoxemia – causes of hypoxemia HIT Cause of Resp failure PE with shock Ventilator: Treat hypercapneicresp failure, vent settings (2) Complications of vent Indications for NIPPV (2) Intrinsic PEEP management (3) Hypoxemia management CHF on vent Pain on vent

  3. The happy smoker 66 yo WM chronic pain, smoker, CHF, brought to ED with SOB. Recent URI, thin, scattered wheezes and crackles on exam. 7.26/55/75 BNP 1200 HCT 30 Platelet 220,000 What do you do?

  4. Admit to MICU • Bipap? • Nebs, Steroids, Antiobiotics • Lasix? • DVT prophylaxis • GI prophylaxis – NO!

  5. MICU • Why non-invasive positive pressure ventilation (NIPPV)? • What are indications for NIPPV? Diuresed 3 Liters Creatinine 1.2 BP 100/60, HR 70 7.16/70/70 HCT 25 • Obstructive lung disease • Asthma, COPD, etc • Acute congestive heart failure • OHS • Immunocompromised with infiltrates Now what?

  6. MICU • Intubate – Dr. Garriga goosed 3 times. • Dr. Steele pushed him aside. • Grade I view, chip shot. Vent Settings: Volume control Vt 500cc Rate 15 FiO2 100% PEEP 5 BP 85/40 HR 120 RR 25 7.24/60/60 Now what?

  7. MICU • Create a problem list, ddx and gather information 1. Respiratory acidosis – on vent in COPD? 2. Tachypnea on vent – pain, dyspnea? 3. Hypotension – shock, hypovolemia, intrinsic PEEP? Gather information and treat Look at vent settings Empirically treat pain IVF for hypotension

  8. Ventilator Management

  9. PEAK Pressure PLATEAU Time Volume Control: Peak and Plateau Pressure • Peak: Distention pressure in lungs as tidal volume is being delivered (flow-related pressure) • Plateau: Distention pressure in lungs after volume delivered before expiration (static pressure)

  10. Ventilator Management – obstructive lung disease Treatment plan for obstructive lung disease: High intrinsic PEEP? Unhook ventilator? Slow respiratory rate? IVF for hypotension related to poor filling pressures in setting of high intra-thoracic pressure?

  11. Pain Management in ICU 45% with no provider perceived reason for pain actually have pain • Pain, Agitation, Delirium Bundle • 1. Pain control – fentanyl, morphine, oral • 2. Agitation – propofol, dexmedetomidine, intermittent benzodiazepines Payen, JF. DOLOREA Investigators. Anesthesiology 2007; 106:687–95 Chanques,G. Anesthesiology. 2007;107:858–860 CritCare Med. 2013 Jan;41(1):263-306

  12. MICU • You get through the night…. Then am labs: 7.35/48/85 HCT 25, Platelet 85 Creatinine 1.5mg/dL

  13. MICU • Thrombocytopenia in the ICU • DDX? • Decreased Production: • Primary Marrow failure • Secondary Marrow failure • Malnutrition, sepsis, PCN, Ceph,vanc, H2 blockers, chemotherapy • Increased Destruction: • TTP, DIC, Liver/Spleen • Drugs • Intravascular devices • Immune: • Drugs induce immune destruction – vancomycin • HIT (4T’s, Serotonin Release assay, anti-PF4 ab) Gets through the night stable, but agitated. AM labs: 7.36/45/80 HCT 18 PLT 75 Chest. 2011;139(2):271-278. Crit Care Clinics 2012;28(3):399-41

  14. MICU • Give 2 uts PRBC’s – why 2? • Start PPI – you forgot to put him on GI prophylaxis  PRBC infusion finishes. More tachypneic, more agitated, T 102.1, Sp02 84% DDX: Pulmonary edema s/p PRBC infusion – systolic CHF exacerbation TRALI VAP ARDS JAMA. 2002 Sep 25;288(12):1499-507

  15. Elevated Peak/Plateau Pressures Decreased Compliance of Whole System Pressure Time Alveolar Filling ARDS Pulmonary Edema Pneumonia Right Mainstem Intubation Pneumothorax

  16. Abnormal A-a gradient HypoxemiaA-a gradient =(PA02-Pa02)[150 – 1.25(PaCO2)] – pa02Normal ≤ Age/4 + 4 a A 1. Shunt - Alveolar filling (blood, pus, water) - Difficult to correct with supplemental O2 2. V/Q Mismatch - PE, COPD 3. Diffusion limitation (rare, low yield) -Elite Exercise Normal A-a gradient 1. Hypoventilation - Opiates, drugs, CVA, OHS 2. Low fi02 (high altitude) PAO2 = [(Patm – PH2O) x FiO2] – [PaCO2/RQ]

  17. MICU • Treatment Plan: • TRALI • Timing, supporting, low WBC • CHF • Vent – diuresis • VAP • Antibiotics – which ones? How long? • ARDS vent management • FACTT (Fluids and Catheters Treatment Trial) – match I/O’s vs liberal ~7L +

  18. ARDS • Definition • Acute • Bilateral infiltrates • Pa02/Fi02 <200** • PCWP <18mmHg – or no clinical reason for elevated LVEDP DDX - congestive heart failure, pneumonia, organizing pneumonia, eosinophilic pneumonia, high altitude, sickle cell disease, vasculitis, TRALI, etc…. **Berlin Definition of ARDS – 2012 – unsure if will be on boards mild P/F <300 (25% mortality), moderate P/F <200 (32% mortality), severe P/F <100 (45% mortality) JAMA 2012 Jun 20;307(23):2526-33

  19. Pa02/Fi02 < 200 (or 300)

  20. Causes of ARDS/ALI • Pneumonia • Sepsis – any source ***Especially alcoholics • Aspiration • Transfusion (TRALI) – Fresh frozen plasma is most common • Pulmonary embolus 6. Pancreatitis 7. Trauma – Especially Thoracic Anything that can cause systemic or pulmonary inflammation!

  21. ARDSnet • Low Vt (tidal volume) ventilation – 6cc/kg • Plateau Pressure >30cm H20 • pH >7.3 – permissive hypercapnea • Higher PEEP, lower Fi02 • Pa02 >55 mmHg • Minimize fluids beyond normal losses (conservative strategy) This strategy decreases mortality from 39% to 31% (P<.007). Salvage ventilatory modes – none improve mortality. Extracorporeal Membrane Oxygenation – CESAR Trial High Frequency Oscillatory Ventilation – 300 breaths per minute Nitric Oxide – inhaled to dilate vessels through ventilated alveoli Prone ventilation – put patient on stomach, recruits lung bases New England Journal of Medicine 2000; 342:1301-08

  22. ARDSnet

  23. ARDSnet

  24. ARDSnet Do not memorize this chart!!! Know to implement its high PEEP/low Fi02 strategy.

  25. ARDSnet

  26. ARDSnet

  27. The end • He was extubated on day 12. • Called the house team at 0829. • The patient stays in ICU for 6 days waiting on a bed.

  28. Medicine In-Service Topics General: Honk Fluids in ARDS ARDS – vent settings, manage vent, gas exchange. (6) TRALI Hemoptysis – positioning Pulmonary shunt as cause of hypoxemia – causes of hypoxemia HIT Cause of Resp failure PE with shock Ventilator: Treat hypercapneicresp failure, vent settings (2) Complications of vent Indications for NIPPV (2) Intrinsic PEEP management (3) Hypoxemia management CHF on vent Pain on vent

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