How should I be thinking? (a suggested way of doing it)

1. How should I be thinking? (a suggested way of doing it) Dr. Ed Martinez (Intensivist wanna be)

2. Our patients • In ICU almost all of our patients are very sick • Very old • Multiple co morbidities • Multiple injuries • Susceptible to multiple complications • Haven’t looked after themselves

4. The CICM says that: • “Intensive care specialists require an extensive knowledge of medical and surgical conditions and mastery of practical skills. The intensive care specialist anticipates clinical problems, is able to assess and define clinical problems in the critically ill in the broader context and can develop and facilitate a diagnostic and management plan, which has the highest probability of a satisfactory outcome.” • Objectives of advanced training and competencies. College of intensive care medicine of Australia and New Zealand.

5. The Approach to Acute Illness • Immediate assessment and therapy (resuscitation) • Prioritize: • who to admit and not admit • Resuscitate vs. Diagnose • Obtain relevant information • Recognize and respond rapidly to adverse events

6. The Approach to Acute Illness • Assessment • Obtain and record relevant info from patient, relatives, others • Recognise and diagnose system failure or diseases • Order appropriate investigations

7. Approach to Acute Illness • Problem Definition • Create a list of DDx. • You might need to confirm or refute some of these before your data gathering is complete • Deal with ambiguity • Make contingency plans

8. Approach to Acute Illness • Make a Plan • Choose the best course of action considering risk vs. Benefit • ICU requires multidisciplinary input and decide who else needs to be involved • Plan counter measures • Define the circumstances where supportive therapy should be limited or discontinued

9. Approach to Acute Illness • Progress • Use clinical and physiological markers to assess severity and likely outcome • Know that sudden gross changes in certain parameters are life threatening • Develop criteria for discharge

10. So, what do we need?...

13. A Structured Approach • Make a List of DDx • Look for clues • Confirm your suspicions • Make a plan • Immediate: resuscitate • Short term: therapy, who else needs to be involved • Long term: where is this patient going to go after ICU

14. So now... • Common problems in ICU • How to tackle them when we first encounter them

15. The Shocked Patient

16. The Shocked Patient • Shock: • Clinical state that occurs when an imbalance of oxygen supply and demand results in the development of tissue hypoxia

17. The Shocked Patient • Physiologically • Hypoxic • Anaemic • Stagnant • histotoxic • Clinically • Cardiogenic -Septic • Obstructive -Neurogenic • Hypovolaemic -Anaphylactic

18. The Shocked Patient • Common scenarios in ICU • Sepsis: as a primary cause of admission or as a consequence of nosocomial infections • Trauma with ongoing blood loss • Cardiogenic shock in association with APO

19. The Shocked Patient • Look for clues • Are they bleeding? • What is their MAP and pulse pressure? • HR and rhythm: SR vs. AF? • CVP: high or low? • Sats: is there an adequate trace? • What is their U/O?

20. The Shocked Patient • Look for clues • Hypovolaemic shock • Fluid balance • Actively bleeding? • Check for haemothorax and distended abdomen • Any other major fluid losses (eg. Intra-abdo in pancreatitis)

21. The Shocked Patient • Look for clues • Obstructive shock • Tension pneumothorax? ICCs blocked? • Cardiac tamponade • PE? Signs of DVTs?

22. The Shocked Patient • Look for clues • Distributive Shock • Septic? • Febrile, warm, vasodilated? • Meningococcal rash, neck stiffness? • Neurological shock due to spinal injury? • Anaphylaxis or Addisonian crisis?

23. The Shocked Patient • Look for clues • Cardiogenic shock • HR • Rhythm • Preload • Pump function • After load

24. The Shocked Patient • Confirm your diagnosis • CXR • ECG • Echo • ABGs and lactate • FBCs, EUCs • Troponin

29. The Shocked Patient • Make a plan • Immediate • Resuscitate with IVF. How much? Which type? • Inotropes, vasopressors or both? • Transfuse. RPC, FFP, Platelets? • Steroids? • Do we need to plumb this patient? When is a good time to that?

30. The Shocked Patient • Make a plan • Short term • OT to control bleeding, source control? • Involve Anes. and Sx. • ATBs? Which ones? • Involve ID • Ongoing transfusion due to coagulopathy? • Involve Haematology • Do they need to go to angio suite? • Involve the cardiologist.

31. The Shocked Patient • Evidence for what we do • Surviving Sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004: 32: 858-873 • Recommendations with the intention of improving outcome, some of the conclusions are still being debated

32. The Shocked Patient • Evidence for what we do • A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Eng J Med 2004; 350: 2247-2256 • Multicenter RCT w/ 6997 pts. No difference in 28-day mortality, no difference in how they did overall. Subgroup analysis did show a trend to reduced mortality w/albumin in septic shock and increased mortality in trauma patients, especially those w/ TBI. • So, lets try and use crystalloids because it’s cheaper.

33. The Shocked Patient • Evidence • Early revascularization in acute myocardial infarction complicated by cardiogenic shock. N Eng J Med 1999; 341:625-634 • Cardiogenic shock complicates 10% of AMI and is associated with 80% mortality. • RCT w/302 pts. Who underwent revascularization (PCI or CABG) or medical management; 80% in both groups got IABPs • No difference in 30 day mortality but at 6mo. Pts. Who got revasc. Had a survival advantage

34. The Shocked Patient • Evidence • Vasopressor use in septic shock: an update. Current Opinion in Anaesthesiology. 2008; 21: 141-7 • Catecholamines for shock: the quest for high-quality evidence. Crit Care Resusc. 2007 Dec; 9(4): 352-6 • Both says there’s no clear evidence of which is better or worse

35. The Anuric Patient

36. The Anuric Patient • Acute renal failure: • rapid decrease in the kidney’s ability to eliminate waste products. • Clinical classification: • Prerenal • Parenchymal • Postrenal

37. The Anuric Patient

38. The Anuric Patient • Common scenarios in ICU • ARF related to • Shock • MOF • Rhabdomyolysis • Hepatorenal failure • Nephrotoxic drugs or contrast agents • Ruptured AAA

39. The Anuric Patient • Look for clues from the history • Is this acute, acute on chronic or chronic ? • Is there a pre-renal cause? • Is there raised intra-abdo pressure? • Is there a renal cause? Have nephrotoxins or contrasts been given? Is there a vasculitis? • Is there a post-renal cause? Is the IDC blocked? Has the patient had pelvic Sx?

40. The Anuric Patient • Look for clues from the examination • Compartment syndromes: tense limbs, buttocks, abdo • Abdo scar from major vascular or abdo surgery • Signs of chronic liver disease • Signs suggesting diabetes: scarred fingertips, abdo fat atrophy or hypertrophy from insulin injections

41. The Anuric Patient • Confirm your suspicions • EUC, CMP, LFTs • Urine dipstick and microscopy: leukocytes and nitrites as indices of infection, blood reflecting urinary tract trauma, haemoglobin or myoglobinuria • Check serum and urinary electrolytes: help differentiate pre-renal from renal causes • ABGs: look for metabolic and electrolyte derrangements

42. The Anuric Patient

43. The Anuric Patient

44. The Anuric Patient • Make a Plan • To treat ARF we need to: • 1) reverse its cause • 2) maintain homeostasis while recovery occurs • Immediate: • do we need to resuscitate this patient? • Are they hyperkalaemic to the point they could die?

45. The Anuric Patient • Make a plan • Short term: • Nutritional support • Metabolic acidosis • Anaemia • Adjust drug doses • Lasix if they still making urine to avoid fluid overload • Vascath and CRRT

46. The Anuric Patient • Make a plan • Short term: • Indications for CRRT • Oliguria: U/O<200ml/12hrs • Anuria: U/O 0-50ml/12hrs • Ur.>35mmol/L • Cr.>400mmol/L • K+>6.5mmol/L or rapidly rising • APO unresponsive to diuretics

47. The Anuric Patient • Make a plan • Short term: • Indications for CRRT • Uncompensated met. Acidosis pH<7.1 • Na+ <110mmol/L or >160mmol/L • Temp. >40 • Uraemic complications: encephalopathy, myopathy, neuropathy, pericarditis • Overdose w/dialysable toxin: eg. Lithium

48. The Anuric Patient • Make a plan • Long term • Involve the renal or urology team • Will this patient need dialysis long term? • Will they need a fistula?

49. The Anuric Patient • Evidence for what we do • Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ. 2006 Aug 26: 333 (7565): 420 • Meta-analysis of 9 RCT totalling 849 pts. to investigate the potential beneficial and adverse effects of frusemide to prevent and treat acute renal failure in adults • Found that frusemide is not associated with any significant clinical benefits in the prevention or treatment of adults, but, high doses can cause ototoxicity

50. The Anuric Patient • Evidence • CVVHDF vs. IHD for acute renal failure in patients with multiple organ dysfunction: a multicenter randomized trial. Lancet 2006; 368: 379-385 • Prospective randomized study w/360 pts. w/ARF due to MODS. • No difference in 60 day mortality with same efficacy, no difference in duration of renal support • No more hypotension with IHD, CVVHDF caused more hypothermia