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ICU 101

ICU 101. a.k.a. “Papers You Should Know” Ashley Henderson, MD May 4, 2010. New England Journal of Medicine 2001;345:1368-77. Early Recognition. IF: suspected infection + SIRS criteria Temp > 38C or < 36C HR > 90 RR > 20 or PaCO2 < 32 WBC > 12, < 4, or > 10% bands

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ICU 101

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  1. ICU 101 a.k.a. “Papers You Should Know” Ashley Henderson, MD May 4, 2010

  2. New England Journal of Medicine 2001;345:1368-77

  3. Early Recognition • IF: suspected infection + SIRS criteria • Temp >38C or <36C • HR >90 • RR >20 or PaCO2 <32 • WBC>12, <4, or >10% bands • THEN: check lactate and obtain cultures • IF: lactate >4mMol or SBP <90 with 20ml/kg NS bolus and not cardiogenic • THEN: Patient meets criteria for septic shock

  4. Early Goal Directed Therapy Protocol (Achieve within 6 hours) ATTENTION New England Journal of Medicine 2001;345:1368-77

  5. Why EGDT? • Reduced in-hospital mortality • (30.5 vs. 46.5%) • Reduced 28d and 60d mortality • (33.3 vs. 49.4%; 44.3 vs. 56.9%)

  6. Mechanical Ventilation • Improves gas exchange; decreases work of breathing • Uncomfortable, not risk-free • PTX • Pneumonia and other infections • Increased intrathoracic pressure/cardiovascular compromise • Increased mortality if prolonged

  7. Mortality Prediction with PMV • Prolonged mechanical ventilation (PMV)=21 d • 4 predictive variables: • Age >50 • Thrombocytopenia (<150) • Use of pressors • HD Crit Care Med 2008 Vol. 36, No. 7

  8. Mortality Prediction with PMV One year mortality: No risk factors: 15% All four risk factors: 97% (age, pressors, platelets, HD) Crit Care Med 2008 Vol. 36, No. 7

  9. Mortality and MV Type TWO TYPES TO REMEMBER: • COPD with hypercapnea: NPPV • Cochrane Review 2004; Ann IM 2003 138: 861 • Decreased mortality (11 vs 21%) • ARDS: Low Tidal Volume Ventilaton

  10. Low Vt in ARDS • 12 ml/kg vs. 6ml/kg • Mean Vt 11.8 vs. 6.2 • Decreased mortality with low Vt • 31.0% vs. 39.8% • Greater number of days vent-free (at 28d) • 12 vs. 10 NEJM May 4, 2000 vol 342:18

  11. Low Tidal Volume Ventilation NEJM May 4, 2000 vol 342:18

  12. Questions • How do you calculate 6 ml/kg? • PBW • [50 + 0.91(Ht in cm-152.4)] male • [45.5 + 0.91(Ht in cm-152.4)] female • Define ARDS • P/F <200 • Bilateral infiltrates • No Left Atrial Hypertension

  13. ARDSNet, Part ?6 • FACTT trial (Fluid and Catheter Treatment Trial) • PA catheter not better than central venous • Conservative fluid better by 3.2d (MV) • NEJM 2006

  14. Weaning in Mechanical Ventilation

  15. Modes of Ventilation Weaning

  16. Weaning mode from MV • Patients had to have improvement or resolution of underlying cause of respiratory failure and • P/F >200 • PEEP at 5 or less • Temp <38 • Hgb >10 • No pressors • Took ‘difficult to wean’ patients • Had failed a spontaneous breathing trial even though • MIP >-20 • Vt >5ml/kg • RR <35 • (extubated if passed SBT) • Enrolled them in one of 4 modes of ventilation • IMV • PSV • SBT qd • SBT multiple times/day

  17. NEJM Feb 9, 1995, vol 332:345

  18. Rate of successful weaning: SBT qd vs. IMV: 2.83 (p <0.006) SBT qd vs. PSV: 2.05 (p <0.04) SBT qd vs. SBT mult times: 1.24 (p 0.54) NEJM Feb 9, 1995, vol 332:345

  19. MV: Readiness Testing Yang, KL and Tobin, MJ. A Prospective Study of Indexes Predicting the Outcome of Weaning From Mechanical Ventilation. NEJM 1991; 324: 1445 • Looked at ‘traditional predictors’ of weaning: VE and PImax and developed two indexes • f/Vt • CROP • f/Vt: • RSBI <105 breaths/min/L with sensitivity of 97% and NPV of 95%

  20. Readiness Testing with Spontaneous Breathing Trials

  21. SBTs • Screened patients for readiness testing • Combined previous trials for predictors • P/F ratio >200 • PEEP 5 or less • Adequate cough • f/Vt >105 (for one minute measure for screening) • No pressors or continuous sedatives • If passed, underwent SBT with CPAP 5 (or 5/0) for 2 hours • Notified the primary MD if passed

  22. Days of MV 4.5 vs. 6

  23. Sedation in Mechanical Ventilation Reduces distress/discomfort, but • Prolongs MV (increased complications/mortality/cost….) • Increases delirium

  24. Daily Awakening

  25. Daily Awakening • Sedation held daily until pt interactive or agitated unless the following: • On 80% or greater FIO2 • Has unstable surgical lesion • Decreased median duration of MV • 4.9 vs. 7.3d • Decreased median length of stay in ICU • 6.4 vs. 9.9d • Decreased head scans, decreased complications

  26. Daily Awakening

  27. ABC Trial

  28. ABC Trial • Combined Daily Awakening (SAT) + Spontaneous Breathing Trials (SBT) • Both groups had SBT, intervention was SAT vs. no SAT • Increased number of days breathing without assistance in 28d • 14.7 vs. 11.6d (p=0.02) • Decreased days in ICU, decreased days in hospital • 9.1 vs. 12.9d (p=0.01); 14.9 vs. 19.2 (p=0.04) • NNT=7

  29. ABC Trial

  30. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial Thomas Strom, Torben Mortinussen, Palle Toft Lancet Vol 375 Feb 6, 2010

  31. Data Not To Stress About • Tight glucose control in medical ICU patients • Steroid ‘replacement’ in septic shock

  32. Plea for Help • Send me your COPD patients that produce sputum and have an FEV1>30% and FEV1/FVC ratio <70% predicted • agh@med.unc.edu • 919-966-2531

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