Critical Care ABIM Certification Exam Review Course Leslie - - PDF document

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Critical Care ABIM Certification Exam Review Course

Leslie Zimmerman, MD Professor of Clinical Medicine, UCSF ICU Director, SFVAMC

Lecture Outline

 Cardiopulmonary Failure  Sepsis/ARDS  GI issues  Odd and ends for $200

Question 1

A middle aged man collapses at the ballpark. He is unresponsive and has no pulse or respirations. Correct interventions include:

• A. Chest compressions alone at 100/minute
• B. Use of AED only by ACLS trained personnel
• C. 3 “stacked” shocks as soon as defibrillator is

available

• D. Rapid ventilation (bag or mouth)

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CPR and Defibrillation for Sudden Cardiac Death

 Sudden cardiac death causes 300,000+

deaths/year

 Strongly associated with coronary artery disease*  Despite the overall decrease in CV mortality, the

proportion of cardiovascular death from sudden cardiac death has remained constant

*Weaver WD, et al. Circulation. 1976;54:895-900.

CPR and Defibrillation for Sudden Cardiac Death

 Survival rates for out-of-hospital cardiac arrest

vary from 5% to 18%, depending on the presenting rhythm

 Early bystander CPR can double or triple the

victim’s chance of survival

 CPR plus defibrillation within 3 to 5 minutes of

collapse can produce survival rates as high as 49% to 75%

BLS 2013

A-B-C  C-A-B

IF you want to check for pulse, limit to 10 seconds IF you are trained in rescue breaths: Chest compressions FIRST! then 2 breaths/ 30 compressions IF NOT, just give chest compressions!

circ.ahajournals.org

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CPR

CPR: Hard and fast in middle of patient’s chest (between nipples) with minimal interruptions. Hand over heal. Adults: depress 2 inches (1/3 of AP diameter). Allow for complete recoil between. AT LEAST 100/minute.

AHA motto: “Push Hard and Fast!”

circ.ahajournals.org

CPR

No breathing  Open airway Still no breathing  2 breaths/ 30 compressions 2nd person – asynchronous breaths 8-10/minute If someone arrives trained to do rescue breaths, let them do rescue breaths

circ.ahajournals.org

Mouth‐to‐mouth resuscitation?

Hallstrom A, et al. NEJM 2000;342:1546-53. CPR by chest compression alone or with mouth-to- mouth ventilation.

 911 randomized instructions to bystanders  Instructions for compressions-only required less

time

 Survival to hospital discharge among patients

assigned to chest compressions-only was as good as full CPR (14.6% vs. 10.4%).

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CPR‐AHA Recommendations

 If a bystander is not trained in CPR, then the

bystander should provide hands-only CPR

 If bystander previously trained in CPR is confident

in ability to provide rescue breaths with minimal interruptions in chest compressions, bystander should provide either conventional CPR using a 30:2 compression-to-ventilation ratio

• r hands-only CPR

Mouth or bag‐mask…

 May discourage bystanders from starting CPR  May interrupt good quality chest compressions  Can overinflate lungs and decrease venous

return

 At some point, you do need to start ventilation…

AED Arrives

circ.ahajournals.org

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AED

www.heartsmart-aed.com/Philips-AED

AED

Open Put pads on chest Push On Follow Instructions It will advise shock and will charge for V tach & V fib, but not for Asystole or PEA

www.laerdal.com/us/

AED Pads: apply to chest

circ.ahajournals.org

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AED Effective?

Marenco JP JAMA. 2001;285:1193-200.

 Use of AEDs by first responders and

laypersons reduced time to defibrillation and improved survival from sudden cardiac arrest

Question 1

A middle aged man collapses at the ballpark. He is unresponsive and has no pulse or respirations. Correct interventions include:

• A. Chest compressions alone at 100/minute
• B. Use of AED only by ACLS trained personnel
• C. 3 “stacked” shocks as soon as defibrillator is

available

• D. Rapid ventilation (bag or mouth)

One shock, CPR x 2 min, shock Too fast can decrease venous return

Sequence: not drug then shock

CPR Shockable rhythm? Shock! Epi

2 minutes 5 minutes

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ACLS– Cutting Edge

Use of in-line End tidal CO2 monitor:

More circulation, more CO2 delivered to lungs, more exhaled; first sign of ROSC Falling ET CO2, less circulation, tiring CPR performer, switch out

www.nonin.com

ACLS– Cutting Edge

Defib pads that tell you when CPR is inadequate!

ACLS– Cutting Edge

In hospital cardiac arrest:

Goldberger ZD, et al. “Duration of Resuscitation Efforts and Survival after In-Hospital Cardiac Arrest: An Observational Study. Lancet 2012; 380:1473.

• 80% PEA or asystole at presentation
• ROSC 48%
• 15% survived to discharge with good

neurological recovery

• The LONGER the resuscitative effort, the

better the outcome in PEA arrest

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Question 2

A 68 yo man with a history of smoking, HTN and DM presents to the ED with confusion, SOB, and increasing peripheral edema. Exam: BP 135/90 HR 110 Moderately obese, tired but oriented. Lungs with rales ½ up; rare wheezes. Cor: tachy without murmurs. 4+ edema to thighs. Labs: Hct 52% WBC: 22,000 BNP 900 BUN 28 Glucose 255 ABG: 7.30/ PaCO2 62/ PaO2 45

Question 2

CXR: Moderate cardiomegaly and vascular congestion. RX: O2, Diuretics, bronchodilators, antibiotics. He is still lethargic, but oriented. F/u ABG on 2 LPM O2: 7.29/ PaCO2 65/ PaO2 52

Question 2

68 yo, initial ABG: 7.30/ PaCO2 62/ PaO2 45 F/u ABG 2 LPM O2: 7.29/ PaCO2 65/ PaO2 52 Next, you should:

• A. Give sodium bicarbonate
• B. Increase O2 to 6 LPM
• C. Intubate patient and begin assist control

ventilation

• D. Order sleep study
• E. Start noninvasive positive pressure ventilation

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NiPPV

Non-invasive Positive Pressure Ventilation

 Ventilation without endotracheal tube or

tracheostomy

 Best in rapidly reversible conditions: CHF,

COPD exacerbation, or post-extubation

NiPPV

The patient wears a tight-fitting mask which is connected to a CPAP, Bilevel PAP, or ventilator Patient gets larger tidal volume with same inspiratory

• effort. This

improves PaCO2 & decreases work of breathing

www.clevelandclinicmeded.com

Why does it work?

 Decreases

microatelectasis

 Drives water out of

alveoli

 Larger tidal volume

with same inspiratory effort

 If ventilator, can

add mandatory rate Oxygenation Work of Breathing

 Positive pressure

counterbalances inspiratory threshold related to intrinsic PEEP

 Reduction in inspiratory

muscle work

 No ETT resistance load

CO2 elimination

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Potential Disadvantages of NiPPV (vs. intubation)

 System

• Slower correction of gas exchange abnormalities
• Increased initial time commitment (need 1:1 RT)

 Mask

• Air leakage poor correction of gas exchange
• Transient hypoxemia from accidental removal

 Lack of airway access and protection

• Suctioning of secretions harder

Complications

• Facial skin erythema/ skin breakdown

#1 complication

• Nasal congestion/nasal/oral dryness
• Nasal bridge ulceration
• Sinus/ear pain
• Eye irritation
• Gastric distension (< 2%)
• Aspiration pneumonia
• Poor control of secretions

Respiratory acidosis Secretions, low CO2, apnea CHF, COPD exacerbation,

• r post-extubation

Severe encephalopathy, agitated or uncooperative Respiratory distress: High RR, accessory muscle use, paradoxical breathing Aspiration risk, facial trauma or facial or gastro-esophageal surgery Code blue, unstable hemodynamics or rhythm

Good Bad

Example: Coughing up thick secretions, ABG 7.33/25/45  Secretions, hypoxic with metabolic acidosis  NiPPV ? NO!!!

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NiPPV

NiPPV- if going to work, should see improvement clinically and in PaCO2 within 2-3 hours. Key is the balance between avoiding intubation with risk of VAP vs. delay in necessary intubation (risk of cardiac ischemia)

• COPD exacerbations: Decreased intubation, hospital

length of stay, mortality.*

• CHF: + pressure decreases pre-load. Decreased

intubation** & mortality***.

* Ram FS, et al. (Cochrane Review). Cochrane Database Syst Rev 2004; :CD004104. ** Gray A, et al. NEJM 2008;359:142. *** Masip J, et al. JAMA 2005; 294:3124.

How to start?

 Head of bed up 30+ degrees  RT able to be 1:1 with patient?  Select mask (fit small, medium, large)  Select machine  Oxygen to keep saturation > 90%  Start low IPAP 8-10; EPAP 5, then increase IPAP  Put mask up to patient’s face, few breaths, take off and

reassure patient, place back on; patient can hold

 Increase IPAP if needed to decrease dyspnea  Once settled, then add straps, check for leaks

Drives TV

EPAP prevents early airway closure increases FRC

CPAP vs. BiPAP in CHF?

CHF  no clear advantage (patient tolerance) COPD  ventilation is an issue  BiPAP (+/- back-up rate).

BiPAP CPAP Gray A, et al. NEJM 2008;359:142

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NiPPV for Respiratory Failure

Best mask?

 Full face mask: Best physiologic and arterial blood

gas improvement

 Nasal mask: More comfortable, easier to cough up

secretions, easier to speak

 50% of those started on nasal mask have to be

switched to full face mask

Full Nasal Mask Nasal Pillows Full Face Mask

Mask fits to:

CPAP

• Set one

pressure: continuous Bilevel PAP

• Set two

pressures: inspiratory & expiratory Full mode Ventilator

• Any mode, but

usually Pressure Support + CPAP; can set back-up rate Home use for OSA or chronic hypoventilation Limited or No display of numbers CPAP or BiPAP +/- available back-up rate; cheaper than vent

Check for Leaks

 Look at patient  noisy leak?  Look at display and compare inspiratory

tidal volume to expiratory tidal volume

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Question 2

68 yo with initial ABG: 7.30/ PaCO2 62/ PaO2 45 F/u ABG on 2 LPM O2: 7.29/ PaCO2 65/ PaO2 52 Next, you should:

• A. Give sodium bicarbonate
• B. Increase O2 to 6 LPM
• C. Intubate patient and begin assist control ventilation
• D. Order sleep study
• E. Start noninvasive positive pressure ventilation

Improve pH, but not paCO2 Need to ventilate Chronic sleep disorders may have chronic CO2 retention, but pH should be more normal Very good data in right patient

Question 3

64 yo man with COPD with FEV1 of .9L (40%) was intubated x 5 days for pneumonia. He is now afebrile, secretions are minimal, he is awake and following commands but

• anxious. ABG is 7.39/60/60 on 35% FIO2 on 10/5 of

pressure support. RSBI is 75. (f/TV in L 23/.300) Next, you should:

• A. Decrease FIO2 to 30%
• B. Give him Diamox (acetazolamide)
• C. Extubate now, see if he needs BiPAP
• D. Extubate to BiPAP
• E. Schedule tracheotomy

Post‐extubation rescue

Esteban, A, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. NEJM 2004; 350:2452. 221 patients with respiratory failure within 48 hours after extubation randomized to +/- trial of NPPV. Mortality higher with NiPPV! With no difference in rate of

• reintubation. Increased mortality from cardiac ischemia,

diaphragmatic fatigue, and/or aspiration? Waited too long? Ferrer M, et al. AJRCCM 2006;173:164. EARLY NPPV at time of extubation  less reintubation if chronic respiratory failure and elevated PaCO2 during SBT

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Question 3

64 yo man with COPD with FEV1 of .9L (40%) was intubated x 5 days for pneumonia. He is now afebrile, secretions are minimal, he is awake and following commands but

• anxious. ABG is 7.39/60/60 on 35% FIO2 on 10/5 of

pressure support. RSBI is 75. (f/TV in L 23/.300) Next, you should:

• A. Decrease FIO2 to 30%
• B. Give him Diamox (acetazolamide)
• C. Extubate now, see if he needs BiPAP
• D. Extubate to BiPAP
• E. Schedule tracheotomy

Will likely desaturate pH okay Risk late rescue Not even one chance???

Question 4

A 55 year old woman with asthma is admitted to the ICU following surgery for multiple fractures from a MVA She develops ARDS. The patient is on a volume- control ventilation: RR 14 breaths/min, FIO2 0.4, PEEP 5 cm H20, and tidal volume of 500. The peak pressure increases and the patient appears to be in respiratory distress: Initial Subsequent Peak pressure (cm H2O) 28 48 Plateau pressure (cm H2O) 22 26

Question 4

Initial Subsequent Peak pressure 28 48 Plateau pressure 22 26 Which of the following is most likely to account for this patient’s respiratory distress?

• A. Pulmonary embolism
• B. Cardiac ischemia with pulmonary edema
• C. Pneumothorax
• D. Bronchospasm
• E. Leak in the ventilator circuit

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Peak vs. Plateau Pressures

All are plotted vs. time

Pressure Flow Volume

Inspiratory Pressures

≈ Lung Elastance + Airflow Resistance Inspiratory Peak Pressure (plateau + airway pressure) Inspiratory Plateau Pressure ≈ Lung Elastance

Either too high  High peak pressure alarm

How stiff the lungs are

How narrow the airways are

Inspiratory Pressures

Pneumothorax CHF ARDS Bronchospasm Large airway plugs

Plateau Pressure Peak - Plateau Pressure

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Ventilators: Inspiratory Pressures

Inflation Inflation Hold Exhalation Proximal Airway Pressure

Peak pressure Plateau pressure

Acute Decompensation During Mechanical Ventilation

Ppeak

Too low Too high Pplateau Elevated NOT Elevated Airways Obstruction Decreased Compliance e.g. Pneumothorax, CHF, ARDS, pneumonia

Air Leak

Question 4

Initial Subsequent Peak pressure 28 48 Plateau pressure 22 26 Which of the following is most likely to account for this patient’s respiratory distress?

• A. Pulmonary embolism
• B. Cardiac ischemia with pulmonary edema
• C. Pneumothorax
• D. Bronchospasm
• E. Leak in the ventilator circuit

Shouldn’t change pressures Will increase both Plateau & Peak Low pressures

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Question 5

A 43 year old man with seizures has a witnessed aspiration and develops ARDS. Mechanical ventilation is begun with a RR 30/min, tidal volume 6.5 mL/kg, FiO2 0.50, PEEP 10 cm H20. Plateau pressure is 34 cm H20. Chest X-ray: ARDS. ABG: pH 7.28/pCO2 55/pO2 60.

Question 5

ABG: pH 7.28/pCO2 55/pO2 60

According to the Acute Respiratory Distress Syndrome Network protocol for ventilation management, which of the following should you do next?

• A. Decrease tidal volume to 6.0 mL/kg and

recheck plateau pressure

• B. Increase tidal volume to 8.0 mL/kg and

recheck plateau pressure

• C. Increase Fi02
• D. Infuse bicarbonate
• E. Start ECMO

ARDS

 There are no proven pharmacologic

therapies for ARDS

 “Usual” tidal volumes of 10-15 mL/kg may

worsen lung injury in patients with ARDS by excessive stretch, repeated opening and closing of small airways, or stress at margins of atelectatic lung

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ARDS Network NEJM 2000;342:1301

 861 patients randomized to tidal volume of

12 mL/kg vs 6 mL/kg

 Goal plateau pressure < 30 cm H20 Mortality: 31% the low tidal volume group vs. 40% in the traditional group And 2 fewer days on the ventilator

NEJM 2000;342:1301

ARDS – Best PEEP?

Pressure Volume Tidal volume too high PEEP too low

“Best” PEEP would open all parts that can open without overinflating good lung

Use Plateau Pressure to guide Guide?

Best PEEP? “Open Lung Ventilation”

Pressure Volume

Open Lung strategy Improves oxygenation Some other clinical outcomes Not mortality

Find “inflection point” above which volume rapidly increases with additional pressure and set PEEP 2 cm H2O above that “Best” PEEP would open all parts that can open without overinflating good lung

19 What causes barotrauma in ARDS?

Too much PEEP? Too high Tidal Volume? Too high Peak Pressure? (that’s what alarms!) Bad luck?

Intensive Care Med. 2002;28(4):406 Alveoli inflate and deflate around fixed structures of small airways  rupture

Alveoli pressure correlates best with plateau pressure Barotrauma increases with Pplat > 35 mmHg Air tracks along path of least resistance to ward hila then mediastinum then thoracic inlet  PTX and/or SQ emphysema

Question 5

ABG: pH 7.28/pCO2 55/pO2 60. TV

6.5 mL/kg, FiO2 0.50, PEEP 10 cmH20. Plateau pressure 34 cmH20. Chest Xray:

• ARDS. Which of the following should you

do next?

• A. Decrease tidal volume to 6.0 mL/kg and

recheck plateau pressure

• B. Increase tidal volume to 8.0 mL/kg and

recheck plateau pressure

• C. Increase Fi02
• D. Infuse bicarbonate
• E. Start ECMO

Plateau Pressure Is already 34

pO2 60

Cut off is < 7.15 Save for those on max support

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ARDS– Cutting Edge

Beta-agonists increase ENaC clearance. Useful in ARDS?

Smith GF et al. Lancet 2012;379:229.

• Intravenous b-agonist bad idea in sick ICU

patients ARDS Clinical Trial Network Am J Respir Crit Care med 2011;184:561

• Inhaled albuterol, no difference

ARDS– Cutting Edge

Omega-3 fatty acids useful in ARDS? Diet rich in these decreases inflammation.

Rice TW et al. JAMA 2011;306:1574. Stapleton RD et al. Crit Care Med 2011;39:1655

• Taken together, either not beneficial and potentially

harmful

• JAMA study, trend toward more ventilation and higher

mortality

• More diarrhea

ARDS– Cutting Edge

High Frequency Ventilation?

Young D et al. High-Frequency Oscillation for Acute Respiratory Distress Syndrome” NEJM 2013; 368:806

 No difference

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ARDS– Cutting Edge

Guerin C. et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. NEJM Online 5/20/2013

 Randomized patients with severe ARDS  Within 24 hours  Prone  16 hours in prone position  Mortality 33% in standard vs. 16%

ARDS– Cutting Edge

New definitions for ARDS! “Berlin” Definition JAMA 2012;307:2526

• Acute onset
• PaO2/FIO2 < 300 measured on at least 5 PEEP
• Bilateral CXR infiltrates
• No “Acute lung injury”
• Mild P/F 200-300
• Moderate P/F 100-200
• Severe P/F < 100
• “Not CHF” and Echocardiography recommended

4 8 12 16 20 24 28

PCWP

Question 6

19 year old man with asthma is admitted with progressive symptoms. BP is 140/70, pulsus paradoxus 25, ABG 7.30/49/58. He is intubated and ventilated in volume-cycled mode with RR 15, TV 1000 mL, FiO2 0.5, PEEP 5. Inspiratory flow rate is 60 L/min. Twenty minutes after intubation BP drops to 80/30. ABG: 7.20/57/50. Breath sounds remain symmetrically decreased.

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Question 6

BP 140/70  80/30 ABG 7.30/49/58  7.20/57/50 Which of the following should you do now?

• A. Briefly detach from ventilator
• B. Echocardiography
• C. Increase tidal volume to 1200 mL
• D. Decrease flow rate
• E. Place thoracostomy tube

Dynamic Hyperinflation

 Major problem in obstructive lung diseases like

COPD and asthma

 Increased airway resistance  inadequate time

for expiration

 If there is not enough time for expiration, this can

lead to gas trapping (i.e., auto-PEEP)

 Consequences of auto-PEEP include

barotrauma (pneumothorax) and hypotension

 Need to allow adequate time for expiration

Dynamic Hyperinflation

Inadequate time for exhalation Hypotension not uncommon

• Hypovolemia
• Sedatives
• Excess ventilation

Lung From Right Ventricle To Left Ventricle Decreases venous return Increases Alveolar Pressure Decrease return to LV

23 Set Ventilator Settings to Maximize Expiration and Avoid Hyperinflation

For serious hypotension, may need to briefly detach patient from ventilator. If DH is cause, BP should rise quickly Then adjust ventilator settings to maximize exhalation time. If making only one change, decreasing RR usually trumps anything else! May increase PaCO2  permissive hypercapnea is usually well tolerated

Question 6

BP 140/70  80/30 ABG 7.30/49/58  7.20/57/50 Which of the following should you do now?

• A. Briefly detach from ventilator
• B. Echocardiography
• C. Increase tidal volume to 1200 mL
• D. Decrease flow rate
• E. Place thoracostomy tube

No risk factors for tamponade Already a lot! Even MORE volume to exhale Where? Increase!

Question 7

75 year old man with lung cancer and newly discovered 1.5 cm brain mass presents with productive cough, fever to 104 F (40.0 C), pulse 115, BP 70/40. Exam: lethargic man with crackles in the right base. Labs: Hgb 10.5 mg/dl, WBC 18K with left shift, BUN of 54, lactic acid level 6 meq/L (nl .6-1.8) After cultures and broad spectrum antibiotics, 2L NS (20 cc/kg): pulse 110, BP 75/50

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Question 7

A 75 year old man with… After 2L NS: pulse 110, BP 75/50 At this time, you should:

• A. Assess volume status by some means
• B. Start ECMO
• C. Start vasopressin IV
• D. Transfuse packed RBCs

Rivers E et al. Early goal-directed therapy in the treatment

• f severe sepsis and septic shock. NEJM 2001;345:1368.

1C Recommendations: Single RTC; single center

 CVP 8-12 mmHg  MAP > 65 mmHg  UO > .5 cc/kg/hr  SVC O2 sat (Scvo2) > 70% or Mvo2 > 65%

Surviving Sepsis: Recommendations

Crit Care Med 2012

Adherence low in f/u international performance study

Question 7

A 75 year old man with… After 2L NS, pulse 110, BP 75/50 At this time, you should:

• A. Assess volume status by some means
• B. Start ECMO
• C. Start vasopressin IV
• D. Transfuse packed RBCs

What has changed is concern that CVP doesn’t tell you much about where you are on curve

Cardiac Output

LVEDV Will adding volume help?

25 Q 8: All of the following may be useful parameters for assessing tissue perfusion in septic patients EXCEPT?

• A. Aortic blood flow peak velocity variation
• B. Central line with CVP and central venous O2

saturation

• C. Lactate clearance
• D. PCWP
• E. Respiratory change in the radial artery pulse

pressure

Aortic blood flow peak velocity variation

But requires transesophageal echo Positive pressure ventilation decreases venous return ESPECIALLY if hypovolemic

Volume resuscitated

Same thing happens on A‐line

Peak to peak systolic variation

More variation with respiration means more pre-load dependence of BP  volume depletion. Good PPV and we think good NPV! Need to be in sinus rhythm

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Lactate clearance

Give NS until CVP > 8 mmHg, then if MAP < 65 mm Hg  pressors then Check VENOUS Lactate level

• JAMA. 2010;303(8):739-746

Time 0 hrs 2 hrs Lactate level Time 0 hrs 2 hrs Lactate level Not meeting goals Meeting goals! > 10% drop

Q 8: All of the following may be useful parameters for assessing tissue perfusion in septic patients EXCEPT?

• A. Aortic blood flow peak velocity variation
• B. Central line with CVP and central venous O2

saturation

• C. Lactate clearance
• D. PCWP
• E. Respiratory change in the radial artery pulse

pressure

PCWP: poor predictor of fluid responsiveness in sepsis; and SvO2 is similar to ScvO2; which can be obtained from a CVP line; not been shown to improve outcomes.

Back to Question 7

A 75 year old man with… After 2L NS, pulse 110, BP 75/50 At this time, you should:

• A. Assess volume status by some means
• B. Start ECMO
• C. Start vasopressin IV
• D. Transfuse packed RBCs

In EGDT, if not at CvO2 sat> 70%  transfuse if Hct < 30.

• Vs. Chronically ill in the ICU  restrictive transfusion better

But in this question, do not know yet if VOLUME rescucitated!

Rescue for hypoxemia, not hypotension

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Can you ever have too much fluid?

N Engl J Med. 2006;354(24):2564

ALI

If pulmonary edema at start  diuretics. If low CI and urine output  fluids until CI > 2.5 L/min/m2 & UO > .5 ml/kg/hr Conservative Day 1 = 4.2 L in Liberal Day 1 = 5.0 L in Lasix/fluid to target CVP 8-14 Day 1: 2.5L NET Day 2, 3: + 1L/day Days 4, 5, 6: +.5 L/day Lasix/fluid to target CVP 4-8 Day 1: 1.1L NET Day 2, 3:

• 0.4L/day

Days 4, 5, 6: even/day

No change 60 day mortality

Can you ever have too much fluid?

N Engl J Med. 2006;354(24):2564

ALI

Conservative Total += 0L Liberal Total += 7 L

Better oxygenation 2 fewer vent days 2 fewer ICU days No increased in shock or dialysis

BOTTOM LINE: If Sepsis & ARDS Give volume day 1 based on some parameter, then ask do you still need? In ED, don’t be afraid of volume resuscitation upfront in hypotensive patients with flat neck veins!

BUT

Question 9

Per the Vasopressin in Septic Shock Trial (VASST), low dose vasopressin in addition to Levophed (norepinephrine) was shown to significantly:

• A. Decrease overall 28 day mortality in sepsis
• B. Decrease overall 28 day mortality in the less

severe septic patients

• C. Decrease organ dysfunction
• D. None of the above

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VASST: NEJM 2008;358:877

Vasopressin: non-adrenergic pressor

Trend but not significant, driven by the “less sick”

Question 9

Per the Vasopressin in Septic Shock Trial (VASST), low dose vasopressin in addition to Levophed (norepinephrine) was shown to significantly:

• A. Decrease overall 28 day mortality in sepsis
• B. Decrease overall 28 day mortality in the less

severe septic patients

• C. Decrease organ dysfunction
• D. None of the above

We will add if needed, but not use a combination routinely upfront.

Question 10

A 57 yo man is in shock. The use of dopamine as a pressor instead of norepinephrine is associated with

• A. Improved survival
• B. More atrial fibrillation
• C. Better gut perfusion
• D. Less renal failure

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Dopamine vs. Norepinephrine

No difference in mortality Dopamine Norepinphrine Afib 20.5% 11% Vtach 2.4% 1% Bowel Ischemia 1.3% .7% Dialysis days slightly fewer Mortality in Cardiogenic Worse shock

N Engl J Med. 2010;362:779.

Shock

 Cardiogenic shock: IABP no improvement

NEJM 2012;367:1287

 Septic shock: Starch worse (as compared with

Ringers acetate) for resuscitation: (mortality, severe bleeding, ARF) NEJM 2012;367:124

 All ICU patients: Is .9NS the best for volume?

Not sure… JAMA 2012;308:1566

Question 11

48 year old woman with Graves Disease and early menopause, chronic fatigue presents with nausea and vomiting. While walking into the ED, she passes out. Her BP is 65/40. Labs: Hct 36% Glucose 67 mg/dl BUN 28 mg/dl Creat 1.0 mg/dl Sodium 134 meq/L Potassium 5.1 meq/L Chloride 98 meq/L Bicarb 25 meq/L

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Question 11

A 48 yo woman… BP 65/40. You should order (in addition to volume resuscitation):

• A. Abdominal CT scan
• B. Ceftriaxone + Vancomycin
• C. Glucagon
• D. Hydrocortisone
• E. Thyroxine

Question 11

This woman: Other autoimmune endocrine problems (Graves Disease), early menopause (ovarian failure?), with classic symptoms of fatigue, then with signs (N/V) and syncope, hypotension. Labs: Clues are Glucose 67 loss of glucocorticoid Sodium 134 loss of minerocorticoid Potassium 5.1 loss of minerocorticoid If CBC with differential, look for elevated eosinophil count

Question 11

This woman: likely has autoimmune adrenalitis (most common cause of Addisons in US) You should order (in addition to volume resuscitation):

• A. Abdominal CT scan
• B. Ceftriaxone + Vancomycin
• C. Glucagon
• D. Hydrocortisone
• E. Thyroxine

Delay in treatment Meningococcemia can cause adrenal crisis, but nothing on exam Is a treatment for hypoglycemia if no IV access, if IV access, just give glucose (in this case need D5NS – need glucose & volume) If adrenal insufficiency possible, Never given thyroid replacement first

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Glucose control in the ICU

VISEP study: NEJM 2008;358:125. Septic patients targeted glucose 80-110 vs. 180-200. Stopped early due to high rate of hypoglycemia. Glucontrol study: Intensive Care Med 2009;35:1738. Targeted glucose 80-110 vs. 140-180. Stopped early due to trend towards increased mortality in hypoglycemic patients. NICE SUGAR: NEJM 2009;360:1283 & NEJM 2012:367;1108. Large, international, randomized trial of adults in ICU. Targeted glucose 81-108 higher mortality than <180. And hypoglycemia associated with higher mortality.

Question 12

45 year old man presents with alcoholic pancreatitis. A feeding tube is placed and the following x-ray is

• btained.

Question 12

45 year old man … pancreatitis. You should:

• A. Also place central line for TPN, patient will not

be able to tolerate full enteral feedings for caloric needs

• B. Insert feeding tube further until tip is in jejunum
• C. Start semi-elemental enteral feedings
• D. Start semi-elemental enteral feedings only

when amylase has returned to normal

• E. Remove tube and order chest x-ray

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Pancreatitis & Nutrition

Enteral feedings

• Lower infectious complications
• Maintains intestinal barrier
• No TPN infection risks
• Pancreatic stimulation decreases the further

away from pylorus

• Place early; patients have high metabolic

demands

• Not going to able to wait for normalization of

labs

• Can’t get to goal (pain, ileus) may need

supplemental TPN

Question 12

This patient however…. Tip of tube in LLL bronchus

How about this one?

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Question 12

You should:

• A. Also place central line for TPN, patient will not

be able to tolerate full enteral feedings for caloric needs

• B. Insert feeding tube further until tip is in jejunum
• C. Start semi-elemental enteral feedings
• D. Start semi-elemental enteral feedings only

when amylase has returned to normal

• E. Remove tube and order chest x-ray

Don’t know yet Yikes!

Question 13

52 year old man POD #1 from repair of liver/spleen/ pancreas lacerations from blunt trauma (MVA). Intra-

• p, he required 8 units of PRBCs, 8 L of LR.

Initially fairly stable post-op, in last few hours, BP has decreased from 110/80 to 90/55. On ventilator, peak and plateau airway pressures have increased. Urine

• utput has fallen to < 20 ml/hr. CVP has increased

from 10 cm to 16 cm H20. Exam: good bilateral breath sounds, tachycardia without murmurs. Abd: distended, heavily bandaged without change in dressing color.

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Question 13

CXR: Bilateral elevated hemidiaphragms, No PTX, no free air ECG: Sinus tachycardia, no ischemic changes ABG: This morning 7.44/41/87 Now on same vent settings 7.28/55/60 Lactic acid level is 4.0 meq/L You should…

Question 13

52 yo post-op abd trauma, PRBC/volume

• resuscitated. Now with dropping BP, UO,

elevated lactate, poor gas exchange, smaller lungs. You should order:

• A. Cross table lateral KUB to check for free air
• B. IV norepinephrine (Levophed)
• C. NaHCO3 in anticipation of stat abdominal CT

scan

• D. Stat Echocardiogram to rule out tamponade
• E. Urinary bladder pressure

Abdominal Compartment Syndrome

Increase in abdominal pressure which compromises tissue perfusion locally AND pressure backs blood up (rising CVP & PCWP)

• Also presses diaphragm up, so increased

airway pressures, smaller lung volumes

• Can also increase ICP
• Suspect if tensely distended abdomen,

progressive oliguria, and increased ventilatory requirements.

• Measure bladder pressure

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Abdominal Compartment Syndrome

Measure bladder pressure

• Normally 0, but slight increase on vent
• Inject 50 cc of sterile saline into

aspiration port, clamp drainage tube, jab another 18 gauge needle into aspiration port and attach to pressure transducer

• < 10 mmHg okay; > 25 mmHg bad
• Manage – back to OR to decompress

Question 13

You should order:

• A. Cross table lateral KUB to check for free air
• B. IV norepinephrine (Levophed)
• C. NaHCO3 for stat abdominal CT scan
• D. Stat Echocardiogram to rule out effusion with

tamponade

• E. Urinary bladder pressure

Had surgery, could have intraperitoneal air

Tachycardia, low BP, and rising CVP consistent, but why the lactic acid and small lung volumes Not that hypotensive and doesn’t address problem Is at risk for ischemic bowel…

Question 14

What is the MOST common cause of abdominal compartment syndrome?

• A. Abdominal trauma
• B. Burns
• C. Ischemic bowel
• D. Massive ascites
• E. Necrotizing pancreatitis

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Question 14

What is the MOST common cause of abdominal compartment syndrome?

• A. Abdominal trauma
• B. Burns
• C. Ischemic bowel
• D. Massive ascites
• E. Necrotizing pancreatitis

Anything with vigorous volume resuscitation, inflammatory process with capillary leak, space occupying (retroperitoneal bleed, ascites) or with non-distending skin (burns)

Question 15

65 yo man s/p MVA w/ bilateral femoral & pelvic fractures & splenic laceration. In OR: stabilization of fractures and splenectomy. Resuscitated with 5 units RBCS/ 7L LR. Extubated. 48 hours post-op, agitated and tachypneic. 99.5F, BP 135/72; HR 125. Exam: bilateral subconjunctival & anterior chest wall petechiae. Bilateral crackles in lung base. Abd non-distended. Labs: Hct 37% WBC 14K Platelets 70,000 BUN/creatinine – normal ABG on 60% FM 7.49/28/50

Question 15

65 yo with MVA… The deterioration is MOST consistent with:

• A. Abdominal compartment syndrome
• B. Air embolism

C.Fat embolism D.TRALI

• E. TTP (Thrombotic thrombocytopenic

purpura)

37

TRALI?

Transfusion Related Acute Lung Injury

• Leukoagglutination: reaction of anti-granulocyte

antibodies (donor) and granulocytes (recipient)  endothelial injury  ALI

• Risk from all blood products, greatest with FFP,
• lder blood
• Problem with donor, not recipient, esp. multiparous

donors.

• Blood bank implications  that donor can not

donate and all products pulled

• Recipient is not at higher risk for another reaction
• Fever, tachycardia, and tachypnea within first few

hours post transfusion

• Supportive care, typically resolves by 48 hours

TTP?

Thrombotic thrombocytopenic purpura appears a lot more often on boards than in real life – in the ICU it seems that everyone has fever, somewhat low platelets, rising BUN, and is confused, but they will make it more dramatic

• Microangiopathic hemolytic anemia - Not anemic
• Thrombocytopenia, often with purpura – Average

platelet count @ 25,000 – okayish

• Acute renal insufficiency – Not present
• Neurologic abnormalities, usually fluctuating
• Fever

Question 15

65 yo with MVA… The deterioration is MOST consistent with:

• A. Abdominal compartment syndrome
• B. Air embolism
• C. Fat embolism
• D. TRALI
• E. TTP (Thrombotic thrombocytopenic purpura)

Too late

Not enough criteria, they will typically show smear or describe hemolytic picture

Wouldn’t explain exam

• r low platelets

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Air vs. FAT Embolism

Air embolism Fat embolism

After neuro or ENT surgery

• r central vein manipulation

After long & pelvic bone fracture, SCA, lipid infusions Acute dyspnea “air lock” can plug PA 24-72 hours post fx: Acute dyspnea  ALI If to arterial side, stroke or

• ther organ damage

CNS – confusion Fat emboli to skin, eyes Low platelets if endothelial injury DIC syndrome Dx: Echo or CT Rx: L decub Trendelenberg, If R heart air  remove air, support, hyperbaric Dx: Clinically Rx: Supportive

Question 15

65 yo with MVA… The deterioration is MOST consistent with:

• A. Abdominal compartment syndrome
• B. Air embolism
• C. Fat embolism
• D. TRALI
• E. TTP (Thrombotic thrombocytopenic purpura)

They will give obvious risk factor, like acute change post central line

Question 16

75 year old man from NH on chronic antibiotics for cavitary lung lesion develops diarrhea. He presents with fever, hypotension, and increasing abdominal distention 2 days after starting po metronidazole for C. difficile. Abdominal CT shows marked colonic dilatation and wall-thickening; pt taken to OR for subtotal colectomy/end ileostomy/mucus fistula. What next?

39

60 year old s/p subtotal colectomy.. What next?

Question 16

You should:

• A. Look for another cause of the colonic

distension; c. diff does not do this

• B. Grab the nearest can of alcohol foam to clean

your hands

• C. Switch to IV metronidazole & po vancomycin
• D. Start IV vancomycin he looks sick!

60 year old s/p subtotal colectomy.. What next? You should:

• A. Look for another cause of the colonic

distension; c. diff does not do this

• B. Grab the nearest can of alcohol foam to clean

your hands

• C. Switch to IV metronidazole & po vancomycin
• D. Start IV vancomycin he looks sick!

Spores need to be washed off

IV vancomycin – no good

Question 16

Severe C. diff

 No consensus definition

• Classic WBC > 20k
• Elevated creatinine
• Esp. with first episode (rather than relapse)
• Can have no diarrhea! Or if diarrhea decreases while

abdomen expands  think toxic megacolon

 Switch to oral vancomycin & IV metronidazole;

add pr vanco if ileus slowing delivery

 Metronidazole & vancomycin equally effective

for the treatment of mild dz, but vancomycin is superior for treating patients with severe dz.

Zar FA et al. Clin Infect Dis. 2007, 1;45:302.

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The End!