Critical Care Review : Pre-ICU Management for the Internist CSIM November 1, 2017 Shel elly Dev MD F D FRCPC Natal alie ie W Wong M MD F FRCPC Critical C ical Care M Medicin icine Critical C ical Care a and I Internal al Medicin cine Sunny nnybrook H Health S Scienc nces St. M Michae ael’ l’s Hospit ital al Centre re Toronto to Toronto to
Ma jor Obje c tive s for Pa rt I a nd II At the e nd o f this se ssio n le a rne rs will b e a b le to : De sc rib e the ke y ste ps in ma na g e me nt o f the se ptic pa tie nt Disc uss ma na g e me nt stra te g ie s fo r a c ute re spira to ry fa ilure Appre c ia te the b urde n o f illne ss o f c ritic a lly ill pa tie nts a fte r disc ha rg e fro m the I CU
Disc losure s • Nothing to disc lose
PART I
T he Me dic al Consult: Mr . R “He ’ s sta rting to b e c o me mo re unsta b le .”
Mr. R • 50M no t fe e ling we ll fo r 2 da ys • Sho rt o f b re a th, no n-pro duc tive c o ug h • No c he st pa in • PMHx: No ne • So c ia l Hx: No re c e nt tra ve l
Mr. R Vita l Sig ns • T e mpe ra ture 38.0 o C • He a rt ra te 128 • Blo o d pre ssure 100/ 58 • Re spira to ry ra te 36 • Oxyg e n sa tura tio n is 90% o n ro o m a ir
Mr. R Clinic a l F inding s: • Ca n’ t c o mple te se nte nc e s e a sily • Dia pho re tic • Co nfuse d a b o ut time a nd pla c e • Che st is “c ra c kly a nd whe e zy”
Is T his Se psis?
MORTALITY UP TO 40%
qSOFA Altered LOC Tachycardia GCS < 13 Hypotension Confusion SBP < 100 Vasodilation Tachypnea, RR > 22 SaO 2 <90% PaO 2 /FiO 2 ≤ 300
SOFA Altered LOC Tachycardia GCS < 13 Hypotension Confusion MAP < 70 Vasodilation Tachypnea SaO 2 <90% ↓ Urine output PaO 2 /FiO 2 ≤ 300 ↑ Creatinine > 110 Bilirubin > 20 ↑ Enzymes ↓ Platelets < ↓ Albumin 150 Ileus ↑ PT/APTT ↓ Protein C ↑ D-dimer
Additional Tests Blood cultures Lactate VBG Urinalysis CXR CK/Troponin Altered LOC Tachycardia GCS < 13 Hypotension Confusion MAP < 70 Vasodilation Tachypnea SaO 2 <90% ↓ Urine output PaO 2 /FiO 2 ≤ 300 ↑ Creatinine > 110 Bilirubin > 20 ↑ Enzymes ↓ Platelets < ↓ Albumin 150 Ileus ↑ PT/APTT ↓ Protein C ↑ D-dimer
Mr. R Vita l Sig ns • T e mpe ra ture 38.0 o C • He ar t r ate 128 • Blo o d pre ssure 100/ 58 • Re spir ator y r ate 36 • Oxyg e n sa tura tio n is 90% o n ro o m a ir • Confuse d
“Wha hat S Shoul uld W We Do Do Now?”
Fluids
“How M Much F Fluid S Should W We G Give?”
(2015 Revisions)
(2015 Revisions)
Cell Interstitium Blood
LUNGS ABDOMEN
AFTER ER E EVER ERY B BOLUS US REASSESS!: ⇢ Targets: Lactate, MAP trend, urine output, neuro status ⇢ Passive leg raise! (Yes, really!) ⇢ Tissues: Lungs (O 2 requirements increasing?) Abdomen (tense?) Appearance overall
AFTER ER E EVER ERY B BOLUS US REASSESS!: ⇢ Targets: Lactate, MAP trend, urine output, neuro status ⇢ Passive leg raise! (Yes, really!) ⇢ Tissues: Lungs (O 2 requirements increasing?) Abdomen (tense?) Appearance overall
AFTER ER E EVER ERY B BOLUS US REASSESS!: ⇢ Targets: Lactate, MAP trend, urine output, neuro status ⇢ Passive leg raise! (Yes, really!) ⇢ Tissues: Lungs (O 2 requirements increasing?) Abdomen (tense?) Appearance overall
AFTER ER E EVER ERY B BOLUS US REASSESS!: ⇢ Targets: Lactate, MAP trend, urine output, neuro status ⇢ Passive leg raise! (Yes, really!) ⇢ Tissues: Lungs (O 2 requirements increasing?) Abdomen (tense?) Appearance overall
AFTER ER E EVER ERY B BOLUS US REASSESS!: ⇢ Targets: Lactate, MAP trend, urine output, neuro status ⇢ Passive leg raise! (Yes, really!) ⇢ Tissues: Lungs (O 2 requirements increasing?) Abdomen (tense?) Appearance overall
AFTER ER E EVER ERY B BOLUS US REASSESS!: ⇢ Targets: Lactate, MAP trend, urine output, neuro status ⇢ Passive leg raise! (Yes, really!) ⇢ Tissues: Lungs (O 2 requirements increasing?) Abdomen (tense?) Appearance overall
I g a ve 2L whe n the la c ta te wa s 5. It’s still 5!
Reperfusion? Ischemia? Why i is t the LACTATE still h ll high? Organ failure? It’s Just Not Going to Get Better
Antibiotics
Blood cultures! Remove Tubes & Roll your patient Urinalysis! Lines! over! Back to the History! CXR ?Other Imaging?
A positive urinalysis isn’t always urosepsis, smartypants.
…and don’t relax just because the chest x-ray looks fine, either.
Antibiotics Is there a risk for MDR bugs? • Immunosuppressed • Recent abx • Recent hospitalization/institutionalization • Lines (including IVDU) ⇢ If “Yes”: Meropenem/Pip-Tazo +/- Vancomycin ⇢ If “No”: Ceftriaxone +/- Azithromycin (+/- Vancomycin) • IN-Hospital: Gram-positives > Gram-negatives > mixed/fungal
Antibiotics Is there a risk for MDR bugs? • Immunosuppressed • Recent abx • Recent hospitalization/institutionalization • Lines (including IVDU) ⇢ If “Yes”: Meropenem/Pip-Tazo +/- Vancomycin ⇢ If “No”: Ceftriaxone +/- Azithromycin (+/- Vancomycin) • IN-Hospital: Gram-positives > Gram-negatives > mixed/fungal
Antibiotics Is there a risk for MDR bugs? • Immunosuppressed • Recent abx • Recent hospitalization/institutionalization • Lines (including IVDU) ⇢ If “Yes”: Meropenem/Pip-Tazo +/- Vancomycin ⇢ If “No”: Ceftriaxone +/- Azithromycin (+/- Vancomycin) • IN-Hospital: Gram-positives > Gram-negatives > mixed/fungal
Antibiotics Is there a risk for MDR bugs? • Immunosuppressed • Recent abx • Recent hospitalization/institutionalization • Lines (including IVDU) ⇢ If “Yes”: Meropenem/Pip-Tazo +/- Vancomycin ⇢ If “No”: Ceftriaxone +/- Azithromycin (+/- Vancomycin) • Gram-positives > Gram-negatives > mixed/fungal
If the WBC > 30 and the risks are right… THINK C.DIFF!
Ceftriaxone and Azithromycin for presumed community- acquired pneumonia
Blood Cut off is Hb 70 unless: • Active bleeding • Acute coronary syndrome
Pe rsiste nt Ba dne ss “I’ve give n him 3L of fluid and the systolic pr e ssur e is still only 75… ”
Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance Stroke Volume x Heart Rate Preload Contractility [Afterload]
What’s happening here?
Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance Dehydration Stroke Volume x Heart Rate Insensible Losses Bleeding Volume Responsive Preload Contractility Limited Volume [Afterload] Response Obstructive
Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance Stroke Volume x Heart Rate Preload Contractility [Afterload]
Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance Stroke Volume x Heart Rate Distributive Shock Sepsis Preload Anaphylaxis Contractility [Afterload] Neurogenic Steroid Insufficiency Liver failure
FLOW
We Still Ha ve Pe rsiste nt Ba dne ss “I’ve give n him 3L of fluid and the systolic pr e ssur e is still only 75… ”
FLOW
Think about pressors after 2-3L but be prepared to see raised eyebrows…!
AFTE TER TH THE B BOLUSES REASSESS: ⇢ Targets: Lactate, MAP trend, urine output, neuro status ⇢ Passive leg raise! (Yes, really!) ⇢ Tissues: Lungs (O 2 requirements increasing?) Abdomen (tense?) Appearance overall
IV Ac c e ss “He has an iv but doe sn’t have a c e ntr al line ? Should we or de r a PICC? ”
Whe r e is the BE ST Site for the L ine ?
Anothe r Proble m “We ’r e inc r e asing the nor e pine phr ine and the blood pr e ssur e is only 85/ 50.”
• Source? • Shock? • Vasopressor?
Key Concepts
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