Critical Care Review : Pre-ICU Management for the Internist CSIM - - PowerPoint PPT Presentation

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Critical Care Review : Pre-ICU Management for the Internist CSIM - - PowerPoint PPT Presentation

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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

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Critical Care Review : Pre-ICU Management for the Internist

Natal alie ie W Wong M MD F FRCPC Critical C ical Care a and I Internal al Medicin cine

  • St. M

Michae ael’ l’s Hospit ital al Toronto to Shel elly Dev MD F D FRCPC Critical C ical Care M Medicin icine Sunny nnybrook H Health S Scienc nces Centre re Toronto to

CSIM November 1, 2017

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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

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Disc losure s

  • Nothing to disc lose
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PART I

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T he Me dic al Consult: Mr . R

“He ’ s sta rting to b e c o me mo re unsta b le .”

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  • 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

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SLIDE 7
  • Mr. R

Vita l Sig ns

  • T

e mpe ra ture 38.0oC

  • 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
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SLIDE 8
  • 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”
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Is T his Se psis?

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MORTALITY UP TO 40%

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Tachycardia Hypotension SBP < 100 Vasodilation Altered LOC GCS < 13 Confusion Tachypnea, RR > 22 SaO2 <90% PaO2/FiO2 ≤300

qSOFA

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SLIDE 18

Tachycardia Hypotension MAP < 70 Vasodilation Bilirubin > 20 ↑ Enzymes ↓ Albumin Ileus Altered LOC GCS < 13 Confusion Tachypnea SaO2 <90% PaO2/FiO2 ≤300 ↓ Urine output ↑ Creatinine > 110 ↓ Platelets < 150 ↑ PT/APTT ↓ Protein C ↑ D-dimer

SOFA

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SLIDE 19

Tachycardia Hypotension MAP < 70 Vasodilation Bilirubin > 20 ↑ Enzymes ↓ Albumin Ileus Altered LOC GCS < 13 Confusion Tachypnea SaO2 <90% PaO2/FiO2 ≤300 ↓ Urine output ↑ Creatinine > 110 ↓ Platelets < 150 ↑ PT/APTT ↓ Protein C ↑ D-dimer

Additional Tests

 Blood cultures  Lactate  VBG  Urinalysis  CXR  CK/Troponin

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SLIDE 20
  • Mr. R

Vita l Sig ns

  • T

e mpe ra ture 38.0oC

  • 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
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“Wha hat S Shoul uld W We Do Do Now?”

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Fluids

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“How M Much F Fluid S Should W We G Give?”

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(2015 Revisions)

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(2015 Revisions)

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Blood Interstitium Cell

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LUNGS ABDOMEN

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AFTER ER E EVER ERY B BOLUS US

REASSESS!:

⇢Targets: Lactate, MAP trend, urine output, neuro status ⇢Passive leg raise! (Yes, really!) ⇢Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) Appearance overall

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SLIDE 38

AFTER ER E EVER ERY B BOLUS US

REASSESS!:

⇢Targets: Lactate, MAP trend, urine output, neuro status ⇢Passive leg raise! (Yes, really!) ⇢Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) Appearance overall

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SLIDE 39

AFTER ER E EVER ERY B BOLUS US

REASSESS!:

⇢Targets: Lactate, MAP trend, urine output, neuro status ⇢Passive leg raise! (Yes, really!) ⇢Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) Appearance overall

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AFTER ER E EVER ERY B BOLUS US

REASSESS!:

⇢Targets: Lactate, MAP trend, urine output, neuro status ⇢Passive leg raise! (Yes, really!) ⇢Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) Appearance overall

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SLIDE 41

AFTER ER E EVER ERY B BOLUS US

REASSESS!:

⇢Targets: Lactate, MAP trend, urine output, neuro status ⇢Passive leg raise! (Yes, really!) ⇢Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) Appearance overall

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SLIDE 42

AFTER ER E EVER ERY B BOLUS US

REASSESS!:

⇢Targets: Lactate, MAP trend, urine output, neuro status ⇢Passive leg raise! (Yes, really!) ⇢Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) Appearance overall

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I g a ve 2L whe n the la c ta te wa s 5. It’s still 5!

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Why i is t the LACTATE still h ll high?

Reperfusion? Ischemia? Organ failure? It’s Just Not Going to Get Better

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Antibiotics

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Remove Tubes & Lines! CXR ?Other Imaging? Back to the History! Blood cultures! Urinalysis! Roll your patient

  • ver!
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A positive urinalysis isn’t always urosepsis, smartypants.

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…and don’t relax just because the chest x-ray looks fine, either.

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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
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SLIDE 51

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
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SLIDE 52

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
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SLIDE 53

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
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If the WBC > 30 and the risks are right… THINK C.DIFF!

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Ceftriaxone and Azithromycin for presumed community- acquired pneumonia

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Cut off is Hb 70 unless:

  • Active bleeding
  • Acute coronary

syndrome

Blood

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Pe rsiste nt Ba dne ss

“I’ve give n him 3L

  • f fluid and the systolic

pr e ssur e is still only 75… ”

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Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance

Stroke Volume x Heart Rate Preload Contractility

[Afterload]

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What’s happening here?

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Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance

Stroke Volume x Heart Rate

Preload

Contractility

[Afterload]

Volume Responsive Limited Volume Response Dehydration Insensible Losses Bleeding Obstructive

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Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance

Stroke Volume x Heart Rate Preload

Contractility

[Afterload]

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Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance

Stroke Volume x Heart Rate Preload Contractility

[Afterload]

Distributive Shock

Sepsis

Anaphylaxis Neurogenic Steroid Insufficiency Liver failure

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FLOW

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We Still Ha ve Pe rsiste nt Ba dne ss

“I’ve give n him 3L

  • f fluid and the systolic

pr e ssur e is still only 75… ”

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FLOW

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Think about pressors after 2-3L but be prepared to see raised eyebrows…!

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AFTE TER TH THE B BOLUSES

REASSESS:

⇢Targets: Lactate, MAP trend, urine output, neuro status ⇢Passive leg raise! (Yes, really!) ⇢Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) Appearance overall

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IV Ac c e ss

“He has an iv but doe sn’t have a c e ntr al line ? Should we

  • r

de r a PICC? ”

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Whe r e is the BE ST Site for the L ine ?

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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.”

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  • Source?
  • Shock?
  • Vasopressor?
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Key Concepts