PEEP recruitment maneuver Step 1 (lung) PEEP Recruits (opens) - PDF document

2/1/2013 Case 1: 40 yo Male restrained driver high speed MVA  P 140, RR 40 labored, BP 100/70, O 2 sat 70  Chest—wheeze, crackles Robert M. Rodriguez, MD FAAEM  Tender sternum and ribs without crepitus Clinical Professor of Medicine and Emergency Medicine,  FAST negative UCSF  Head, neck, abdominal/pelvis CT negative You expertly intubate him Continued Hypoxia on 100%: Ventilation for ARDS—Pulmonary Improve Oxygenation—2 ways Contusion  Improve gas exchange in the lung  Use PEEP for hypoxia—open lung  PEEP  Low tidal volume (6 cc/kg)  Prostacyclin/Epoprostenol  Prone positioning  High rate (20 or more)  Control pressures (plateau < 30)  Improve situation in the periphery (systemic efforts)  Permissive hypercapnea  Increase O 2 delivery ( Increase cardiac output)  Decrease metabolism/oxygen demand PEEP recruitment maneuver Step 1 (lung) ‐‐ PEEP  Recruits (opens) collapsed alveoli  FiO 2 100%, hyperventilate for 30 seconds  Put on CPAP at 20 cm H 2 O  Changes compliance curve  Increase CPAP to 30 cm H 2 O for 10 seconds  Best for diffuse symmetric disease  Increase CPAP to 40 cm H 2 O for 40 seconds (ARDS/contusion)  Decrease CPAP to 30 cm H 2 O for 10 seconds  Not so good for differential lung disease  Set PEEP to 20‐25 cm H 2 O and resume ventilation (patchy one sided pneumonia)  Monitor carefully –dysrhythmias 1

2/1/2013 Decrease O 2 Consumption Step 2 (systemic): Optimize O 2 delivery  Sedate‐‐Narcotics  O 2 delivery = HR x SV x Hb x 1.34 x O 2  Paralyze? content  Treat fever  Transfuse to around HB 10  Optimize CO‐‐?Dobutamine?  Follow mixed venous sat or lactate levels Step 3 ‐‐ Should you paralyze? Prostacyclin/epoprostenol  Prostaglandin made by endothelial cells  Concerns of prolonged weakness/paralysis—stuck on vent  Pulmonary vasodilator  NEJM RCT—double blind  IV or inhaled  Within 48 hours onset  Virtually identical improvement pO 2 as NO  Better 90 day survival  Increase time of survival  Not toxic/easier to use  No increase weakness  Lasts a few days Rescue Maneuvers: Prone positioning  Improves atelectasis/heart compression of lung  Improves V/Q  Lasts days to week  No improve mortality  How?  VERY CAREFULLY  Rotational beds 2

2/1/2013 Case 2: ECMO 60 yo homeless male h/o EtOH C/O cough, Australia: H1N1 Flu—severe hypoxemic resp failure SOB, fever 48/68 = 71% survived to ICU discharge  T 41.4, P 140, RR 40 labored, BP 100/70, Sat Review of 3 RCTs showed mortality benefit 70% on 100% NRB Odds Ratio mortality 0.78  Chest—ronchi on the left, right clear Recent large RCT showed significant benefit Make a plan Use for young Transfer early Bad unilateral pneumonia: Still use low tidal volume Hypoxia with  Meta‐analyis of 20 studies—non ARDS  Lower mortality unilateral lung disease  Lower incidence of lung injury  Lower incidence of nosocomial infections Avoid excessive PEEP USE GRAVITY‐‐‐GOOD LUNG DOWN! Fluids when hypoxic: Depends Later fluids (save the lung) on perfusion and timing  Established ARDS—conservative fluid better  Less time on vent  Early fluid resuscitation (save the kidneys)  Fewer ICU days  Shock mortality correlates with renal failure  No change in organ failure  EGDT (early fluids rather than later)  Only when no longer shock  Don’t worry about volume overload WHEN IN SHOCK 3

2/1/2013 Case 3 BiPAP  60 yo F COPD  Early rather than late  C/O cough, SOB  Better for COPD than asthma  T 37, P 120, RR 30 labored, BP 100/70, Sat 80  Not so good for pneumonia  Chest—wheeze, little air movement  Awake, 2 word sentences  ABG ‐‐ 7.20/70/70 How to make BiPAP work Case 4: 68 yo male VF arrest  If no improvement post 20 min—won’t work ROSC with defibrillation  Sit there with them Intubated  Adjust straps  Adjust I and E appropriately Vent settings?  Sedatives can help  Fentanyl  KETAMINE Hyperoxia after Cardiac Arrest Kilgannon: Hyperoxia  Adults post ‐ medical arrest  Is too much oxygen bad post ‐ arrest?  Over 6200 ICU patients  Post ‐ arrest: oxidant stress leads to increased  ABG in first 24 hours: cell death  Hyperoxia: > 300 mm Hg: 18%  Experimental models of hyperoxia  Normoxia: < 300 mm Hg: 19%  Worse oxidative stress  Hypoxia: < 60 mm Hg: 63%  Worse neuro outcomes 4

2/1/2013 Hyperoxia Bottom Line—FiO2  Hyperoxia—highest mortality (63%)  No reason to give too much  Hypoxia– (57%)  Titrate down using pulse oxymetry to sat  Normoxia– (45%) 95%  Among survivors significantly lower independent function with hyperoxia (29% vs 38%)  Odds ratio poor outcome 1.8 for hyperoxia Case 4 What type of fluids?  72 yo female with urosepsis  Crystalloid  Has history of CHF  Hypotensive 76/48  Colloid does not work with possibly 1  HR 120 exception  Bicarb not helpful even in extreme acidosis How to do Early Goal Directed Therapy without Catheters Lactate for EGDT  Lactate is best perfusion marker in sepsis  3 rd goal in EGDT = ScvO2 > 70  Serial lactates equivalent to ScVO2  Traditional: catheter for serial ScvO2  Clearance of 10% lactate  Send every 2 hours  Catheters expensive and not widely available  Most hospitals not prepared to do this with  Peripheral venous is fine catheters 5

2/1/2013 Which crystalloid in sepsis Vasopressors—when?  Sequential trial of ICU patients When do you start pressor?  First 780 patients given mostly chloride rich (NS)  Washout period, then 780 rescrictive chloride (Lactated Hartmann’s, plasmalyte) ANYTIME—don’t have to wait for “full tank” Chloride group had more AKI, more renal replacement therapy Quick burst: ephedrine or phenylephrine Bottom line—not definitive, but would switch to LR after 2 liters of NS Sepsis: Dopamine vs NE Sepsis pressors: Bottom line  Prob should use NE  Surviving sepsis campaign – both dopamine  Look at HR and norepinephrine first line  If low HR, might use dopamine  Critical Care Med meta ‐ analysis:  If high HR or any dysrhythmias—use NE  2800 patients  Dopa greater mortality and more Add vasopressin if refractory shock (fixed dose) dysrhythmias No clear mortality benefit Allows lower NE dose Etomidate for sepsis Post ‐ intubation care intubation?  2 independent meta ‐ analyses  Watch for hypotension—push fluids  Both show with single dose etomidate  No nasal tubes  Increased adrenal insufficiency and  HOB at 30  Increased mortality  Oral gastric tube  GI prophylaxis Bottom line: We have alternatives  Give sedative, esp if used rocuronium (ketamine) so use them. 6