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

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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 Chestwheeze, crackles Robert M. Rodriguez, MD FAAEM Tender sternum and ribs without crepitus Clinical Professor of Medicine

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2/1/2013 1

Robert M. Rodriguez, MD FAAEM Clinical Professor of Medicine and Emergency Medicine, UCSF

Case 1:

40 yo Male restrained driver high speed MVA  P 140, RR 40 labored, BP 100/70, O2 sat 70  Chest—wheeze, crackles  Tender sternum and ribs without crepitus  FAST negative  Head, neck, abdominal/pelvis CT negative You expertly intubate him

Ventilation for ARDS—Pulmonary Contusion

Use PEEP for hypoxia—open lung Low tidal volume (6 cc/kg) High rate (20 or more) Control pressures (plateau < 30) Permissive hypercapnea

Continued Hypoxia on 100%: Improve Oxygenation—2 ways

 Improve gas exchange in the lung

 PEEP  Prostacyclin/Epoprostenol  Prone positioning

 Improve situation in the periphery (systemic efforts)

 Increase O2 delivery (Increase cardiac output)

 Decrease metabolism/oxygen demand

Step 1 (lung)‐‐PEEP

Recruits (opens) collapsed alveoli Changes compliance curve Best for diffuse symmetric disease (ARDS/contusion) Not so good for differential lung disease (patchy one sided pneumonia)

PEEP recruitment maneuver

 FiO2 100%, hyperventilate for 30 seconds  Put on CPAP at 20 cm H2O  Increase CPAP to 30 cm H2O for 10 seconds  Increase CPAP to 40 cm H2O for 40 seconds  Decrease CPAP to 30 cm H2O for 10 seconds  Set PEEP to 20‐25 cm H2O and resume ventilation  Monitor carefully –dysrhythmias

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2/1/2013 2 Step 2 (systemic): Optimize O2 delivery

O2 delivery = HR x SV x Hb x 1.34 x O2 content Transfuse to around HB 10 Optimize CO‐‐?Dobutamine? Follow mixed venous sat or lactate levels

Decrease O2 Consumption

Sedate‐‐Narcotics Paralyze? Treat fever

Should you paralyze?

 Concerns of prolonged weakness/paralysis—stuck on vent  NEJM RCT—double blind

 Within 48 hours onset  Better 90 day survival  Increase time of survival  No increase weakness

Step 3‐‐

Prostacyclin/epoprostenol

Prostaglandin made by endothelial cells Pulmonary vasodilator IV or inhaled Virtually identical improvement pO2 as NO Not toxic/easier to use 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

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ECMO

Australia: H1N1 Flu—severe hypoxemic resp failure 48/68 = 71% survived to ICU discharge Review of 3 RCTs showed mortality benefit Odds Ratio mortality 0.78 Recent large RCT showed significant benefit Make a plan Use for young Transfer early

Case 2:

60 yo homeless male h/o EtOH C/O cough, SOB, fever T 41.4, P 140, RR 40 labored, BP 100/70, Sat 70% on 100% NRB Chest—ronchi on the left, right clear

Bad unilateral pneumonia: Still use low tidal volume

Meta‐analyis of 20 studies—non ARDS Lower mortality Lower incidence of lung injury Lower incidence of nosocomial infections

Hypoxia with unilateral lung disease

Avoid excessive PEEP USE GRAVITY‐‐‐GOOD LUNG DOWN!

Fluids when hypoxic: Depends

n perfusion and timing

Early fluid resuscitation (save the kidneys) Shock mortality correlates with renal failure EGDT (early fluids rather than later) Don’t worry about volume overload WHEN IN SHOCK

Later fluids (save the lung)

Established ARDS—conservative fluid better

Less time on vent Fewer ICU days No change in organ failure Only when no longer shock

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Case 3

60 yo F COPD C/O cough, SOB T 37, P 120, RR 30 labored, BP 100/70, Sat 80 Chest—wheeze, little air movement Awake, 2 word sentences ABG ‐‐ 7.20/70/70

BiPAP

Early rather than late Better for COPD than asthma Not so good for pneumonia

How to make BiPAP work

If no improvement post 20 min—won’t work Sit there with them Adjust straps Adjust I and E appropriately Sedatives can help

Fentanyl KETAMINE

Case 4:

68 yo male VF arrest ROSC with defibrillation Intubated Vent settings?

Hyperoxia after Cardiac Arrest

Is too much oxygen bad post‐arrest? Post‐arrest: oxidant stress leads to increased cell death Experimental models of hyperoxia

Worse oxidative stress Worse neuro outcomes

Kilgannon: Hyperoxia

Adults post‐medical arrest Over 6200 ICU patients ABG in first 24 hours:

Hyperoxia: > 300 mm Hg: 18% Normoxia: < 300 mm Hg: 19% Hypoxia: < 60 mm Hg: 63%

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Hyperoxia

Hyperoxia—highest mortality (63%) Hypoxia– (57%) Normoxia– (45%) Among survivors significantly lower independent function with hyperoxia (29% vs 38%) Odds ratio poor outcome 1.8 for hyperoxia

Bottom Line—FiO2

No reason to give too much Titrate down using pulse oxymetry to sat

95%

Case 4

 72 yo female with urosepsis  Has history of CHF  Hypotensive 76/48  HR 120

What type of fluids?

Crystalloid Colloid does not work with possibly 1 exception Bicarb not helpful even in extreme acidosis

How to do Early Goal Directed Therapy without Catheters

3rd goal in EGDT = ScvO2 > 70 Traditional: catheter for serial ScvO2 Catheters expensive and not widely available Most hospitals not prepared to do this with catheters

Lactate for EGDT

Lactate is best perfusion marker in sepsis Serial lactates equivalent to ScVO2 Clearance of 10% lactate Send every 2 hours Peripheral venous is fine

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Which crystalloid in sepsis

 Sequential trial of ICU patients  First 780 patients given mostly chloride rich (NS)  Washout period, then 780 rescrictive chloride (Lactated Hartmann’s, plasmalyte) Chloride group had more AKI, more renal replacement therapy

Bottom line—not definitive, but would switch to LR after 2 liters of NS

Vasopressors—when?

When do you start pressor? ANYTIME—don’t have to wait for “full tank” Quick burst: ephedrine or phenylephrine

Sepsis: Dopamine vs NE

Surviving sepsis campaign – both dopamine and norepinephrine first line Critical Care Med meta‐analysis:

2800 patients Dopa greater mortality and more

dysrhythmias

Sepsis pressors: Bottom line

 Prob should use NE  Look at HR

 If low HR, might use dopamine  If high HR or any dysrhythmias—use NE