Question 1 Lecture Outline A 42 yo woman is brought to the ED - - PDF document

1

Critical Care ABIM Certification Exam Review Course

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

Conflict of Interest/Disclosures

n None

Lecture Outline

n Resuscitation (first 6 hours) n Ventilators/ARDS (first 6 hours) n Sepsis n GI issues n Odd and ends for $200

Question 1

A 42 yo woman is brought to the ED pulseless. Resuscitation is started. Extremities reveal multiple skin scars c/w with long standing IVDU. Peripheral IV access cannot be obtained. Which of the following is the best option for access?

• A. Continued attempt at peripheral vein access
• B. Internal jugular vein
• C. External jugular vein
• D. Femoral vein
• E. Intraosseus access

2

Question 1

A 42 yo woman is brought to the ED pulseless. Resuscitation is started. Extremities reveal multiple skin scars c/w with long standing IVDU. Peripheral IV access cannot be obtained. Which of the following is the best option for access?

• A. Continued attempt at peripheral vein access
• B. Internal jugular vein
• C. External jugular vein
• D. Femoral vein
• E. Intraosseus access

Code blue access

Neck access interferes with intubation and crowds the head of the bed Femoral access: “accuracy” is difficult à no pulse so easy to confuse artery and vein (ABG in code may not distinguish) Intraosseus: quick access; can use x 24 hours

• Do need to create a “space” in medullary bone
• Infusions require pressure bag

Intraosseous Access

Create “pocket” with IVP saline All drips with pressure bag

Question 2

A 52 yo man admitted for pancreatitis suddenly becomes unresponsive and has no pulse or

• respirations. Resuscitation is started. Initial rhythm

is PEA. Which of the following suggests a “Return

• f Spontaneous Circulation” or ROSC during the

code?

• A. A change to “fine” ventricular fibrillation on

monitor

• B. A sudden decrease in serum lactic acid
• C. A sudden increase in ET CO2
• D. Pupils 4-5 mm in diameter

3

Question 2

A 52 yo man admitted for pancreatitis suddenly becomes unresponsive and has no pulse or

• respirations. Resuscitation is started. Initial rhythm

is PEA. Which of the following suggests a “Return

• f Spontaneous Circulation” or ROSC during the

code?

• A. A change to “fine” ventricular fibrillation on

monitor

• B. A sudden decrease in serum lactic acid
• C. A sudden increase in ET CO2
• D. Pupils 4-5 mm in diameter

Hospital Codes are changing….

§ Hospital: More PEA and less Vtach/Vfib (better cardiac interventions à smaller MIs, more AICDs?) § Survival rates are better! (15.4%) § Separate study à if > 65 and survived to d/c post code, 50% alive at 1 year*

Lancet 2012;380:1473. * NEJM 2013;368:11.

ACLS– Using ET CO2 Monitoring

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

www.nonin.c om

In contrast Good à ETT in airways ET CO2 flat lines? Apnea or ETT out How about?

Question 2

A 52 yo man admitted for pancreatitis suddenly becomes unresponsive and has no pulse or

• respirations. Resuscitation is started. Initial rhythm

is PEA. Which of the following suggests a “Return

• f Spontaneous Circulation” or ROSC during the

code?

• A. A change to “fine” ventricular fibrillation on

monitor

• B. A sudden decrease in serum lactic acid
• C. A sudden increase in ET CO2
• D. Pupils 4-5 mm in diameter

Asystole usually nextL Not good Improved washout or drop in CO? Bad

4

Updates on BLS ACLS (2015)…

n Chest compressions first n 2 inches depth on adults, full recoil n Check for breathing and carotid pulse at the

same time (10 seconds max)

n Chest compressions 100/min à 100 -120/ min n Vasopressin: no advantage n For suspected Opioid overdose:

• pulse but diminished breathing: IM or IN

(intra- nasal) Narcan

• if opiate-suspected cardiac arrest: Narcan

autoinjector (IM)

SAME

Question 3

A 52 yo man admitted with chest pain and has a Vfib arrest. After 30 minutes, he is resuscitated. VSs post code are HR 110, BP 95/60, RR: intubated; no spontaneous breaths. He remains

• unresponsive. Cardiology is coming to the
• bedside. Next steps are:
• A. Anticoagulation
• B. Central line access to target CVP 8-12 mmHg
• C. Hypothermia to 32-34oC
• D. Placement of an IABP
• E. Tight glucose control

Question 3

A 52 yo man admitted with chest pain and has a Vfib arrest. After 30 minutes, he is resuscitated. VSs post code are HR 110, BP 95/60, RR: intubated; no spontaneous breaths. He remains

• unresponsive. Cardiology is coming to the
• bedside. Next steps are:
• A. Anticoagulation
• B. Central line access to target CVP 8-12 mmHg
• C. Hypothermia to 32-34oC
• D. Placement of an IABP
• E. Tight glucose control

Post Code Care

§ Determine cause:

• Cardiac, PE, PTX, AAA rupture, GI bleed,

Drug, electrolytes, sepsis

§ Maintain MAP > 65 § Don’t over or under -ventilate § Avoid hypoxemia, but don’t keep PaO2 >

300

§ Therapeutic hypothermia if remains

unresponsive post code

5

Therapeutic Hypothermia

NEJM 2002;346:557-

• 63. Target =

33oC. NEJM 2002; 346:549-56. Target 32- 34oC.

Therapeutic Hypothermia

n Extended to in-hospital arrests n Extended to PEA arrests

Best temperature?

NEJM 2013; 369:2197-2206

33 vs. 36oC? No difference Definitely treat fever!

Question 3

A 52 yo man admitted with chest pain and has a Vfib arrest. After 30 minutes, he is resuscitated. VSs post code are HR 110, BP 95/60, RR: intubated; no spontaneous breaths. He remains unresponsive despite BP & HR. Cardiology is coming to the bedside. Next steps are:

• C. Hypothermia to 32-34oC
• E. Tight glucose control

Specifically post cardiac arrest?

• “Tight” control (70 to 108

mg/dL) no better than “good” control (up to 144 mg/dL)

Intensive Care Med. 2007;33:2093

Question 4

The new qSOFA score helps to diagnose early sepsis:

• A. True
• B. False

6

Question 4

The new qSOFA score helps to diagnose early sepsis:

• A. True
• B. False

Even the old SOFA score was more of an “organ dysfunction” score, not a way to diagnose sepsis

Identifying Risk in Early Sepsis: (intended to be used outside the ICU to ID

patient’s at risk of dying from sepsis)

Sequential (Sepsis-related) Organ Failure Assessment score (SOFA) Points for bad P/F ratio, MAP

• r pressor needs, bilirubin,

platelet count, creatinine/urine

• utput, GCS

quickSOFA (qSOFA): 2016 1 point each:

• respiratory rate ≥22/minute
• altered mentation
• systolic BP ≤100 mmHg

A score ≥2 is associated with poor outcomes due to sepsis

Sepsis Definition

Sepsis is a clinical syndrome that has physiologic, biologic, and biochemical abnormalities caused by a dysregulated inflammatory response to infection.

n Key elements are

• Organ dysfunction
• Infection

Septic shock is sepsis that has circulatory or metabolic abnormalities such as persistent hypotension or elevated lactate despite adequate fluid resuscitation SIRS: T > 38°C or < 36°C; HR >90; RR>24 or PaCO2 <32; WBC >12k or < 4k. > 2 = SIRS

Epidemiology of Sepsis

More sepsis… …But better outcomes

7

Question 5

75 year old man with pneumonia. T 104oF , 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

Question 5

A 75 year old man with… After 2L .9NS: pulse 110, BP 75/50 (MAP=58) Hgb 10.5 At this time, you should:

• A. Assess volume status by some means
• B. Measure SMVO2
• C. Start ECMO
• D. Start Norepinephrine IV to target MAP of 80
• E. Transfuse packed RBCs

Question 5

A 75 year old man with… After 2L .9NS: pulse 110, BP 75/50 (MAP=58) Hgb 10.5 At this time, you should:

• A. Assess volume status by some means
• B. Measure SMVO2
• C. Start ECMO
• D. Start Norepinephrine IV to target MAP of 80
• E. Transfuse packed RBCs

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

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

Single RTC; single center

n CVP 8-12 mmHg n MAP > 65 mmHg n UO > .5 cc/kg/hr n SVC O2 sat (Scvo2) > 70% or SMVo2 >

65% >Transfusion or Dobutamine for this last goal…

Trip down memory lane…Surviving Sepsis: Recommendations

Crit Care Med 2012 Adherence low in f/u international performance study

8

VS.

A Randomized Trial of Protocol-Based Care for Early Septic Shock The ProCESS Investigators NEJM 2014; 370:1683.

1351 Patients Protocol “standard therapy” Protocol EGDT “Usual” care

VS.

Protocol “standard therapy” Protocol EGDT “Usual” care

üCentral Line üFluids til CVP 8-12 üOnce at CVP goal, Pressors til MAP > 65 üOnce at MAP goal, if ScvO2 < 70% üTransfuse to Hct 30 üIf Hct > 30, add inotrope (dobutamine) ü2 large peripheral IVs ü2 L fluid (1 hour target) unless tank full üIf SBP < 100, more fluids (.5L units) unless tank full àPressors (target 1 hour) üIf SBP > 100, but high lactate, low UO, etc., recheck volume status

Bedside MD made all decisions

VS.

Protocol “standard therapy” Protocol EGDT “Usual” care

üCentral Line üFluids til CVP 8-12 üOnce at CVP goal, Pressors til MAP > 65 üOnce at MAP goal, if ScvO2 < 70% üTransfuse to Hct 30 üIf Hct > 30, add inotrope (dobutamine) ü2 large peripheral IVs ü2 L fluid (1 hour target) unless tank full üIf SBP < 100, more fluids (.5L units) unless tank full àPressors (target 1 hour) üIf SBP > 100, but high lactate, low UO, etc., recheck volume status

Bedside MD made all decisions

Early fluid bolus: Are we just doing this now anyway?

Question 5

A 75 year old man with… After 2L NS: pulse 110, BP 75/50 (MAP=58) Hgb 10.5 At this time, you should:

• A. Assess volume status by some means
• B. Measure SMVO2
• C. Start ECMO
• D. Start Norepinephrine IV to target MAP of 80
• E. Transfuse packed RBCs

Rescue for hypoxemia, not hypotension

9

Question 5

A 75 year old man with… After 2L NS: pulse 110, BP 75/50 (MAP=58) Hgb 10.5 At this time, you should:

• A. Assess volume status by some means
• B. Measure SMVO2
• D. Start Norepinephrine IV to target MAP of 80
• E. Transfuse packed RBCs

Use standard cut-off of 7 mg/dl

TRISS trial confirmed in ACUTELY SEPTIC patients NEJM 2014;371:1381

Question 5

A 75 year old man with… After 2L NS: pulse 110, BP 75/50 (MAP=58) Hgb 10.5 At this time, you should:

• A. Assess volume status by some means
• B. Measure SMVO2
• D. Start Norepinephrine IV to target MAP of 80

What is the best target for MAP?

• MAP better indication of perfusion pressure than Sys/Dias
• > 60 required for tissue perfusion pressure
• Target is > 65
• Is higher better?

?

NEJM 2014;370:1583 MAP 65-70 vs. 80-85? Just more afib

Question 5

A 75 year old man with… After 2L NS, pulse 110, BP 75/50 Hgb 10.5 At this time, you should:

• A. Assess volume status by some means
• B. Measure SMVO2

After volume status assessment SCVO2 = SCENTRALVENOUSO2 SMVO2 = SMIXEDVENOUSO2

O2 O2

Oxygen Consumption CaO2-CvO2

CO=

75% 95%

SvO2:

• Low is bad (<60%)
• Dropping is bad

Question 5

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

“EGDT”: Rivers protocol criticism Static CVP doesn’t tell you much about where you are

• n curve

Cardiac Output LVEDV Will adding volume help? Pulmonary edema

10

Q 6: All of the following may be useful parameters for assessing tissue perfusion in septic patients EXCEPT?

• A. Aortic blood flow peak velocity variation
• B. Straight leg raise
• C. Lactate clearance
• D. PCWP
• E. Respiratory change in the radial artery pulse

pressure

Q 6: All of the following may be useful parameters for assessing tissue perfusion in septic patients EXCEPT?

• A. Aortic blood flow peak velocity variation
• B. Straight leg raise
• 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

Cardiac Output LVEDV

Same thing happens on A-line

Peak to peak systolic variation

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

11

Same thing happens with straight leg raise

Increased venous return BP goes up? Suggests volume may help!

Bedside Ultrasound Assessment

n Yes, we do check JVP…

T

• p of column

Short Axis Long Axis

Let’s find the IVC! (Happy Whale)

Plump and doesn’t vary with respiration à volume repleted Narrow and collapses a lot with respiration à more volume may help increase BP

Ultrasound of IVC

Lactate clearance

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

12

Q 5: All of the following may be useful parameters for assessing tissue perfusion in septic patients EXCEPT?

• A. Aortic blood flow peak velocity variation
• B. Straight leg raise
• C. Lactate clearance
• D. PCWP
• E. Respiratory change in the radial artery pulse

pressure

PCWP: poor predictor of fluid responsiveness in sepsis; following PCWP has not been shown to improve outcomes.

Can you ever have too much fluid?

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

ALI

If pulmonary edema at start à diuretics. If low CI and urine output à 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 2: 2.5L NET Day 3, 4: + 1L/day Days 5, 6, 7: +.5 L/day Lasix/fluid to target CVP 4-8 Day 2: 1.1L NET Day 3, 4:

• 0.4L/day

Days 5, 6, 7: even/day

No change 60 day mortality

Don’t use that term anymore

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 àGive volume bolus (2L seems good) then assess some parameter and ask do you still need? In ED, don’t be afraid of volume resuscitation upfront in hypotensive patients with flat neck veins!

BUT

Question 7

A 49-year-old man presents with hypotension, abdominal pain and evidence

• f acute pancreatitis. Large-volume fluid

resuscitation with .9NS has been associated with which of the following?

• A. Metabolic alkalosis
• B. Acute kidney injury
• C. Increased transfusion needs

13

Question 7

A 49-year-old man presents with hypotension, abdominal pain and evidence

• f acute pancreatitis. Large-volume fluid

resuscitation with .9NS has been associated with which of the following?

• A. Metabolic alkalosis
• B. Acute kidney injury
• C. Increased transfusion needs

More hyperchloremic metabolic acidosis Not really

Volume Resuscitation

What doesn’t work?

n Starch (more AKI, more dialysis) n Albumin (worse mortality in TBI)… but story

not done in sepsis…

Colloids Crystalloids Albumin .9NS Gelatin Lactated Ringers Dextran Lactated acetate Hydroxyethyl Starch (HES) Hartmann’s solution Colloids: no difference in volume requirements

Volume Resuscitation

Crystalloids What is it? Tonicity .9NS 154 mEq Na & Cl Hypertonic (308 mosm/L) Lactated Ringers Na 130; K 4.5 Cl 109; Ca 2.7 Lactate 28 Hypotonic (280 mosm/L) Hartmann’s solution Na 131; K 5 Cl 111; Ca 4 Lactate 29 Hypotonic (279 mosm/L)

n JAMA. 2012 Oct 17; 308(15):1566-72 : chloride-

rich versus chloride-poor solutions. There was less AKI and RRT with chloride-poor solutions.

Question 8

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

14

Question 8

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

Dopamine vs. Norepinephrine

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

N Engl J Med. 2010;362:779.

Summarizing Sepsis Resuscitation

n 2L .9NS immediately, then reassess, .5 L

boluses if more fluid

n Early source control n Norepinephrine best pressor n MAP to 65 n If lots of fluids needed, consider switch to

LR to protect the kidneys

Question 9

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

15

Question 9

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 9

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 9

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 9

This woman: likely has autoimmune adrenalitis (most common cause of Addisons in US) Y

• u should order (in addition to volume resuscitation):
• A. Abdominal CT scan
• B. Ceftriaxone + V

ancomycin

• 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

16

Glucose control in the ICU

VISEP study: NEJM 2008;358:125. Septic patients targeted glucose 80-1 10 vs. 180-200. Stopped early due to high rate of hypoglycemia. Glucontrol study: Intensive Care Med 2009;35:1738. Targeted glucose 80-1 10 vs. 140-180. Stopped early due to trend towards increased mortality in hypoglycemic patients. NICE SUGAR: NEJM 2009;360:1283 & NEJM 2012:367;1

• 108. Large, international, randomized

trial of adults in ICU. Targeted glucose 81-108 higher mortality than <180. And hypoglycemia associated with higher mortality. Less < 180 mg/dL reasonable

Question 10

A 68 yo man with a history of HTN and DM presents to the ED with confusion, SOB, and increasing peripheral edema. Exam: afebrile 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 52/ PaO2 45

Question 10

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 55/ PaO2 52

Question 10

68 yo with CHF Initial ABG: 7.30/ PaCO2 52/ PaO2 45 F/u ABG 2 LPM O2: 7.29/ PaCO2 55/ 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

17

Question 10

68 yo with CHF Initial ABG: 7.30/ PaCO2 52/ PaO2 45 F/u ABG 2 LPM O2: 7.29/ PaCO2 55/ 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

NiPPV

Non-invasive Positive Pressure Ventilation

n Ventilation without endotracheal tube or

tracheostomy

n Best in rapidly reversible conditions: CHF,

COPD exacerbation, or post-extubation (new data on high flow O2 – this may be better)

NiPPV

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

• effort. This

improves PaCO2 & decreases work of breathing

www.c lev elandc linic m eded.c om

Why does it work?

n Decreases

microatelectasis

n Drives water out of

alveoli

n Larger tidal volume

with same inspiratory effort

n If ventilator, can

add mandatory rate Oxygenation Work of Breathing

n Positive pressure

counterbalances inspiratory threshold related to intrinsic PEEP

n Reduction in

inspiratory muscle work

n No ETT resistance

load CO2 elimination if BPAP

18

Potential Disadvantages of NiPPV (vs. intubation)

n

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

n

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

n

• No airway protection if aspiration
• Suctioning of secretions harder

System Mask Airway

Complications of NIV

• 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/low TV , 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 à Secretions, hypoxic with metabolic acidosis, and ventilation is ok à NiPPV ? NO!!!

NiPPV

NiPPV- if going to work, should see improvement clinically and in PaCO2 within 2-3 hours. Key is balance between avoiding intubation with risk of V AP 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.

19

How to start?

n Head of bed up 30+ degrees n RT able to be 1:1 with patient n Select mask (small, medium, large) n Select machine (CHF:CPAP/BPAP; COPD:BPAP) n Oxygen to keep saturation > 90% n If BPAP è Start low IPAP 8-10; EPAP 5, then increase

IPAP

n Put mask up to patient’s face, few breaths, take off and

reassure patient, place back on; patient can hold

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

∆ Drives TV EPAP prevents early airway closure increases FRC

CPAP vs. BPAP in CHF?

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

BPAP CPAP NEJM 2008;359:142

NiPPV for Respiratory Failure

Best mask?

n Full face mask: Best physiologic and arterial blood

gas improvement

n Nasal mask: More comfortable, easier to cough up

secretions, easier to speak

n 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, BPAP =

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

20

Check for Leaks

n Look at patient à noisy leak? n Look at display and compare inspiratory

tidal volume to expiratory tidal volume

Question 10

68 yo with initial ABG: 7.30/ PaCO2 52/ PaO2 45 F/u ABG on 2 LPM O2: 7.29/ PaCO2 55/ 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 11

A 65-year-old man presents with increased shortness of breath in the setting of urosepsis. ABG: pH 7.23/ PCO2 30/PO2 55 on 6 LPM NC. He is awake and alert. His chest x-ray shows diffuse pulmonary infiltrates. His JVP is low, ultrasound of his IVC shows collapse with respiration. He should be managed with which the following?

• A. Noninvasive positive pressure ventilation

B.

Oxygen via facemask

C.

High flow nasal cannula

Question 11

A 65-year-old man presents with increased shortness of breath in the setting of urosepsis. ABG: pH 7.23/ PCO2 30/PO2 55 on 6 LPM NC. He is awake and alert. His chest x-ray shows diffuse pulmonary infiltrates. His JVP is low, ultrasound of his IVC shows collapse with respiration. He should be managed with which the following?

• A. Noninvasive positive pressure ventilation

B.

Oxygen via facemask

C.

High flow nasal cannula

21

“Early” ARDS

Frat JP et al. FLORALI Study. “High flow oxygen through nasal cannula in acute hypoxemic respiratory failure.” NEJM 2015 372: 2185.

All Patients PaO2:FIO2 < 200 (worse ARDS)

LESS INTUBATION

Intubation Intubation

“Early” ARDS

BETTER SURVIVAL

Was tidal volume goal set too high (7-10 cc/kg)?

Bottom Line: Respiratory Failure

CHF COPD Early ARDS CPAP or BPAP High flow Nasal Cannula BPAP

And of course, don’t delay intubation if patient failing

NIV

Question 12

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 22/.300)

Next, you should:

• A. Decrease FIO2 to 30%
• B. Give him Diamox (acetazolamide)
• C. Extubate now, see if he needs BP

AP later

• D. Extubate to High Flow Nasal Cannula
• E. Schedule tracheotomy
• F. Wait until RSBI is < 50

22

Question 12

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 22/.300)

Next, you should:

• A. Decrease FIO2 to 30%
• B. Give him Diamox (acetazolamide)
• C. Extubate now, see if he needs BP

AP later

• D. Extubate to High Flow Nasal Cannula
• E. Schedule tracheotomy
• F. Wait until RSBI is < 50

Post-extubation rescue

NEJM 2004; 350:2452. Patients with respiratory failure within 48 hours after extubation randomized to +/- trial of NIV . Mortality higher with delayed NIV! Waited too long? AJRCCM 2006;173:164. EARLY NIV at time of extubation for chronic CO2 retainers à less reintubation

Bottom Line: EXTUBATE STRAIGHT TO SUPPORT IN MARGINAL PATIENTS

Question 12

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 22/.300)

Next, you should:

• A. Decrease FIO2 to 30%
• B. Give him Diamox (acetazolamide)
• C. Extubate now, see if he needs BP

AP later

• D. Extubate to High Flow Nasal Cannula
• E. Schedule tracheotomy
• F. Wait until RSBI is < 50

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

Question 12

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 22/.300)

Next, you should:

• F. Wait until RSBI is < 50

Rapid Shallow Breathing Index

Bedside assessment of readiness to wean RSBI > 105 = predicts weaning failure RSBI < 105 à less predictive of weaning success Though lower is better, not likely that this person will get better. Waiting may just mean longer on vent. NEJM 1991;324(21):1445.

23

Question 12

64 yo man with COPD with FEV1 of .9L (40%) was intubated x 5 days for pneumonia. Afebrile, minimal secretions, awake ABG: 7.39/60/60 on 35% FIO2 on 10/5 of pressure support. RSBI is 75. (f/TV in L 22/.300) Next, you should: Extubate to High Flow Nasal Cannula vs extubate to NIV (either good) (don’t wait until fails)

Delivers high flow humidified gas at whatever FIO2 set AJRCCM 2014; 190:282: and JAMA 2016;315:1354 Better tolerated than face mask, less need for rescue NIV and reintubation

Question 13

A 55 year old woman with asthma is admitted to the ICU following surgery for multiple fractures from a MV A 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 13

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

Question 13

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

24

Paw

PEEP Peak

Investigate high airway pressures

Plateau PEEP

Add inspiratory hold Paw

DDX and interventions

Airway problem (dynamic compliance) = Bronchospasm Mucus plugs Kinked ETT Biting tube

Big difference between

Peak & Plateau pressures

Paw

DDX and interventions

Airsac problem (static compliance)= Gradual: Worsening

• Pneumonia
• CHF
• ARDS

Fast:

• Pneumothorax

SMALL difference between

Peak & Plateau pressures

Paw

PEEP Peak

Investigate airway pressures

Plateau PEEP

Add inspiratory hold

High pressures? Look Listen Suction Ambu and Check plateau pressures

25

Question 13

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 airway pressures Peak↑ because Plateau↑ (small ∆) Low pressures

Question 14

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 mechanically ventilated with RR 20, TV 700 mL, FiO2 0.5, PEEP 5. Twenty minutes after intubation, BP drops to 80/30. ABG: 7.20/57/50. Breath sounds remain symmetrically decreased. Bedside ultrasound shows lung sliding bilaterally.

Question 14

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

• A. Briefly detach from ventilator
• B. Echocardiography
• C. Increase tidal volume to 800 mL
• D. Start norepinephrine (Levophed)
• E. Order CXR to rule out tension pneumothorax

Question 14

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

• A. Briefly detach from ventilator
• B. Echocardiography
• C. Increase tidal volume to 800 mL
• D. Start norepinephrine (Levophed)
• E. Order CXR to rule out tension pneumothorax

26

Dynamic Hyperinflation

n Big problem in COPD and asthma n Increased airway resistance à inadequate time

for expiration

n If not enough time for expiration, this can lead to

air trapping (i.e., auto-PEEP)

n Consequences: barotrauma (pneumothorax)

and hypotension

n Need to allow adequate time for expiration Flow

Inhalation Exhalation

Next breath starting before patient has fully exhaled 3 seconds

Dynamic Hyperinflation

Inadequate time for exhalation àHypotension not uncommon

• Hypovolemia
• Sedatives
• Excess ventilation

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

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! PaCO2 may go up! à permissive hypercapnea is usually well tolerated

Question 14

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

• A. Briefly detach from ventilator
• B. Echocardiography
• C. Increase tidal volume to 800 mL
• D. Start norepinephrine (Levophed)
• E. Order CXR to rule out tension pneumothorax

No risk factors for tamponade Low BP = problem & more ventilation might not lower PaCO2 Doesn’t address problem

27

Question 14

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

• A. Briefly detach from ventilator
• E. Order CXR to rule out tension pneumothorax

“Bedside ultrasound shows lung sliding bilaterally”

US for PTX: Look anterior chest wall lateral @ 2nd – 3rd ICS

May be more sensitive than CXR for PTX ICU patients are supine, so air goes anterior

Ultrasound: Lung

Ribs Skin Pleural Line

“Ants crawling on a log” = “lung sliding” = no pneumothora x (check both R & L sides!)

M-Mode: “Waves on the beach” = No pneumothorax

Waves Beach C Recall that M mode is single plane image over time; chest wall doesn’t move, but lung movement causes granular “beach” at lung depth

28

M-Mode: Pneumothorax

Waves, No beach

AKA “Bar Code” sign

Question 14

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

• A. Briefly detach from ventilator
• E. Order CXR to rule out tension pneumothorax

“Bedside ultrasound shows lung sliding bilaterally”

Makes PTX unlikely & can figure dynamic hyperinflation in 15 seconds

Question 15

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 550 ml, FiO2 0.50, PEEP 10 cm H20. Plateau pressure is 34 cm H20. Chest X-ray: ARDS. ABG: pH 7.28/pCO2 55/pO2 65.

Question 15

ABG: pH 7.28/pCO2 55/pO2 65 (550ml x 30, PEEP 10, FiO2 0.5). According to the Acute Respiratory Distress Syndrome Network protocol for ventilation management, which of the following should you do next?

• A. Calculate P:F ratio
• B. Increase PEEP
• C. Infuse bicarbonate
• D. Measure patient’s height
• E. Prone ventilation

29

Question 15

ABG: pH 7.28/pCO2 55/pO2 65 (550ml x 30, PEEP 10, FiO2 0.5). According to the Acute Respiratory Distress Syndrome Network protocol for ventilation management, which of the following should you do next?

• A. Calculate P:F ratio
• B. Increase PEEP
• C. Infuse bicarbonate
• D. Measure patient’s height
• E. Prone ventilation

ARDS

n There are no proven pharmacologic

therapies for ARDS

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

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

ARDS Network NEJM 2000;342:1301

n Patients randomized to tidal volume of 12

mL/kg vs 6 mL/kg

n 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

Low tidal volume for ALI/ARDS

Starting point is 6 mL/kg , then adjust down more if Plateau Pressure > 30 cm H2O Predicted Body Weight is based on Height Males = 50 + 2.3 [height (inches) – 60] Females = 45.5 + 2.3 [height (inches) – 60]

Our patient started on TV 550ml Okay if 92 kg is his “ideal weight”, but for that he would need to be 6’5”.

30

ARDS – Best strategy?

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 TV Guide?

Best PEEP? “Open Lung Ventilation”

Pressure Volume

Open Lung strategy vImproves oxygenation vSome other clinical outcomes vNot mortality

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

Question 15

ABG: pH 7.28/pCO2 55/pO2 65 (550ml x 30, PEEP 10, FiO2 0.5). According to the Acute Respiratory Distress Syndrome Network protocol for ventilation management, which of the following should you do next?

• A. Calculate P:F ratio
• B. Increase PEEP
• Mild:

P/F 200-300

• Moderate:

P/F 100-200

• Severe:

P/F ≤100 ARDS This patient: 65/.5 = 130

Question 15

ABG: pH 7.28/pCO2 55/pO2 65 (550ml x 30, PEEP 10, FiO2 0.5). According to the Acute Respiratory Distress Syndrome Network protocol for ventilation management, which of the following should you do next?

• B. Increase PEEP

Lower PEEP/higher FiO2

FiO2 0.5 0.5 0.60 PEEP 8 10 10

Higher PEEP/lower FiO2

FiO2 0.5 0.5 0.5-0.8 PEEP 16 18 20

Two strategies:

• Low PEEP
• High PEEP

ALVEOLI Trial NEJM 2004; 351:327-336

• Overall à dud
• Subgroup of more severe

ARDS may do better

31

Too much pressure? à Barotrauma

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 à 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 à PTX and/or SQ emphysema

ARDS: Prone Positioning

Guerin C. et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. NEJM 2013:368:2159. Randomized patients with severe ARDS

n Within 24 hours à Prone n 16 hours in prone position n Mortality 33% in standard vs. 16% n Done at centers with “prone protocol” n ↑ risk of decubs

Was this the critical part?

ARDS – Severe Hypoxemia “Toolkit”

n Recruitment maneuvers n Paralysis n Prone positioning n iNO n ECMO

Not shown to improve outcomes

32

Question 15

ABG: pH 7.28/pCO2 55/pO2 65 (550ml x 30, PEEP 10, FiO2 0.5). According to the Acute Respiratory Distress Syndrome Network protocol for ventilation management, which of the following should you do next?

• C. Infuse bicarbonate
• D. Measure patient’s height
• E. Prone ventilation

Despite low TV ventilation, majority don’t need If you believe…. This may have early role, but FIRST get correct TV

Question 16

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

• btained.

Question 16

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

Question 16

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

33

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 16

This patient however…. Tip of tube in LLL bronchus

How about this one?

34

Question 16

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 17

52 year old man POD #1 from repair of liver/spleen/ pancreas lacerations from blunt trauma (MV A). 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 1 10/80 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.

Question 17

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 17

52 yo post-op abd trauma, PRBC/volume

• resuscitated. Now with dropping BP, UO, elevated

lactate, poor gas exchange, increased vent pressures, smaller lungs. You should order:

• A. Cross table lateral KUB to check for free air
• B. IV norepinephrine (Levophed)
• C. FAST exam
• D. Stat Echocardiogram
• E. Urinary bladder pressure

35

Question 17

52 yo post-op abd trauma, PRBC/volume

• resuscitated. Now with dropping BP, UO, elevated

lactate, poor gas exchange, increased vent pressures, smaller lungs. You should order:

• A. Cross table lateral KUB to check for free air
• B. IV norepinephrine (Levophed)
• C. FAST exam
• D. Stat Echocardiogram
• E. Urinary bladder pressure

Abdominal Compartment Syndrome

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

• Presses diaphragm up, so increased airway

pressures, smaller lung volumes

• Can increase ICP
• Suspect if tensely distended abdomen,

progressive oliguria, and increased ventilatory requirements.

• Measure bladder pressure

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 17

Y

• u should order:
• A. Cross table lateral KUB to check for free air
• B. IV norepinephrine (Levophed)
• C. FAST Exam
• D. Stat Echocardiogram
• 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

36

FAST exam

Focused Assessment with Sonography for Trauma Initial screening for adult trauma patient Blood or air where it shouldn't be.

• R & L flanks
• Suprapubic
• Subxiphoid
• R&L anterior chest

Fluid suggests intra-abdominal bleeding Hemopericardium Tension PTX

Question 18

What is the MOST common cause of abdominal compartment syndrome?

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

Question 18

What is the MOST common cause of abdominal compartment syndrome?

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

Question 18

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)

37

The End!