icu tutorial 2011

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ICU Tutorial

Medical Residents 2011



A67-year-oldisadmi0edtoaMICUwithARDS.BS=135mg/dl.

Intensive insulin therapy was started. An outcome about

intensiveglucosecontrolincludeswhichofthefollowing.

A. Increasedriskofhypoglycemia

B. Reducedmortalityindependentofthetargetglucoselevel

C. Reduced mortality only if the paKents could be maintainedwithaBS≤11mg/dl

D. ShorthospitalLOS

1



How hyperglycemia is harm?



• BS>14mg/dl+HbA1C>6.5%suspectedpreexisKngDM.• Intensiveglucosecontrol8-11mg/dl.

• RRmortality.93(95%CI.83-1.4)

• SmallRRmortalitybenefitinSICU.63(95%CI.44-.91)

• RRhypoglycemia6.(95%CI4.5-8.)• LasttrialNICE-SUGARstudy

• Intensiveglucosecontrolincreasedabsoluteriskofdeathat9days

• Numberneededtoharm38



NICE-SUGARStudyInvesKgatorsNEJM29;36:1283-97.



Daily SBTs in paKents supported by MV with stable andimprovingcardiorespiratoryfuncKonhavebeenshowntofacilitate

thevenKlatorwithdrawalprocess.InaddiKontomonitoringRR,gasexchange,hemodynamics,and

comfortduringtheSBT,whatotherstrategywillbehelpfulinthisprocess?

A. UseofmodethatautomaKcallyreducespressuresupportinbetweendailySBTa0empts

B. RequiredallpaKentstohaveaf/VT<15beforeiniKaKngSBT

C. RequiringP.1<8cmH2ObeforeiniKaKngSBT

D. Usingpressuresupportof5-8cmH2OduringSBT.

2



Clinicalassessment • Adequatecough

• AbsenceofexcessivetracheobronchialsecreKon

• ResoluKonofdiseaseacutephaseforwhichthepaKentswasintubated

ObjecKve

measurements Clinicalstability

-Stablecardiovascularstatus(HR<14,SBP9-16mmHg,noor

minimalvasopressor)

-StablemetabolicstatusAdequateoxygenaKon-SaO2>9%onFiO2≤.4(orPaO2/FiO2≥15mmHg)

-PEEP≤8cmH2OAdequatepulmonaryfuncKon

-RR<35/min

-MIP≤-2--25cmH2O

-VT>5ml/kg-VC>1ml/kg

-f/VT<15

-NosignificantrespiratoryacidosisAdequatementaKon

-NosedaKonoradequatementaKononsedaKon)

Readinesstowean



Measurementsofoxygena4onanddeadspace

PaO2/FiO2

PaO2/PAO

2Deadspace(VD/VT)Simpletestsofrespiratoryloadandmuscularcapacity

NIP(MIP)

Respiratorysystemcomplianceandresistance

MV

MVV

VC

RR

VTTestthatintegratemorethanonemeasurement

f/VTCROPindex(compliance,RR,oxygena4on,pressure)=CdynxPImaxx[PaO2/PAO2])/rate

Complexmeasurements

Airwayocclusionpressure

P0.1/MIP

Esophagealpressurements

Oxygencostofbreathing,WOB

GastricmucosalpH

WeaningPredictors



YangL,TobinMJ.NEJM1991;324:1445-5.



• T-piece

• Lowlevelpressuresupport(reduceresisKvework)

• 7-8cmH2Oinadult

• 1cmH2Oinpediatric

• AutomaKcTubeCompensaKon

• DuraKonofSBT=12min(Ingeneral)

• IdealduraKonofSBT(3minVS12min)dependonduraKonofvenKlaKonandunderlyingcauseforrespiratoryfailure

SBTs



Poten4alcausesofweaningfailure Auto PEEP

pneumoniapulmonary edema

Atelectasis

PTX

Pleural effusion

Abdominal distensionSecretions

Bronchoconstriction

ET-problemsDead space

VCO2

Metabolic acidosis

Anxiety

Pain

Oversedation

Metabolic alkalosis

CNS process

OHS

↓Mg, Ca, K, PO4

Steroids

Malnutrition

Sepsis

Medications

HypothyroidismPhrenic nerve injury

CIP, CIMCardiac disease

Psychological disease



A 43-yr-old man was admi0ed to ICU with seizure and mentalstatuschanges.HewasBT38.5

๐C.HehadhistoryofHIVandnon-

compliantART.HisCD4count=13/µL.CTbrainshowndiffusebrain atrophy and no focal mass lesion. LP was done and CSFprotein=72mg/dL,glucose68mg/dL,WBC78/ µL(85%L),RBC3.6x16/ µL. He began vancomycin, ampicillin, ceazidime,amphotericin B and acyclovir. Day2 aer admission his Cr

1.3→2.7mg/dL.UrineisshowninFig.

Whichoneofthefollowingisthe

mostlikelycauseofAI?

A. AmphotericinB

B. AcyclovirC. Contrastinducednephropathy

D. AcuteintersKKalnephriKs

3



Acyclovir

CrystalinducedAKI

Needlelikebirefringent

Sulfonamide

Sulfadiazine

Needleshape

Shockofwheat

Dumbbell

Indinavir

Starbursts

Fanshapes



• Rapidexcretedinurineandlowurinesolubility

• Riskfactors• Highdose

• Rapidinfusion

• VolumedepleKon• Renalimpairment

• PrevenKon

• Isotonicsalinebeforeacyclovirinfusion

• Highurineflowrate• Slowinfusionin1-2hr

Acyclovirnephrotoxicity



A73yearoldmanpresentedwithseverechestpainfor2hr.ECGshowedSTEMIatinferiorwall.Hewasgivenalteplaseover

9 min and admi0ed to ICU. Next 48 hr severe dyspneadeveloped.FollowingintubaKon,furosemide,andinsertedPAC.

Pulmonary artery pressure waveform tracing are capturedduring balloon inflaKon in Fig. Which of the following bestexplains why the waveform changes shape as the balloon is

inflated? A. Balloon has wedged in PA

B. Catheter is malpositioned and

overwedged.

C. Catheter is malpositioned and

migrated back to RA

D. Balloon has failed to inflate due

to balloon rupture.

4



PACposi4on • NormallyPAdiastolic>PCWP~1-4mmHg

• PAdiastolic–PCWP>5mmHg:éPVR



GiantVwaves



Overwedging



Limita4onofPAOP



Avarietyofdrugsmaybe used forinducKon of sedaKonduringRSI.ForwhichoneofthefollowingpaKentswouldyoupreferably

c h o o s e e t o m i d a t e i n s t e a d o f k e t a m i n e f o r R S I ?

A. A 6 5 - y e a r - o l d m a n w i t h s e p K c s h o c k .

B. A45-year-oldmanwhoishypertensiveand hasanacuteMI

C. A25-year-oldwomanwithasthmawhois8weekspregnantD. A 3-year-old woman with thoracic and abdominal injuries

f r o m v e h i c l e s a c c i d e n t w h o i s h y p o t e n s i v e .

5



• .1-.5mg/kg

• Analgesia+Amnesia

• Notnecessarilycausealossofconsciousnessbutnotaware.

• Amnesia,alteredshorttermmemory,decreasedabilitytoconcentrate,alteredcogniKveperformance,nightmares,N/V

• CombinaKonwithsmalldosesofBDZdoesprolongrecoveryfromketamine,buteliminatestheseadverseeffects

• DirectsKmuliANS,tachycardiaandincreasesBP

• Bronchodilatoreffect.

Ketamine



• Dose2mg/kg.

• Containing1%soybeanoil,2.25%glycerol,1.2%eggphosphaKde.

• Mostfrequentlycontaminatedbybacteria.

• Noanalgesia

• HepaKcclearance+extrahepaKcsiteseliminaKon

• Rapidrecoveryevenaerprolonginfusion

• Dosedependenthypotension,respiratorydepression

• AdjusteddosebyvolumestatusandcardiacfuncKon

• Bronchodilatoreffect

Propofol



• Metabolicacidosis,

• CardiacdysfuncKon,

• Hyperkalemia,hypertriglyceridemia,

• Rhabdomyolysis

• AI

• Triggerdosetoxicity≥5mg/kg/hrx48hr

Propofolrelatedinfusionsyndrome



InwhichofthefollowingpaKentscenarioswouldtherapeuKchypothermiabemostclearlyindicated?

A. A55-year-oldmaninacomafollowinganin-hospitalcardiacarrestwithPEAduetomassivepulmonaryembolism.

B. A6-year-oldmaninacomafollowinganout-of-hospitalVF

C. A59-year-oldmantransferredfromanoutlyinghospitalforconKnuedcarefollowingaVFarrest1weekagowithanoxicencephalopathy

D. A3-year-oldmaninacomafollowingamotorvehicleaccidentwithheadtrauma

6



• ComatoseadultpaKentswithROSCaerout-of-hospitalVF

cardiacarrest(classI,LOEB)• ComatoseadultpaKentswithROSCaerin-hospitalcardiacarrest

ofanyiniKalrhythmoraerout-of-hospitalcardiacarrestwithaniniKalrhythmofPEAorasystole(ClassIIb,LOEB).

• Cooledto32°Cto34°Cfor12to24hours

• Mechanisms

• Slowdowncerebralmetabolicrate

• InhibiKondeleteriousbiochemicalorcerebraleventsbetweenreperfusion

• ↓freeradicalproducKon&excitatoryaminoacidrelease

• Promoteneuronalrecovery

• ↓ICP



1.Induc4onphase• AimcoreBT<34

๐C

• DowntotargetBTasquicklyaspossible

• Sideeffectsarehypovolemia,electrolytedisorders,hyperglycemia

2.Maintenancephase• TightlycontrolcoreBT,minorornofluctuaKon(max.2-.5

๐C)

3.Rewarmingphase

• .2-.5๐

C/hour

• Electrolytedisorders(hyperkalemia,hyperphosphatemia)

• Bewarereboundhyperthermia

.Maintenancenormothermicphase



1. Arrhythmias,hemodynamicchangesandCVSeffects

• Cardiacoutput↓25-4%

• CVP↑,SVR↑,BP↑

• Hypovolemia(colddiuresis)

• CoreBT<35.5๐

C→sinusbradycardia

• CoreBT~32๐

C→HR~4-45bpm

• CoreBT<28-3๐

C→VForVT

2.Drugclearance

• ↑Drugleveland/orenhanceeffect

3.Electrolytesdisorder

• Hypomagnesaemia

• Hyperkalemiainrewarmingphase



5.Hyperglycemia6.CoagulaKonparameter

• BT<35๐

C→plateletfuncKon

• BT<33๐

C→coagulaKonfactor

• NormalstandardcoagulaKontestbecausewarmbloodpriortest

7.InfecKon

8.Shivering

• NMBA(++++)

• Meperidine(++++)

7



A 46-year-old man is rescued from his home following ahurricane with regional power outages; he is found to be

confusedanddisoriented.Helivedtherefor3dayswithlightandheatprovidedbyaportablegenerator.Hispulseis13/min,BP14/9mmHg,RR28/min,SpO 298%.TheremainderPEnormal.Which of the following should be done immediately.

A. A d m i n i s t e r 1 % o x y g e n

B. U r i n e t o x i c o l o g y s c r e e n

C. C T s c a n o f h e a d

D. L u m b a r p u n c t u r e

7



Carbonmonoxide(CO) • COisacolorless,odorless,tastelessandnonirritantgas

• ProducKoninvarietyofways

• IncompletecombusKonoffires

• FaultyheaKngsystems

• InternalcombusKonengines• Woodstoves

• Charcoalgrills

• VolcanicerupKons

• InvivohepaKcproducKon• Methylenechloridepoisoning:paintthinners

• Accidental:automobileexhaustandsmokeinhalaKon



Pathophysiology

• COeasilydiffusesacrossalveolar-capillarymembranes

• RapidlytakenupbyRBCs

• BindtoironofHbwithaffinity24Kmes>O2

• Summary4mechanismsofCOintoxicaKon

• DecreaseintheO2carryingcapacityofblood

• DecreasedO2deliverytoperipheralKssueasaresultoftheleshiin

theoxyhemoglobindissociaKoncurve

• MitochondrialdysfuncKonandimpairmentofcellularrespiraKonby

inhibiKonofcytochromeoxidaseacKvity

• LipidperoxidaKonofbrainduringreoxygenaKon



Clinicalpresenta4on • Headache,dizziness,sorethroat,nausea,SOBandfaKgue

• EnKrefamilyisaffectedrelatedtoafaultyhomeheaKng

systemduringthewintermonths

• Lossofconsciousness

• Severitycorrelatebe0erwithduraKonofexposure

• BrainandheartareverysensiKvetoCOintoxicaKon

• CVSdisorderเกดไดเรวถาผ ปวยม preexisKngCVSdisease

• LacKcacidosis,rhabdomyolysis,ARF

• ตายแนถา level>6%



Diagnosis • Cherry-redlips,cyanosis,reKnalhemorrhage(infrequent)

• IncreasedlevelofCOHbèDx

• CoHbตองวดโดย cooximeter

• ABG:PaO2normal

• Electrolyte(AG),C,lactate• EG,cardiacenzymes

• ChestX-ray:noncardiogenicpulmonaryedema

• Bloodandurinecyanide

• Suicide:drugscreen

Eff f COHb d O 4 b



EffectofCOHbonmeasuredO2satura4onby

pulseoximetry



Treatment • Removalfromsourceofexposure

• 1%O2สามารถลด T½ ของ COHbจาก 4-6 hr. เปน 40-80

min

• IntubaKonตาม indicaKons

• O2ควรใหจน

COHbreturntonormalexceptpregnancy

• HBOT:1.5-3ATMลด half-lifeของ COHbจาก 5-6hrเปน 2min

• IndicaKonofHBOTหนาตอไป



8



ApaKentwithARDSissupportedbyMVwiththemodedepictedinFig.WhatdescripKonbestfitsthismode?

8

A. PressuresupportvenKlaKon

B. AirwaypressurereleasevenKlaKon

C. VolumeassistedcontrolvenKlaKon

D. VC-SIMV



• OxygenaKonindex(OI)=(FiO2xmPawx1)/PaO

2• Predictorofpooroutcome

• HighOI12to24haeronsetofARDSandrisingareindependentrisk

factorsformortality

• OI>3representfailureofconvenKonalvenKlaKon

• MajorityofpaKentswithARDSdiefrommulKorganfailure

Ven4latorymanagementofARDS

l



Variables ProtocolVenKlatormode Volumeassistcontrol VT ≤6ml/kgpredictedBW Plateauairwaypressure ≤3cmH2OVenKlaKonrate/pHgoal 6-35/min,adjustedtoachievearterialpHof

>7.3ifpossibleInspiratoryflow AdjustforI:E=1:1-1:3 OxygenaKon PaO2≥55and≤8mmHgorSaO2≥88%

and≤95%CombinaKonofFiO2andPEEP(cmH2O) .3/5,.4/5,.4/8,.5/8,.5/1,.6/1,

.7/1,.7/12,.7/14,.8/14,.9/14,.9/16,.9/18,1./18,1./22and1./24

Weaning A0emptbyPSwhenFiO2/PEEPcombinaKon

is<.4/8

ARDSnetLow-VTprotocol



P b bili f i l h h D 90



ProbabilityofsurvivalthroughDay90

PEEP i f h i



PEEPinrefractoryhypoxemia • ThreeRCTsformodestVShighlevelsofPEEP

• ALEOLI(NEJM24;351:327-36)

• LOVS(JAMA28;299:637-45)

• EXPRESS(JAMA28;299:646-55)

• SystemaKcreviewandmeta-analysis

• JAMA21;33:865-73(March)



Ch t i 4 f i l d d t i l



Characteris4csofincludedtrials



PEEP t t i (LOVS)



PEEPstrategies(LOVS)



R i t i bl i fi t k



Respiratoryvariablesinfirstweek



Summary



Summary • Inhospitalmortality

• AllpaKents:higherPEEP=lowerPEEP• ARDS:higherPEEP>lowerPEEP

• RelaKvemortalityreducKon1%

• NNT25

• ALI:higherPEEP=lowerPEEP(high<low)

• VenKlatorfreedays

• AllpaKents:higherPEEP=lowerPEEP

• ARDS:higherPEEP>lowerPEEP

• ALI:higherPEEP=lowerPEEP(high<low)

Lung recruitment maneuvers



• Transientincreaseintranspulmonarypressure

• Reopeningofcollapsedalveoli.

• UseInrefractoryhypoxemia

• Varietyoftechniques

• SustainedinflaKonmaneuvers

• HighPCV

• IncrementalPEEP

• Intermi0entsigh

• Extendedsigh

Lungrecruitmentmaneuvers

Sustained infla4on technique



Sustainedinfla4ontechnique • CPAP4cmH2forupto6sec.

• Advantages• Reducinglungatelectasis

• ImprovingoxygenaKonandrespiratorymechanics

• PrevenKngETsucKoning-inducedalveolarderecruitment

• Disadvantages

• IneffecKve

• Short-lived

• Circulatoryimpairment• Increasedriskofbaro/volutrauma

• Reducednetalveolarfluidclearance

• WorsenedoxygenaKon

Stepwise maximum RM



StepwisemaximumRM • PaO2+PaCO2≥4mmHgasan

indicatorofmaximumRM

• DecrementalPEEPKtraKon

• Start25cmH2Ofor4min

↓ 2 cmH2O

• LowestPEEPmaintainPaO2+

PaCO2≥4mmHg(opKmalPEEP)

• RMatlaststepagain• PEEPatopKmalPEEP

BorgesJBetal.AmJRespirCritCareMed26;174:268–78.

Recruitment Maneuvers for ALI



RecruitmentManeuversforALI

ASystemicReview • 4arKclesanalyzed:meansamplesize3,total1185pts• Studydesigns

• 4RCT

• 32prospecKvecohort

• 4retrospecKvecohort

• TypeofRMs

• SustainedinflaKon18

• HighPCV9

• IncrementalPEEP8

• HighVT/sigh4

• Other1



Fanetal.AmJRespirCritCareMed28;178:1156-63.

PCV inverse ra4o ven4la4on



PCVinverse-ra4oven4la4on •

InspiratoryKme>expiratoryKme• NobenefitormarginalbenefitofPCIRV

• Li0leimprovementinoxygenaKon

• Elevatedmeanairwaypressure+autoPEEP• Adverseeffecttohemodynamics

• RequiredsedaKonandparalysis

Airway pressure release ven4la4on



Airwaypressurereleaseven4la4on

APRV seng



APRVseng • Phigh

• DesiredPpla(typically2-35cmH2O)

• Phigh>35cmH2Owhen ↓ thoracic&amdominal

complianceormorbidobesity

• Plow :cmH2O

• Thigh :4-6secs(8-95%oftotalcycleKme)

• Tlow :.2-.8secs(endexpiratoryflow=5-75%

ofPEFR)



Mortality



Prone posi4oning



Proneposi4oning • ReducemortalityinseverebyPaO2/FiO2<1mmHg

(p=.1;RR.84;95%CI.74-.96)

• MeanproneduraKon14hr/day

• NotreducemortalityinoverallpaKents

• ImproveoxygenaKon27-39%

• âVAP

• NoeffectonvenKlatorfreedayorduraKonofMV

• Adverseeffects:pressureulcers,ETobstrucKon,tracheostomytubedislodgement

HFOV



HFOV



G T t M h i d i HFV



The major gas-transport mechanisms that are operaKve under physiologic condiKons in each region (convec4on, convec4on anddiffusion,anddiffusionalone) areshown.Thereare sevenpotenKalmechanisms:turbulenceinthelargeairways,causingenhanced

mixing;directven4la4onofclosealveoli;turbulentflowwithlateralconvecKvemixing;pendellu(asynchronousflowamongalveolidue

toasymmetriesinairflowimpedance);gasmixingduetovelocityprofilesthatareaxiallyasymmetric(leadingtothestreamingof“fresh”

gastowardthealveolialongtheinnerwalloftheairwayandthestreamingof“alveolar”gasawayfromthealveolialongtheouterwall);

laminarflowwithlateraltransportbydiffusion(Tayordispersion);andcollateralven4la4onthroughnonairwayconnecKons

Gas-TransportMechanismsduringHFV

HFOV



HFOV • SafeandeffecKveinimproveoxygenaKon

• Nolowermortality

• MayimprovemortalityinpaKentswithhighOI

NO inhala4on



NOinhala4on

Griffithsetal.NEJM25;353:2683–95.



Administra4onofiNOinadult



• Majortoxicity

• MetHb:uncommoninusualdose,measureq6hr

• NO2:rapidcoverttonitricacidinaqueoussoluKonthattoxictorespiratorytract

• DosetreatmentinPHT>ARDS

• Maximumdose4ppm• Required2%riseinPaO2onFiO21.

• ImprovedV/Qmismatch

• Be0eroxygenaKon

• Nosurvivalbenefit

• NoreducKoninvenKlatorfreedays

9



WhichofthefollowingbestdescribesthemonitoringofglucosecontrolinICU?

A. AlaboratoryglucosemeasurementispreferredoveraPOCT.

B. Acentralorperipheralbloodsampleispreferredtocapillarysample

C. Asinglemorning(eg.6.am)glucoselevelispreferredoverameanmorningglucoselevel

D. Ameanmorningglucoselevelispreferredoverameandailyglucoselevel



SamplingBlood(vascularcatheter) DangerofcontaminaKonwithIVfluidFingersKck(notrecommended) InaccurateinpaKentswithedemaoranemia

MeasurementGlucometer Fastest,leastaccurateBloodgasmachine Fast(ifinICU),accurateLaboratoryanalysis Slowest,mostaccurate



Acuterespiratory

d t i K



deterioraKonPeakinspiratorypressure

Decreased Increased NochangePlateaupressure• Airleak

• HypervenKlaKon• Pulmonaryembolism

• ExtrathoracicProcessNochange Increase

AIRWAYOBSTRUCTION• AspiraKon

• Bronchospasm

• SecreKons

• Trachealtube

• ObstrucKon

DECREASEDCOMPLIANCE• Abdominaldistension

• Asynchronousbreathing

• Atelectasis

• AutoPEEP

• Pneumothorax

• Pulmonaryedema



11



A28 yearoldwoman is admi0edtoICUforfever, hypotension,andmildlowermiddleabdominalpain,dysuria.Sheunderwenta

C/S 9 months ago and intraoperaKve bleeding required PRCtransfusion. Review of system, she has some intermi0entheadaches and faKgue. She had noted a decrease in milkproducKonaer4weeksandnothadamenstrualperiodsincethedelivery

OnexaminaKonBT38.5C,BP8/5mmHg,PR1/min,RR15/min.DespiteinfusionofNSSandanKbioKcs,sheremainshypotensive.Whichofthefollowingshouldnextbeaddedtoherregimen?

A. HydrocorKsone

B. Dopamine

C. Norepinephrine

D. Drotrecoginalfa

Ini4al resuscita4on



Ini4alresuscita4on CVP8-12mmHg MAP≥65mmHg

Urineoutput≥0.5ml/kg/hr ScVO2≥70mmHgSVO2≥65mmHg

Goal6hrs

Higher target CVP



HighertargetCVP • MechanicalvenKlaKon• Decreasedventricularcompliance

• IAH

• DiastolicdysfuncKon

• Pulmonaryarteryhypertension

Indices of fluid responsiveness



Indicesoffluidresponsiveness • PulsepressurevariaKon• Passivelegraising

• CVPvariaKoninspontaneousbreathing

•Respiratory changes in pulse pressure



• Respiratorychangesinpulsepressure

• Definedasresponder

• Threshold>13%

• SensiKvity94%

• Specificity96%

• MorereliablethanSPV

PPmaxPPmin

∆PP(%)=1x(PPmax-PPmin)(PPmax-PPmin)/2

Early goal directed therapy



Earlygoaldirectedtherapy

Diagnosis



Diagnosis • ObtainappropriateculturesbeforestarKng

anKbioKcs

• ≥2BCs(percutaneousandvascularaccess)

• Cultureothersitesasclinicallyindicated• Imagingtoconfirmandsampleanysourceof

infecKon



Source control



Sourcecontrol Clinical(suspected)

diagnosis consider SourcecontrolPneumonia Empyema Drainage2๐ peritoniKs OngoingcontaminaKon ExteriorizaKonofleakingGItract,drainageof

peritonealfluidPancreaKKs InfectedpancreaKc

necrosis DebridementofpancreaKcKssueUTI Catheter-related RemovecatheterBacteremia Catheter-related RemovecatheterSSI NF ResecKonofnecroKcKssue–explorewhen

suspectedonclinicalgroundsPyelonephriKs Urinarytractlithiasis Debridement–lithiasisremovalMediasKniKs EsophagealperforaKon SurgicaldrainageSinusisKs Abscess AspiraKonanddrainage–removeNGtubeAcalculous

cholecysKKs Abscess,hydrops Percutaneousdrainage–chlecystectomyPericardiKs Drainage

Fluid therapy



Fluidtherapy • Crystalloid=colloid• Fluidchallenge

• Crystalloid≥1mlover3min

• Colloid≥3-5mlover3min

Vasopressors



Vasopressors • MAP≥65mmHg:toolowinpaKentswithsevere

uncontrolledHT

• NEordopamineasthe1stchoice

• Epinephrine:poorlyresponsivetoNEordopamine

Inotropic therapy



Inotropictherapy • DobutamineformyocardialdysfuncKon(elevated

cardiacfillingpressureorlowcardiacoutput)

• NouseofstrategytoincreaseCItosupranormal

level

Cor4costeroids



Cor4costeroids • HydrocorKsone:BPpoorlyresponsetofluid

therapyandvasopressor

• Notpreferdexamethasone

• FludrocorKsoneisopKonal

12



WhichofthefollowingintervenKons,ifusedrouKnely,wouldbe

expectedtoreducetheincidenceofVAP?

A. OralapplicaKonofanKsepKcs

B. Frequentrespiratorycircuitchanges

C. Standardelectrictoothbrushing

D. Early tracheostomy among paKents expected to require

prolongedmechanicalsupport



VAPpreven4on



Source of VAP

Pathogen Prevention Goal Specific MeasuresAerodigestive

colonization Prevent colonization by

exogenous routes • Hand hygiene

• Microbial surveillance and targeted

barrier isolation

• Preemptive barriers: Routine gloving &

gowning Dedicated equipmentSuppress oropharyngealmucosal colonization • Oral decontamination with

chlorhexidine

• SDD

• Aerosolized antimicrobials

• Sucralfate instead of H2-blockersPrevent aspiration • NIV

• Semirecumbant positioning

• Novel endotracheal tube permitting

continuous subglottic suctioning

VAPpreven4on



Source of VAP

Pathogen Prevention Goal Specific MeasuresContaminated

respiratory therapy

equipment and

medical aerosols

Safe equipment and

medical aerosols • Procedures for reprocessing

bronchoscopes and reused

respiratory therapy equipment

• Training and education of reprocessing

staff and respiratory therapists

• Procedures for use of aerosolized

medicationsReducing contamination

of ventilator circuit • Heat-and-moisture exchanger

• Periodically drain condensate from

circuit

• Sterile water for bubble-through

humidifiers• Aseptic procedures for suctioning of

ventilated patients

VAPpreven4on



Source of VAP

Pathogen Prevention Goal Specific MeasuresContaminated tap

water

( Legionella

species,

Pseudomonas

aeruginosa)

Safe water • Sterile water for:

Cleaning respiratory therapy equipment

Rinsing bronchoscopes

Aerosolized medications

• Hospital surveillance for cases of

nosocomial legionellosis

• Microbial surveillance of hospital water for

contamination by legionellae

• Engineering controls for contaminated

water:

Superheat and flush Ultraviolet light

HyperchlorinationSilver-copper ionization

Ozonation

VAPpreven4on



Source of VAP

Pathogen Prevention Goal Specific MeasuresContaminated

ambient air

(filamentous fungi,

Mycobacterium

tuberculosis,SARS

coronavirus)

Safe air • Procedures for minimizing communicable

airborne infections:

Disease recognition

Administrative controls

Engineering controls• Procedures for minimizing risk to

immunocompromised patients:

High-efficiency particulate arrester

(HEPA)-filtered rooms

N95 masks for intrahospital transports

• Policies and procedures for managementduring periods of construction and renovation



Endotracheal intubaKon in a young hemodynamically stable

14



Endotracheal intubaKon in a young, hemodynamically stable

paKent with 3% third-degree burns and sepsis would best be

accomplishedwiththefollowingIVdrugcombinaKon.

A. Propofolandsuccinylcholine

B. etamineandrocuronium

C. EtomidateandsuccinylcholineD. Etomidateandrocuronium



NondepolarizedNMBA



• CompeKKveantagonistsandinhibitAChbindingtopostsynapKc

nAChRs• Benzylisoquinolinium

• mivacurium,atracurium,cisatracurium,anddoxacurium

• Aminosteroid

• vecuronium,rocuronium,pancuronium,andpipecuronium.



NIV



RecommendedindicaKons

1. COPDexacerbaKons

2. Acutecardiogenicpulmonaryedema

3.

FacilitaKngextubaKoninCOPDPaKents4. ImmunocompromisedPaKents



FactorsassociatedNIVsuccess Synchronous breathing with venKlator



SynchronousbreathingwithvenKlatorDentateLessairleakingFewersecreKonsGoodtoleranceRespiratoryrate<3/min*LowerAPACHEIIscore(<29)*pH>7.3*Glasgowcomascore15*PaO2/FiO2>146aerfirsthourifhypoxemicrespiratoryfailureCOPD,CPENopneumonia,ARDSBestpredictorofsuccessisagoodresponsetoNPPVwithin1to2h:ReducKoninrespiratoryrate

ImprovementinpH

ImprovementinoxygenaKon

ReducKoninPaCO2

A 5-year-old woman with severe bronchioliKs obliterans is

16



receiving mechanical venKlaKon support. She has developed

hypotension. The graphic display is pictured in Fig. Which

combinaKon of the following manipulaKons of the MV can beperformed to confirm the diagnosis and to ameliorate the

c o n d i K o n ?

A. Performaninspiratorypause,increaseinspiratorypressure

B. Performanexpiratorypause,

increaseinspiratorypressure

C. Performaninspiratorypause,

reducethesetrate

D. Performanexpiratorypause,

reducethesetrate

AutoPEEP



MeasurementofautoPEEP



In addiKon to hand hygiene, strict adherence to asepKc

17



yg , ptechnique with maximal sterile barrier precauKons, skinanKsepKcwithCHX,preferenKaluseofsubclavianinserKon,and

prompt removal of unnecessary catheters, which of thefollowing pracKces is associated with a reduced incidence ofC R B S I i n I C U ?

A. Heparin-coatedcatheterscomparedwithuncoatedcathetersB. Transparent occlusive dressings compared with gauze

C. Dressing with CHX-impregnated sponge compared with noa n K s e p K c

D. Changingtransparentdressingsevery3dayscomparedwithe v e r y 7 d a y s

Preven4onCVCrelatedinfec4on



1. Set&usecathetercareprotocols

• EducaKonalprogramswithhygienetraining

• CatheterinserKon:prepare,skinanKsepKc,inserKontechnique

• CathetermanipulaKon:handhygiene,manipulaKonoftaps

• Cathetercare:catheterreplacementmodaliKes,type&frequencyof

dressing

• EvaluaKonincidenceofCRBSIandfeedback

2. StaffeducaKonal/Qualityimprovementprogram

3. Typeofcatheter

• Polyurethanecatheter

• CatheterscoatedwithaniKmicrobial/anKsepKc(CHX/

silversulfadiazine,minocycline/rifampicin)

• CVCswithmulKlumen→noincreaseriskofCRBSI



Preven4onCVCrelatedinfec4on



11. Venouslinemaintenance

• ChangeIVsetq3days• Bloodproduct,lipidemulsion(parenteral+propofol)changeq1dayor

immediatelybefinished

• HandhygienebeforecathetermanipulaKon

• HabsandsamplingportscleaningwithCHXbasedanKsepKcbefore

access

• Nochangecatheterfollowingbyscheduled

• Changecatheterviaguidewire→↑CRBSI

• AnKbioKcoranKsepKcointments→↑ riskof fungalcolonizaKon

• ProphylacKcheparing↓ thrombosisg↓ nidus formaKong↓ colonizaKon

A56-year-oldalcoholicmanwithARDSfrommassiveaspiraKoni i i MV H i f d i h € V 12 l/

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is requiringMV.He is transferredto you with se€ngVT12ml/kg,RR2/min,PEEP1cmH2O,FiO2.5andPplat36cmH2O.His

PaO293mmHg,PaCO239mmHgandpH7.41.YoureducehisVTto6ml/kgandincreaseRRto3/min.withthesechanges,hisPplat falls to 23 cmH2O, PaO2 65 mmHg, PaCO2 56 mmHg andp H 7 . 3 1

You wish to follow the ARDS net protocol, at this point

y o u s h o u l d

A. Increase VT to 9 ml/kg to improve both PaO2 and PaCO2

B. S w i t c h t o A P R V

C. Increase PEEP to improve PaO2 and leave VT se€ng alone

D. R e m a i n o n c u r r e n t s e € n g s

A68yearoldmanisadmi0edwithsepKcshockandARDSduetoCAP H i d d d l d MV i h RR 34/ i H

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severeCAP.HeissedatedandplacedonMVwithsetRR34/min.Heappearscomfortableandpassive.OnVT6ml/IBW,Pplat29cmH2O

andPaCO243mmHg.WithFiO2.7andPEEP12cmH2O,SaO288%.AppropriatedanKbioKchavebeeniniKated.Aer12handfollowing4LfluidresuscitaKon,MAP58mmHgonNE8µg/min,HR112/min.Urineoutput2mlsinceICUadmission.Youareconsideringgivingfluid bolus. Which of the following measures will most accurately

predict whether a fluid bolus will increase perfusion?

A. TherespiratoryvariaKoninPPaerVTisincreasedto1ml/kg

B. T h e P A O P m e a s u r e d a t e n d - e x p i r a K o n

C. TheCVPreferencedtothephlebostaKcaxiswithsupineposiKonD. T h e S c V O 2 m e a s u r e d f r o m a C V C



Pulsepressurevariation



∆PP(%)=100x(PPmax-PPmin)(PPmax-PPmin)/2

Definedasresponder

• Threshold>13%• SensiKvity94%

• Specificity96%

MorereliablethanSPV

MICHARDFandetal.AJRCCM2000;162:13–8.



Passivelegraisingtest(PLR)



• Selfvolumechallenge3ml

• MeasuresaorKcbloodfloworpulsepressure

• 3-9sec• AorKcbloodflow> 1%(sensiKvity97%,specificity94%)

• Pulsepressureincreased>12%(sensiKvity6%,specificity85%)

MonnetXandetal.CritCareMed26

A5yearoldpaKentwithsevereARDSfromsepsisissupportedby

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y p p pp yassistcontrolvenKlaKon.HeisrequiringanFiO2of.8andaPEEPof12cmH2OtoproduceaPaO257mmHg.Youelecttotrytoimprove

gas exchange and lower the FiO2 exposure by using a RM of 4cmH2Ofor4sec.Atendofmaneuver,thePaO2hasrisento16mmHg.

TheduraKonifthisimprovementdependsmostimportantlyon:

A. WhetheraddiKonalPEEPisadded

B. Performingrepeated4cmH2ORMsevery1-2h

C. Performingrepeated4cmH2ORMsevery3-6h

D. ImmediatelyrepeaKngtheRMwith5cmH2OandrepeaKngRMseveryhouriftheSpO2falls

icu tutorial 2011

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