ismail tan bin mohd ali tan intensive care -...
TRANSCRIPT
ISMAIL TAN BIN MOHD ALI TAN
Department of Anaesthesia and
Intensive Care
Hospital Kuala Lumpur
A 28 year old lady admitted to the ICU for mechanical
ventilation for hypoxemia secondary to severe community
acquired pneumonia.
On arrival, spo2 81% on manual ventilation
Connected to the ventilator on IPPV fio2 1.0 PeeP 20 Ip
38
Pao2 51 Paco2 38
How do you improve her
oxygenation ?
Strategies in ARDS
Protective lung strategies
Prone positioning
ECMO
HFOV
Novel methods : iNO, restrictive fluid
therapy, steroids, immunmodulation
12ml/kg vs 6ml/kg
N=861
Mortality : 31% vs 39 %
(p 0.007)
Vent free days :12 vs
10 (p 0.007)
Ventilation strategies
- Low Tidal volume (< 8ml/kg PBW)
- Limit Plateau pressure ( < 30 cmH20)
- Maintain optimum Peep (
- Paco2 55 - 80 mmHg or Spo2 88 – 95%
- pH goal 7.3- 7.45
1st step
Prone positioning ( proning )
Conceptualized in 1970s Bryan AC, Am Rev Resp Dis 1974
Magareth A, Crit Care Med 1976
○ 5 case reports
William Douglas, Am Rev Resp Dis 1977
○ 6 pts, supine and prone
Slow adopters…..
- Evolutionary standpoint
- The animal kingdom amongst 4 legged animals
Prone positioning ( proning )
Conceptualized in 1970s Bryan AC, Am Rev Resp Dis 1974
Magareth A, Crit Care Med 1976
○ 5 case reports
William Douglas, Am Rev Resp Dis 1977
○ 6 pts, supine and prone
Slow adopters…..
- Evolutionary standpoint
- The animal kingdom amongst 4 legged animals
Prone positioning ( proning )
Evidence : What are we waiting for?
- Improved oxygenation
- Reduced mortality
Prone positioning ( proning )
Evidence : What are we waiting for?
- Improved oxygenation ?
- Reduced mortality ?
Prone positioning ( proning )
Evidence : What are we waiting for?
- Improved oxygenation …yes
- Reduced mortality ?
Gattinoni NEJM 2001 • n = 304
• Supine vs
prone
• 7 h per day
Prone positioning ( proning )
Evidence : What are we waiting for?
- Improved oxygenation …yes
- Reduced mortality ?
Guerin 2004
• n = 791
• Prone vs supine
• 8 h per day
no difference in mortality….
Prone positioning ( proning )
Evidence : What are we waiting for?
- Improved oxygenation..yes
- Reduced mortality…no convincing evidence,
until recently
Questions…
- Specific population
- Duration of proning
# 1 : Is Proning Effective ?
Positioning
Gatinoni, 2013
Physiological
Effects of
Proning
• Alters comformation of
lungs
• Reduce gradient of
pleural-pulmonary
pressures resulting in
more uniform lung
expansion
• Improve ventilation
perfusion V/Q matching
• Increase Functional
Residual Capacity(FRC)
• Recruitment of atelectatic
lung units
• Encourage mouthward
migration of secretions
• Reduce VILI risk
Positioning effects
Why ?
Gatinoni, 2013
# 1 : Is Proning Effective ?
• Less pressure of heart
on lungs
• More evenly distributed
volumes and pressures
• Improved V/Q matching
Positioning
Gatinoni, 2013
Physiological
Effects of
Proning
• Alters comformation of
lungs
• Reduce gradient of
pleural-pulmonary
pressures resulting in
more uniform lung
expansion
• Improve ventilation
perfusion matching
• Increase Functional
Residual Capacity(FRC)
• Recruitment of atelectatic
lung units
• Encourage mouthward
migration of secretions
• Reduce VILI risk
#3 : How to prone
Manual
Cost effective
BUT
more difficult,
additional nursing,
?Emergency Rx delay
How to prone
Manual
- With support
- Without support
Automated
# 2 : Indications
ARDS : Berlin definition
Mild : p/f ratio 200- 300
Moderate : p/f ratio 100-200
Severe : p/f ratio < 100
# 3 : Contraindications
Spinal instability
Hemodynamic instability
Abdominal surgery with ? Bogota bag, stoma
Intracranial hypertension
Facial trauma
Fresh tracheostomy
Is this true ?
# 4 : When to prone and how long
P/f ratio
How soon…?
< 12 or > 48 h
# 4 : When to prone and how long
HU et al, Crit Care 2014
# 4 : When to prone and how long
p =0.18
p = 0.3
p = 0.03
Severe ARDS
HU et al, Crit Care 2014
• p/f ratio < 150
• Enrolment between
12h to 72 h
Park SY et al, J thoracic Disease 2015
• N= 466
• p/f ratio < 150
• Enrolment within 12h
to 72 h
• Early proning in more
severe ARDS ,
Guerin 2013
Park SY et al, J thoracic Disease 2015
When to prone and how long
Duration of
proning :
• 7h per day to
18 h per day
• 18h to 10 days
When to prone and how long
• Duration of
proning ranges
between 7h
per day to 18 h
per day
• Between 18h
to 10 days
17 hours daily for 4
days !
When to prone and how long
p = 0.09
p = 0.6
Longer proning
is better !
#5 : Hazards and risks
Patient
Healthcare providers
Proning
Risks
Pressure
sores Dislodged
ETT
Dislodged
lines
Edema Hemodynamics
desaturation
Cardiac
arrest
Proning Risks
Pressure sore
Loss of venous
access
Proning Risks
prone supine
Non significant
increase in :
• pneumothorax
• Ventilator
associated
pneumonia
• Cardiac arrest
ETT
displacement
Outcome of proning
Sachin Sud et al. CMAJ 2014
Outcome of proning
Outcome of proning
Outcome of proning
Mortality
Requirements for proning
Staff
Bed
Support/pillow/pressure points protection
Access : diagnostics and therapeutic
Monitors
Inform next of kin
Duration and timeout plan
Protocols/guidelines in event of emergency
Equipment
Pillows : shoulder, pelvis, ankles
Padding : pressure points
Eyelid tape and protector
ETT tape/dressing ( water proof )
Doughnut pillow for head
ECG leads
Emergent cart
Pre proning plan
Secured ETT/RT
Eye protection
Pre-oxygenate patient
Suctioning of oral cavity/ETT
Remove and cap lines/tubes
Change necessary dressings
Remove and re-site ECG leads to posterior chest
Optimise sedation/analgesia and neuromuscular blockade
Turning checklist
Minimum staff needed ( 2 each side )
Identify turn leader
Doctor at head end – secure airway
Closest arm to ventilator tucked under patient
Sp02 probe at on limb not being turned under the patient
Place pillows/bolsters on chest
Flat sheet on top of pillows/bolsters
Slide patient to edge of bed ( away from ventilator)
Check ETT, lines, tubes; assess for kinks/dislodgements/air entry
Turning checklist
Face towards ventilator
Arms raised
Ensure position of pillows under shins and toes off
bed
Reattach lines/cables
Reassess ETT cuff pressures, Tidal Volumes, HR,
BP
Ensure eye position
Ensure free abdomen
Pressure points monitoring
pull
lateral
support
turn
Local protocol and guidelines Will it make a difference ?
Indications..early recognition of ARDS
Contraindications
Equipment checklist
Proning team ?
conclusion
Protective lung strategies AND proning is effective
Moderate to severe ARDS
Do it early
Need longer duration, > 12h
Aware of risks
Local guidelines or protocol
Thank you