1200 - Johnson - Critical Care

7/27/2019 1200 - Johnson - Critical Care

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Recent Advances in Critical Care

Medicine: A Case Based ReviewMargaret M. Johnson, MD

Associate Professor of Medicine

Chair, Division of Pulmonary MedicineMayo Clinic Florida

[email protected]



33 year old non-smoking, previously

healthy female

• No prior hospitalizations

• T 38.9 (po)

• RR 22 bpm

• HR 138 bpm• BP 70/40

• Coarse rhonchi bilaterally

• O2 saturation 82%

– Up to 95% on face mask

• Mottled skin

• Anuric

• Lactate 6.2

http://www.google.com/url?sa=i&rct=j&q=cxr+with+bilateral+infiltrates&source=images&cd=&cad=rja&docid=UdO7VyjsYOGjiM&tbnid=Iu3HfSJJkq9UdM:&ved=0CAUQjRw&url=http%3A%2F%2Fcid.oxfordjournals.org%2Fcontent%2F53%2F2%2F167%2FF3.expansion.html&ei=oOEoUb_NGYu69gTnh4G4DQ&bvm=bv.42768644,d.eWU&psig=AFQjCNGn64ChzVIB4STqIBnA5WVkfXGg7g&ust=1361717932721200



Overview

• Updated Surviving Sepsis Guidelines – Management of shock

• Fluid resuscitation

• Vasopressor support

• Role of steroids

• Respiratory management

– Intubation

– Ventilator management• High frequency ventilation, prone ventilation

• Management strategies to decrease delirium

• Outcome



SURVIVING SEPSIS GUIDELINES: 2012

Joint collaboration between SSCM and European Respiratory

Society

Third edition

No industry funding used in revision process

Critical Care Medicine February 2013www.survivingsepsis.org

http://www.survivingsepsis.org/

http://www.survivingsepsis.org/



Sepsis: Fluid Resuscitation

• Crystalloid, normally saline, is primary choice

– Initial: 30 ml/kg = 2.1 L for 70 kg

– Subsequent boluses to defined endpoint

– Endpoints:• Normal mixed venous oxygen saturation 65-70%

• Normal lactate

• Urine output > 0.5 ml/kg/hr

• MAP > 65 mm Hg• Weak indication for albumin (Grade 2B)

• Avoid hetastarch with high molecular weight (> 200 kD)



Potential Dangers of Saline

• Saline administration

– Hypertonic relative to blood

– Often causes hyperchloremic metabolic acidosis

• Does it cause renal injury ?• Prospective, sequential, single institution pilot study

• Chloride restrictive v. chloride liberal

– Restrictive

• Lactated solution or plasma-lyte• N = 776 (liberal)

• N = 773 (restrictive)

Nor’azim MY. JAMA 2012; 308(15):1566-1572



Results

• Limiting use of normal saline

– Less acute kidney injury and reduced need for dialysis in

hospital

– No difference in length of stay or mortality – No difference in need for dialysis after hospital discharge

• Current take home

– Uncertain

– Have a reason for giving saline – Probably should consider alternative fluid if large volume

required

Nor’azim MY. JAMA 2012; 308(15):1566-1572



Sepsis:Vasopressors

• Norepinephrine is first choice – Grade 1B

• Epinephrine is an alternative

• Vasopressin can be added to norepinephrine• Dopamine use limited by tachycardia

– NO INDICATION FOR RENAL DOSE

DOPAMINE

• Dobutamine if cardiac dysfunction or

persistent shock despite volume

• Value of Bedside ECHO



Are Steroids Indicated ???

Sigh….Will we ever know

• Current recommendations

– Don’t perform cosotropyn stimulation test to decide need forsteroids

– Consider steroids with persistent shock despite fluids andvasopressors

– Hydrocortisone 200 mg/day

• Boluses or infusion

• Avoid dexamethasone

– Don’t need fludrocortisone if hydrocortisone used

– Wean steroids when off vasopressors



Six Hours Later

BP 106/72

HR 90

RR 32

Received 4 L NSSNorepinephrine 12

ug/min

ABG:

7.32/42/310 on 100% O2

PaO2/fiO2 310



Intubation: Safety of Etomidate

• Meta-analysis: Etomidate associated with

– Increased risk of death

• 865 evaluated for mortality, RR 1.2 (1.02-1.42)

– Increased risk of adrenal insufficiency• 1303 evaluated with cosotropyn stimulation test, RR

1.33 (1.22-1.46)

• Take home

– Causality not concluded, but….alternative should beconsidered, especially in sepsis

Chan CM Crit Care Med 2012 40(11) 2945



Does She Have ARDS ?

New Berlin Definition

• Maintains emphasis on PaO2/fiO2 ratio – < 300 but > 200 = mild – < 200 but > 100 = moderate – < 100 = severe

• Other components – Acute ( < 7 days)

• Difficulty with chronic disease

– Bilateral infiltrates• Either computed tomography or chest x-ray

– No need to exclude heart failure• Heart failure can’t “solely explain respiratory

failure” JAMA 2012; 307 (23):2526



Value of “New Berlin” Definition

• Improved prognostic value:

– PaO2/fiO2 < 300 but > 200 = mild• 27% mortality

– PaO2/fiO2 < 200 but > 100 = moderate• 32% mortality

– PaO2/fiO2 < 100 = severe

• 45% mortality



Lower tidal volumes associated

with decreased mortality

6 cc/kg IBW v. 12 cc/kg

ARDSNet NEJM 2000

http://content.nejm.org/content/vol342/issue18/images/large/01f1.jpeg

http://content.nejm.org/content/vol342/issue18/images/large/01f1.jpeg



Low Tidal Volume Ventilation in

Absence of ARDS

• Meta-analysis of patients WITHOUT ARDS

• Tidal volume

– 6.5 v. 10.6 cc/kg IBW

• Lower tidal volumes associated with:

– Lower chance of developing ARDS

– Decreased pulmonary infection or atelectasis

– Mortality

Neto AS. JAMA 2012; 307 (23):2526



Is High Frequency Ventilation Helpful?

• OSCAR Trial – 795 patients

– Multi-centered in UK

– Identical 30 day mortality (41%)» Young D NEJM 2013;368:806

• OSCILLATE Trial

– High frequency oscillator trial stopped

prematurely due to increased mortality

• 47% v. 35%

» Ferguson N. NEJM 2013



Is Prone Positioning Beneficial ?

• Background

– Prone positioning has previously been shown to

improve oxygenation but not mortality in ARDS

• 237 patients proned v. 229 control

– Severe ARDS PaO2: fiO2 < 150

• Started early

– Within 36 hrs of ARDS

– 16 hrs/session

• 28 day mortality

– 16% (prone) v. 32.8% (control) (p< 0.001)

Guerin C. NEJM 2013;368:2159



Is Prone Positioning Beneficial ?

• Not blinded• Control group-higher

acuity scores

• Practical implementation – Did not use specialty beds

– Proning was not

associated with increasedcomplications

• BUT…these were

experienced centers

Guerin C. NEJM 2013;368:2159



9 Days Later

• “Agitated and combative”

• Receiving continuous infusions of

lorazepam and fentanyl• Agitation limits weaning attempts

• Is she delirious?

– Assessment of delirium

– Prevention and treatment



ICU Delirium

• Exact incidence is unknown but common – Up to 85% in some series

• Negatively impacts both short and long term

outcomes• Short term

• Length of stay & duration of ventilation

• Mortality

• Long term

• Cognition

• Depression and post traumatic stress disorder



Structural Changes Correlate with

Delirium and Cognition

Hopkins, RO Crit Care Med 2012



Greater Ventricle/Brain Ratio

Correlates with Delirium

Hopkins, RO Crit Care Med 2012



Recognition of Delirium

• Objective tools

– Confusion Assessment Method CAM-ICU

• Performed in conjunction with assessment of level of

sedation (Richmond agitation and sedation score-RASS)• www.icudelirium.org

• May be “hyperactive” or “hypoactive”



Ely EW. 2002



THINK…Rather than prescribe…

• Toxic environments

– Shock, CHF

– “Delirogenic Drugs”

• Hypoxemia

– Consider Haloperidol

• Infection/Immobilization

• Nonpharmacologic interventions/Nutrition

– Eyeglasses, Hearing aides, re-orientation, sleep wake

cycle restoration, sleep hygiene, noise control

• K+ electrolyte abnormalities



Risk of Delirium Associated with Use of Lorazepam &

Severity of Illness

Pandhandipari P. Anestheshiology 2006

LORAZEPAM DOSE (MG) APACHE SCORE

I N C I D E N C E

O F D E L I R I U M



Less delirium with Dexmedetomidate

v. Midazolam

Rikker RR. JAMA 2009

N = 375

Similar time at

goal sedation



Sedation Comparison

• MENDS Trial (n = 106)

– Dexmetomonidine v. lorazepam in mechanically

ventilated

– More days alive without delirium or coma with

dexmetomidine» Pandharipande JAMA 2007

• Reade, et al ( n=20)

– Dexmetomidine v. haldoperidol intubated patientswhose delirium prevented extubation

– Extubation sooner in dexmetomidine group» Crit Care 2009



Sleep, Delirium, and Cognition

• Observational pre and post intervention study

• Daily checklist to improve sleep and maintain

day-night cycles

• 634 (pre) v. 826 (post) patient days

• Subjective ratings of sleep not improved but

less delirium and less noise post intervention

Kamdar BB. Crit Care Med 2013



Now What

• Discharged from the ICU on Day 17

• Home on Day 23

• What should she and her family expect?



Denehy Curr Opin Crit Care Med 2013



Ways to Improve Functional Recovery

• In ICU – Limit sedation use and development of delirium

– Utilize early mobility programs, physical, and

occupational therapy

– Try to enhance sleep

• After ICU

– Coordinated post-discharge care including

physical, occupational, and cognitive rehabilitation

– Inform patients and caregivers that functional

limitations' commonly persist



Take Home Points

• New sepsis guidelines – Fluid 30 cc/kg normal saline

– No renal dose dopamine

– Avoid high molecular weight hetastarch – Norepinephrine (+/- vasopressin)

– No role for cosotropyn stimulation test

– Use hydrocortisone as steroid for stress dose – Chloride rich solutions associated with

development of kidney injury



Take Home Points

• Caution with the use of etomidate -especially in sepsis• Low tidal volume ventilation beneficial even in absence of ARDS

• High frequency ventilation has not shown mortality benefit

• Prone positioning associated with improved mortality

• Delirium is common and associated with worsened outcomes – Objectively assess

– ? Avoid/Limit benzodiazepines

– Consider nonpharmacological therapies

• Long term impairments often follow critical illness

– Inform patients and caregivers

– Strategies to improve long term outcomes are ongoing

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