Interactive Clinical Forum

Transcription

1 Interactive Clinical Forum The rules for this session Avery Tung, M.D, FCCM Department of Anesthesia and Critical Care University of Chicago 5 decisions embedded in a Clinical Scenario All are clinically controversial Vote Voting is anonymous Literature review Revote Did the literature change your mind? Who s sitting next to you? How many years have you been practicing? 1. < >20 19% 17% 33% 31% A 55 yr otherwise healthy steelworker is caught in an explosion at work He suffers 40% flame burns to his chest, back, face, and upper arms Due to the presence of soot in his oropharynx, he is intubated at the scene with Etomidate and Rocuronium. He is brought to your Burn ICU sedated on a morphine drip Tung: 4 < >20 Although he was knocked down by the explosion, he did not lose consciousness. 1

2 Over the next 8 hours, your resuscitation is smooth His BP is 100/50 and HR is 95 except that the patient require more fluid than the standard consensus formula (4cc/kg/%burn, ½ over first 8h = 800cc/hr) You suspect associated inhalation injury and, in fact, over the next 6 hours his peak airway pressures rise from 26 to 35cmH 2 O (TV = 500cc) His PO 2 falls from 180 to 90mmHg (FiO 2 = 80%), and a CXR shows worsening pulmonary edema. Even more worrisome than his pulmonary edema is his urine output, which has dwindled to <10cc/hr despite progressively increasing the LR infusion to 1250cc/hr. The nurse notes that his abdomen is noticeably more tense and reports that his bladder pressure = 20 mmhg. BP now 95/50, HR 110, PPV = 20 Decision point #1 (55 yr M with 40% TBSA, ARDS, bladder pressure and UO) Would you switch to albumin to limit 3 rd space fluid extravasation? Although aggressive resuscitation for hypovolemia is a cornerstone of initial burn care, complications of third space fluid extravasation may also occur This patient has two potential complications of crystalloid administration: abdominal compartment syndrome and pulmonary edema. Switching to albumin may reduce third space extravasation during the initial phase of burn resuscitation. Although outcome studies are generally mixed, many burn centers use albumin early in resuscitation Decision point #1 (55 yr M with 40% TBSA, ARDS, bladder pressure and UO) Would you switch to albumin? 1. Yes 2. No 62% 38% Yes No 2

3 Albumin 38 trials, 10,842 patients, 1,958 deaths Burns: RR = 2.93 ( ) Albumin should only be used within the context of well concealed and adequately powered clinical trials Cochrane Database Syst Rev. 2011;(11):CD Anaesth Intensive Care 2010;38: USS Arizona Dec 7, 1941 All seven patients were given albumin, and all showed prompt clinical improvement, including one whose state was so critical that the administration of albumin to him was debatable. There was no question as to his response: He was unconscious in the morning when he was given 250 gm. of albumin. In the afternoon, he was talking but was disoriented. The following morning, he was given the same amount of albumin. Twenty-four hours later, the edema had disappeared and he was taking food by mouth. -I Ravdin, Conference on Albumin, NRC, 5 Jan

4 1,955 patients USA All 6,997 patients No differences in: Death ICU days Hospital days Ventilator days RRT days *80% for impaired perfusion or vital sign normalizaion Critical Care 2010;14:R185 N Engl J Med 2004;350: SAFE subgroup analysis (SIRS & infection & organ dysfunction) 1,218 patients with sepsis Mortality 17 studies and 1,977 patients Relative to crystalloid Albumin OR for mortality = 0.82 Crit Care Med 2011;39: Crit Care Med 2011;39:

5 The ALBumin Italian Outcome Sepsis study 100 centers, N = 1810 Randomized after volume resuscitation Albumin infusion if Plasma albumin < 25 g/l Overall mortality = 34.8% (46% for septic shock) Presented by the ALBIOS team at the Critical Care Canada Forum Nov 10, 2013 Presented by the ALBIOS team at the Critical Care Canada Forum Nov 10, 2013 No overall mortality difference but better survival in patients with septic shock! Presented by the ALBIOS team at the Critical Care Canada Forum Nov 10, 2013 Presented by the ALBIOS team at the Critical Care Canada Forum Nov 10,

6 2007 survey of ISBI and ABA members CVP Albumin Saline <8 mmhg mmhg >12 mmhg MAP after 6h Albumin Saline >65mmHg 86% 82.5% NEJM 2014;370: Nearly 50% (49.5%) add colloid during the first 24h Burns 2010;36: Decision point #1 Second chance (55 yr M with 40% TBSA, ARDS, bladder pressure and UO) Would you switch to albumin? 1. Yes 2. No 57% 43% You switch to albumin at 1250 cc/hr His urine output improves and over the next 4h you are able to reduce the albumin rate to 750 cc/hr. PO 2 is now 70mmHg on 80% FiO 2 and UO = 20 cc/hr His blood pressure (88/50) remains low, however and albumin boluses are ineffective. Your most recent lactate has increased from 1.2meq/L to 5meq/L You place a central line to clarify your suspicions about the circulation. The initial CVP is 19mmHg and SvO 2 = 65%. Hb = 14 and SpO 2 = 95%. Yes No 6

7 But his lactate keeps climbing Decision point #2 (55 yr M with inhalation injury, CVP, UO, lactate) A repeat value is now 6 meq/l and bladder pressure is now 21mmHg. You perform a bedside echo (limited and of poor quality due to his burns) and obtain a short axis view suggesting LVH, possible RV enlargement, and LV hypovolemia Your friend the cardiac surgeon stops by to chat. Why don t you put in a swan?, she asks. That s what we would do in the CTICU! Would you place a PA catheter? For 18 years, clinical trials have failed to find a benefit to intraoperative PA catheterization Yet, a majority of cardiac surgeries and liver transplants are still done with routine use of PA catheters In this case, your CVP, lactate, and A-a gradient are high, and your urine output and SvO 2 is low. And you still have hours of resuscitation to go. A PA catheter may allow better overall hemodynamic assessment. Decision point #2 (55 yr M with inhalation injury, CVP, UO, lactate) Would you place a PA catheter? 1. Yes 2. No 36% 64% Yes No 13 studies and 5,686 patients RR (mortality) for MICU patients = 1.02 RR (mortality) for preop optimization= 0.98 R (mortality) for for intraop monitoring = 1.1 Cochrane Database of Systematic Reviews 2013,2:CD

8 * 1,933 patients managed with PAC vs controls stratified to base deficit, ISS, age SCA annual meeting 2010 New Orleans, LA April 24, 2010 N = 28 *BD= -11, age 61-90, ISS Crit Care Med 2006; 34: We don t NEED the Swan anymore! 502 patients with PA catheters and propensity matched controls FEWER deaths in PAC group (1.4 vs 4.4%, HR = 0.3) HR 0.09 for SBP<100 We have PPV We have TEE We have Esophageal doppler We have arterial waveform analysis Int J Cardiol 2014;172:

9 But Pulse Pressure variation 27 pigs PPV<13% vs CVP 12-15mmHg may NOT work with: Arrhythmia Increased abdominal pressure Spontaneous ventilation TV < 8 cc/kg RV failure phtn Liver transplant AUC (CVP) = 0.77 AUC (PPV) = 0.74 Acute resuscitation guided by PPV was comparable with the strategy guided by CVP Shock 2013;40: patients undergoing OLT The PPV index was not shown to be a reliable predictor of fluid responsiveness during OLT Br J Anaesth 2009;103: /1/14 9

10 * 325 paired PAC/ FlowTrac data in 14 ICU patients 30% agreement on hypovolemia* *PC = pulse contour, ED = esophageal doppler Anesth Analg 2011;113:751 7 *PPV >13% RVEDVI > 130ml/m2 J Intensive Care Med 2014; [epub] 2007 survey of ISBI and ABA members Decision point #2 Second chance (55 yr M with inhalation injury, high CVP, and low UO) Would you place a PA catheter? 1. Yes 2. No 69% 31% Burns 2010;36: Yes No 10

11 You place a PA catheter The procedure is bloody His initial PAP = 45/20, CO = 3.0lpm (Index = 2.0) and wedge pressure = 7mmHg. Armed with this information, you continue aggressive albumin resuscitation and cross your fingers Fortunately, at hour #16 he turns the corner, his fluid requirements fall, his lactate begins to normalize, and his urine output increases. By PBD #2 he is relatively stable and he is taken to the OR. His arms and chest are excised and grafted with skin from his lower legs He is given 12U PRBC, 9U FFP, and 2U platelets Postoperatively, he is relatively stable. Immediately afterwards, Hb = 9g/dl, INR = 1.5, and platelet count = 70,000 You give 2u PRBC overnight. The next morning his Hb is 8.7, INR is 1.7, and his platelet count is 19,000 He doesn t look like he is bleeding anymore and his overnight Is/Os =3400cc/800cc Decision point #3 (55 yr M with 40% TBSA, POD#1 after E&G, platelet count) Would you prophylactically transfuse platelets? Existing data in bone marrow transplant patients suggests that patients not undergoing procedures may tolerate platelet counts as low as 10,000 without spontaneous hemorrhage But this patient is not a bone marrow transplant. He has had major surgery, and may thus be at greater risk for bleeding than if he had not had a procedure He does not currently look like he is bleeding so platelets in this situation could be considered prophylactic But how would you know? And, a burn hematoma would predispose to graft failure Decision point #3 (55 yr M with 40% TBSA, POD#1 after E&G, platelet count) Would you prophylactically transfuse platelets? 1. Yes 2. No 60% 40% Yes No 11

12 118 of 261 patients with PLT count < 50K 76 platelet transfusions Transfusion 2006;46: Anesthesiology 2006;105: Risks of platelet transfusion ABO major Bacterial contamination 2 reports in the US in 2012 TRALI 17 of 74 US fatalities reported ABO minor (O donor) 10-40% of platelet transfusions in the US are ABO noncompatible Allergic reactions As high as 21% Transfus Med Rev 2007; 21:1 12 Transfusion 2012; 52: Transfusion 2013; 53: Vox Sang 2014 Mar 20 epub Transfusion 2012;52:

13 159 stem cell transplant patients randomized to prophylactic platelet transfusion at platelet counts of 10K vs 20K Results No difference in bleeding events (14% in 10K arm vs 17%) No difference in CNS bleeds (2 in 10K and 1 in 20K group) There is no evidence that a prophylactic platelet transfusion policy prevents bleeding There is no evidence that platelet dose affects the incidence of WHO grade 4 bleeding Biol Blood Marrow Transplant 2002;8: insertions in 193 patients 600 patients randomized to prophylaxis (>10K) vs transfusion for bleeding or procedures Platelet count Odds Ratio of bleeding < > N Engl J Med 2013;368: Transfusion 2011;51:

14 389 massively transfused trauma patients J Trauma 2011;71: S Ann Surg 1960;152: Decision point #3 Second chance (55 yr M with 40% TBSA, POD#1 after E&G, low platelet count) Would you prophylactically transfuse platelets? 1. Yes 2. No 61% 39% Yes No You decide to transfuse 1U platelets And his count rises to 29,000 He undergoes a second debridement a day later but unfortunately you only have enough donor skin to partly cover his back. You cover the rest with allograft and wait for donor skin to regenerate He remains intubated with PO 2 = 63mmHg on 70% FiO 2, TV = 450cc, and PEEP = 12cm H 2 O He is sedated with continuous infusions of midazolam and fentanyl 14

15 The next day the hospital quality pharmacist pages you I notice you are not practicing daily sedative interruption, she says It s hospital policy unless the primary attending specifically documents a contraindication, she continues Those are: sedation for seizure control, active myocardial ischemia, use of paralytics, and FiO 2 > 70%, she reminds you Does your patient fit any of these categories?, she asks Decision point #4 (55 yr M with 40% TBSA, PEEP = 12, Midazolam/Fentanyl drips) Would you implement a DSI protocol? While literature support for DSI has been relatively strong, ICU caregivers have been extremely reluctant to implement DSI protocols Criticisms include harm to self, awareness, clinical destabilization, and inadvertent removal of critical devices and lines More recent evidence suggests that the benefit of DSI depends on the comparison group This patient has severe ARDS, and allowing him to wake up may result in significant gas exchange abnormalities Decision point #4 (55 yr M with 40% TBSA, PEEP = 12, Midazolam/Fentanyl drips) Would you implement a DSI protocol? 1. Yes 2. No 11% 89% Classic DSI 1. Every morning, stop all sedative infusions 2. Wait until the patient emerges or becomes difficult to control 3. Restart sedative infusions at ½ the starting dose 4. Repeat daily until extubation Yes No 15

16 105 patients DSI group* had fewer: Ventilator days (4.9 vs 7.3) ICU days (6.4 vs 9.9) CT scans (9 vs 27) NO difference in complications *64 in each group NEJM 2000;342: AJRCCM 2003;168: patients 128 patients FEWER complications in the DSI group! Crit Care Med 2004;32: Crit Care Med 2007; 35:

17 Crit Care Med 2006;34: ,381 patients in 43 French ICUs 50 Results: Ramsay most common scale Midazolam most common sedative NO SITE (0%) WAS USING DSI!!! Anesthesiology 2007;106: MICU patients randomized to DSI or control: Results: DSI protocol amended after 3 study related adverse events 4 DSI patients withdrawn at the request of the family DSI: mortality, Longer MV duration, ICU and hospital LOS Study terminated after 74 patients NO difference in ventilator days NO difference in ICU days NO difference in delirium Greater nursing workload with DSI Critical Care 2008;12:R70 JAMA 2012;308:

18 Decision point #4 Second chance (55 yr M with 40% TBSA, PEEP = 12, Midazolam/Fentanyl drips) Would you implement a DSI protocol? 1. Yes 2. No 76% 24% Crit Care Med 2013;41: Yes No You invoke the FiO 2 exemption After 5 days of antibiotics And choose not to implement a DSI protocol The patient s next grafting opportunity is delayed by a bout of pseudomonas sepsis He requires 24 hours of pressor use, aggressive fluid administration, holding tube feeds, and IV/topical antibiotics However, he doesn t bounce back as easily as you hope His fever has dissipated and his white cell count has fallen from a high of 28K to 18K But he remains dependent on 0.1 mcg/kg/min Norepinephrine and 50 mcg/min Phenylephrine to keep MAP > 60mmHg His Creatinine has also increased with the sepsis episode and has now risen to 2.3 over the 5 day period You check a random cortisol level at 10am and it comes back 22. BP 90/50, HR 90, PPV 9 18

19 Decision point #5 (55 yr M with 40% TBSA, sepsis, & vasopressor requirement) Would you give steroids for shock reversal? Decision point #5 (55 yr M with 40% TBSA, sepsis, & vasopressor requirement) Would you give steroids for shock reversal? The use of steroids for septic shock remains controversial, and clinical consensus has swung from benefit to harm twice over the last 40 years 1. Yes Current SCCM surviving sepsis guidelines suggest (2B) steroid replacement at 200mg hydrocortisone per day but 2. No 52% 48% only if fluids and vasopressors are ineffective Considerable practice variability thus exists among critical care physicians. Although this patient had no history or risk factors for adrenal insufficiency, he was intubated with Etomidate which has been associated with prolonged effects on adrenal function Yes No How old are you? : Steroids are Good in septic shock Schumer W: Steroids in the treatment of clinical septic shock. Ann Surg 1976;184: : Steroids are Bad in septic shock Bone et al, A controlled clinical trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock. N Engl J Med 1987;317: : Steroids are Good in septic shock Annane et al. Effect of treatment with low doses of hydrocortisone and fludrocortisones on mortality in patients with septic shock. JAMA 2002;288: present: Steroids are Bad in septic shock Sprung et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008;358: Retrospective review of 155 patients given hydrocortisone for septic shock Crit Care Med 2013;41:

20 I thought this patient got Etomidate? 1. Do not give steroids in the absence of shock (1D) 2. Only give steroids if fluid resuscitation and vasopressor therapy have failed to restore hemodynamic stability (2C) mg IV hydrocortisone per day (2C) 4. Do not use the ACTH test (2B) 5. Taper steroids when vasopressors no longer needed (2D) Doesn t Etomidate suppress adrenal activity? Crit Care Med 2013; 41: patients requiring mechanical ventilation 865 patients and 5 trials Nonresponders* were: Sicker (SAPS 60 vs 48) More likely to require vasopressors (81 vs 51%) More likely to die (70 vs 31%) More likely to have gotten Etomidate (70 vs 26%) * To cosyntropin stimulatoin Intensive Care Med 2005;31: Crit Care Med 2012;40:

21 106 patients intubated in the ER with sepsis 74 received Etomidate Results: No difference in LOS No difference in mortality Suggestions that the use of etomidate for intubation in the ED be abandoned are not supported by these data 8 trials 1,063 patients For Shock reversal: OR 2.07 at 7 days ( ) OR 1.49 at 28 days ( ) Acad Emerg Med 2009;16:11-14 Anesth Analg 2014;118: Decision point #5 Second chance (55 yr M with 40% TBSA & persistent vasopressor requirement) Would you give steroids for shock reversal? 1. Yes 2. No Yes 61% No 39% You give steroids to this patient His blood pressure improves and he is easily weaned off vasopressors Over the next 7 days you gradually taper his steroids, his renal function recovers, he begins to tolerate feeds, and his prealbumin levels increase to 15 mg/dl His donor sites are ready for reharvest 3 days later and he returns to the OR for successful E&G He is successfully extubated 10 days later, moved to the floor 4 days later and is sent to a burn rehabilitation center 20 days later 6 months later he sends you a picture of him fishing on lake Michigan! 21

22 Thank you for your help! Avery Tung, M.D. FCCM 22