Caring For the ICU Boarder. Kami M. Hu, MD Depts of Emergency & Internal Medicine University of Maryland SOM
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1 Caring For the ICU Boarder Kami M. Hu, MD Depts of Emergency & Internal Medicine University of Maryland SOM
2 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s)and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercialproduct/device in my presentation.
3 Identify measures that affect morbidity and mortality from the ED
4 Identify measures that affect morbidity and mortality from the ED Provide practice tips and/or evidencebased actions to optimize these measures
5 Outcomes for ICU Patients Boarding in the ED ED boarding an independent risk factor for ICU & hospital mortality Higher incidence of persistent organ dysfunction and death Chalfin et al, Crit Care Med 2007 Al-Qahtani et al, BMC Emerg Med 2017 Matthews et al, Crit Care Med 2018
6 emdocs.net
7 Improving Outcomes Limit depth of sedation Ensure lung protective ventilation and adjust ventilator settings according to patient need Re-give appropriate antibiotics Evaluate patients for fluid responsiveness Maintain specific care goals post-cardiac arrest
8 Intubations in the ED
9 Knoop et al, Atlas of Emergency Medicine, 4 th Ed.
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12 64% of pts deeply sedated (RASS -3) Deep sedation associated with more ventilator days and higher mortality Stephens et al, Chest 2017
13 Deep sedation (RASS -3) in the first 48 hours associated with: Increased mortality Increased ventilator days Increased delirium Stephens et al, Crit Care Med 2018
14 Light sedation over deep Address pain first (using opiate) Non-benzodiazepine sedative preferred
15 thoracickey.com
16 thoracickey.com
17 My approach: Propofol + opiate while paralyzed Reevaluate off propofol treat pain with morphine or dilaudid IV or oxycodone per OGT If patient is agitated/delirious haldol IV - Tolerate for QTc <530, optimize magnesium If sedation truly required precedex or ketamine Propofol for deep sedation
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19 Only 13% of patients had FiO2 decreased from initial setting of 1.0 No blood gas in 17% of patients Abnormal PCO2 and PO2 did not result in changes to ventilator Al Ashry et al, Respir Care 2018
20 40% with non-lung protective vent settings 49% with PEEP 5 and FiO 2 of 100% Only 22% had any changes made to the ventilator Wilcox et al, Am J Emerg Med 2016
21 5 versus 3 interventions = decreased mortality OR 4.25 (95% CI 1.15 to 15.75) Bhat et al, West J Emerg Med 2014
22 Bhat et al, West J Emerg Med 2014
23 - D Fuller et al, Ann Emerg Med 2017
24 Fuller et al, Ann Emerg Med 2017
25 Fuller et al, Ann Emerg Med 2017
26 Fuller et al, Ann Emerg Med 2017
27 % of patients on lung protective vent settings % of patients with HOB elevated Pre- Intervention Postintervention < 50% 96% 39% 93% Fuller et al, Ann Emerg Med 2017
28 Decreased ventilator days Decreased ICU and hospital LOS Absolute risk reduction for mortality of 14.5% (AOR 0.47; 0.35 to 0.63) Fuller et al, Ann Emerg Med 2017
29 My Approach HOB up OGT confirmatory CXR Measure patient set TV to 6ml/kg and adjust RR Immediately titrate FiO2 to SpO2 >90% while standing at bedside increase PEEP if needed
30 My Approach If hypercapneic, ensure ETCO2 improving Check VBG at 30 min post-intubation (ABG if particularly hypoxic or in shock states) Tell RN to find you if vent alarming
31 powerpoint.crystalgraphics.com
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33 ecatalog.baxter.com
34 giphy.com
35 43% of patients experiencing major delay to 2 nd dose abx = ED boarders Major delay associated with: - risk of in-hospital mortality - new need for mechanical ventilation Leisman et al, Crit Care Med 2017
36 pedicardiology.net
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39 Fluid balance at 12 hours & 4 days predicts mortality CVP < 8mmHg at 12 hrs best survival Boyd et al, Crit Care Med 2011
40 13 trials, 1652 patients Dynamic assessment = SVV, PPV, PLR or mini-fluid challenge Decreased mortality, ICU LOS, duration of mechanical ventilation Bednarczyk et al, Crit Care Med 2017
41 Predicting Fluid Responsiveness Passive leg raise - CO of 15% by US - ETCO2 5 - ΔPPV >3.5% Respiratory variation in IVC diameter - 15% vented, 50% spontaneously breathing Mini-fluid challenge - 100mL of colloid Jalil et al, Am J Emerg Med 2018
42 My Approach Initial 30 ml/kg IVF Check passive leg raise with ETCO2 or US If not responsive, start vasopressors If pressors escalating, recheck fluid responsiveness If not likely fluid responsive, cardiac US - add pressor, inotrope, ± stress-dose steroid as appropriate
43 Post-Resuscitation Care
44 Temperature Management Start cooling (32 36 C) Actively prevent fever Manage shivering Callaway et al, Circulation 2015
45 Respiratory Goals Hyperoxia in the first 6 hrs worsens outcomes Target PaO SpO2 94% Target normocarbia for most patients Kilgannon et al, Circulation 2011 Youn et al, Crit Care Med 2018
46 Hemodynamics Definite MAP > 65 MAP > 80? Awaiting NEUROPROTECT results Callaway et al, Circulation 2015 Beylin et al, Intensive Care Med 2013
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48 Take Homes Target goal RASS 0 to -2 Start lung protective vent settings & follow-up Schedule antibiotics so repeat doses aren t delayed Assess for volume responsiveness before ordering that next IVF bolus Goals for post-cardiac arrest: - Temp 32 to 36 C, SpO2 94, normocarbia, MAP >65
49 @kwhomd
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