CLIP: Checklist for Lung Injury Prevention. US Critical Illness and Injury Trials Group: Lung Injury Prevention Study Investigators (USCIITG LIPS)
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1 CLIP: Checklist for Lung Injury Prevention US Critical Illness and Injury Trials Group: Lung Injury Prevention Study Investigators (USCIITG LIPS)
2 USCIITG-Lung Injury Prevention Group A collaborative research network of 20 institutions for mechanistic studies and Acute Lung Injury prevention trials: Treatment options limited in Little research on Acute Lung Injury prevention Early (ED, OR) identification of patients at risk Multidisciplinary USCIIT group facilitates research in early stages of critical illness
3 Mount Sinai School of Medicine Temple University School of Medicine The Johns Hopkins University University of Medicine and Dentistry of New Jersey Denver Health Medical Center Hospital of the University of Pennsylvania Brigham and Women's Hospital Mayo Clinic Rochester U of Michigan University Hospital University of Washington, Harborview Medical Center Parkland Health and Hospital System Dallas, Texas University of Illinois at Chicago Wake Forest University Health Sciences Mayo Clinic Jacksonville Bridgeport Hospital, Yale New Haven Health Massachusetts General Hospital Akdeniz University Hospital, Turkey Beth Israel Deaconess Medical Center Miami Valley Hospital Emory University, Atlanta Uludag University School of Medicine, Turkey University of Missouri - Columbia Lung Injury Prevention Study1: Develop and validate clinical prediction model to identify patients at high risk of developing Acute Lung Injury during their first 6 hours of hospital admission
4 Acute Lung Injury Pathophysiology Initial Injury High tidal volume Mechanical Acid aspiration Chemical Membrane Injury + Direct Pneumonia Biological Indirect SIRS, Abdomenal sepsis, TRALI Acute Lung Injury Inflammation 30-40% Mortality $$_ QALY
5 Pathophysiology of Acute Lung Injury- Multiple Hit Hypothesis Risk modifiers that may risk of ALI (2 nd hit): High tidal volume, transfusion, delayed resuscitation, inappropriate antibiotics, aspiration, high FiO2, Risk modifiers that may risk of ALI: PEEP
6 Lung Injury Prevention Study Score
7 LIPS Score
8 Many proven therapies are underutilized Lower tidal volume in ALI/ARDS Transfusion in ICU Kalhan R, et al. CCM. 2006, Netzer G et. al. Transfusion. 2010
9 Practice Variation Between Institutions and Within Institutions Restrictive transfusion policies 50% of ICU, 12.5% of ED, 6% of OR Sepsis protocol 69% of ICU, 6% of ED, 13% of OR Structured handoffs on transfer 35% between ED and ICU 24% between ED and anesthesia 36% between ED and surgical staff
10 CLIP Element Clinically Supported practices AHA grade Adequate empiric antimicrobial treatment and source control Lung protective mechanical ventilation Aspiration precautions Early reassessment of noninvasive ventilation (to prevent delayed intubation) Fluid management: - Early fluid administration in septic shock - Limiting fluid overload after resuscitation Restrictive transfusion According to suspected site of infection, health care exposure, and immune suppression Tidal volume <6-8 ml/kg predicted body weight and plateau pressure <25 cm H2O; PEEP 5 cm H2O, minimize FIO2 (target O2sat 88-92% after early shock) Rapid sequence intubation supervised by experienced providers, elevated head of the bed, oral care with chlorhexidine, gastric acid neutralization Early reassessment of the work of breathing 30 minutes into the onset of noninvasive ventilation - Resuscitation according to institutional protocol and IHI sepsis bundle - Modified ARDSnet FACCT protocol after early shock (first 12 hours) Hemoglobin target >7 g/dl in the absence of acute bleeding and/or ischemia Class I Class IIa Class IIA-IIb Class IIb - Class IIa - Class IIa Class IIa Appropriate handoff of patients at risk Structured handoff such as SBAR Class IIa
11 Sample Patient 72 yo man with diabetes and CAD presents to the ED from acute rehab hospital at 4 AM with SOB. Initial work-up: Temperture 102 Heartrate 119 Respiratory Rate 32 Blood Pressure 85/65 Oxygen saturation 92% on RA WBC 18 ABG 66/36/7.36 CXR with LLL infiltrate
12 Sample Patient By 9 AM, the patient was awake, responsive: BP 92/69 on levophed at 3 mcg/min after only 3 liters of NS O2 sat 95% on 40% face mask
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14 Lung Injury Prediction Score (LIPS) = 7 > 20% of pts with LIPS =7 develop ALI
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21 The Project IPad/Iphone app to calculate the Lung Injury Prevention Score Checklist of items for lung injury prevention Usability Testing: Multicenter Group
22 Questions? Raquel Bartz Dept. of Anesthesiology
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