Beyond the Golden Hour: Caring for the ICU Boarder
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1 Beyond the Golden Hour: Caring for the ICU Boarder Kami M. Hu, MD Dept. of Emergency Medicine Dept. of Pulmonology & Critical Care 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 commercial product/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 in intubated patients Re-give appropriate antibiotics Ensure lung protective ventilation & adjust vent settings according to patient need Evaluate patients for fluid responsiveness Maintain specific care goals post-cardiac arrest
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12 64% of pts deeply sedated (RASS -3) Deep sedation associated with more ventilator days, ICU and hospital LOS, and higher mortality Stephens et al, Chest 2017
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14 Deep sedation (RASS -3) in the first 48 hours associated with: Increased hospital mortality (27% vs 9%) Increased ventilator days Increased delirium Stephens et al, Crit Care Med 2018
15 Light sedation over deep Address pain first (using opiate) Avoid benzodiazepines
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18 My approach: Propofol + opiate while paralyzed Reevaluate off propofol treat pain with IV opiate or oxycodone per OGT If patient is agitated/delirious haldol IV If sedation truly required precedex or ketamine Propofol for deep sedation or specific indications
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20 Only 13% of patients had FiO2 decreased from initial setting of 100% No blood gas in 17% of patients Only 11% of abnormal blood gases resulted in changes to ventilator Al Ashry et al, Respir Care 2018
21 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
22 5 versus 3 interventions = decreased mortality OR 4.25 (95% CI 1.15 to 15.75) Bhat et al, West J Emerg Med 2014
23 Bhat et al, West J Emerg Med 2014
24 - D Fuller et al, Ann Emerg Med 2017
25 Fuller et al, Ann Emerg Med 2017
26 Fuller et al, Ann Emerg Med 2017
27 Fuller et al, Ann Emerg Med 2017
28 96% of patients on lung protective vent settings 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/AXR 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 or they have to go up on FiO2
31 powerpoint.crystalgraphics.com
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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
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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 67% with volume overload at day 1 48% still overloaded at day 3 Increased mortality in overloaded patients Kelm et al, Shock 2015
41 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
42 Predicting Fluid Responsiveness Passive leg raise - CO of 15% by US - ETCO2 5 - PPV >3.5% (PPV > 12%)* IVC collapsibility - 15% vented, 25-50% spontaneously breathing Mini-fluid challenge - 100mL of colloid, 250mL of crystalloid Jalil et al, Am J Emerg Med 2018 Corl et al, J Crit Care 2017
43 My Approach Initial 30 ml/kg IVF Bedside US: cardiac function, IVC, passive leg raise If not responsive, start vasopressors If pressors escalating arterial line & reassess volume responsiveness If not likely fluid responsive, add pressor/inotrope, ± stress-dose steroid as appropriate
44 Post-Resuscitation Care
45 Temperature Management Start cooling (32 36 C) Actively prevent fever Manage shivering Surface counter-warming Buspirone Magnesium Meperidine Callaway et al, Circulation 2015
46 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
47 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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49 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 liter of IVF Goals for post-cardiac arrest: - Temp 32 to 36 C, SpO2 94, normocarbia, MAP >65
50 @kwhomd
Caring For the ICU Boarder. Kami M. Hu, MD Depts of Emergency & Internal Medicine University of Maryland SOM
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