Rounds in the ICU. Eran Segal, MD Director General ICU Sheba Medical Center

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1 Rounds in the ICU Eran Segal, MD Director General ICU Sheba Medical Center

2 Real Clinical cases (including our mistakes) Emphasis on hemodynamic monitoring Usually no single correct answer

3 We will conduct rounds in our ICU,

5 PICCO

6 Normal ranges Parameter Range Unit CI l/min/m 2 SVI ml/m2 ITBI ml/m 2 ELWI* ml/kg SVV 10 % PPV 10 %

7 What equipment will we use? PiCCO Cardiac output Thermodilution and continuous Preload indicators ITBVI, GEDVI Fluid responsiveness SVV, SPV, PPV Pulmonary edema EVLW LiMON Plasma disappearance rate of ICG

8 LiMON

9 The Plasma Disappearance Rate of ICG-PULSION (PDR) is influenced by liver function and liver perfusion. Changes of ICG-PDR within a short period of time are reflecting liver respectively splanchnic perfusion, as the function of liver cells does not change rapidly.

10 PDR threshold value An ICG-PDR 16 %/min requires intervention.

11 Pancreatitis Dalal ER Case Patient AF-SIRS END Tal Abdominal sepsis Post whipple Head injury

12 A young woman with a severe infection

13 A 22 year old woman is admitted to the medical floor following 5 days of fever and severe muscular pains, generalized weakness and rash The patients only medical history is notable for a mitral valve prolapse. On examination she is has extreme muscular tenderness, almost quadriplegic, and very short of breath.

14 Labs: WBC 4000 => Platelets 60,000 =>32,000

15 She is transferred to the ICU where she requires intubation the next day because of increasing shortness of breath. Three blood cultures grow S.Aureus which is methicillin sensitive

16 Antibiotics: Cloxacillin and rifampin Xigris

17 HR 125 BP 100/60 (Mean 75) Lactate 26

18 A central line is inserted CVP 8 mmhg ScvO2 58%

19 What should we do now? 1. Increase fluids to improve cardiac output 2. Increase cardiac output using Dobutamine 3. Increase vascular tone using Noradrenaline 4. Improve renal function with Dopamine

20 Two fluid boluses of 500 ml LR are given over 30 minutes Next hemodynamics: HR 120 BPM Blood pressure 90/45 mmhg CVP 10 mmhg

21 What is her cardiac output? 1. Less than 3 LPM 2. 3 to 6 LPM 3. 6 to 9 LPM 4. More than 9 LPM A PiCCO Catheter is inserted and hemodynamics measured CO 6 LPM EVLWI 14ml/kg ITBVI 880ml/m 2

26 What is the reason for the infiltrates 1. Heart failure 2. Pleural effusion 3. ARDS 4. Aspiration 5. Pulmonary embolism

27 Large infiltrates with high extravascular lung water High cardiac output Low-normal filling volumes All indicate ARDS due to sepsis High output with increased permeability pulmonary edema

28 A CT is performed

29 The next day a TEE is performed A large vegetation on the mitral valve with a very large abscess is seen The patient is taken to surgery and a MVR is performed

30 A patient with pancreatitis is admitted to the ICU A 47 year old man with severe ischemic heart disease PMH is notable for an extensive anterior MI Currently with significant heart failure

31 Presented to the hospital and admitted to general surgery because of severe abdominal pain On CT in the ER, pancreatitis was diagnosed. As part of the workup, a cardiac echo is performed.

32 Large LV and LA Very poor global LV function EF 15-20%

33 The patient was initially hemodynamically stable but over the next two days he develops worsening hypoxemia and hypotension

34 He is intubated and ventilated, and transferred to the ICU

36 In the ICU HR 120 BPM BP 83/44 (57) mmhg CVP 10-6 Temp 35 C

37 How should we treat his hypotension? 1. With pancreatitis, he is very likely hypovolemic give fluids 2. With the type of heart failure he has, he probably needs inotropic support, give Dobutamine 3. With the SIRS he has, he needs a vasoconstrictor Give Norepinephrine 4. With his heart failure, don t give Norepinephrine it will only decrease his cardiac output

38 ScvO2 is 94%

39 1. < >9 What do you expect this patient s CO to be?

41 So what should we do now? 1. Give fluids 2. Give Dobutamine 3. Give Dopamine 4. Give Noradrenaline 5. Give Vasopressin

42 A combination of low dose Norepinephrine and vasopressin is started Patient s CO remains 9-10 LPM However BP increases to 120/55 Urine output remains low for the next days

43 Conclusions

44 Patient with abdominal sepsis

45 65 year old woman is admitted to the ICU following laparotomy for intestinal obstruction After surgery patient is hemodynamically unstable with a low blood pressure and a high lactate

46 In the ICU Blood pressure is 108/40 mmhg Heart rate is 135 AF CVP is 11 mmhg There is no urine output Temperature is 38 C

47 ABG FiO2-0.7 ph 7.25 SpO2 95 po2 80 mmhg pco2 42 mmhg Lactate-56

48 How would you treat her hypotension? 1. Fluid bolus until CVP is mmhg 2. Start Dopamine at a renal dose 3. Start vasopressin 4. Start Noradrenaline

49 PiCCO parameters CO -6 LPM ITBVI 790 ml/m2 SVR - 560

51 What is the reason for the patient s infiltrates? 1. Cardiogenic pulmonary edema 2. ARDS 3. Pneumonia 4. Pleural effusion 5. Consolidation of posterior lung fields

52 EVLWI is 8 ml/kg

53 What is the reason for the 1. Cardiogenic pulmonary edema 2. ARDS 3. Pneumonia 4. Pleural effusion 5. Consolidation of posterior lung fields patient s infiltrates?

56 A recruitment maneuver is performed in addition to inhaled NO and patient s oxygenation is improved The next day she is weaned from NO

57 After 3 days, the patient again deteriorates Blood pressure is 120/64 mmhg HR is BPM CVP is 16 mmhg CO is 8 LPM po2/fio2-160

59 What is the reason for the 1. Cardiogenic pulmonary edema 2. ARDS 3. Pneumonia 4. Pleural effusion 5. Consolidation of posterior lung fields patient s infiltrates?

60 EVLWI is 14 ml/kg, what are the lung infiltrates? 1. ARDS 2. Pleural effusion 3. Consolidation

62 What would you do? 1. Increase fluid removal with CVVH 2. Increase CO with ionotropes 3. Increase PEEP 4. Place the patient in prone position

63 Patient is placed on CVVHD Aggressive fluid removal is initiated with a negative fluid balance of 11 liters over 3 days Her oxygenation improves as well as degree of anasarca Abdominal pressure decreases from 25 mmhg to 15 mmhg

65 EVLWI - 12

66 EVLWI - 9

67 Patient with severe SIRS

68 A 54 year old female is brought to the ICU with severe SIRS due to a large retroperitoneal mass due to a lymphoma She develops MOF over the first 2 days in the ICU and requires mechanical ventilation and inotropic support

69 We are called to her bedside because of an acute arrhythmia

70 What do you think happened to her CO? 1. It decreased look at the HR 2. It is unchanged 3. It increased look at the HR 4. The BP indicates that the CO decreased

72 What is the mechanism for the reduced CO? 1. The SVR is reduced which led to this effect 2. The stroke volume is decreased 3. The blood pressure reduction led to the reduced CO

73 What would you do? 1. Give Amiodarone 2. Give beta blocker 3. D/C cardioversion 4. Wait

77 Patient with severe MOF

78 What happened to this patient s CO? 1. It is unchanged, since blood pressure is not significantly changed 2. It probably decreased significantly because of the atrial fibrillation 3. It probably increased because of the increase in heart rate

79 What about the patient SV? 1. It is unchanged since the patient s CO did not decrease 2. It is increased to compensate for the high heart rate 3. It must have decreased

95 Patient with severe head injury

96 A 34 year old man is brought to the ICU after multiple trauma in a car accident Injuries include: Head injury with DAI and multiple contusions Facial injuries Orthopedic injuries

97 The patient is sedated and ventilated

98 On the 4 th day in the ICU ICP increases despite maximal efforts to control it: Hyperventilation to pco2 of 30 mmhg Hypothermia to 35 C Increasing sedation, muscle relaxation and barbiturates Diuretics Patient also develops significant hypoxemia with po2/fio2-130

100

101 How would you manage his fluids? 1. Give normal maintanance fluids to keep CO adequate 2. Keep him on the dry side to reduce brain and pulmonary edema 3. Keep him hypervolemic to optimize cerebral blood flow

102 PiCCO parameters CO 5 LPM ITBVI 650 ml/m2 EVLWI 13 ml/kg Lactate 20 SVV- 18% PDR-19

103 We chose to diurese the patient: Fluid balance over the next day is -750ml The following day it is -600ml ICP is still mmhg CPP maintained with noradrenaline to keep MAP at mmhg

104 CO 4.5 LPM EVLWI 11 ml/kg ITBVI 600 PDR 12% Lactate 19 SVV- 19%

105 What would you do now? 1. Reduce his fluid intake even more 2. Continue the same course. He is responding to the diuresis 3. Increase his fluid to improve visceral blood flow

106 Patient is given a fluid bolus of ml colloid CO SVV 18% ITBVI 700 PDR 17% EVLWI-11

Sepsis Combine experience and Evidence. Eran Segal, MD Director General ICU, Sheba Medical Center, Israel

Sepsis Combine experience and Evidence Eran Segal, MD Director General ICU, Sheba Medical Center, Israel The Science of Sepsis A complex and diverse clinical entity Outcome is affected by: Infecting organism