Robert M. Rodriguez, MD FAAEM Clinical Professor of Medicine and Emergency Medicine, UCSF Case 1: 40 yo Male restrained driver high speed MVA P 140, RR 40 labored, BP 100/70, O 2 sat 70 Chest wheeze, crackles Tender sternum and ribs without crepitus FAST negative Head, neck, abdominal/pelvis CT negative You expertly intubate him Ventilation for ARDS Pulmonary Contusion Use PEEP for hypoxia open lung Low tidal volume (6 cc/kg) High rate (20 or more) Control pressures (plateau < 30) Permissive hypercapnea Continued Hypoxia on 100%: Improve Oxygenation 2 ways Improve gas exchange in the lung PEEP Prostacyclin/Epoprostenol Prone positioning Improve situation in the periphery (systemic efforts) Increase O 2 delivery (Increase cardiac output) Decrease metabolism/oxygen demand Step 1 (lung) PEEP Recruits (opens) collapsed alveoli Changes compliance curve Best for diffuse symmetric disease (ARDS/contusion) Not so good for differential lung disease (patchy one sided pneumonia) PEEP recruitment maneuver FiO 2 100%, hyperventilate for 30 seconds Put on CPAP at 20 cm H 2 O Increase CPAP to 30 cm H 2 O for 10 seconds Increase CPAP to 40 cm H 2 O for 40 seconds Decrease CPAP to 30 cm H 2 O for 10 seconds Set PEEP to 20 25 cm H 2 O and resume ventilation Monitor carefully dysrhythmias 1
Step 2 (systemic): Optimize O 2 delivery O 2 delivery = HR x SV x Hb x 1.34 x O 2 content Transfuse to around HB 10 Optimize CO?Dobutamine? Follow mixed venous sat or lactate levels Decrease O 2 Consumption Sedate Narcotics Paralyze? Treat fever Should you paralyze? Concerns of prolonged weakness/paralysis stuck on vent NEJM RCT double blind Within 48 hours onset Better 90 day survival Increase time of survival No increase weakness Step 3 Prostacyclin/epoprostenol Prostaglandin made by endothelial cells Pulmonary vasodilator IV or inhaled Virtually identical improvement po 2 as NO Not toxic/easier to use Lasts a few days Rescue Maneuvers: Prone positioning Improves atelectasis/heart compression of lung Improves V/Q Lasts days to week No improve mortality How? VERY CAREFULLY Rotational beds 2
ECMO Australia: H1N1 Flu severe hypoxemic resp failure 48/68 = 71% survived to ICU discharge Review of 3 RCTs showed mortality benefit Odds Ratio mortality 0.78 Recent large RCT showed significant benefit Make a plan Use for young Transfer early Case 2: 60 yo homeless male h/o EtOH C/O cough, SOB, fever T 41.4, P 140, RR 40 labored, BP 100/70, Sat 70% on 100% NRB Chest ronchi on the left, right clear Bad unilateral pneumonia: Still use low tidal volume Meta analyis of 20 studies non ARDS Lower mortality Lower incidence of lung injury Lower incidence of nosocomial infections Hypoxia with unilateral lung disease Avoid excessive PEEP USE GRAVITY GOOD LUNG DOWN! Fluids when hypoxic: Depends on perfusion and timing Early fluid resuscitation (save the kidneys) Shock mortality correlates with renal failure EGDT (early fluids rather than later) Don t worry about volume overload WHEN IN SHOCK Later fluids (save the lung) Established ARDS conservative fluid better Less time on vent Fewer ICU days No change in organ failure Only when no longer shock 3
Case 3 60 yo F COPD C/O cough, SOB T 37, P 120, RR 30 labored, BP 100/70, Sat 80 Chest wheeze, little air movement Awake, 2 word sentences ABG 7.20/70/70 BiPAP Early rather than late Better for COPD than asthma Not so good for pneumonia How to make BiPAP work If no improvement post 20 min won t work Sit there with them Adjust straps Adjust I and E appropriately Sedatives can help Fentanyl KETAMINE Case 4: 68 yo male VF arrest ROSC with defibrillation Intubated Vent settings? Hyperoxia after Cardiac Arrest Is too much oxygen bad post arrest? Post arrest: oxidant stress leads to increased cell death Experimental models of hyperoxia Worse oxidative stress Worse neuro outcomes Kilgannon: Hyperoxia Adults post medical arrest Over 6200 ICU patients ABG in first 24 hours: Hyperoxia: > 300 mm Hg: 18% Normoxia: < 300 mm Hg: 19% Hypoxia: < 60 mm Hg: 63% 4
Hyperoxia Hyperoxia highest mortality (63%) Hypoxia (57%) Normoxia (45%) Among survivors significantly lower independent function with hyperoxia (29% vs 38%) Odds ratio poor outcome 1.8 for hyperoxia Bottom Line FiO2 No reason to give too much Titrate down using pulse oxymetry to sat 95% Case 4 72 yo female with urosepsis Has history of CHF Hypotensive 76/48 HR 120 What type of fluids? Crystalloid Colloid does not work with possibly 1 exception Bicarb not helpful even in extreme acidosis How to do Early Goal Directed Therapy without Catheters 3 rd goal in EGDT = ScvO2 > 70 Traditional: catheter for serial ScvO2 Catheters expensive and not widely available Most hospitals not prepared to do this with catheters Lactate for EGDT Lactate is best perfusion marker in sepsis Serial lactates equivalent to ScVO2 Clearance of 10% lactate Send every 2 hours Peripheral venous is fine 5
Which crystalloid in sepsis Sequential trial of ICU patients First 780 patients given mostly chloride rich (NS) Washout period, then 780 rescrictive chloride (Lactated Hartmann s, plasmalyte) Chloride group had more AKI, more renal replacement therapy Vasopressors when? When do you start pressor? ANYTIME don t have to wait for full tank Quick burst: ephedrine or phenylephrine Bottom line not definitive, but would switch to LR after 2 liters of NS Sepsis: Dopamine vs NE Surviving sepsis campaign both dopamine and norepinephrine first line Critical Care Med meta analysis: 2800 patients Dopa greater mortality and more dysrhythmias Sepsis pressors: Bottom line Prob should use NE Look at HR If low HR, might use dopamine If high HR or any dysrhythmias use NE Add vasopressin if refractory shock (fixed dose) No clear mortality benefit Allows lower NE dose Etomidate for sepsis intubation? 2 independent meta analyses Both show with single dose etomidate Increased adrenal insufficiency and Increased mortality Bottom line: We have alternatives (ketamine) so use them. Post intubation care Watch for hypotension push fluids No nasal tubes HOB at 30 Oral gastric tube GI prophylaxis Give sedative, esp if used rocuronium 6