Five Common Errors in the ICU I have no conflicts of interest to - PDF document

10/21/17 Disclosures Five Common Errors in the ICU I have no conflicts of interest to disclose. Management of the Hospitalized Patient October 21, 2017 “Bombarded with more Solution than 7,000 independent pieces of information per More premium subscribers day” 1

10/21/17 40,500 ICU patients may die of misdiagnosis annually. Impact max growth XX% sales increase 1. Volume Status Five Common 2. Pressor Choice Errors in the ICU 3. Non-Invasive Ventilation 4. Bronchs in the ICU 5. Communication 2

10/21/17 Volume Status: The ICU’s Holy Grail 1. Volume Status Five Common “Fluids for everyone 2. Pressor Choice Errors in the ICU hypotensive!” 3. Non-Invasive Ventilation 4. Bronchs in the ICU 5. Communication A Case: How would you assess his volume status? Marik, CVP, and the Seven Mares “Fluids for everyone hypotensive!” A.IVC Ultrasound B. CVP off a central line C. A-line pulse pressure variability D.Straight leg (claw?) raise Marik et al. Chest 2008 3

10/21/17 Will My Unstable Patient Respond to a Bolus? “Failure to Reassess” and our EHR Passive leg raise vs CVP vs A-line PPV vs IVC U/S Bentzer et al. JAMA 2016 Don’t forget to D/C IVF long before D/C Home! Key Point Volume status is dynamic and difficult to assess: reassess frequently and de-escalate early. Weyker et al. Clin Chest Med 2016 4

10/21/17 First-line pressor of choice in cardiogenic shock? 1. Volume Status Five Common A.Dopamine 2. Pressor Choice Errors in the ICU B. Dobutamine 3. Non-Invasive Ventilation C. Norepinephrine 4. Bronchs in the ICU D.Epinephrine 5. Communication All that is Hypotensive is NOT Sepsis Key Point ❏ Cardiogenic shock ❏ Pulmonary embolism ❏ Acute valvular dysfunction ❏ Cardiac tamponade ❏ Hypovolemia/Hemorrhage ❏ Aortic dissection Pressors are like antibiotics: don’t fear them and ❏ Myxedema coma ❏ Anaphylaxis select the correct drug for the physiology. ❏ Toxidromes ❏ Adrenal crisis 5

10/21/17 ICU’s Favorite Equation! No long tables! Match Physiology with Vasopressor ❏ Pure vascular tone problem (e.g. post-procedural) V = IR ❏ Phenylephrine (Pure SVR) ❏ Septic shock MAP = CO X SVR ❏ Norepinephrine (SVR & CO) Match Physiology with Vasopressor Special Cases? Get Help for PH & Critical AS ❏ Very subtle & complex! ❏ Cardiogenic shock ❏ Careful attention to volume ❏ Norepinephrine (SVR & CO) +/- dobutamine (CO) status – often need to keep ❏ Hemorrhagic shock diuresing ❏ Resuscitation! Fill the SV with blood! ❏ Avoid stopping vasodilators ❏ Caution w/ beta-blockade 6

10/21/17 A Plea to Use Generic Names 1. Volume Status Five Common 2. Pressor Choice Errors in the ICU 3. Non-Invasive Ventilation 4. Bronchs in the ICU 5. Communication Norepinephrine “Levo” Phenylephrine “Neo” Not an Indication for Non-Invasive Ventilation? Non-Invasive Ventilation: When to Use it? A. Hypercapnic respiratory failure ❏ COPD exacerbation with hypercapnic acidosis B. Cardiogenic pulmonary edema C. Hypoxemia in a DNR/DNI ❏ Cardiogenic pulmonary dragon edema D.Weaning from the ventilator ❏ Post-extubation respiratory failure 7

10/21/17 Contraindications to Non-Invasive Ventilation Flow vs. Pressure: Who Wins? NIV HFNC ❏ Cardiac or respiratory arrest Counterbalances auto-PEEP More comfortable than NIV ❏ Facial or neurological surgery/trauma/deformity ❏ Inability to protect airway/cooperate Reduces work of breathing Higher FiO2 delivery ❏ Inability to clear secretions Improves lung compliance Decreased dead space ❏ High risk for aspiration Mask can be uncomfortable Not good for hypercapnia ❏ Goals of care 8

10/21/17 Don’t be falsely reassured! Key Point ❏ Survey of fellows and RTs at UCSF ❏ 90% of fellows & 68% RTs felt that HFNC falsely reassured providers about how Think carefully about contraindications and to what hypoxemic patients were you are bridging. Continually reassess if they need intubation, whether HFNC or NIV. The Consult Question 1. Volume Status Five Common 2. Pressor Choice Errors in the ICU 3. Non-Invasive Ventilation 4. Bronchs in the ICU 5. Communication 9

10/21/17 When Is It Safe for Bronchoscopy? To Bronch or Not to Bronch? A. Intubated, FiO2 100% B. 15 L HFNC C. Intubated, FiO2 40% D. Bronch a dragon at your own peril! Can We? Stability for Bronchoscopy in the ICU Should We? Indications for Bronchoscopy in the ICU ❏ Degree of hypoxemia ❏ Rule-out diffuse alveolar hemorrhage ❏ Size of endotracheal tube ❏ Rule-out PJP! Gold standard! ❏ If awake, ability to tolerate anesthesia ❏ Check the ET tube position/awake ❏ (Hemodynamic stability) fiberoptic intubation ❏ (Coagulopathy) ❏ NOT for mucus plugging! 10

10/21/17 Quick Note: Don’t forget PJP Prophylaxis! Key Point ❏ HIV ❏ Pred 20mg PO daily for 1 mo. + other immunocompromise ❏ Combo of TNF-alpha + prednisone Think about whether bronchoscopy is the best ❏ Primary immunodeficiency clinical test to determine the cause of hypoxemia and ❏ Post-solid organ transplant if it is safe to do so. ❏ Post-HSCT The beginning of the ICU stay: Admission 1. Volume Status Five Common ❏ Notify patient’s PMD AND longitudinal 2. Pressor Choice Errors in the ICU outpatient subspecialty team 3. Non-Invasive Ventilation ❏ Close communication with the ICU team 4. Bronchs in the ICU from the start 5. Communication 11

10/21/17 The “middle” of the ICU stay: C/S Management The “end” of the ICU stay: Discharge ❏ F/u with PMD & outpt specialist ❏ Consider multidisciplinary team meetings if multiple consult services: ❏ Clear communication b/w ICU & ward SECURE: email chain with all teams ❏ Family meetings for end-of-life care - be explicit ❏ Face-to-face is best for learning & ❏ Remember the sequelae of post-ICU syndrome patient care! 1. Volume Status! Key Point Five Common 2. Pressor choice Errors in the ICU 3. Non-Invasive Ventilation 4. Bronchs in the ICU Communication is critical throughout every point in the ICU patient’s stay. 5. Communication 12

10/21/17 Thank You! Questions? Lekshmi.Santhosh@ucsf.edu @LekshmiMD 13