Review Course Leslie Zimmerman, MD Professor of Clinical - PDF document

Cri$cal ¡Care ¡ ABIM ¡Cer$fica$on ¡Exam ¡ Review ¡Course ¡ Leslie Zimmerman, MD Professor of Clinical Medicine, UCSF ICU Director, SFVAMC Conflict of Interest/Disclosures n None 1

Lecture ¡Outline ¡ n Resuscitation (first 6 hours) n Ventilators/ARDS (first 6 hours) n Sepsis n GI issues n Odd and ends for $200 Ques$on ¡1 ¡ A 42 yo woman is brought to the ED pulseless. Resuscitation is started. Extremities reveal multiple skin scars c/w with long standing IVDU. Peripheral IV access cannot be obtained. Which of the following is the best option for access? A. Continued attempt at peripheral vein access B. Internal jugular vein C. External jugular vein D. Femoral vein E. Intraosseus access 2

Code ¡blue ¡access ¡ Neck access interferes with intubation and crowds the head of the bed Femoral access: “accuracy” is difficult à no pulse so easy to confuse artery and vein (ABG in code may not distinguish) Intraosseus: quick access; can use x 24 hours • Do need to create a “space” in medullary bone • Infusions require pressure bag Intraosseous Access 3

Ques$on ¡2 ¡ A 52 yo man admitted for pancreatitis suddenly becomes unresponsive and has no pulse or respirations. Resuscitation is started. Initial rhythm is PEA. Which of the following suggests a “Return of Spontaneous Circulation” or ROSC during the code? A. A change to “fine” ventricular fibrillation on monitor B. A sudden decrease in serum lactic acid C. A sudden increase in ET CO2 D. Pupils 4-5 mm in diameter Hospital ¡Codes ¡are ¡changing…. ¡ § Hospital: More PEA and less Vtach/Vfib (better cardiac interventions à smaller MIs, more AICDs?) § Survival rates are better! (15.4%) Lancet 2012;380:1473. § Separate study à if > 65 and survived to d/c post code, 50% alive at 1 year* * NEJM 2013;368:11. 4

ACLS– ¡Using ¡ET ¡CO2 ¡Monitoring ¡ Good à ETT in airways More circulation, more CO2 delivered to lungs, more www.nonin.com exhaled; first sign of ROSC In contrast How about? Falling ET CO2, less ET CO2 flat lines? circulation, = tiring CPR Apnea or ETT out performer à switch out Ques$on ¡2 ¡ A 52 yo man admitted for pancreatitis suddenly becomes unresponsive and has no pulse or respirations. Resuscitation is started. Initial rhythm is PEA. Which of the following suggests a “Return of Spontaneous Circulation” or ROSC during the code? Asystole usually next L A. A change to “fine” ventricular fibrillation on monitor Not good Improved B. A sudden decrease in serum lactic acid washout or drop in CO? C. A sudden increase in ET CO2 D. Pupils 4-5 mm in diameter Bad 5

Question 3 A 52 yo man admitted with chest pain and has a Vfib arrest. After 30 minutes, he is resuscitated. VSs post code are HR 110, BP 95/60, RR: intubated; no spontaneous breaths. He remains unresponsive despite BP & HR. Cardiology is coming to the bedside. Next steps are: A. Anticoagulation B. Central line access to target CVP 8-12 mmHg C. Hypothermia to 32-34 o C D. Placement of an IABP E. Tight glucose control Post ¡Code ¡Care ¡ § Determine cause: • Cardiac, PE, PTX, AAA rupture, GI bleed, Drug, electrolytes, sepsis § Maintain MAP > 65 § Don’t over or under -ventilate § Avoid hypoxemia, but don’t keep PaO2 > 300 § Therapeutic hypothermia if remains unresponsive post code 6

Therapeu$c ¡Hypothermia ¡ NEJM 2002;346:557- 63. Target = 33 o C. NEJM 2002; 346:549-56. Target 32-34 o C. Therapeu$c ¡Hypothermia ¡ n Extended to in-hospital arrests n Extended to PEA arrests Best temperature? NEJM 2013; 369:2197-2206 33 vs. 36 o C? No difference Definitely treat fever! 7

Question 3 A 52 yo man admitted with chest pain and has a Vfib arrest. After 30 minutes, he is resuscitated. VSs post code are HR 110, BP 95/60, RR: intubated; no spontaneous breaths. He remains unresponsive despite BP & HR. Cardiology is coming to the bedside. Next steps are: Ok to do with hypothermia, but not routine post code A. Anticoagulation B. Central line access to target CVP 8-12 mmHg C. Hypothermia to 32-34 o C Fluids based on needs D. Placement of an IABP NEJM 2012;367:1287 E. Tight glucose control IABP in post MI Dud cardiogenic shock Question 3 A 52 yo man admitted with chest pain and has a Vfib arrest. After 30 minutes, he is resuscitated. VSs post code are HR 110, BP 95/60, RR: intubated; no spontaneous breaths. He remains unresponsive despite BP & HR. Cardiology is coming to the bedside. Next steps are: Specifically post cardiac C. Hypothermia to 32-34 o C arrest? - “Tight” control (70 to 108 E. Tight glucose control mg/dL) no better than “good” control (up to 144 mg/dL) Intensive Care Med. 2007;33:2093 8

Ques$on ¡4 ¡ 75 year old man with pneumonia. T 104 F (40.0 C), pulse 115, BP 70/40. Exam: lethargic man with crackles in the right base. Labs: Hgb 10.5 mg/dl, WBC 18K with left shift, BUN of 54, lactic acid level 6 meq/L (nl .6-1.8) After cultures and broad spectrum antibiotics, 2L NS (20 cc/kg): pulse 110, BP 75/50 Ques$on ¡4 ¡ A 75 year old man with … After 2L NS: pulse 110, BP 75/50 (MAP=58). Hgb 10.5. At this time, you should: A. Assess volume status by some means B. Measure S MV O2 C. Start ECMO D. Start Norepinephrine IV to target MAP of 80 E. Transfuse packed RBCs 9

Trip down memory lane … Surviving Sepsis: Recommendations Crit Care Med 2012 Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368. Single RTC; single center n CVP 8-12 mmHg n MAP > 65 mmHg n UO > .5 cc/kg/hr n SVC O2 sat (Scvo 2 ) > 70% or S MV o 2 > 65% > Transfusion or Dobutamine for this last goal … Adherence low in f/u international performance study VS. ¡ ¡ A Randomized Trial of Protocol-Based Care for Early Septic Shock The ProCESS Investigators NEJM 2014; 370:1683. 1351 Patients Protocol EGDT Protocol “standard “Usual” care therapy” 10

VS. ¡ ¡ Protocol EGDT Protocol “standard “Usual” care therapy” Bedside MD ü 2 large peripheral IVs ü Central Line ü 2 L fluid (1 hour target) made all ü Fluids til CVP 8-12 unless tank full ü Once at CVP goal, decisions ü If SBP < 100, more Pressors til MAP > 65 fluids (.5L units) unless ü Once at MAP goal, if tank full à Pressors ScvO2 < 70% (target 1 hour) ü Transfuse to Hct 30 ü If SBP > 100, but high ü If Hct > 30, add lactate, low UO, etc., inotrope (dobutamine) recheck volume status VS. ¡ ¡ Protocol EGDT Protocol “standard “Usual” care therapy” ü 2 large peripheral IVs Bedside MD ü Central Line ü 2 L fluid (1 hour target) made all ü Fluids til CVP 8-12 unless tank full ü Once at CVP goal, decisions ü If SBP < 100, more Pressors til MAP > 65 fluids (.5L units) unless ü Once at MAP goal, if tank full à Pressors ScvO2 < 70% (target 1 hour) ü Transfuse to Hct 30 ü If SBP > 100, but high ü If Hct > 30, add lactate, low UO, etc., inotrope (dobutamine) recheck volume status Early fluid bolus: Are we just doing this now anyway? 11

Ques$on ¡4 ¡ A 75 year old man with … After 2L NS: pulse 110, BP 75/50 (MAP=58). Hgb 10.5. At this time, you should: A. Assess volume status by some means B. Measure S MV O2 C. Start ECMO D. Start Norepinephrine IV to target MAP of 80 E. Transfuse packed RBCs Rescue for hypoxemia, not hypotension Ques$on ¡4 ¡ A 75 year old man with … After 2L NS: pulse 110, BP 75/50 (MAP=58). Hgb 10.5. At this time, you should: A. Assess volume status by some means B. Measure S MV O2 D. Start Norepinephrine IV to target MAP of 80 E. Transfuse packed RBCs Use standard cut-off of 7 mg/dl TRISS trial confirmed in ACUTELY SEPTIC patients NEJM 2014;371:1381 12

Ques$on ¡4 ¡ A 75 year old man with … After 2L NS: pulse 110, BP 75/50 (MAP=58). Hgb 10.5. At this time, you should: A. Assess volume status by some means B. Measure S MV O2 ? D. Start Norepinephrine IV to target MAP of 80 What is the best target for MAP? - MAP better indication of perfusion pressure than Sys/Dias - > 60 required for tissue perfusion pressure - Target is > 65 NEJM 2014;370:1583 - Is higher better? MAP 65-70 vs. 80-85? Just more afib Ques$on ¡4 ¡ A 75 year old man with … After 2L NS, pulse 110, BP 75/50. Hgb 10.5. At this time, you should: A. Assess volume status by some means B. Measure S MV O2 After volume status assessment S CV O2 = Oxygen Consumption CO= S CENTRALVENOUS O2 CaO2-CvO2 O2 75% 95% SvO2: S MV O2 = - Low is bad (<60%) S MIXEDVENOUS O2 O2 - Dropping is bad 13

Ques$on ¡4 ¡ A 75 year old man with … After 2L NS, pulse 110, BP 75/50 At this time, you should: A. Assess volume status by some means Will adding volume help? “ EGDT ” : Rivers protocol Cardiac Output NO criticism Static CVP doesn ’ t tell YES you much about where you are on curve LVEDV Pulmonary edema Q ¡5: ¡All ¡of ¡the ¡following ¡may ¡be ¡useful ¡ parameters ¡for ¡assessing ¡$ssue ¡ perfusion ¡in ¡sep$c ¡pa$ents ¡EXCEPT? ¡ A. Aortic blood flow peak velocity variation B. Straight leg raise C. Lactate clearance D. PCWP E. Respiratory change in the radial artery pulse pressure 14