ICU 101 a.k.a. “Papers You Should Know” Ashley Henderson, MD May 4, 2010

New England Journal of Medicine 2001;345:

Early Recognition IF: suspected infection + SIRS criteria –Temp >38C or <36C –HR >90 –RR >20 or PaCO2 <32 –WBC>12, 10% bands THEN: check lactate and obtain cultures IF: lactate >4mMol or SBP <90 with 20ml/kg NS bolus and not cardiogenic THEN: Patient meets criteria for septic shock

Early Goal Directed Therapy Protocol (Achieve within 6 hours) ATTENTION New England Journal of Medicine 2001;345:

Why EGDT? Reduced in-hospital mortality –(30.5 vs. 46.5%) –Reduced 28d and 60d mortality –(33.3 vs. 49.4%; 44.3 vs. 56.9%)

Mechanical Ventilation Improves gas exchange; decreases work of breathing Uncomfortable, not risk-free –PTX –Pneumonia and other infections –Increased intrathoracic pressure/cardiovascular compromise –Increased mortality if prolonged

Mortality Prediction with PMV Prolonged mechanical ventilation (PMV)=21 d 4 predictive variables: –Age >50 –Thrombocytopenia (<150) –Use of pressors –HD Crit Care Med 2008 Vol. 36, No. 7

Mortality Prediction with PMV One year mortality : No risk factors: 15% All four risk factors: 97% (age, pressors, platelets, HD) Crit Care Med 2008 Vol. 36, No. 7

Mortality and MV Type TWO TYPES TO REMEMBER: COPD with hypercapnea: NPPV –Cochrane Review 2004; Ann IM : 861 –Decreased mortality (11 vs 21%) ARDS: Low Tidal Volume Ventilaton

Low Vt in ARDS 12 ml/kg vs. 6ml/kg –Mean Vt 11.8 vs. 6.2 Decreased mortality with low Vt –31.0% vs. 39.8% –Greater number of days vent-free (at 28d) –12 vs. 10 NEJM May 4, 2000 vol 342:18

Low Tidal Volume Ventilation NEJM May 4, 2000 vol 342:18

Questions How do you calculate 6 ml/kg? –PBW [ (Ht in cm-152.4)] male [ (Ht in cm-152.4)] female Define ARDS –P/F <200 –Bilateral infiltrates –No Left Atrial Hypertension

ARDSNet, Part ?6 FACTT trial (Fluid and Catheter Treatment Trial) –PA catheter not better than central venous –Conservative fluid better by 3.2d (MV) –NEJM 2006

Weaning in Mechanical Ventilation

Modes of Ventilation Weaning

Weaning mode from MV Patients had to have improvement or resolution of underlying cause of respiratory failure and P/F >200 PEEP at 5 or less Temp <38 Hgb >10 No pressors Took ‘difficult to wean’ patients Had failed a spontaneous breathing trial even though MIP >-20 Vt >5ml/kg RR <35 (extubated if passed SBT) Enrolled them in one of 4 modes of ventilation IMV PSV SBT qd SBT multiple times/day

NEJM Feb 9, 1995, vol 332:345

Rate of successful weaning: SBT qd vs. IMV: 2.83 (p <0.006) SBT qd vs. PSV: 2.05 (p <0.04) SBT qd vs. SBT mult times: 1.24 (p 0.54)

MV: Readiness Testing Yang, KL and Tobin, MJ. A Prospective Study of Indexes Predicting the Outcome of Weaning From Mechanical Ventilation. NEJM 1991; 324: 1445 Looked at ‘traditional predictors’ of weaning: VE and PI max and developed two indexes f/Vt CROP f/Vt: RSBI <105 breaths/min/L with sensitivity of 97% and NPV of 95%

Readiness Testing with Spontaneous Breathing Trials

SBTs Screened patients for readiness testing Combined previous trials for predictors –P/F ratio >200 –PEEP 5 or less –Adequate cough –f/Vt >105 (for one minute measure for screening) –No pressors or continuous sedatives If passed, underwent SBT with CPAP 5 (or 5/0) for 2 hours Notified the primary MD if passed

Days of MV 4.5 vs. 6

Sedation in Mechanical Ventilation Reduces distress/discomfort, but Prolongs MV (increased complications/mortality/cost….) Increases delirium

Daily Awakening

Sedation held daily until pt interactive or agitated unless the following: –On 80% or greater FIO2 –Has unstable surgical lesion Decreased median duration of MV –4.9 vs. 7.3d Decreased median length of stay in ICU –6.4 vs. 9.9d –Decreased head scans, decreased complications

Daily Awakening

ABC Trial

Combined Daily Awakening (SAT) + Spontaneous Breathing Trials (SBT) –Both groups had SBT, intervention was SAT vs. no SAT Increased number of days breathing without assistance in 28d –14.7 vs. 11.6d (p=0.02) Decreased days in ICU, decreased days in hospital –9.1 vs. 12.9d (p=0.01); 14.9 vs (p=0.04) –NNT=7

ABC Trial

A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial Thomas Strom, Torben Mortinussen, Palle Toft Lancet Vol 375 Feb 6, 2010

Data Not To Stress About Tight glucose control in medical ICU patients Steroid ‘replacement’ in septic shock

Plea for Help Send me your COPD patients that produce sputum and have an FEV1>30% and FEV1/FVC ratio <70% predicted