1. 2/19/14

2. General: Honk Fluids in ARDS ARDS – vent settings, manage vent, gas exchange. (6) TRALI Hemoptysis – positioning Pulmonary shunt as cause of hypoxemia – causes of hypoxemia HIT Cause of Resp failure PE with shock Ventilator: Treat hypercapneic resp failure, vent settings (2) Complications of vent Indications for NIPPV (2) Intrinsic PEEP management (3) Hypoxemia management CHF on vent Pain on vent Medicine In-Service Topics

3. The happy smoker 66 yo WM chronic pain, smoker, CHF, brought to ED with SOB. Recent URI, thin, scattered wheezes and crackles on exam. 7.26/55/75 BNP 1200 HCT 30 Platelet 220,000 What do you do?

4. Admit to MICU  Bipap?  Nebs, Steroids, Antiobiotics  Lasix?  DVT prophylaxis  GI prophylaxis – NO!

5. MICU  Why non-invasive positive pressure ventilation (NIPPV)?  What are indications for NIPPV? 1.Obstructive lung disease Asthma, COPD, etc 2.Acute congestive heart failure 3.OHS 4.Immunocompromised with infiltrates Diuresed 3 Liters Creatinine 1.2 BP 100/60, HR 70 7.16/70/70 HCT 25 Now what?

6. MICU  Intubate – Dr. Garriga goosed 3 times.  Dr. Steele pushed him aside. Grade I view, chip shot. Vent Settings: Volume control Vt 500cc Rate 15 FiO2 100% PEEP 5 BP 85/40 HR 120 RR 25 7.24/60/60 Now what?

7. MICU  Create a problem list, ddx and gather information 1. Respiratory acidosis – on vent in COPD? 2. Tachypnea on vent – pain, dyspnea? 3. Hypotension – shock, hypovolemia, intrinsic PEEP? Gather information and treat 1.Look at vent settings 2.Empirically treat pain 3.IVF for hypotension

8. Ventilator Management

9. Volume Control  Set a Tidal volume of 6cc/kg (70 kg patient) 420 Time Volume Time Pressure Variable Non-compliant Normal

10. Volume Control: Peak and Plateau Pressure  Peak: Distention pressure in lungs as tidal volume is being delivered (flow-related pressure)  Plateau: Distention pressure in lungs after volume delivered before expiration (static pressure) PEAK PLATEAU Time Pressure

11. Ventilator Management – obstructive lung disease Treatment plan for obstructive lung disease: 1.High intrinsic PEEP? 2.Unhook ventilator? 3.Slow respiratory rate? 4.IVF for hypotension related to poor filling pressures in setting of high intra-thoracic pressure?

12. Pain Management in ICU 45% with no provider perceived reason for pain actually have pain  Pain, Agitation, Delirium Bundle 1. Pain control – fentanyl, morphine, oral 2. Agitation – propofol, dexmedetomidine, intermittent benzodiazepines Payen, JF. DOLOREA Investigators. Anesthesiology 2007; 106:687–95 Chanques,G. Anesthesiology. 2007;107:858–860 Crit Care Med. 2013 Jan;41(1):263-306

13. MICU  You get through the night…. Then am labs: 7.35/48/85 HCT 25, Platelet 85 Creatinine 1.5mg/dL

14. MICU  Thrombocytopenia in the ICU DDX? Decreased Production: -Primary Marrow failure -Secondary Marrow failure -Malnutrition, sepsis, PCN, Ceph,vanc, H2 blockers, chemotherapy Gets through the night stable, but agitated. AM labs: 7.36/45/80 HCT 18 PLT 75 Chest. 2011;139(2):271-278. Crit Care Clinics 2012;28(3):399-41 Increased Destruction: -TTP, DIC, Liver/Spleen -Drugs -Intravascular devices Immune: -Drugs induce immune destruction – vancomycin -HIT (4T’s, Serotonin Release assay, anti-PF4 ab)

15. MICU  Give 2 uts PRBC’s – why 2? Start PPI – you forgot to put him on GI prophylaxis  PRBC infusion finishes. More tachypneic, more agitated, T 102.1, Sp02 84% DDX: Pulmonary edema s/p PRBC infusion – systolic CHF exacerbation TRALI VAP ARDS JAMA. 2002 Sep 25;288(12):1499-507

16. Elevated Peak/Plateau Pressures Time Pressure Alveolar Filling ARDS Pulmonary Edema Pneumonia Right Mainstem Intubation Pneumothorax Decreased Compliance of Whole System

17. Hypoxemia A-a gradient =(P A 0 2 -Pa0 2 ) [150 – 1.25(PaCO 2 )] – pa0 2 Normal ≤ Age/4 + 4 Normal A-a gradient 1. Hypoventilation - Opiates, drugs, CVA, OHS 2. Low fi0 2 (high altitude) Abnormal A-a gradient 1. Shunt - Alveolar filling (blood, pus, water) - Difficult to correct with supplemental O 2 2. V/Q Mismatch - PE, COPD 3. Diffusion limitation (rare, low yield) -Elite Exercise A a PAO 2 = [(Patm – PH 2 O) x FiO 2 ] – [PaCO 2 /RQ]

18. MICU  Treatment Plan: TRALI ○ Timing, supporting, low WBC CHF ○ Vent – diuresis VAP ○ Antibiotics – which ones? How long? ARDS vent management ○ FACTT (Fluids and Catheters Treatment Trial) – match I/O’s vs liberal ~7L +

19. ARDS  Definition 1. Acute 2. Bilateral infiltrates 3. Pa02/Fi02 <200** 4. PCWP <18mmHg – or no clinical reason for elevated LVEDP DDX - congestive heart failure, pneumonia, organizing pneumonia, eosinophilic pneumonia, high altitude, sickle cell disease, vasculitis, TRALI, etc…. **Berlin Definition of ARDS – 2012 – unsure if will be on boards mild P/F <300 (25% mortality), moderate P/F <200 (32% mortality), severe P/F <100 (45% mortality) JAMA 2012 Jun 20;307(23):2526-33

20. Pa02/Fi02 < 200 (or 300)

21. Causes of ARDS/ALI 1. Pneumonia 2. Sepsis – any source ***Especially alcoholics 3. Aspiration 4. Transfusion (TRALI) – Fresh frozen plasma is most common 5. Pulmonary embolus 6. Pancreatitis 7. Trauma – Especially Thoracic Anything that can cause systemic or pulmonary inflammation!

22. ARDSnet  Low Vt (tidal volume) ventilation – 6cc/kg  Plateau Pressure >30cm H20  pH >7.3 – permissive hypercapnea  Higher PEEP, lower Fi02  Pa02 >55 mmHg  Minimize fluids beyond normal losses (conservative strategy) New England Journal of Medicine 2000; 342:1301-08 This strategy decreases mortality from 39% to 31% (P<.007). Salvage ventilatory modes – none improve mortality. 1.Extracorporeal Membrane Oxygenation – CESAR Trial 2.High Frequency Oscillatory Ventilation – 300 breaths per minute 3.Nitric Oxide – inhaled to dilate vessels through ventilated alveoli 4.Prone ventilation – put patient on stomach, recruits lung bases

23. ARDSnet

25. Do not memorize this chart!!! Know to implement its high PEEP/low Fi02 strategy.

26. ARDSnet

28. The end  He was extubated on day 12.  Called the house team at 0829.  The patient stays in ICU for 6 days waiting on a bed.

29. General: Honk Fluids in ARDS ARDS – vent settings, manage vent, gas exchange. (6) TRALI Hemoptysis – positioning Pulmonary shunt as cause of hypoxemia – causes of hypoxemia HIT Cause of Resp failure PE with shock Ventilator: Treat hypercapneic resp failure, vent settings (2) Complications of vent Indications for NIPPV (2) Intrinsic PEEP management (3) Hypoxemia management CHF on vent Pain on vent Medicine In-Service Topics