icu tutorial 2011
TRANSCRIPT
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ICU Tutorial
Medical Residents 2011
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A67-year-oldisadmi0edtoaMICUwithARDS.BS=135mg/dl.
Intensive insulin therapy was started. An outcome about
intensiveglucosecontrolincludeswhichofthefollowing.
A. Increasedriskofhypoglycemia
B. Reducedmortalityindependentofthetargetglucoselevel
C. Reduced mortality only if the paKents could be maintainedwithaBS≤11mg/dl
D. ShorthospitalLOS
1
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How hyperglycemia is harm?
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• BS>14mg/dl+HbA1C>6.5%suspectedpreexisKngDM.• Intensiveglucosecontrol8-11mg/dl.
• RRmortality.93(95%CI.83-1.4)
• SmallRRmortalitybenefitinSICU.63(95%CI.44-.91)
• RRhypoglycemia6.(95%CI4.5-8.)• LasttrialNICE-SUGARstudy
• Intensiveglucosecontrolincreasedabsoluteriskofdeathat9days
• Numberneededtoharm38
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NICE-SUGARStudyInvesKgatorsNEJM29;36:1283-97.
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Daily SBTs in paKents supported by MV with stable andimprovingcardiorespiratoryfuncKonhavebeenshowntofacilitate
thevenKlatorwithdrawalprocess.InaddiKontomonitoringRR,gasexchange,hemodynamics,and
comfortduringtheSBT,whatotherstrategywillbehelpfulinthisprocess?
A. UseofmodethatautomaKcallyreducespressuresupportinbetweendailySBTa0empts
B. RequiredallpaKentstohaveaf/VT<15beforeiniKaKngSBT
C. RequiringP.1<8cmH2ObeforeiniKaKngSBT
D. Usingpressuresupportof5-8cmH2OduringSBT.
2
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Clinicalassessment • Adequatecough
• AbsenceofexcessivetracheobronchialsecreKon
• ResoluKonofdiseaseacutephaseforwhichthepaKentswasintubated
ObjecKve
measurements Clinicalstability
-Stablecardiovascularstatus(HR<14,SBP9-16mmHg,noor
minimalvasopressor)
-StablemetabolicstatusAdequateoxygenaKon-SaO2>9%onFiO2≤.4(orPaO2/FiO2≥15mmHg)
-PEEP≤8cmH2OAdequatepulmonaryfuncKon
-RR<35/min
-MIP≤-2--25cmH2O
-VT>5ml/kg-VC>1ml/kg
-f/VT<15
-NosignificantrespiratoryacidosisAdequatementaKon
-NosedaKonoradequatementaKononsedaKon)
Readinesstowean
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Measurementsofoxygena4onanddeadspace
PaO2/FiO2
PaO2/PAO
2Deadspace(VD/VT)Simpletestsofrespiratoryloadandmuscularcapacity
NIP(MIP)
Respiratorysystemcomplianceandresistance
MV
MVV
VC
RR
VTTestthatintegratemorethanonemeasurement
f/VTCROPindex(compliance,RR,oxygena4on,pressure)=CdynxPImaxx[PaO2/PAO2])/rate
Complexmeasurements
Airwayocclusionpressure
P0.1/MIP
Esophagealpressurements
Oxygencostofbreathing,WOB
GastricmucosalpH
WeaningPredictors
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YangL,TobinMJ.NEJM1991;324:1445-5.
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• T-piece
• Lowlevelpressuresupport(reduceresisKvework)
• 7-8cmH2Oinadult
• 1cmH2Oinpediatric
• AutomaKcTubeCompensaKon
• DuraKonofSBT=12min(Ingeneral)
• IdealduraKonofSBT(3minVS12min)dependonduraKonofvenKlaKonandunderlyingcauseforrespiratoryfailure
SBTs
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Poten4alcausesofweaningfailure Auto PEEP
pneumoniapulmonary edema
Atelectasis
PTX
Pleural effusion
Abdominal distensionSecretions
Bronchoconstriction
ET-problemsDead space
VCO2
Metabolic acidosis
Anxiety
Pain
Oversedation
Metabolic alkalosis
CNS process
OHS
↓Mg, Ca, K, PO4
Steroids
Malnutrition
Sepsis
Medications
HypothyroidismPhrenic nerve injury
CIP, CIMCardiac disease
Psychological disease
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A 43-yr-old man was admi0ed to ICU with seizure and mentalstatuschanges.HewasBT38.5
๐C.HehadhistoryofHIVandnon-
compliantART.HisCD4count=13/µL.CTbrainshowndiffusebrain atrophy and no focal mass lesion. LP was done and CSFprotein=72mg/dL,glucose68mg/dL,WBC78/ µL(85%L),RBC3.6x16/ µL. He began vancomycin, ampicillin, ceazidime,amphotericin B and acyclovir. Day2 aer admission his Cr
1.3→2.7mg/dL.UrineisshowninFig.
Whichoneofthefollowingisthe
mostlikelycauseofAI?
A. AmphotericinB
B. AcyclovirC. Contrastinducednephropathy
D. AcuteintersKKalnephriKs
3
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Acyclovir
CrystalinducedAKI
Needlelikebirefringent
Sulfonamide
Sulfadiazine
Needleshape
Shockofwheat
Dumbbell
Indinavir
Starbursts
Fanshapes
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• Rapidexcretedinurineandlowurinesolubility
• Riskfactors• Highdose
• Rapidinfusion
• VolumedepleKon• Renalimpairment
• PrevenKon
• Isotonicsalinebeforeacyclovirinfusion
• Highurineflowrate• Slowinfusionin1-2hr
Acyclovirnephrotoxicity
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A73yearoldmanpresentedwithseverechestpainfor2hr.ECGshowedSTEMIatinferiorwall.Hewasgivenalteplaseover
9 min and admi0ed to ICU. Next 48 hr severe dyspneadeveloped.FollowingintubaKon,furosemide,andinsertedPAC.
Pulmonary artery pressure waveform tracing are capturedduring balloon inflaKon in Fig. Which of the following bestexplains why the waveform changes shape as the balloon is
inflated? A. Balloon has wedged in PA
B. Catheter is malpositioned and
overwedged.
C. Catheter is malpositioned and
migrated back to RA
D. Balloon has failed to inflate due
to balloon rupture.
4
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PACposi4on • NormallyPAdiastolic>PCWP~1-4mmHg
• PAdiastolic–PCWP>5mmHg:éPVR
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GiantVwaves
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Overwedging
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Limita4onofPAOP
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Avarietyofdrugsmaybe used forinducKon of sedaKonduringRSI.ForwhichoneofthefollowingpaKentswouldyoupreferably
c h o o s e e t o m i d a t e i n s t e a d o f k e t a m i n e f o r R S I ?
A. A 6 5 - y e a r - o l d m a n w i t h s e p K c s h o c k .
B. A45-year-oldmanwhoishypertensiveand hasanacuteMI
C. A25-year-oldwomanwithasthmawhois8weekspregnantD. A 3-year-old woman with thoracic and abdominal injuries
f r o m v e h i c l e s a c c i d e n t w h o i s h y p o t e n s i v e .
5
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• .1-.5mg/kg
• Analgesia+Amnesia
• Notnecessarilycausealossofconsciousnessbutnotaware.
• Amnesia,alteredshorttermmemory,decreasedabilitytoconcentrate,alteredcogniKveperformance,nightmares,N/V
• CombinaKonwithsmalldosesofBDZdoesprolongrecoveryfromketamine,buteliminatestheseadverseeffects
• DirectsKmuliANS,tachycardiaandincreasesBP
• Bronchodilatoreffect.
Ketamine
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• Dose2mg/kg.
• Containing1%soybeanoil,2.25%glycerol,1.2%eggphosphaKde.
• Mostfrequentlycontaminatedbybacteria.
• Noanalgesia
• HepaKcclearance+extrahepaKcsiteseliminaKon
• Rapidrecoveryevenaerprolonginfusion
• Dosedependenthypotension,respiratorydepression
• AdjusteddosebyvolumestatusandcardiacfuncKon
• Bronchodilatoreffect
Propofol
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• Metabolicacidosis,
• CardiacdysfuncKon,
• Hyperkalemia,hypertriglyceridemia,
• Rhabdomyolysis
• AI
• Triggerdosetoxicity≥5mg/kg/hrx48hr
Propofolrelatedinfusionsyndrome
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InwhichofthefollowingpaKentscenarioswouldtherapeuKchypothermiabemostclearlyindicated?
A. A55-year-oldmaninacomafollowinganin-hospitalcardiacarrestwithPEAduetomassivepulmonaryembolism.
B. A6-year-oldmaninacomafollowinganout-of-hospitalVF
C. A59-year-oldmantransferredfromanoutlyinghospitalforconKnuedcarefollowingaVFarrest1weekagowithanoxicencephalopathy
D. A3-year-oldmaninacomafollowingamotorvehicleaccidentwithheadtrauma
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• ComatoseadultpaKentswithROSCaerout-of-hospitalVF
cardiacarrest(classI,LOEB)• ComatoseadultpaKentswithROSCaerin-hospitalcardiacarrest
ofanyiniKalrhythmoraerout-of-hospitalcardiacarrestwithaniniKalrhythmofPEAorasystole(ClassIIb,LOEB).
• Cooledto32°Cto34°Cfor12to24hours
• Mechanisms
• Slowdowncerebralmetabolicrate
• InhibiKondeleteriousbiochemicalorcerebraleventsbetweenreperfusion
• ↓freeradicalproducKon&excitatoryaminoacidrelease
• Promoteneuronalrecovery
• ↓ICP
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1.Induc4onphase• AimcoreBT<34
๐C
• DowntotargetBTasquicklyaspossible
• Sideeffectsarehypovolemia,electrolytedisorders,hyperglycemia
2.Maintenancephase• TightlycontrolcoreBT,minorornofluctuaKon(max.2-.5
๐C)
3.Rewarmingphase
• .2-.5๐
C/hour
• Electrolytedisorders(hyperkalemia,hyperphosphatemia)
• Bewarereboundhyperthermia
.Maintenancenormothermicphase
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1. Arrhythmias,hemodynamicchangesandCVSeffects
• Cardiacoutput↓25-4%
• CVP↑,SVR↑,BP↑
• Hypovolemia(colddiuresis)
• CoreBT<35.5๐
C→sinusbradycardia
• CoreBT~32๐
C→HR~4-45bpm
• CoreBT<28-3๐
C→VForVT
2.Drugclearance
• ↑Drugleveland/orenhanceeffect
3.Electrolytesdisorder
• Hypomagnesaemia
• Hyperkalemiainrewarmingphase
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5.Hyperglycemia6.CoagulaKonparameter
• BT<35๐
C→plateletfuncKon
• BT<33๐
C→coagulaKonfactor
• NormalstandardcoagulaKontestbecausewarmbloodpriortest
7.InfecKon
8.Shivering
• NMBA(++++)
• Meperidine(++++)
7
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A 46-year-old man is rescued from his home following ahurricane with regional power outages; he is found to be
confusedanddisoriented.Helivedtherefor3dayswithlightandheatprovidedbyaportablegenerator.Hispulseis13/min,BP14/9mmHg,RR28/min,SpO 298%.TheremainderPEnormal.Which of the following should be done immediately.
A. A d m i n i s t e r 1 % o x y g e n
B. U r i n e t o x i c o l o g y s c r e e n
C. C T s c a n o f h e a d
D. L u m b a r p u n c t u r e
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Carbonmonoxide(CO) • COisacolorless,odorless,tastelessandnonirritantgas
• ProducKoninvarietyofways
• IncompletecombusKonoffires
• FaultyheaKngsystems
• InternalcombusKonengines• Woodstoves
• Charcoalgrills
• VolcanicerupKons
• InvivohepaKcproducKon• Methylenechloridepoisoning:paintthinners
• Accidental:automobileexhaustandsmokeinhalaKon
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Pathophysiology
• COeasilydiffusesacrossalveolar-capillarymembranes
• RapidlytakenupbyRBCs
• BindtoironofHbwithaffinity24Kmes>O2
• Summary4mechanismsofCOintoxicaKon
• DecreaseintheO2carryingcapacityofblood
• DecreasedO2deliverytoperipheralKssueasaresultoftheleshiin
theoxyhemoglobindissociaKoncurve
• MitochondrialdysfuncKonandimpairmentofcellularrespiraKonby
inhibiKonofcytochromeoxidaseacKvity
• LipidperoxidaKonofbrainduringreoxygenaKon
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Clinicalpresenta4on • Headache,dizziness,sorethroat,nausea,SOBandfaKgue
• EnKrefamilyisaffectedrelatedtoafaultyhomeheaKng
systemduringthewintermonths
• Lossofconsciousness
• Severitycorrelatebe0erwithduraKonofexposure
• BrainandheartareverysensiKvetoCOintoxicaKon
• CVSdisorderเกดไดเรวถาผ ปวยม preexisKngCVSdisease
• LacKcacidosis,rhabdomyolysis,ARF
• ตายแนถา level>6%
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Diagnosis • Cherry-redlips,cyanosis,reKnalhemorrhage(infrequent)
• IncreasedlevelofCOHbèDx
• CoHbตองวดโดย cooximeter
• ABG:PaO2normal
• Electrolyte(AG),C,lactate• EG,cardiacenzymes
• ChestX-ray:noncardiogenicpulmonaryedema
• Bloodandurinecyanide
• Suicide:drugscreen
Eff f COHb d O 4 b
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EffectofCOHbonmeasuredO2satura4onby
pulseoximetry
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Treatment • Removalfromsourceofexposure
• 1%O2สามารถลด T½ ของ COHbจาก 4-6 hr. เปน 40-80
min
• IntubaKonตาม indicaKons
• O2ควรใหจน
COHbreturntonormalexceptpregnancy
• HBOT:1.5-3ATMลด half-lifeของ COHbจาก 5-6hrเปน 2min
• IndicaKonofHBOTหนาตอไป
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ApaKentwithARDSissupportedbyMVwiththemodedepictedinFig.WhatdescripKonbestfitsthismode?
8
A. PressuresupportvenKlaKon
B. AirwaypressurereleasevenKlaKon
C. VolumeassistedcontrolvenKlaKon
D. VC-SIMV
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• OxygenaKonindex(OI)=(FiO2xmPawx1)/PaO
2• Predictorofpooroutcome
• HighOI12to24haeronsetofARDSandrisingareindependentrisk
factorsformortality
• OI>3representfailureofconvenKonalvenKlaKon
• MajorityofpaKentswithARDSdiefrommulKorganfailure
Ven4latorymanagementofARDS
l
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Variables ProtocolVenKlatormode Volumeassistcontrol VT ≤6ml/kgpredictedBW Plateauairwaypressure ≤3cmH2OVenKlaKonrate/pHgoal 6-35/min,adjustedtoachievearterialpHof
>7.3ifpossibleInspiratoryflow AdjustforI:E=1:1-1:3 OxygenaKon PaO2≥55and≤8mmHgorSaO2≥88%
and≤95%CombinaKonofFiO2andPEEP(cmH2O) .3/5,.4/5,.4/8,.5/8,.5/1,.6/1,
.7/1,.7/12,.7/14,.8/14,.9/14,.9/16,.9/18,1./18,1./22and1./24
Weaning A0emptbyPSwhenFiO2/PEEPcombinaKon
is<.4/8
ARDSnetLow-VTprotocol
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P b bili f i l h h D 90
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ProbabilityofsurvivalthroughDay90
PEEP i f h i
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PEEPinrefractoryhypoxemia • ThreeRCTsformodestVShighlevelsofPEEP
• ALEOLI(NEJM24;351:327-36)
• LOVS(JAMA28;299:637-45)
• EXPRESS(JAMA28;299:646-55)
• SystemaKcreviewandmeta-analysis
• JAMA21;33:865-73(March)
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Ch t i 4 f i l d d t i l
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Characteris4csofincludedtrials
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PEEP t t i (LOVS)
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PEEPstrategies(LOVS)
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R i t i bl i fi t k
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Respiratoryvariablesinfirstweek
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Summary
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Summary • Inhospitalmortality
• AllpaKents:higherPEEP=lowerPEEP• ARDS:higherPEEP>lowerPEEP
• RelaKvemortalityreducKon1%
• NNT25
• ALI:higherPEEP=lowerPEEP(high<low)
• VenKlatorfreedays
• AllpaKents:higherPEEP=lowerPEEP
• ARDS:higherPEEP>lowerPEEP
• ALI:higherPEEP=lowerPEEP(high<low)
Lung recruitment maneuvers
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• Transientincreaseintranspulmonarypressure
• Reopeningofcollapsedalveoli.
• UseInrefractoryhypoxemia
• Varietyoftechniques
• SustainedinflaKonmaneuvers
• HighPCV
• IncrementalPEEP
• Intermi0entsigh
• Extendedsigh
Lungrecruitmentmaneuvers
Sustained infla4on technique
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Sustainedinfla4ontechnique • CPAP4cmH2forupto6sec.
• Advantages• Reducinglungatelectasis
• ImprovingoxygenaKonandrespiratorymechanics
• PrevenKngETsucKoning-inducedalveolarderecruitment
• Disadvantages
• IneffecKve
• Short-lived
• Circulatoryimpairment• Increasedriskofbaro/volutrauma
• Reducednetalveolarfluidclearance
• WorsenedoxygenaKon
Stepwise maximum RM
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StepwisemaximumRM • PaO2+PaCO2≥4mmHgasan
indicatorofmaximumRM
• DecrementalPEEPKtraKon
• Start25cmH2Ofor4min
↓ 2 cmH2O
• LowestPEEPmaintainPaO2+
PaCO2≥4mmHg(opKmalPEEP)
• RMatlaststepagain• PEEPatopKmalPEEP
BorgesJBetal.AmJRespirCritCareMed26;174:268–78.
Recruitment Maneuvers for ALI
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RecruitmentManeuversforALI
ASystemicReview • 4arKclesanalyzed:meansamplesize3,total1185pts• Studydesigns
• 4RCT
• 32prospecKvecohort
• 4retrospecKvecohort
• TypeofRMs
• SustainedinflaKon18
• HighPCV9
• IncrementalPEEP8
• HighVT/sigh4
• Other1
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Fanetal.AmJRespirCritCareMed28;178:1156-63.
PCV inverse ra4o ven4la4on
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PCVinverse-ra4oven4la4on •
InspiratoryKme>expiratoryKme• NobenefitormarginalbenefitofPCIRV
• Li0leimprovementinoxygenaKon
• Elevatedmeanairwaypressure+autoPEEP• Adverseeffecttohemodynamics
• RequiredsedaKonandparalysis
Airway pressure release ven4la4on
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Airwaypressurereleaseven4la4on
APRV seng
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APRVseng • Phigh
• DesiredPpla(typically2-35cmH2O)
• Phigh>35cmH2Owhen ↓ thoracic&amdominal
complianceormorbidobesity
• Plow :cmH2O
• Thigh :4-6secs(8-95%oftotalcycleKme)
• Tlow :.2-.8secs(endexpiratoryflow=5-75%
ofPEFR)
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Mortality
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Prone posi4oning
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Proneposi4oning • ReducemortalityinseverebyPaO2/FiO2<1mmHg
(p=.1;RR.84;95%CI.74-.96)
• MeanproneduraKon14hr/day
• NotreducemortalityinoverallpaKents
• ImproveoxygenaKon27-39%
• âVAP
• NoeffectonvenKlatorfreedayorduraKonofMV
• Adverseeffects:pressureulcers,ETobstrucKon,tracheostomytubedislodgement
HFOV
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HFOV
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G T t M h i d i HFV
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The major gas-transport mechanisms that are operaKve under physiologic condiKons in each region (convec4on, convec4on anddiffusion,anddiffusionalone) areshown.Thereare sevenpotenKalmechanisms:turbulenceinthelargeairways,causingenhanced
mixing;directven4la4onofclosealveoli;turbulentflowwithlateralconvecKvemixing;pendellu(asynchronousflowamongalveolidue
toasymmetriesinairflowimpedance);gasmixingduetovelocityprofilesthatareaxiallyasymmetric(leadingtothestreamingof“fresh”
gastowardthealveolialongtheinnerwalloftheairwayandthestreamingof“alveolar”gasawayfromthealveolialongtheouterwall);
laminarflowwithlateraltransportbydiffusion(Tayordispersion);andcollateralven4la4onthroughnonairwayconnecKons
Gas-TransportMechanismsduringHFV
HFOV
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HFOV • SafeandeffecKveinimproveoxygenaKon
• Nolowermortality
• MayimprovemortalityinpaKentswithhighOI
NO inhala4on
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NOinhala4on
Griffithsetal.NEJM25;353:2683–95.
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Administra4onofiNOinadult
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• Majortoxicity
• MetHb:uncommoninusualdose,measureq6hr
• NO2:rapidcoverttonitricacidinaqueoussoluKonthattoxictorespiratorytract
• DosetreatmentinPHT>ARDS
• Maximumdose4ppm• Required2%riseinPaO2onFiO21.
• ImprovedV/Qmismatch
• Be0eroxygenaKon
• Nosurvivalbenefit
• NoreducKoninvenKlatorfreedays
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WhichofthefollowingbestdescribesthemonitoringofglucosecontrolinICU?
A. AlaboratoryglucosemeasurementispreferredoveraPOCT.
B. Acentralorperipheralbloodsampleispreferredtocapillarysample
C. Asinglemorning(eg.6.am)glucoselevelispreferredoverameanmorningglucoselevel
D. Ameanmorningglucoselevelispreferredoverameandailyglucoselevel
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SamplingBlood(vascularcatheter) DangerofcontaminaKonwithIVfluidFingersKck(notrecommended) InaccurateinpaKentswithedemaoranemia
MeasurementGlucometer Fastest,leastaccurateBloodgasmachine Fast(ifinICU),accurateLaboratoryanalysis Slowest,mostaccurate
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Acuterespiratory
d t i K
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deterioraKonPeakinspiratorypressure
Decreased Increased NochangePlateaupressure• Airleak
• HypervenKlaKon• Pulmonaryembolism
• ExtrathoracicProcessNochange Increase
AIRWAYOBSTRUCTION• AspiraKon
• Bronchospasm
• SecreKons
• Trachealtube
• ObstrucKon
DECREASEDCOMPLIANCE• Abdominaldistension
• Asynchronousbreathing
• Atelectasis
• AutoPEEP
• Pneumothorax
• Pulmonaryedema
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A28 yearoldwoman is admi0edtoICUforfever, hypotension,andmildlowermiddleabdominalpain,dysuria.Sheunderwenta
C/S 9 months ago and intraoperaKve bleeding required PRCtransfusion. Review of system, she has some intermi0entheadaches and faKgue. She had noted a decrease in milkproducKonaer4weeksandnothadamenstrualperiodsincethedelivery
OnexaminaKonBT38.5C,BP8/5mmHg,PR1/min,RR15/min.DespiteinfusionofNSSandanKbioKcs,sheremainshypotensive.Whichofthefollowingshouldnextbeaddedtoherregimen?
A. HydrocorKsone
B. Dopamine
C. Norepinephrine
D. Drotrecoginalfa
Ini4al resuscita4on
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Ini4alresuscita4on CVP8-12mmHg MAP≥65mmHg
Urineoutput≥0.5ml/kg/hr ScVO2≥70mmHgSVO2≥65mmHg
Goal6hrs
Higher target CVP
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HighertargetCVP • MechanicalvenKlaKon• Decreasedventricularcompliance
• IAH
• DiastolicdysfuncKon
• Pulmonaryarteryhypertension
Indices of fluid responsiveness
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Indicesoffluidresponsiveness • PulsepressurevariaKon• Passivelegraising
• CVPvariaKoninspontaneousbreathing
•Respiratory changes in pulse pressure
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• Respiratorychangesinpulsepressure
• Definedasresponder
• Threshold>13%
• SensiKvity94%
• Specificity96%
• MorereliablethanSPV
PPmaxPPmin
∆PP(%)=1x(PPmax-PPmin)(PPmax-PPmin)/2
Early goal directed therapy
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Earlygoaldirectedtherapy
Diagnosis
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Diagnosis • ObtainappropriateculturesbeforestarKng
anKbioKcs
• ≥2BCs(percutaneousandvascularaccess)
• Cultureothersitesasclinicallyindicated• Imagingtoconfirmandsampleanysourceof
infecKon
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Source control
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Sourcecontrol Clinical(suspected)
diagnosis consider SourcecontrolPneumonia Empyema Drainage2๐ peritoniKs OngoingcontaminaKon ExteriorizaKonofleakingGItract,drainageof
peritonealfluidPancreaKKs InfectedpancreaKc
necrosis DebridementofpancreaKcKssueUTI Catheter-related RemovecatheterBacteremia Catheter-related RemovecatheterSSI NF ResecKonofnecroKcKssue–explorewhen
suspectedonclinicalgroundsPyelonephriKs Urinarytractlithiasis Debridement–lithiasisremovalMediasKniKs EsophagealperforaKon SurgicaldrainageSinusisKs Abscess AspiraKonanddrainage–removeNGtubeAcalculous
cholecysKKs Abscess,hydrops Percutaneousdrainage–chlecystectomyPericardiKs Drainage
Fluid therapy
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Fluidtherapy • Crystalloid=colloid• Fluidchallenge
• Crystalloid≥1mlover3min
• Colloid≥3-5mlover3min
Vasopressors
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Vasopressors • MAP≥65mmHg:toolowinpaKentswithsevere
uncontrolledHT
• NEordopamineasthe1stchoice
• Epinephrine:poorlyresponsivetoNEordopamine
Inotropic therapy
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Inotropictherapy • DobutamineformyocardialdysfuncKon(elevated
cardiacfillingpressureorlowcardiacoutput)
• NouseofstrategytoincreaseCItosupranormal
level
Cor4costeroids
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Cor4costeroids • HydrocorKsone:BPpoorlyresponsetofluid
therapyandvasopressor
• Notpreferdexamethasone
• FludrocorKsoneisopKonal
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WhichofthefollowingintervenKons,ifusedrouKnely,wouldbe
expectedtoreducetheincidenceofVAP?
A. OralapplicaKonofanKsepKcs
B. Frequentrespiratorycircuitchanges
C. Standardelectrictoothbrushing
D. Early tracheostomy among paKents expected to require
prolongedmechanicalsupport
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VAPpreven4on
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Source of VAP
Pathogen Prevention Goal Specific MeasuresAerodigestive
colonization Prevent colonization by
exogenous routes • Hand hygiene
• Microbial surveillance and targeted
barrier isolation
• Preemptive barriers: Routine gloving &
gowning Dedicated equipmentSuppress oropharyngealmucosal colonization • Oral decontamination with
chlorhexidine
• SDD
• Aerosolized antimicrobials
• Sucralfate instead of H2-blockersPrevent aspiration • NIV
• Semirecumbant positioning
• Novel endotracheal tube permitting
continuous subglottic suctioning
VAPpreven4on
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Source of VAP
Pathogen Prevention Goal Specific MeasuresContaminated
respiratory therapy
equipment and
medical aerosols
Safe equipment and
medical aerosols • Procedures for reprocessing
bronchoscopes and reused
respiratory therapy equipment
• Training and education of reprocessing
staff and respiratory therapists
• Procedures for use of aerosolized
medicationsReducing contamination
of ventilator circuit • Heat-and-moisture exchanger
• Periodically drain condensate from
circuit
• Sterile water for bubble-through
humidifiers• Aseptic procedures for suctioning of
ventilated patients
VAPpreven4on
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Source of VAP
Pathogen Prevention Goal Specific MeasuresContaminated tap
water
( Legionella
species,
Pseudomonas
aeruginosa)
Safe water • Sterile water for:
Cleaning respiratory therapy equipment
Rinsing bronchoscopes
Aerosolized medications
• Hospital surveillance for cases of
nosocomial legionellosis
• Microbial surveillance of hospital water for
contamination by legionellae
• Engineering controls for contaminated
water:
Superheat and flush Ultraviolet light
HyperchlorinationSilver-copper ionization
Ozonation
VAPpreven4on
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Source of VAP
Pathogen Prevention Goal Specific MeasuresContaminated
ambient air
(filamentous fungi,
Mycobacterium
tuberculosis,SARS
coronavirus)
Safe air • Procedures for minimizing communicable
airborne infections:
Disease recognition
Administrative controls
Engineering controls• Procedures for minimizing risk to
immunocompromised patients:
High-efficiency particulate arrester
(HEPA)-filtered rooms
N95 masks for intrahospital transports
• Policies and procedures for managementduring periods of construction and renovation
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Endotracheal intubaKon in a young hemodynamically stable
14
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Endotracheal intubaKon in a young, hemodynamically stable
paKent with 3% third-degree burns and sepsis would best be
accomplishedwiththefollowingIVdrugcombinaKon.
A. Propofolandsuccinylcholine
B. etamineandrocuronium
C. EtomidateandsuccinylcholineD. Etomidateandrocuronium
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NondepolarizedNMBA
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• CompeKKveantagonistsandinhibitAChbindingtopostsynapKc
nAChRs• Benzylisoquinolinium
• mivacurium,atracurium,cisatracurium,anddoxacurium
• Aminosteroid
• vecuronium,rocuronium,pancuronium,andpipecuronium.
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NIV
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RecommendedindicaKons
1. COPDexacerbaKons
2. Acutecardiogenicpulmonaryedema
3.
FacilitaKngextubaKoninCOPDPaKents4. ImmunocompromisedPaKents
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FactorsassociatedNIVsuccess Synchronous breathing with venKlator
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SynchronousbreathingwithvenKlatorDentateLessairleakingFewersecreKonsGoodtoleranceRespiratoryrate<3/min*LowerAPACHEIIscore(<29)*pH>7.3*Glasgowcomascore15*PaO2/FiO2>146aerfirsthourifhypoxemicrespiratoryfailureCOPD,CPENopneumonia,ARDSBestpredictorofsuccessisagoodresponsetoNPPVwithin1to2h:ReducKoninrespiratoryrate
ImprovementinpH
ImprovementinoxygenaKon
ReducKoninPaCO2
A 5-year-old woman with severe bronchioliKs obliterans is
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receiving mechanical venKlaKon support. She has developed
hypotension. The graphic display is pictured in Fig. Which
combinaKon of the following manipulaKons of the MV can beperformed to confirm the diagnosis and to ameliorate the
c o n d i K o n ?
A. Performaninspiratorypause,increaseinspiratorypressure
B. Performanexpiratorypause,
increaseinspiratorypressure
C. Performaninspiratorypause,
reducethesetrate
D. Performanexpiratorypause,
reducethesetrate
AutoPEEP
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MeasurementofautoPEEP
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In addiKon to hand hygiene, strict adherence to asepKc
17
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yg , ptechnique with maximal sterile barrier precauKons, skinanKsepKcwithCHX,preferenKaluseofsubclavianinserKon,and
prompt removal of unnecessary catheters, which of thefollowing pracKces is associated with a reduced incidence ofC R B S I i n I C U ?
A. Heparin-coatedcatheterscomparedwithuncoatedcathetersB. Transparent occlusive dressings compared with gauze
C. Dressing with CHX-impregnated sponge compared with noa n K s e p K c
D. Changingtransparentdressingsevery3dayscomparedwithe v e r y 7 d a y s
Preven4onCVCrelatedinfec4on
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1. Set&usecathetercareprotocols
• EducaKonalprogramswithhygienetraining
• CatheterinserKon:prepare,skinanKsepKc,inserKontechnique
• CathetermanipulaKon:handhygiene,manipulaKonoftaps
• Cathetercare:catheterreplacementmodaliKes,type&frequencyof
dressing
• EvaluaKonincidenceofCRBSIandfeedback
2. StaffeducaKonal/Qualityimprovementprogram
3. Typeofcatheter
• Polyurethanecatheter
• CatheterscoatedwithaniKmicrobial/anKsepKc(CHX/
silversulfadiazine,minocycline/rifampicin)
• CVCswithmulKlumen→noincreaseriskofCRBSI
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Preven4onCVCrelatedinfec4on
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11. Venouslinemaintenance
• ChangeIVsetq3days• Bloodproduct,lipidemulsion(parenteral+propofol)changeq1dayor
immediatelybefinished
• HandhygienebeforecathetermanipulaKon
• HabsandsamplingportscleaningwithCHXbasedanKsepKcbefore
access
• Nochangecatheterfollowingbyscheduled
• Changecatheterviaguidewire→↑CRBSI
• AnKbioKcoranKsepKcointments→↑ riskof fungalcolonizaKon
• ProphylacKcheparing↓ thrombosisg↓ nidus formaKong↓ colonizaKon
A56-year-oldalcoholicmanwithARDSfrommassiveaspiraKoni i i MV H i f d i h € V 12 l/
18
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is requiringMV.He is transferredto you with se€ngVT12ml/kg,RR2/min,PEEP1cmH2O,FiO2.5andPplat36cmH2O.His
PaO293mmHg,PaCO239mmHgandpH7.41.YoureducehisVTto6ml/kgandincreaseRRto3/min.withthesechanges,hisPplat falls to 23 cmH2O, PaO2 65 mmHg, PaCO2 56 mmHg andp H 7 . 3 1
You wish to follow the ARDS net protocol, at this point
y o u s h o u l d
A. Increase VT to 9 ml/kg to improve both PaO2 and PaCO2
B. S w i t c h t o A P R V
C. Increase PEEP to improve PaO2 and leave VT se€ng alone
D. R e m a i n o n c u r r e n t s e € n g s
A68yearoldmanisadmi0edwithsepKcshockandARDSduetoCAP H i d d d l d MV i h RR 34/ i H
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severeCAP.HeissedatedandplacedonMVwithsetRR34/min.Heappearscomfortableandpassive.OnVT6ml/IBW,Pplat29cmH2O
andPaCO243mmHg.WithFiO2.7andPEEP12cmH2O,SaO288%.AppropriatedanKbioKchavebeeniniKated.Aer12handfollowing4LfluidresuscitaKon,MAP58mmHgonNE8µg/min,HR112/min.Urineoutput2mlsinceICUadmission.Youareconsideringgivingfluid bolus. Which of the following measures will most accurately
predict whether a fluid bolus will increase perfusion?
A. TherespiratoryvariaKoninPPaerVTisincreasedto1ml/kg
B. T h e P A O P m e a s u r e d a t e n d - e x p i r a K o n
C. TheCVPreferencedtothephlebostaKcaxiswithsupineposiKonD. T h e S c V O 2 m e a s u r e d f r o m a C V C
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Pulsepressurevariation
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∆PP(%)=100x(PPmax-PPmin)(PPmax-PPmin)/2
Definedasresponder
• Threshold>13%• SensiKvity94%
• Specificity96%
MorereliablethanSPV
MICHARDFandetal.AJRCCM2000;162:13–8.
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Passivelegraisingtest(PLR)
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• Selfvolumechallenge3ml
• MeasuresaorKcbloodfloworpulsepressure
• 3-9sec• AorKcbloodflow> 1%(sensiKvity97%,specificity94%)
• Pulsepressureincreased>12%(sensiKvity6%,specificity85%)
MonnetXandetal.CritCareMed26
A5yearoldpaKentwithsevereARDSfromsepsisissupportedby
20
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y p p pp yassistcontrolvenKlaKon.HeisrequiringanFiO2of.8andaPEEPof12cmH2OtoproduceaPaO257mmHg.Youelecttotrytoimprove
gas exchange and lower the FiO2 exposure by using a RM of 4cmH2Ofor4sec.Atendofmaneuver,thePaO2hasrisento16mmHg.
TheduraKonifthisimprovementdependsmostimportantlyon:
A. WhetheraddiKonalPEEPisadded
B. Performingrepeated4cmH2ORMsevery1-2h
C. Performingrepeated4cmH2ORMsevery3-6h
D. ImmediatelyrepeaKngtheRMwith5cmH2OandrepeaKngRMseveryhouriftheSpO2falls