Recent Advances in Critical Care

Medicine: A Case Based Review

Margaret M. Johnson, MD
Associate Professor of Medicine
Chair, Division of Pulmonary Medicine
Mayo Clinic Florida
Johnson.margaret2@mayo.edu

33 year old non-smoking, previously
healthy female

No prior hospitalizations
T 38.9 (po)
RR 22 bpm
HR 138 bpm
BP 70/40
Coarse rhonchi bilaterally
O2 saturation 82%
Up to 95% on face mask
Mottled skin
Anuric
Lactate 6.2
Overview
Updated Surviving Sepsis Guidelines
Management of shock
Fluid resuscitation
Vasopressor support
Role of steroids
Respiratory management
Intubation
Ventilator management
High frequency ventilation, prone ventilation
Management strategies to decrease delirium
Outcome




SURVIVING SEPSIS GUIDELINES: 2012

Joint collaboration between SSCM and European Respiratory
Society

Third edition
No industry funding used in revision process

Critical Care Medicine February 2013
www.survivingsepsis.org
Sepsis: Fluid Resuscitation
Crystalloid, normally saline, is primary choice
Initial: 30 ml/kg = 2.1 L for 70 kg
Subsequent boluses to defined endpoint
Endpoints:
Normal mixed venous oxygen saturation 65-70%
Normal lactate
Urine output > 0.5 ml/kg/hr
MAP > 65 mm Hg
Weak indication for albumin (Grade 2B)
Avoid hetastarch with high molecular weight (> 200 kD)
Potential Dangers of Saline
Saline administration
Hypertonic relative to blood
Often causes hyperchloremic metabolic acidosis
Does it cause renal injury ?
Prospective, sequential, single institution pilot study
Chloride restrictive v. chloride liberal
Restrictive
Lactated solution or plasma-lyte
N = 776 (liberal)
N = 773 (restrictive)

Norazim MY. JAMA 2012; 308(15):1566-1572
Results
Limiting use of normal saline
Less acute kidney injury and reduced need for dialysis in
hospital
No difference in length of stay or mortality
No difference in need for dialysis after hospital discharge
Current take home
Uncertain
Have a reason for giving saline
Probably should consider alternative fluid if large volume
required

Norazim MY. JAMA 2012; 308(15):1566-1572
Sepsis:Vasopressors
Norepinephrine is first choice
Grade 1B
Epinephrine is an alternative
Vasopressin can be added to norepinephrine
Dopamine use limited by tachycardia
NO INDICATION FOR RENAL DOSE
DOPAMINE
Dobutamine if cardiac dysfunction or
persistent shock despite volume
Value of Bedside ECHO
Are Steroids Indicated ???
Sigh.Will we ever know
Current recommendations
Dont perform cosotropyn stimulation test to decide need for
steroids
Consider steroids with persistent shock despite fluids and
vasopressors
Hydrocortisone 200 mg/day
Boluses or infusion
Avoid dexamethasone
Dont need fludrocortisone if hydrocortisone used
Wean steroids when off vasopressors
Six Hours Later
BP 106/72
HR 90
RR 32
Received 4 L NSS
Norepinephrine 12
ug/min


ABG:
7.32/42/310 on 100% O2
PaO2/fiO2 310
Intubation: Safety of Etomidate
Meta-analysis: Etomidate associated with
Increased risk of death
865 evaluated for mortality, RR 1.2 (1.02-1.42)
Increased risk of adrenal insufficiency
1303 evaluated with cosotropyn stimulation test, RR
1.33 (1.22-1.46)
Take home
Causality not concluded, but.alternative should be
considered, especially in sepsis
Chan CM Crit Care Med 2012 40(11) 2945
Does She Have ARDS ?
New Berlin Definition
Maintains emphasis on PaO2/fiO2 ratio
< 300 but > 200 = mild
< 200 but > 100 = moderate
< 100 = severe

Other components
Acute ( < 7 days)
Difficulty with chronic disease

Bilateral infiltrates
Either computed tomography or chest x-ray

No need to exclude heart failure
Heart failure cant solely explain respiratory
failure
JAMA 2012; 307 (23):2526
Value of New Berlin Definition
Improved prognostic value:
PaO2/fiO2 < 300 but > 200 = mild
27% mortality

PaO2/fiO2 < 200 but > 100 = moderate
32% mortality

PaO2/fiO2 < 100 = severe
45% mortality


Lower tidal volumes associated
with decreased mortality

6 cc/kg IBW v. 12 cc/kg
ARDSNet NEJM 2000
Low Tidal Volume Ventilation in
Absence of ARDS

Meta-analysis of patients WITHOUT ARDS
Tidal volume
6.5 v. 10.6 cc/kg IBW
Lower tidal volumes associated with:
Lower chance of developing ARDS
Decreased pulmonary infection or atelectasis
Mortality
Neto AS. JAMA 2012; 307 (23):2526
Is High Frequency Ventilation Helpful?
OSCAR Trial
795 patients
Multi-centered in UK
Identical 30 day mortality (41%)
Young D NEJM 2013;368:806
OSCILLATE Trial
High frequency oscillator trial stopped
prematurely due to increased mortality
47% v. 35%
Ferguson N. NEJM 2013

Is Prone Positioning Beneficial ?
Background
Prone positioning has previously been shown to
improve oxygenation but not mortality in ARDS
237 patients proned v. 229 control
Severe ARDS PaO2: fiO2 < 150
Started early
Within 36 hrs of ARDS
16 hrs/session
28 day mortality
16% (prone) v. 32.8% (control) (p< 0.001)

Guerin C. NEJM 2013;368:2159
Is Prone Positioning Beneficial ?
Not blinded
Control group-higher
acuity scores
Practical implementation
Did not use specialty beds
Proning was not
associated with increased
complications
BUTthese were
experienced centers


Guerin C. NEJM 2013;368:2159
9 Days Later
Agitated and combative
Receiving continuous infusions of
lorazepam and fentanyl
Agitation limits weaning attempts
Is she delirious?
Assessment of delirium
Prevention and treatment

ICU Delirium
Exact incidence is unknown but common
Up to 85% in some series
Negatively impacts both short and long term
outcomes
Short term
Length of stay & duration of ventilation
Mortality
Long term
Cognition
Depression and post traumatic stress disorder
Structural Changes Correlate with
Delirium and Cognition
Hopkins, RO Crit Care Med 2012

Greater Ventricle/Brain Ratio
Correlates with Delirium
Hopkins, RO Crit Care Med 2012
Recognition of Delirium
Objective tools
Confusion Assessment Method CAM-ICU
Performed in conjunction with assessment of level of
sedation (Richmond agitation and sedation score-RASS)
www.icudelirium.org

May be hyperactive or hypoactive
Ely EW. 2002
THINKRather than prescribe
Toxic environments
Shock, CHF
Delirogenic Drugs
Hypoxemia
Consider Haloperidol
Infection/Immobilization
Nonpharmacologic interventions/Nutrition
Eyeglasses, Hearing aides, re-orientation, sleep wake
cycle restoration, sleep hygiene, noise control
K+ electrolyte abnormalities
Risk of Delirium Associated with Use of Lorazepam &
Severity of Illness
Pandhandipari P. Anestheshiology 2006
LORAZEPAM DOSE (MG) APACHE SCORE
I
N
C
I
D
E
N
C
E

O
F

D
E
L
I
R
I
U
M

Less delirium with Dexmedetomidate
v. Midazolam
Rikker RR. JAMA 2009
N = 375
Similar time at
goal sedation
Sedation Comparison
MENDS Trial (n = 106)
Dexmetomonidine v. lorazepam in mechanically
ventilated
More days alive without delirium or coma with
dexmetomidine
Pandharipande JAMA 2007
Reade, et al ( n=20)
Dexmetomidine v. haldoperidol intubated patients
whose delirium prevented extubation
Extubation sooner in dexmetomidine group
Crit Care 2009

Sleep, Delirium, and Cognition
Observational pre and post intervention study
Daily checklist to improve sleep and maintain
day-night cycles
634 (pre) v. 826 (post) patient days
Subjective ratings of sleep not improved but
less delirium and less noise post intervention

Kamdar BB. Crit Care Med 2013
Now What
Discharged from the ICU on Day 17
Home on Day 23
What should she and her family expect?
Denehy Curr Opin Crit Care Med 2013
Ways to Improve Functional Recovery
In ICU
Limit sedation use and development of delirium
Utilize early mobility programs, physical, and
occupational therapy
Try to enhance sleep
After ICU
Coordinated post-discharge care including
physical, occupational, and cognitive rehabilitation
Inform patients and caregivers that functional
limitations' commonly persist
Take Home Points
New sepsis guidelines
Fluid 30 cc/kg normal saline
No renal dose dopamine
Avoid high molecular weight hetastarch
Norepinephrine (+/- vasopressin)
No role for cosotropyn stimulation test
Use hydrocortisone as steroid for stress dose
Chloride rich solutions associated with
development of kidney injury





Take Home Points
Caution with the use of etomidate -especially in sepsis
Low tidal volume ventilation beneficial even in absence of ARDS
High frequency ventilation has not shown mortality benefit
Prone positioning associated with improved mortality
Delirium is common and associated with worsened outcomes
Objectively assess
? Avoid/Limit benzodiazepines
Consider nonpharmacological therapies
Long term impairments often follow critical illness
Inform patients and caregivers
Strategies to improve long term outcomes are ongoing