1 2007
AcuteLungInjuryandAcuteRespiratoryDistress
Syndrome
Definition,Management,Protocol
2 2007
Acutelunginjury(ALI) AcuteRespiratoryDistressSyndrome(ARDS)(Mortalityrate40%~70%) HypoxemiaMultipleOrgansDysfunctionSyndrome(MODS)(1Organ>15%;2Organs>45%;3Organs>90%;>3Organs>100%)
ALI/ARDS Hypoxemia ALI/ARDSCriteria( ICU CR)
ICU
ALI/ARDS Saturation
Hypoxemia Braindamage
ICU
.
Indication
3 2007
1. 2. DefinitionandCommonEtiologiesinALIandARDS
3. BasicsettinginVentilationofALIandARDS
4. EarlyGoalDirectedTherapy5. HemodynamicMonitorinALIandARDS6. HighFrequencyOscillatoryVentilationinALIandARDS
7. PronePositioninARDS 8. NOinhalationinALIandARDS9. ExtracorporealMembraneOxygenation(ECMO)inALIandARDS
4 2007
ALI ARDS Definition
AcuteonsetandMechanicalventilationisrequired. BilateralinfiltratesonCXR Noevidenceofleftatrialhypertensionifmeasured,PCWP
5 2007
ALI/ARDS
IdealBodyWeight IBW=50+0.91x(heightincentimeters152.4) IBW=45.5+0.91x(heightincentimeters152.4)
Variables ProtocolVentilatorMode VolumeAssistControl(ACMode)TidalVolume 6mL/kgpredictedbodyweightPlateauPressure 30cmH2OVentilationRate/PHGoals
635/min,adjustedtoachievearterialpH7.30ifpossible
Inspiratoryflow,I:E AdjustflowtoachieveI:Eof1:11:3Oxygenationgoal 55PaO280mmHgor 88SpO295%Fio2/PEEP(mmHg)
Weaning Attemptstoweanby pressuresupportrequiredwhenFiO2/PEEP=0.40/8
FiO2(%) 30 40 50 60 70 80 90 100PEEP 5 5~8 8~10 10 10~14 14 14~18 2024
VitalSign
() Sedation Paralysis AssistControlMode,TidalVolume 8ml/kg 1~2 7ml/kg 1~2 ( 3~4 ) 6ml/kg Idealbodyweight
PEEP FiO2 100% SaO2 2cmH2O PEEP SaO2 88%18~20cmH2O
PEEP Pneumothorax Barotrauma PEEP
MICU On PiCCO
ARDS Complication
6 2007
Complications of ARDS Management Complications Preventive measures
Neck/thoracic
Tracheal stenosis, vocal cord dysfunction Identify appropriate time for
tracheostomy
Ventilator-associated pneumonia Head elevation, suctioning,
expeditious weaning
Gastrointestinal
Stress-related gastrointestinal hemorrhage Use of stress ulcer prophylaxis
Barotrauma
Pneumothorax, pneumomediastinum,
pneumoperitoneum, air embolism Limit airway and/or plateau pressures
Cardiac/hemodynamic
Hypotension Limit excessive diuresis; limit
excessive use of PEEP
Vascular
Mechanical damage from central line
placement
Careful attention to appropriate
central line placement technique
Other
Excessive sedation Titrate sedation according to sedation
assessment scales
Excessive paralysis Continuous monitoring of level of
paralysis with train of four stimulation
Pneumothorax
TidalVolumePneumothorax HighPEEP CVPlevel HighPEEP Intrathoracicpressure CVPlevel ()
CVP PEEP
OnSwanGanz OnPiCCO Extravascularlungwater Fluidresuscitation( CVP (mmHg))
7 2007
EarlyGoalDirectedTherapy
FromStrategiestoTimelyObviatetheProgressionofSepsisLomaLindaUniversity
EGDT Sepsis 46.5%30.5% 50%
8 2007
HemodynamicMonitor
IndicationsShock( Refractoryshock)ALI/ARDS (#10) ICUBook(3rdEdition)PiCCO SwanGanz
MICU2 MICU5 PiCCO PiCCO Arterialline MICU2 ()
MICU (ICU CR)
9 2007
HighFrequencyOscillatoryVentilationinALIandARDS
Algorithmforhighfrequencyoscillatoryventilation
(ChestWall) Sedation Paralysis
(Daily)( ArterialBloodGas) CXR
10 2007
PronePositioninARDS Indications for prone positioning
Oxygen index (PaO2/FiO2) of 150 or less, when ventilation has been optimised. Positive end-expiratory pressure greater than 7.5cm H2O. Radiological evidence of acute respiratory distress syndrome/acute lung injury
(ARDS/ALI), which requires prone therapy.
Computerised tomography evidence of ARDS or ALI requiring prone therapy. Patients receiving prolonged ventilation for respiratory failure. Patients who, in the absence of primary metabolic acidosis, have a PaCO2 greater than
6.5kPa or pH less than 7.25.
Patients who have evidence of basal collapse/consolidation and require postural drainage for effective secretion removal.
Contraindications and barriers to prone positioning Poorly or inappropriately trained
staff.
Low staffing levels. Lack or absence of equipment. Patient with a large abdomen,
pregnant patients in their second or
third trimester or patients who weigh
more than 125kg.
Head injuries, raised intracranial pressure or raised intraocular
pressure.
Patients presenting with seizures. Multiple trauma, pelvic and chest
fractures, spinal instability.
External pelvic fixation or limb/neck traction.
Facial trauma or surgery. Recent cardiothoracic surgery. Open abdominal wound. Danger of
complications after abdominal or
pelvic surgery (advice from surgical
team may be required).
Hemodynamic instability, despite fluid resuscitation and inotropic
support.
New tracheotomy (less than 24 hours).
Recent cardiac arrest: one in the past 48 hours or two or more in the
previous five days.
Patients who previously demonstrated poor tolerance of
prone positioning.
MICU2 Prone Position Saturation
Prone Position Complication Cardiac output
Supine position
Complication(MICU2 )
11 2007
NitricOxideinhalationinARDSIndications 1.Severe ARDS Optimally ventilated PaO2 24 mmHg, TPG > 15, PVR > 400 dynes-scm
Must support systemic circulation: inotropes, etc. Beware adverse effects on the left
ventricle
Dose
1.Maximum dose 40 ppm NO
ventilator
20PPM
2.Dose titration: 20-10-5-0 ppm for 30 min
3.A 20 % rise in PaO2 on FIO2 100% required
4.Use minimum effective dose
5.RSCF: 20-40 ppm
Delivery
1.Continuous injection or synchronised inspiratory injection devices suitable with
injection near to ventilator
2.Medical NO/N2 gas mixture
3.Stainless steel pressure regulators, connectors and flow meter needle valves
4.Calibrated flow meter
5.Position of humidifier unimportant
Monitoring
1.Continuous inspiratory NO and NO2 at Y-piece CO-oximeter
panel
Methaemoglobin
2.Electrochemical monitoring adequate
3.Monitors correctly calibrated
4.Methaemoglobin levels: time 0, 1 and 6 h then daily
5.Expiratory monitoring not necessary
Exposure
1.Maximum inhaled NO < 40 ppm NONO2
NO
2.Maximum inhaled NO2 < 3 ppm
3.Maximum environmental NO < 25 ppm for 8-h TWA
4.Maximum environmental NO2 < 3 ppm for 8-h TWA
5.Minimum effective dose for shortest periods advised
(safety data up to 28 days available)
Scavenging
1.Not required in well ventilated unit
2.Environmental monitoring required in units with less than 10-12 air changes per hour
and scavenging if exposure limits exceeded
Scavenging
techniques
1.Filtration
2.Active scavenging
3.Passive scavenging
Contraindications Absolute: methaemoglobinaemia
Relative: bleeding diathesis, intracranial hemorrhage, severe LVF
RSCF:rightsidedcardiacfailure MPAP:meanpulmonaryarterypressureTPG:transpulmonarygradient PVR:pulmonaryvascularresistanceNO2:nitrogendioxide TWA:timeweightedaverage LVF:leftventricularfailure
12 2007
ECMO(Extracorporealmembraneoxygenator)forALI/ARDS
Indications () (91/12/01 )
Bridge stunned heart prolong bypass pulmonary embolism or infarction
ARDS
Qsp/Qs>30intrapulmonary Rto L shuntnormal45cmH2O TSLCs610 for 8Hrs AaDO2=Patm47PaO2PaCO2>600 for 12Hrs PaO2
13 2007
Neonate extracorporeal life support criteria Indications
Duration of ventilation 10~14days Reversible lung pathology Oxygenation
A-aDO2 >605620 for not > 412 hrs Oxygenation index>25
Contraindications Prolonged conventional mechanical ventilation Intracranial hemorrhage (>grade I) Incurable disease Age2/3 systemic blood pressure Unresolved surgical issues
Consult
14 2007
Reference1. Treatment of ARDS Chest 2001; 120:13471367 2. Acute Respiratory Distress Syndrome Am Fam Physician 2002;65:1823-30 3. High-frequency oscillatory ventilation for acute respiratory distress syndrome in adult
patients Crit Care Med 2003; 31[Suppl.]:S317S323
4. Prone positioning in patients with acute respiratory distress syndrome Nurs Stand. 2005 Nov 9-15;20(9):52-5
5. Severe respiratory failure: Advanced treatment options Crit Care Med 2006; 34[Suppl.]:S278-S290
6. UK guidelines for the use of inhaled NO in adult ICUs Intensive Care Med (1997) 23: 1212-1218
7. Early goal-directed therapy in the treatment of severe sepsis and septic shock N Engl J Med 2001;345:1368-77
8. Assessment of Cardiac Output, Intravascular Volume Status, and Extravascular Lung Water by Transpulmonary Indicator Dilution in Critically Ill Neonates and Infants
Journal of Cardiothoracic and Vascular Anesthesia, Vol 16, No 5, 2002: 592-597
9. Extravascular lung water determined with single transpulmonary thermodilution correlates with the severity of sepsis-induced acute lung injury
Crit Care Med 2006; 34:16471653
10. Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives to the pulmonary artery catheter
Am J Physiol Lung Cell Mol Physiol 291: L1118L1131, 2006
ARDS
Coma Weaning ^^
Guideline
ALI ARDS (RecruitmentManeuvers ) .~~~
M.K. Tsai 2007/Feb/5 01:10AM ~~~
15 2007
Saturation
D
Disclaimer (v9.1) This is a clinical template and clinician should use judgment for
individual patient encounters. Loma Linda University Copyright 2005
ScvO2 < 70
NO YES NO
YES
NO
NO NO
YES
YES
YES
Lactate > 2
ScvO2 > 70
SBP 90-140 (MAP 65-90)
CVP 8-12
HR < 120
HR > 120
Hgb > 10
AND/OR
Hgb < 10
SBP > 160 (MAP > 110)
CVP > 15 and SBP > 160 (MAP > 110)
CVP < 8
1. Arterial Line Placement (preferred) 2. Norepinephrine 2-20 mcg/min 3. Dopamine 5-20 mcg/kg/min 4. Phenylephrine 40-200 mcg/min
(if HR > 120) 5. Vasopressin 0.01-0.04 U/min
(if on another Vasopressor) 6. Epinephrine 2-10 mcg/min 7. Dexamethasone 2 mg IV q 6 hrs OR
Hydrocortisone 50 mg IV q 6 hrs after CST (if on Vasopressor or Adrenal Insufficiency)
1. Nitroglycerin 10-60 mcg/min 2. Hydralazine 10-40 mg IV
YES
Strategies to Obviate the Progression of Sepsis Loma Linda University
Suspected Infection
SepsisSBP < 90 after Bolus
Septic Shock
Lactate > 4 mmol/L or >1 Organ Dysfunction
SevereSepsis
Early Goal-Directed Therapy
Initiate Sepsis Orders Central Line Placement for CVP/ScvO2 Monitoring
Supplemental Oxygen OR Mechanical Ventilation with Lung Protective Strategies
CVP
SBP/ MAP
ScvO2
Heart Rate
Goals Achieved
1. NS 500 mL Bolus until CVP 8-12, then Continue at 150 mL/hr
2. Consider Adding Colloid if CVP < 4
Nitroglycerin 10-60 mcg/min until CVP < 12 or
SBP < 140 (MAP < 90)
Transfuse PRBC1. Arterial Line Placement (preferred) 2. Dobutamine 2.5-20 mcg/kg/min (if HR < 100 and SBP > 100) 3. Dopamine 5-10 mcg/kg/min
Intubation and Mechanical
Ventilation with Lung Protective
Strategies
Hgb
Consider Digoxin 0.25 0.5 mg IV
Consider Drotrecogin alfa activated
24 mcg/kg/hr x 96 hr
Two or more of the following:1) Temp > 38.3C(100.9F) or < 36.0C(96.8F) 2) Heart Rate > 90 3) Resp Rate > 20 or PaCO2 < 32 mmHg 4) WBC > 12K, < 4K or > 10% Bands
Initiate Broad Spectrum Antibiotics
SBP < 90 (MAP < 65)
Re-Assess Re-Assess
Antibiotics and Re-Assess
Re-check Lactate
APACHE II > 25
Obtain Appropriate Cultures
Check Lactate
Initiate CVP/ScvO2 Monitoring within 2 hours Give Broad Spectrum Antibiotics within 4 hours Achieve Hemodynamic Goals within 6 hours
o CVP > 8 mmHg o MAP > 65 mmHg / SBP > 90 mmHg o ScvO2 > 70%
Monitor for Decreasing Lactate Give Steroid if on Vasopressor or suspect Adrenal
Insufficiency
6-Hour STOP Sepsis Bundle Goals for Severe Sepsis or Septic Shock
Disclaimer (v9.1) This is a clinical template and clinician should use judgment for
individual patient encounters. Loma Linda University Copyright 2005
ACTH
Stimulation
Start/Continue dexamethasone
No steroid or discontinue
steroid
Discontinue Steroid Therapy
Change dexamethasone to hydrocortisone and
fludrocortisone, continue for 7 days
Glucose > 150 mg/dL
ICU Insulin Infusion Guidelines to
target glucose < 150 mg/dL
Sedation/ Analgesia
Titrate to Modified Ramsey Sedation Scale & Pain Scale
pPlat < 30 cm H2O
Refer to Lung Protective Strategy protocol Decrease tidal volume to 4-8 mL/kg Maintain pH >7.20
Nutrition Nutrition consult within 24 hrs of admission
Attempt to wean off ventilator Titrate vasopressor PT/OT Follow-up on cultures and imaging studies
After 96 hours, reassess patient for continuedaggressive support
Adrenal Insufficiency
Off pressor
On pressor
Drotrecogin alfa activated 24 mcg/kg/hr x 96 hrs
Discontinue if serious bleeding (>2 Units PRBC in 48 hrs)Activated Protein C
APACHE II > 25
APACHE II < 25 Reassess q 24 hrs
Stress Ulcer/ DVT Prophylaxis
H2 Blocker / PPI
Heparin SQ / SCD
24 hr goals achieved?
Yes
No
Antimicrobial Therapy
Reassess antimicrobial therapy q 12 hrs based on culture & sensitivity results
Cortisol > 9 mcg/dL
Blood Glucose Control
Cortisol < 9 mcg/dl
Continue 6-hour goals while achieving 24-hour goals
Initiate steroids for catecholamine resistance/adrenal insufficiency
Initiate drotrecogin alfa activated if APACHE II >25 Maintain blood glucose control < 150 mg/dL Achieve plateau pressure 8 mmHg o MAP > 65 mmHg / SBP > 90 mmHg o SvO2/ScvO2 > 70% on FiO2 < 0.5
24-Hour STOP Sepsis Bundle Goals for Severe Sepsis or Septic Shock
Strategies to Obviate the Progression of Sepsis Loma Linda University
Sepsis has recently received renewed interest, beginning with a revised international definition. Therapies that significantly decrease sepsis mortality include: early antibiotics, early goal-directed therapy, corticosteroid, recombinant human activated protein C, lung protective strategies, and tight glucose control. These advances have resulted in a management guidelines from the international Surviving Sepsis Campaign. In implementing the new guidelines, the Institute for Healthcare Improvement recommends the development of sepsis change bundles. These bundles include a group of interventions that must be given to patients with severe sepsis as they present and are admitted to the hospital. These efforts are endorsed by 11 international medical societies with the goal of decreasing sepsis mortality by 25 percent. Levy MM, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International sepsis definitions conference. Crit Care Med 2003;31:1250-1256. Dellinger RP, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-73.
Diagnostic criteria for sepsis Infection, documented or suspected, and some of the following: General variables
Fever (core temperature >38.3C) Hypothermia (core temperature 90/min or
>2 SD above the normal value for age Tachypnea Altered mental status Significant edema or positive fluid balance
(>20 mL/kg over 24 hrs) Hyperglycemia
plasma glucose >120 mg/dL in the absence of diabetes
Inflammatory variables Leukocytosis (WBC count >12,000/L) Leukopenia (WBC count 10% bands Plasma C-reactive protein >2 SD above normal Plasma procalcitonin >2 SD above normal
Hemodynamic variables Arterial hypotension
SBP 85% or 3.5 L/min
Organ dysfunction variables Arterial hypoxemia (PaO2/FIO2 1.5 or aPTT >60 secs) Ileus (absent bowel sounds) Thrombocytopenia (platelet count 4 mg/dL)
Tissue perfusion variables Hyperlactatemia (>2 mmol/L) Decreased capillary refill or mottling
PiCCO
Extravascular Lung Water Index
ELWI
3~7 ml/kg
ELWI>10,(ALI)ARDS
EVLW ALIARDS
X ABG
EVLW
Lung
Pulmonary Vascular Permeability Index
PVPI
1~3
PVP
PVPI=EVLW/PBV PVPI EVLW Hydrostatic Lung edema PVPI EVLW Permeability Lung edema
Global Enddiastolic Volume Index
GEDI
680~800 ml/m2
GEDI Preload
CVP PreloadPAOP PreloadPreload(Volume).
Intrathoracic Blood Volume Index
ITBI
850~1000
ml/m2
ITBI
/ Preload ,: N/S,
HAES, Plasma
Preload Volume
Stroke Volume Variation
SVV 10%
ITBI
Cardiac Index Pulse Contour Cardiac Index
CI
PCCI
3~5.5 l/min/m2
CCO(
)
, CO 3.8%(Paper )
Afterload
Systemic Vascular Resistance Index
SVRI
1700~2400 dys*s*cm*m2
SVR=(MAP-CVP/C.O.)
Global Ejection Fraction
GEF
25~35%
GEF=4*SV/GEDV Contractility
Cardiac Function Index
CFI
4.5~6.5 l/min
CFI=CI/GEDI
Normal rangesParameter Range UnitParameter Range Unit
CI 3.0 5.0 l/min/m2
SVI 40 60 ml/m2SVRI 1200 1800 dyn*s*cm-5*mMAP 70 90 mmHgGEF 25 35 %CFI 4.5 6.5 1/minHR 60 90 1/minGEDVI 680 800 ml/m2
ITBVI 850 1000 ml/m2
SVV 10 %EVLWI 3.0 7.0 ml/kgPVPI 1.0 3.0
Decision tree for hemodynamic / volumetric monitoring
CI (l/min/m2) >3.0850850
10
4.5
750 850
>5.5
4.5
750 850
>5.5