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Critical Care Update: Pressure. Michelle Harkins. Outline. Blood Pressure: Norepinephrine versus Dopamine Lung Pressure: ARDS ventilation Standard Protocols Perflurocarbons Prone positioning Jet Ventilation ECMO. Vasoactive Support of Shock.

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Critical Care Update: Pressure


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outline
Outline
  • Blood Pressure:
    • Norepinephrine versus Dopamine
  • Lung Pressure: ARDS ventilation
    • Standard Protocols
    • Perflurocarbons
    • Prone positioning
    • Jet Ventilation
    • ECMO
vasoactive support of shock
Vasoactive Support of Shock
  • Septic shock accounts for predominate ICU mortality
  • Fluid resuscitation and pressors main tx
  • Multiple choices: dopamine, dobutamine, epinephrine, norepinephrine, phenylephrine, vasopressin
  • Is there a preferred agent?
ne vs da
NE vs. DA
  • 1679 patients randomized from 12/03-10/07
    • Belgium, Spain, Austria
  • Endpoints: Death at 28 days
    • Number of days without need for organ support
    • Adverse events
  • DA associated with increased rate of death among cardiogenic shock patients (N=280)
  • DA associated with more arrhythmias
    • De Backer, et al; SOAP II investigators. Comparison of dopamine and norepinephrine in the treatment of shock. NEJM 2010 362: 779-89.
methods
Methods
  • Dose determined by patient’s body weight
  • Target BP determined by MD in charge for each individual patient
  • If patient was still hypotensive after max dose of either agent, open-label norepinephrine was added
    • Open-label dopamine was not allowed at any time
    • Epinephrine and vasopressin were used only as rescue therapy
    • Inotropic agents could be used prn to increase CO
conclusion
Conclusion
  • Equal mortality outcomes and less than half the incidence of arrhythmias put norepinephrine preferentially ahead of DA for treatment of shock.
  • Fluid resuscitation protocol limited
  • ? tachyarrhythmia as a mechanism for increased mortality in cardiogenic shock subgroup treated with DA, especially in first 4 days
slide13
Case
  • 50 yo female presents with altered mental status, hypotension and leg ulcers / cellulitis.
  • Goes to the OR for wet gangrene.
  • Treated for septic shock with fluids and pressors.
case cont d
Case (cont’d)
  • Develops progressive respiratory failure.
  • Intubated.
what is ards
What is ARDS
  • Acute Lung Injury
  • Acute onset
  • Bilateral infiltrates consistent with pulmonary edema
  • A ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) between 201 and 300 mmHg. (The PaO2 is measured in mmHg and the FiO2 is expressed as a decimal between 0.21 and 1.00.)
  • No clinical evidence for an elevated left atrial pressure. If measured, the pulmonary capillary wedge pressure is 18 mmHg or less.
  • ARDS : Above + P/F ratio <200
clinical manifestations
Clinical Manifestations
  • Usually present with progressive dyspnea, over a short time frame.
  • History more relevant to precipitant and ruling out other conditions than ARDS.
  • Exam: Tachypnea, cyanosis, use of accessory muscles, occasional crackles, absence of signs of heart failure.
  • Hypoxic respiratory failure
precipitants of ards
Precipitants of ARDS
  • Pulmonary
    • Pneumonia
    • Toxic Inhalation
    • Aspiration of Gastric acid
    • Negative Pressure Pulmonary Edema
  • Extra-Pulmonary
    • Sepsis
    • Pancreatitis
    • Burns / Trauma
    • TRALI
    • Medications …
    • Obstetric Catastrophies
    • Narcotic induced pulmonary edema
mortality and morbidity of ards
Mortality and Morbidity of ARDS
  • Case fatality rate has decreased over time
    • 1970s 90%, 1991 55%, 1997 35%
    • 2004-05 26%
    • factors increasing mortality: number of organs failing, severity of lung injury, nature of underlying disease
    • High cost to healthcare system
          • Erickson, et al Crit Care Med 2009 37:1574-79
outcomes among ards survivors
Outcomes among ARDS survivors

Herridge et al. NEJM 2003

standard treatment for ards
Standard Treatment for ARDS
  • Conventional mechanical ventilation
  • PEEP
  • Treating underlying cause, infection
  • Supportive care with nutrition, antibiotics, judicious fluid management
fluid and ards
Fluid and ARDS

ARDSnet NEJM 2006

alternate modes of mechanical ventilation
Alternate Modes of Mechanical Ventilation
  • Inverse Ratio Ventilation
    • Pressure Control
    • Volume Control
  • High Frequency Jet Ventilation
  • Low Frequency Ventilation
the baby lung and ventilator induced lung injury
The Baby Lung and Ventilator-Induced Lung Injury
  • Several animal models of ARDS demonstrated that high VT or shearing alveoli lead to increased ARDS and increased generation of pro-inflammatory mediators

Gattinoni, ICM 2005

baby lung or sponge lung
Baby Lung is not an anatomical unit, but a result of Lung Edema and compressive forces that are dependantBaby lung or Sponge Lung

Gattinoni, ICM 2005

low tidal volume
Low tidal volume
  • Amato 38 vs 71 %
  • 3 smaller studies 7 vs 10 ml/kg no difference

ARDSnet NEJM 2000

low vt protocol
Low Vt protocol

ARDSnet website

pressure volume curves
Pressure Volume Curves

Albaiceta GM et al. Current Opinion in Crtical Care 2008;14:80-86

slide29
PEEP
  • Initial high PEEP studies also had control and intervention groups with different Vt.
  • Alveoli study compared aggressive PEEP increase versus FiO2 increase.

ARDSnet NEJM 2004

recruitment maneuvers
Recruitment Maneuvers
  • Part of Alveoli trial, showed only modest, transient benefit and were dropped afterward.
  • More severe ARDS has more recruitable lung.

Gattinoni et al., NEJM 2006

prone positioning
Prone Positioning
  • In spite of large trials, no improvement in mortality is seen although proning does consistently cause improvements in oxygenation
high frequency oscillatory ventilation
Two trials of “jet” ventilation in ARDS. Derdak had a trend toward reduction in mortality. This was mitigated by the high Vt in the control group (8ml/kg)High Frequency Oscillatory Ventilation
other vent modalities
Other Vent Modalities
  • APRV – Poorly studied
  • Perflurocarbon – Partial liquid Ventilation (over 400 patients studied…no benefit)
  • Non- invasive: Poorly studied, no evidence of benefit.
ecmo for ards
ECMO for ARDS
  • Early study demonstrated no benefit in adults. (Zapol, JAMA 1979!).
  • 10% survival in each group
  • Many small series since then VV and VA. (Morris et al. 1994)
role of ecmo
Role of ECMO
  • No controlled studies in H1N1
    • JAMA 2009: Australia, NZ experience
    • Reported use in Michigan, Taiwan
    • UNM also
  • CESAR trial (Lancet 16 Sept 09)
    • RCT Conventional ventilatory support vs. ECMO
    • 180 patients and randomly assigned to consideration of ECMO (n=90) vs. conventional (n=90)
cesar
CESAR
  • Exclusion criteria: Pip > 30 or FiO2>80% for more than 7 days, ICH, heparin contraindication
  • Primary outcome = death or severe disability at 6 months
  • Power calculations were based on a 70% mortality in the conventional group
randomized to ecmo
Randomized to ECMO
  • Patients hemodynamically stable  put on standard ARDSnet-like protocol
    • Pplateau < 30, optimize peep to PaO2, diuresis to dry weight, Hct 40%, prone positioning, nutrition
  • If didn’t respond to above within 12 hours (FiO2> 90 still needed to obtain SaO2>90%), pH < 7.2 either respiratory or metabolic, or became hemodynamically unstable, then was put on ECMO
cesar1
CESAR
  • 90 patients considered for ECMO
    • 68 received ECMO
      • Other patients received ARDSnet-like protocol
    • 1 contraindication to heparin
    • 2 died during transfer
    • 3 died within 48hr of transfer
    • Overall 47 died
          • Peek et al, Efficacy and economic assessment of conventional ventilatory support vs ECMO for severe adult respiratory failure (CESAR). Lancet. September 2009
slide41

57 who received ECMO (63%) survived to 6 months without disability

    • vs. 47% (41/87) of those with conventional tx
ecmo is not the answer
ECMO is not THE answer
  • Very expensive treatment: longer stay, more expense
  • ECMO centers will have better outcomes: CESAR was a referral to ECMO centers in the UK
  • NM has the capacity to have 4 machines up and running at one time for Hanta, neonates and ARDS
other proven strategies
Other Proven Strategies
  • Sedation Vacation: Improves liberation from ventilator and mortality
  • Daily Weaning Trials: Decrease Ventilator days and improve mortality
  • Awake and Breath protocols also improve cognitive outcomes months later
        • Jackson, et. al. Am J Respir Crit Care Med 2010