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