Younsuck Koh, MD, PhD, FCCMDept. of Pulmonary & CCM

Asan Medical Center, Univ. of UlsanSeoul, Korea

11th Congress of the TSMSICM

What to Consider during Organ Support?

Intensive Care

To save a life through the support of organ function

Issues in Organ Support1.Failed organ2.When to start, How, How much3.Safety & Cost4.Technology support5.Monitoring6.When to quit7.Chronically critically ill8.Essential measures in our daily

practice

Insult

Dysregulation bwt organs, immune, hormone, nerve

Genetics & Host factorsInitial Tx

Low Level Moderate Level

High Level

Virulence

DO2

VO2

How to be failed?

300-350 ml/min/m2

Normal: 0.5-1.5 mmol/LIf lactate > 4 mmol and pH is less than 7.30, consider tissue hypoxia

Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure

-100 consecutive high-risk surgical op. in 98 pts.- the tissue O2 deficit = the measured VO2 – the estimated VO2 requirement

Net cumulativeVO2 deficit

Shoemaker WC, et al. Crit Care Med 1988; 16:1117

Multiorgan Failure• The MOF in sepsis occurs due to a

substantial cumulative tissue oxygen debt, not always due to inadequate DO2.

The effects of vasodilation with prostacyclin on oxygen delivery and uptake in critically ill patients. N Engl J Med. 1987: 317(7):397-403.

Prostacyclin produced increase in oxygen delivery was associated with a significantly greater increase in oxygen uptake in the patients who died as compared with the survivors (median increase, 19 vs. 5 percent, P<0.001).

In the survivors, the oxygen extraction ratio fell (median change, -17 percent; range, -27 to -6 percent) and the mixed venous oxygen tension increased. In the patients who died, the extraction ratio rose (median change, 11 percent; range -24 to +40 percent) and the mixed venous oxygen tension did not change.

When to support?

Crit Care Med 2014. 42; 801-8

Preemptive management

Crit Care Med 2014. 42; 801-8

How Much?

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” Hippocrates (460?-377 BC)

Long Debate

DO2

VO2

New Critical point

Goal-Oriented Tx

Rivers E, et al. N Engl J Med 2001;345:1368-77

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock:

Achievement of target values

Another Goal-Directed Tx

49.2%

33.3%

0

10

20

30

40

50

60

Standard Therapy n=133

EGDTn=130

P = 0.01*

*Key difference was in sudden CV collapse, not MODS

28-day Mortality

Rivers E. N Engl J Med 2001;345:1368-77.

The ProCESS Investigators. NEJM 2014;370:1683-93

31 ER in USMR by 60 days: 18.2-21%

Do not harm

Do not harm is not easy…

DO2(ml/min) = CO x (1.39 x Hb x SaO2 + 0.0031 x PaO2)

RBC Transfusion

Euvolemic & critically ill.N Engl J Med 1999; 340: 409-417

Less is More

Early versus Late Parenteral Nutrition in Critically Ill Adults

Compared early initiation of PN (within 2 days) with late initiation (early enteral + initiated PN on day 8) in adults in the intensive care unit (ICU)

Patients in the late-initiation group had a relative increase of 6.3% in the likelihood of being discharged alive earlier from the ICU (hazard ratio, 1.06; 95% confidence interval [CI], 1.00 to 1.13; P=0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00 to 1.13; P=0.04), without evidence of decreased functional status at hospital discharge.

Casaer MP, et al. NEJM 2011;365:506-17

Side Effect

Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006 25;354(21):2213-24.

.. PAC-guided therapy did not improve survival or organ function but was associated with more complications than CVC-guided therapy.

White LE, at al. J Surg Res.2011; 167(2): 306–315.

Organ interaction

Organ interaction

Ischemic AKI induces pulmonary EC apoptosis in whole-lung tissue in rats.Micrographs (40x), ischemia-reperfusion injury stained with TUBEL (green)White LE, et al. Shock 2012;38:320-327

Target

0

20

40

60

80

100

120

1 2 3 4 5No. of acute organ failure

No. o

f pat

ient

s

0

50

100

Hosp

ital m

orta

lity(

%)

distribution Mortality

Place to PerformThe impact of intensive care unit admissions following early resuscitation on the outcome of patients with severe sepsis and septic shock.Surat T, Viarasilpa T, Permpikul C.J Med Assoc Thai. 2014 Jan;97 Suppl 1:S69-76.

..There were trends toward a lower 28 day mortality (18% vs. 25.6%, p = 0.33) among the patients in the ICU group.

Apart from the early goal-directed therapy, early ICU admission substantially improves the outcomes of septic shock patients.

• Vital signs: BT, PR, RR, BP• And..

How to Monitor

• General condition: cold & clammy skin, UO, mentality rapid shallow respiration

• Hemodynamic parameters• Respiratory parameters• Metabolic parameters

Monitoring tools

Pa(Sa)O2

NIRS

MAPSV, CO

Cap. Perfusion imaging

PExLactateMVO2

ScvO2

pHi

Choosing Monitoring Parameters

For resource limiting countries

Serum Lactate

Normal: 0.5-1.5 mmol/LIf lactate > 4 mmol and pH is less than 7.30, consider tissue hypoxia

Metabolic

Biomarker for the Prediction of All-Cause Mortality in Critically ill:A systemic review and meta-analysis

Zhang Z & Xu X. Crit Care Med 2014

Chronically Critically ILL

defined as those who survive initial life-threatening, possibly reversible organ failure(s) but are unable to recover rapidly to a point at which they are fully independent of life supportTheir mean lengths of stay in the ICU and in the hospital: 42.9+/-36.4 and 83.9+/-100.5 days ICU and six-month cumulative mortality rates: 42.6% and 75.9%

The SOFA score on day 21 and comorbidity in the ICU appears to be a valuable prognostic indicators in chronically critically ill patients.Lee K, et al. Anaesth Intensive Care. 2008;36(4):528-34

Resource use in the ICU: short- vs. long-term patients..In this university-based, medical-surgical adult ICU, 11% of all patients stayed more than 7 days in the unit and consumed more than 50% of all resources.

Stricker K, et al. Acta Anaesthesiol Scand. 2003;47:508-15.

When to Quit

The Frequency and Cost of Treatment Perceived to Be Futile in Critical CareHuynh TN, et al. JAMA Intern Med 2013;173:1887-94

Essential Measures to be Performed

1. Patients’ bed head elevation > 30°2. Stress ulcer prophylaxis 3. DVT prophylaxis 4. Low tidal volume ventilation 5. Early removal of central venous & Foley

catheter 6. Early enteral feeding

Independent predictors of mortality

Prompting Physicians to Address a Daily Checklist and Process of Care and Clinical Outcomes

Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13–0.96; P = 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P = 0.014). Weiss CH, et al. Am J Respir Crit Care Med. 2011; 184(6): 680–686

Conclusion• Stick to Basic Essential Measures.• The earlier, the better • Consider organ interactions when to resuscitate.• Frequently less is more.• Should stop non-responding measures.

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