Saturday January 28th
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Transcript of Saturday January 28th
A one day ‘basics’ of intensive care course
A Practical Introduction to Intensive Care
ICU Housekeeping
How did your 1st day on the ICU go?
Where do you start?
Does it matter?Topic Author Outcome Recommendation
Steroids in septic shock
Spring, 2008 No effect on 28d or 1 year mortalityFaster time to resoultion of shock
Steroids for those on CV support (inotropes/pressors) may reduce duration of support
Semi-recumbent positioning
Drakulovic, 1999 Reduced ventiator associated pneumonia
All mechanically ventilated patients should be 45 head up
Tight Glycaemic control
NICE-sugar investigators, 2009
Increased hypoglycaemia and mortality with tight control
Keep BM 4-10 but tight control (BM4.5-6) not recommended
Sedation holidays Kress, 2000 Reduced duration of mech ventilationReduced LOS on ICU
Daily sedation holds recommended
Topic Author Outcome Recommendations
Low tidal Volume ventilation(6mls/Kg v 12mls/Kg)
ARDSnet, 2000 Low VT associated with lower in-hospital mortality(NNT 11)
Aim for VT no greater than 6mls/Kg keeping Pplat<30 cmH2O
Transfusion Triggers Herbert, 1999 Restrictive v liberal(<7 vs <10)
Restrictive stratergy is probably better in non-cardiac patients
DVT prophylaxis(Enoxaparin 20/40mg)
Samama, 1999 Reduced DVT incidence
Prophylactic LMWH should be administered unless contraindicated
A Practical Solution …the Handover Sheet
Problem Lists: A Solution
Airway
Breathing (Ventilatory Mode)
PaO2:FiO2 Ratio
Positive End Expiratory Pressure
RR:TV Ratio
Peak Airway Pressure
Secretions
Chest X-Ray
Respiratory & Ventilation
P1: VAP? A1: Start Ceftazidime
Acute Lung Injury Acute Respiratory Distress Syndrome
ALI ARDS
<300 (mmHg) <200 (mmHg)
<40 (kPa) <27 (kPa)
P:F Ratios
PaO2 10 on 21%
≠
PaO2 10 on FiO2 100%
P:F = PaO2 / FiO2
Everything’s fine, doc
“Weanable” Not “Weanable”
RR/TV <80 RR/TV >100
Spontaneous Breathing Trial
Pressure Sup port Ventilation
RR/TV
Weaning
Cardiovascular
Rate and Rhythm
MAP
Inotrope / Vasopressor No. 1
Inotrope / Vasopressor No. 2
Steroids
Hb
Markers of PerfusionClinical – Warm Well PerfusedCentral Venous Oxygen SaturationLactateBase Deficit
Cardiovascular Numbers
MAP 65 mmHg is OK
0.5 mcg/kg/min (Adr / NAd) is A LOT
ScvO2 <70% is TOO LOW
Lactate >2 mmol/l is TOO HIGH
Base deficit < -2 is TOO MUCH
Steroids in Sepsis
ControversialPreviously shown to reduce mortality amongst
those unable to mount a steroid stress response (Synacthen)
CORTICUS study (2008): No effect on mortality but faster time to
resolution of shock (i.e. reduced inotrope/vasopressor duration).
Same for responders and non-responders thus synacthen test no longer indicated
Renal
Target Fluid Balance
Achieved Fluid Balance
Urine Output in 24hrs(= hourly urine output)
Oedema
BiochemistryNaKUreaCreatinineMagnesiumPhosphate
Fluid Balance
ControversialCrispy or Bloated?
Colloids for FillingCrystalloids for Maintenance
+500ml / day is normalAdd if febrile / diarrhoea
Subtract if oedema / bad lungs
Renal Numbers
Normal Mg2+ >0.8Give 10mmol over 1 hour
Normal PO43- > 0.8
<0.5 mmol / kg over 6 hours
Target Nutrition In
Achieved Nutrition In
Nutrition Out
Ulcer prophylaxis
BM - Glycaemia
Bilirubin
GI / Liver
Nutrition
Controversial
Starvation is bad (eventually)30ml/kg/day
TNIN ≠ ANIN?Metoclopramide
Gastric Protection
Controversial
Ranitidine / Sucralfate
Ventilator Associated Pneumonia
Glycaemic Control
NICE-SUGAR (2009)Tight (4.5-6 mmol/L) vs conventional
(4.5-10mmol/L) glycaemic control---------------------------------------------------Increased mortality and hypoglycaemic
episodes for tight control. Conventional range recommended
Bilirubin
Haemoglobin
Platelets
Clotting
DVT Prophylaxis
Haematology
Blood in Critical Care
Controversial
TRICC
Exceptions
DVT Prophylaxis
Don’t forget
Sedation Scores
Hypnotic DoseOpiate Dose
Sedation Holidays
CNS Intact?
PNS Intact?
Neuro & Sedation
Temperature
White Cell CountC-Reactive Protein
Organism Site of infection
Antibiotic 1 DayAntibiotic 2 Day
║(Lines ) Central Arterial Vascath
Micro & Sepsis