2/19/14
Medicine In-Service Topics
General:
Honk
Fluids in ARDS
ARDS – vent settings, manage vent, gas exchange. (6)
TRALI
Hemoptysis – positioning
Pulmonary shunt as cause of hypoxemia – causes of hypoxemia
HIT
Cause of Resp failure
PE with shock
Ventilator:
Treat hypercapneic resp failure, vent settings (2)
Complications of vent
Indications for NIPPV (2)
Intrinsic PEEP management (3)
Hypoxemia management
CHF on vent
Pain on vent
The happy smoker
66 yo WM chronic pain, smoker, CHF,
brought to ED with SOB. Recent URI, thin,
scattered wheezes and crackles on exam.
7.26/55/75
BNP 1200
HCT 30
Platelet 220,000
What do you do?
Admit to MICU
Bipap?
 Nebs, Steroids, Antiobiotics
 Lasix?
 DVT prophylaxis
 GI prophylaxis – NO!

MICU
Why non-invasive positive pressure
ventilation (NIPPV)?
 What are indications for NIPPV?

1. Obstructive lung disease
• Asthma, COPD, etc
2. Acute congestive heart
failure
3. OHS
4. Immunocompromised with
infiltrates
Now what?
Diuresed 3 Liters
Creatinine 1.2
BP 100/60, HR 70
7.16/70/70
HCT 25
MICU
Intubate – Dr. Garriga goosed 3 times.
 Dr. Steele pushed him aside.

 Grade I view, chip shot.
Vent Settings:
Volume control
Vt 500cc
Rate 15
FiO2 100%
PEEP 5
BP 85/40
HR 120
RR 25
7.24/60/60
Now what?
MICU

Create a problem list, ddx and gather
information
1. Respiratory acidosis – on vent in COPD?
2. Tachypnea on vent – pain, dyspnea?
3. Hypotension – shock, hypovolemia, intrinsic PEEP?
Gather information and treat
1. Look at vent settings
2. Empirically treat pain
3. IVF for hypotension
Ventilator Management
Volume Control: Peak and Plateau Pressure

Peak: Distention
pressure in lungs as
tidal volume is being
delivered (flow-related
pressure)
Plateau: Distention
pressure in lungs after
volume delivered
before expiration
(static pressure)
PEAK
Pressure

PLATEAU
Time
Ventilator Management –
obstructive lung disease
Treatment plan for obstructive lung disease:
1. High intrinsic PEEP?
2. Unhook ventilator?
3. Slow respiratory rate?
4. IVF for hypotension related to poor filling pressures
in setting of high intra-thoracic pressure?
Pain Management in ICU
45% with no provider perceived reason for
pain actually have pain

Pain, Agitation, Delirium Bundle
 1. Pain control – fentanyl, morphine, oral
 2. Agitation – propofol, dexmedetomidine,
intermittent benzodiazepines
Payen, JF. DOLOREA Investigators. Anesthesiology 2007; 106:687–95
Chanques,G. Anesthesiology. 2007;107:858–860
Crit Care Med. 2013 Jan;41(1):263-306
MICU

You get through the night….
Then am labs:
7.35/48/85
HCT 25, Platelet 85
Creatinine 1.5mg/dL
MICU

Thrombocytopenia in the ICU
 DDX?
Decreased Production:
- Primary Marrow failure
- Secondary Marrow failure
- Malnutrition, sepsis, PCN,
Ceph,vanc, H2 blockers,
chemotherapy
Gets through the night stable, but agitated.
AM labs:
7.36/45/80
HCT 18
PLT 75
Increased Destruction:
- TTP, DIC, Liver/Spleen
- Drugs
- Intravascular devices
Immune:
- Drugs induce immune
destruction – vancomycin
- HIT (4T’s, Serotonin
Release assay, anti-PF4 ab)
Chest. 2011;139(2):271-278.
Crit Care Clinics 2012;28(3):399-41
MICU

Give 2 uts PRBC’s – why 2?
 Start PPI – you forgot to put him on GI prophylaxis 
PRBC infusion finishes.
More tachypneic, more agitated, T 102.1, Sp02 84%
DDX:
Pulmonary edema s/p PRBC
infusion – systolic CHF exacerbation
TRALI
VAP
ARDS
JAMA. 2002 Sep 25;288(12):1499-507
Elevated Peak/Plateau Pressures
Pressure
Decreased Compliance of Whole
System
Alveolar Filling
ARDS
Pulmonary Edema
Pneumonia
Right Mainstem Intubation
Pneumothorax
Time
Hypoxemia
A
A-a gradient =(PA02-Pa02)
[150 – 1.25(PaCO2)] – pa02
Normal ≤ Age/4 + 4
a
Normal A-a gradient
Abnormal A-a gradient
1. Hypoventilation
- Opiates, drugs,
CVA, OHS
1. Shunt
2. Low fi02 (high altitude)
2. V/Q Mismatch
- Alveolar filling (blood,
pus, water)
- Difficult to correct with
supplemental O2
- PE, COPD
3. Diffusion limitation (rare, low yield)
-Elite Exercise
PAO2 = [(Patm – PH2O) x FiO2] – [PaCO2/RQ]
MICU

Treatment Plan:
 TRALI
○ Timing, supporting, low WBC
 CHF
○ Vent – diuresis
 VAP
○ Antibiotics – which ones? How long?
 ARDS vent management
○ FACTT (Fluids and Catheters Treatment Trial) –
match I/O’s vs liberal ~7L +
ARDS

Definition
1. Acute
2. Bilateral infiltrates
3. Pa02/Fi02 <200**
4. PCWP <18mmHg – or no
clinical reason for elevated
LVEDP
DDX - congestive heart failure, pneumonia, organizing pneumonia,
eosinophilic pneumonia, high altitude, sickle cell disease, vasculitis, TRALI,
etc….
**Berlin Definition of ARDS – 2012 – unsure if will be on boards
mild P/F <300 (25% mortality), moderate P/F <200 (32%
mortality), severe P/F <100 (45% mortality)
JAMA 2012 Jun 20;307(23):2526-33
Pa02/Fi02 < 200 (or 300)
Causes of ARDS/ALI
1.
2.
Pneumonia
Sepsis – any source
***Especially alcoholics
3.
4.
5.
Aspiration
Transfusion (TRALI) –
Fresh frozen plasma
6. Pancreatitis
is most common
7. Trauma – Especially
Pulmonary embolus
Thoracic
Anything that can cause systemic or pulmonary
inflammation!
ARDSnet
Low Vt (tidal volume) ventilation – 6cc/kg
 Plateau Pressure >30cm H20
 pH >7.3 – permissive hypercapnea
 Higher PEEP, lower Fi02
 Pa02 >55 mmHg
 Minimize fluids beyond normal losses (conservative strategy)

This strategy decreases mortality from 39% to 31% (P<.007).
Salvage ventilatory modes – none improve mortality.
1. Extracorporeal Membrane Oxygenation – CESAR Trial
2. High Frequency Oscillatory Ventilation – 300 breaths per minute
3. Nitric Oxide – inhaled to dilate vessels through ventilated alveoli
4. Prone ventilation – put patient on stomach, recruits lung bases
New England Journal of Medicine 2000; 342:1301-08
ARDSnet
ARDSnet
ARDSnet
Do not
memorize
this chart!!!
Know to
implement its
high
PEEP/low
Fi02 strategy.
ARDSnet
ARDSnet
The end
He was extubated on day 12.
 Called the house team at 0829.


The patient stays in ICU for 6 days
waiting on a bed.
Medicine In-Service Topics
General:
Honk
Fluids in ARDS
ARDS – vent settings, manage vent, gas exchange. (6)
TRALI
Hemoptysis – positioning
Pulmonary shunt as cause of hypoxemia – causes of hypoxemia
HIT
Cause of Resp failure
PE with shock
Ventilator:
Treat hypercapneic resp failure, vent settings (2)
Complications of vent
Indications for NIPPV (2)
Intrinsic PEEP management (3)
Hypoxemia management
CHF on vent
Pain on vent