Dr. Ed Martinez(Intensivist wanna be)
Our patientsIn ICU almost all of our patients are very sick
Very old Multiple co morbiditiesMultiple injuriesSusceptible to multiple complicationsHaven’t looked after themselves
The CICM says that:• “Intensive care specialists require an extensive
knowledge of medical and surgical conditions and mastery of practical skills. The intensive care specialist anticipates clinical problems, is able to assess and define clinical problems in the critically ill in the broader context and can develop and facilitate a diagnostic and management plan, which has the highest probability of a satisfactory outcome.”
• Objectives of advanced training and competencies. College of intensive care medicine of Australia and New Zealand.
The Approach to Acute Illness• Immediate assessment and therapy
(resuscitation)– Prioritize:
• who to admit and not admit• Resuscitate vs. Diagnose• Obtain relevant information• Recognize and respond rapidly to adverse events
The Approach to Acute IllnessAssessment
Obtain and record relevant info from patient, relatives, others
Recognise and diagnose system failure or diseases
Order appropriate investigations
Approach to Acute IllnessProblem Definition
Create a list of DDx.You might need to confirm or refute some of
these before your data gathering is completeDeal with ambiguityMake contingency plans
Approach to Acute IllnessMake a Plan
Choose the best course of action considering risk vs. Benefit
ICU requires multidisciplinary input and decide who else needs to be involved
Plan counter measuresDefine the circumstances where supportive
therapy should be limited or discontinued
Approach to Acute IllnessProgress
Use clinical and physiological markers to assess severity and likely outcome
Know that sudden gross changes in certain parameters are life threatening
Develop criteria for discharge
A Structured Approach• Make a List of DDx• Look for clues• Confirm your suspicions• Make a plan
– Immediate: resuscitate– Short term: therapy, who else needs to be
involved– Long term: where is this patient going to go
after ICU
So now...1. Common problems in ICU2. How to tackle them when we first encounter
them
The Shocked Patient
The Shocked PatientShock:
Clinical state that occurs when an imbalance of oxygen supply and demand results in the development of tissue hypoxia
The Shocked Patient• Physiologically
– Hypoxic– Anaemic– Stagnant– histotoxic
• Clinically– Cardiogenic -Septic – Obstructive -Neurogenic– Hypovolaemic -Anaphylactic
The Shocked PatientCommon scenarios in ICU
Sepsis: as a primary cause of admission or as a consequence of nosocomial infections
Trauma with ongoing blood lossCardiogenic shock in association with APO
The Shocked PatientLook for clues
Are they bleeding?What is their MAP and pulse pressure?HR and rhythm: SR vs. AF?CVP: high or low?Sats: is there an adequate trace?What is their U/O?
The Shocked PatientLook for clues
Hypovolaemic shock Fluid balance Actively bleeding? Check for haemothorax and distended abdomen Any other major fluid losses (eg. Intra-abdo in
pancreatitis)
The Shocked PatientLook for clues
Obstructive shock Tension pneumothorax? ICCs blocked? Cardiac tamponade PE? Signs of DVTs?
The Shocked PatientLook for clues
Distributive Shock Septic? Febrile, warm, vasodilated? Meningococcal rash, neck stiffness? Neurological shock due to spinal injury? Anaphylaxis or Addisonian crisis?
The Shocked PatientLook for clues
Cardiogenic shock HR Rhythm Preload Pump function After load
The Shocked PatientConfirm your diagnosis
CXRECGEchoABGs and lactateFBCs, EUCsTroponin
The Shocked PatientMake a plan
Immediate Resuscitate with IVF. How much? Which type? Inotropes, vasopressors or both? Transfuse. RPC, FFP, Platelets? Steroids? Do we need to plumb this patient? When is a good
time to that?
The Shocked Patient• Make a plan
– Short term• OT to control bleeding, source control?
– Involve Anes. and Sx.• ATBs? Which ones?
– Involve ID• Ongoing transfusion due to coagulopathy?
– Involve Haematology• Do they need to go to angio suite?
– Involve the cardiologist.
The Shocked PatientEvidence for what we do
Surviving Sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004: 32: 858-873 Recommendations with the intention of improving
outcome, some of the conclusions are still being debated
The Shocked PatientEvidence for what we do
A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Eng J Med 2004; 350: 2247-2256 Multicenter RCT w/ 6997 pts. No difference in 28-
day mortality, no difference in how they did overall. Subgroup analysis did show a trend to reduced mortality w/albumin in septic shock and increased mortality in trauma patients, especially those w/ TBI.
So, lets try and use crystalloids because it’s cheaper.
The Shocked PatientEvidence
Early revascularization in acute myocardial infarction complicated by cardiogenic shock. N Eng J Med 1999; 341:625-634 Cardiogenic shock complicates 10% of AMI and is
associated with 80% mortality. RCT w/302 pts. Who underwent revascularization
(PCI or CABG) or medical management; 80% in both groups got IABPs
No difference in 30 day mortality but at 6mo. Pts. Who got revasc. Had a survival advantage
The Shocked PatientEvidence
Vasopressor use in septic shock: an update. Current Opinion in Anaesthesiology. 2008; 21: 141-7
Catecholamines for shock: the quest for high-quality evidence. Crit Care Resusc. 2007 Dec; 9(4): 352-6 Both says there’s no clear evidence of which is
better or worse
The Anuric Patient
The Anuric PatientAcute renal failure:
rapid decrease in the kidney’s ability to eliminate waste products.
Clinical classification:PrerenalParenchymalPostrenal
The Anuric Patient
The Anuric PatientCommon scenarios in ICU
ARF related to Shock MOF Rhabdomyolysis Hepatorenal failure Nephrotoxic drugs or contrast agents Ruptured AAA
The Anuric PatientLook for clues from the history
Is this acute, acute on chronic or chronic ?Is there a pre-renal cause?Is there raised intra-abdo pressure?Is there a renal cause? Have nephrotoxins or
contrasts been given? Is there a vasculitis?Is there a post-renal cause? Is the IDC
blocked? Has the patient had pelvic Sx?
The Anuric PatientLook for clues from the examination
Compartment syndromes: tense limbs, buttocks, abdo
Abdo scar from major vascular or abdo surgerySigns of chronic liver diseaseSigns suggesting diabetes: scarred fingertips,
abdo fat atrophy or hypertrophy from insulin injections
The Anuric PatientConfirm your suspicions
EUC, CMP, LFTsUrine dipstick and microscopy: leukocytes and
nitrites as indices of infection, blood reflecting urinary tract trauma, haemoglobin or myoglobinuria
Check serum and urinary electrolytes: help differentiate pre-renal from renal causes
ABGs: look for metabolic and electrolyte derrangements
The Anuric Patient
The Anuric Patient
The Anuric PatientMake a Plan
To treat ARF we need to: 1) reverse its cause 2) maintain homeostasis while recovery occurs
Immediate: do we need to resuscitate this patient? Are they hyperkalaemic to the point they could die?
The Anuric PatientMake a plan
Short term: Nutritional support Metabolic acidosis Anaemia Adjust drug doses Lasix if they still making urine to avoid fluid
overload Vascath and CRRT
The Anuric PatientMake a plan
Short term:Indications for CRRT
Oliguria: U/O<200ml/12hrs Anuria: U/O 0-50ml/12hrs Ur.>35mmol/L Cr.>400mmol/L K+>6.5mmol/L or rapidly rising APO unresponsive to diuretics
The Anuric PatientMake a plan
Short term:Indications for CRRT
Uncompensated met. Acidosis pH<7.1 Na+ <110mmol/L or >160mmol/L Temp. >40 Uraemic complications: encephalopathy, myopathy,
neuropathy, pericarditis Overdose w/dialysable toxin: eg. Lithium
The Anuric PatientMake a plan
Long term Involve the renal or urology team Will this patient need dialysis long term? Will they need a fistula?
The Anuric PatientEvidence for what we do
Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ. 2006 Aug 26: 333 (7565): 420 Meta-analysis of 9 RCT totalling 849 pts. to
investigate the potential beneficial and adverse effects of frusemide to prevent and treat acute renal failure in adults
Found that frusemide is not associated with any significant clinical benefits in the prevention or treatment of adults, but, high doses can cause ototoxicity
The Anuric PatientEvidence
CVVHDF vs. IHD for acute renal failure in patients with multiple organ dysfunction: a multicenter randomized trial. Lancet 2006; 368: 379-385 Prospective randomized study w/360 pts. w/ARF
due to MODS. No difference in 60 day mortality with same
efficacy, no difference in duration of renal support No more hypotension with IHD, CVVHDF caused
more hypothermia
The Patient with a Head Injury
The Patient with a Head InjuryPrimary Brain Injury
Severity determined by degree of neuronal damage Determines outcome
Include all types of injury to brain parenchyma and vasculature
Adverse outcomes include: Traumatic SAH Non-evacuable mass lesions
The Patient with a Head InjurySecondary brain injury
Reduction in cerebral substrate utilization, mostly oxygen Systemic:
Hypoxia, hypotension, hypocapnia, hyperthermia, hypoglycaemia are the worst
Also: hyperglycaemia, hyper and hyponatraemia, hyperosmolality, infections
Intracranial: Seizures, delayed haematoma, SAH, vasospasm,
hydrocephalus, neuroinfection
The Patient with a Head InjuryDDX
Is this an isolated injury or not?Was this patient intoxicated?Is this patient not waking up after trauma to
another part of the body? (eg. Fat embolus)What other factors will influence management?
(eg. Ortho Sx.)
The Patient with Head InjuryLook for clues
What type of sedation are they on? When was it stopped?
Any neuromuscular blockers given? When was the last dose?
Do they have an ICP monitor, will they need one?
What are their HR, BP, Sats, Temp?
The Patient with Head InjuryLook for clues
Head woundsStigmata of base of skull fracture:
haemotympanum, CSF from ears or nose, Battle’s sign, racoon eys
Assess GCS: use bilat. Central and peripheral painful stimuli
Check pupils: size, shape, symmetry, light response, think of traumatic midriasis
The Patient with Head InjuryConfirm your suspicions
X-rays: chest, pelvis, C-spineCT head: if there was LOC, combative with
EtOH, drugs, extracranial injuriesCerebral angiography: when vascular injury is
suspectedMRI: better used as prognostic tool
The Patient with Head InjuryMake a plan
Immediate: in ED Immobilize Decide whether we need to intubate
Severe TBI=GCS<9 Rapidly declining LOC Altered LOC and “uncooperative”
The Patient with Head InjuryMake a plan
Immediate: in ED After intubated
PO2>100mmHg PCO2 36-40mmHg Hb =100g/L MAP>90 Mannitol if: dilated pupil, deteriorating LOC
The Patient with Head Injury Make a plan
Immediate: in ED Indications for ICP monitoring
GCS<9 and abnormal CT GCS<9 and normal CT and 2 of:
Age >40 Significant hypotension Motor posturing
GCS>8 and Severe extracranial injuries and neuro assessment
will be difficult due to prolonged anaesthesia and sedation
The Head injury PatientMake a plan
Short term Will they need to go to OT?
Involve NeuroSx, anaes Follow BTF guidelines to prevent secondary injury
Homeostasis is the name of the game Control intracranial hypertension
The Patient with Head InjuryMake a plan
Long term When will we wake them up? Will they need a trachie? How are we going to prevent complications Is rehab going to be needed?
Involve rehab physicians
The Patient with Head InjuryEvidence for what we do
Brain Trauma Foundation guidelines. Management and prognosis of severe traumatic brain injury. www.braintrauma.org Consensus guidelines from experts, based on
evidence, provide protocols that may improve outcomes.
Initially published in 1995 and revised in 2005: key change was loweriing of CPP from 70 to 60mmHg due to probable assoc. With ARDS
The Patient with Head InjuryEvidence
Lack of effect of induction of hypothermiaafter acute brain injury. N Eng J Med 2001; 344: 556-563. Cooling them doesn’t work, although ICP were
lower in hypothermia
The Patient with Head InjuryEvidence
Effect of intravenous corticosteroids on death within 14 days in10,008 adults with clinically significant head injury. (MRC CRASH trial): randomised placebo-controlled trial. Lancet 2004; 364: 1321-1328 Methylpred. Vs. Placebo Increased risk of death from all causes in those who
got steroids Mechanism of harm is unclear
So...Lots to learnIts better to be systematicCome up with your own system and run with
it!
Thank you!