Critical Care Review: Pre-ICU Management for the Internist

CSIM November 1, 2017

Natalie Wong MD FRCPC Shelly Dev MD FRCPC Critical Care and Internal Medicine Critical Care Medicine Sunnybrook Health Sciences St. Michael’s Hospital Centre Toronto Toronto Major Objectives for Part I and II

At the end of this session learners will be able to: Describe the key steps in management of the septic patient Discuss management strategies for acute respiratory failure Appreciate the burden of illness of critically ill patients after discharge from the ICU Disclosures

• Nothing to disclose PART I The Medical Consult: Mr. R

“He’s starting to become more unstable.” Mr. R

• 50M not feeling well for 2 days • Short of breath, non-productive cough • No chest pain

• PMHx: None • Social Hx: No recent travel Mr. R

Vital Signs • Temperature 38.0oC • Heart rate 128 • Blood pressure 100/58 • Respiratory rate 36 • Oxygen saturation is 90% on room air Mr. R

Clinical Findings: • Can’t complete sentences easily • Diaphoretic • Confused about time and place • Chest is “crackly and wheezy” Is This Sepsis?

MORTALITY UP TO 40%

qSOFA

Altered LOC GCS < 13 Tachycardia Confusion Hypotension SBP < 100 Tachypnea, Vasodilation RR > 22 SaO2 <90% PaO2/FiO2 ≤300 SOFA

Altered LOC GCS < 13 Tachycardia Confusion Hypotension MAP < 70 Vasodilation Tachypnea SaO <90% 2 ↓ Urine output PaO /FiO ≤300 2 2 ↑ Creatinine > 110 Bilirubin > 20 ↑ Enzymes ↓ Albumin ↓ Platelets < Ileus 150 ↑ PT/APTT ↓ Protein C ↑ D-dimer  Blood cultures Additional Tests  Lactate  VBG  Urinalysis  CXR  CK/Troponin Altered LOC GCS < 13 Tachycardia Confusion Hypotension MAP < 70 Vasodilation Tachypnea SaO <90% 2 ↓ Urine output PaO /FiO ≤300 2 2 ↑ Creatinine > 110 Bilirubin > 20 ↑ Enzymes ↓ Albumin ↓ Platelets < Ileus 150 ↑ PT/APTT ↓ Protein C ↑ D-dimer Mr. R

Vital Signs • Temperature 38.0oC • Heart rate 128 • Blood pressure 100/58 • Respiratory rate 36 • Oxygen saturation is 90% on room air • Confused “What Should We Do Now?” Fluids “How Much Fluid Should We Give?” (2015 Revisions)

(2015 Revisions) Cell Interstitium Blood

LUNGS ABDOMEN

AFTER EVERY BOLUS

REASSESS!: Targets: Lactate, MAP trend, urine output, neuro status Passive leg raise! (Yes, really!) ⇢ ⇢ Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) ⇢ Appearance overall AFTER EVERY BOLUS

Why is the LACTATE still high?

Organ failure?

It’s Just Not Going to Get Better Antibiotics

Blood cultures! Remove Tubes & Roll your patient Urinalysis! over! Lines!

Back to the History!

CXR ?Other Imaging? A positive urinalysis isn’t always urosepsis, smartypants. …and don’t relax just because the chest x-ray looks fine, either. Antibiotics Is there a risk for MDR bugs? • Immunosuppressed • Recent abx • Recent hospitalization/institutionalization • Lines (including IVDU)

If “Yes”: Meropenem/Pip-Tazo +/- Vancomycin If “No”: Ceftriaxone +/- Azithromycin (+/- Vancomycin) ⇢ • IN-Hospital: Gram-positives > Gram-negatives > mixed/fungal ⇢ Antibiotics Is there a risk for MDR bugs? • Immunosuppressed • Recent abx • Recent hospitalization/institutionalization • Lines (including IVDU)

If “Yes”: Meropenem/Pip-Tazo +/- Vancomycin If “No”: Ceftriaxone +/- Azithromycin (+/- Vancomycin) ⇢ ⇢ • Gram-positives > Gram-negatives > mixed/fungal If the WBC > 30 and the risks are right…

THINK C.DIFF! Ceftriaxone and Azithromycin for presumed community- acquired pneumonia Blood

Cut off is Hb 70 unless: • Active bleeding • Acute coronary syndrome Persistent Badness “I’ve given him 3L of fluid and the systolic pressure is still only 75…” Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance

Stroke Volume x Heart Rate

Preload Contractility [Afterload] What’s happening here? Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance

Stroke Volume x Heart Rate Dehydration Insensible Losses Bleeding

Volume Responsive Preload Contractility [Afterload] Limited Volume Response Obstructive Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance

Stroke Volume x Heart Rate

Preload Contractility [Afterload] Mean Arterial Pressure = Cardiac Output x Systemic Vascular Resistance

Stroke Volume x Heart Rate

Distributive Shock Sepsis Preload Contractility Anaphylaxis [Afterload] Neurogenic Steroid Insufficiency Liver failure FLOW

We Still Have Persistent Badness “I’ve given him 3L of fluid and the systolic pressure is still only 75…” FLOW Think about pressors after 2-3L but be prepared to see raised eyebrows…! AFTER THE BOLUSES

REASSESS: Targets: Lactate, MAP trend, urine output, neuro status Passive leg raise! (Yes, really!) ⇢ ⇢ Tissues: Lungs (O2 requirements increasing?) Abdomen (tense?) ⇢ Appearance overall IV Access

“He has an iv but doesn’t have a central line? Should we order a PICC?” Where is the BEST Site for the Line? Another Problem

“We’re increasing the norepinephrine and the blood pressure is only 85/50.” • Source? • Shock? • Vasopressor? Key Concepts