mechanical ventilation in patients with sepsis Armin Kalenka, MD, Ph.D. head of anaesthesia/intensive care med [email protected] 2 conflict of interest consultant, travel expenses, lecture fees 3 What is your focus for a patient on the ventilator? • Oxygenation • CO2 Elimination • Lung protection 4 Best practice in mechanical ventilation? • VT: 6 ml/kg pbw for all patients? • NEJM 2000 • PEEP: ARDS network table based on Oxygenation? • NEJM 2000 or NEJM 2004 • High PEEP: for severe ARDS • JAMA 2010 • Prone: for severe ARDS • NEJM 2013 • NMB: for severe ARDS • NEJM 2010 • No NIV for severe ARDS • AJRCCM 2017 5 6 ARDS and Sepsis ARDS Sepsis 7 ARDS and Sepsis Sepsis ARDS 8 ARDS and Sepsis ARDS Sepsis 9 How often is ARDS in severe sepsis? Shock; 2013:40: 375-382 10 Fluids, Sepsis and ARDS LIPS: adult patients with one or more ARDS risk factors admitted to the hospital through the Emergency Department or admitted for high-risk elective surgery. Ann Intensive Care 2017; 7: 11 11 Best practice in mechanical ventilation? • VT: 6 ml/kg pbw for all patients? • NEJM 2000 • PEEP: ARDS network table based on Oxygenation? • NEJM 2000 or NEJM 2004 • High PEEP: for severe ARDS • JAMA 2010 • Prone: for severe ARDS • NEJM 2013 • NMB: for severe ARDS • NEJM 2010 • No NIV for severe ARDS • AJRCCM 2017 ? 12 Normalisation because of unknown size of the „baby“ lung the driving pressure: ΔP = VT/Comp 13 tidal volume should not longer be the target! 14 goal partial pressure of oxygen in arterial blood range of 55–80 mm Hg fiO2 of 0.5 = 0 increasing deaths with higher oxygenation in all groups of ARDS severity Crit Care Med 2017; DOI: 10.1097/CCM.0000000000002886 15 n = 861 Oxygenation should not be the 6 ml∙kg-1: n = 432 key parameter 12 ml∙kg-1: n = 429 for the ventilator settings ! Mortality [%] paO2/fiO2 190 50 * * * 40 180 30 170 20 160 10 150 0 0 6 ml∙kg-1 12 ml∙kg-1 1 2 7 days 16 alveolar stability is unrelated to arterial oxygenation Andrews et al. Intensive Care Medicine Experimental (2015) 3:16 17 Odds Ratio to hospital discharge rise in CO2 of 1 mmHg with a 3% increase in odds of survival Crit Care Med 2017; DOI: 10.1097/CCM.0000000000002918 18 19 The Rivers protocol 1. stratify according to severity 2. measure relevant parameter 3. individualize therapy 20 Niemann et al Intensive Care 21 Expr. 2017; 5:8 1. End-expiratory lung volume (EELV) at a given PEEP 2. Transpulmonary pressure gradient (Pplat - Poes/EI) - (PEEP - Peos/EE) Cortes and Marini Critical Care 2013, 17:219 22 23 baby lung size ≈ EELV Male 188 cm Male 188 cm 24 Why oxygenation is not a good target Kalenka et al, unpublished data 25 26 27 Tidal volume of 420 ml based on kg iBW at different FRC (EELV) 0,7 0,525 n i a 0,35 r t S 0,175 0 0 650 1300 1950 2600 3250 EELV dynamic strain = VT/EELV 28 dynamic strain = VT/EELV aim for dynamic strain < 0.25 29 Courtesy of Antonio Pesenti 30 31 32 Strain: „the driving pressure“ VT/EELV ≠ VT/ml/iKG Stress: PTP ≠ PAW Stress = k * Strain k = Specific Elastance (EL,s) = Stress/Strain Specific Elastance = 13 – 15 cmH2O 33 Individualized titration of PEEP and VT Ppulm. = Palv – Ppl ~ Poes 34 optimize PEEP and VT with measurement of esophageal pressure and transpulmonary pressure gradient 1. PEEP > endexspiratory esophageal pressure 2. VT max = transpulmonary pressure gradient < 10 (20) (Pplat - Poes/EI) - (PEEP - Peos/EE) 35 VT and PEEP ? male 172 cm 86 kg EF 20% respiratory distress high dose vasopressor fiO2 0.9 spO2 88 % 36 400/2000=0.2 400/1600=0.25 37 38 TPP = (35-26)-(20-18) = 9-2=7 39 SOP „Friday night“ Minerva Anestesiologica 2014; 80: 1046 40 BiLevel-VG decremental Moderate Recruitment PEEP InView Ann Emerg Med. 2017;70:406-418. 42 43 Résumé 44.