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Early Recognition and Management of Sepsis and Ventilation Strategies in Critical Care

This article outlines the early recognition of sepsis using SIRS criteria, emphasizing the importance of lactate levels and cultures in diagnosing septic shock. It discusses Early Goal Directed Therapy (EGDT) protocols that significantly reduce mortality rates. The paper also explores mechanical ventilation strategies, including the use of low tidal volume ventilation for ARDS and readiness testing for weaning patients off mechanical ventilation. Key studies and trials are highlighted, providing a comprehensive overview of critical care management.

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Early Recognition and Management of Sepsis and Ventilation Strategies in Critical Care

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  1. ICU 101 a.k.a. “Papers You Should Know” Ashley Henderson, MD May 4, 2010

  2. New England Journal of Medicine 2001;345:1368-77

  3. Early Recognition • IF: suspected infection + SIRS criteria • Temp >38C or <36C • HR >90 • RR >20 or PaCO2 <32 • WBC>12, <4, or >10% bands • THEN: check lactate and obtain cultures • IF: lactate >4mMol or SBP <90 with 20ml/kg NS bolus and not cardiogenic • THEN: Patient meets criteria for septic shock

  4. Early Goal Directed Therapy Protocol (Achieve within 6 hours) ATTENTION New England Journal of Medicine 2001;345:1368-77

  5. Why EGDT? • Reduced in-hospital mortality • (30.5 vs. 46.5%) • Reduced 28d and 60d mortality • (33.3 vs. 49.4%; 44.3 vs. 56.9%)

  6. Mechanical Ventilation • Improves gas exchange; decreases work of breathing • Uncomfortable, not risk-free • PTX • Pneumonia and other infections • Increased intrathoracic pressure/cardiovascular compromise • Increased mortality if prolonged

  7. Mortality Prediction with PMV • Prolonged mechanical ventilation (PMV)=21 d • 4 predictive variables: • Age >50 • Thrombocytopenia (<150) • Use of pressors • HD Crit Care Med 2008 Vol. 36, No. 7

  8. Mortality Prediction with PMV One year mortality: No risk factors: 15% All four risk factors: 97% (age, pressors, platelets, HD) Crit Care Med 2008 Vol. 36, No. 7

  9. Mortality and MV Type TWO TYPES TO REMEMBER: • COPD with hypercapnea: NPPV • Cochrane Review 2004; Ann IM 2003 138: 861 • Decreased mortality (11 vs 21%) • ARDS: Low Tidal Volume Ventilaton

  10. Low Vt in ARDS • 12 ml/kg vs. 6ml/kg • Mean Vt 11.8 vs. 6.2 • Decreased mortality with low Vt • 31.0% vs. 39.8% • Greater number of days vent-free (at 28d) • 12 vs. 10 NEJM May 4, 2000 vol 342:18

  11. Low Tidal Volume Ventilation NEJM May 4, 2000 vol 342:18

  12. Questions • How do you calculate 6 ml/kg? • PBW • [50 + 0.91(Ht in cm-152.4)] male • [45.5 + 0.91(Ht in cm-152.4)] female • Define ARDS • P/F <200 • Bilateral infiltrates • No Left Atrial Hypertension

  13. ARDSNet, Part ?6 • FACTT trial (Fluid and Catheter Treatment Trial) • PA catheter not better than central venous • Conservative fluid better by 3.2d (MV) • NEJM 2006

  14. Weaning in Mechanical Ventilation

  15. Modes of Ventilation Weaning

  16. Weaning mode from MV • Patients had to have improvement or resolution of underlying cause of respiratory failure and • P/F >200 • PEEP at 5 or less • Temp <38 • Hgb >10 • No pressors • Took ‘difficult to wean’ patients • Had failed a spontaneous breathing trial even though • MIP >-20 • Vt >5ml/kg • RR <35 • (extubated if passed SBT) • Enrolled them in one of 4 modes of ventilation • IMV • PSV • SBT qd • SBT multiple times/day

  17. NEJM Feb 9, 1995, vol 332:345

  18. Rate of successful weaning: SBT qd vs. IMV: 2.83 (p <0.006) SBT qd vs. PSV: 2.05 (p <0.04) SBT qd vs. SBT mult times: 1.24 (p 0.54) NEJM Feb 9, 1995, vol 332:345

  19. MV: Readiness Testing Yang, KL and Tobin, MJ. A Prospective Study of Indexes Predicting the Outcome of Weaning From Mechanical Ventilation. NEJM 1991; 324: 1445 • Looked at ‘traditional predictors’ of weaning: VE and PImax and developed two indexes • f/Vt • CROP • f/Vt: • RSBI <105 breaths/min/L with sensitivity of 97% and NPV of 95%

  20. Readiness Testing with Spontaneous Breathing Trials

  21. SBTs • Screened patients for readiness testing • Combined previous trials for predictors • P/F ratio >200 • PEEP 5 or less • Adequate cough • f/Vt >105 (for one minute measure for screening) • No pressors or continuous sedatives • If passed, underwent SBT with CPAP 5 (or 5/0) for 2 hours • Notified the primary MD if passed

  22. Days of MV 4.5 vs. 6

  23. Sedation in Mechanical Ventilation Reduces distress/discomfort, but • Prolongs MV (increased complications/mortality/cost….) • Increases delirium

  24. Daily Awakening

  25. Daily Awakening • Sedation held daily until pt interactive or agitated unless the following: • On 80% or greater FIO2 • Has unstable surgical lesion • Decreased median duration of MV • 4.9 vs. 7.3d • Decreased median length of stay in ICU • 6.4 vs. 9.9d • Decreased head scans, decreased complications

  26. Daily Awakening

  27. ABC Trial

  28. ABC Trial • Combined Daily Awakening (SAT) + Spontaneous Breathing Trials (SBT) • Both groups had SBT, intervention was SAT vs. no SAT • Increased number of days breathing without assistance in 28d • 14.7 vs. 11.6d (p=0.02) • Decreased days in ICU, decreased days in hospital • 9.1 vs. 12.9d (p=0.01); 14.9 vs. 19.2 (p=0.04) • NNT=7

  29. ABC Trial

  30. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial Thomas Strom, Torben Mortinussen, Palle Toft Lancet Vol 375 Feb 6, 2010

  31. Data Not To Stress About • Tight glucose control in medical ICU patients • Steroid ‘replacement’ in septic shock

  32. Plea for Help • Send me your COPD patients that produce sputum and have an FEV1>30% and FEV1/FVC ratio <70% predicted • agh@med.unc.edu • 919-966-2531

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