Pulmonary Issues- Critical Care Review

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Pulmonary Issues- Critical Care Review

• Akella Chendrasekhar MD FACS FCCP

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When do you start your antibiotics for VAP?

1. Upon clinical suspicion empiric
2. After Gram stain data is obtained
3. After cultures data is obtained and verified
4. I have all my intubated patients on antibiotics
   regardless of clinical presentation

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Presumptive antibiotic treatment based on gram
staining reduced the incidence of ARDS in
mechanically ventilated patients

• Asako Matsushima, MD, Osamu Tasaki, MD, Kentaro
  Shimizu, MD, Kazunori Tomono, MD,
• Hiroshi Ogura, MD, Takeshi Shimazu, MD, and
  Hisashi Sugimoto, MD
• J Trauma. 200865309 315.

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Methods

• Inclusion criteria
• Patients intubated for more than 72 hours
• All patients enrolled in this study underwent
  emergency intubation without any preparation such
  as oral care or fasting
• Exclusion criteria
• Patients less than age 16
• Patients who suffered brain death
• Patients who were intubated for planned operation

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2 study groups

• 2 time periods
• First period VAP diagnosed by ATS guidelines
• The presence of a new or progressive radiographic
  infiltrate plus at least two of three clinical
  features (fever greater than 38C, leukocytosis
  or leukopenia, and purulent secretion).
• 2nd time period-bedside gram staining of purulent
  tracheobronchial secretions of patients with high
  fever (greater than 38C) or leukocytosis, and
  started antibiotic treatment if bacterial
  phagocytosis was seen under the microscope even
  before lung infiltration was seen on a chest
  X-ray film.

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2nd group
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Antibiotics used
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Pathogens
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Conclusions

• In this 2-phase study, a more aggressive
  antibiotic regimen based upon Grams stain
  results and despite the absence of infiltrates on
  CXR was associated with a several-fold reduction
  in incidence of ARDS and VAP without increased
  using more antibiotics.

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SEPSIS
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Tiered System of Progressively More Severe
Inflammatory States (ACCP)

• SIRS 2 or more of the following mortality 7
  
• Temp gt 38 C or lt36 C
• HR gt 90/min
• RR gt20/min, PaCO2 lt 32 mmHg
• WBC gt 12K, lt 4K or gt10 bands
• Sepsis SIRS compelling evidence of infection
  mortality 16
• Severe Sepsis Sepsis At least 1 end organ
  dysfunction mortality 20
• Septic Shock Severe Sepsis Hypotension
  refractory to volume expansion mortality 46

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Early Goal Directed Therapy in Sepsis-

• I follow the EGDT guidelines in the management of
  ALL of my patients in sepsis or severe sepsis
• I follow the EGDT guidelines for the management
  of MOST of my patients in septic shock or severe
  sepsis
• I do not follow any EGDT guidelines routinely.

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Initial Resuscitation

• Resuscitation should begin as soon as severe
  sepsis or sepsis induced tissue hypoperfusion is
  recognized
• Elevated Serum lactate identifies tissue
  hypoperfusion in patients at risk who are not
  hypotensive
• Goals of therapy within first 6 hours are
  Grade B

• Central Venous Pressure 8-12 mm Hg (12-15 in
  ventilator pts)
• Mean arterial pressure gt 65 mm Hg
• Urine output gt 0.5 mL/kg/hr
• ScvO2 or SvO2 70 if not achieved with fluid
  resuscitation during first 6 hours
  - Transfuse PRBC to hematocrit gt 30 and/or
  - Administer dobutamine (max 20 mcg/kg/min)
  to goal

-
Rivers E. N Engl J Med 20013451368-77.
Dellinger, et. al. Crit Care Med 2004, 32
858-873.
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Early Goal-Directed Therapy Results
28-day Mortality
60
49.2
P 0.01
50
40
33.3
30
20
10
0
Standard Therapy n133
EGDT n130
Key difference was in sudden CV collapse, not
MODS
Rivers E. N Engl J Med 20013451368-77.
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How do you manage fluids in patients with sepsis
and acute lung injury ?

1. Liberal with fluids using mostly crystalloids
2. Liberal with fluids using mostly colloids
3. Conservative with fluids
4. Fluid management irrelevant as pt is on ventilator

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The importance of fluid management in acute lung
injury secondary to septic shock.

• Murphy, C. V., Schramm, G. E., Doherty, J. A.,
  Reichley, R. M., Gajic, O., Afessa, B., et al.
  (2009). Chest, 136(1), 102-109.

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Methods

• Retrospective analysis
• Primary outcome parameter- hospital mortality
• Patients with septic shock were identified by
  diagnostic codes
• patients with ALI were also identified using
  chest radiograph reports, Pao2/fraction of
  inspired oxygen (Fio2) ratio, the requirement for
  mechanical ventilation, and medical record and
  available echocardiographic data indicating the
  absence of acute cardiac disease as the etiology
  for the pulmonary infiltrates

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Methods

• Location - Barnes-Jewish Hospital (St. Louis, MO)
  and in the medical ICU of Mayo Medical Center
  (Rochester, MN).
• Adequate initial fluid resuscitation-AIFR
  administration of an initial fluid bolus of gtor
  20 mL/kg prior to and achievement of a central
  venous pressure of gtor 8 mmHg within 6 h after
  the onset of therapy with vasopressors. early
  goal directed therapy
• Conservative late fluid management (CLFM)
  even-to-negative fluid balance measured on at
  least 2 consecutive days during the first 7 days
  after septic shock onset.

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Methods

• Study Cohort- 212patients with septic shock who
  developed acute lung injury
• Compared survivors to non-survivors to see what
  impacted on mortality.

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ACUTE LUNG INJURY
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44 year old male presents with acute lung injury
after trauma how would you manage the patient ?

1. Liberal fluid provision throughout the hospital
   course
2. Conservative keep the patient hypovolemic
   throughout fluid management
3. Liberal fluid provision initially followed by
   conservative fluid management
4. I am not sure

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Less Is More Improved Outcomes in Surgical
Patients with Conservative Fluid Administration
and Central Venous Catheter Monitoring

• Presented at the Southern Surgical Association
  120th Annual Meeting, West Palm Beach, FL,
  December 2008.Ronald M. Stewart MD, FACSa, ,
  Pauline K. Park MD, FACSb, John P. Hunt MD,
  FACSc, Robert C. McIntyre Jr MD, FACSd, Janet
  McCarthy RNa, Lee Ann Zarzabal MSa, Joel E.
  Michalek PhDe and NIH/NHLBI ARDS Clinical Trials
  Network

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Methods

• The ARDS Clinical Trials Network Fluid and
  Catheter Treatment Trial (FACTT) addressed fluid
  management and central monitoring of patients
  with acute respiratory distress syndrome/acute
  lung injury (ARDS/ALI).
• Posthoc, surgical subgroup analysis of 1,000
  patients enrolled in the FACTT.
• 244 surgical patients

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The conservative fluid-management group had
significantly more negative fluid balance at day
7.
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There were more ventilator-free days with
conservative fluid management and no difference
in dialysis-free days with liberal or
conservative fluid.
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Results

• Risk of death within 60 days of randomization did
  not vary with catheter or fluid management, and a
  corresponding lack of effect was evident with
  regard to dialysis-free day.

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Steroids in sepsis
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A 50 year old female presents with septic shock
do you use steroids ?

1. Yes high dose
2. Yes low dose
3. No
4. Not sure what to do.

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Steroids
Grade C

• Intravenous corticosteroids are recommended in
  patients with septic shock who require
  vasopressor therapy to maintain blood pressure
• Administer intravenous hydrocortisone 200-300
  mg/day for 7 days in three or four divided doses
  or by continuous infusion
• Shown to reduce mortality rate in patients with
  relative adrenal insufficiency

Annane, D. JAMA, 2002 288 (7) 868
Dellinger, et. al. Crit Care Med 2004, 32
858-873.
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Steroids

• May use 250 mcg ACTH stimulation test to identify
  responders and discontinue therapy in these
  patients
• Responders can be defined as gt9 mcg/dL increase
  in cortisol 30-60 minutes post ACTH
  administration
• Clinicians should not wait for ACTH stimulation
  test results to administer corticosteroids
• After the resolution of septic shock, may
  decrease dosage of steroids
• Consider tapering the dose of corticosteroids at
  the end of therapy
• May add fludrocortisone to the hydrocortisone
  regimen

Grade E
Annane, D. JAMA, 2002 288 (7) 868
Dellinger, et. al. Crit Care Med 2004, 32
858-873.
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Steroids
Low-Dose Steroids 28-day Mortality
Patients with Relative Adrenal Insufficiency
(ACTH Test Non-responders) (77)
Patients Without Relative Adrenal Insufficiency
(ACTH Test Responders) (23)
P0.04
P0.96
28-day Mortality
N114
N36
N34
N115
Annane, D. JAMA, 2002 288 (7) 868
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Steroids
Grade A

• Doses of hydrocortisone gt300 mg daily should NOT
  be used in septic shock or severe sepsis for the
  purpose of treating shock
• In the absence of shock, corticosteroids should
  not be used for treatment of sepsis

Grade E
Bone RC. N Engl J Med 1987653-658. VA Systemic
Sepsis Cooperative Study Group. N Engl J Med
1987317659-665.
Dellinger, et. al. Crit Care Med 2004, 32
858-873.
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Original Article Hydrocortisone Therapy for
Patients with Septic Shock
Charles L. Sprung, M.D., Djillali Annane, M.D.,
Ph.D., Didier Keh, M.D., Rui Moreno, M.D., Ph.D.,
Mervyn Singer, M.D., F.R.C.P., Klaus Freivogel,
Ph.D., Yoram G. Weiss, M.D., Julie Benbenishty,
R.N., Armin Kalenka, M.D., Helmuth Forst, M.D.,
Ph.D., Pierre-Francois Laterre, M.D., Konrad
Reinhart, M.D., Brian H. Cuthbertson, M.D.,
Didier Payen, M.D., Ph.D., Josef Briegel, M.D.,
Ph.D., for the CORTICUS Study Group
N Engl J Med Volume 358(2)111-124 January 10,
2008
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Study Overview

• The benefit of adjuvant use of corticosteroids in
  patients with septic shock remains controversial
• In this international, multicenter, double-blind,
  placebo-controlled trial, adjunctive therapy with
  hydrocortisone in nearly 500 patients with septic
  shock was not found to be clinically helpful
• This lack of benefit was also found in a subgroup
  of patients who did not have a response to a
  corticotropin test

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Enrollment and Outcomes
Sprung CL et al. N Engl J Med 2008358111-124
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Demographic Characteristics of the Patients,
According to Subgroup
Sprung CL et al. N Engl J Med 2008358111-124
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Clinical Characteristics of the Patients at
Baseline, According to Subgroup
Sprung CL et al. N Engl J Med 2008358111-124
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Kaplan-Meier Curves for Survival at 28 Days
Sprung CL et al. N Engl J Med 2008358111-124
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Outcomes According to Subgroup
Sprung CL et al. N Engl J Med 2008358111-124
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Kaplan-Meier Curves for the Time to Reversal of
Shock
Sprung CL et al. N Engl J Med 2008358111-124
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Adverse Events (Per-Protocol Population)
Sprung CL et al. N Engl J Med 2008358111-124
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Conclusion

• Hydrocortisone did not improve survival or
  reversal of shock in patients with septic shock,
  either overall or in patients who did not have a
  response to corticotropin, although
  hydrocortisone hastened reversal of shock in
  patients in whom shock was reversed

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H1N1 Influenza

• CDC REPORT

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Epidemiology

• 122 countries 94,512 cases reported
• 429 fatal
• Rapidly progressive lower respiratory tract
  disease
• Development of ARDS
• Prolonged ICU admission
• Focused review of 10 consecutive patients with
  severe ARDS and H1N1 infection seen at a
  tertiary care center in michigan, USA

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Clinical characteristics

• 90 - BMI greater than or equal to 30
• 70 -BMI greater than 40
• 50 - pulmonary emboli
• 90 - Multiple organ dysfunction
• 30 mortality