ICU Basics Anita Holtz MD Southwest Pulmonary Associates

ICU Basics Anita Holtz, MD Southwest Pulmonary Associates July 24, 2017

Preamble • Where to go • ICU orientation packet • Read before you come, read during the rotation • Educate yourselves!! (This does not mean up to date everything) • Educate Us!! *** Original articles*** Your knowledge should be evident in your own original note and ideally in your presentation • Patient stability first, orders next, documentation last

Care team • Nurses • RTs • Pharmacists • Primary providers • Techs • Cleaning crew

What should I read? • Marino ICU book • Surviving sepsis trial • Ardsnet protocol • IDSA/ATS guidelines on pneumonia • Any of the national guidelines for your patient's disease process

Expectations: Interns • • • Recorders Be prepared, be honest, and prepare to work Learn to identify sick patients Put years of book work into disease processes Develop a problem list and learn how these diseases are treated Learn the guidelines Procedures Talking with patients and their families Follow through Learn how to consult Learn each other’s patients

Expectations: Residents • Evolve • Be prepared, be honest, and prepare to work • Learn to identify sick patients • Develop a broad differential and learn how to answer questions • Learn above the guidelines • Educate your intern • Judiciously order tests and learn from consultants • Procedures • Developed conversations with patients and their families • Follow through • Learn each other’s patients

• a) 25 year old runner comes into the ER after running a marathon. She is warm but no longer sweating, lethargic with HR 140 s, RR 30 s, BP 98/42 • b) 68 yo M with CHF, COPD poorly controlled DM presents with a LLE wound that hot and crunchy. HR 110 Temp 101 BP 85/42 RR 18 • c) 36 yo asthmatic who is awake, alert, anxious with RR 26 BP 140/90 HR 99 SPO 2 100%. ABG 7. 32/47/160 on 2 L nc after 2 rounds of consecutive nebs • d) 84 yo F with DM, alzheimers, CAD, bedbound who presents with foul smelling urine. Lethargic, BP 60/p, HR 130 s IRIR, creatinine 4. 2, troponin 2. 9, bicarb 10

Pitfalls • “Dear Ms X, your mom is doing fine. ” • “Dear Ms X, you mom is stable” • Not telling primary team or surgeon / interventionist change in pt status • “Well there's no way to really know” • Making up data • Not coming prepared, every day • Not learning from your mistakes

Consultations • You are internists first, even if you will only be here for a year • Your job is to maximize your knowledge about the patient and disease management first • Obvious immediate consults: acute abdomen, profound hyponatremia or anuria, STEMI, acute stroke, etc • Know what the question is before you call. Onboard is not a question • Have a well thought out differential. Call in a time appropriate manner • Work with and learn from the consultant

Procedures Know the indications, alternatives and risks before consenting patient NEJM tutorials Obtain consent and materials Talk with your attending prior to the procedure

Code status discussions should be a natural part of your H&P or consultations (much like that rectal or vaginal exam) As should be surrogate decision maker conversations

Code status does not mean all care (including aggressive interventions) vs palliative care Patients and families are in shock. They need simple words they can digest. This may be the last memory they have of their loved one and what you say matters

Code status The conversation should never be phrased as “do you everything to be done? ” Or to offer an A-la carte menu of possible interventions. Use the expression “life support” If you do not know enough about the patient’s condition please politely excuse yourself from the conversation

Code status The primary objective is to know what the patient’s wishes are. Your duty is to honor the patient’s informed wishes (either directly obtained from the patient or vis a vis their surrogate) If the patient or family does not understand the gravity or complexity of their situation, kindly and compassionately explain to patient and family.

Code status It is absolutely ok and welcome to allow family’s time to consider their options Please do not pressure the family. If you come to the conversation well prepared and you articulate your opinion clearly and with empathy and the family can’t decide, leave them alone. Call a chaplain. Let them deliberate. Advise them if the patient looks grave or imminent to have family and friends to visit the patient

Code status Predictions: our inability to predict or not predict outcomes drives patient and family uncertainty. Prediction models DO exist. And yes some are better than others Like all things, we are doctors, scientists. We do not know the future. So sometimes we are wrong

Code status You job is not to change everyone to DNR In patients who are predicted to do poorly or die despite maximal medical interventions, a delicate conversation must be held with family There is NO ROLE for the breaking ribs conversation

End of life This is not the same as the code status question You will see people die. I did not write patients, I wrote people You will not feel good about this and we all need to acknowledge this This is someone else’s worst day of their life and often the awake and interactive family member’s second worst day of their life. Please remember this

End of life How far do we go? Well it depends on patient wishes and that depends on your understanding of how “well” they will do Sometimes it is a full court press until we hit an endpoint (resp failure, arrest) Sometimes it is defined as, do what you can that won’t make mom or dad feel badly

End of life Withdrawal of support is not euthanasia Respect what the patient and their family would want Directing our efforts and energies from curing disease to treating the pain and anxiety at the end of life.

Resuscitation • • • Early goal directed therapy- know the Nguyen, Rivers trial Hypovolemia ≠ dehydration How to resuscitate and with what R = 8µL/πr 4 • 2 large bore ivs- (16 or 18 gauge) = short and fat = less resistance • Triple lumen = 2 x 18 g (depends on kit) + 1 x 20 g • PICC = 2 to 7 Fr. 6 Fr ~ 14 g but 2 Fr ~ 22 g and they are LONG • Cordis: 9 Fr • IO: up to 5 liters per hour •

The IV menu • 60% TBW is fluid, 2/3 fluid is intracellular, 1/3 extracellular, ¾ of extracellular fluid is extravascular • Give liberally but most of what you give whatever you chose will go to extravascular space

IVF • NS: 154 meq Na, 154 meq Cl, p. H 5. 7, 308 Osm • ½ NS: 77 meq Na, 77 meq Cl • LR: 130 meq Na, 110 meq Cl, 28 meq Lactate, 4 meq K, 3 meq Ca++, p. H 6. 4, 273 Osm • Lactate converts to bicarb, avoid during transfusion (ca binding to citrate in blood prods) • D 5: 5% dextrose ~ 50 gr • Bicarb- 3 amps in D 5 W (not in NS or ½ NS) ~ 150 meq Na • Normal Plasma: 140 Na, 103 Cl, 4 K, Ca 5, Mg 2, p. H 7. 4, 289 Osm

Colloid • • • Albumin- 5% or 25%- do not give if hypovolemic • 5% -20 mm. Hg oncotic pressure (COP), ½ life 16 hrs • 25% has 70 mm. Hg oncotic pressure, expands plasma 45 x volume administered • Can be given in acute liver injury, burns, with other blood products Hespan 6% starch 30 mm. Hg onc pressure Dextran 6% and 10% (40 mm Hg each) Blood products Colloid is expensive, no increase in mortality in using colloid, can worsen AKI, eventually leaches into the interstitium in distributive shock, coagulopathy- SAFE study 2004 NEJM, Cochrane review 2009, BMJ 1998; 316: 961 Albumin may help in hypoalbuminemic patients (< 30 g/L) Crit Care Med. 2006 Oct; 34(10): 2536 -40.

Vents • 2 goals- oxygenation and ventilation • AC vs IMV vs SIMV • When to intubate? • Hemodynamic instability/code (though no longer part of ACLS, so don’t stop compressions for an airway) • Hypoxemic respiratory failure • Hypercapneic respiratory failure • Status asthmaticus, copd that is tiring out • Severe met acidemia • “airway protection”- not everyone that is intoxicated needs an airway. Delirious people who are aspirating yes

Intubation • Get everything ready first • call RT, notify the nurse and ask for sedation meds (below) • have bag mask, nasal trumpet (key) or oral airway or LMA available just in case • ETT- size 6 if nasal intub, typically want 7. 5 (less optimal) or 8 -0 ETT, inflate the balloon yourself and release it, +/- lubricant • Suction, everyone forgets suction. Ck the laryngoscope- 3 or 4 MAC or Miller typically works • Looking is free, touching will cost you • Meds: you need an induction agent (etomidate, ketamine, propofol, versed, thiopental), +/- paralytic (rocuronium T ½ 1. 5 hr, 4 hr liver injury, 2. 5 h renal pt or vecuronium T ½ 65 -75 min). Do not use Sux in renal patients, hyper. K, rhabdo or patients with neuromuscular disease • Sniffing position except in RA (unstable occipito-atlanto join), neck fracture • Know when to stop and let anesthesia go at it- prior h/o difficult intubation, large neck, can’t see cords, patient quickly deteriorating

Vents • • Settings- assume AC Can set the following • Vt ~ 8 cc/kg up to 10 cc/kg in normal person in acute failure, use IBW if morbidly obese. 6 -8 cc/kg if ARDS (use ARDS net protocol), asthma/copd 6 -10 cc/kg • RR think minute ventilation (VE = Vt x RR). Normal 10 - 16, COPD/asthma most important is leaving time to exhale so RR 10 -14 or VE = 10 L/min, ARDS <35 bpm • Fi. O 2 • PEEP: normals 5, in hypoxemia depends on Fi. O 2 (see ARDSnet), Asthma = 0, copd 0 -3 • I: E normally 1: 2, can go 1: 3 or longer (eg copd) • Ck an ABG 1 hr after adjusting the vent and every AM, also ck chest xr q. AM • Permissive hypercapnea is ok as long as the patient is oxygenating • Do not try to normalize the ABG, your goals are 1) oxygenate, 2) maintain sufficient ventilation 3)decrease the work of breathing 4) synchrony

ABG • <7. 35 = acidemia, > 7. 45 = alkalemia • p. H = [p. CO 2]/[HCO 3]. For approp p. H both p. CO 2 and HCO 3 must move together to maintain p. H balance • Can have 3 disturbances, can never have concomitant resp alkalosis and resp acidosis 1. acidemia vs alkalemia 2. what is the primary disturbance (if acidemia, is the p. CO 2 high or is the bicarb low) 3. Is there a compensation and is the compensation appropriate. If the compensation is not appropriate a 3 rd disturbance exists

ABG • If the primary disturbance is acidemia: • Primary respiratory, expect p. H to decrease 0. 08 for every 10 mm Hg increase in p. CO 2. expect bicarb to acutely increase by 1 for each 10 mm Hg increase or chronically increase by 3 for each 10 p. CO 2 • Primary met acidemia. Ck for AG. If AGMA, then look for delta gap/NAGMA. Then look for respiratory compensation. Expect p. CO 2 to be 1. 5 x [hco 3] = 8 +/- 2 (winter’s formula).

Hypoxemia • Dyspnea ≠ hypoxemia • 4 main causes of hypoxemia • V/Q mismatch (compromised perfusion to ventilated alveolar units)- biggest contributor • Shunt (perfusion is fine, but there are is no ventilation) • Low Fi. O 2 (altitude) • Rare hypoventilation • Diffusion impairment (ie severe emphysema, fibrotic lung disease) • Know A-a gradient, we often miss the time to intervene in ALI until patient deteriorates into ARDS

Sepsis • • SIRS with a likely or known source Distributive shock • • • What other types of shock exist? Neuro, cardiac, hypovolemic (includes hemorrhagic) Shock is not a BP, it is lack of blood flow/perfusion to vital organs resulting in end organ damage (aki, delirium, syncope, troponemia, acute liver injury) SIRS: systemic, pro inflammatory state, cytokines run askew • T< 36 or >38, HR >90, RR >20 or p. CO 2 <32, wbc <4 K or > 12 K or > 10% bands

Things we missed Antibiotics Cardiogenic shock Arrhythmias Endo emergencies- very fun stuff, and AI Pressors Nutrition GI bleeding Transfusions and transfusion related illnesses AKI Pneumonia

Thank you