five common errors in the icu - ucsf [email protected] @lekshmimd. title:...
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10/21/17
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Five Common Errorsin the ICU
Management of the Hospitalized PatientOctober 21, 2017
Disclosures
I have no conflicts of interest to disclose.
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Five Common Errors in the ICU
1. Volume Status
2. Pressor Choice
3. Non-Invasive Ventilation
4. Bronchs in the ICU
5. Communication
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Five Common Errors in the ICU
1. Volume Status
2. Pressor Choice
3. Non-Invasive Ventilation
4. Bronchs in the ICU
5. Communication
Volume Status: The ICU’s Holy Grail
“Fluids for everyone hypotensive!”
A Case: How would you assess his volume status?
A. IVC Ultrasound
B. CVP off a central line
C. A-line pulse pressure variability
D. Straight leg (claw?) raise
Marik, CVP, and the Seven Mares
“Fluids for everyone hypotensive!”
Marik et al. Chest 2008
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Will My Unstable Patient Respond to a Bolus?
Passive leg raise vs CVP vs A-line PPV vs IVC U/S
Bentzer et al. JAMA 2016
“Failure to Reassess” and our EHR
Don’t forget to D/C IVF long before D/C Home!
Weyker et al. Clin Chest Med 2016
Key PointVolume status is dynamic and difficult to assess:
reassess frequently and de-escalate early.
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Five Common Errors in the ICU
1. Volume Status
2. Pressor Choice
3. Non-Invasive Ventilation
4. Bronchs in the ICU
5. Communication
First-line pressor of choice in cardiogenic shock?
A. Dopamine
B. Dobutamine
C. Norepinephrine
D. Epinephrine
Key PointPressors are like antibiotics: don’t fear them and
select the correct drug for the physiology.
All that is Hypotensive is NOT Sepsis
❏ Cardiogenic shock
❏ Acute valvular dysfunction
❏ Hypovolemia/Hemorrhage
❏Myxedema coma
❏ Toxidromes
❏ Pulmonary embolism
❏ Cardiac tamponade
❏ Aortic dissection
❏ Anaphylaxis
❏ Adrenal crisis
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ICU’s Favorite Equation! No long tables!
V = IR
MAP = CO X SVR
Match Physiology with Vasopressor
❏ Pure vascular tone problem (e.g. post-procedural)
❏ Phenylephrine (Pure SVR)
❏ Septic shock
❏ Norepinephrine (SVR & CO)
Match Physiology with Vasopressor
❏ Cardiogenic shock
❏ Norepinephrine (SVR & CO) +/- dobutamine (CO)
❏ Hemorrhagic shock
❏ Resuscitation! Fill the SV with blood!
Special Cases? Get Help for PH & Critical AS
❏ Very subtle & complex!
❏ Careful attention to volume status – often need to keep diuresing
❏ Avoid stopping vasodilators
❏ Caution w/ beta-blockade
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A Plea to Use Generic Names
Norepinephrine “Levo” Phenylephrine “Neo”
Five Common Errors in the ICU
1. Volume Status
2. Pressor Choice
3. Non-Invasive Ventilation
4. Bronchs in the ICU
5. Communication
Not an Indication for Non-Invasive Ventilation?
A. Hypercapnic respiratory failure
B. Cardiogenic pulmonary edema
C. Hypoxemia in a DNR/DNI dragon
D. Weaning from the ventilator
Non-Invasive Ventilation: When to Use it?
❏ COPD exacerbation with hypercapnic acidosis
❏ Cardiogenic pulmonary edema
❏ Post-extubation respiratory failure
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Contraindications to Non-Invasive Ventilation
❏ Cardiac or respiratory arrest
❏ Facial or neurological surgery/trauma/deformity
❏ Inability to protect airway/cooperate
❏ Inability to clear secretions
❏ High risk for aspiration
❏ Goals of care
Flow vs. Pressure: Who Wins?
NIV HFNC
Counterbalances auto-PEEP More comfortable than NIV
Reduces work of breathing Higher FiO2 delivery
Improves lung compliance Decreased dead space
Mask can be uncomfortable Not good for hypercapnia
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Don’t be falsely reassured!
❏ Survey of fellows and RTs at UCSF
❏ 90% of fellows & 68% RTs felt that HFNC falsely reassured providers about how hypoxemic patients were
Key PointThink carefully about contraindications and to what you are bridging. Continually reassess if they need
intubation, whether HFNC or NIV.
Five Common Errors in the ICU
1. Volume Status
2. Pressor Choice
3. Non-Invasive Ventilation
4. Bronchs in the ICU
5. Communication
The Consult Question
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To Bronch or Not to Bronch? When Is It Safe for Bronchoscopy?
A. Intubated, FiO2 100%
B. 15 L HFNC
C. Intubated, FiO2 40%
D. Bronch a dragon at your own peril!
Can We? Stability for Bronchoscopy in the ICU
❏ Degree of hypoxemia
❏ Size of endotracheal tube
❏ If awake, ability to tolerate anesthesia
❏ (Hemodynamic stability)
❏ (Coagulopathy)
Should We? Indications for Bronchoscopy in the ICU
❏ Rule-out diffuse alveolar hemorrhage
❏ Rule-out PJP! Gold standard!
❏ Check the ET tube position/awake fiberoptic intubation
❏ NOT for mucus plugging!
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Quick Note: Don’t forget PJP Prophylaxis!
❏ HIV
❏ Pred 20mg PO daily for 1 mo. + other immunocompromise
❏ Combo of TNF-alpha + prednisone
❏ Primary immunodeficiency
❏ Post-solid organ transplant
❏ Post-HSCT
Key PointThink about whether bronchoscopy is the best
clinical test to determine the cause of hypoxemia and if it is safe to do so.
Five Common Errors in the ICU
1. Volume Status
2. Pressor Choice
3. Non-Invasive Ventilation
4. Bronchs in the ICU
5. Communication
The beginning of the ICU stay: Admission
❏ Notify patient’s PMD AND longitudinal outpatient subspecialty team
❏ Close communication with the ICU team from the start
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The “middle” of the ICU stay: C/S Management
❏ Consider multidisciplinary team meetings if multiple consult services:SECURE: email chain with all teams
❏ Face-to-face is best for learning & patient care!
The “end” of the ICU stay: Discharge
❏ F/u with PMD & outpt specialist
❏ Clear communication b/w ICU & ward
❏ Family meetings for end-of-life care - be explicit
❏ Remember the sequelae of post-ICU syndrome
Key PointCommunication is critical throughout every point in
the ICU patient’s stay.
Five Common Errors in the ICU
1. Volume Status!
2. Pressor choice
3. Non-Invasive Ventilation
4. Bronchs in the ICU
5. Communication
