Preven&ng Intensive Care admissions A Ganapathy... · treatment guidelines are to reduce the MAP...
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Preven&ng Intensive Care admissions Anusoumya Ganapathy, MBBS, ABIM Staff Intensivist, GGH
Transcript of Preven&ng Intensive Care admissions A Ganapathy... · treatment guidelines are to reduce the MAP...
Preven&ngIntensiveCareadmissions
AnusoumyaGanapathy,MBBS,ABIMStaffIntensivist,GGH
Objec&ves
• ReviewICUadmissioncriteriaforeachorgansystem
• U&lizeanearlywarningscoringsystem• Discussendstagediseases/ICUadmissionappropriatenessandearlyinvolvementofrapidresponseteams
• Increasinglycomplexhospitalpa&ents• Limitedresources(ICUbeds)• Higherdemandsfromthepa&ents• Longevityofcurrentpopula&on
Priori&za&onmodel
• Level1:Cri&callyillunstablepa&entswhocannotbemanagedoutsideofICU
• Level2:pa&entswithchroniccomorbidi&esandsuddenacuteillnessordeteriora&on
• Level3:Unstablepa&entswithreducedlikelihoodofrecoveryevenfromICU
• Level4:Inappropriatepa&entstoICU
Cardiovascularsystem
• Acutecoronarysyndrome:– Unstableangina– Requiringintravenousinfusionofnitroglycerinforsymptomcontrol
– Conges&veheartfailureconcomitantly– Arrhythmias– Progressiontocardiogenicshock
Complexarrhythmias
• Unabletocontrolwithoralmedica&ons• Unstablewithwidefluctua&onsinbloodpressure
• Underlyingstructuralcardiacdiseasethatmakesmanagementdifficult
• Blocks-completeheartblockandmobitztype2blocks-thatpoten&allycandegradetoasystole
Conges&veheartfailure
• Withimpendingrespiratoryfailurerequiringnoninvasiveposi&vepressureven&la&onorimpendingmechanicalven&la&on
• WithcomplexarrythmiasthatwouldnotbecontrolledunlessunderlyingCHFistreated
• Withacutesymptoma&chypotension
Conges&veheartfailure
• BewareofCHFalikes:lowalbumin,PE,CKDwithvolumeoverload
• Management&ps:CHFwithhypoalbuminemia– Mayusealbuminandlasix
Cardiogenicshock
• Decreasedcardiacoutputwithevidenceof&ssuehypoxiainthepresenceofadequateintravascularvolume
• Clinicallycoldclammyperiphery• Hypotension• Lac&cacidosisdueto&ssuehypoperfusion
Hypotension
• Typesofshock:Vasodilatory,obstruc&ve,cardiogenic,anaphylac&c,bloodloss
• Acuteonsetratherthanchronichypotension• CheckBPinbotharms:many4mesthereisa“subclavianstenosiscausingafalsealarm”
• ConsideraCBC,electrolytes,lactate,VBG,bloodcultures
Chronichypotension
• Endstagediseasessuchas– cirrhosis– conges&veheartfailurewithseveresystolicdysfunc&on,Cri&calAS
– autonomicdysfunc&on– chronicadrenalinsufficiency– Centralautonomicdysfunc&on(ShyDagersyndrome)
• Consider:Midodrine,stockings,fluodrocor&sone
ShockIndex
• HRdividedbySBP• Iden&fypa&entsatriskofearlysepsis• Normalindexbetween0.5-0.7• Anythingover1.0willbeofconcern• Tips:helpsonlywithearlyrecogni&on,notwithvolumeresuscita&on
Acuterespiratoryfailure
– HypoxemiaFiO2over50%generallyshouldnotbemanagedontheward
– Hypercapnia-againifitisacuteandtheprimarydisordernotimproved(likeCOPD)andarepeatVenousbloodgasdoesnotshowimprovement,shouldnotbeontheward
– Anothercaveat..obesityhypoven&la&onsyndrome-thisgroupofpa&entscanprogresstorespiratoryarrestwithanykindofsuperimposedrespiratoryissuelikepneumonia,copd…
Hypercapnicrespiratoryfailure
• COPD,Asthma,Obesityhypoven&la&onsyndrome,PEs,
• VBGsvsABG(VBGuselessifhypoxiaaconcern)
• AlsobewareofCOPDpa&entswhoalsohaveconcomitantrenalfailureastheycannotcompensate
Pulmonaryembolism
• MassivePEwithhemodynamicinstability(centralPE)(bewareaSBPof110inahypertensivepa&entcouldbeconsideredasshock!!
• SubmassivePEwithsignificanthypoxiaand/orRVdilata&on
• Bewareofresidualclotburden• Echoanddopplerssupplementinforma&on
Hypertensivecrises
• Hypertensiveurgency:– Bloodpressureisseverelyelevated[180orhigherforyoursystoleand/or110orhigherforyourdiastole],butthereisnoassociatedorgandamage
– Usuallyrequiresaddi&onaloraldosing/seldomhospitaliza&onalthoughfailureofthiswouldneedurgenttreatmentinamonitoredsehng
Hypertensiveemergency
• Hypertensiveemergenciesgenerallyoccuratbloodpressurelevelsexceeding180systoleOR120diastole
• Couldalsooccuratevenlowerlevelsinpa&entswhosebloodpressurehadnotbeenpreviouslyhigh
• Withevidenceofendorgandamage
Hypertensiveemergency• Theconsequencesofuncontrolledbloodpressureinthisrangecanbe
severeandinclude• Stroke• Lossofconsciousness/Encephalopathy• MI• Lossofvision• Renalfailure• Aor&cdissec&on• Angina• Pulmonaryedema• Eclampsia
Hypertensiveemergenciesmanagement
• Inhypertensiveencephalopathy,thetreatmentguidelinesaretoreducetheMAP25%over8hours
• Labetalol,Nicardipine,esmololarethepreferredmedica&ons;nitroprussideandhydralazineshouldbeavoided.
ICHandBPmanagement
• Inacuteintracranialhemorrhage,MAPlessthan130orSBParound180ifnoevidenceofraisedICP
• IfraisedICPsuspected,thenMAParound110toavoidhematomagrowth(andSBPlessthan160)
• Inmoststudies,targetSBPwas140!!Forpreven&nghematomagrowth
HypertensionandCHF
• Prefervasodilators• Nitrates• ACEI• Diure&cs(alsohavevasodilatoryeffect)
Pericardialeffusion
• Verylargewithimpendingtamponade• Orrapidaccumula&onofpericardialfluidevenif50-100ml
• Usuallypresentswithhypotension,tachycardia,elevatedJVP,clearlungs,largecardiacshadowonaCXR
Massivehemoptysis
• Watchoutforvolume(nottheonlycriteria)• Roughly100mlin24hours/ooenexaggeratedbypa&ents..mixedwithsaliva..
• Alsoconsidertherateofbleedingwhichismoreimportant
• Lookforabnormalitywithgasexchange/consideranABG
• Cancauseairwayobstruc&on/lookforstridor
Massivehemoptysis
• Hemodynamicinstability• Inabilitytocleartheclots• AlteredLOC
Miscellaneousrespiratorycondi&ons
• Condi&onsrequiringmorenursingcareandrespiratorysupport
• Pa&entswithprogressiverespiratorydecline• Beware:Pa&entswithGBS,ALS,myotonicdystrophyandtheirabilitytocoughandclearsecre&ons!!
• ConsideraskingRTtoseeandgetpeakflows,MIPS,MEPS
Neurologicdisorders
• Acutestroke:– Withalteredmentalstatus/veryominoussign– Bewareofposteriorfossastrokes(especiallyhemorrhagicstrokes)-canquicklydeteriorateandmightneedsurgicalmanagement
– Someofthesepa&entsmightneedQ1-2hourmonitoringwhichisnotavailableonthewards
– Similarly,theymighthavewidehemodynamicvaria&ons
AcutestrokeandHTN
• Alwaysrememberaboutintracranialperfusionpressure
• HTNverycommonaroundacutestroketoperfusetheischemicpenumbra
• Withhemorrhagicstroke–targetBParound160/90orless
• Withischemicstroke/BPdropshouldnotbeover15%over24hourstoavoidcerebraledema
ICH
• ICHrequiringhemodynamicmonitoringduetouncontrolledhypertension
• An&hypertensivesthatcanbeusedonlyinahighlymonitoredsehnglikelabetololandnitroprusside
• ICHthatifworsenshasascopeforneurosurgicalmanagement
• Acutesubarachnoidhemorrhage(e&ology/CTA)
Neuromusculardisorders
• Myopathies,ALS,GBS,myastheniagravis,MSandmanymore!!
• Whattomonitor:– Cough,MIPandMEP,VBGs,peakflow
• Howtoprevent:– Knowyourfloor,PTandRT,aggressivechestPTandcoughassist,breathstackingexercises
Statusepilep&cus
• Twoormoreseizureswithoutrecoveryofconsciousnessinbetweentheepisodesormorethan30minutesofcon&nuousseizureac&vity
MiscellaneousCNScondi&ons
• Suspectedmeningi&sorencephali&swithalteredLOC
• MildtomoderateTBIwithotherconfoundingfactors
• Braindeadorpoten&allybraindeadpa&entswithascopefororgandona4on
Gastrointes&naldisorders
• MassiveGIbleedingpresen&ngwith– Hypotension– Tachycardia– CADwithsymptomsorothercomorbidi&es– UpperGIbleederswithcirrhosisandconcernforvaricealhemorrhage(considerAbxearly)
• Severepancrea&&s• Hepa&cfailure• Esophagealperfora&on
Endocrine
• Hyponatremiawithsodiumespeciallylessthan115(consideracuityandsymptoms)– Bewarecorrec&oninalcoholics,cirrhosis,liverdysfunc&on(highestriskforCPM)
• HypernatremiawithseizuresorAMS• Severehypocalcemia(postopaoerparathyroidectomy..)presen&ngwithtetany– IonizedCalessthan1.0ortotalcorrectedlessthan1.9
Endocrine
• Severehypercalcemia(needlargevolumesoffluidforresuscita&on)
• Hypoorhypermagnesemiawith– Hemodynamicinstability– Arrythmias
• Hypo(lessthan2.2)orhyperkalemias(over6.5)– Muscleweakness– Arrythmias
Endocrine
• Diabe&cketoacidosis(VBG,serumketones,BG,history)– Moderatetosevere(pHbelow7.25)– Ongoingemesisandorinfec&ousprocessthatwouldpreventrapidimprovementinDKA
– Caveats:Bridgeinsulin(Longac&ngplusSAonehourwithIVinsulinbeforeturningoffIV),tryasmuchtokeeppa&entNPOun&lAGnormalized
• Hyperosmolarcoma(VBG-noacidosis,AMSandhyperglycemia)
Endocrine
• Hypophosphatemiawithmuscleweakness– Watchforrespiratorymuscleweakness
• Refeedingsyndrome:– Happenswithin4daysorstar&ngtofeedaoerprolongednutri&onaldeple&on
– Hypophosphatemia,hypoMg,hypoCa,lowthiamine
– Deathfromarrythmias– Respiratoryarrest
Oncologicalemergencies
• Tumorlysissyndrome:– Seenwithacuteleukemiasorhighgradelymphomas
– Hyperuricemia,hyperkalemia,hyperphophatemia,hypercalcemia,acuterenalfailure
• SVCsyndrome:– AcuteSOB,upperbodyedema,cyanosis,nausea,confusion,lightheadedness,stridor
– Radiologicalfindings
Oncologicalemergencies
• DIC:– Differen&atefromTTP– Orderfullcoagula&onworkup(D-dimers,Fibrinogen,INRandPTT)
• Spinalcordcompression• CNSlymphoma• Bleedingfromfactordeficiencies(cannotbecontrolledimmediately)
Oncologicalemergencies
• Hyperviscositysyndrome:– Leucostasis– Waldenstrom’smacroglobulinemia
Drugoverdose
• WithalteredLOC• Poten&alforworseningLOC(sustainedreleaseprepara&ons)
• Possibilityforarrythmias• Seizures• Hemodynamicinstability• Requiringrenalreplacementtocleartoxins
DVT
• Phlegmasiaalbadolens(PAD)• Phlegmasiaceruleadolens(PCD)• InvolvingextensiveDVTespeciallysuprainguinalDVT
• Limbthreateningischemia• MassivePEsleadingtodeathnotedinupto30%ofPCDpts
• Signs• Management
Earlywarningsystem
• Usesacombina&onofvitalsignsandlevelofconsciousness
• Studieshaveindicatedthatinthemajorityofpa&entswithcodebluesorcardiacarrestinhospital,therearewarningsigns6-8hourspriortotheevent
• Fewsystemsbeingusedinclude:MEWS,AEGIS
EndstagediseasesandICUadmission
• Veryooenwefacepa&entswithendstagediseaseslikemalignancy,CHF,COPDandCKDreques&ng“everythingtosustainlife”
• Earlydiscussionaboutgoalsofcare• CouldinvolveICUaswearehappytohavethisdiscussionwiththefamilies
• Ooenlackofunderstandingontheirpart• LookoutofSDMhierarchyandPOA
Case1
• 36yroldmalewithahistoryofalcoholabuse• Recentlyadmivedtothehospitalwithacutepancrea&&sanddischargedhome,querycoffeegroundemesis
• Foundonthefloorconfusedbyneighborandbroughttothehospital
• PMHx:alcoholabuse,pancrea&&s• Admissionvitals:HR112,BP154/95,GCS13althoughconfused,afebrile,Sats97%onRA
Case1
• Bloodwork:HB98(previously107),WBC9.8,Platelets135,Na132,K3.6,Cl89,bicarb26,Cr95(previously65),AST500,ALT225,GGT400,ALP189,INR1.5,Albumin35,Amylasenormal,Ammonia89
• AdmivedtothewardwithCIWAprotocolwithrapidadmitordersovernight.
Case1
• Couldmanagementbedifferent?• Anymoreinves&ga&onstoorder• Whatmorecouldbemonitoredhere?• WouldyouconsultICUearlyon?
Case2
• 31yearoldfemale• Admivedwithprogressivehypoxiatothehospital,startedAbx
• KnowntohavebreastCAwithmetastasistospinealone,offchemotherapyforafewmonths–nohxoflungmets.
• OnVenturimask-FiO2between30-50%• CTchest–noPE,showsextensivemul&lobarinvolvementwithseptalthickening
Case2
• Admivedbyintakehospitalist• Respirologyconsulted-bronch-noe&ologyfound
• Pa&entappearsverycomfortableandcalm.• TreatedwithbroadspectrumAbx,lasixanda&van
Case2
• Shewishestobea“fullcode”• Onday3,sheappears&redandexhaustedatmorningrounds.Sats93%on50%Fio2.
• RNpagesMRParound4PMasptislethargicbutincreasedworkofbreathing
• VBGobtainedwhichrevealsapHof7.07,PCO2of90.
Case2
• Pa&enttransferredtoICU• Onarrival,pH6.8,rapidlydeclines,cardiacarrestwithinanhouranddies.
• Ques&ons:1) Couldwehavechangedmanagementherein
anyway?2) Differen&aldiagnosis3) Endoflifecare
Case3
• 85yearoldpa&ent• DNRbutyestomedicalmanagement• Livesindependently(RH),nocogni&veimpairment
• KnowntohaveCHF,HTN,OA• Comeswithrapidatrialfibrilla&on• VitalsintheER:– BP108/65,HR110/min,RR18,sats93%on3LpmNP,afebrile
Case3
• IntheER,onedoseofcardizemIV15mgisadministered.
• SubsequentlyBPdropsto88/52,HR88,Sats94%on3lpmNP,doesnotfeeldizzybutfeelsweak
• 500mlofIVNSisadministered• Thensatsdropto90%on3lpmNP-improvesto94%on4lpmNP
• CXRonadmissionshowsmildpulmedema,nopneumonia
• Bloodworkofsignificance:Cr82,trops0.07,CK150
Case3
• Admivedtotheward• Con&nueswithsimilarvitals• HRagainupto99/mt• Onassessmentonthefloor,sheisslightlydyspneic,abletotalk,BPis99/75
Case3
• Ques&ons:– Anyotherbloodworkthatyouwouldlike?– Managementop&ons– WouldyoucallICU?
References
• Societyofcri&calcaremedicine.GuidelinesforICUadmission,dischargeandtriage,1999
• Earlywarningscoringsystem-Systema&cReview,January2014,Evidencebasedsynthesisprogram,DepartmentofVeteransaffair
• Managementofbloodpressureinacuteandrecurrentstroke,Stroke,2009;40:2251-2256
References
• Massivehemoptysis,Europeanrespiratoryjournal,Volume32,Number4,1131-2.
• Hematologicalemergencies,AnnalsofOncology18(Supplement1):i45–i48,2007
