17 the brigham board review in critical care medicine 2017

Weinhouse, MD Assistant Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine Department of Medicine Brigham and Women’s Hospital Faculty Rebec

CMEinfo presents a

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THE BRIGHAM BOARD REVIEW IN

CRITICAL CARE MEDICINE

from

DATE OF ORIGINAL RELEASE: May 31, 2017

DATE CREDITS EXPIRE: May 31, 2020

TARGET AUDIENCE:

The primary group of learners will be fellows/trainees and practicing critical care specialists (MDs), NP’s, and other professional affiliates (internists with an interest in critical care) who are preparing to take ABIM Board Review or Recertification Examinations or who seek CME

activities to improve patient care in the area of critical care medicine Currently, the target

audience is regional, national & international

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METHOD OF PARTICIPATION: Review Video/Audio program, complete the

• Identify and Apply current therapeutic options for specific critical care disorders;

• Analyze and Interpret up-to-date literature relevant to clinical practice in critical care medicine;

• Recognize and Apply knowledge of pathophysiology as it applies to management of critical care disorders;

• Apply knowledge gained to the ABIM certification/recertification critical care

examinations

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Course Director Gerald L Weinhouse, MD

Assistant Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine

Department of Medicine Brigham and Women’s Hospital

Faculty

Rebecca M Baron, MD

Assistant Professor of Medicine

Harvard Medical School

Division of Pulmonary and Critical Care

Harvard Medical School

Division of Thoracic Surgery

Department of Surgery

Brigham and Women’s Hospital

Bartolome R Celli, MD

Professor of Medicine

Harvard Medical School

Division of Pulmonary and Critical Care

Medicine

Department of Medicine

Brigham and Women’s Hospital

Kenneth B Christopher, MD

Assistant Professor of Medicine

Harvard Medical School

Department of Obstetrics and Gynecology Brigham and Women’s Hospital

James F Gilmore, PharmD

Clinical Pharmacy Specialist Department of Pharmacy Services Brigham and Women’s Hospital

Brigham and Women’s Hospital

Samuel Goldhaber, MD

Professor of Medicine

Harvard Medical School

Division of Cardiovascular Medicine

Department of Medicine

Brigham and Women’s Hospital

Kathleen Haley, MD

Assistant Professor of Medicine

Harvard Medical School

Division of Pulmonary and Critical Care

Medicine

Department of Medicine

Brigham and Women’s Hospital

Galen Henderson, MD

Assistant Professor of Neurology

Harvard Medical School

Department of Neurology

Brigham and Women’s Hospital

Margo Hudson, MD

Assistant Professor of Medicine

Harvard Medical School

Division of Endocrinology, Diabetes and

Harvard Medical School

Division of Infectious Diseases

Department of Medicine

Brigham and Women’s Hospital

Brigham and Women’s Hospital

Daniela Lamas, MD

Instructor in Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine

Department of Medicine Brigham and Women’s Hospital

Anthony F Massaro, MD

Instructor in Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine

Department of Medicine Brigham and Women’s Hospital

Melanie Maytin, MD

Instructor in Medicine Harvard Medical School Division of Cardiovascular Medicine Department of Medicine

Brigham and Women’s Hospital

Paul F Nuccio, MS, RRT, FAARC

Director of Pulmonary Services

Division of Pulmonary and Critical Care

Medicine

Department of Medicine

Brigham and Women’s Hospital

Dana-Farber Cancer Institute

James Rawn, MD

Instructor in Surgery

Harvard Medical School

Division of Cardiac Surgery

Department of Surgery

Brigham and Women’s Hospital

Chanu Rhee, MD

Instructor in Population Medicine

Harvard Medical School

Division of Infectious Diseases

Department of Medicine

Brigham and Women’s Hospital

Malcolm K Robinson, MD

Assistant Professor of Surgery

Harvard Medical School

Division of General Surgery

Department of Surgery

Brigham and Women’s Hospital

Anna Rutherford MD, MPH

Assistant Professor of Medicine

Harvard Medical School

Division of Gastroenterology, Hepatology

and Endoscopy

Department of Medicine

Brigham and Women’s Hospital

Benjamin M Scirica, MD, MPH, FACC

Associate Professor of Medicine Harvard Medical School

Division of Cardiovascular Medicine Department of Medicine

Brigham and Women’s Hospital

Simon Talbot, MD

Assistant Professor of Surgery Harvard Medical School Division of Plastic Surgery Department of Surgery Brigham and Women’s Hospital

Taylor Thompson, MD

Professor of Medicine Harvard Medical School Division of Pulmonary and Critical Care Medicine

Department of Medicine Massachusetts General Hospital

J Kevin Tucker, MD

Assistant Professor of Medicine Harvard Medical School

Renal Division Department of Medicine Brigham and Women’s Hospital

Book Page #

Septic Shock - Princples and Practices of Resuscitation

Invasive and non-Invasive Mechanical Ventilation:

Basic Principles and Goals

Paul F Nuccio, MS, RRT, FAARC

237

Mechanical Ventilation:Liberation and ABCDEF Bundle

Acute Coronary Syndromes

Arrhythmias

Indications and management of implantable electronic cardiac

devices in ICU patients

Melanie Maytin, MD

343

Post-Cardiac Arrest Care

SHOCK

RESPIRATORY FAILURE

CARDIAC ISSUES IN THE ICU

Book Page #

ENDOCRINE ISSUES IN THE ICU

GI ISSUES IN THE ICU

NEURO ISSUES IN THE ICU

HEMATOLOGIC ISSUES IN THE ICU

RENAL ISSUES IN THE ICU

INFECTIOUS DISEASE ISSUES IN THE ICU

Book Page #

Fundamentals of Clinical Nutrition: Essentials for the Critical Care Specialist

Critical Care Pharmacology

GENERAL CARE ISSUES IN THE ICU

SURGICAL CRITICAL CARE ISSUES IN THE ICU

MISCELLANEOUS ICU ISSUES

Disclosures: None

• SEPSIS: (>10% mortality)

• Life-threatening organ dysfunction

• Caused by dysregulated response to infection

• Increase SOFA score of ≥ 2

• Out of hospital, ED, Ward settings

• Worse outcomes predicted from sepsis with 2 of:

• Respiratory Rate ≥ 22/min

• Altered mental status (GCS ≤ 13)

• Requires real-world validation prior to use

What about fluid resuscitation?

*Treatment began in E.D.: 6-hours

*A-line, Central line insertion

*Monitored: Mean arterial BP (MAP)

Central venous pressure (CVP) Central venous O2 sat (SCVO2) Hematocrit

NEJM 2001; 345:1368

Oxygen Supply vs Demand

EARLY Goal-Directed Therapy

HOW’D THEY DO THAT??

EARLY Goal-Directed Therapy

IT WORKED!!

ProCESS*: What does it mean?

Mortality in usual care group substantially lower than in EGDT in first trial (18% vs 46%), thus “usual care” has evolved.

Severe sepsis without septic shock wasn’t studied in ProCESS.

Two Other large trials similar results

This trial and general practice supports

early antibiotics and fluids and uncertain re:

CVC for everyone, PRBCs ** , dobutamine Surviving Sepsis Bundle Changes 2016.

13

**TRISS trial, NEJM 2014: restrictive strategy

*and ARISE and PROMISE trials,

*

BWH Trends in “Usual Care”

What about fluid balance in

sepsis?

*Initially, later anti-inflammatory host response

From Macro- to Microcirculation

19Crit Care 2005; 9(Suppl 4):S13

Sepsis: Source Control

EARLY (1h), BROAD, EMPIRIC antibiotic therapy

Not the time to be elegant!

Think of sources needing SURGICAL

INTERVENTION

Catheter / device Remove it

Soft tissue abscess Drain it

Endocarditis Abx/Valve replacement Septic arthritis Joint debridement

“Fill the Tank”

SV x HR LVEDV x contractility

Must restore intravascular volume

Need rapid & aggressive use of crystalloid

vs colloid

Deliver as bolus infusion (via 2 large-bore iv’s and/or Cordis)

Avoid use of vasopressors as will

potentially exacerbate tissue hypoxia

Treat the underlying problem

The SAFE Study Investigators, N Engl J Med 2004;350:2247-2256

SAFE Trial: Saline vs Albumin

(for all-comers with shock)

1818 patients : crystalloid vs

crystalloid+20% albumin

Primary outcome: 28d mortality

NO DIFFERENCE in 28d mortality or other

776 patients with septic shock: MAP 80-85

vs MAP 65-70 mm Hg

Primary endpoint 28d mortality

NO DIFFERENCE in 28d mortality, 90d mortality, or adverse events

More new atrial fibrillation in high target group Chronic HTN: less RRT in high target group

25

What type of Volume resuscitation:

type of crystalloid?

Question raised of ‘danger’ of NS

No clear answer as to optimal fluid

If use NS as primary fluid, is reasonable to

Action of Vasoactive Catecholamines

Chest 2007; 132:1678-1687

Vasoconstriction

β1: HR, Contractility

β2: Vasodilation

Primary endpoint: 28d Mortality

Multi-center, RCT, 1679 patients with shock

(858 patients DA; 821 NE)

No Significant Difference

Secondary and Subgroup Analyses:

cardiogenic shock subgroup

Epinephrine as 2 nd -line Pressor

(after Norepinephrine)

330 Patients with Septic Shock:

NE + Dobut (if needed) vs EpiPrimary Outcome: 28d Mortality

No Difference

Similar secondary outcomes and adverse

“Vasopressin Deficiency” in Sepsis?

Vasopressin Depletion

Figure A- section of neurohypophysis from normal dog stained w/ antivasopressin serum Figure B- Dog after severe hemorrhagic

Norepinephrine vs NE+Vasopressin

VASST Trial NEJM 2008;358

Multicenter, Double-Blind

778 Patients Septic Shock

Primary endpoint: 28d Mortality

No Difference (35.4% Vaso vs 39.3% NE)

Subgroup of less severe septic shock: Lower mortality with Vaso 26.5% vs 35.7% p=0.05

Norepinephrine vs Vasopressin

About 400 septic shock subjects

Vaso/steroids vs vaso vs NE/steroids vs NE

No difference in kidney failure free days at 28d

Surviving Sepsis Guidelines 2016, CCM 2017

Adjunctive Sepsis Care

“Old protocol”: Treat if random cortisol<15 or increase of

<10 with ACTH-stim?

“New approach”: Perhaps consider low-dose steroids only for sickest patients not responsive to vasopressors?

Target glucose adjusted to ≤ 180 mg/dl.

1 NEJM 2008;358:111; 2 NEJM 2009;360:1283; 3 NEJM 2000;342:1301;

Sepsis Overview

Early Identification of Patients with Sepsis

Source Control and Early Broad-Spectrum

Antibiotics (as soon as possible)

Early fluid resuscitation, primarily with crystalloid (“Early Goal Directed Therapy” – monitor

response; monitor lactate levels if elevated)

Norepinephrine as First Pressor of Choice

Consider Addition of Vasopressin to Levophed Consider Epinephrine as 2nd-line Agent for

Refractory Hypotension to Levophed

Limited role for Dopamine and Neosynephrine

as initial agents of choice

Consensus Guidelines, Crit Care Med 2017 39

Sepsis Overview

Activated Protein C is no longer available.

Consider low-dose hydrocortisone for patients with

sepsis-induced refractory hypotension despite fluids and pressors (without use of ACTH stim test to guide

decision-making).

Uncertain goal of glucose control, but target ≤ 180 mg/dL (instead of tighter control) suggested until more data

available Hourly monitoring of glucose levels while on

an insulin drip is critical, and avoid hypoglycemia.

Attention to standard ICU care (e.g., ventilator bundle, DVT and GI prophylaxis, central line care, etc).

No better

High Risk of Death

NO rhAPC

Start LD HC(??)

LOW Risk of Death

Improving

Check Cx’s -> narrow Abx

Question #1

A 47 yo woman with alcoholic cirrhosis is brought to your ER with fevers, confusion, shortness of breath, and worsening ascites SBP is 50 mmHg, HR 150 bpm, RR 40/min, and O2 sat 80% with a CVP of 4

mm Hg CXR shows diffuse infiltrates, and peritoneal fluid returns with a leukocyte count of 1000/ µ L (95% polys) Initial management of hemodynamics should entail use of:

a Vasopressin

b Norepinephrine

c Norepinephrine + Lasix

d Intravenous fluids

Question #1

A 47 yo woman with alcoholic cirrhosis is brought to your ER with fevers, confusion, shortness of breath, and worsening ascites SBP is 50 mmHg, HR 150 bpm, RR 40/min, and O2 sat 80% with a CVP of 4

mm Hg CXR shows diffuse infiltrates, and peritoneal fluid returns with a leukocyte count of 1000/ µ L (95% polys) Initial management of hemodynamics should entail use of:

Question #2

Your administer broad-spectrum antibiotics to treat presumed spontaneous bacterial peritonitis, give her supplemental O2 (now saturating 90% on 100% FM), and after fluid resuscitation with 3L of crystalloid, her

HR comes down to 100 bpm, her SBP has risen to

65 mm Hg with a mean arterial pressure (MAP) of 50

mm Hg, and the CVP is 13 mm Hg You next order:

HR comes down to 100 bpm, her SBP has risen to

65 mm Hg with a mean arterial pressure (MAP) of 50

mm Hg, and the CVP is 13 mm Hg You next order:

a Vasopressin

b Norepinephrine

c Norepinephrine + Lasix

d 1 Unit of PRBCs

“EARLY Goal-Directed Therapy”

INTERVENTION

Norepinephrine 500cc IVF Q 30 min!

A Few Key References

C.I Pro, D.M Yealy, J.A Kellum, D.T et al A randomized trial of protocol-based care for early septic shock, N Engl J Med 370(18) (2014)

1683-93.

M Singer, C.S Deutschman, C.W Seymour, et

al The Third International Consensus

Definitions for Sepsis and Septic Shock 3), JAMA 315(8) (2016) 801-10.

(Sepsis-A Rhodes, L.E Evans, W Alhazzani, et al.

Surviving Sepsis Campaign: International

Guidelines for Management of Sepsis and

Septic Shock: 2016, Crit Care Med 45(3)

1 Epidemiology and Burden

2 Definitions and Diagnosis

3 Updates to Management Guidelines

Sepsis: See it, Treat it, Defeat it

The Brigham Health Sepsis Task Force

Why All the Fuss About Sepsis?

Sepsis Burden in the U.S.

• >1 million sepsis cases/year1

• #1 cause of death in noncoronary ICU’s2

• Most expensive condition treated in hospitals3

• May contribute to up to 30-50% of hospital

deaths4

• Survivors also at high risk for recurrent sepsis,

readmission, cognitive and functional

impairment5

1 Gaieski, Crit Care Med (2011)

2 Minino, NCHS Data Brief (2012)

3 Torio, HCUP Statistical Brief #160 (2013)

4 Liu, JAMA (2014)

5 Winters, Crit Care Med (2010)

• April 2012 – 12 year old boy died of septic shock in NY City

• Symptoms not initially recognized by pediatrician / ER

• Family embarked on nationwide campaign to raise sepsis

awareness and prevent further deaths

Recent Public Attention

A New Era of Policy Initiatives for Sepsis

• In 2012, New York State mandated sepsis

protocols in all state hospitals (“Rory’s

Regulations”)

• Followed by public reporting and

benchmarking for protocol adherence

• CMS sepsis quality measure (SEP-1) took effect October 1st, 2015

• Pay-for-reporting measure: hospitals report

compliance with 3 and 6 hour bundles for

patients diagnosed with sepsis

So what is sepsis, really?

• Sepsis was described more than 2,000 years ago

• Clearly refers to a “bad infection”

• But clinicians still struggle to define it

• Florid cases (e.g., meningococcemia) are a

minority of cases

• 5 case vignettes of patients with suspected or

confirmed infection and possible organ

dysfunction distributed to 94 academic

intensivists

Respondents classified cases as SIRS alone,

sepsis, severe sepsis, septic shock, or none of the above

Rhee et al, Crit Care 2016

Case Vignette

67 year old male with severe congestive heart

failure presents with several days of progressive

shortness of breath, lower extremity swelling,

malaise, productive cough, and subjective

fevers.

Low grade fever in ED, rapid atrial fibrillation,

hypotensive, with signs of volume overload

Labs with elevated WBC, lactate, and acute

kidney injury

Chest X-ray with pulmonary edema and possible left lower lobe infiltrate

Case Vignette, continued

Gets fluids, diltiazem, and antibiotics

Decompensates into respiratory failure, shock and

altered mental status, requiring intubation and

vasopressors

Admitted to ICU – continued on vasopressors,

antibiotics, anti-arrhythmic medications, and

diuresis

Improves and gets extubated Blood and sputum

cultures negative Finishes course of antibiotics

Sepsis is a complex syndrome without a

pathological gold standard

• Often unclear if a patient is infected or not

• Vague thresholds for defining organ

dysfunction

• Attributing physiologic signs and organ

dysfunction to infection vs other causes is subjective

Challenges in Diagnosing Sepsis

Purpose of Sepsis Definitions

Sepsis has no true “gold standard” – even expert clinicians disagree (very often) as to who has “sepsis”

So why try to define sepsis in the first place?

• Sepsis “definitions” are really clinical criteria meant to aid

clinicians:

Help identify patients at high risk of adverse

outcomes, in whom early interventions can improve outcomes

• Secondarily, defining sepsis helps us:

Understand its epidemiology

Track outcomes and quality of care

Define criteria for clinical studies