Updates from recent International Meeting

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Updates from recent International Meeting

• Husain A Alawadhi MD
• Senior Consultant
• Hamad General Hospital
• Doha, Qatar

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Professor Jean-Louis Vincent
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www.mecriticalcare.net
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I HAVE TO SAY

• 30 MINUTES ? 4 DAYS
• MANY ALREADY PRESENTED
• NO SLIDES AVAILABLE
• NEW
• A flower from each bustan

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What is the main language in Belgium? One or more
than one answer .

• Belgish (Belgium) language?
• English language ?
• Euro language ?

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Diamond Chocoltae
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STREPTOCOCCAL INFECTION and XYGRIS Update
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KIDNEY

• Thank you

• Prevention of AKI
• Diagnosis of AKI
• Treatment of AKI

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Claudio Ronco is Professor of Clinical Nephrology
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Still using RIFLE criteria
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As of 2010 , what can protect the kidney ?
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Alkaline phosphatase (AP) attenuates inflammatory
responses by lipopolysaccharide detoxification
and may prevent organ damage during sepsis. Dr
peter Pikkers
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Results

• The 28-day overall mortality after inclusion in
  the AP-treated group was 24, compared with 36
  in the placebo-treated group (p 0.45).
• The mortality rate in patients with AKI tended to
  be lower in the AP group relative to the placebo
  group (AP 27 placebo 60 p 0.21).

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Diagnosis of AKI
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Treatment TIMING

• We do not know, what is the BEST TIME to start
  hemodialysis .
• ( BEST study ). Beginning and Ending Supportive
  Therapy for Kidney. a multicenter study in 23
  countries JAMA 2005 813-818.
• Met analysis suggested Early initiation may have
  better outcome .Am J Kidney Dis 2008 52 272-284.

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Clin J Am Soc Nephrol 3 876-880, 2008
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Conclusions 20 ML/KG 35 ML/KG
Conclusions Intensive renal support in critically
ill patients with acute kidney injury did not
decrease mortality, improve recovery of kidney
function, or reduce the rate of nonrenal organ
failure as compared with less-intensive therapy
involving a defined dose of intermittent
hemodialysis three times per week and continuous
renal-replacement therapy at 20 ml per kilogram
per hour.
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25 ML/KG 40 ML/KG
Conclusions In critically ill patients with acute
kidney injury, treatment with higher-intensity
continuous renal-replacement therapy did not
reduce mortality at 90 days.
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TREATMENT OF AKI 2010
Haemofiltration Study IVOIRE (hIgh VOlume in
Intensive Care Early high voume (70 ml/kg/h)
VS (35 ml/kg/h)
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What are the new things for the heart ?
1-learn ECHO 2-External machine
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ECHO by Non cardiologist
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Intra-Aortic Balloon Pump (IABP).
11/3/2013
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• Intra-Aortic Balloon Pump (IABP) -.
• It is inserted into the descending aorta via the
  femoral artery either percutaneously or by
  surgical cut-down.
• The balloon rapidly deflates just before
  ventricular systole to reduce the impedance (A
  measure of the total opposition to current flow
  in an alternating current circuit) to left
  ventricular ejection

11/3/2013
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No we can do it from outside
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Counterpulsation from outside

Enhanced External Counterpulsation
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Postulated Mechanisms of Action
Hemodynamic Effects of EECP
Increase Cardiac Output
Increase coronary Perfusion
Diastolic Augmentation
Pressure Gradients
Improve Diastolic Filling
Diastolic Retrograde Flow
occlusion
Increase Venous return
Systolic unloading
Enhance Collateral capillary sprouting
Remodeling
Increase Shear Stress on endothelium
Neurohormonal Release Increases NO,
ANP Deceases BNP, ET-1, ACE,
ANG II
Angiogenesis and Arteriogenesis
Release of Growth Factors
Improve Endothelial Function
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• HOW TO PROTECT THE LUNG FURTHER FROM Ventilator
  Injury
• HFOV

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Lung protectiv strategy. ARDSnet protocol

• Ensures oxygenation without causing further
  damage to the lung or other organs. it's always a
  priority!
• - low tidal volume (6 ml/kg in ALI/ARDS)gtgtpermissi
  ve Hypercapnea
• - limited alveolar pressure (lt 30-35 mH2O) gtgt
  permissive hypercapnea

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Figure 2. The normal alveolus compared with the
injured alveolus in the early phase of ALI and
ARDS. Under the influence of proinflammatory
cytokines such as IL-8, IL-1, and TNF,
neutrophils initially undergo sequestration in
the pulmonary microvasculature, followed by
margination and egress into the alveolar space,
where they undergo activation. Activated
neutrophils release a variety of
factors(leukotrienes, oxidants, proteases, and
PAF) which contribute to local tissue damage,
accumulation of edema fluid in the airspaces,
surfactant inactivation, and hyaline membrane
formation. Macrophage inhibitory factor (MIF)
released into the local milieu sustains the
ongoing pro-inflammatory response. Subsequently,
the release of macrophage-derived fibrogenic
cytokines (TGF-ß and PDGF) stimulate fibroblast
growth and collagen deposition a/w the healing
phase of injury.                                  
                                            
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• Giving oxygen Oxygenation
• Washing Co2 ventilation
• Can we wash Co2 without ventilator??
• Since the word capnograpghy monitoring Co2, we
  can make a new word in medical terminology .

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Washing Co2 from inside IVC
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Prof Welte Tobias
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2008
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LUNG ASSISTANT DEVICE iLA Membrane Ventilator
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INDICATION ( as per company)

• COPD
• VENTILATOR WEANING
• ARDS/ALI
• BRIDGE TO TRANSPLANATTION
• INCREASED ICP
• BRONCHOPLEURAL FISTULAS
• INTENSIVE CARE TRANSPORATION

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Decapneization, in summary

• Lung assistant device
• Extracorporeal Ventilation( NOT ECMO)
• Rest lung
• No ventilator induced Lung Injury
• Can be used to prevent INTUBATION
• Can be used during VENTILATION
• Can be used during Weaning
• Can be used Post EXTUBATION , to avoid
  re-intubation
• Less intubation Less sedation less infection

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What is good for the brain ?
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Cool the brain after cardiac arrest or severe
raised ICP
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Hypertonic Saline 23.4

• Improves CPP and brain tissue O2 levels
• Decreased ICP by 35 (8-10 mm HG)
• CPP increased by 14
• MAP remained stable
• Greatest benefit in those with higher ICP and
  lower CPP
• Repeated doses were not associated with rebound,
  hypovolemia or HTN
• 30 mL of 23.4 over 15 minutes

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DEAD SEA 33.7 salinity
On comparison, seawater in the world's oceans has
a salinity of about 3.5.
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• H1 N1 influenza virus

• Invasive Streptococcal Disease

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H1N1 peak is coming down.

• Literature is full about this outbreak.
• Some publications suggested a benefit role of
  HFOV.
• We have to look gain in depth to HFOV in our ARDS
  patients.

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IF YOU NEED MORE INFORMATION ABOUT H1N1
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NEW
OLD
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DISEASES CAUSED BY STREPTOCOCCUS PNEUMONIAE
PNEUMOCOCCAL INFECTION

• Non-invasive disease
• Sinusitis (sinuses)
• Otitis media (middle ear)
• Pneumonia (lungs)

• Invasive disease
• Bacteraemia (blood)
• Meningitis (CNS)
• Endocarditis (heart)
• Peritonitis (body cavity)
• Septic arthritis (bones and joints)
• Others (appendicitis, salpingitis, soft-tissue
  infections)

Musher, in Principles and Practice of
Infectious Diseases, 1995
2.13
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Michael Niederman MD
636 pages
448 pages
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• Start combination Antistreptoccocal
  antibiotics.Michael niderman

• REASON one The streptococcus may be PCN
  resistant. So dual therapy will overcome this ,
  in the first 72 critical hours.
• REASON two IPD fatality is high in the first
  few days, so combination therapy is recommended
  for SHORT period of time ,until pt improves
  clinically .

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Treatment outcome

• Overall mortality rates for patients with
  pneumococcal Bacteremia have consistently ranged
  from 15 to 20 in the antibiotic era.
• Death mainly in the first three days.
• More death
• if age gt65 ( 15-35)
• severity if illness,
• underlying immunosuppressant.

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MONITORING YOUR PATINT
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Monitoring ISSUES

• PAgtgtgtgt out if fashion
• Noninvasive Technology gtgtgtin fashion
• Simple and non sophisticatedgtgt coming into
  fashion
• LACTATE
• SVO2
• TISSUE IS THE ISSUE

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What is StO2?

• StO2 hemoglobin oxygen saturation of the
  microcirculation

ScvO2 measures O2 saturation in the superior vena
cava. SvO2 measures O2 saturation in the
pulmonary artery.
SaO2 and SpO2 measure O2 saturation in the
arteries.
SaO2 SpO2
ScvO2 SvO2
InSpectra StO2
StO2 measures O2 saturation in the microcirculatio
n where O2 diffuses to tissue cells. StO2 is a
measure of tissue oxygenation and is a sensitive
indicator of tissue perfusion status.
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Clinical Range of StO2

• InSpectra StO2 below 75 indicates serious
  hypoperfusion associated with MODS and death in
  trauma patients.1
• InSpectra StO2 above 75 indicates adequate
  perfusion.1
• InSpectra StO2 functions as well as base deficit1
  and lactate2 in indicating hypoperfusion in
  trauma patients.

Reduced O2 Consumption??8
1Cohn SM, Nathens AB, Moore FA, Rhee P, Puyana
JC, Moore EE, Beilman GJ. Tissue Oxygen
Saturation Predicts the Development of Organ
Dysfunction During Traumatic Shock Resuscitation.
J Trauma. 200762(1)44-55.
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The InSpectraTM StO2 Tissue Oxygenation System

• Noninvasive
• Easy to use
• Fast response
• Readings unaffected by
• Age
• Gender
• Edema
• Skin pigmentation
• Adipose
• Operates in presence of hypothermia

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• X on the x drug ?
• Most likely No

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Critical Care Med. 2008 Jan36(1)296-327
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SUMMARY SEPSIS GUIDELINES 2008
Strong Recommendation (1) Recommended
A
D
C
B
DVT Prophylaxis
Antibiotics within 1 hr for Septic Shock
EGDT and Protocolized Resuscitation
Antibiotics within 1 hr in No septic Shock
Patients
H2 Blocker PUD Prophylaxis
Glycemic Control
Fluid Challenge
7-10 day Antibiotic Duration
Crystalloid Colloid
BC prior to Abx
No Routine Use of SGC
PPI PUD Prophylaxis
Source Control
Consider Limiting Support
Low VT for ALI
Dopamine or Norepinephrine
No Renal Dose Dopamine
HOB gt45
Limit P plateau lt30 cm H2O
Limited Transfusion
No High Dose Steroids
No Antithrombin II
PEEP
No Erythropoietin
De-escalation Antibiotic Therapy
Intermittent Continuous sedation
Conservative Fluid in ALI with no Shock
Weaning Protocol/SBT
Avoid NMB
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Weak Recommendation (2) Suggested
A
D
C
B
APC in high risk and non-surgical
Wean Steroids
PRBCs or Dobutamine
equivalency of continuous veno-veno
hemofiltration or intermittent hemodialysis
APC for high risk and surgical
Low dose steroids for septic shock
ACTH test not to be done
NIV for ALI/ARDS mild/moderate hypoxemia
B/S lt 150
Prone Position in ARDS
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WHAT IS NEW ABOUT xigris
LONGER duration
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HIGHER dose
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Questions for 2010

• Is larger dose better? ( and still safe ).
• Is longer duration is better? ( and still safe )
• Dose it correlate with Protein C deficiency level
  ?
• Would we put X on the Xigris drug

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THANKS , ANY QUESTIONS ?