kesusc|tanon: Coo||ng,

Drugs, and I|u|ds

8r|an k. Geh|bach, MD
D|v|s|on of u|monary, Cr|nca| Care, &
Cccupanona| Med|c|ne
Un|vers|ty of Iowa
D|sc|osure
none
Cb[ecnves
1. ClLe approprlaLe endpolnLs for resusclLauon ln Lhe
managemenL of sepuc shock.
2. ulscuss Lhe approach Lo uld resusclLauon ln crlucally lll
pauenLs.
3. uescrlbe Lhe use of arLerlal pulse pressure varlauon,
lnsplraLory changes ln cenLral venous pressure, and
ulLrasonographlcally assessed resplraLory changes ln
lnferlor vena cava dlameLer ln deLermlnlng uld
responslveness.
4. uescrlbe Lhe uses of waveform capnography durlng ACLS.
3. uescrlbe Lhe approach Lo neurologlc prognosucauon
followlng cardlac arresL, and how Lhls assessmenL has
been lnuenced by Lherapeuuc hypoLhermla.


A 6S yo ma|e |s adm|ued to your ICU aher presennng 1
hour prev|ous|y to the LD w|th fever, cough, sputum, and
SC8. n|s |s treated w|th annb|oncs, |ntubanon and
mechan|ca| venn|anon, centra| ||ne p|acement, and 3 ||ters
of norma| sa||ne. Cn your exam, he |s an obese man who
|s sedated and synchronous w|th the venn|ator on ACV
w|th 1V 6 m|]kg I8W. 8 |s 7S]S0, pu|se |s 12S, and CV |s
10 mm ng. n|s extrem|nes are somewhat coo|, and h|s
na||bed return |s s|ugg|sh. Chest h|m shows a kLL |nh|trate
w|th b||atera| edema and an adequate|y pos|noned L11.
n|s |actate |s 4.3 and h|s centra| venous saturanon |s SS.
1he arter|a| pu|se pressure var|anon |s 17.

Wh|ch of the fo||ow|ng statements |s true regard|ng
the resusc|tanon of th|s panent?

A. A uld bolus ls unllkely Lo lncrease Lhe pauenL's cardlac
ouLpuL glven LhaL hls Cv ls already 10 mm Pg.
8. lL ls lnapproprlaLe Lo glve ulds because a resLrlcuve
uld approach (malnLalnlng Cv < 4) has been shown Lo
lmprove cllnlcal ouLcomes ln Lhls semng.
C. LacLaLe clearance ls equlvalenL Lo cenLral venous
saLurauon monlLorlng as an endpolnL of resusclLauon ln
Lhe managemenL of sepuc shock.
u. volume should be admlnlsLered. Sallne, albumln, or
10 penLasLarch are all accepLable cholces.
L. lf a vasopressor ls needed, dopamlne ls preferred over
nL ln Lhls slLuauon because lL ls less arrhyLhmogenlc.
Rivers et al NEJM 2001.
Early Goal Directed
Therapy
263 patients randomized to
6 hrs of usual care or EGDT
! in-hospital mortality with
EGDT (30.5% vs 46.5%)
The approach to
resuscitation matters!
EGDT pts received 1.5 liters
more fluid than control pts in
the first 6 hours
Lxamp|es of harm from u|ds: 2 stud|es
IAC11
auenLs wlLh ALl/A8uS
Conservauve vs llberal
approach Lo ulds when
hemodynamlcally sLable
More u|d = more nme on
venn|ator
A8uS neLwork nL!M 2006.
ILAS1
Chlldren wlLh malarla &
lmpalred perfuslon.
^ morta||ty |n both sa||ne
& a|bum|n groups (versus
no bolus group).
klds, & resource-poor
semng, buL sull!
MalLland eL al nL!M 2011.
I|u|d accumu|anon & morta||ty
Bouchard et al. Kidney International 2009.
Shou|d I g|ve u|ds?
Potential benefits
" CO

" BP

" end-organ perfusion
Potential harm
Pulmonary edema

Gut edema

Abdominal
compartment
syndrome

Skin breakdown

Cerebral edema

RV overload

Electrolyte abnl

Dynam|c |nd|ces are best
for pred|cnng u|d
respons|veness
Ap > 13 predlcLs uld
responslveness (! Cl by "13)
-94 sensluve
-96 speclc
Michard et al. AJRCCM 2000.
Important caveats!
keduced sens|nv|ty at |ower 1V (e.g. 6 m|]kg I8W)
1yp|ca||y requ|res deep sedanon (|naccurate |f panent |s
not pass|ve)
Arrhythm|as |nva||date use
Not app||cab|e to the spontaneous|y breath|ng panent.
Does the panent need an |ncreased card|ac output?
lluld-responslve!!
!"#$ &'$ ())*+&, -& . /01
red|cnng u|d respons|veness |n the
spontaneous|y breath|ng panent
! AbsoluLe values of cardlac lllng pressures noL
parucularly helpful.
! lnsplraLory # ln Cv by > 1 mm Pg suggesuve, buL lacks
sensluvlLy.
! asslve leg ralslng-need Lo monlLor change ln blood
ow.
! vlgorous resplraLory eorLs can confound
lnLerpreLauon of pressure Lraclngs
CV trac|ng |n a panent w|th forced
exp|ranon. Is the CV rea||y 28?
Magder S. CCM 2006.
0
40
m
m

n
g

A "reasonab|e guess"
Lnd exp|ranon
Feissel et al. Intensive Care Med 2004.
"s in IVC diameter with
mech insufflation predict
fluid responsiveness in pts
receiving MV
U|trasound
Max DIVC - Min DIVC x 100
Min D
IVC

Max DIVC - Min DIVC x 100
Avg DIVC
>18% predicts response
>12% predicts response
Caveats: obesity, " IAP
Barbier et al. Intensive Care Med 2004.
300 pLs randomlzed Lo lacLaLe clearance vs SCvC
2
as
LargeL

Ls resusclLaLed Lo:
Cv > 8mm Pg
MA > 63 mm Pg
L|ther (a) SCVC
2
of 70 or h|gher or (b) |actate c|earance of
at |east 10
no dlerence ln ln-hosplLal morLallLy (23 SCvC
2
group vs
17 lacLaLe clearance group) or ln LreaLmenL-relaLed
adverse evenLs
Jones et al. JAMA 2010.
Co||o|ds versus crysta||o|ds
no convlnclng evldence for superlorlLy of collolds
over crysLallolds (SAlL sLudy, oLhers)
Parmful eecLs deLecLed from some collolds (e.g.
hydroxyeLhyl sLarch) and ln some semngs (e.g.
albumln ln 18l ln SAlL sLudy)
Collolds are more expenslve
Currently, there exists no established role for colloids in the
routine management of critically ill patients.
Now, which crystalloid??? Stay tuned!
In|na| VA cho|ce by |nd|canon
Card|ogen|c shock w|th adequate 8
uobuLamlne ls Lhe agenL of cholce ln mosL slLuauons.
Card|ogen|c shock w|th hypotens|on
nL (esp ln 8Pl), alone or ln comblnauon wlLh
dobuLamlne.
Sepnc shock
reserved/elevaLed CC: nL epl or low-dose v
ConcomlLanL cardlac dysfuncuon: Conslder dobuLamlne
CompllcaLed by LachyarrhyLhmlas: Conslder
phenylephrlne
uopamlne Lends Lo cause more arrhyLhmlas Lhan nL.
!2-3)4 )$ -4 /'567-&) 8-$-"-() 9:($ ;)3 <=>>? @-(# )$ -4 A'#7&-4 'B C&$)&(+3) /-7) D)E+5+&) <=>>1F
A S8 year o|d ma|e w|th DM, n1N, CAD, CSA, and CkI
who was adm|ued to the hosp|ta| for pneumon|a
exper|ences a card|ac arrest on the second day of
hosp|ta||zanon. 1he |n|na| rhythm |s LA. ACLS |s
prov|ded and the end nda| CC
2
|s 22 mm ng dur|ng
Ck. ne exper|ences kCSC aher 1S m|nutes and |s
transferred, unconsc|ous, to the MICU for connnued
care. When you exam|ne h|m he tr|ggers the
venn|ator and coughs to sucnon|ng but has no
pup|||ary responses.
Wh|ch of the fo||ow|ng statements |s true?
A. Pls lnlual rhyLhm precludes Lhe use of Lherapeuuc
hypoLhermla.
8. 1he end udal CC2 value (22 mm Pg) obLalned durlng
C8 suggesLs LhaL Lhe chesL compresslons were of
hlgh quallLy.
C. 1he absence of puplllary responses ls sLrongly
assoclaLed wlLh a poor long-Lerm neurologlc
ouLcome.
u. 1herapeuuc hypoLhermla, lf performed ln Lhls case,
wlll noL alLer Lhe operaung characLerlsucs of Lhe
varlous Lools used Lo predlcL long-Lerm neurologlc
ouLcome.
L. 1he durauon of C8 ln Lhls case sLrongly predlcLs a
poor prognosls.
Waveform capnography |s recommended |n ACLS to
Conrm & conunuously monlLor Lhe posluon of Lhe Lracheal
Lube
Lnsure quallLy of C8 (LargeL L1CC2 of aL leasL 10-20 mm Pg)
ueLecL 8CSC
Good
Bad
ROSC
Waveforms from hup://emscapnography.blogspoL.com/
ou got h|m back! !"# #%&'(
M||d therapeunc hypotherm|a: |t's recommended!
kecommended for Lhe comaLose (le lack of meanlngful
response Lo verbal commands) adulL pauenL wlLh 8CSC
aer vl/pulseless v1 (Class l, LCL 8).
May be cons|dered for Lhe comaLose adulL pauenL wlLh
8CSC aer LA/asysLole (Class ll8, LCL C).
1argeL 32 Lo 34 C for 12 Lo 24 hours
Circulation 2010.
Wl[dlcks eL al. neurology
2006.
2006
And |n 2013??
racnce parameter:
pred|cnon of outcome
|n comatose surv|vors
aher Ck
rognosncanon |s |n evo|unon, parncu|ar|y when the
panent has been cooled
! CerLaln ndlngs noL as rellable ln pLs LreaLed wlLh
hypoLhermla
! MoLor ndlngs
! resence of myoclonus sLaLus epllepucus
! neuron speclc enolase levels
! Sull reasonably predlcuve of poor ouLcome:
! Absence of boLh corneal and puplllary reexes > 72 hours aer
arresL
! 8llaLeral absence of n20 peak on SSL's
! unreacuve LLC background
8LS1 1C NC1 kLL CN AN SINGLL 1LS1 Ck ASSLSSMLN1

Cddo eL al. Curr Cpln CrlL Care 2011.
otenna| confounders |n
prognosncanon
-Sedauves, analgeslcs, and nM blockers
-Crgan dysfuncuon (llver, kldney.)
-MeLabollc derangemenLs
-Shock
-Sepsls
-PypoLhermla!!
1he 8ouom L|ne
1. uynamlc hemodynamlc lndlces are beuer Lhan sLauc
lndlces aL ldenufylng pLs who mlghL beneL from ulds.
2. 8ouune uld accumulauon durlng Lhe course of crlucal
care ls llkely harmful.
3. 1here ls no advanLage Lo Lhe use of collolds over
crysLallolds ln Lhe mgmL of Lhe Lyplcal lCu pauenL.
4. LacLaLe clearance ls equlvalenL Lo monlLorlng cenLral
venous saLurauon for pLs wlLh sepuc shock.
3. nL ls Lhe drug of cholce for sepuc shock & for
cardlogenlc shock wlLh hypoLenslon.
6. Conunuous waveform capnography provldes valuable
lnformauon durlng ACLS.
7. neurologlc prognosucauon should be more
conservauve when Lherapeuuc hypoLhermla has been
used.
1he vo|ume-respons|ve |ntens|v|st