0945 - Friday - Non Pulmonary Critical Care Pearls - Sessler

Critical Care Pearls
Curtis N. Sessler, MD, FCCP, FCCM

Orhan Muren Professor of Medicine
Virginia Commonwealth University Health System
Director, Center for Adult Critical Care
Medical College of Virginia Hospitals
csessler@vcu.edu
© 2014 American College of Chest Physicians
Curtis N. Sessler, MD, FCCP, FCCM
No potential conflicts of interest to disclose

•  Sedation and analgesia
•  Delirium
•  Severe sepsis
•  Supportive critical care

Sedation & Analgesia

Pain & Analgesia: Clinical Statements &
Recommendations*
•  Incidence of pain •  Treatment of pain
•  ICU patients routinely •  Use preemptive analgesia and/
experience pain or non-pharmacologic
interventions prior to
•  Procedural pain is procedures* (+1C or 2C)
common in adult ICU pts •  i.v. opioids list-line for non-
•  Pain assessment neuropathic pain* (+1C)
•  Routinely monitor pain in •  i.v. opioids are equally effective
all ICU patients (+1B) •  Use nonopioid analgesics (+2C)
•  BPS and CPOT are •  Use gabapentin or
carbamezepine + i.v. opioids for
preferred observational neuropathic pain* (+1A)
pain scales (B)
•  Consider neuraxial anesthesia/
•  Vital signs can be cue but analgesia in selected cases*
not used alone for pain rx © 2014 American College of Chest Physicians
Barr et al. Crit Care Med 2013
Pain Assessment:
For All ICU Patients
•  Self-reported pain is the gold standard Puntillo et al. Chest
2009; 135:1069-74
•  We recommend that pain be routinely monitored in all adult
ICU patients (+1B) Barr et al. Crit Care Med 2013

Pain Assessment: Vital Signs?
•  We suggest that vital signs may be used as a cue to begin further

assessment of pain in these patients (+2C), however
•  We do not suggest that vital signs (or observational pain scales
that include vital signs) be used alone for pain assessment in
adult ICU patients (-2C)

Behavioral Pain Scale
Ø Total score = 3-12

Payen et al. Crit Care Med 2001; 29:2258-63.
Treatment of Pain
•  We suggest that for invasive and potentially painful
procedures, preemptive analgesic therapy and/or non-
pharmacologic interventions may be administered to
alleviate pain (+2C)
•  Stronger recommendation for chest tube removal
(+1C)
Barr et al. Crit Care ©Med 2013

2014 American College of Chest Physicians
Treatment of Pain
•  We suggest that analgesia-first sedation be used in adult
ICU patients who are mechanically ventilated (+2B)

Systematic Evaluation of Pain (BPS) and Agitation (RASS)
in an ICU
Parameter Control Intervention p
Pain events 63% 41% <.01
Agitation events 30% 14% <.01
Duration of ventilation 120h 65h .01
Reintubation 10% 7% .77
Tube/line self-removal 19% 18%
ICU LOS 8.5 7.0 .38
Nosocomial infection 17% 8% <.05
Mortality 12% 15% .76
Changues et al. Crit Care Med 2006; 34:1691 © 2014 American College of Chest Physicians
Treatment of Pain
•  We recommend that intravenous opioids should be
considered as the first-line drug class of choice to treat non-
neuropathic pain in critically ill patients (+1C)
•  All available intravenous opioids, when titrated to similar pain
intensity endpoints, are equally effective (C)

Opioids Commonly Used in ICU
Opioid T1/2 Maint MS Unique Concerns

(h) Dose EDR
Morphine 1.5-5 0.5-50 1 i HR, i BP, bronchospasm,
mg/hr active metabolite
Hydromorphone 3 0.25-50 0.2 Dosing errors due to high
mg/hr potency
Fentanyl 1.3-3 12.5-200 0.015 Rapid onset, delayed offset
mcg/hr after long use, muscle rigidity
Remifentanil 0.05 0.6-15 i HR, i BP, muscle rigidity,
mcg/k/h hyperalgesia
Erstad et al. Chest 2009; 135:1075, Patanwala et al. Ann Pharmacother 2007;41:255
Question
Fentanyl infusion has been associated with which of the following
adverse effects?
A. Neurotoxicity
B. Prolonged QTc-related torsades de pointes
C. Rigidity
D. Histamine release

Common Opioid
Adverse Effects
•  Allergy (MS) •  Myoclonus

•  Arrhythmias (Meth: QTc) •  Nausea / vomiting
•  CNS depression (MS) •  Neurotoxicity (Meperidine)
•  Constipation •  Opioid dependency
•  Cough (Fent) •  Pruritis
•  Dry mouth •  Rigidity (Fent, Remi)
•  Histamine release (MS, Meth) •  Serotonin syndrome
(Meperidine, Meth)
•  Hyperalgesia (Remi)
Erstad et al. Chest 2009; 135:1075-86

Opioid Caveats in
ICU Pain Management
•  Use fentanyl 25-100 mcg IVP q5-15 min for rapid

pain control
•  Avoid morphine in renal failure (active metabolite)
or shock
•  Avoid meperidine (demerol) in critically ill
(neuroexcitatory)

Agitation & Sedation: Clinical Statements &
Recommendations*
•  Monitoring depth of sedation •  Light level of sedation

•  RASS or SAS preferred (B) •  Better outcomes
•  Objective measures (BIS, etc)* •  Physiologic stress
•  Not for routine monitoring •  Psychological stress
•  Ok for coma or NMBA •  Titrate meds to light
•  Ok for non-convulsive level of sedation* (+1B)
seizures •  Use daily interruption of
•  Choice of sedative sedation or light level*
(+1B)
•  Prefer non-benzodiazepine
over benzodiazepines* (+2B) Barr et al. Crit Care Med 2013
Agitation & Sedation
The Richmond Agitation-Sedation Scale (RASS) and Sedation-
Agitation Scale (SAS) are the most valid and reliable sedation
assessment tools for measuring quality and depth of sedation
in adult ICU patients (B)

Question
Dexmedetomidine infusion is commonly associated with which of
the following adverse effects
A. Hypertriglyceridemia
B. Prolonged sedation from active metabolites
C. Metabolic acidosis from propylene glycol
D. Bradycardia

Sedative Medications
Agent Mechanism T1/2, Active Unique properties /
hr metabolite Adverse effects
Midazolam GABA agonist 3-11 Yes i BP, h duration w renal
failure
Lorazepam GABA agonist 8-15 No i BP, propylene glycol-
related acidosis, ATN
Propofol GABA, glycine, 0.5 No i BP, h triglycerides,
nicotinic, pancreatitis, allergic
muscarinic rxn, PRIS. Rapid onset
agonist & offset of action
Dexmede- Selective α2 2-3 No i BP, i HR. Less resp
tomidine agonist depression, $$
Use of Intravenous Infusion Sedation in U.S. Mechanically
Ventilated Patients
Project IMPACT database: > 100,000 mechanically ventilated pts from 174 ICUs
Prop
Benzo
Midaz
Loraz
Dex
2001 2007
Wunsch et al. Crit Care Med 2009; 37:3031-39 © 2014 American College of Chest Physicians
Agitation & Sedation
We suggest that sedation strategies using non-benzodiazepine
sedatives (either propofol or dexmedetomidine) may be preferred
over sedation with benzodiazepines (either midazolam or
lorazepam) to improve clinical outcomes in mechanically
ventilated adult ICU patients (+2B)
Barr et al. Crit Care© 2014

Med 2013
American College of Chest Physicians
Meta-analysis of Propofol vs Alternatives for Moderate to
Long Duration
•  16 RCTs published prior to 2008 totaling 1386 ICU patients; focus
on moderate (2-7d) to Long (> 7d) duration
•  Sedation with propofol…
•  ICU LOS was 1 day shorter than alternative agent (p = 0.0002)
•  If only vs midazolam: 1 d shorter but p =0.3
•  0.3 day shorter duration of MV (p = 0.04)
•  If only vs midazolam: 0.2 d shorter (p = 0.0007)
Ho et al. Intensive Care Med 2008; 34:1969-79 © 2014 American College of Chest Physicians
Meta-analysis of Dexmedetomidine vs Alternatives for ICU
Sedation
•  24 RCTs published prior to 2010 totaling 2419 ICU patients
•  Sedation with dexmedetomidine…
•  ICU LOS was 0.5 day (-0.8,-0.2) shorter than alternative agents (p =
0.002)
•  Duration of mechanical ventilation was not shorter: p =0.42 (-0.5d (-1.8,
0.7)
•  Risk of bradycardia similar (RR = 1.8 (0.6-5.0), p = 0.25) unless loading
dose + high infusion
Tan & Ho. Intensive Care Med 2010; 36:1877-1886 © 2014 American College of Chest Physicians
•  2 multicenter European RCTs (n = 998)
•  Primary end-points
•  Time at target sedation (RASS)
•  Duration of mechanical ventilation
•  Secondary end-points
•  Ability to communicate
•  ICU length of stay

•  Dexmedetomidine associated with…
•  Lighter sedation than Prop or Midaz
•  More rescue sedation than Prop
•  Shorter duration infusion than Prop
•  Shorter duration of mechanical ventilation than Midaz
•  Better arousal, communication, cooperation than Prop or Midaz
•  More hypotension & bradycardia than Midaz
•  Less polyneuropathy, agitation/delirium than Prop

Agitation & Sedation Recommendations
We recommend either daily sedation interruption or a light target

level of sedation be routinely used in mechanically ventilated adult
ICU patients (+1B)
Barr et al. Crit Care Med 2013 © 2014 American College of Chest Physicians
Use Protocols to Achieve Goal Directed Therapy, Minimize
Drug Accumulation
•  Daily interruption of medications
•  Change to intermittent therapy
•  Frequent evaluation of sedation, analgesia, and ICU
therapy tolerance and titrate therapy
•  Target pain and agitation
•  Combination therapy
•  Select best medication

Sedation Protocol Emphasizing Intermittent Therapy
•  RCT: Nursing protocol focuses on reducing sedative /
analgesic infusion; uses intermittent therapy
•  Fentanyl, lorazepam
•  Protocol
•  Shorter duration of mechanical ventilation
•  Shorter ICU and hospital LOS
•  Fewer tracheostomies
Brook et al. Crit Care Med 1999; 27:2609-15

Clinical Trial of
Daily Interruption of Sedation
•  RCT: 2x2 factorial design
•  Midazolam vs propofol
•  Daily interruption of sedation vs routine
•  Daily wake-up until alert/agitated; start ½ dose
•  Protocol
•  Shorter duration of mechanical ventilation
•  Shorter ICU LOS
•  Fewer tests for altered mental status
Kress et al. N Engl J Med 2000; 342:1471-7

Question
Which of the following patients would be the best candidate for daily
interruption of sedation?
A. 35 year old man with cirrhosis and alcohol withdrawal
syndrome
B. 75 year old woman with seizures receiving escalating doses of
sedation for agitation
C. 65 year old man with COPD, CAD, PTSD, and pneumonia
D. 25 year old woman with TBI and h ICP

Daily Interruption of Sedation:
Safety Screen
•  Avoid performing daily interruption of sedation in the
following settings:
•  Receiving sedative infusion for active seizures
or alcohol withdrawal 150
•  Receiving escalating doses due to ongoing 100

agitation 50
•  Receiving neuromuscular blocking agent 0
Epinephrine
•  Myocardial ischemia within past 24hrs (pg/mL)
•  Increased ICP Sedation Awake
Girard et al. Lancet 2008; 371:126-34

Kress et al. Crit Care Med 2007; 35:365-71 © 2014 American College of Chest Physicians
•  RCT of 430 North American ICU patients to sedation protocol vs
sedation protocol + DIS
•  Protocol: continuous infusion targeting light sedation
•  Primary outcome: time to successful extubation
•  Continuous opioid and/or benzo infusions
•  No difference between groups in duration of MV, ICU LOS, hospital
LOS, self-extubation, delirium
•  DIS associated with higher doses of midazolam & fentanyl, greater
RN workload
Mehta et al. JAMA 2012 © 2014 American College of Chest Physicians

Light Sedation Aids Ventilator Weaning and Early
Mobilization
•  DIS + spontaneous breathing trial Girard et al. Lancet 2008
•  Multicenter RCT (n = 336)
•  More ventilator-free days
•  Shorter ICU and hospital LOS
•  DIS + early occupational & physical rx Schweikert et al. Lancet
2009
•  Return to independent functioning
•  Less delirium
•  More ventilator-free days

Delirium

Question
Which of the following is not a diagnostic criteria for
delirium?
A. Prior psychiatric disturbance
B. Cognitive impairment
C. Altered level of consciousness
D. fluctuating symptoms

Delirium: Definitions
Delirium: Acute, reversible

disorder of attention and
cognition, an acute
confusional state.
Gunther et al. Crit Care Clinics 2008; 24:45-65

Subtypes of Delirium
•  Hyperactive (agitation)
•  Restless, agitated, hypervigilant
•  Alcohol or drug withdrawal, drug intoxication,
medication effect
•  Hypoactive (quietly confused)
•  Psychomotor retardation, lethargy, reduced
awareness
•  Sedative / opioid drug obtundation, metabolic,
medication effect
•  Most common in ICU

Outcomes Associated with Delirium
•  Delirium is associated with increased mortality in adult ICU
patients (A)
•  Delirium is associated with prolonged ICU and hospital length
of stay in adult ICU patients (A)
•  Delirium is associated with the development of post-ICU
cognitive impairment in adult ICU patients (B)
Risk Factors for Delirium
•  Baseline factors
•  Coma
•  Dementia
•  Relationship between coma
•  History of hypertension subtypes and delirium needs
•  History of alcoholism study
•  Admission severity of illness •  Medications
•  Benzodiazepines: yes
•  Propofol: maybe
•  Opioids: maybe

Detecting and Monitoring Delirium
•  We recommend routine monitoring for delirium in adult ICU
patients (+1B)
•  The Confusion Assessment Method for the ICU (CAM-ICU)
and the Intensive Care Delirium Screening Checklist (ICDSC)
are the most valid and reliable delirium monitoring tools in
adult ICU patients (A)
•  Routine monitoring of delirium in adult ICU patients is feasible
in clinical practice (B)
Delirium Prevention & Treatment
•  Early mobilization
•  No compelling evidence for pharmacological preventative
therapy
•  Consider non-benzo sedatives
•  Treatment
•  ? Typical / atypical antipsychotics
•  Beware prolonged QTc, Torsades de pointes
•  ? Dexmedetomidine

Delirium Prevention
•  We do not suggest that either haloperidol or atypical
antipsychotics be administered to prevent delirium in adult ICU
patients (-2C)
•  We provide no recommendation for the use of dexmedetomidine
to prevent delirium in adult ICU patients (0C)

Delirium Treatment
•  There is no published evidence that treatment with haloperidol
reduces the duration of delirium in adult ICU patients
•  No difference in duration of delirium, outcomes, AEs in RCT of
haloperidol v placebo Page et al Lancet 2013
•  Atypical antipsychotics may reduce the duration of delirium in
adult ICU patients (C)
•  We do not recommend administering rivastigmine to reduce the
duration of delirium in ICU patients (-1B)

Delirium Treatment
•  We do not suggest using antipsychotics in patients who are at
risk for torsades de pointes (-2C)
•  Patients with baseline prolonged QT interval
•  Patients receiving concomitant QT-prolonging medications
•  Patients with a history of this arrhythmia

Long QT Syndrome: Drugs
Drugs known to cause long-QT syndrome and torsades de pointes

Disopyramide Dofetilide Ibutilide
Procainamide Quinidine Sotalol
Bepridil Bretylium Flecainide
Amiodarone Arsenic Trioxide Cisapride
Clarithromycin Erythromycin Gatifloxacin
Levofloxacin Moxifloxacin Trimethoprim-sulfamethoxa
Fluconazole Ketoconazole Itraconazole
Halofantrine Pentamidine Sparfloxacin
Dihenhydramine Lithium Tricyclic antidepressants
Amantadine Tacrolimus Vasopressin
Domperidone Droperidol Chlorpromazine
Haloperidol Mesoridazine Thioridazine
Pimozide Methadone Digitalis

RCTs of Atypical Antipsychotics in Delirium
Author Year Agent N Major findings

Skrobik 2004 Olanzapine v 73 No difference in delirium score or
Haloperidol benzodiazepine dosage, but less
extrapyramidal SE with O
Girard 2010 Ziprasidone v 101 No difference in delirium-‐coma
Haloperidol v free-‐days, lorazepam dose,
Placebo extrapyramidal SE or mortality
Devlin 2010 QueMapine v 36 Reduced duraMon of delirium, less
Placebo agitaMon, more likely discharged
home or to rehab, trend for more
somnolence with Q
Skrobik et al, Intensive Care Med 2004; Girard et al, Crit Care Med 2010;
Devlin et al Crit Care Med 2010
Delirium Treatment
•  We suggest that in adult ICU patients with delirium which is

not related to either alcohol or benzodiazepine withdrawal,
continuous i.v. infusions of dexmedetomidine rather than
benzodiazepine infusions be administered for sedation in
order to reduce the duration of delirium in these patients
(+2B)

Earplugs Reduce Delirium and Improve Sleep
•  RCT of adult ICU patients

•  Earplugs at night (n=69) vs not (n=67)
•  Lower incidence of confusion (HR = 0.47, (0.27-0.82))
•  Later onset of confusion
•  Better sleep perception after 1st night
Van Rompaey et al. Crit Care 2012;16:R73 © 2014 American College of Chest Physicians
Severe Sepsis

Sepsis: Definitions
•  Sepsis
•  Presence (probable or documented) of infection +
•  Systemic manifestations of infection
•  Severe sepsis
•  Sepsis +
•  Sepsis-induced organ dysfunction or tissue
hypoperfusion
•  Septic shock
•  Sepsis-induced hypotention persisting despite
adequate fluid resuscitation
Dellinger et al . Crit Care Med 2013. © 2014 American College of Chest Physicians
Severe Sepsis: Definitions
•  Sepsis-induced tissue hypoperfusion or organ dysfunction

•  Sepsis-induced hypotension
•  Lactate > upper limits of laboratory normal
•  Urine output < 0.5 mL/kg/hr x 2 hrs after adequate fluid
•  Acute lung injury
•  PaO/FiO2 < 250 without pneumonia
•  PaO2/FiO2 < 200 in presence of pneumonia as infection source
•  Creatinine > 2.0 mg/dL
•  Bilirubin > 2 mg/dL
•  Platelet count < 100,000/uL
•  INR > 1.5
Dellinger et al . Crit Care Med 2013. © 2014 American College of Chest Physicians
Recommendations: Initial Resuscitation & Infection
Issues
•  Initial resuscitation
•  Screening for sepsis & performance improvement
•  Diagnosis
•  Antimicrobial therapy
•  Source control
•  Infection prevention
Dellinger et al . Crit Care Med 2013

Severe Sepsis:
Initial Resuscitation (1st 6 hr)
•  Begin resuscitation immediately in patients with hypotension
persisting after initial fluid challenge or serum lactate > 4
mmol/l (1C)
•  Resuscitation goals (1C)
•  CVP = 8 – 12 mm Hg
•  MAP > 65 mm Hg
•  Urine output > 0.5 ml/kg/h
•  ScvO2 > 70% or SvO2 > 65 %
•  Note that surveys indicate low compliance in practice
with CVP and SvO2 targets Levi et al Crit Care Med
2010
•  Target resuscitation to normalize lactate (2C)
Dellinger et al. Crit Care Med 2013. © 2014 American College of Chest Physicians
Severe Sepsis: Diagnosis
•  Culture as clinically appropriate before antimicrobial therapy if delay
< 45 min (1C)
•  At least 2 sets of blood cx (aerobic & anaerobic)
•  At least 1 drawn percutaneously, 1 from each vascular device
unless new (< 48h) (1C)
•  Imaging studies promptly for potential source of infection (UG)
Dellinger et al. Crit Care Med 2013

Severe Sepsis:
Antimicrobial Therapy
•  Effective i.v. antimicrobials within 1 hr of recognition of septic
shock (1B) and severe sepsis (1C) as goals of therapy
•  Initial empiric anti-infective therapy of one or more drugs active
against all likely pathogens (bacterial, fungal, viral) that penetrate
in adequate concentrations into infected tissue (1B)

Antibiotics:
The Sooner the Better!
Odds Ratio of Death

•  Increase in mortality with longer
time from the onset of
hypotension to the start of
effective antibiotics
•  Increased time beyond 1h
significant
•  Mortality 100x more likely if
> 36h
Delay in Receiving
Antibiotics
Kumar et al. Crit Care Med 2006; 34:1589 © 2014 American College of Chest Physicians
Question
A 48 year old man with myasthenia gravis is admitted with septic
shock, worsening weakness, and hypercapnia. He has history of
recurrent UTIs caused by Pseudomonas species. His urinalysis
shows many WBCs & GNRs
Which of the following empirical antibiotic regimens should be
initiated?
A. Ceftazidime + meropenem
B. Amikacin + meropenem
C. Ciprofloxacin
D. Piperacillin-tazobactam

Severe Sepsis:
Antimicrobial Therapy
•  Combination empirical therapy
•  Neutropenic patients with severe sepsis (2B)
•  Difficult-to-treat multidrug-resistant pathogens (Acinetobacter,
Pseudomonas spp) (2B)
•  Septic shock + respiratory failure: extended spectrum beta-
lactam + aminoglycoside or fluoroquinolone for P. aeruginosa
bactermia (2B)
•  Beta-lactam + macrolide for septic shock from bacteremic
Streptococcus pneumoniae (2B)

Severe Sepsis:
Antimicrobial Therapy: De-escalation
•  Reassess antimicrobial regimen daily for potential de-escalation
(1B)
•  Use low procalcitonin levels (or similar biomarker) to discontinue
empiric abx who have no subsequent evidence of infection (2C)
•  Empiric combination therapy no more than 3-5d; de-escalate to
single therapy asap (2B)
•  Duration of therapy = 7-10 d; longer if…
•  Slow clinical response, undrainable infectious foci, S. aureus
bacteremia, some fungal / viral infections, immunologic
deficiencies (neutropenia) (2C)

Severe Sepsis:
Source Control
•  Diagnose or exclude anatomical diagnosis of infection asap;
perform intervention for source control within 12h of diagnosis if
feasible (1C)
•  Perform effective intervention with least physiologic insult
(percutaneous > surgical drainage of abscess
•  If intravascular access device is possible source of severe sepsis
or septic shock, remove promptly after other vascular access
established (UG)

Supportive Critical Care

•  Blood products
•  Mechanical ventilation / ARDS
•  Sedation / analgesia / NMBA
•  Glucose control
•  Renal replacement therapy
•  DVT / Stress ulcer prophylaxis
•  Nutrition
•  Goals of care

•  Blood products
•  Glucose control
•  Renal replacement therapy
•  Stress ulcer prophylaxis
•  Nutrition
•  Goals of care

Question
Which of the following scenarios represents best practice for blood
product transfusion?
A. pRBC to patient with respiratory failure and Hgb 7.3 Gm/dl
B. FFP to patient with cirrhosis and INR 2.2
C. Platelets to patient with Platelet Ct 65,000 in preparation for
cardiac catheterization
D. pRBC to patient with Hgb 7.8 bleeding from duodenal ulcer

Blood Products
•  Transfuse red blood cells when Hgb < 7.0 g/dL, targeting Hgb = 7.0-9.0
g/dL (1B)
•  Exceptions: tissue hypoperfusion, myocardial ischemia, severe
hypoxemia, acute hemorrhage
•  Do not correct lab clotting abnormalities with fresh frozen plasma in

absence of bleeding or planned invasive procedures (2D)
•  Administer platelet transfusions… (2D)
•  < 10,000 in absence of bleeding
•  < 20,000 if not bleeding but at high risk
•  < 50,000 if actively bleeding, surgery/invasive procedure

Glucose Control
•  Using a protocolized approach target upper blood glucose < 180
mg/dL (1A)
•  Begin protocol when 2 consecutive glucose > 180 mg/dL
•  Most RCTs found no difference in mortality between tight
and conventional glucose control
•  NICE SUGAR showed h mortality with tight control NEJM
2009
•  All studies showed much higher rates of severe
hypoglycemia (< 40)

Glucose Control
•  Using a protocolized approach target upper blood glucose < 180
mg/dL (1A)
•  Begin protocol when 2 consecutive glucose > 180 mg/dL
•  Monitor blood glucose every 1-2h until glucose & insulin
infusion rate stable, then every 4h (1C)
•  Glucose levels obtained with point-of-care testing of capillary
blood may not be accurate (UG)
•  Falsely h levels with anemia, hypotension, pressors
Dellinger et al. Crit Care Med 2013 © 2014 American College of Chest Physicians
Renal Replacement Therapy
•  Continuous renal replacement therapies and intermittent
hemodialysis are equivalent (2B)
•  Somewhat variable data, but consistent among higher
quality (RCT) studies, including largest RCT Vincenneau
Lancet 2006
•  Use continuous therapies to facilitate management of fluid
balance in unstable patients (2D)
Dellinger et al. Crit Care Med 2013 © 2014 American College of Chest Physicians
Stress Ulcer Prophylaxis
•  Administer H2 blocker or proton pump inhibitor to patients with
bleeding risk factors (1B)
•  Risk factors: coagulopathy, mechanical ventilation > 48h,
hypotension
•  Preference for proton pump inhibitors rather than H2 blocker (2D)
•  Do not administer stress ulcer prophylaxis to patients without risk
factors (2B)

Nutrition
•  Administer oral / enteral feedings as tolerated within 48h (2C)

•  Avoid mandatory full caloric feeding in first week, suggest low
dose (trophic) feeding (< 500 cal/d), advancing as tolerated
(2B)
•  Use i.v. glucose and enteral nutrition rather than TPN alone in
the first 7 days
•  Use nutrition with no specific immunomodulating
supplementation (2C)

Setting Goals of Care
•  Discuss goals of care and prognosis with patients and families
(1B)
•  Incorporate goals of care into treatment and EOL care planning,
utilizing palliative care principles (1B)
•  Address goals of care as early as feasible, but at least by 72h
(2C)


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Critical Care Pearls

Curtis N. Sessler, MD, FCCP, FCCM

Curtis N. Sessler, MD, FCCP, FCCM

No potential conflicts of interest to disclose

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

• We suggest that vital signs may be used as a cue to begin further

Barr et al. Crit Care Med 2013

Ø Total score = 3-12

Barr et al. Crit Care ©Med 2013

Barr et al. Crit Care ©Med 2013

Barr et al. Crit Care Med 2013

Opioid T1/2 Maint MS Unique Concerns

© 2014 American College of Chest Physicians

• Allergy (MS) • Myoclonus

Erstad et al. Chest 2009; 135:1075-86

• Use fentanyl 25-100 mcg IVP q5-15 min for rapid

© 2014 American College of Chest Physicians

• Monitoring depth of sedation • Light level of sedation

Barr et al. Crit Care ©Med 2013

© 2014 American College of Chest Physicians

Barr et al. Crit Care© 2014

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

We recommend either daily sedation interruption or a light target

© 2014 American College of Chest Physicians

Brook et al. Crit Care Med 1999; 27:2609-15

Kress et al. N Engl J Med 2000; 342:1471-7

© 2014 American College of Chest Physicians

• Receiving escalating doses due to ongoing 100

Girard et al. Lancet 2008; 371:126-34

Mehta et al. JAMA 2012 © 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

Delirium: Acute, reversible

Gunther et al. Crit Care Clinics 2008; 24:45-65

© 2014 American College of Chest Physicians

Barr et al. Crit Care Med 2013

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

Drugs known to cause long-QT syndrome and torsades de pointes

© 2014 American College of Chest Physicians

Author Year Agent N Major ﬁndings

• We suggest that in adult ICU patients with delirium which is

© 2014 American College of Chest Physicians

• RCT of adult ICU patients

© 2014 American College of Chest Physicians

• Sepsis-induced tissue hypoperfusion or organ dysfunction

Dellinger et al . Crit Care Med 2013

Dellinger et al. Crit Care Med 2013

Dellinger et al. Crit Care Med 2013

Odds Ratio of Death

© 2014 American College of Chest Physicians

Dellinger et al. Crit Care Med 2013

© 2014 American College of Chest Physicians

Dellinger et al. Crit Care Med 2013

© 2014 American College of Chest Physicians

Dellinger et al. Crit Care Med 2013

•  We suggest that vital signs may be used as a cue to begin further

Ø Total score = 3-12

•  Allergy (MS) •  Myoclonus

•  Use fentanyl 25-100 mcg IVP q5-15 min for rapid

•  Monitoring depth of sedation •  Light level of sedation

•  Receiving escalating doses due to ongoing 100

•  We suggest that in adult ICU patients with delirium which is

•  RCT of adult ICU patients

•  Sepsis-induced tissue hypoperfusion or organ dysfunction

•  Administer oral / enteral feedings as tolerated within 48h (2C)