Post Operative Care 2018 Chaianan Sodapak MD

Costs per day alive are higher for very old patients (VOPs) compared to other ICU populations and to the very elderly control population.  https://goo.gl/oaQVtH 

Current Trend in Critical care 2018 :Post op Care Oxygen therapy Resuscitation -NaHCO3 therapy -Small volume resuscitation ;20%albumin -Metabolic resuscitation : Thiamine,Vit C ,Hydrocortisone -Terlipressin vs TTM Small and intermediate TV Pantoprazole in ICU

Oxygen therapy Target SpO2

Effects of supplemental oxygen administration on coronary blood flow in patients undergoing cardiac catheterization TRANSLATIONAL PHYSIOLOGY Patrick H. McNulty, 01 Mar 2005

Routine use of oxygen in people who have had a heart attack : Systematic review 2017 No evidence whether the oxygen is good or harmful We cannot rule out a harmful effect

Oxygen therapy in ST-elevation myocardial infarction Oxygen therapy in ST-elevation myocardial infarction. Euro Jour heart 2018 Aug 1;39(29) Conclusions: Routine use of supplemental oxygen in normoxemic patients with STEMI undergoing primary PCI did not significantly affect 1-year all-cause death, rehospitalization with MI, cardiogenic shock, or stent thrombosis.

No Benefit of Routine Oxygen in Acute Stroke The Stroke Oxygen Study Randomized Clinical Trial JAMA September 26, 2017 When indicated Continuous O2 Nocturnal O2 No Benefit of Routine Oxygen in Acute Stroke

Hyperbaric oxygenation for the treatment of stroke KK Jain MD May 18, 2018 MedLink Neurology • Despite experimental evidence and rationale for neuroprotective effect as well as considerable clinical experience, the use of hyperbaric oxygen has not been officially approved.   • Some of the controlled clinical trials have not shown beneficial effects, and further studies are ongoing to resolve the controversy.

oxygen encourages the formation of toxic free radicals, leading to further damage to the ischaemic brain, especially during reperfusion. Oxidative stress has also been implicated in the activation of cell signalling pathways, which lead to apoptosis and neuronal cell death.

Oxygen therapy for acutely ill medical patients: a clinical practice guideline BMJ 2018; 24 October 2018 O2 Rx when indicate SpO2 drop cause? 100 % monitor

PaCO2 ≤45 pH ≤7.2 HCO3 ≤ 20 SOFA ≥ 4 Lactate ≥ 2 Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial Lancet 2018 Jul 7,392 7.5%NaHCO3 125-250 mL in 30 min max1000 mL / 24 h pH ≤7.2 PaCO2 ≤45 HCO3 ≤ 20 SOFA ≥ 4 Lactate ≥ 2

Sodium bicarbonate solution infusion improves survival outcome in  sepsis patients with AKI stage 2 or 3 and pH < 7.2. 

Metabolic Resuscitation Vitamin C levels invariably fall during sepsis, sometimes dropping below the level of detection. Vitamin C deficiency correlates with multiorgan failure and death (Wilson 2009) Thiamine deficiency is common in sepsis, occurring in perhaps one- third of patients.  This is associated with increased mortality (Manganese2011).

Tanaka H et al. 2000:  Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration  [Vitamin C 66 mg/kg/hr for the first 24 hours of hospitalization]

 Effect of high-dose ascorbic acid on vasopressor requirement in septic shock Zabet MH et al 2016:  Vitamin C 25 mg/kg IV q6hr vs Placebo

Randomized, double-blind, placebo-controlled trial of thiamine as a metabolic resuscitator in septic shock:  A pilot study Donning MW 2016 Thiamine (200 mg IV q12hr) in 88 patients with septic shock.  

Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock Marik P 2017 Standard ICU Care: Proper ATB Conservative fluid Lung protective strategy Limited use of sedative agents Norepinephrine was Enteral nutrition in 24 hours DVT prophylaxis

Result The cocktail is without side effects Start at ER

Thiamine can increase lactate clearance and reduce mortality in septic shock! Woolum Crit Care Med 2018 Nov;46 Retrospective, single-center, matched cohort study.  Medical or surgical ICU No intervention N 369 Dose up to 500 mg iv q 8hr

Proton-Pump Inhibitor Prophylaxis in the ICU — Benefits Worth the Risks? https://nej.md/2J7cAJW No significant difference in the rate of death at 90 days include gastrointestinal bleeding and pneumonia

Ziprasidone up to 40mg/day Haloperidol up to 20 mg/day Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness NEJ October 22, 2018 SAME Ziprasidone up to 40mg/day placebo Haloperidol up to 20 mg/day

Fat 58 g CHO180 g Protein 56 g Fat 27 g CHO 125g Energy-Dense versus Routine Enteral Nutrition in the Critically Ill The TARGET Investigators, for the the ANZICS Clinical Trials Group N Engl J Med Nov 2018 1.5 Kcal/ml Fat 58 g CHO180 g Protein 56 g 1Kcal/ml Fat 27 g CHO 125g  Higher calorie delivery did not affect survival time, receipt of organ support, number of days alive and out of the ICU and hospital or free of organ support, or the incidence of infective complications or adverse events.

DESIGN RCT 6 ICU in Netherlands. Non- ARDS Ventilator free day LOS Effect of a Low vs Intermediate Tidal Volume Strategy onVentilator-Free Days in IntensiveCareUnit Patients WithoutARDS ARandomizedClinical Trial JAMA Nov 2018 DESIGN RCT 6 ICU in Netherlands. Non- ARDS Ventilator free day LOS Survival SAME Intermediate 10-9-8 Low 6-5-4

How best to set the ventilator on extracorporeal membrane lung oxygenation Gattinoni, Luciano Current opinion in critical care Feb 2017 revise feb2018 FiO2 a variable decrease of fraction of inspired oxygen (0.9 to 0.7 or 0.4) A consistent decrease in tidal volume (by 2 ml/kg) No change in positive end-expiratory pressure (maintained around 12–13 cmH2O) RR 22 to 15 bpm Both VV VA ECMO