1. Therapeutic Strategies
PO2 ???
Rebreathing
Electrolytes/ECG monitoring
RESP ALKALOSIS
Sedation

3. Therapeutic Strategies
PO2
PO2
Rebreathing
PCO2
RESP ALKALOSIS
RESP ACIDOSIS
permissive
Electrolytes pH
Sedation
NIV/MV

4. ….Hypoxia kills…..Hypercarbia does not….
Hickling ICM 1989

5. Hypercapnia: clinical relevance and mechanisms of action
…but consider
pH….& Target
Organs
Curr Op Crit Care. 2015;21(1):7-12

6. Permissivity NOT allowed
“mixed” pH
7.08
PCO2 70
HCO3 20

7. Permissivity NOT allowed

8. CPAP vs BIPAP vs MV
….There is always PEEP !!!!!!!!!!!!

9. Alveolar recruitment and PaO2
THE BEST PEEP VD
Alveolar recruitment and PaO2
DO2
low
moderate
high
PEEP

10. H-L INTERACTIONS …….if when the PEEP goes up, the BP goes down…
The HEART is preload dependent…give fluids !!!!!!!!!!

11. NIV vs ETI in respiratory acidosis
TOO EARLY
TOO LATE
2 hours Trial plus
LACTATE CLEARANCE

12. Therapeutic Strategies
PO2
PO2
PCO2
RESP ALKALOSIS
rebreathing
RESP ACIDOSIS
permissive pH
sedation
NIV/MV
fluids
Electrolytes ( K, Mg, Ca)
MET ALKALOSIS
acetazolamide
surgery

13. Total body water MEN WOMEN young 60% b.w. elderly 50% young 50%
40%

14. 70 Kg MAN ICF = 28 L ECF = 14 L 1/3 intravascular 2/3 interstitial
70% veins
18% arteries
3% arterioles

15. Persistance of fluids in blood
Circulating volume
after 60 minutes
5% dextrose = 5% ? =
Cristalloids = 16%
Colloids = 30-50%
5% dextrose =5%
NS=16%
Colloids=30-50%
Albumin=50-80%
Albumin = %
FIRST………….TEST !!!!

16. Therapeutic Strategies
PO2
PO2
PCO2
RESP ALKALOSIS
rebreathing
RESP ACIDOSIS
permissive pH
sedation
NIV/MV
fluids
electrolytes
MET ALKALOSIS
MET ACIDOSIS
perfusion
acetazolamide N
surgery

17. IF (VENOUS) pH IS RAISED BY NaHCO3, IS THERE ANY SALUTARY EFFECT ?
IS A LOW pH BAD ?
CAN ALKALI RAISE pHi ?
IF (VENOUS) pH IS RAISED BY NaHCO3, IS THERE ANY SALUTARY EFFECT ?
DOES NaHCO3 HAVE NEGATIVE SIDE EFFECTS?
CHEST (2000) 117:

18. The CO2 lung presentation & low flowV
O2 demand
DO2
PCO2
VO2
ATP
AMP + H+
Lact- + H+
H+ + HCO3-

20. H+ vs Ca++ & troponins

21. BICARBONATE YES NO LOSSES RENAL FAILURE HYPERKALEMIA INTOXICATIONS
RABDOMIOLYSIS
DKA ?
DYE ?
…………..
HYPOPERFUSION
CARDIAC ARREST
HYPERCAPNIA
HYPOK, HYPOMg, HYPOCa …

22. Four steps in hypoperfusion
best filling
best vascular tone
inotropes
↓ VO2 + MV
Advanced options(ACP,VAD…)

23. Key points
In Respiratory disorders : first O2, then pH/PCO2, permissivity?
In Metabolic Alkalosis: (US-guided) filling & electrolytes
Colloids / Cristalloids / Both……?( think of deresuscitation)
In Metabolic Acidosis …look at perfusion