Hite: Ards And Sepsis

Front 1

Respiratory distress syndrome of premature neonates

Back 1

Babies born before type II pneumocytes have matured

No surfactants

Front 2

Acute Respiratory Distress Syndrome: definition

Back 2

Acute Lung Injury
-Bilateral radiographic infiltrates
-Hypoxemia (PaO2/FiO2<300)
-Reduced lung compliance
-No evidence of left atrial hypertension
-Associated risk factor (sepsis, pneumonia, trauma)

ARDS
-Same as above except P/F ratio<200
-Basically just more severe form of ALI

Front 3

ARDS: Acute pathology

Back 3

Inflammation: neutrophils

Endothelial Inury
Epithelial Injury
Capillary Leak/Non-hydrostatic pulmonary edema
Surfactant Deficiency
-Due to inflammation
Pulmonary Hypertension

Front 4

ARDS: Recovery pathology

Back 4

Fibroproliferative phase: fibrosis and repair

Type II is precursor to Type 1 pneumocyte, so there is a lot of proliferation of them
Pulmonary fibrosis
Pulmonary hypertension

Front 5

ARDS: Etiology

Back 5

DIRECT:
-Pneumonia (all pathogens)
--Viral (H1N1, SARS, Hantavirus…)
-Aspiration/Near Drowning
-Lung Contusion
-Toxic Inhalation Injury
-Reperfusion

INDIRECT
-Sepsis Syndrome (#1 cause)
-Severe Non-Thoracic Trauma/Burns
-Pancreatitis
-Transfusion/TRALI
-Fat Embolism
-Drugs

Front 6

ARDS: Incidence and outcomes, duration of mechanical ventilation, cause of mortality

Back 6

Incidence and outcomes:
-Mortality 35-40%
-200K cases of ALI, 150K cases of ARDS annualy
-As age increases, incidence of ARDS increases and mortality increases

Duration of mechanical ventilation
-Most people off ventilator in 1-2 weeks
-After ~4 weeks only 25% of patients off ventilator and home

Cause of mortality:
-Whatever triggered the problem in the first place (ex: sepsis, traumatic accidents, CNS)
-Not usually respiratory failure that leads to mortality

Front 7

ARDS: Recovery/disability

Back 7

~75% get back to work

FVC, TLC, DLCO get back to approximately normal
-DLCO slowest to recover

SF-36 score not normal

Front 8

ALI/ARDS: Treatment

Back 8

Treat Underlying Etiology
-Mortality is related to cause of ARDS, NOT Respiratory Failure

Anti-Inflammatory
-Non Specific (steroids)
-Specific (anti-cytokine Ab’s, antioxidants, antiproteases,…)

Supportive Care
-Pulmonary
-Fluid Management
-Non-Pulmonary (GI/DVT prophylaxis, prevention of nosocomial infections, limiting sedation, mobility, nutrition)

Front 9

ARDS: Lung protective ventilation

Back 9

Ventilation
-Low Volume/Pressure
--Tidal Volume = 6-8 ml/kg of predicted body weight
--Plateau Pressure < 30
--Permissive Hypercapnea

Oxygenation
-Minimum FiO2 (< 60%)
-PEEP

Too much tidal volume can cause ARDS (overstretching alveolus causes injury)

Front 10

Sepsis: fluid management

Back 10

Give fluids when people are in shock

Once out of shock, can get rid of fluids
-Got people off of ventilator more frequently
-Doesn't cause more renal failure

Front 11

ARDS: corticosteroids

Back 11

No change in mortality when steroids are given
-yet, steroids might be helpful
-but have many side effects

Front 12

SIRS/Sepsis: definition

Back 12

Systemic Inflammatory Response Syndrome (SIRS):
- Definition: any systemic process with 2 or more of:
-- hypo- (< 36°C) or hyperthermia (>38°C)
-- tachycardia (>90 bpm)
-- tachypnea (>20 bpm) or PaCO2 < 32 mmHg
-- leukopenia (WBC < 4K) or leukocytosis (WBC >12K or bands >10%)

Sepsis: SIRS caused by infection

Severe Sepsis : Sepsis with organ dysfunction

Septic Shock: Shock secondary to sepsis that is refractory to fluid resuscitation

Front 13

SIRS/Sepsis: causes

Back 13

Infection (lung is most common)
Trauma
Burns
Other

Front 14

SIRS/Sepsis: Mortality

Back 14

Septic shock
-46% mortality

SIRS2
-7% mortality

Organ failures
CV – vasodilation
Resp – hypoxia, ALI/ARDS
CNS – altered mental status
Renal – oliguria, uremia
Hepatic – increased LFTs
Heme - thrombocytopenia

SOFA Score
-As it increases, mortality increases

Front 15

Severe sepsis: epidemiology

Back 15

Incidence increases during aging
Mortality increases during aging

~500-1000 deaths/day

Front 16

Sepsis treatment

Back 16

Early goal directed therapy

Hemodynamic resuscitation
-“Close” Monitoring: MAP, CVP, SvO2, Lactic Acid
-Fluids
-Vasopressors
-Transfusion
-Antibiotics
-Possibly steroids

Front 17

Sepsis antibiotic selection

Back 17

Initial antibiotic choice MUST be broad enough to cover all reasonable possibilities. Unnecessary antibiotics should be discontinued (“de-escalation”) once culture results available to provide better guidance.

Front 18

Sepsis coagulopathy

Back 18

Tissue factor + factor VIIa

Low levels of antithrombin III

Impaired function of protein C system