Pa O2 How Low Can You Go

PaO2 : How Low Can You Go ? In ARDS Az Rifki Siti Rahmah Islamic Hospital Padang, West Sumatra

ARDS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

1994 American-European Consensus Conference Definition ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Mortality - 26% to 74%

ABNORMALITIES OF GAS EXCHANGE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Mechanical Ventilation induced lung injury ,[object Object],[object Object],[object Object],[object Object]

Ventilator induced lung injury ,[object Object],[object Object],[object Object]

Lung Protective Ventilator Strategies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],ARDS Network

1. Permissive Hypoxemia 2. Low Tidal Ventilation and Permissive Hypercapnia 3. Positive End-Expiratory Pressure (PEEP) 4. Prone ventilation 5. Lung recruitment maneuvers (LRM) 6. Pressure controlled Inverse Ratio Ventilation (PC-IRV) Lung Protective Ventilator Strategies

How much FiO2? ,[object Object],[object Object],[object Object],Am Rev Respir Dis 1981;123:98-103

How much Tidal volume? ARDS Network

How much Tidal volume? ARDS Network ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Mortality

Lower PEEP/Higher FiO 2 FiO 2 .3 .4 .4 .5 .5 .6 .7 .7 .7 .8 .9 .9 .9 1.0 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24 Higher PEEP/Lower FiO 2 FiO 2 .3 .3 .4 .4 .5 .5 .5-.8 .8 .9 1.0 PEEP 12 14 14 16 16 18 20 22 22 22-24 Target enrollment- 750 ALI, ARDS pts.

Results ,[object Object],[object Object],[object Object],ESSENTIALLY NO DIFFERENCE IN OUTCOMES (MORTALITY)

Prone position ventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],No differences in clinical outcome

Severe hypoxemia without evidence of tissue hypoxia in adult respiratory distress syndrome. Lund T , Koller ME , Kofstad J . A patient with severe arterial hypoxemia in adult respiratory distress syndrome (ARDS) secondary to a fractured femur is reported. A marked discrepancy between the clinical condition and laboratory findings was observed. At one point, PaO2 was below 4 kPa (30 mm Hg) on F1O2 0.21 without signs of tissue hypoxia. This patient illustrates beneficial effects of a leftward shift of the oxyhemoglobin dissociation curve. Crit Care Med. 1984 Jan;12(1):75-6.

How harmful is hypoxemia? ,[object Object],[object Object],Your pO2 and SO2 here is ??

How harmful is hypoxemia? ,[object Object],[object Object],Your pO2 and SO2 here is 30 and 78% ,[object Object],[object Object]

What levels of PaO 2 can be targeted? ,[object Object],[object Object],[object Object],[object Object],Suter P. Program and abstracts of the 15th Annual Congress of the European Society of Intensive Care Medicine; September 29-October 2, 2002; Barcelona, Spain.

[object Object],[object Object],[object Object],What levels of PaO 2 can be targeted? Suter P. Program and abstracts of the 15th Annual Congress of the European Society of Intensive Care Medicine; September 29-October 2, 2002; Barcelona, Spain.

[object Object],[object Object],What levels of PaO 2 can be targeted? ITACCS GUIDELINES FOR MANAGEMENT OF MECHANICAL VENTILATION IN CRITICALLY INJURED PATIENTS

Oxygen Dissociation Curve ARDSnet Study 88-94% PaO2 55-80

Tissue Oxygenation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Maintaining Tissue Oxygenation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

OXYGEN EXTRACTION VO 2 = Q x Hb X 13.4 X (SaO 2 - SvO 2 ) Arterial Inflow (Q) capillary O 2 O 2 O 2 O 2 O 2 O 2 O 2 Venous Outflow (Q) C ell O 2 (Adapted from the ICU Book by P. Marino)

OXYGEN DELIVERY DO 2 = Q X CaO 2 DO 2 = Q X (1.34 X Hb X SaO 2 ) X 10 Q = cardiac output CaO 2 = arterial oxygen content Normal DO 2 : 520-570 ml/min/m 2 Oxygen extraction ratio = (SaO 2 -SvO 2 /SaO 2 ) X 100 Normal O 2 ER = 20-30%

HEMODYNAMIC SUPPORT Max O 2 extraction Critical DO 2 Abnormal Flow Dependency DO 2 VO 2 Septic Shock/ARDS Max O 2 extraction Critical DO 2 VO 2 = DO 2 X O 2 ER DO 2 VO 2 Normal

Protective lung ventilation protocol from the ARDSNet study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Summary ,[object Object],[object Object],[object Object],[object Object]

Pa O2 How Low Can You Go

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Pa O2 How Low Can You Go