Salon a 14 kasim 13.30 14.45 younsuck koh

1. 11th Congress of the TSMSICM
What to Consider
during Organ Support?
Younsuck Koh, MD, PhD, FCCM
Dept. of Pulmonary & CCM
Asan Medical Center, Univ. of Ulsan
Seoul, Korea

2. Intensive Care
To save a life through
the support of organ function

3. Issues in Organ Support
1.Failed organ
2.When to start, How, How much
3.Safety & Cost
4.Technology support
5.Monitoring
6.When to quit
7.Chronically critically ill
8.Essential measures in our
daily practice

4. Insult
Genetics & Host factors
Initial Tx
Virulence
Dysregulation bwt organs, immune, hormone, nerve
Low Level Moderate Level High Level

5. DO2
How to be failed?
VO2
300-350 ml/min/m2

6. Normal: 0.5-1.5 mmol/L
If lactate > 4 mmol and pH is less than 7.30,
consider tissue hypoxia

7. Tissue oxygen debt as a determinant of lethal and nonlethal
postoperative organ failure
-100 consecutive high-risk surgical op. in 98 pts.
- the tissue O2 deficit = the measured VO2 – the estimated VO2 requirement
Net cumulative
VO2 deficit
Shoemaker WC, et al. Crit Care Med 1988; 16:1117

8. Multiorgan Failure
• The MOF in sepsis occurs due to a substantial
cumulative tissue oxygen debt, not always due
to inadequate DO2.
The effects of vasodilation with prostacyclin on oxygen delivery and
uptake in critically ill patients. N Engl J Med. 1987: 317(7):397-403.
Prostacyclin produced increase in oxygen delivery was associated with a
significantly greater increase in oxygen uptake in the patients who died as
compared with the survivors (median increase, 19 vs. 5 percent, P<0.001).
In the survivors, the oxygen extraction ratio fell (median change, -17
percent; range, -27 to -6 percent) and the mixed venous oxygen tension
increased. In the patients who died, the extraction ratio rose (median
change, 11 percent; range -24 to +40 percent) and the mixed venous oxygen
tension did not change.

9. When to support?

11. Crit Care Med 2014. 42; 801-8

12. Preemptive management
Crit Care Med 2014. 42; 801-8

13. How Much?
“If we could give every individual the right amount
of nourishment and exercise, not too little and not
too much, we would have found the safest way to
health.” Hippocrates (460?-377 BC)

14. Long Debate
DO2
VO2
New Critical point

15. Goal-Oriented Tx

17. Another Goal-Directed Tx
Rivers E, et al. N Engl J Med 2001;345:1368-77
Early Goal-Directed
Therapy in the Treatment of
Severe Sepsis and Septic
Shock:
Achievement of target
values

18. 49.2%
33.3%
28-day Mortality
60
50
40
30
20
10
0
Standard Therapy
n=133
EGDT
n=130
P = 0.01*
*Key difference was in sudden CV collapse, not MODS
Rivers E. N Engl J Med 2001;345:1368-77.

19. The ProCESS Investigators. NEJM 2014;370:1683-93
31 ER in US
MR by 60 days: 18.2-21%

20. Do not harm

21. Do not harm is not easy…

23. DO2(ml/min)
= CO x (1.39 x Hb x SaO2 + 0.0031 x PaO2)
RBC Transfusion
Euvolemic & critically ill.
N Engl J Med 1999; 340: 409-417
Less is More

24. Early versus Late Parenteral Nutrition in
Critically Ill Adults
Compared early initiation of PN (within 2 days) with late
initiation (early enteral + initiated PN on day 8) in adults in the
intensive care unit (ICU)
Patients in the late-initiation group had a relative increase of
6.3% in the likelihood of being discharged alive earlier from the
ICU (hazard ratio, 1.06; 95% confidence interval [CI], 1.00 to 1.13;
P=0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00 to
1.13; P=0.04), without evidence of decreased functional status at
hospital discharge.
Casaer MP, et al. NEJM 2011;365:506-17

25. Side Effect
Pulmonary-artery versus central venous catheter to guide treatment of
acute lung injury. N Engl J Med. 2006 25;354(21):2213-24.
.. PAC-guided therapy did not improve survival or organ function but was
associated with more complications than CVC-guided therapy.

26. Organ interaction
White LE, at al. J Surg Res.2011; 167(2): 306–315.

27. Organ interaction
Ischemic AKI induces pulmonary EC apoptosis in whole-lung tissue in rats.
Micrographs (40x), ischemia-reperfusion injury stained with TUBEL (green)
White LE, et al. Shock 2012;38:320-327

28. Target
120
100
80
60
40
20
0
1 2 3 4 5
No. of acute organ failure
No. of pat ient s
100
50
0
Hospital mor talit y(% )
dist ribut ion Mortalit y

29. Place to Perform
The impact of intensive care unit admissions following early
resuscitation on the outcome of patients with severe sepsis and
septic shock.
Surat T, Viarasilpa T, Permpikul C.
J Med Assoc Thai. 2014 Jan;97 Suppl 1:S69-76.
..There were trends toward a lower 28 day mortality (18% vs. 25.6%, p =
0.33) among the patients in the ICU group.
Apart from the early goal-directed therapy, early ICU admission
substantially improves the outcomes of septic shock patients.

30. How to Monitor
• Vital signs: BT, PR, RR, BP
• And..

31. • General condition:
cold & clammy skin, UO, mentality
rapid shallow respiration
• Hemodynamic parameters
• Respiratory parameters
• Metabolic parameters

32. Monitoring tools
Pa(Sa)O2
NIRS
MAP
SV, CO
Cap. Perfusion
imaging
PEx
Lactate
MVO2
ScvO2
pHi

33. Choosing Monitoring Parameters
For resource limiting countries

34. Serum Lactate
Metabolic
Normal: 0.5-1.5 mmol/L
If lactate > 4 mmol and pH is less than 7.30,
consider tissue hypoxia

36. Biomarker for the Prediction of All-Cause Mortality in Critically ill:
A systemic review and meta-analysis
Zhang Z & Xu X. Crit Care Med 2014

37. Chronically Critically ILL
defined as those who survive initial life-threatening,
possibly reversible organ
failure(s) but are unable to recover
rapidly to a point at which they are fully
independent of life support
Their mean lengths of stay in the ICU
and in the hospital: 42.9+/-36.4 and
83.9+/-100.5 days
ICU and six-month cumulative mortality
rates: 42.6% and 75.9%
The SOFA score on day 21 and
comorbidity in the ICU appears to be a
valuable prognostic indicators in
chronically critically ill patients.
Lee K, et al. Anaesth Intensive Care. 2008;36(4):528-34

38. Resource use in the ICU: short- vs. long-term
patients
..In this university-based, medical-surgical adult ICU,
11% of all patients stayed more than 7 days
in the unit and consumed
more than 50% of all resources.
Stricker K, et al. Acta Anaesthesiol Scand. 2003;47:508-15.

39. When to Quit

40. The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care
Huynh TN, et al. JAMA Intern Med 2013;173:1887-94

41. Essential Measures to be Performed
1. Patients’ bed head elevation > 30°
2. Stress ulcer prophylaxis
3. DVT prophylaxis
4. Low tidal volume ventilation
5. Early removal of central venous & Foley catheter
6. Early enteral feeding

42. Independent predictors of mortality

43. Prompting Physicians to Address a Daily Checklist and
Process of Care and Clinical Outcomes
Prompted group patients had lower risk-adjusted ICU mortality compared
with the control group (odds ratio, 0.36; 95% confidence interval, 0.13–0.96;
P = 0.041) and lower hospital mortality compared with the control group
(10.0 vs. 20.8%; P = 0.014).
Weiss CH, et al. Am J Respir Crit Care Med. 2011; 184(6): 680–686

44. Conclusion
• Stick to Basic Essential Measures.
• The earlier, the better
• Consider organ interactions when to resuscitate.
• Frequently less is more.
• Should stop non-responding measures.

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