"Best Paper Presentation Award"
Presented at 3rd Annual Critical Care Medicine Conference , Sir Gangaram Hospital, New Delhi
"A Case of H1N1 ARDS - Journey from NIV to Invasive Ventilation to recruitment to proning to ECMO & Nitric Oxide"
For PPT, Check following link
http://www.medicalgeek.com/clinical-cases/36303-h1n1-ards-case-presentation.html
This is an ARDS case study presentation done by a group of Respiratory care students in UOD:
Aziza AlAmri, Fay AlBuainain, Mashail AlRayes, Nora AlWohayeb, Salma Almakinzi .
The original case study:(http://www.researchgate.net/publication/50399037_Acute_Respiratory_Distress_SyndromeA_Case_Study)
This is an ARDS case study presentation done by a group of Respiratory care students in UOD:
Aziza AlAmri, Fay AlBuainain, Mashail AlRayes, Nora AlWohayeb, Salma Almakinzi .
The original case study:(http://www.researchgate.net/publication/50399037_Acute_Respiratory_Distress_SyndromeA_Case_Study)
How to manage a case of acute exacerbation of COPD according to GOLD guidelines. Sincere thanks to Dr. Amardeep Toppo who has prepared most of this presentation.
COPD exacerbation case presentation and disease overview farah al souheil
management of a simulated case scenario: patient presenting with COPD exacerbation: what's the best next step? summary of the guideline is then described
ARDS - Diagnosis and Management
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How to manage a case of acute exacerbation of COPD according to GOLD guidelines. Sincere thanks to Dr. Amardeep Toppo who has prepared most of this presentation.
COPD exacerbation case presentation and disease overview farah al souheil
management of a simulated case scenario: patient presenting with COPD exacerbation: what's the best next step? summary of the guideline is then described
ARDS - Diagnosis and Management
Visit www.medicalgeek.com for more
http://www.medicalgeek.com/lecture-notes/36156-ards-diagnosis-management-presentation-ppt-pdf.html#post89045
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https://only4medical.wordpress.com/
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The patient was involved in an automobile accident, aspirated during orthopedic surgery and became septic.
He was intubated and had been taken off of vasopressors overnight but was looking worse the next morning.
Good overview of acute renal failure but this was written before the most recent ATN data which negates one of the premises of the lectuer that higher doses of dialysis are beneficial in patients in ARF.
Point of Care Testing (POCT) refers to medical testing that is conducted outside of a laboratory setting, typically near or at the location of a patient. This can include testing in a physician's office, at home, in the field, or in a hospital room. POCT is usually performed using portable, handheld, or small benchtop devices. Here are some main features and advantages of POCT:
Convenience and Speed: Since POCT can be done at or near the patient's location, it eliminates the need to send samples to a lab and wait for the results. This can result in quicker diagnosis and treatment.
Immediate Decision Making: With instant results, healthcare providers can make immediate decisions about a patient's care, leading to improved patient outcomes.
Reduced Costs: While some POCT devices can be expensive, they may reduce overall healthcare costs by shortening hospital stays, reducing the number of follow-up visits, and preventing complications.
Simplicity: Many POCT devices are designed to be user-friendly, allowing non-laboratory personnel or even patients themselves to conduct tests.
Connectivity: Modern POCT devices often come with connectivity options, enabling the integration of test results into electronic health records.
Versatility: There's a wide range of tests available for POCT, from blood glucose testing to rapid strep tests and coagulation tests.
However, it's also important to note some challenges with POCT:
Quality Control: Ensuring the accuracy and reliability of POCT results can be challenging, especially if tests are being conducted by non-laboratory personnel.
Cost: Some advanced POCT devices can be costly, and there may be additional costs associated with training and quality control.
Regulation and Oversight: Because POCT is performed outside of the traditional lab setting, there can be challenges related to oversight, regulation, and ensuring that tests meet necessary standards.
In summary, while POCT offers many advantages in terms of speed and convenience, it's essential to ensure that tests are accurate, reliable, and meet necessary standards.
Rapid diagnostic tests (RDTs) in India play a crucial role in the detection and management of various diseases, including infectious diseases like malaria, dengue, and more recently, COVID-19. Here's an overview of RDTs in India:
Importance in Disease Management: In a vast and diverse country like India, with varied healthcare infrastructure across its regions, RDTs provide a quick and effective way to diagnose diseases, especially in remote areas where sophisticated laboratory setups might not be available.
Malaria and Dengue Detection: RDTs for malaria (based on the detection of antigens produced by malaria parasites) and dengue (based on the detection of dengue NS1 antigen and anti-dengue antibodies) are widely used. They offer results in less than
Rapid Diagnostic Tests (RDTs) in India play a crucial role in the quick detection and diagnosis of various diseases. They are espec
Respiratory conditions in Critically ill Surgical patientMohamed Alasmar
للزملاء المتقدمين لامتحانات اجنبية زي MRCS
و للزملاء اللي منتقلين حديثا للعمل بالمملكة المتحدة او بينوو العمل فيها
تابعونا علي الصفحة الجراح
https://www.facebook.com/algarra7/
الفيديو على اليوتيوب
https://youtu.be/gLuRAzmCchI
Hergen Buscher is an Intensivist from St Vincent's hospital in Sydney. He has extensive experience with ECMO, in both veno-venous and veno-arterial contexts. Listen to this talk he gave on the most recent developments in ECMO and where things are heading.
This talk was given live in September 2014 for an Intensive Care Network (ICN) NSW meeting.
Go to www.intensivecarenetwork.com for more.
Weaning from mechanical ventilation , also called ventilator liberation, refers to the process of the patient assuming more and more of the work of breathing and finally demonstrating that ventilator support is no longer required.
Simply it means the process of withdrawing mechanical ventilatory support and transferring the work of breathing from the ventilator to the patient . Weaning can be accomplished with an endotrachel tube ( ETT) or a tracheostomy tube in place.
In the case of the ETT, the final step in the process is the removal of the tube( extubation). With a tracheostomy, the final step may be the ability to breath spontaneously for a designated period of time with the tube in place.
Weaning success is defined as absence of ventilatory support 48 hours following the extubation.
While the spontaneous breaths are unassisted by mechanical ventilation, supplemental oxygen, bronchodilators, low level pressure support ventilation or continuous positive airway pressure (CPAP) may be used to support and maintain adequate spontaneous ventilation and oxygenation.
Purpose
The purpose is to assess the probability that mechanical ventilation can be successfully discontinued.as
75% of mechanically ventilated patients are easy to be weaned off the ventilator with simple process.
10-15% of patients require a use of a weaning protocol over a 24-72 hours.
5-10% require a prolonged weaning plan.
1% of patients become dependent on chronic mechanical ventilation.
Indication
Improvement of the cause of respiratory failure.
Absence of major system dysfunction.
Appropriate level of oxygenation.
Adequate ventilatory status.
Intact airway protective mechanism.
Contraindication
Altered sensorium either drowsiness or restlessness.
Spo2 ˂90%
Rising PaCO2 with drop in PH
Tachypnoea ˃35/ min
Tachycardia ˃120 /min
Drop in systolic blood pressure
Sweating
Cold clammy skin
Signs of diaphragmatic weakness
Paradoxical abdominal wall movement
Assessment of readiness for weaning
Hemodynamic stability
Minimum inotropic support
Adequate cardiac output
Afebrile
Hematocrite greater than 25%
Respiratory stability
Improved chest x-ray
Arterial oxygen tension (PaO2) greater than 60mm Hg with fraction of inspired oxygen ( FiO2) less than 0.5
PaO2/FiO2 greater than 300 mm Hg
Positive end expiratory pressure (PEEP) less than 0-5 cm H2O
Vital capacity (VC) 10-15ml/kg
Spontaneous tidal volume (VT) 5ml/Kg
Respiratory rate less than 30 breaths/mim
Minute ventilation 5-10 L/min
Negative inspiratory pressure greater than -20cm H2O
Rapid shallow breathing index (RSBI) less than 105
metabolic factors stable
Electrolytes within normal range.
ABGs( Arterial blood gases) normalized
Other
Adequate management of pain and anxiety.
Patient is well rested
Weaning criteria
Weaning criteria are used to evaluate the readiness of a patient for a weaning trial and the likelihood of weaning success.
Clinical criteria
Ventilatory criteria
Oxygenation criteria
Ventilatory management of Acute Hypercapnic Respiratory FailureVitrag Shah
Presentation on ventilatory management in Acute Hypercapnic Respiratory Failure
Updated information till 17/8/16
For powerpoint format, contact dr.vitrag@gmail.com
http://www.medicalgeek.com/presentation/36513-ventilatory-management-acute-hypercapnic-respiratory-failure-presentation.html
Download review articles and guidelines for ventilatory management in COPD & Asthma
http://www.medicalgeek.com/articles-and-news/36514-articles-ventilatory-management-copd-asthma.html
Ventilatory management in obstructive airway diseasesVitrag Shah
Presentation on ventilatory management in COPD & Asthma
Updated information till 26/5/16
For powerpoint format, contact dr.vitrag@gmail.com
http://www.medicalgeek.com/presentation/36441-ventilatory-management-obstructive-airway-diseases-presentation.html
Tetanus Presentation
77 slides
Including drip rates of muscle relaxants
PDF : http://www.mediafire.com/download/k00ciibf73d7y6p/
For more, visit www.medicalgeek.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
H1N1 ARDS Case Presentation
1. A Case of Acute Hypoxemic
Respiratory Failure
DR. VITRAG SHAH
FIRST YEAR FNB RESIDENT,
DEPARTMENT OF CCEM,
SGRH, DELHI
2. History
• 32 year old male
• Farmer by occupation
• Resident of Gwalior
• No past comorbidities
• Non-smoker, Non-Alcoholic
• Symptoms :
• Fever with chills
• Cough with scanty expectoration for 5 days
• Breathlessness mMRC II—III for 3 days
• No other significant history
3. History
• Initially admitted at Gwalior on 29/09/15
• Routine blood tests : Normal
• Chest x-ray : B/L lower zone infiltrates (Lt>Rt)
• Managed with IV antibiotics, oxygen & other supportive
treatment
• Then brought to SGRH for further management &
admitted to Respiratory HDU on 02/10/15.
• Initially maintained SpO₂ 90-92% on 100% O₂ mask
• On 03/10/15 in view of worsening breathlessness and
desaturation on 100% mask, patient was shifted to ICU
5. Physical Examination on ICU admission
• Patient was conscious, oriented
• Respiratory distress present, using accessory muscles
• Temperature : 37.6°c (Axillary)
• Pulse : 104/min, regular
• RR : 32/min, thoracoabdominal
• BP : 130/70 mmhg
• SpO₂ : 88% on 100% Oxygen Mask
• No pallor, clubbing, cyanosis, edema, lymphadenopathy
6. Systemic Examination on ICU admission
Respiratory system :
• Inspection – bilateral hemithorax movement equal
• Palpation – bilateral hemithorax expansion equal
• Percussion – no abnormality seen
• Auscultation – Bronchial breath sounds & bilateral fine
inspiratory creps heard over bilateral infraaxillary and
infrascapular region
7. Other System Examination
Cardiovascular – S1, S2 heard-normal and no murmurs
Gastroenterology – soft, bowel sounds heard, no free fluid or
organomegaly seen, no guarding/rigidity
Neurological – Higher function – normal, no focal
neurological deficit
9. Rest Investigations
• RBS : 118, ECG : Incomplete RBBB
• H1N1 RT PCR was also sent on the day of admission
and report was awaited.
• Malarial antigen, PS for MP, Scrub typhus IgM,
Leptospirosis IgM, Dengue NS1 antigen & IgM-IgG were
sent
• Blood & urine culture were sent. Cough was non-
productive, so sputum gram stain-culture were not sent.
14. Management plan on Day-1 ICU admission
• NIV (CPAP-PSV) ,Plan for SOS ET Intubation, relatives
were counseled for same
• IV Antibiotics (Meropenam & Teicoplanin)
• Cap. Doxycycline (For atypical coverage & scrub typhus)
• Tab.Oseltamivir (For H1N1 Influenza)
• SOS Inj.Paracetamol (Antipyretic) , Other supportive
treatment & IV Fluids
15. Course in ICU
• Malarial antigen, PS for MP, Scrub typhus IgM,
Leptospirosis IgM, Dengue NS1 antigen & IgM-IgG were
negative.
• Initial Blood & urine culture were negative.
• H1N1 RT PCR came positive.
• 2D Echo on Day-1 ICU admission – Normal , No PAH
• USG Abdomen – Normal
16. Course in ICU
• ICU Day 1&2 (03/10/15 - 04/10/15) :
• Managed on NIV (CPAP-PSV), was maintaining
SpO2 around 93-94%
• ABGA on ICU Day-2 ICU(04/10/15) :
• pH 7.45 PO₂ 82 PCO₂ 39 HCO3 26.8 Lactate 1.91
• ICU Day 3 (05/10/15) :
• I/V/O decreasing SpO₂ and increasing respiratory
distress, intubated & taken on mechanical ventilator
18. How will you ventilate
this patient?
• What is Lung Protective Ventilation?
• What is open lung ventilation?
• How to Titrate PEEP?
• Fluid management
• Evidence
19. Initial Ventilatory Settings
• Ventilated as per lung protective ventilation strategy
• Height - 175 cm , IBW - 70.5kg
Mode : CMV
FiO₂ : 100% 85%
PEEP : 12
RR : 24
TV : 430
• ABGA after 6 hours of mechanical ventilation :
• pH 7.37 PCO₂ 44 PO₂ 75 HCO₃ 25.7 Lactate 1.46
20. How will you manage
further?
• Proning
• Recruitment maneuvers
21. Course in ICU (ICU Day 3 onward)
• Still PO2/FiO2 < 100, so proning done for 26 hours. After
1st cycle of proning, there was significant improvement in
oxygenation.
• ABGA (on CMV, 40% FiO2):
• pH 7.37 PCO2 52 PO2 97.7 HCO3 29.8 Lactate 1.03
• Total 5 cycles of proning ranging from 16-26 hours were
done from 05/10/15 to 10/10/15
• Patient has very high sedation requirement. To prevent
ventilatory dyssynchrony, patient was on atracurium +
Midazolam+Fentanyl infusion with regular sedation &
relaxant free interval in between.
22. Course in ICU (ICU Day 7 onward)
• CXR showed worsening with increasing TLC
• ET c/s – Acinetobacter
• Antibiotics were modified to Cefipime, Tigecycline and
Colistin.
• Serum Galactomannan – negative
• 10/10/15 onwards, patient was not maintaining adequate
saturation above 90% on 100% FiO2 & 12 PEEP & not even
while proning and after recruitment manuvouers.
23. How will you proceed
further?
• How will you manage refractory
hypoxemia?
• Role of Extracorporeal membrane
oxygenation (ECMO)
• VV vs VA ECMO
• Indications & Contraindication
• Evidence
24. Further plan of action
• ABGA on 11/10/15:
• pH 7.36 PO2 55.7 PCO2 70 HCO3 39 Lactate 2.35
• Till now, patient was hemodynamically stable, sensorium
was intact, had no other organ dysfunction & was passing
adequate urine output.
• Consensus was arrived after detailed discussion with
chest physician, among ICU team & with family to put
patient on ECMO. Patient was kept on VV ECMO on
11/10/15 with Right IJ & Right Femoral cannulation.
• Multiple sessions of bronchoscopies were done for lavage
as well as sampling.
31. ECMO Monitoring Protocol
• 1. Ventilatory settings : Low FiO2 (25-30%), Rate
(12/min) Pi (24-26) ; PEEP (10-12) to keep alveoli
open
• 2. Blood gas targets : PO2 > 50, sPO2 >88% PCO2
40-45, pH 7.35-7.45
• 3. Investigations : CBC, ABGA, Electrolytes 8 hourly
for 2 days and then twice daily, ACT 4 hourly, PT,aPTT
once a day, Fibrinogen once and then every 3-4 day
• 4.Fluid management : To maintain flow and prepump
• 5. Adequate urine output and monitor color of urine
32. ECMO Monitoring Protocol
• 6.Transfusion Targets: Hb >9 , Platelet : >30,000 if not
bleeding and >75,000 if bleeding
• 7. Sedation as per requirement
• 8. Heparin infusion 20unit/kg/hr to target ACT around 180
• 9. No lipid based drugs (Propofol, liposomal amphotericin)
• 10. Adequate enteral nutrition
• 11. Genral nursing care while maintaing flow and
saturation
39. ECMO weaning
• There was no significant radiological improvement, but
Lung compliance was improved after 10 days.
• From 21/10/15, ECMO weaning was started.
• On 25/10/15, finally ECHO was discontinued.
40. Course after ECMO removal
• Central line & Foley’s catheter were changed on
26/10/15
• Percutaneous tracheostomy was done on 26/10/15
• After tracheostomy, sedation requirement was
significantly decreased. Patient was neurologically
sound.
• Patient was maintaing sPO2 >90% for 3 days after
ECMO removal with FiO2 50-60% and PEEP 8, initially
on PCV and then on CMV.
41. Date pH PCO2 HCO3 Lactate PO2 FiO2 PEEP
11/10
Before ECMO Initiation
7.36 70 39 2.35 55.7 100% 12
11/10
After ECMO Initiation
7.42 35 23 1.01 81 100% 12
25/10
Before ECMO removal
7.38 47 27 1.12 79 45% 6
26/10
1 day after ECMO Removal
7.33 57 29 1.23 86 60% 8
27/10
2 day after ECMO Removal
7.37 56 32 1.01 99 45% 8
28/10
3 day after ECMO Removal
7.43 48 31 1.12 130 45% 8
30/10
5 day after ECMO Removal
7.25 90 39 2.42 48.1 100% 8
31/10
6 day after ECMO Removal
7.27 96 44 2.74 37.4 100% 8
43. Course after ECMO removal
• 2D ECHO (26/10/15) : WNL except PASP 74mmhg.
• iNO at 10-15 ppm was started on 26/10/15.
• Repeat 2D ECHO on 28/10/15 : PASP 45mmhg
• On 29/10/15, patient had increasing FiO2 requirement,
continuous fever, went into shock, vasopressors were
started & antibiotics were modified.
45. Further Course in ICU
• Patient’s condition deteriorated inspite of all above
measures, patient developed refractory hypoxia & shock
on 30/10/15 and expired on 31/10/15.
46. Course in Hospital - Summary
2/10
• Admitted in Respi. HDU, ABG s/o Acute Hypoxemic Respiratory Failure, initially maintained sPO2
>90% on 100% O2 Mask
3/10
• Respiratory distress increased, not maintaing sPO2 >90% on 100% Mask
• Shifted to ICU, Managed with NIV (CPAP-PSV)
5/10
• Intubated in view of increasing distress & desaturation
• Taken on mechanical ventilator
5/10
•After 6 hours of mechcanial ventilation, PO2/FiO2 <100% despite recruitment manuvouer, so proning done for 26 hours
•PO2/FiO2 improved to >200 after 1st cycle of proning
5/10-
10/10
•Total 5 cycles of proning done ranging from 16-26 hours from 5/10 to 10/10
• PO2/FiO2 dropped <100 after 4 cycle of proning, Plan to start ECMO discussed with Family after 5th cycle of proning
11/10-
19/10
•ECMO initiated with minimum ventilatory support and 12 PEEP to keep alveoli open, Multiple sessions of broncoscopies done
•Lung complainance improved and ECMO weaning tried from 19/10
19/10-
25/10
• Lung Complaince gradually improved from 21/10 and ECMO weaning progressed
• Finally ECMO removed on 25/10
26/10-
28/10
•Central line & foley’s cather changed & tracheostomy done on 26/10; iNO started on 26/10 at 10-15 ppm i/v/o PASP 74mmhg
•Patient maintained sPO2 till 28/10, PASP went down upto 45
29/10-
31/10
• From 29/10, patient has gone into secondory sepsis with shock, & refractory hypoxia
• Inspite of all above efforts, patient expired on 31/10/15 due to refractory shock and hypoxia.
47.
48. Important trials related to ARDS
• ARMA trial
• FACCT Trial
• Meta-analysis on N-M Blockers (Cisatracurium)
• Meta-analysis on role of steroid
• EXPRESS, LOVS, ALVEOLI trial & Metaanalysis
• OSCAR & OSCILLATE trial
• PROSEVA trial & previous meta-analysis on proning
• Meta-analysis on recruitment maneuvers