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SSC 2021 Updates
Ventilation and additional therapy
DR. Mohamed Saber
ICU Physician
Meeqat General hospital - KSA
Part 3
Conservative oxygen targets (generally defined as PaO2 55–70
mmHg; SpO2 88–92%)
Types of respiratory failure:
Type 1 (Hypo...
 WOB mild improvement
 FiO2 95%-100%
 Can avoid NIV
complications
 Mild PAP
 Can improve WOB
 FiO2 up to100%
 NIV c...
If NIV is used for patients with
sepsis-associated hypoxic
respiratory failure, we suggest
monitoring for an early
reducti...
According to Berlin definition (2012):
Mild ARDS (Previously Acute lung injury): PO2/FiO2 =
200-300
Moderate ARDS: PO2/FiO...
Recommended:
Set the ventilator to CPAP mode and
increase the pressure to 30–40 cm
H2O for 30–40 s
Not Recommended:
 Use ...
NBMA benefits:
 May improve chest wall compliance
 Prevent respiratory dyssynchrony
 Reduce peak airway pressures
 May...
Liberal (Hemoglobin threshold, < 9 g/dl)
Restrictive strategy (Hemoglobin threshold, < 7 g/gl)
Eligible patients are those with septic shock
(within 48 h of the onset of vasopressor therapy
and AKI
AKI is defined as o...
RECAP
1.No sufficient recommendation of using Target SpO2 88-92% in Adults with
sepsis-induced RF.
2.For adults with sepsi...
12.For adults with sepsis-induced severe ARDS: using VV ECMO when
conventional MV fails
13.For adults with septic shock: u...
17.For adults with sepsis or septic shock and AKI who require renal replacement:
We suggest either continuous or intermitt...
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
sepsis SSC 2021 Updates Ventilation and additional therapy
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DR. Mohamed Saber
ICU Physician
Meeqat General hospital - KSA

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sepsis SSC 2021 Updates Ventilation and additional therapy

  1. 1. SSC 2021 Updates Ventilation and additional therapy DR. Mohamed Saber ICU Physician Meeqat General hospital - KSA Part 3
  2. 2. Conservative oxygen targets (generally defined as PaO2 55–70 mmHg; SpO2 88–92%) Types of respiratory failure: Type 1 (Hypoxemic): PaO2 < 60 mmHg Type 2 (Hypercapnic): PCO2 > 50 mmHg ± PaO2 < 60mmHg
  3. 3.  WOB mild improvement  FiO2 95%-100%  Can avoid NIV complications  Mild PAP  Can improve WOB  FiO2 up to100%  NIV complications: • Increased risk of gastric insufflation and aspiration • Facial skin breakdown • Excessively high tidal volumes • Patient discomfort related to inability to eat or effectively phonate during therapy.  PAP Both therapies avoid the complications of intubation and invasive mechanical ventilation
  4. 4. If NIV is used for patients with sepsis-associated hypoxic respiratory failure, we suggest monitoring for an early reduction in work of breathing and close monitoring NIV may be able to achieve similar physiologic benefits including improved gas exchange and reduced work of breathing in select patients, while avoiding complications associated with intubation, invasive ventilation, and accompanying sedation. In contrast, NIV can cause mask- related discomfort, unrecognized patient-ventilator asynchrony due to leaks, and gastric insufflation. The main risk of NIV for the indication of acute respiratory failure is the potential for delaying needed intubation
  5. 5. According to Berlin definition (2012): Mild ARDS (Previously Acute lung injury): PO2/FiO2 = 200-300 Moderate ARDS: PO2/FiO2 = 100-200 Severe ARDS: PO2/FiO2 < 100 Example: PaO2 = 90 mmHg on FiO2 60% (0.6) So P/F ratio = 90/0.6 = 150 → Moderate ARDS
  6. 6. Recommended: Set the ventilator to CPAP mode and increase the pressure to 30–40 cm H2O for 30–40 s Not Recommended:  Use pressure controlled ventilation  Set respiratory rate to zero and turn off apnea alarm  increase PEEP to 40 cmH20 for 40 seconds
  7. 7. NBMA benefits:  May improve chest wall compliance  Prevent respiratory dyssynchrony  Reduce peak airway pressures  May reduce oxygen consumption by decreasing the work of breathing
  8. 8. Liberal (Hemoglobin threshold, < 9 g/dl) Restrictive strategy (Hemoglobin threshold, < 7 g/gl)
  9. 9. Eligible patients are those with septic shock (within 48 h of the onset of vasopressor therapy and AKI AKI is defined as oliguria (< 0.3 ml/kg/h for ≥ 24 h), anuria for 12 h or more, or a serum creatinine level 3 times baseline accompanied by a rapid increase of ≥ 0.5 mg/dl. Indications for dialysis Uremic complications Refractory academia Refractory fluid overload Hyperkalemia).
  10. 10. RECAP 1.No sufficient recommendation of using Target SpO2 88-92% in Adults with sepsis-induced RF. 2.For adults with sepsis-induced RF: We suggest using HFNC > NIV 3.For adults with sepsis-induced RF: No sufficient recommendation for the use of NIV over IPPV 4.Use of low Vt (<6ml/kg) in sepsis-induced ARDS 5.Use of low Vt (6-8ml/kg) in sepsis-induced RF without ARDS 6.For sepsis-induced ARDS: use an upper limit gal for pPlateau of 30 cm H2O 7.For sepsis-induced ARDS: use of Higher PEEP > Lower PEEP 8.For sepsis-induced moderate-severe ARDS: using traditional recruitment maneuvers 9.We recommend against Against using incremental PEEP titration/strategy
  11. 11. 12.For adults with sepsis-induced severe ARDS: using VV ECMO when conventional MV fails 13.For adults with septic shock: using IV 200mg hydrocortisone at norepinephrine dose ≥ 0.25 mcg/kg/min at least 4 h after initiation. 14.For adults with sepsis or septic shock: we suggest against Polymexin B hemoperfusion 15. No sufficient evidence to make a recommendation on the use of other blood purification techniques. 16.For adults with sepsis or septic shock we recommend using Hb threshold < 7g/dl not Hb < 9 g/dl 17.For adults with sepsis or septic shock: We suggest using IVIG 15.For adults with sepsis or septic shock/at risk of GIB: We suggest using stress Ulcer prophylaxis 16.For adults with sepsis or septic shock: we recommend using pharmacologic
  12. 12. 17.For adults with sepsis or septic shock and AKI who require renal replacement: We suggest either continuous or intermittent renal replacement therapy. 18.We recommend against RRT without indication. 19.For adults with sepsis or septic shock: We recommend initiating insulin therapy at a glucose of ≥ 180mg/dL 20.For adults with sepsis or septic shock: We suggest against using IV vitamin C. 21.For adults with sepsis or septic shock and hypoperfusion-induced lactic academia We suggest against using Na HCO3 22.For adults with septic shock: pH ≤ 7.2 + AKI (AKIN score 2 or 3) We suggest Using Na HCO3. 23.For adults with sepsis or septic shock: We suggest early (within 72 h) initiation of enteral nutrition.

DR. Mohamed Saber ICU Physician Meeqat General hospital - KSA

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