vimwiki

commit 2fff437036e758afa79959cdaf3d69fcff550382
parent fb8276f2e98006eaa11f4df66bfb0e479054fbb7
Author: Beau <cbeauhilton@gmail.com>
Date:   Tue,  5 Oct 2021 08:34:39 -0500

ards

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medicine/2021-10-05-micu-morning.md
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+# ARDS
+
+Noncardiogenic pulmonary edema.
+
+## How to confirm "Noncardiogenic"?
+
+Gold standard would be RHC, 
+but clinically
+
+## [Berlin Criteria](https://www.mdcalc.com/berlin-criteria-acute-respiratory-distress-syndrome#evidence)
+
+P/F ratio. 
+
+Severity ratings (for prognostication, do not influence tx)
+- <300 mild
+- 100-200 moderate
+- <100 severe
+
+PEEP >= 5.
+
+Acute: onset w/in 1wk of insult
+
+## Etiologies
+
+Two major branches:
+Pulmonary vs extrapulmonary.
+
+Extrapulmonary: anything inflammatory (pancreatitis, sepsis)
+
+
+## Mgmt
+
+### Low-tidal volume ventilation: 6mL/kg of ideal body weight
+
+[NEJM 2000](https://www.nejm.org/doi/full/10.1056/nejm200005043421801)
+
+Finer points from this article:
+- 6 vs 12
+- plateau pressure targets differed
+- allowances for adjusting tidal volume based on ventilation needs
+- used pressure control, which has led to wider use of this mode
+
+### Conservative fluid mgmt
+
+[NEJM 2006](https://www.nejm.org/doi/full/10.1056/nejmoa062200)
+
+- no mortality difference
+- improvements in ventilator-days and ICU days
+- CVP endpoint less than 4, almost never reached == never cease to diurese
+
+### Proning
+
+[NEJM 2013](https://www.nejm.org/doi/full/10.1056/nejmoa1214103)
+
+- large reported mortality benefit
+- results called into question
+
+### Paralysis
+
+[NEJM 2019](https://www.nejm.org/doi/full/10.1056/nejmoa1901686)
+
+- no mortality benefit
+- still will paralyse patients, but not early as part of routine practice
+
+### Steroids (all-comers)
+
+[Lancet 2020](https://pubmed.ncbi.nlm.nih.gov/32043986/)
+
+- done just prior to COVID-19
+- long enrollment period, very strict enrollment criteria
+- possible improvement in ventilator-days and mortality
+
+### VV Ecmo
+
+[NEJM 2018](https://www.nejm.org/doi/full/10.1056/NEJMoa1800385)
+
+![EOLIA KM Curve](https://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2018/nejm_2018.378.issue-21/nejmoa1800385/20190311/images/img_medium/nejmoa1800385_f2.jpeg)
+
+- trial ended early for futility, but KM curves did diverge