Current Topics in Critical Care

Current Topics in Critical Care

Susan M. Hellervik, MSN, ACNP-BC MICU NP Service

Objectives

? Describe current studies related to selected critical care topics.

? Integrate knowledge of the evidence related to selected critical care topics into practice.

Selected Topics

? Use of Beta Blockers in Critical Illness ? Post-Intensive Care Syndrome (PICS) ? Choosing Wisely

Beta Blockers in Critical Care

? Critical illness is characterized by increased resting energy expenditure due to sympathetic activation and a hyper-metabolic state; Beta blockers are known to decrease tissue oxygen consumption.

? Sympathetic overstimulation or prolonged stimulation can lead to cardiovascular and systemic effects that can contribute to morbidity and mortality.

? It has been hypothesized that modulation of this process with the use of beta blockers may have a protective effect on cardiac and systemic effects of sympathetic overstimulation

? Recent studies have investigated the effects of Beta blockers on critically ill patients and sub-groups of patients with septic shock, acute respiratory failure and TBI.

Effects of Sympathetic Overstimulation

Cardiovascular Effects

? Cardiac depression ? Decreased LVEF ? Apical ballooning ? Myocardial stunning ? Apoptosis and necrosis

Systemic Effects

? Catabolic state ? Hyperglycemia ? Insulin resistance ? Hypercoagulability ? Immunosuppression ? Enhanced bacterial growth ? Other inflammatory

derangements

Special Populations

Sepsis

? Early sepsis increases cardiac contractility and HR to meet metabolic demands ? these effects are initially beneficial, but these can become deleterious if excessive or prolonged

Acute Respiratory Failure

TBI

? Frequent occurrence of COPD ? Non-neurologic organ

exacerbations and cardiac co-

dysfunction due to sympathetic

morbidities

hyperactivity contributes to

? Chronic -2 agonist therapy

mortality in severely brain

may increase the incidence of

injured patients.

cardiovascular morbidity.

? Catecholamine surges have

? The use of -blockers has been

been observed after TBI and in

shown to be safe and

patients with non-traumatic

beneficial as the potential

SAH

benefits may outweigh the

? Stress cardiomyopathy and

risks

neurologic pulmonary edema

? ARDS, independent of etiology

contribute to poor outcomes

is a critical illness

independently of the severity

accompanied by sympathetic

of the initial brain injury.

overstimulation, presenting an ? Local - blockade may decrease

interesting area of research

parenchymal vessel

vaso-constriction, reducing

secondary brain injury,

improving perfusion and

oxygenation.

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