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61-80 of 356 results by Mike Winters
Volume Responsiveness, Carotid Ultrasound, and the PLR
- Passive Leg Raise (PLR) is accomplished by starting with the patient at a 45’ semi recumbent position, lowering the body to horizontal, passively raising the patients legs to 45’ for 30-90 seconds, then returning the patient to the semi-recumbent position.
- To assess volume responsiveness using PLR, you must assess cardiac output (CO) and not simply look at the changes in blood pressure or heart rate.
- Previous papers have shown EtCO2 to be a reasonable surrogate of CO with PLR when ventilation is unchanged.
- Another option for measuring CO is carotid ultrasound. One study demonstrated good correlation between carotid ultrasound and invasive measurements on ICU patients. It is calculated using the equation Diameter * VTi, where VTI is the velocity time integral.
- Take Home Point - Be sure to measure CO with a PLR to help determine volume responsiveness- EtCO2 or carotid ultrasound can be considered as surrogates of CO.
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DOACs and the Critically Ill
- The use of DOACs for the prevention of stroke and venous thromboembolism is increasing.
- Though DOACs may be non-inferior to warfarin for these indications, it is important to consider the following pearls on DOACs in the critically ill patient:
- Acute kidney injury can double the half-life of dabigatran to more than 30 hours
- Hepatic failure can markedly increase the half-life of the factor Xa inhibitors
- PT, aPTT, and INR may not accurately assess the risk of bleeding. Use dilute thrombin time (TT), ecarin clotting time (ECT), or TEG/ROTEM to assess coagulopathy
- Can consider PCC (25 to 50 IU/kg) for life-threatening hemorrhage. The evidence supporting this recommendation is not robust.
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Acute on Chronic Liver Failure
- Patients with cirrhosis can comprise up to 5% of an ICU population.
- Many of these patients will present to the ED, and be admitted to the ICU, for acute on chronic liver failure.
- A few management pearls for these patients include:
- Consider albumin in patients with hepatorenal syndrome, large-volume paracentesis (> 5 L), and SBP
- Norepinephrine is the initial vasopressor of choice; target a MAP ≥ 60 mm Hg
- The INR does not accurately reflect bleeding in these patients. Use platelet count and fibrinogen.
- There is no need to correct coagulation abnormalities prior to routine procedures (e.g., central venous catheterization)
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Peri-Intubation Cardiac Arrest
- Endotracheal intubation is a high-risk procedure, especially in the critically ill patient.
- The incidence of peri-intubation cardiac arrest ranges from 2% to 5%, and is associated with significant increases in morbidity and mortality.
- Authors of a recent retrospective analysis across 64 French ICUs sought to determine risk factors for cardiac arrest during ICU intubation.
- Among 1,847 intubations, the main predictors of cardiac arrest during intubation were:
- Pre-intubation arterial hypotension (SBP < 90 mm Hg) (OR 3.4)
- Pre-intubation hypoxemia (OR 3.99)
- Absence of preoxygenation (OR 3.58)
- Obesity (OR 2)
- Age > 75 years of age (OR 2.25)
- Take Home Point
- Pay close attention to these risk factors and "resuscitate before you intubate".
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Hyperoxia and the Post-Arrest Patient
- Current post-arrest guideilnes recommend titrating supplemental O2 to avoid hypoxia and limit exposure to hyperoxia.
- Importantly, these recommendations are based primarily on retrospective studies that have used ABG values within the first 24 hours following ROSC.
- The latest study to evaluate the impact of hyperoxia following cardiac arrest was just published in Circulation.
- This study is a prospective, cohort study that evaluated the association between early hyperoxia and poor neurologic outcome in adults following cardiac arrest. (ABGs were obtained at 1 hour and 6 hours following ROSC)
- Of 280 patients, 38% were exposed to early hyperoxia (defined as a PaO2 > 300 mm Hg)
- Take Home Points
- Early hyperoxia was found to be an independent predictor of poor neurologic outcome at hospital discharge.
- One hour longer duration of hyperoxia was associated with a 3% increase in the risk of poor neurologic outcome
- SaO2 could not reliably exclude the presence of hyperoxia.
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Septic Cardiomyopathy
- Cardiac dysfunction is common in patients with sepsis.
- Though mulitiple definitions exist, sepsis cardiomyopathy (SCM) is generally defined as an "acute syndrome of cardiac dysfunction that is unrelated to ischemia in patients with sepsis".
- Depending on the study, the incidence of SCM ranges anwywhere from 7% to 70%.
- Risk factors for SCM include:
- Male
- Younger age
- High lactate at admission
- History of heart failure
- The best approach to treating patients with SCM is to maximize your treatment of sepsis.
- Dobutamine is no longer routinely recommended for SCM based solely on measurements of ScvO2.
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Sedating The Critically Ill Patient
- Sedating critically ill ED patients can be challenging.
- Excessive sedation is associated with a prolonged duration of mechanical ventilation, ICU LOS, and may increase mortality.
- Important pearls to consider when managing these patients include:
- Prioritize pain management first - may reduce the need for sedative medications
- When possible, target a calm and interactive patient shortly after intubation - consider adding a atypical antipyschotic with propofol or dexmedetomodine
- Use a validated tool (i.e., RASS) to dose opioids and sedative medications
- Avoid continuous infusions of benzodiazepines
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Mechanical Ventilation in Shock
- Emergency physicians and intensivists routinely resuscitate patients in shock.
- For patients who manifest signs of persistent shock (i.e., rising lactate), consider intubation and mechanical ventilation, even in the absence of acute respiratory failure.
- The respiratory muscles are avid consumers of oxygen. In fact, up to 50% of available O2 can be used by the respiratory muscles to perform the work of breathing.
- Initiation of mechanical ventilation can reduce oxygen consumption and allow oxygen to be shunted to other vital organs.
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Improving CPR Performance
- High-quality CPR is the cornerstone of successfull resuscitation from cardiac arrest.
- In fact, high-quality CPR is considered the most important intervention for achieving ROSC and good neurologic recovery.
- Pearls for optimizing CPR performance include:
- Use a team-focused approach
- Avoid leaning and ensure complete recoil of the chest
- Target a chest compression fraction of at least 60%
- Use POCUS, but pay attention to the duration of hands-off time
- Target ETCO2 of > 20 mm Hg
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Post-Arrest Tidal Volume Setting
- Most patients with ROSC from out-of-hospital cardiac arrest undergo endotracheal intubation and mechanical ventilation.
- Optimal management of mechanical ventilation for the post-arrest patient is currently not well defined.
- A recent retrospective cohort study sought to determine if a lower tidal volume (Vt) was associated with improved neurocognitive outcome at hospital discharge.
- Of 256 patients included in the study, investigators found:
- 38% were ventilated with Vt > 8 ml/kg predicted body weight
- Lower Vt was significantly associated with favorable neurocognitive outcome, decreased duration of mechanical ventilation, and decreased ICU length of stay
- Take Home Pearl: Pay attention to Vt in the post-arrest patient.
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Hyponatremic Encephalopathy
- Hyponatremic encephalopathy is a true emergency and due to hypoosmolar-induced cerebral edema.
- In contrast to the asymptomatic patient with hyponatremia, treatment of hyponatremic encephalopathy is determined by symptoms and not the duration of hyponatremia.
- Clinical manifestations include nausea, vomiting, headache, confusion, seizures, respiratory failure, and coma.
- Hypertonic saliine is the treatment of choice
- Administer 2 ml/kg 3% hypertonic saline (100 ml in many cases)
- This will typically raise serum sodium 2 mEq/L
- In most cases, a 4-6 mEq/L rise will reverse neurologic symptoms
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Improving Resuscitation Performance
- Resuscitating the critically ill patient can often be quite stressful.
- Stress has been shown to decrease the quality and effectiveness of decisions, decrease the amount of information a person can process, and lead to short-term memory deficits.
- Recently, there has been emphasis on the use of performance-enhancing psychological skills (PEPS) to allow providers to think clearly, maintain situational awareness, recall important information, and perform skills efficiently.
- A recent article highlights 4 key elements of an EM model for PEPS that can be used to improve performance in resuscitations.
- Breathe - consider tactical breathing
- Talk - positive instructional or motivational self-talk
- See - visualize the steps of a procedure before actually performing it
- Focus - use a trigger word as a prompt to shift attention to a prioritized task
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Ventilation During Cardiopulmonary Resuscitation
- Cardiopulmonary resuscitations are often highly stressful and chaotic situations. As a result, it is no surprise that ventilation rates can be as high as 60 breaths per minute.
- Hyperventilation during cardiopulmonary resuscitation can increase intrathoracic pressure, impair venous return, decrease coronary perfusion pressure, and ultimately decrease survival.
- It is imperative that the team leader pay close attention to ventilation and ensure that approximately 8 to 10 breaths per minute are delivered.
- Once ROSC is achieved, the respiratory rate should be adjusted to maintain a PaCO2 between 40 and 45 mm Hg.
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Antibiotics in Sepsis
- Currently international guidelines for the management of sepsis and septic shock recommend antibiotic administration within 1 hour of recognition.
- With the persistent problem of ED boarding, many patients with sepsis and septic shock remain in the ED long after the initial dose of broad-spectrum antibiotics.
- A recent single center, retrospective cohort study demonstrated that 1 out of 3 patients with sepsis or septic shock experienced major delays in the time to the second dose of antibiotics. In fact, over 70% of patients who were given an initial antibiotic with a 6-hr recommended dosing interval experienced major delays.
- Inpatient boarding in the ED was found to be an independent risk factor for major delays.
- Take Home Point: Don't forget to write for additional doses of antibiotics in your boarding patients with sepsis.
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Ventilator Settings for the Post-Arrest Patient
- The majority of patients with ROSC from OHCA require intubation and mechanical ventilation.
- Correctly managing the ventilator in the post-arrest patient is critical for improving outcomes.
- As patients are at high risk for ARDS, use lung-protective ventilation with tidal volumes between 6 to 8 ml/kg of ideal body weight and PEEP of 5 to 8 cm H2O.
- There is a U-shaped relationship between neurologic outcomes and both PaO2 and PaCO2.
- Target normoxia (SpO2 94% to 96%) and avoid hyperoxia and hypoxia.
- Target normocapnia (PaCO2 40 to 50 mm Hg) and avoid hypercapnia and hypocapnia.
- Use an analgosedation approach with short-acting analgesics and sedatives, such as fentanyl and propofol.
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DSI, Ketamine, and Apnea
- In recent years, delayed sequence intubation (DSI) with ketamine has been used in select patients to maximize preoxygenation and dinitrogenation.
- Importantly, DSI is not well studied. In the only prospective trial of DSI, patients received approximately 1.4 mg/kg of ketamine.
- Driver, et al. report the abrupt onset of apnea in a patient who received a much lower dose of ketamine (25 mg) for DSI.
- Take Home Point: If DSI is a part of your preoxygenation armamentarium, apnea can occur even at low doses of ketamine. Stand at the patient's bedside and be ready to immediately intubate the patient.
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Preoxygenation in Critically Ill Patients
- Achieving adequate preoxygenation and denitrogenation prior to intubating critically ill patients can be challenging.
- Critically ill patients have physiologic alterations (i.e., derangements in oxygen consumption, anemia, reduced cardiac output, air space disease) that can markedly reduce safe apnea time.
- For patients with significant air space disease and shunt physiology, noninvasive ventilation (NIV) can decrease shunt fraction, increase functional residual capacity, improve PaO2, and lengthen safe apnea time.
- Importantly, NIV should be used for at least 3 minutes to achieve improvements in alveolar recruitment.
- It is also important to remove NIV just prior to larygnoscopy, as alveoli will begin to derecruit when NIV is removed.
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Sepsis Mimics
- Emergency physicians are well versed in the resuscitation of patients with sepsis and septic shock.
- With the recent publication of the 2016 SSC Guidelines and the emphasis in meeting various quality measures, sepsis is routinely included in the differential diagnosis of critically ill patients.
- Notwithstanding, it is important to consider other disease states that can present similarly to sepsis or septic shock. Some of these include:
- Anaphylaxis
- Adrenal insufficiency
- DKA
- Thyroid storm
- Toxic ingestion or withdrawal
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Epinephrine in Anaphylaxis
- Delayed administration of epinephrine for patients witih anaphylaxis is associated with increased morbidity and mortality.
- Providers are often hesitant to administered epinephrine to older patients with anaphylaxis for fear of precipitating an adverse cardiovascular event.
- A recent retrospective study of almost 500 patients demonstrated that older patients were significantly less likely to receive epinephrine, despite meeting the definition for anaphylaxis.
- Furthermore, cardiovascular complications occurred in just 9 patients, 6 of which received an excessive dose via the IV route.
- Take Home Point: There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis. Give the initial dose IM into the anterolateral thigh.
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PaCO2 and the Post-Arrest Patient
- Alterations in PaCO2 are common during the post-arrest period and have been associated with worse patient centered outcomes.
- Hypercarbia can dilate cerebral vessels, increase cerebral blood flow, and may increase intracranial pressure.
- Conversely, hypocarbia can constrict cerebral vessels and may reduce cerebral blood flow.
- Though the current evidence is primarily limited to observational trials, a recent meta-analysis found that "normocarbia" was associated with improved hospital survival and neurologic outcome.
- Take Home: Adjust mechanical ventilation to target normocarbia (PaCO2 or ETCO2) in the post-arrest patient.