UMEM Educational Pearls - By Mike Winters

Category: Critical Care

Title: Serial lactate Levels

Keywords: Lactate, Sepsis, Infection (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Emailed: 7/8/2007) (Updated: 10/15/2024)
Click here to contact Mike Winters, MBA, MD

Obtain serial lactate levels in ED patients with infection * Elevated serum lactate is associated with an increased risk of death in critically ill patients with infection * An initial lactate level > 4.0 mmol/l is significant and, in some series, is associated with a mortality of approximately 40% * Obtain serial venous lactate measurements every 3-4 hours * If serial levels remain > 4 mmol/l, or rise, be more aggressive with resuscitation Reference: Trzeciak S, et al. Serum lactate as a predictor of mortality in patients with infection. Inten Care Med 2007;33:970-7.



Category: Critical Care

Title: Start antibiotics ASAP in patients with septic shock

Keywords: Antiobiotics, Sepsis (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Emailed: 7/8/2007) (Updated: 10/15/2024)
Click here to contact Mike Winters, MBA, MD

Start antibiotics ASAP in patients with septic shock * For patients with septic shock, start antibiotics within the first hour * For each additional hour that antibiotics are delayed, survival decreases by 7%-8%! * Once you address the ABC's, obtain appropriate cultures, and hang the antimicrobials * Make sure you are providing effective antimicrobials (take a look at the patient's history to see if they have resistant bugs) Reference: Kumar A, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in septic shock. Crit Care Med 2006;34:1589-96.

Category: Critical Care

Title: Intubated Patients HOB Recommendations

Keywords: Intubation, ventilation, VAP, bed (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Emailed: 7/8/2007) (Updated: 10/15/2024)
Click here to contact Mike Winters, MBA, MD

In the absence of contraindications, keep the head of the bed elevated 30 degrees for intubated patients * Mechanical ventilation places patients at risk for ventilator-associated pneumonia (VAP) * ICU mortality for VAP ranges from 30% to 70% * Elevating the head of the bed has been shown to decrease the frequency of VAP Reference: Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004;141:305-13.

Category: Critical Care

Title: Life- or Limb-saving Escharotomy

Keywords: Escharotomy, burn, ischemia (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Emailed: 7/8/2007) (Updated: 10/15/2024)
Click here to contact Mike Winters, MBA, MD

Life- or Limb-saving Escharotomy * At some point in your career you may have to perform an emergent escharotomy to safe a life or limb * Deep thickness circumferential chest burns act like a straight jacket and impair respiration * Circumferential limb burns act like a tourniquet and impairs both venous output and arterial input resulting in ischemia * Limb escharotomy should be performed as soon as pulses diminish - do not wait for them to disappear * The picture illustrates the incision lines for escharotomy (note the bold lines highlight the importance of going across any involved joint)

Attachments

0707141915_escharotomy.jpg (5 Kb)



Category: Critical Care

Title: Subclavian central venous access

Keywords: Venous, catheter, subclavian (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Emailed: 7/8/2007) (Updated: 10/15/2024)
Click here to contact Mike Winters, MBA, MD

Subclavian central venous access * Many consider the subclavian to be the preferred route for central venous access * Approximately 5-6% of subclavian's are associated with misdirection of the catheter tip into the internal jugular * Directing the J-tip of the guidewire caudally significantly reduces the incidence of malpositioning Reference: Tripathi M, et al. Direction of the J-Tip of the guidewire, in seldinger technique, is a significant risk factor in misplacement of subclavian vein catheters: a randomized, controlled study. Anesth Analg 2005;100:21-4.

Category: Critical Care

Title: Oxygenation goals

Posted: 3/11/2009 by Mike Winters, MBA, MD (Emailed: 10/15/2024) (Updated: 10/15/2024)
Click here to contact Mike Winters, MBA, MD

Oxygenation goals

  • In recent pearls we have talked about 'lung protective' ventilation strategies to reduce volutrauma, barotrauma, and oxygen toxicity.
  • Using 'lung protective' strategies, such as low tidal volumes, results in higher levels of CO2 and a lower pH.  These are tolerated in favor of lower and safer alveolar pressures.
  • In addition to higher pCO2 values and lower pH, oxygenation goals are slightly lower than conventional teaching.
  • In these patients, you want to maintain SpO2 > 88% and PaO2 > 55 mm Hg.