UMEM Educational Pearls - By Mike Winters

Title: Critical care of patients with HIV/AIDS - Lactic Acidosis

Keywords: HIV, Lactic, Acidosis (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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Critical care of patients with HIV/AIDS - Lactic Acidosis * Lactic acidosis can be a life-threatening complication of HAART - mortality as high as 77% * It can occur with any of the nucleoside/nucleotide reverse transcriptase inhibitors (most common are didanosine and stavudine) * Common presenting symptoms include abdominal pain, nausea, vomiting, myalgias, and elevation of transaminases * In patients with these symptoms check a lactate -> a value > 5 mmol/L is considered life-threatening * Treatment is supportive care with removal of the offending medication * In anecdotal reports, L-carnitine, thiamine, and riboflavin may reverse toxicity Reference: Morris A, Masur H, Huang L. Current issues in the critical care of the human immunodeficiency virus-infected patient. Crit Care Med 2006;34:42-9.

Title: Serial lactate Levels

Category: Critical Care

Keywords: Lactate, Sepsis, Infection (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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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.

Title: Start antibiotics ASAP in patients with septic shock

Category: Critical Care

Keywords: Antiobiotics, Sepsis (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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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.

Title: Intubated Patients HOB Recommendations

Category: Critical Care

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

Posted: 7/14/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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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.

Title: Life- or Limb-saving Escharotomy

Category: Critical Care

Keywords: Escharotomy, burn, ischemia (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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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)

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Title: Subclavian central venous access

Category: Critical Care

Keywords: Venous, catheter, subclavian (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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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.

Title: Oxygenation goals

Category: Critical Care

Posted: 3/11/2009 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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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 S_pO₂ > 88% and P_aO₂ > 55 mm Hg.