UMEM Educational Pearls - By Mike Winters

Title: Intubated Patients HOB Recommendations

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

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/28/2024)
Click here to contact Mike Winters, 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, MD (Emailed: 7/8/2007) (Updated: 4/28/2024)
Click here to contact Mike Winters, 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, MD (Emailed: 7/8/2007) (Updated: 4/28/2024)
Click here to contact Mike Winters, 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, MD (Emailed: 4/28/2024) (Updated: 4/28/2024)
Click here to contact Mike Winters, 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 S_pO₂ > 88% and P_aO₂ > 55 mm Hg.