UMEM Educational Pearls - By Mike Winters

POCUS in the Critically Ill Pregnant Patient

  • POCUS can be a valuable tool in the assessment and management of critically ill pregnant patients.
  • Conditions to consider in the critically ill pregnant patient who presents with acute RUQ pain include acute fatty liver of pregnancy (AFLP), liver infarction, liver hematoma, and Budd-Chiari Syndrome.
  • POCUS findings for these conditions include:
    • AFLP: a "bright" liver
    • Infarction: a wedge-shaped hypoechoic area (late finding)
    • Hematoma: a heterogeneous fluid collection below the capsule or intraparenchymal
    • Budd-Chiari Syndrome: lack of blood flow or thrombus in a hepatic vein or within the IVC.

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Post-Arrest Prophylactic Antibiotics?

  • Pneumonia is the most common infective complication in post-cardiac arrest patients. It may develop in up to 60% of patients and is associated with an increased ICU length of stay.
  • Given the challenges in diagnosing pneumonia in the post-cardiac arrest patient, many clinicians consider prophylactic antibiotic administration.
  • A recent systematic review and meta-analysis sought to evaluate the effect of early antibiotic use on survival and survival with good neurologic outcome in adult patients resuscitated from cardiac arrest. Key study results include:
    • 11 studies (3 RCTs, 8 observational trials)
    • 6149 patients
    • No change in overall survival or survival with good neurologic outcome
  • Take Home Point: Current data does not support the prophylactic administration of antibiotics to adults resuscitated from cardiac arrest.

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Management of Coagulopathy in Acute Liver Failure

  • Patients with acute liver failure (ALF) frequently require rapid resuscitation to prevent decompensation and multiorgan failure.
  • The most common cause of ALF remains drug-induced injury (i.e., acetaminophen).
  • Though coagulopathy is common in patients with ALF, the prophylactic administration of blood products has not been shown to have clinical benefit.
  • The routine correction of coagulation abnormalities is not currently recommended, unless the patient undergoes a major procedure (e.g., liver transplant).

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Mechanical Ventilation in the Obese Critically Ill

  • Rates of obesity have steadily risen over the past three decades.  In fact, the prevalance of obesity in the ICU is now estimated at 20%.
  • Obesity affects numerous organ systems and impacts the resuscitation and management of these patients.
  • The pulmonary systems undergoes several changes that include decreased lung compliance, decreased chest wall compliance, increased O2 consumption, increased CO2 production, and increased work of breathing.
  • When initiating mechanical ventilation in the obese patient without ARDS, consider the following initial settings:
    • Tidal volume 6 ml/kg ideal body weight
    • PEEP of 10-12 cm H2O
    • RR to achieve a PaCO2 35-45 mmHg
    • FiO2 to maintain SpO2 92-95%
    • Driving pressure < 15 cm H2O

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The Lung Transplant Patient in Your ED

  • Infections are the most common reason for ICU admission in lung transplant patients.
  • Not surprisingly, healthcare-aquired pneumonia is the most common infection seen in lung transplant recipients.
  • In contrast to non-transplant patients, gram-negative bacteria (i.e., Pseudomonas aeruginosa) are the most common pathogens.
  • Be sure to include antimicrobial coverage for Pseudomonas in your lung transplant patients presenting to the ED with pneumonia.

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Hyponatremia in the Brain Injured Patient

  • Hyponatremia is the most common electrolyte disorder in neurocritical care and is associated with increased ICP.
  • The two most common causes of hyponatremia in this patient population are cerebral salt wasting syndrome and SIADH.
  • Symptomatic hyponatremia should be treated with hypertonic saline:
    • 30-45 ml of 10% NaCl or
    • 100-150 ml of 3% NaCl
  • In order to prevent osmotic demyelination syndrome (ODM), sodium should not be corrected by more than 10 mmol/L/day.
  • The risk of ODM is low when acute hyponatremia develops in less than 48 hours.

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A True Tracheostomy Emergency

  • Patients with a tracheostomy often present to the ED for evaluation of a potential complication.
  • Consider a tracheoarterial fistula in any patient with a tracheostomy who presents with brisk bleeding.
  • Most occur within 3 to 4 weeks following tracheostomy placement, and the most common location is the innominate artery.
  • Up to 50% of patients will present with a sentinel bleed - an episode of brisk bleeding that has usually stopped at the time of presentation.
  • For patients who present with active hemorrhage, overinflate the tracheostomy cuff in an attempt to tamponade the bleeding.
  • If that does not stop the bleeding, remove the tracheostomy and compress the artery against the poterior sternum with your finger.

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Does This Patient Have Pericardial Tamponade?

  • Echocardiography is critical for the identification of a pericardial effusion and rapid diagnosis of pericardial tamponade.
  • Common echocardiography findings that suggest tamponade include diastolic right ventricular collapse, systolic right atrial collapse, a plethoric IVC with minimal respiratory variation, and potentially exaggerated respiratory cycle changes in mitral and triscupid inflow velocities.
  • Of these, systolic right atrial collapse is the earliest echocardiographic sign of tamponadewith a sensitivity ranging from 50% to 100%.
  • Of the 4 standard echo views, systolic right atrial collapse can best be viewed in the apical 4-chamber and subxiphoid views.

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Management of Acute Variceal Bleeding

  • Patients with an acute UGIB secondary to esophageal or gastric varices frequently present in extremis.
  • The initial resuscitation of patients with a variceal bleed should focus on the administration of antibiotics, packed red blood cells (PRBC), vasoactive agents, and emergent endoscopy.
  • Antibiotics have been shown to reduce recurrent bleeding and mortality. A third-generation cephalosporin (e.g., ceftriaxone) is commonly recommended as the initial antibiotic of choice.
  • Utilize a restrictive PRBC transfusion strategy to target a Hb between 7 to 8 g/dL.
  • Vasoactive agents (e.g., octreotide) reduce portal pressure through splanchnic vasoconstriction and have been shown to reduce acute bleeding and the need for transfusion.

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Respiratory Complications of ICIs

  • Acute respiratory failure (ARF) is the leading cause of ICU admission for immunocompromised patients.
  • While infectious etiologies remain the most common cause of ARF in these patients, there is an increasing prevalence of non-infectious, treatment-related causes.
  • Immune check-point inhibitors (ICIs) are now used with increasing frequency, and can cause severe pulmonary toxicity in approximately 6% of patients.
  • Pearls for ICI pulmonary toxicity include:
    • Acute pneumonitis is the most common presentation
    • Median time of onset of approximately 4 months after treatment initiation
    • Symptoms include dry cough, hypoxemia, and infiltrates not c/w CHF, infection, or progression of malignancy
    • Treatment is to DC the ICI and initiate steroids

 

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Category: Critical Care

Title: Renal Transplant Patients

Posted: 1/8/2019 by Mike Winters, MD (Updated: 8/17/2022)
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Critically Ill Renal Transplant Patients

  • Renal transplant patients are at high risk of critical illness from a variety of etiologies.
  • Sepsis is the most common reason for critical illness and ICU admission.  
  • Due to their immunosuppression, renal transplant patients are at risk of a multitude of infections.
  • Notwithstanding, acute bacterial pyelonephritis of the transplant is the most frequent cuase of sepsis, followed by bacterial pneumonia.
  • Be sure to consider these two etiologies when faced with a critically ill, septic renal transplant patient.

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Dyspnea in the Intubated Patient

  • Dyspnea may occur in up to 50% of intubated patients and has been associated with prolonged mechanical ventilation.
  • A number of assessment tools are available to detect dyspnea in the intubated patient.
  • Regardless of the tool used, once dyspnea is diagnosed, consider the following;
    • When possible, reduce nonrespiratory stimuli of the respiratory drive (i.e., fever, acidosis, anemia)
    • Minimize respiratory impedance (i.e., bronchodilators, thoracentesis for pleural effusion)
    • Optimize ventilator settings (i.e., change modes if applicable, increase inspiratory flow, increase PEEP)
    • Pharmacologic treatment (i.e., opioids, benzodiazepines)

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Noninvasive Ventilation in De-Novo Respiratory Failure

  • Noninvasive ventilation (NIV) is a primary therapy for patients with acute hypercapnic respiratory failure, especially those with an acute COPD exacerbation.
  • Notwithstanding its benefits in COPD and acute cardiogenic pulmonary edema, NIV should be used cautiously in patients with "de-novo" respiratory failure.
  • Many patients with de-novo respiratory failure will meet criteria for ARDS and have a high rate of intubation (30% - 60%).
  • The use of NIV with delayed intubation in this patient population has been associated with increased mortality. 

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Category: Critical Care

Title: Critically Ill Cancer Patient?

Posted: 11/13/2018 by Mike Winters, MD (Updated: 8/17/2022)
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Identifying Critically Ill Cancer Patients in the ED

  • Immunosuppressed patients with malignancy are at high risk of complications and rapid decompensation.
  • Select pearls in identifying ED patients with cancer that are at high risk of critical illness include:
    • Patients with profound neutropenia (< 100/mm3) are at high risk for fungal infections (i.e., aspergillosis)
    • Hypoxemia that requires oxygen is a predictor of later ICU admission.
    • Patients with bilateral infiltrates on CXR are at high risk of decompensation. Consider ICU admission.
    • Patients with promyelocytic leukemias are at high risk of DIC. Patients with this complication should be admitted to the ICU.

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Sedating Mechanically Ventilated Patients

  • Providing appropriate analgesia and sedation to mechanically ventilated patients is of paramount importance.
  • In a recent systematic review and meta-analysis, Stephens et al. assessed the impact of deep sedation within the first 48 hours of initiation of mechanical ventilation.
  • In 9 studies that included over 4,500 patients, deep sedation within the first 48 hours of initiation of mechanical ventilation was associated with increased mortality, increased ICU LOS, and increased frequency of delirium.
  • Take Home Points
    • When possible, target lighter levels of sedation in mechanically ventiilated patients.
    • Though no universally accepted definition of light sedation exists, most studies use a RASS of -2 to +1

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Does Lactated Ringer's Raise Serum Lactate?

  • Intravenous fluid administration is a cornerstone of resuscitation and the treatment of many critically ill ED patients.
  • Recent publications have suggested that balanced crystalloid solutions may be better than 0.9% normal saline (NS) for select conditions.
  • Lactated Ringer's (LR) is a common balanced crystalloid solution often used for fluid resuscitation in critically ill patients.
  • AS LR contains approximately 28 mmol/L of sodium lactate, the question of whether LR elevates serum lacate is frequently asked.
  • In a recent small, randomized, double-blind, controlled trial, investigators randomized healthy volunteers to receive 30 ml/kg of either 0.9% NS or LR. The authors report no statistical difference in the mean serum lactate when comparing LR to 0.9% NS.

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Critical Post-Arrest Interventions

  • Critical interventions to optimize neurologic outcome in the post-cardiac arrest patient include optimizing hemodynamics, preventing lung injury, maintaining normal O2 and CO2 tensions, targeted temperature management, and treating the underlying cause of the arrest.
  • Current guidelines recommend the following:
    • Target MAP > 70 mm Hg with IVFs, vasopressors, and inotropes.
    • Use a low tidal volume strategy of 6 to 8 ml/kg predicted body weight.
    • Decrease FiO2 to maintain SpO2 94% to 97%.
    • Adjust RR to maintain PaCO2 35 to 45 mm Hg
    • Initiate TTM with the goal temperature between 32 to 36o C

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Improving Analgesia in Mechanically Ventilated ED Patients

  • An analgosedation approach for mechanically ventilated patients has been shown to decrease the duration of mechanical ventilation and ICU LOS.
  • The latest guidelines from the Society of Critical Care Medicine recommend an opioid as the initial agent, followed by a non-benzodiazepine sedative.
  • Benzodiazepines have been shown to increase ICU delirium, increase the duration of mechanical ventilation, and increase ICU LOS.
  • In a recent cohort study, ED physicians increased the use of opioid analgesics and markedly decreased the use of benzodiazepines in mechanically ventilated ED patients through an educational campaign and implementation of an electronic orderset.
  • Take Home Point: An electronic health record orderset for mechanically ventilated ED patients can be helpful to guide clinicians and utilize an analgosedation approach.

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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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