UMEM Educational Pearls - By Mike Winters

Category: Critical Care

Title: Sedating Mechanically Ventilated Patients

Posted: 9/18/2018 by Mike Winters, MD
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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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Category: Critical Care

Title: Does LR Increase Serum Lactate?

Posted: 9/4/2018 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Post-Arrest Interventions That Make A Difference

Posted: 8/21/2018 by Mike Winters, MD
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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 36^o C

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Category: Critical Care

Title: Analgesia In Ventilated ED Patients

Posted: 7/24/2018 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Volume Responsiveness and the PLR (Courtesy John Peffer)

Posted: 6/26/2018 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: DOAC Pearls for the Critically Ill Patient

Posted: 5/1/2018 by Mike Winters, MD
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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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Category: Critical Care

Title: Acute on Chronic Liver Failure

Posted: 4/3/2018 by Mike Winters, MD
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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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Category: Critical Care

Title: Risk Factors for Peri-Intubation Cardiac Arrest

Posted: 3/20/2018 by Mike Winters, MD
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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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Category: Critical Care

Title: Hyperoxia in the Post-Arrest Patient

Posted: 2/6/2018 by Mike Winters, MD
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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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Category: Critical Care

Title: Septic Cardiomyopathy

Posted: 1/9/2018 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Sedating the Critically Ill Patient

Posted: 12/12/2017 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Mechanical Ventilation in Shock

Posted: 11/14/2017 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Improving CPR Performance

Posted: 10/17/2017 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Post-Arrest Mechanical Ventilation

Posted: 9/19/2017 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Hyponatremic Encephalopathy

Posted: 8/22/2017 by Mike Winters, MD
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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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Category: Critical Care

Title: Improving Resuscitation Performance

Posted: 7/25/2017 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Ventilation During Cardiopulmonary Resuscitation

Keywords: CPR, ventilation, respiratory rate, PaCO2 (PubMed Search)

Posted: 6/27/2017 by Mike Winters, MD
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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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Category: Critical Care

Title: Don't Forget that Second Dose!

Posted: 5/23/2017 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Ventilator Settings in the Post-Arrest Patient

Posted: 4/25/2017 by Mike Winters, MD (Updated: 9/27/2023)
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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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Category: Critical Care

Title: Ketamine is Not Without Risk

Posted: 3/28/2017 by Mike Winters, MD (Updated: 9/27/2023)
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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.