UMEM Educational Pearls - By Mike Winters

Category: Critical Care

Title: Sickle Cell Disease in the ICU

Posted: 12/29/2015 by Mike Winters, MD (Updated: 9/28/2023)
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Acute Chest Syndrome

Acute chest syndrome (ACS) accounts for the most common cause of ICU admission and the most common cause of death in sickle cell patients.
Important pearls for ACS include:
- Chlamydophila pneumonia is the most common bacterial cause of ACS in adults, whereas Mycoplasma pneumonia is the most common bacterial cause in children.
- CXR abnormalities may be absent early in disease.
- Children are more likely to have middle lobe disease, in contrast to adults who often have lower lobe involvement.
- Acute RV failure is a well recognized complication of ACS - use ultrasound to evaluate the RV and be careful with fluids.

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Category: Critical Care

Title: Ventilatory Support in Resource-limited Settings

Posted: 12/1/2015 by Mike Winters, MD (Updated: 9/28/2023)
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Mechanical Ventilation for Septic Patients in Resource-Limited Settings

An international team of physicians just published a series of recommendations for ventilatory support of septic patients in resource-limited settings.
Pearls from these recommendations include:
- Elevate the head of the bed to 30^o - 45^o
- Consider tidal volumes of 5 - 7 ml/kg PBW in all patients
- Use minimum levels of PEEP ( 5 cm H₂O) in all patients with sepsis and acute respiratory failure (unless the patient has moderate to severe ARDS)
- Lower F_iO₂ to target SpO₂ > 88% or PaO₂ > 60 mm Hg
- Use lung ultrasound to evaluate pulmonary edema when CXR is not available
- Consider using SpO₂ to FiO₂(S/F) as an alternative to P/F when blood gas analyzers are not available

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Category: Critical Care

Title: Myths Regarding Pain Management in the Critically Ill

Posted: 11/3/2015 by Mike Winters, MD
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Pain Management in the Critically Ill Patient

Pain is common, often underappreciated, and routinely undertreated in our critically ill patients.
Poorly treated pain has been shown to adversely affect both short- and long-term outcomes.
Key pearls when treating pain in the critically ill:
- Vital signs should not be used in isolation to assess pain
- Use a validated assessment tool to objectively quantify pain (i.e., Critical Care Pain Observation Tool)
- An analgosedation strategy (analgesics before sedative medications) has been shown to decrease duration of mechanical ventilation and decrease ICU LOS
- Opioids have no maximum or ceiling dose. The appropriate dose is that which controls pain with the fewest side effects.

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Category: Critical Care

Title: Hyperoxia in Critical Illness

Posted: 9/8/2015 by Mike Winters, MD (Updated: 9/28/2023)
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Hyperoxia in the Critically Ill

Oxygen is liberally administered to many critically ill patients, thereby exposing them to supranormal arterial oxygen levels.
Hyperoxia results in the formation of reactive oxygen species, which adversely affect the pulmonary, vascular, cnetral nervous, and immune systems.
Though the optimal P_aO₂ remains unknown, recent evidence indicates that hyperoxia is associated with increased mortality in post-cardiac arrest, CVA, acute coronary syndrome, and traumatic brain injury patients.
Take Home Point: Carefully titrate oxygen to the lowest tolerable level to meet the patient's needs.

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Category: Critical Care

Title: Diseases That Resemble ARDS

Posted: 8/11/2015 by Mike Winters, MD
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Is It Really ARDS?

Recent literature suggests that the incidence of ARDS in intubated ED patients may be as high as 10%.
The Berlin Definition of ARDS includes the acute onset of bliateral opacities (CXR or chest CT) that is not fully explained by pulmonary edema or fluid overload.
Emergency physicians and Intensivists are well versed in lung-protective ventilator settings for patients with ARDS.
However, several diseases can appear simliar to ARDS and may require different ventilator strategies and treatments.
In the absence of clinical risk factors for ARDS (e.g., sepsis, trauma), consider the following in your differential:
- Idiopathic pulmonary fibrosis
- Interstitial pneumonitis
- Granulomatosis with polyangitis (Wegener's)
- Diffuse alveolar hemorrhage
- Goodpasture's syndrome

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Category: Critical Care

Title: Severe Preeclampsia

Posted: 7/14/2015 by Mike Winters, MD
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Blood Pressure Management in Severe Preeclampsia

Severe preeclampsia (preeclampsia + at least one severe complication) accounts for almost 40% of deaths in obstetrical ICU admissions.
Systolic arterial hypertension is the most important predictor of morbidity in patients with severe preeclampsia.
First-line agents to reduce blood pressure in severe preeclampsia are nicardipine and labetalol.
Hydralazine is no longer recommended as first-line therapy.
Magnesium is used as an anticonvulsant and should not be considered an antihypertensive.

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Category: Critical Care

Title: Stress-Induced Cardiomyopathy

Posted: 5/26/2015 by Mike Winters, MD
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Stress-Induced Cardiomyopathy

Stress-induced cardiomyopathy (SIC) can be seen in a variety of critical illnesses, especially severe neurologic conditions.
SIC is believed to be caused by excess sympathetic stimulation of the myocardium.
When managing a patient with SIC, limit further catecholamine exposure by avoiding vasopressors if possible.
If the patient requires inotropic support, consider using an agent without catecholamine activity, such as milrinone.

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Category: Critical Care

Title: SIRS and Sepsis

Posted: 4/28/2015 by Mike Winters, MD
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SIRS and Severe Sepsis Screening

Sepsis remains one of the most common critical illnesses managed by emergency medicine and critical care physicians.
Many EDs and ICUs have screening protocols for early detection of the patient with sepsis. Most protocols use the systemic inflammatory response syndrome (SIRS) as a central component of early identification.
A recent study stresses caution when simply using the SIRS criteria to screen for severe sepsis:
- Retrospective review of the ANZICS Adult Database
- Divided patients into SIRS-positive ( 2 SIRS criteria with at least 1 organ failure) and SIRS-negative ( < 2 SIRS criteria with at least 1 organ failure)
- 109,663 patients
- 12% of patients diagnosed with severe sepsis or at least 1 organ failure had < 2 SIRS criteria at admission.
- Mortality for the SIRS-negative cohort remained relatively high at 16.1%
Take Home Point
- Using the SIRS criteria to screen patients for severe sepsis will miss 1 out of every 8 patients with infection and organ dysfunction.

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Category: Critical Care

Title: Mechanical Ventilation Practices in the ED

Posted: 3/31/2015 by Mike Winters, MD
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Mechanical Ventilation in the ED

Emergency physicians (EPs) intubate patients on a daily basis. Due to prolonged lengths of stay for many of these patients, the EP must manage the ventilator during the crucial early hours of critical illness.
Despite the marked increase in critically ill patients, emergency medicine residents receive very little training in mechanical ventilation (MV).¹
In addition, recent literature has demonstrated some common themes regarding MV in the ED.^2,3
- Use of higher than recommended tidal volumes
- Infrequent use of lung protective ventilation strategies
- Infrequent monitoring of plateau pressures
Take Home Points
- Pay attention to tidal volume
- Monitor and maintain plateau pressures < 30 cm H2O

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Category: Critical Care

Title: HFNC for Apneic Oxygenation

Posted: 3/3/2015 by Mike Winters, MD
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High-Flow Nasal Cannula for Apneic Oxygenation

In recent years, much has been written about the use of apneic oxygenation for patients who require endotracheal intubation (ETI).
Critically ill patients often have little cardiopulmonary reserve and can rapidly desaturate during ETI.
High-flow nasal cannula (HFNC) devices can deliver heated, humidified O2 up to 60 L/min and can provide a modest amount of positive pressure.
A recent study evaluated the use of a HFNC device for apneic oxygenation in ICU patients requiring ETI:
- Prospective, quasi-experimental, before-after study
- 101 patients in a single ICU in France
- Compared NRB + nasal cannula to HFNC for preoxygenation/apneic oxygenation
- Prevelance of severe hypoxemia (SpO2 < 80%) was significantly lower in the HFNC group
Clinical Application: Consider using HFNC for apneic oxygenation in critically ill patients with mild-to-moderate hypoxemia who require ETI.

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Category: Critical Care

Title: Hypertensive Emergencies

Posted: 2/3/2015 by Mike Winters, MD
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Hypertensive Emergency Pearls

It is well known that a hypertensive emergency is not defined by an arbitrary blood pressure reading. Rather, it is characterized by the presence of end-organ dysfunction, often due to a sudden increase in sympathetic activation.
When treating patients with a hypertensive emergency, consider the following:
- Many are hypovolemic due to a pressue-induced natriuresis - give them fluids and avoid diuretics.
- BP should be reduced in a controlled manner using short-acting titratable intravenous agents. Rapid reductions in BP can lead to organ hypoperfusion.
- Avoid oral, sublingual, and transdermal medications until end-organ dysfunction has resolved.
- Clevidipine is the newest agent
  - A third-generation dihydropyridine
  - Relaxes arteriolar smooth muscle
  - Rapid onset (2-4 min) and short acting (5-15 min)
  - Compares favorably with nicardipine in available studies

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Category: Critical Care

Title: Tips for the Resuscitationist - "PQRST"

Posted: 1/6/2015 by Mike Winters, MD
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"PQRST" - Capnography in Cardiac Arrest

Resuscitation of the patient in cardiac arrest can be stressful, chaotic, and variable depending on the setting.
Capnography is a valuable tool in the management of patients in cardiac arrest.
Heradstveit, et al. published a pneumonic for the use of capnography during cardiac arrest:
- P - Position of the tube
  - The sensivity and specificity of capnography for endotracheal tube confirmation is superior to auscultation and capnometry.
- Q - Quality of CPR
  - Early detection of poor-quality compressions.
- R - ROSC
  - A sudden increase in end-tidal CO2 can indicate ROSC without interrupting CPR for pulse checks.
- S - Strategy
  - May assist clinicians in determining underlying etiology of cardiac arrest.
- T - Termination
  - An end-tidal CO2 value < 10 mm Hg after 20 min of resuscitation has been shown to be very accurate in predicting death.

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Category: Critical Care

Title: The Critically Ill Patient with Ebola Virus Disease

Posted: 12/9/2014 by Mike Winters, MD
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The Critically Ill Patient with Ebola Virus Disease

The current outbreak of Ebola Virus Disease (EVD) is the largest ever recorded and has been declared "a public health emergency of international concern" by the WHO.
Pearls regarding critically ill patients within the current EVD outbreak include:
- Clinical Features
  - Tachycardia, tachypnea, oliguria, and alterations in mental status are common and generally seen about 7-12 days after symptom onset.
  - Shock is often due to profound hypovolemia from GI losses.
  - Hemorrhage is a late finding and most often manifests as lower GIB.
- Labs
  - Common lab abnormalities include hypokalemia, hypocalcemia, hypoalbuminemia, and lactic acidosis.
- Treatment
  - The mainstay of treatment is aggressive fluid resuscitation and electrolyte repletion (especially potassium).
  - Blood products can be administered for those with coagulopathy and hemorrhage.
  - Empiric antibiotics and antimalarial medications should be considered while awaiting confirmatory testing for EVD.

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Category: Critical Care

Title: Aminoglycosides in the Critically Ill

Posted: 11/11/2014 by Mike Winters, MD (Updated: 11/12/2014)
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Aminoglycosides in Critically Ill Patients

Aminoglycosides remain an important class of antibiotics in critically ill patients, especially those infected with multidrug-resistant organisms (i.e., Klebsiella and Pseudomonas spp.).
Importantly, aminoglycosides are concentration-dependent antibiotics and a greatly affected by the increased volume of distribution and altered elimination commonly seen in the critically ill.
As a result, recommended doses are often too low to be effective.
Initial doses of aminoglycosides should, therefore, be higher in critically ill patients.
- Amikacin: 25-30 mg/kg
- Gentamicin: 7-9 mg/kg
- Tobramycin: 7-9 mg/kg
Subsequent doses are based on drug level monitoring.

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Category: Critical Care

Title: Hemoglobin Threshold in Septic Shock

Posted: 10/14/2014 by Mike Winters, MD (Updated: 9/28/2023)
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Hemoglobin Threshold in Septic Shock

Numerous trials have demonstrated the benefit of lower hemoglobin thresholds for blood transfusion in critically ill patients.
The recently published Transfusion Requirements in Septic Shock (TRISS) trial evaluated the effects on mortality of a lower versus higher hemoglobin threshold in ICU patients with septic shock.
The TRISS trial randomized 1005 patients to a lower hemglobin threshold (7 g/dL) or a higher hemoglobin threshold (9 g/dL).
Overall, there was no difference in 90-day mortality between groups.
Patients randomized to the lower threshold received significantly fewer units without any increase in ischemic or adverse events.
Take Home Point: A hemoglogin threshold of 7 g/dL for blood transfusion appears effective for most patients with septic shock.

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Category: Critical Care

Title: Infectious Risks of Targeted Temperature Management

Posted: 9/16/2014 by Mike Winters, MD
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Infectious Risks Associated with TTM

Targeted temperature management (TTM) is commonly used in the care of patients resuscitated from cardiac arrest.
Despite improving neurologic outcomes, TTM can increase the risk of infection, bleeding, coagulopathy, arrhythmias, and electrolyte derangements.
Infectious complications of TTM are associated with increases in ICU length of stay, along with increases in the duration of mechanical ventilation.
Pneumonia and bacteremia are the two most common infectious complications of TTM, with S.aureus the most common single pathogen isolated in cases of infection.
Since TTM may suppress normal signs of infection, it is important to be vigilant for these two infectious complications.
At present, evidence does not support prophylactic antibiotics for all patients receiving TTM.

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Category: Critical Care

Title: Sepsis Pearls from the Recent Literature

Posted: 8/19/2014 by Mike Winters, MD (Updated: 9/28/2023)
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Sepsis Pearls from the Recent Literature

Sepsis remains one of the most common critical illnesses managed by emergency physicians and intensivists.
Recent publications and meta-analyses (i.e., ProCESS, ALBIOS, SEPSISPAM) have further refined the management of these complex patients.
A few pearls from the recent literature:
- Early broad-spectrum antibiotics remains the most important factor in reducing morbidity and mortality.
- Appropriate fluid resuscitation with a balanced crystalloid solution targeting 30 ml/kg. Use a dynamic measure of volume responsiveness to determine if additional fluid needed (i.e., PLR with a minimally invasive or noninvasive cardiac output monitor)
- Maintain adequate tissue perfusion with IVFs and vasopressors (norepinephrine) targeting a MAP > 65 mm Hg. Patients with chronic HTN may benefit from a higher MAP goal. If the diastolic BP is < 40 mm Hg upon presentation, start vasopressors concurrent with IVF resuscitation.

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Category: Critical Care

Title: Predicting Neurologic Outcome in the Era of TTM

Posted: 7/22/2014 by Mike Winters, MD
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Predicting Neurologic Outcome in Patients Treated with TTM

Whether you target 36^oC or 33^oC, targeted temperature management (TTM) improves survival and long-term neurologic oucome in survivors of out-of-hospital cardiac arrest.
TTM, however, can affect the accuracy and timing of commonly used tests to predict poor neurologic outcome.
Golan, et al just published a meta-analysis evaluating the accuracy of select diagnostic tests to predict outcome in patients treated with TTM.
- 20 studies (1,845 patients)
- Most accurate tests to predict poor neurologic outcome were:
  - Bilaterally absent pupillary reflex (LR 10.45)
  - Bilaterally absent somatosensory-evoked potentials (LR 12.79)
- Specificity of tests improved when testing was delayed > 72 hours
- Other commonly used tests (i.e., corneal reflexes, GCS motor score, unfavorable EEG readings) had higher false positive rates and lower LRs

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Category: Critical Care

Title: Prophylactic FFP for Procedures?

Posted: 6/24/2014 by Mike Winters, MD (Updated: 9/28/2023)
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Prophylactic FFP for Procedures?

FFP is commonly transfused to correct abnormal coagulation studies prior to performing procedures in nonbleeding critically ill patients.
Despite common practice, there is little to no supportive evidence to demonstrate a clinical benefit to transfusing FFP in this patient population.
Muller, et al recently evaluated the use of FFP before invasive procedures in critically ill patients. Brief highlights include:
- Prospective, randomized, open-label study at 4 sites in the Netherlands
- 76 adult ICU patients with INRs between 1.5 and 3.0
- Procedures: central line placement, thoracentesis, percutaneous tracheostomy
- Result: no difference in major bleeding events between those who received FFP and those randomized to no FFP
Take Home Point: In the nonbleeding critically ill patient, routine transfusion of FFP to correct lab abnormalities prior to procedures is not indicated.

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Category: Critical Care

Title: Intermediate Lactate Levels

Posted: 5/27/2014 by Mike Winters, MD
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Are Intermediate Lactate Levels Concerning in Patients with Suspected Infection?

It is well known that lactate levels > 4 mmol/L are associated with increased mortality in patients with suspected infection.
What is unclear, however, is the prognostic value of intermediate lactate levels (2.0-3.9 mmol/L) in patients with suspected infection.
Puskarich, et al. performed a systematic review to determine the risk associated with intermediate lactate levels.
- 8 studies (> 11,000 patients) were included in the analysis
- Mortality for patients with intermediate lactate levels but without hypotension was 15%
- Mortality was > 30% for hypotensive patients with intermediate levels of lactate.
Take Home Point: Patients with intermediate lactate levels have an increased risk of mortality.
Though no current guidelines exist for the optimal care of these patients, aggressive care should continue until repeat levels demonstrate normalization.