UMEM Educational Pearls - By Mike Winters

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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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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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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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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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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"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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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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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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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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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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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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Predicting Neurologic Outcome in Patients Treated with TTM

  • Whether you target 36oC or 33oC, 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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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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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.

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Antibiotic Timing in Severe Sepsis/Septic Shock

  • Though the recent ProCESS trial has questioned the utility of central hemodynamic monitoring and protocol-based resuscitation, early antibiotic administration remains paramount in the care of patients with severe sepsis/septic shock.
  • Retrospective studies have demonstrated that delays in antibiotic administration are associated with marked increases in hospital mortality.
  • Notwithstanding, delays in antibiotic administration remain all too common.
  • Ferrer et al, have just published the largest cohort to date analyzing the association of antibiotic timing to hospital mortality in patients with severe sepsis or septic shock.  The key findings include:
    • Retrospective cohort of 17,990 patients from the SSC database.
    • Hospital mortality rose linearly for each hour delay in antibiotic administration.
    • Odds ratio for hospital mortality increased from 1 to 1.52, as the delay increased from 0 to 6 hours after presentation.
  • Key Point: Antibiotic timing matters!

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Coagulopathies in Critical Illness - DIC

  • Disseminated intravascular coagulation (DIC) is an acquired syndrome of intravascular coagulation and is commonly encountered in critically ill patients.
  • Think about DIC in the critically ill patient with oozing at vascular sites (or wounds) and the following lab abnormalities:
    • Thrombocytopenia
    • Prolonged PT and aPTT
    • Decreased fibrinogen
    • Elevated fibrin split products and D-dimer
  • Guidelines for the management of DIC are primarily based on expert opinion and include:
    • Treat the underlying condition (i.e., sepsis)
    • Transfuse platelets if < 50,000 per mm3
    • Transfuse FFP to maintain PT and aPTT < 1.5 times normal control
    • Transfuse cryoprecipitate to maintain fibrinogen levels > 1.5 g/L
  • The use of heparin remains controversial and cannot be routinely recommended.

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Recruitment Maneuvers for ARDS

  • Patients with ARDS who are ventilated with lung protective settings are at risk of derecruitment/collapse of lung units.
  • Recruitment maneuvers are processes that transiently increase transpulmonary pressure to open collapsed units.
  • These maneuvers can improve oxygenation and have been used in patients with ARDS and those with refractory hypoxemia.
  • The various types of recruitment methods include:
    • Airway pressure-based maneuver: a continuous positive airway pressure of 35-45 cm H2O is applied for 30-40 seconds
    • Ventilator modes: Airway pressure release ventilation (APRV) and high-frequency oscillatory ventilation (HFOV)
    • Prone positioning
  • Adverse events can occur with recruitment maneuvers and include hypotension, hypoxia, and pneumothorax (rare).

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Category: Critical Care

Title: Mechanical Ventilation During ECMO

Keywords: VV-ECMO, mechanical ventilation, ultra-lung protective ventilation (PubMed Search)

Posted: 2/4/2014 by Mike Winters, MD
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Mechanical Ventilation During ECMO

  • ECMO is a rapidly emerging therapy for critically ill patients with severe acute respiratory failure (VV-ECMO) and circulatory failure (VA-ECMO).
  • Mechanical ventilation (MV) settings may have important effects on patients receiving either VV- or VA-ECMO.
  • Though no large, randomized trials, consensus guidelines and expert opinion recommend the following initial settings for patients receiving VV-ECMO:
    • Tidal volume: < 4 ml/kg predicted body weight
    • Plateau pressure: < 25 cmH2O
    • PEEP: 10-15 cmH2O
    • FiO2: titrated to maintain sats > 85%
    • RR: 4 to 6 breaths per minute

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Category: Critical Care

Title: LVAD Pearls

Posted: 1/7/2014 by Mike Winters, MD (Updated: 8/17/2022)
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Pearls for the Crashing LVAD Patient

  • Left ventricular assist devices (LVAD) are placed as a bridge to transplant, bridge to recovery, or as destination therapy.
  • As thousands of LVADs have been implanted, it is likely that a sick LVAD patient will show up in your ED or ICU.
  • In addition to pump thrombosis (UMEM pearl 12/31/13), two complications to also consider in the crashing LVAD patient include infection and arrhythmias.
  • Infection:
    • The driveline and pump pocket are the most common locations for device infection.
    • Most are caused by Staphylococcus and Enterococcus organisms.
    • For pump pocket and deeper wound infections be sure to also add coverage against Pseudomonas species. 
  • Arryhthmias:
    • The highest incidence is within the first month after implantation.
    • Consider a "suction event," where the inflow cannula contacts the ventricular septum.
    • Suction events can be caused by hypovolemia, small ventricular size, or RV failure and are treated with fluid resuscitation and decreasing the LVAD speed.

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Category: Critical Care

Title: The CORE Scan

Posted: 12/10/2013 by Mike Winters, MD (Updated: 8/17/2022)
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The Concentrated Overview of Resuscitative Efforts (CORE) Scan

  • Ultrasound has become an essential tool in the evaluation and management of the crashing patient.
  • The CORE scan utilizes emergency bedside ultrasonography to systematically evaluate and resuscitate the rapidly deteriorating patient.
  • Essentially steps in the CORE scan include:
    • Endotracheal tube assessment
    • Lung assessment
      • Pneumothorax?
      • Pleural effusion?
      • Hemothorax?
    • Cardiac assessment
      • Pericardial effusion?
      • Massive PE?
      • Estimated ejection fraction?
    • Aorta assessment
      • Abdominal aortic aneurysm?
      • Aortic dissection?
    • IVC assessment
    • Abdominal assessment
      • Intraperitoneal fluid?

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