Category: Critical Care
Posted: 9/17/2024 by William Teeter, MD
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I wanted to send out two websites curated in part by UMEM current and past faculty/residents/fellows which have a wealth of critical care lectures and resources:
Disclosure: *I am one of the webmasters for the STCMTCC, but have no affiliation with MCCP other than as an enthusiastic reader.
Category: Critical Care
Posted: 7/23/2024 by William Teeter, MD
(Updated: 12/4/2024)
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Do Sepsis Alert Systems Work?
Researchers in Korea completed a high quality systematic review and meta-analysis of sepsis alert systems for adult ED patients
Using high quality methods, they identified over 3000 studies with 22 meeting criteria.
They found these systems were associated with:
Electronic alerts were further associated with:
Summary (+ a little editorialization)
As annoying as we may find these systems in our daily practice, there is growing evidence that they do provide some benefit with impacts on task saturation and decreasing cognitive load in addition to real patient benefit. While there is also recent evidence that physician gestalt performs well against these systems, there is a suggested benefit in their inclusion in clinical decision making as a safety net or as an “assist”.
The incorporation of rule-based algorithms like these in more advance machine learning methods are covered quite well in a recent opinion piece on “The AI Future of Emergency Medicine”. However, it is important to always know the source of any “algorithm” that you are using, whether rule or mathematically based, given real concerns for bias and error.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821277
https://www.sciencedirect.com/science/article/pii/S019606442400043X
https://www.sciencedirect.com/science/article/abs/pii/S0196064424000994
Category: Critical Care
Posted: 6/4/2024 by William Teeter, MD
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This really interesting study suggests that the classic site of CPR “in the middle of the chest” may actually not be the ideal place to perform CPR. Previous imaging studies demonstrate that the ventricles are primarily beneath the lower third of the sternum and that standard placement of CPR compressions may deform the aortic valve, blocking the LVOT, and theoretically limiting perfusion of the coronaries and brain.
This study compared a standard CPR group with those undergoing TEE-guided chest compressions to avoid aortic valve compression. Those in the non-AV compression group had significantly increased likelihood of ROSC, survival to ICU, and higher femoral arterial diastolic pressures. However, there was no difference in long-term outcomes or end-tidal CO2.
Summary: Avoiding AV compression during CPR significantly improved the chance at ROSC in adult OHCA, but this small observational study did not show any difference in long term outcomes when compared to standard practice. Lowering the point of chest compressions in CPR to the lower third of the sternum may be beneficial.
Category: Critical Care
Posted: 4/17/2024 by William Teeter, MD
(Updated: 4/24/2024)
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Moderate to High-Risk Pulmonary Embolism
In stable patients, call your local PE Response Team (PERT) for advice. The UMMC PERT team is available for any patient in the region and can be contacted through Maryland Access Center.
UMMC PERT stratifies by BOVA (with lactate criteria), CTA imaging, and patient physiology/history. For the consult, we will use the patients most recent vitals, their ROOM AIR sat if available, presence of RV dysfunction on echo/CTA, recent lactate, troponin, BNP, bedside/formal echo, and HPI.
Broad management recommendations for moderate or high-risk patients
PERT Acceptance for Transfer to UMMC/CCRU
See below for more information.
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Definitions of RV dysfunction
Absolute Contraindications to Fibrinolytic Therapy in Pulmonary Embolism
UMMC Relative Exclusion Criteria for VA ECMO for PE
HI-PEITHO (NCT04790370) “is a prospective, multicenter RCT comparing Ultrasound-facilitated catheter-directed therapy (USCDT) and best medical therapy (BMT; systemic anticoagulation) with BMT alone in patients with acute intermediate–high-risk PE.”
Inclusion Criteria
Category: Critical Care
Posted: 1/10/2024 by William Teeter, MD
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Many of us in the endovascular resuscitation space were eagerly awaiting some clarity on REBOA from this trial. Unfortunately, this is not the definitive trial that either confirms or denies the utility of REBOA in trauma.
Unfortunately, even this well-designed trial suffered from major problems, most notably enrollment issues (ITT: of the 46 in the REBOA group, only 19 actually got REBOA!!) and matching issues (Brain AIS was significantly higher in the REBOA group versus standard practice [3 vs 0] & initial systolic pressure was lower in the REBOA group, both of which are known risk factors for poor outcome in REBOA).
This trial's failure to provide a definitive benefit or the nail-in-the-coffin is frustrating to say the least. Until that day, we will continue to be selective of the "right" patient and to put in femoral arterial lines early and often.
Zaf Qasim has an excellent talk on EMRAP about this study, as does St. Emlyn's.
Category: Critical Care
Posted: 11/23/2023 by William Teeter, MD
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https://pubmed.ncbi.nlm.nih.gov/37142091/
Category: Critical Care
Keywords: peripheral pressors, central line, CVC, CLABSI (PubMed Search)
Posted: 10/4/2023 by William Teeter, MD
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Bottom line: As part of a systematic protocol, peripheral pressors administered through a peripheral line greater 22Ga or larger reduced the number of days of central venous catheter (CVC) use in a MICU population at an academic medical center. 35 (5.5%) patients had an extravasation event all with “minimal” tissue injury complications. None required surgery. 51.6% of patients did not require a CVC as a result of the protocol
Details
Notes on protocol
PIV were placed and confirmed with US, were between wrist and AC fossa with q2h patency checks. Max allowable dose of NE 15 mcg/min with requirement that patients be able to report pain at site. Initially, max infusion time was set at 48h but was eventually liberalized to indefinite use.
https://pubmed.ncbi.nlm.nih.gov/37611862/
Category: Critical Care
Posted: 8/8/2023 by William Teeter, MD
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Targeted Therapeutic Mild Hypercapnia after Resuscitated Cardiac Arrest (TAME)
Current guidelines recommend normocapnia for out-of-hospital cardiac arrest (OHCA), the TAME Study asked is mild hypercapnia better?
Conclusion: "In patients with coma who were resuscitated after out-of-hospital cardiac arrest, targeted mild hypercapnia did not lead to better neurologic outcomes at 6 months than targeted normocapnia."
https://www.nejm.org/doi/full/10.1056/NEJMoa2214552
https://clinicaltrials.gov/study/NCT03114033
https://www.thebottomline.org.uk/blog/ebm/tame/
Category: Critical Care
Posted: 4/20/2023 by William Teeter, MD
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CCM recently published Stanford's experience with their Emergency Critical Care Program (ECCP), an ED based intensivist consultation/management model staffed by EM/CC during peak hours with the "goals of improving care of the critically ill in the ED, offloading the ED team, and optimizing ICU bed utilization without the need for a dedicated physical space."
Conclusions:
This is the third group to document decrease in overall mortality utilizing an early or dedicated critical care consult model. EC3 and the CCRU here at UMMC have also both shown improvements in patient transfer and resource utilization metrics. As with all studies in this space, there are many limitations to these studies in both design and generalizability, even amongst each other. However, the literature is replete with data that increased boarding time in the ED for critically ill patients is associated with worse outcomes and these studies are now a body of complementary and growing evidence that teams such as this can perhaps bridge that gap. Hopefully come to an ED near you soon...
Study Details:
Objectives: To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED).
Design: Single-center, retrospective cohort study from a tertiary academic medical center using ED-visit data between 2015 and 2019 for adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival.
Pre and post intervention (2017) cohort analysis of patients when facility implemented dedicated bedside critical care by an ED-based intensivist "following initial resuscitation by the ED team". A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015–2017) and the intervention period (2017–2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours).
Primary outcomes: In-hospital mortality and proportion of patients downgraded to non-ICU status while in the ED within 6 hours
Results:
Mitarai, Tsuyoshi; Gordon, Alexandra June; Nudelman, Matthew J et al. Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department. Critical Care Medicine ():10.1097/CCM.0000000000005835.
Gunnerson KJ, Bassin BS, Havey RA, et al.: Association of an emergency department–based intensive care unit with survival and inpatient intensive care unit admissions. JAMA Netw Open 2019; 2:e197584
Tran QK, O’Connor J, Vesselinov R, et al.: The critical care resuscitation unit transfers more patients from emergency departments faster and is associated with improved outcomes. J Emerg Med 2020; 58:280–289
Category: Critical Care
Posted: 2/21/2023 by William Teeter, MD
(Updated: 2/22/2023)
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Given my previous post on APRV (11/6/2022) and while I take issue with many of the author's statements, I wanted to share a very well referenced article with an excellent discussion on the current gaps in the knowledge around APRV and its use.
One statement I do agree with is the need for a well-designed and adequately powered trial of this mode in an admittedly difficult-to-study population.
Fortunately, this article has an invited rebuttal pending from Dr. Habashi which I am sure will appear in the Educational Pearls in short order.
Good luck to the residents on the ITE!
Parhar, Ken Kuljit S. MD, MSc1,2,3; Doig, Christopher MD, MSc1,2,4. Caution—Do Not Attempt This at Home. Airway Pressure Release Ventilation Should Not Routinely Be Used in Patients With or at Risk of Acute Respiratory Distress Syndrome Outside of a Clinical Trial. Critical Care Medicine ():10.1097/CCM.0000000000005776, January 20, 2023. | DOI: 10.1097/CCM.0000000000005776
Article at https://pubmed.ncbi.nlm.nih.gov/36661571/
Category: Critical Care
Keywords: APRV, TCAV, Mechanical Ventilation (PubMed Search)
Posted: 11/2/2022 by William Teeter, MD
(Updated: 12/4/2024)
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Airway Pressure Release Ventilation (APRV) is an "advanced" mode of mechanical ventilation that has long been considered a "rescue" mode of ventilation and has recently garnered much more attention during the COVID pandemic. Given the long boarding times of critical care patients in the ED with widespread improvement in sight, I wanted to send out some great resources that have come out recently delineating the difference in thought process between APRV as a "rescue" mode and as a "primary" mode.
Rory Spiegel of EMNerd and former UMMC CCM fellow has recently given a great talk on APRV and its use as a rescue mode of ventilation. See also Phil Rola's recent paper listed on that webpage.
https://emcrit.org/emcrit/aprv-for-lung-rescue/
APRV as a primary mode of ventilation has been used in the STC for years and is often referred to in the literature according to the basic ventilatory philsophy called Time Controlled Adaptive Ventilation. I realize this may be heresy to some and perhaps a curiousity to others. I recommend you take some time to peruse the following resources:
1. Dr. Habashi has done a great deal of work in the basic and translation literature on APRV and TCAV. His recent review dispels many myths and concerns surrounding APRV
Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal - https://www.frontiersin.org/articles/10.3389/fphys.2022.928562/full
2. The TCAV Network has great resources for those who want to do a deeper dive into this topic.
https://www.tcavnetwork.org/
(Can also find their recommended protocols at the Multi Trauma Critical Care education website: https://stcmtcc.com/handouts/)
Category: Critical Care
Keywords: intubation, propofol, RSI, SOFA (PubMed Search)
Posted: 9/7/2022 by William Teeter, MD
(Updated: 12/4/2024)
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Take Home:
This is essentially a secondary analysis of a previous prospective observational cohort study with high quality methods. The authors have an excellent discussion of the previous studies on this topic (which for those with an interest I highly recommend you read). They conclude that this study supports previous literature which I would think would be seemingly obvious, which is that those who are more ill to begin with have less tolerance of propofol (in a dose-independent relationship) in this and previous studies. Their use of IPTW extends the analysis on this large international population by addressing confounders in a novel way.
Their overall conclusion is that propofol is bad for the critically ill, and especially bad for those with pre-existing risk factors for intubation complications. I agree: This study suggests in even stronger terms that propofol should be used carefully and probably only in unhealthy patients when other options are unavailable.
Study Background and Characteristics
Findings
Russotto V, Tassistro E, Myatra SN, Parotto M, Antolini L, Bauer P, Lascarrou JB, Szu?drzy?ski K, Camporota L, Putensen C, Pelosi P, Sorbello M, Higgs A, Greif R, Pesenti A, Valsecchi MG, Fumagalli R, Foti G, Bellani G, Laffey JG. Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study. Am J Respir Crit Care Med. 2022 Aug 15;206(4):449-458. doi: 10.1164/rccm.202111-2575OC. PMID: 35536310.
Category: Critical Care Literature Update
Keywords: balanced crystalloid, saline, resuscitation, kidney injury (PubMed Search)
Posted: 7/14/2022 by William Teeter, MD
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Balanced crystalloids: So Hot Right Now
Brief Read:
The use of balanced crystalloids has been the subject of several RCTs with conflicting results. However, recent post-hoc and meta-analyses of these same trials suggest that balanced crystalloids may be the best choice initially. See nice summary at: https://www.atsjournals.org/doi/full/10.1164/rccm.202203-0611ED.
Long Read:
While I had thought about summarizing the recently published data on EPR from the CRITICAL trial in Japan, JournalFeed today covered the recent post-hoc analysis of the BaSICS trial originally seen on CC Pearls back in August 31, 2021 by Dr. Sjelocha. This subject is as important as it is confusing. There are large and relatively well done RCTs that point in opposite and sometimes strange directions. However, as the authors of the SMART trial summarized, even an NNT of 94 in this population could be a huge number of patients!
The use of balanced crystalloids (e.g. Plasmalyte) has been the subject of several previous RCTs (SMART and SALT-ED) with conflicting results. Recently the PLUS RCT and BaSICS trials seemed to push the literature towards to concluding there was no difference, but there are caveats for both trials now in the literature:
This paper makes a nice point which I think is important for us in the ED: the evidence is suggesting a commonality in many critical care concepts, which is that decisions made in early resuscitation may have an outsized impact on patient outcomes. However, this will not be the last we hear on this subject, but for the time being, I agree with Dr. Lacy that “It might not matter as much what fluids you choose when patients are on their third, fourth, or fifth liter of fluid – but especially for the sickest patients, it sure seems like the initial resuscitation fluid makes a difference.”
BaSICS post hoc: https://www.atsjournals.org/doi/full/10.1164/rccm.202111-2484OC (See JournalFeed post from today and the accompanying editorial)
BASICS: https://jamanetwork.com/journals/jama/fullarticle/2783039 (summary stolen from Dr. Sjeklocha’s August 31, 2022 CC Pearl)
PLUS: https://www.nejm.org/doi/10.1056/NEJMoa2114464
SMART: https://www.nejm.org/doi/full/10.1056/nejmoa1711584
SALT-ED: https://www.nejm.org/doi/full/10.1056/nejmoa1711586
https://journalfeed.org/article-a-day/2022/back-to-basics-first-fluid-choice-matters-a-reanalysis-of-the-basics-rct/
Category: Critical Care
Posted: 5/23/2022 by William Teeter, MD
(Updated: 12/4/2024)
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Encountered a situation in CCRU where we needed to prepare for a patient exsanguinating from gastric varices, and found a great summary of the different types of gastroesophageal balloons from EMRAP.
Summary: https://www.youtube.com/watch?v=Yv4muh0hX7Y
More in depth video on the Minnesota tube: https://www.youtube.com/watch?v=4FHIiA_doWU
Nice review article: https://www.sciencedirect.com/science/article/abs/pii/S0736467921009136
Category: Critical Care
Keywords: OHCA, shock, epinephine, norepinephrine, cardiac arrest (PubMed Search)
Posted: 3/23/2022 by William Teeter, MD
(Updated: 12/4/2024)
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The use of catecholamines following OHCA has been a mainstay option for management for decades. Epinephrine is the most commonly used drug for cardiovascular support, but norepinephrine and dobutamine are also used. There is relatively poor data in their use in the out of hospital cardiac arrest (OHCA). This observational multicenter trial in France enrolled 766 patients with persistent requirement for catecholamine infusion post ROSC for 6 hours despite adequate fluid resuscitation. 285 (37%) received epinephrine and 481 (63%) norepinephrine.
Findings
Limitations:
Summary:
Norepinephrine may be a better choice for persistent post-arrest shock. However, this study is not designed to sufficiently address confounders to recommend abandoning epinephrine altogether, but it does give one pause.
Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med. 2022 Mar;48(3):300-310. doi: 10.1007/s00134-021-06608-7.
Category: Critical Care
Posted: 1/27/2022 by William Teeter, MD
Click here to contact William Teeter, MD
A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at UT Southwestern.
801 critically ill patients requiring emergency intubation were randomly assigned 1:1 at the time of intubation using standard RSI doses of etomidate and ketamine.
Primary endpoint: 7-day survival, was statistically and clinically significantly lower in the etomidate group compared with ketamine 77.3% (90/396) vs 85.1% (59/395); NNH = 13.
Secondary endpoints: 28-day survival rate was not statistically or clinically different for etomidate vs ketamine groups was no longer statistically different: 64.1% (142/396) vs 66.8% (131/395). Duration of mechanical ventilation, ICU LOS, use and duration of vasopressor, daily SOFA for 96 hours, adrenal insufficiency not significant.
Other considerations:
1. Similar to a 2009 study, ketamine group had lower blood pressure after RSI, but was not statistically significant. 2
2. Etomidate inhibits 11-beta hydroxylase in the adrenals. Associated with positive ACTH test and high SOFA scores, but not increased mortality.2
3. Ketamine raises ICP… just kidding.
Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med. 2021 Dec 14. doi: 10.1007/s00134-021-06577-x. Online ahead of print.
Jabre P, Combes X, Lapostolle F, et al.; KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009 Jul 25;374(9686):293-300. doi: 10.1016/S0140-6736(09)60949-1. Epub 2009 Jul 1. PMID: 19573904.
Bruder EA, Ball IM, Ridi S, Pickett W, Hohl C (2015) Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev 1(1):CD010225. https://doi.org/10.1002/1ecweccccccccccc4651858.CD010225.pub2
Wang, X., Ding, X., Tong, Y. et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 28, 821–827 (2014). https://doi.org/10.1007/s00540-014-1845-3