UMEM Educational Pearls - By Kami Windsor

Category: Critical Care

Title: Keeping Dead Patients on the Vent -- Can We Use Mechanical Ventilation during CPR?

Keywords: cardiac arrest, OHCA, airway, mechanical ventilation, resuscitation, bag-valve mask, manual ventilation (PubMed Search)

Posted: 4/10/2024 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

In cardiac arrest, avoidance of excessive ventilation is key to achieving HQ-CPR and minimizing decreases in venous return to the heart. The controversy regarding BVM vs definitive airway and OHCA outcomes continues, but data indicates that mechanical ventilation during CPR carries no more variability in airway peak pressures and tidal volume delivery than BVM ventilation [1], with the AHA suggestion to keep in-hospital cardiac arrest patients with COVID-19 on the ventilator during the pandemic [2]. 

So, can we automate this part of CPR?

Two recent studies looked at mechanical ventilation (MV) compared to bagged ventilation (BV) in intubated patients with out-of-hospital-cardiac arrest (OHCA).  

Shin et al.'s pilot RCT evaluated 60 intubated patients, randomizing half to MV and half to BV, finding no difference in the primary outcome of ROSC or sustained ROSC, or ABG values, despite significantly lower tidal volumes and minute ventilation in the MV group [3]. 

Malinverni et al. retrospectively compared MV and BV OHCA patients from the Belgian Cardiac Arrest Registry, finding that MV was associated with increased ROSC although not with improved neurologic outcomes. Of note, patients across the airway spectrum were included (mask, supraglottic, intubated), and the mechanical ventilation was a bilevel pressure mode called Cardiopulmonary Ventilation (CPV) specific to their ventilators, specifically for use during cardiac arrest [4]. 

Bottom Line: Larger randomized trials will be necessary to get a definitive answer as to how mechanical ventilation affects outcomes in OHCA, but in instances where the cause of arrest is not primarily pulmonary (severe asthma, pneumothorax) and the ED is short-staffed or prolonged resuscitations are likely (such as in accidental hypothermic arrests), it is probably reasonable to keep patients on the ventilator:

  • in a control mode
  • with a target tidal volume of 6ml/kg,
  • a PEEP of 5-8cmH2O (depending on habitus)
  • and an FiO2 of 100% while still in arrest.
  • Set the trigger to “off” to avoid additional breaths triggered by chest compressions
  • Pressure alarms may need adjustment to allow asynchronous breath delivery during chest compressions

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Category: Critical Care

Title: Which Vasopressor Should You Use to Manage Shock After Cardiac Arrest?

Keywords: ROSC, OHCA, cardiac arrest, shock, vasopressors, norepinephrine, noradrenaline, epinephrine, adrenalin (PubMed Search)

Posted: 3/19/2024 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Post-arrest shock is a common entity after ROSC. There is support for the use of continuous norepinephrine infusion over epinephrine to treat shock after ROSC, due to concerns about increased myocardial oxygen demand and associations with higher rates of rearrest [1,2] and mortality [2,3] with the use of epinephrine compared to norepinephrine, and increased refractory shock with use of epinephrine infusion after acute MI [4].

An article in this month’s AJEM compared norepinephrine and epinephrine infusions to treat shock in the first 6 hours post-ROSC in OHCA [5].  With a study population of 221 patients, they found no difference in the primary outcome of incidence of tachyarrhythmias, but did find that in-hospital mortality and rearrest rates were higher in the epinephrine group. 

Bottom Line: Absent definitive evidence, norepinephrine should probably be the first pressor you reach for to manage post-arrest shock, especially if there is strong suspicion for acute myocardial infarction.

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Category: Critical Care

Title: GCS less than/equal to 8? Don't be in a rush to intubate!

Keywords: poisoning, intoxication, altered mental status, GCS, endotracheal intubation (PubMed Search)

Posted: 2/20/2024 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Background: Acutely intoxicated / poisoned patients are commonly encountered in the ED, with the classic teaching that a GCS < 9 is an indication to intubate for airway protection. But we’ve probably all had a patient who was borderline, or who we thought was still protecting their airway pretty well despite a lower GCS. Are we risking our patient’s health and our careers by holding off on intubation? Maybe not. 

The NICO trial, a multicenter, randomized controlled trial, looked at patients presenting by EMS with GCS <9 due to suspected poisoning, without immediate indication for intubation (defined by signs of respiratory distress with hypoxia, clinical suspicion of any brain injury, seizure, or shock with systolic BP <90 mmHg). They found that withholding intubation with close monitoring, compared to the standard practice of intubating at the EMS or ED physician’s discretion, resulted in: 

  • No deaths in either group
  • Fewer intubations (18.1% vs 59.6%; AR difference 41.5%, 95% CI -54.1 to -30.9)
  • Fewer intubation-associated adverse events (6% vs. 14.7%; 95% CI -16.6 to -0.7)
  • Decreased incidence of pneumonia (6.9% vs 14.7%; 95% CI -15.9 to 0.3)
  • Fewer ICU admissions (39.7% vs. 66.1%) and decreased hospital and ICU LOS

Comparing the patients who were intubated in each group, there was no significant difference between groups in:

  • Rate of intubation-associated adverse events or first-pass failure
  • Median ICU or hospital length of stay

Notes: 

  • French study – EMS setup there is different from ours in the US
  • Median GCS = 6, study population skewed young and male (mean age 33yo, 62% male) 
  • Mostly alcohol or benzodiazepine intoxication
  • Unblinded study

Bottom Line: Without clear indication for intubation such as respiratory distress or accompanying head bleed, etcetera, intubation for mental status alone shouldn't be dogma in acute intoxication. Close monitoring will identify need for intubation, without apparent worsened outcomes due to a watchful waiting approach.

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Category: Critical Care

Title: Empiric antibiotics for sepsis and associated AKI -- avoid vanc-and-zosyn right?

Keywords: sepsis, antibiotics, AKI, ACORN, zosyn, piperacillin-tazobactam, cefepime (PubMed Search)

Posted: 1/31/2024 by Kami Windsor, MD (Updated: 4/24/2024)
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Background: For better or worse, the combination of “vanc-and-zosyn” has long been a go-to empiric regimen for the treatment of septic shock. Piperacillin-tazobactam is known to cause decreased creatinine secretion into the urine leading to an increased serum creatinine without any actual physiologic harm to the kidney, but the results of previous studies have led researchers to posit an increase in actual AKI with the vanc and zosyn combo. This concern has led to some physicians choosing cefepime for anti-pseudomonal gram-negative coverage instead, despite its known potential for neurotoxicity and cefepime-associated encephalopathy.

The ACORN trial: The recently published ACORN trial compared cefepime to piperacillin-tazobactam in adult patients presenting to the ED or medical ICU with sepsis or suspected serious infection. The primary outcome was a composite of highest stage of AKI or death at 14 days.

  • Single-center, unblinded, pragmatic, randomized control trial
  • 2500 patients, approx. 20% with chronic kidney disease
  • Approximately 77% received vancomycin as well
  • ~20% antibiotic crossover in each group

Results: 

  • No difference between groups in the primary outcome, or in major adverse kidney events, even in subgroup that also received vancomycin
  • No difference in hospital length of stay, vasopressor days, ventilator days
  • Slightly higher incidence of delirium or coma in the cefepime group 

Bottom Line:  Good antibiotic stewardship would probably decrease the frequency of vanc-and-zosyn administration, but concern for renal dysfunction alone shouldn’t guide the choice between cefepime or piperacillin-tazobactam, even in those with CKD, and even in those patients also receiving vancomycin.

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The BRASH syndrome (Bradycardia, Renal failure, AV nodal blockade, Shock, Hyperkalemia) has been increasingly described in the literature in the past 3-5 years.  

The inciting factor is generally considered to be something that prompts acute kidney injury, often hypovolemia of some sort.  Rather than AV nodal blocker overdose or severe hyperkalemia causing conduction problems, the combination of AV nodal blocker use (most often beta-blockers, but can be any type) and hyperkalemia (often only moderate) has a synergistic effect on cardiac conduction with ensuing bradycardia that can devolve into a cycle of worsening renal perfusion and shock.

Treatment is supportive, but most effective when the syndrome is recognized and all parts simultaneously managed.  ED physicians should be familiar with its existence for targeted whole-syndrome stabilization and to avoid diagnostic delay.

  • Shock – If hypovolemic, IV fluid resuscitation. Concomitantly or if still hypotensive, epinephrine infusion is recommended as it provides both chronotropy and inotropy, and also assists with hyperkalemia.
  • Hyperkalemia – usually mild/moderate; IV calcium for any ECG abnormalities, intracellular shifting medications, and kaliuresis (may require high-dose loop diuretics, with IV fluids if needed to maintain volume)
  • Bradycardia – will usually respond to IV calcium and chronotropy (epinephrine, isoproterenol); pacing rarely but sometimes needed
  • Renal failure – IVF and perfusion support as noted above, but patients may require dialysis if renal failure is severe and hyperkalemia is unable to be medically managed

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Category: Critical Care

Title: CT FIRST: Should we pan-CT everyone post-ROSC?

Keywords: OHCA, ROSC, cardiac arrest, resuscitation, CT, pan-scan, computed tomography (PubMed Search)

Posted: 7/25/2023 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

Background: Prior evidence1,2 has suggested that early “pan-scan” after ROSC provides clinically-relevant information that assists in the care of the patient in question, when the cause of OHCA is unclear.

The recent CT FIRST trial looked at patients pre- and post- implementation of a protocol for head-to-pelvis CT within 6 hours of ROSC for adult patients without known cause or evidence of possible cardiac etiology, stable enough for scan. *Patients with GFR <30 were excluded from assignment to CT, although were included in the post/CT cohort if their treating doctors ordered CT scans based on perceived clinical need. To balance this, a similar number of patients with GFR <30 were included in the pre/“standard of care” cohort.

  • Pre/SOC cohort (143 pts) vs. Post/SOC+CT cohort (104 pts)
  • CT protocol: Dry head CT, CTA chest, venous phase CT abd/pelvis
  • In pre/SOC group, CTs ordered by treating docs in 52% (one or mix of the above CTs)

Outcomes After Protocol (Pre- vs. Post-):

  • Increased identification of OHCA diagnosis (75% vs. 92%, p = 0.001)
    • In SOC + CT group, diagnosis only found by CT in 13%
    • In SOC group, diagnosis only found by CT in 17%
  • Faster OHCA diagnosis (14.1h vs. 3.1h, p= 0.0001)
     
  • Fewer delays in time-critical diagnoses* (62% vs. 12%, p= 0.001)  *both OHCA dx and resuscitation-related injury
     
  • No difference in ultimate diagnosis of time-critical diagnoses, rates of AKI, or survival to hospital discharge, allergic contrast reactions (0), scan complications (0), inappropriate treatments based on CT findings (0)

 

Bottom Line: Early pan-CT allows for earlier definitive diagnosis and stabilization without increase in adverse events. While this earlier diagnosis does not seem to yield better survival, earlier stabilization may provide some benefits in terms of resource allocation and disposition, a notable benefit during our current crisis of staffing shortages and ED boarding. 

 

CT FIRST

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Category: Critical Care

Title: Thrombocytopenia and CVCs -- Are Platelet Transfusions Needed?

Keywords: thrombocytopenia, bleeding, hemorrhage, platelets, transfusions, central lines, CVCs (PubMed Search)

Posted: 5/30/2023 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Question

Background: In general practice, platelets are typically transfused for invasive procedures when the platelet count falls below 50 x 109/L. Regarding the placement of central venous catheters (CVCs), there is minimal data to support or refute decisions to transfuse platelets in these patients, although the 2015 Clinical Practice Guideline from the AABB (formerly, the American Association of Blood Banks) recommends deferring platelet transfusion until a platelet count of 20 x 109/L for CVC placement [weak recommendation, low quality evidence].1

In a study published this month in NEJM,2 van Baarle et al. performed a multicenter randomized controlled noninferiority trial comparing platelet transfusion to no transfusion in patients with platelets 10 to 50 x 109/L prior to US-guided CVC insertion. The primary outcome was the occurrence of catheter-related bleeding Grades 2-4 (Grade 1 = oozing; managed with <20 min of manual compression, not requiring RBC transfusion, & Grades 2-4 is everything else up to death) within 24 hours post-procedure. 

  • Noninferiority was not met, with primary outcome in 4.8% vs. 11.9% of transfused and nontransfused patients, respectively (RR 2.45, 90% CI: 1.27 to 4.70).
  • Major catheter-related bleeding (Grades 3-4) occured in 2.1% vs 4.9% (RR 2.43, 90% CI: 0.75 to 7.93).  
  • Other factors associated with higher bleeding risk included hematologic malignancy, platelets 10-20 x 109/L, and tunneled catheter placement.
  • Difference in bleeding rates between transfusion vs. no-transfusion groups was higher however, in patients with platelets 20-30 x 109/L (0 vs 15.7%), those receiving nontunneled lines (3.6% vs 10.8%), or CVCs placed in the subclavian vein (2.8% vs 18.6%). 

Bottom Line: The jury is still out on best platelet transfusion practices prior to CVC placement, but I would strongly consider prophylactic platelet transfusion in patients with platelets < 30 x 109/L, those with underlying hematologic malignancy, and patients receiving larger CVCs such as dialysis lines. How much to transfuse in those with more severe thrombocytopenia is uncertain.

Separately, I would also strongly recommend use of US-guidance for any CVC placement in this population as well, based on practical common sense and some supportive literature as well.5

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Category: Critical Care

Title: Steroids in Severe CAP

Keywords: pneumonia, acute hypoxic respiratory failure, steroids (PubMed Search)

Posted: 4/5/2023 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Background: The use of steroids in pneumonia has long been controversial with conflicting data, and the recent ESCAPe randomized controlled trial by Meduri et al. showing no mortality benefit with their use, but likely underpowered due to recruitment issues. The recently published CAPE COD study by Dequin et al. may change the game.

Design: Double-blind, placebo-controlled, multicenter, RCT

  • 31 hospitals in France, 2015 to March 2020
  • Adults with severe (P:F <300 on 50% FiO2 or NRB, mechanical ventilation, or pulmonary severity index >130) CAP (+symptoms and imaging)
  • Notable exclusion criteria: vasopressors, aspiration-related, influenza, chronic steroids (equiv to >15mg prednisolone)

Intervention: Early hydrocortisone within 24 hrs, 200mg/day x 4-8 days depending on improvement, then preset taper

  • 800 patients: 401 hydrocortisone, 399 placebo

Primary outcome:  Death at 28 days

  • Hydrocortisone 6% vs Placebo 12% (p = 0.006)

Secondary outcomes:

  • Death at 90 days: Hydrocortisone 9.3% vs placebo 14.7%
  • Decreased cumulative incidence of endotracheal intubation by day 28 (if not initially intubated)
  • Decreased cumulative incidence of vasopressor initiation by day 28
  • Higher median daily dose insulin in hydrocortisone group
  • No difference in rate of hospital acquired infections or GIB

Bottom Line:  The addition of hydrocortisone to antibiotics in severe CAP may decrease need for intubation and development of shock, and in this well-done study, decreased 28 and 90-day mortality. 

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Category: Critical Care

Title: Sodium Bicarbonate for Nonshockable OHCA

Keywords: sodium bicarbonate, bicarb, OHCA, cardiac arrest, CPR, resuscitation (PubMed Search)

Posted: 2/8/2023 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Question

 

Background: The use of sodium bicarbonate in the treatment of out-of-hospital cardiac arrest (OHCA) has been longstanding despite conflicting data regarding its benefit, outside of clear indications such as toxic ingestion or hyperkalemic arrest.

Study: A recent retrospective cross-sectional study by Niederberger et al.1 examined prehospital EHR data for ALS units responding to nonpregnant adults with nontraumatic OHCA, noting use of prehospital bicarb and the outcomes of 1) ROSC in the prehospital encounter and 2) survival to hospital discharge. They created propensity-matched pairs of bicarb and control patients, with a priori confounders: age, sex, race, witnessed status, bystander CPR, prearrival instructions, any defibrillation attempt, use of CPR feedback devices, any attempted ventilation, length of resuscitation, number of epi doses.

There were 23,567 arrests (67.4% asystole, 16.6% PEA, 15.1% VT/VF), 28.3% overall received sodium bicarb. 

Results: 

In the propensity-matched sample, survival was higher in bicarb group (5.3% vs. 4.3%; p=0.019).

  • Asystole (bicarb 3.3 vs 2.4%; p = 0.020)
  • PEA (bicarb 8.1% vs 5.4%; p=0.034)

There were no differences in rate of ROSC overall, but looking at the different rhythms, ROSC was higher in the bicarb group with asystole as the presenting rhythm (bicarb 10.6 vs 8.8%; p=0.013) but not PEA or VT/VF.

*There is no indication by the authors as to the dosing of bicarb most associated with survival to hospital discharge (or ROSC in asystole) in the study, however a previous study has indicated that a single amp of bicarb is unlikely to significantly improve severe metabolic acidosis (pH <7.1),2 so the general recommendation of at least 1-2mEq/kg should be employed.

Bottom Line: The use of sodium bicarb may increase survival in OHCA with initial PEA/asystole. The recommended initial dose is 1-2mEq/kg; giving at least 2 amps of bicarb (rather than the standard 1) should achieve this in many patients.

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Category: Critical Care

Title: PRES in the Post-transplant Patient Population

Keywords: posterior reversible encephalopathy syndrome, PRES, transplant, calcineurin inhibitors, tacrolimus, cyclosporine (PubMed Search)

Posted: 10/18/2022 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

Emergency physicians are familiar with posterior reversible [leuko]encephalopathy syndrome as an entity associated with untreated hypertension. It also happens to be a well-documented entity amongst solid organ transplant patients.  

While the exact pathophysiology remains unclear, PRES is characterized by posterior subcortical vasogenic edema due to blood-brain barrier disruption, usually in the setting of elevated blood pressure with loss of cerebral autoregulation and/or endothelial dysfunction.

The immunosuppressants used in this population, namely calcineurin inhibitors (CNI) such as tacrolimus and cyclosporine, are thought to contribute most to this endothelial dysfunction and development of PRES in transplant patients, although high-dose corticosteroids, ischemia-reperfusion injury during surgery, and antibiotics have also been implicated. 

Presentation of PRES post-transplant:

Clinical symptoms:

  • Seizures (75-85%)
  • AMS - confusion/somnolence (30-40%)
  • Headache (25-50%)
  • Vision disturbance (20-40%)

Time course:

  • Within weeks to a year posttransplant, rarely after a year
  • Rapid onset once it starts, can develop over hours to days

Diagnostics:

  • Labs nonspecific, although supratherapeutic CNI levels are often associated with:
    • Acute renal injury
    • Hyperchloremic metabolic acidosis
    • Hyperkalemia
    • Hypomagnesemia
    • Hypercalciuria
  • Thoughts on checking FK506 (tacrolimus) levels
    • For transplant patients, usually advise only checking troughs (~12 hrs after last dose)
    • A low random level may rule out CNI toxicity but not PRES
    • A high random level isn't really helpful
  • MRI is diagnostic modality of choice >> subcortical edema, usually bilateral, symmetric, in parieto-occipital regions

Management:

  1. Stabilization via supportive care – seizure, cerebral edema, BP management as applicable, etc.
  2. Withdrawal/holding of offending agent – will require consultation with transplant physician and pharmacist usually by inpatient team
    • Mixed data re: use of CYP-inducers to lower CNI levels in CNI toxicity

Bottom Line: 

Patients with a history of solid organ transplant are at risk for PRES. While ED stabilization of these patients remains the same, recognition of PRES as a potential etiology for a transplant patient's presentation is crucial to proceed with important testing and necessary changes to their immunosuppressive regimen. 

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Category: Critical Care

Title: Avoid Over-Sedation of Intubated ED Patients

Keywords: analgosedation, sedation, intubation, (PubMed Search)

Posted: 8/23/2022 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

Deep sedation in the ED has previously been associated with longer duration of mechanical ventilation, longer lengths of stay, and higher mortality.1 Current guidelines recommend light sedation, consistent with a goal RASS of -2 to 0, for most critically-ill patients in the ICU.2

The ED-SED3 multicenter, pragmatic, before-and-after feasibility study implemented an educational initiative (inservices, regular reminders, laminated sedation charts) to help target lighter sedation depths in newly-intubated adult patients without acute neurologic injury or need for prolonged neuromuscular blockade.

  • 415 patients (196 pre-, 219 post-intervention), majority white (50%) and black (40%)
  • Main reasons for intubation: sepsis, trauma, airway protection
  • Majority of patients on fentanyl (85%) and propofol (76%), midazolam (20%)

After educational intervention:

  • 21% fewer patients with deep sedation & 20% more patients achieving light sedation
    • 10% decrease in comatose levels of sedation (RASS -4 to -5)
  • Lower hospital mortality (20.4 vs 10%, p < 0.01)
  • Similar rates of self-extubation and paralysis awareness
  • More patients extubated in the ED, downgraded from ICU admission, and discharged from the ED

Even with the caveats of the confounding and bias that can exist in before-and-after studies, these results are consistent with prior sedation-related studies and offer more evidence to support for avoiding deep sedation in our ED patients. The study also demonstrates the importance of nurse-driven sedation in achieving sedation goals.

Bottom Line: Our initial care in the ED matters beyond initial stabilization and compliance with measures and bundles. Avoid oversedating intubated ED patients, aiming for a goal RASS of -2 to 0. 

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Category: Critical Care

Title: Dodging DKA Dogma with Subcutaneous Insulin

Keywords: Insulin infusion, diabetes mellitus, diabetic ketoacidosis, DKA, subcutaneous, long-acting (PubMed Search)

Posted: 6/29/2022 by Kami Windsor, MD (Updated: 9/21/2022)
Click here to contact Kami Windsor, MD

Question

 

Background: It is classically taught that the tenets of DKA management are IV fluids, electrolyte repletion, and an insulin infusion that is titrated until approximately 2 hours after anion gap closure, when long-acting subcutaneous insulin is administered if the patient is tolerating oral intake. It has been previously found that earlier administration of subcutaneous long-acting insulin can shorten the time to anion gap closure, while other small studies have noted similar efficacy in subcutaneous insulin compared to IV in mild/moderate DKA. 

A recent JAMA article presents a retrospective evaluation of a prospectively-implemented DKA protocol (see "Full In-Depth" section) utilizing weight-based subcutaneous glargine and lispro, rather than IV regular insulin, as part of initial and ongoing floor-level inpatient treatment.

When compared to the period before the DKA protocol: 

  • ICU admissions decreased (27.9% from 67.8%, p<0.001)
  • There was no difference in overall amount of insulin and time to anion gap closure
  • There was no difference in 30-day mortality
  • There was no difference in incidence of hypoglycemc events.

The only exclusion criteria were age <18 years, pregnancy, and presence of other condition that required ICU admission. 

Bottom Line: Not all DKA requires IV insulin infusion.

At the very least, we should probably be utilizing early appropriate-dose subcutaneous long-acting insulin. With ongoing ICU bed shortages and the importance of decreasing unnecessary resource use and hospital costs, perhaps we should also be incorporating subcutaneous insulin protocols in our hospitals as well.

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Category: Critical Care

Title: Adding Vasopressin and Steroids to the Code Cocktail? Not so fast...

Keywords: in-hospital cardiac arrest, IHCA, resuscitation, code, epinephrine, vasopressin, methylprednisolone (PubMed Search)

Posted: 5/2/2022 by Kami Windsor, MD (Emailed: 5/3/2022)
Click here to contact Kami Windsor, MD

Question

 

Based on prior studies1 indicating possibly improved outcomes with vasopressin and steroids in IHCA (Vasopressin, Steroids, and Epi, Oh my! A new cocktail for cardiac arrest?), the VAM-IHCA trial2 compared the addition of both methylprednisolone and vasopressin to normal saline placebo, given with standard epinephrine resuscitation during in hospital cardiac arrest (IHCA).

The use of methylprednisolone plus vasopressin was associated with increased likelihood of ROSC: 42% intervention vs. 33% placebo, RR 1.3 (95% CI 1.03-1.63), risk difference 9.6% (95% CI 1.1-18.0%); p=0.03.

BUT there was no increased likelihood of favorable neurologic outcome (7.6% in both groups).

Recent publication on evaluation of long-term outcomes of the VAM-ICHA trial3 showed that, at 6-month and 1-year follow-up, there was no difference between groups in:

  • Survival
  • Favorable neurologic outcome (CPC 1 or 2; mRS 0-3)
  • Health-related quality of life (per EQ-5D5L survey)

 

Bottom Line: Existing evidence does not currently support the use of methylprednisolone and vasopressin as routine code drugs for IHCA resuscitation. 

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Category: Critical Care

Title: Traumatic PTX on PPV: Okay to observe?

Keywords: trauma, pneumothorax, positive pressure ventilation, invasive mechanical ventilation, tension pneumothorax (PubMed Search)

Posted: 1/14/2022 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Background: Conventional medical wisdom long held that patients with pneumothorax (PTX) who require positive pressure ventilation (PPV) should undergo tube thoracostomy to prevent enlarging or tension pneumothorax, even if otherwise they would be managed expectantly.1

  • Small retrospective and observational studies have demonstrated safety to an observational approach for both occult (only detectable on CT) and larger PTXs even in patients requiring noninvasive or invasive mechanical ventilation, whether traumatic/iatrogenic or spontaneous.2-6
  • The Western Trauma Association recently released a guideline for the management of traumatic PTX, which includes observation with 6-hour follow up CXR for patients with small (<20% aka <2cm from chest wall on CXR or <35 mm on CT scan) hemodynamically stable pneumothoraces, even if mechanical ventilation is required.7
    • They note a 10% subsequent failure rate (i.e. chest tube requirement) with no difference between patients who do or do not undergo PPV. 
  • The OPTICC trial, found however, that while the rate of respiratory distress development was not different between those randomized to observation vs initial chest tube management, there was an increase from a 25% chest tube requirement in the obs group to a 40% failure rate in patients requiring >4 days of mechanical ventilation.8 

Bottom Line: The cardiopulmonar-ily stable patient with small PTX doesn’t need empiric tube thoracostomy simply because they’re receiving positive pressure ventilation. If you are unlucky enough to still have them in your ED at day 5 in these COVID times, provide closer monitoring as the observation failure rate may increase dramatically around this time.

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Category: Critical Care

Title: Targeted Temperature Management: NOT set it and forget it!

Keywords: OHCA, IHCA, targeted temperature management, therapeutic hypothermia, postcardiac arrest (PubMed Search)

Posted: 11/16/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

Fever has long been understood to be associated with worse outcomes in patients post-cardiac arrest. Whether ascribing to the goal of 33-34°C, 36°C, or simply <38°C, close monitoring and management of core temperatures are a tenet of post-cardiac arrest care.

A recently published study compared the effectiveness of several methods in maintaining temperatures <38°C…

  • Both ICHA and OHCA, shockable and unshockable, nontraumatic arrests
  • Single center retrospective cohort study looking at 1/2012 – 9/2015
  • Treatment and temperatures over first 48 hours

Results:

Maintenance of temp <38°C:

  • Antipyretics only group: 57.7% 
  • Invasive cooling by intravascular catheter +/- antipyretics:  82.1%

Mean change in temp from baseline:

  • Antipyretics only: +1.1°C
  • Intravascular alone: -3.4°C
  • Antipyretics + Intravascular cooling: -5.2°C

Limitations:

  • Varied range of antipyretic dosing per body weight
  • No mention of noninvasive cooling methods (cooling pads, ice packs, etc.)
  • Patients w/ intravascular cooling likely getting more aggressive care in general
  • Not powered for clinical outcomes assessment

 

Bottom Line:

  • Antipyretics alone greatly ineffective at preventing fever 
  • Even with invasive cooling -- not meeting goal 18% of the time
  • With longer ED boarding times nationwide, we must pay active attention to body temperature management and not assume that that we can set it and forget it, even with techniques as invasive as intravascular cooling.

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Background:

There are also no clear guidelines regarding how fast fluid boluses should be administered, and there has been debate about whether different infusion rates could lead to different outcomes in patients receiving intravenous fluid (IVF) boluses (i.e. fast infusions may cause more third spacing due to the rapidity of the expansion of the intravascular space compared to fluid administered more slowly). A recent study compared IVF infusion rates in ICU patients.

-- Unblinded, randomized

-- 10,520 patients clinically requiring a fluid challenge, from 75 ICUs in Brazil

-- Infusion rate 333 mL/hr vs 999 mL/hr

   * (Trial also compared plasmalyte vs 0.9% saline, analyzed in separate study)

-- Some notable exclusion criteria: severe hypo/hypernatremia, AKI or expected to need RRT 6 hrs after admission

--Other caveats:

   * Faster infusion rates allowed at physician discretion in patients with active bleeding or severe      hypotension (SBP < 80 or MAP < 50 mmHg); patient was returned to assigned rate after condition resolved

   * Almost 1/2 the patients received at least 1L of IVF in 24 hours prior to enrollment

-- Results: No sig difference in 90-day survival, use of RRT, AKI, mechanical ventilator free days, ICU/hospital mortality/LOS 

Bottom Line: There is not yet compelling evidence that there are differences in patient outcomes in patients receiving fluid boluses given at 333 cc/hr vs. 999 cc/hr.

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Approximately 15,000 children experience an in hospital cardiac arrest (IHCA) with little improvement in outcomes over the last two decades. During that time, epinephrine has been the constant basis for resuscitation of these patients. Current recommendations by the AHA recommend bolus dosing of epinephrine every 3-5 minutes in a pediatric cardiac arrest. Animal studies suggest that more frequent dosing of epinephrine may be beneficial. 

This was a retrospective study of 125 pediatric IHCAs with 33 receiving “frequent epinephrine” interval (≤2 minutes). Pediatric CPC score 1-2 or no change from baseline was used as primary outcome to reflect favorable neurologic outcome, with frequent dosing associated with better outcome (aOR 2.56, 95%CI 1.07 to 6.14). Change in diastolic blood pressure was greater after the second dose of epinephrine among patients who received frequent epinephrine (median [IQR] 6.3 [4.1, 16.9] vs. 0.13 [-2.3, 1.9] mmHg, p=0.034). 

This study is subject to all sorts of confounding and should be studied more rigorously, but suggests that more frequent dosing for pediatric IHCA may be of benefit.

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Category: Critical Care

Title: Limiting Hands-Off Time in Cardiac Arrest

Keywords: cardiac arrest, CPR, cardiopulmonary resuscitation, hands-off time, CCF, chest compression fraction (PubMed Search)

Posted: 7/6/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

Despite the knowledge that minimizing interruptions in chest compressions during CPR is key to maintaing coronary perfusion pressure and chance of ROSC,1-4 difficulties in limiting hands-off time remain. 

Dewolf et al.5 recently performed a prospective observational study using body cameras to find that 33% (623/1867) of their CPR interruptions were longer than the recommended 10 seconds:

  • 51.6% Rhythm/pulse checks
  • 11.1% Installation/use mechanical CPR device
  •   6.7% Manual CPR provider switch
  •   6.2% ETT placement

Previous studies have shown an increase in hands-off time associated with the use of cardiac POCUS during rhythm checks as well.6,7

 

Bottom Line:

  • Physicians must be mindful of hands-off time to improve their chance of obtaining ROSC, minimizing each CPR interruption to <10 seconds, and maintaining a hands-on time (also known as chest compression fraction) of >80%. 
  • Change your pulse check to a rhythm check utilizing arterial line placement, end-tidal monitoring, or US/doppler at the femoral artery in order to minimize the search for a pulse as a reason for prolonged CPR interruption.
  • Consider having someone on the team count the seconds out loud during pauses so the entire team is aware of the interruption time and will recognize when CPR needs to be resumed.

 

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Category: Critical Care

Title: Pan-Scan for OHCA?

Keywords: cardiac arrest, ROSC, computed tomography, CT scan, imaging (PubMed Search)

Posted: 6/16/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

A recent prospective observational study examined the diagnostic usefulness of head-to-pelvis sudden death computed tomography (SDCT) in 104 patients with ROSC and unclear OHCA etiology.

  • Obtained within 6 hours of hospital arrival
  • Noncontrast head CT + ECG-gated chest CTA with abbreviated coronary imaging + contrasted CT of the abdomen to just below the pelvis. 

 

Diagnostic performance: 

  • Detected 95% of OHCA etiologies diagnosable by CT
  • Detected 98% of time-critical diagnoses requiring emergent intervention (including complications of resuscitation)
  • The sole reason for diagnosis of OHCA etiology in 13%

 

Safety:

  • 28% of patients with elevated creatinine at 48h (down from 55% at presentation; study excluded GFR < 30ml/min unless treating provider felt the data was needed for care)
  • 1% (1 patient) required RRT 
  • No false positives noted, no allergic contrast reactions, 1 contrast IV extravasation

 

Bottom Line: For OHCA without clear etiology, SDCT explicitly including a thoracic CTA may have diagnostic benefit over standard care alone with the added benefit of identification of resuscitation complications. 

 

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Category: Critical Care

Title: Avoid Over-Oxygenation in Acute COPD Exacerbation

Keywords: COPD, emphysema, acute respiratory failure, hypoxia, oxygen saturation (PubMed Search)

Posted: 4/20/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

Supplemental oxygen therapy is frequently required for patients presenting with acute respiratory distress and COPD exacerbation. Over-oxygenation can derail compensatory physiologic responses to hypoxia,1 resulting in worsening VQ mismatch and, to a lesser degree, decreases in minute ventilation, that cause worsened respiratory failure.

The 2012 DECAF (Dyspnea, Eosinopenia, Consolidation, Acidaemia, and Atrial Fibrillation) score was found to predict risk of in-hospital mortality in patients admitted with acute COPD exacerbation.2,3 Data from the DECAF study’s derivation and external validation cohorts were examined specifically to look at outcome associated with varying levels of oxygen saturation.

  • 1027 patients from 6 UK hospitals receiving supplemental oxygen at admission
  • Lowest in-hospital mortality seen in the 88-92% cohort 

 

 

  • Adj OR for in-hospital mortality in ≥97% vs 88-92% group: 2.97 (95% CI 1.58-5.58, p=0.001)
  • Adj OR for in-hospital mortality in 93-96% vs 88-92% group: 1.98 (95% CI 1.09-3.60, p=0.025)
  • Surprisingly, mortality risk seen more in normocapnic than hypercapnic patients
  • Association between admission SpO2 and mortality persisted after adjusting for baseline risk and disease severity using the DECAF and NEWS 2 score

 

Bottom Line

In patients presenting to the ED with acute COPD exacerbation requiring oxygen supplementation, a target oxygen saturation of 88-92% is associated with the lowest in-hospital mortality, and higher oxygen saturations should be avoided independent of patients' PCO2 levels.

 

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