UMEM Educational Pearls - By Kami Windsor

Category: Critical Care

Title: IVF Resuscitation in Obese Septic Patients: Not one-weight-fits-all?

Keywords: sepsis, resuscitation, obesity, IV fluids, bolus (PubMed Search)

Posted: 12/5/2017 by Kami Windsor, MD
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Background:

We are all familiar with the Surviving Sepsis Campaign recommendation (& CMS core measure) for an initial 30ml/kg bolus of IV crystalloid within the first 3 hours for our patients with septic shock. There is minimal data, however, on how much IVF we should be giving our patients with BMIs ≥30.

 

A recent study in obese patients with septic shock retrospectively stratified the total fluids administered at 3 hours into 3 different weight categories, to categorize patients as having received 30mL per kg of ___ body weight, whether actual (ABW), adjusted (AjdBW), or ideal (IBW**).

AdjBW = (ABW – IBW) *40% + IBW

They found:

  • Most patients received fluids based on actual body weight, BUT
  • Patients at highest BMIs received ABW fluids less often
  • 30ml/kg dosing according to adjusted body weight was associated with improved mortality compared to IVF per actual or ideal body weight.

 

Bottom Line:

  • If the 30ml/kg IVF bolus seems clinically appropriate for your obese patient, consider administering according to Adjusted Body Weight first.
  • As always, reevaluate your septic shock patients frequently to determine if additional fluids are necessary, and go to vasopressors early if they are not fluid responsive.

 

**IBW calculated using Devine’s formula for men and women:

  • Males:  IBW = 50 + 2.3*(# inches over 5 feet)
  • Females: IBW = 45.5 + 2.3*(# inches over 5 feet)

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Category: Critical Care

Title: Unplanned Transfers to the ICU

Keywords: ICU, risk factors, upgrade, decompensation (PubMed Search)

Posted: 11/7/2017 by Kami Windsor, MD
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Should that patient be admitted to the floor? 

Several studies have evaluated factors associated with upgrade in admitted patients from the floor to an ICU within 24 or 48 hours. Elevated lactate, tachypnea, and "after-hours" admissions have been repeatedly identified as some of the risk factors for decompensation. 

Two recent studies tried again to identify predictors of eventual ICU requirement...

Best predictors of subsequent upgrade:

  • Hypercapnia*
  • Tachypnea (in sepsis patients)*
  • Hypoxemia (in pneumonia patients)
  • Nighttime admission
  • Initial lactate ≥ 4

The most common reasons for upgrade:

  1. Respiratory failure
  2. Hemodynamic instability

Effect on mortality

Despite a more stable initial presentation, mortality of patients who decompensated on the floor (25%) matched that of patients initially admitted to the ICU.

*One of the studies noted that although respiratory rate was demonstrated to be the most important vital sign, it was missing in 42% of the study population, while PCO2 was only obtained in 39% of patients.

Bottom Line: 

  • Make sure to physically reassess patients you've stabilized/improved in the ED with current vital signs (including an accurate respiratory rate!) before okaying their admission/transfer to the floor. 
  • If you get a blood gas, make sure to pay attention to the PCO2 and address any abnormalities appropriately.

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Category: Critical Care

Title: Liver Dialysis on MARS (Molecular Adsorbent Recirculating System)

Keywords: liver failure, dialysis, MARS, Molecular Adsorbent Recirculating System (PubMed Search)

Posted: 10/10/2017 by Kami Windsor, MD
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Takeaways

Molecular Adsorbent Recirculating System (MARS) is an artificial liver support system colloquially known in the medical field as "dialysis for the liver."  

  • Limited data, small studies
  • Consistently shown to improve hemodynamics, toxin clearance, and hepatic homeostasis
  • No consistent proven mortality benefit
  • Only performed by limited number of US hospitals (including the University of Maryland)
  • May depend on the acute liver failure subpopulation, but best use currently seems to be for severe acute liver failure due to a potentially reversible/recoverable cause (toxin ingestion, trauma, acute alcoholic hepatitis, etc) or as a bridge to transplant

Take-Home:

1. Consider MARS in your patient with severe acute liver failure due to potentially reversible/recoverable etiology

2. Know if and where MARS is offered near you

 

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Category: Critical Care

Title: Negative-Pressure Pulmonary Edema

Keywords: respiratory failure, pulmonary edema, airway obstruction (PubMed Search)

Posted: 9/12/2017 by Kami Windsor, MD
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Takeaways

Negative-pressure pulmonary edema (NPPE) is a well-documented entity that occurs after a patient makes strong inspiratory effort against a blocked airway. The negative pressure causes hydrostatic edema that can be life-threatening if not recognized, but if treated quickly and appropriately, usually resolves after 24-48 hours. These patients may have any type of airway obstruction, whether due to edema secondary to infection or allergy, laryngospasm, or traumatic disruption of the airway, such as in attempted hangings.

Management: 

1.     Alleviate or bypass the airway obstruction.

·      Usually via intubation; may require a surgical airway

·      If obstruction in an intubated patient is due to biting on tube or dyssynchrony, add bite-block (if not already in place), sedation, and even paralysis if needed.

2.     Provide positive pressure ventilation and oxygen supplementation.

3.     Use low tidal volume ventilation.

4.     In severe hypoxemia without shock, add a diuretic agent and consider additional measures such as proning and even ECMO if the hypoxemia is refractory to standard therapy.  

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Background: Sedation and analgesia are key components for mechanically ventilated patients. While significant data exists regarding how to manage sedation and analgesia in the ICU setting, very little data exists on management in the ED.

Data: A prospective, single-center, observational study of mechanically-ventilated adult patients used linear regression to identify ED sedation practices and outcomes, with a focus on sedation characteristics using the Richmond Agitation-Sedation Scale (RASS).

Findings:

  • 15% of intubated patients had no sedation or analgesia ordered
  • 64% of intubated patients were documented as deeply-sedated (RASS -3 to -5)
  • Deep sedation was not only associated with more ventilator days, but also increased mortality, with an adjusted OR of 0.77 (95% CI 0.54-0.94) favoring patients with lighter sedation.


Bottom line:  Avoid early deep sedation in your intubated patients as this may be directly associated with increased mortality. Instead, a goal RASS of 0 to -2 should be appropriate for most non-paralyzed, mechanically-ventilated ED patients, extrapoloating from ICU guidelines.

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Category: Critical Care

Title: Catastrophic Antiphospholipid Syndrome

Keywords: autoimmune, rheumatology, thrombosis, hematology (PubMed Search)

Posted: 8/15/2017 by Kami Windsor, MD
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Catastrophic Antiphospholipid Syndrome (CAPS):

A life-threatening “thrombotic storm” of multi-organ micro & macro thrombosis in patients with antiphospholipid syndrome (known or unknown).

Triggered circulating antibodies (usually by infection, but can be prompted by malignancy, pregnancy, and lupus itself) cause endothelial disruption and inflammation leading to prothrombotic state, commonly with SIRS response.

Mortality is high at an estimated 40%.

Confirm diagnosis with antiphospholipid antibody titers.

Treat ASAP with unfractionated heparin, corticosteroids, and Hematology consultation for plasma exchange and/or IVIG.

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Category: Critical Care

Title: Benefits of Family Presence During CPR

Keywords: Resuscitation, CPR, family, policy (PubMed Search)

Posted: 7/17/2017 by Kami Windsor, MD
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Takeaways

When surveyed, half of general medicine patients interviewed stated that they would prefer to have a loved one present if they were to develop cardiac arrest and require CPR. So far, studies have demonstrated that…

Allowing family presence during CPR is associated with the following benefits to family members:

  • Decreased rates of PTSD-related symptoms
  • Decreased scores on anxiety and depression scales
  • Decreased incidence of complicated grief
  • Decreased incidence of family member regret (at having been present vs absent during CPR)

And is NOT associated with a difference in:

  • Survival rate
  • Duration of resuscitation efforts
  • Type or dose of administered medications
  • Number of shocks delivered
  • Emotional stress level of medical providers
  • Occurrence of medicolegal conflict

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Takeaways

In patients with persistent VT/VF cardiac arrest, giving epinephrine before the 2nd defibrillation attempt (which should follow initial shock and 2 minutes of CPR) is associated with decreased ROSC, decreased hospital survival, and decreased functional outcome. 

Take Home Point:

"Electricity before Epi" in patients with persistent VT/VF arrest, at least for the initial epinephrine dose.

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Takeaways

High flow nasal cannula (HFNC) is a valid option in the management of acute hypoxic respiratory failure (AHRF) without hypercapnia, as evidenced by multiple studies including the FLORALI trial. Failure of HFNC, however, may result in delayed intubation and worsened clinical outcomes. 

Factors predicting HFNC failure and subsequent intubation include:

  • Lack of RR improvement at 30 and 45 minutes after initation of HFNC
  • Lack of SpO2% improvement at 15, 30, and 60 minutes
  • Persistence of paradoxic breathing (thoracoabdominal dyssynchrony) at 15, 30, 60, and 120 minutes
  • Presence of additional organ system failure, especially hemodynamic (shock) or neurologic (depressed mental status)

Consider whether or not HFNC is appropriate in your patient with AHRF, and if you use it, reevaluate your patient to ensure improvement, or escalate their respiratory support. 

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Category: Critical Care

Title: Use Ultrasound to confirm CVC placement

Keywords: Central venous catheter, ultrasound (PubMed Search)

Posted: 4/18/2017 by Kami Windsor, MD (Updated: 8/15/2022)
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Takeaways

Save time by using bedside ultrasound to confirm above-the-diaphragm central venous catheter (CVC) placement rather than waiting for chest x-ray confirmation:

1. Perform rapid push of saline (it doesn’t have to be agitated) through CVC while cardiac probe is placed with right atrium in view. Immediate visualization of bubbles (or “atrial swirl”) essentially confirms correct placement.

2. Perform the usual search for ipsilateral lung-sliding and the waves-on-the-beach to rule out procedural pneumothorax.

 

 

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