Category: Critical Care
Keywords: ARDS, respiratory failure, ventilator settings, critical care (PubMed Search)
Posted: 2/26/2019 by Kami Windsor, MD
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Despite ongoing research and efforts to improve our care of patients with ARDS, it remains an entity with high morbidity and mortality. Early recognition of the disease process and appropriate management by emergency physicians can have profound effects on the patient's course, especially in centers where ICU boarding continues to be an issue.
Recognition of ARDS (Berlin criteria)
*An ABG should be obtained in the ED if physicians are unable to wean down FiO2 from high settings, if oxygenation by pulse ox is marginal, or if the patient is in a shock state.
Tenets of ARDS Management:
*IBW Males = 50 + 2.3 x [Height (in) - 60] / IBW Females = 45.5 + 2.3 x [Height (in) - 60]
Strategies for Refractory Hypoxemia in the ED: You can't prone the patient, but what else can you do?
1. Escalate PEEP in stepwise fashion
2. Recruitment maneuvers
3. Appropriate sedation and neuromuscular blockade
4. Inhaled pulmonary vasodilators (inhaled prostaglandins, nitric oxide) if known or suspected right heart failure or pulmonary hypertension
Bottom Line: Emergency physicians are the first line of defense against ARDS. Early recognition of the disease process and appropriate management is important to improve outcomes AND to help ICU physicians triage which patients need to be emergently proned or even who should potentially be referred for ECMO.
Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Me.. 2018;46(11):1820-31.
Category: Critical Care
Keywords: neutropenic fever, typhlitis, necrotizing enterocolitis, sepsis, septic shock (PubMed Search)
Posted: 2/12/2019 by Kami Windsor, MD
(Updated: 4/4/2025)
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Neutropenic enterocolitis can occur in immunosuppressed patients, classically those being treated for malignancy (hematologic much more commonly than solid tumor). When involving the cecum specifically, it is known as "typhlitis."
It should be considered in any febrile neutropenic patients with abdominal pain or other symptoms of GI discomfort (diarrhea, vomiting, lower GI bleeding), and can be confirmed with CT imaging.
A recent study found that invasive fungal disease, most often candidemia, occurred in 20% of febrile neutropenic patients with CT-confirmed enteritis, a rate that increased to 30% if the patient was in septic shock.
Take Home:
1. Have a lower threshold for abdominal CT imaging in your patients with febrile neutropenia and abdominal pain/GI symptoms, especially if they are critically ill.
2. Consider addition of IV antifungal therapy if they are hemodynamically unstable with enterocolitis on CT.
Duceau B, Picard M, Pirrachio R, et al. Neutropenic enterocolitis in critically ill patients: Spectrum of the disease and risk of invasive fungal disease. Crit Care Med. 2019. [Epub ahead of print] doi: 10.1097/CCM.0000000000003687.
Category: Critical Care
Keywords: OHCA, cardiac arrest, resuscitation, maternal cardiac arrest, pregnancy (PubMed Search)
Posted: 1/29/2019 by Kami Windsor, MD
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Historically, there has been very limited data regarding the epidemiology of OHCA in pregnant females. Two recently-published studies tried to shed some light on the issue.
Both Maurin et al.1 and Lipowicz et al.2 looked at all-cause out-of-hospital maternal cardiac arrest (MCA) data in terms of numbers and management, in Paris and Toronto respectively, from 2009/2010 to 2014. Collectively, they found:
A few reminders from the 2015 AHA guidelines for the management of cardiac arrest in pregnancy:
Bottom Line: Although maternal cardiac arrest is relatively rare, survival in OHCA is lower than perhaps previously thought. Areas to improve include public education on the importance of bystander CPR in pregnant females, and appropriate physician adherence to PMCS recommendations, with decreased on-scene time by EMS in order to decrease time to PMCS.
Maurin et al. looked at documented out-of-hospital maternal cardiac arrest (MCA) in pregnant females ≥18 years old, in Paris from 2009 to 2014 and reported on some aspects of prehospital care. Prehospital management there includes activation of both a BLS (which usually arrives first) and ALS team, with a prehospital emergency physician being a member of the ALS team.
Lipowicz et al. similarly looked at MCA from 2010 to 2014 using data from the Toronto Regional RescuNet cardiac arrest database:
Category: Critical Care
Keywords: circulatory dysfunction, hypotension, shock, fluid resuscitation, IV fluids (PubMed Search)
Posted: 1/1/2019 by Kami Windsor, MD
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The European Society of Intensive Care Medicine (ESICM) recently released a review with recommendations from an expert panel for the use of IV fluids in the resuscitation of patients with acute circulatory dysfunction, especially in settings where invasive monitoring methods and ultrasound may not be available.
Points made by the panel include:
Recommendations from the panel include:
Bottom Line: Utilize all the information you have about your patient to determine whether or not they require IVF, and reevaluate their physical and biochemical (lactate) response to fluids to ensure appropriate IVF administration and avoid volume overload.
Cecconi M, Hernandez G, Dunser M, et al. Intensive Care Med. 2018. https://doi-org.proxy-hs.researchport.umd.edu/10.1007/s00134-018-5415-2
Category: Critical Care
Keywords: hyperoxia, oxygen therapy, saturation, SpO2, critical care, mechanical ventilation (PubMed Search)
Posted: 12/4/2018 by Kami Windsor, MD
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Hyperoxia has been repeatedly demonstrated to be detrimental in a variety of patients, including those with myocardial infarction, cardiac arrest, stroke, traumatic brain injury, and requiring mechanical ventilation,1-4 and the data that hyperoxia is harmful continues to mount:
Bottom Line: Avoid hyperoxia in your ED patients, both relatively stable and critically ill. Remove or turn down supplemental O2 added by well-meaning pre-hospital providers and nurses, and wean down ventilator settings (often FiO2). A target SpO2 of >92% (>88% in COPD patients) or PaO2 >55-60 is reasonable in the majority of patients.8
Category: Critical Care
Keywords: resuscitation, liver failure, cirrhosis (PubMed Search)
Posted: 11/20/2018 by Kami Windsor, MD
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A few (out of 10) tips for the care of sick patients with liver failure:
Fuhrmann V, Whitehouse T, Wendon J. The ten tips to manage critically ill patients with acute-on-chronic liver failure. Intensive Care Med. 2018;44(11):1932-5.
Category: Critical Care
Keywords: resuscitation, cardiac arrest, post-cardiac arrest care, blood pressure, MAP, ROSC (PubMed Search)
Posted: 11/5/2018 by Kami Windsor, MD
(Updated: 11/6/2018)
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The most recent AHA guidelines for goal blood pressure after return of spontaneous circulation (ROSC) post-cardiac arrest recommend a definite mean arterial pressure (MAP) goal of > 65 mmHg.1 There is no definitive data to recommend a higher specific goal, but there is some evidence to indicate that maintaining higher MAPs may be associated with better neurologic outcomes.2
A recently published prospective, observational, multicenter cohort study looked at neurologic outcomes corresponding to different MAPs maintained in the initial 6 hours post-cardiac arrest.3
Findings:
1. Compared to lower blood pressures (MAPs 70-90 mmHg), the cohort with MAPs > 90 mmHg had:
2. The association between MAP > 90 mmHg and good neurologic outcome was stronger among patients with a previous diagnosis of hypertension, and persisted regardless of initial rhythm, use of vasopressors, or whether the cardiac arrest occured in or out of hospital.
3. There was a dose-response increase in probability of good neurologic outcome among all MAP ranges above 90 mmHg, with MAP >110 mmHg having the strongest association with good neurologic outcome at hospital discharge.
Note: The results of a separate trial, the Neuroprotect post-CA trial, comparing MAPs 85-100 mmHg to the currently recommended MAP goal of >65 mmHg, are pending.4
Bottom Line: As per current AHA guidelines, actively avoid hypotension, and consider use of vasopressor if needed to maintain MAPs > 90 mmHg in your comatose patients post-cardiac arrest, especially those with a preexisting diagnosis of hypertension.
Category: Critical Care
Keywords: High flow nasal cannula, acute respiratory failure, hypoxia, hypercarbia, non-invasive ventilation (PubMed Search)
Posted: 10/9/2018 by Kami Windsor, MD
(Updated: 4/4/2025)
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We know that high flow nasal cannula is an option in the management of acute hypoxic respiratory failure without hypercapnea. A newer iteration of high flow, "high velocity nasal insufflation" (HVNI), may be up-and-coming.
According to its makers (Vapotherm), it is reported to work mainly by using smaller bore nasal cannulae that deliver the same flows at higher velocities, thereby more rapidly and repeatedly clearing dead space, facilitating gas exchange and potentially offering ventilatory support.
In an industry-sponsored non-inferiority study published earlier this year:
Bottom Line:
The availability of a nasal cannula that helps with CO2 clearance would be great, and an option for patients who can't tolerate the face-mask of NPPV would be even better.
HVNI requires more investigation with better studies and external validation before it can really be considered noninferior to NPPV, but it certainly is interesting.
Category: Critical Care
Keywords: acidosis, acidemia, sodium bicarbonate, shock (PubMed Search)
Posted: 9/11/2018 by Kami Windsor, MD
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The recently published BICAR-ICU study looked at the use of bicarb in critically ill patients with severe metabolic acidemia...
Bottom Line:
Consider administration of sodium bicarbonate for your critically ill ED patients with severe metabolic acidosis and AKI, especially if acidosis &/or renal function is not improved with usual initial measures (such as IVF, etc).
*Acute Kidney Injury Network Staging Criteria
Jaber S, Paugam C, Futier E, et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.
Category: Critical Care
Keywords: Resuscitation, OHCA, prehospital medicine, cardiac arrest, epinephrine (PubMed Search)
Posted: 8/14/2018 by Kami Windsor, MD
(Updated: 4/4/2025)
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The highly-awaited PARAMEDIC2 trial results are in:
Interestingly, the authors also queried the public as to what mattered to them most:
Bottom Line:
A Few Things:
Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018. doi: 10.1056/NEJMoa1806842.
Category: Critical Care
Keywords: noninvasive positive pressure ventilation, NIV, NIPPV, DNI, do-not-intubate, palliative care, end-of-life, respiratory distress (PubMed Search)
Posted: 7/17/2018 by Kami Windsor, MD
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When a do-not-intubate (DNI) hospice patient arrives in the ED with respiratory distress, consideration of non-invasive positive pressure ventilation (NIPPV) could invoke either a “What other option do I have?” or “Why torture the patient and prolong the dying process?” sentiment.
But what’s the data?
A recently-published meta-analysis1 found that in DNI patients receiving NIPPV, there was a 56% survival rate to hospital discharge and 32% survival to 1-year.
Independent studies have demonstrated:
Bottom Line:
Category: Critical Care
Keywords: cardiac arrest, CPR, obesity (PubMed Search)
Posted: 6/19/2018 by Kami Windsor, MD
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Although not specifically a part of current recommendations due to lack of data, the AHA has previously recommended shifting upward on the sternum during CPR in the pulseless pregnant patient in order to account for upward displacement of the heart by a gravid uterus. Should the same be done for our obese patients?
Lee et al. performed a retrospective study that reviewed chest CTs to determine the location on the sternum that corresponded to the optimal point of maximal left ventricular diameter (OPLV), in both obese and non-obese patients.
They found that the OPLV was higher (more cranial) on the sternum for obese patients than for patients with normal weight, although 96% of obese patients' OPLV fell within 2cm of where the guidelines recommend standard hand placement should be, compared to a notable 52% in non-obese patients.
*as measured from the distal end of the sternum
Bottom Line: Radiographically, the location on the sternum that corresponds to optimal compression of the LV is more cranial in obese patients than in non-obese patients. It remains to be seen whether the recommendations for hand placement in CPR should be adjusted, but we may want to consider staying within 4cm of the bottom of the sternum in patients of normal weight.
Lee J, Oh J, Lim TH, et al. Comparison of optimal point on the sternum for chest compression between obese and normal weight individuals with respect to body mass index, using computer tomography: A retrospective study. Resuscitation. 2018; 128:1-5.
Category: Critical Care
Keywords: sepsis, septic shock, guidelines (PubMed Search)
Posted: 5/22/2018 by Kami Windsor, MD
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Take Home Points:
For additional reading:
EMNerd, Dr. Rory Spiegel https://emcrit.org/emnerd/em-nerd-case-temporal-fallacy/
Surviving Sepsis Campaign http://www.survivingsepsis.org/Guidelines/Pages/default.aspx
Category: Critical Care
Keywords: acute hypoxic respiratory failure, intubation, noninvasive positive pressure ventilation, high flow nasal cannula, BiPAP, vapotherm (PubMed Search)
Posted: 4/25/2018 by Kami Windsor, MD
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ED physicians frequently utilize modailities such as noninvasive positive pressure ventilation (NIV) and high flow nasal cannula (HFNC) to support and potentially avoid intubation in patients presenting with acute hypoxic respiratory failure. Unfortunately, failure of these measures, resulting in "delayed" intubation, has been associated with increased mortality.1,2
A recent post-hoc analysis of data from a multicenter randomized controlled trial evaluated 310 patients with acute hypoxic respiratory failure managed with supplemental O2 by regular nasal cannula, HFNC, or NIV.3
The following factors were predictive of eventual intubation in the different groups:
Of note, 45% of the 310 patients eventually required intubation, and these patients in general had a higher initial respiratory rate and lower PaO2 at presentation, and were more likely to have bilateral infiltrates on CXR.
Bottom Line: Reevaluate your patients frequently. If RR remains high, P:F ratio remains low, or patient respiratory effort/work of breathing is not alleviated by noninvasive measures, consider pulling the trigger on intubation earlier.
Category: Critical Care
Keywords: cardiac arrest, OHCA, ROSC, targeted temperature management, oxygen, hyperoxia (PubMed Search)
Posted: 3/27/2018 by Kami Windsor, MD
(Updated: 4/4/2025)
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Background:
Animal studies in post-ROSC management after cardiac arrest have repeatedly demonstrated poorer neurological outcomes with higher amounts of oxygen administration.1 Studies in humans have also demonstrated dose-dependent associations between hyperoxia and poorer neurologic outcomes, as well as in-hospital mortality.2,3
Recent Data
A retrospective analysis of prospectively-collected data in 187 OHCA patients undergoing postarrest care with targeted temperature management found worse neurologic outcomes in patients experiencing hyperoxia in the first 6 hours following ROSC.4
This association was dose-dependent, with worsening outcomes as with higher PaO2 levels >200.
Bottom Line:
Category: Critical Care
Keywords: ICU, fungal infection, septic shock, antifungal therapy, empiric (PubMed Search)
Posted: 2/27/2018 by Kami Windsor, MD
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Which septic patients should receive empiric antifungal therapy?
Patients with fungemia only make up about 5% of patients presenting with septic shock, but invasive fungal infections are associated with increased hospital mortality (40-50%), prolonged ICU and hospital length of stay, and increased costs of care.1
The EMPIRICUS trial showed no mortality benefit to empiric antifungals for all, even patients with candidal colonization and recent exposure to antibiotics.2
Bottom Line
Therapy should always be tailored to the specific patient, but providers should strongly consider admininistering empiric echinocandin (micafungin, caspofungin) over fluconazole in patients with severe sepsis/septic shock and:
*Especially consider addition of antifungal in patients who do not show improvements after initial management with IVF and broad spectrum antibiotics in the ED.*
Which septic patients should receive empiric antifungal therapy?
Patients with fungemia only make up about 5% of patients presenting with septic shock, but invasive fungal infections are associated with increased hospital mortality (40-50%), prolonged ICU and hospital length of stay, and increased costs of care.1
The EMPIRICUS trial showed no mortality benefit to empiric antifungals for all, even patients with candidal colonization and recent exposure to antibiotics. (It demonstrated decreased rate of new invasive fungal infection, but did not increase survival).2
Risk factors for invasive fungal infections include:3
Which antifungal agent should we use?
Although older studies have not shown benefits to echinocandin, such as micafungin, over fluconazole as initial empiric antifungal therapy,4,5 a recent study by Garnacho-Montero et al. demonstrated improved 30 and 90-day mortality in patients with candidemia whose initial antibiotic was an echinocandin rather than fluconazole.6
Category: Critical Care
Keywords: sepsis, septic shock, glucocorticoids, steroids, hydrocortisone (PubMed Search)
Posted: 1/29/2018 by Kami Windsor, MD
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As hospital volumes increase and ED patient boarding becomes more commonplace, emergency physicians may find themselves managing critically ill patients beyond the initial resuscitation.
The benefit of glucocorticoids in critically ill patients with septic shock has remained a topic of controversy for decades due to conflicting studies, including the 2002 Annane trial and the 2008 CORTICUS trial, which had opposing results when it came to the mortality benefit of steroids.
The results of the eagerly-awaited ADRENAL trial, a multicenter randomized controlled trial investigating the benefit of steroids in septic shock, were released earlier this month:
Take Home Points:
1. Administration of standard daily dose hydrocortisone by infusion does not seem to affect mortality in septic shock.
2. Emergency providers should continue to consider stress-dose steroids in patients with shock and a high risk of adrenal insufficiency (e.g., chronic steroid therapy, genetic disorders, infectious adrenalitis, etc).
Category: Critical Care
Keywords: endotracheal intubation, cardiac arrest, airway, respiratory failure (PubMed Search)
Posted: 1/2/2018 by Kami Windsor, MD
(Updated: 1/4/2018)
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Although the data is limited, current published rates of in-hospital, non-operating room peri-intubation cardiac arrest (PICA) range from 2 to 6%.1,2,3
Several risk factors associated with PICA have been identified and include:
Other common findings:
Bottom Line: Endotracheal intubation is one of the riskiest procedures we regularly perform as emergency physicians.
References
1. Heffner AC, Swords DS, Neale MN, Jones AE. Inicidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013; 84(11):1500-4.
2. Kim WY, Kwak MK, Ko BS, et al. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One. 2011; 9(11):e112779.
3. Wardi G, Villar J, Nguyen T, et al. Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation. Resuscitation. 2017; 121:76-80.
Category: Critical Care
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:
Bottom Line:
**IBW calculated using Devine’s formula for men and women:
Category: Critical Care
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:
The most common reasons for upgrade:
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: