Category: Critical Care
Posted: 3/21/2018 by Ashley Menne, MD
Click here to contact Ashley Menne, MD
Worsening hypoxemia is not uncommon upon initiation of VV ECMO for severe ARDS as tidal volumes drop to double digits (often <20cc) after transition to “lung rest” ventilator settings. The following are strategies to improve peripheral oxygenation:
1. Increase the blood’s oxygen content
- Ensure FIO2 of ECMO sweep gas is 1
- Increase ECMO blood flow
o Limited by cannula size and configuration – may require placement of additional venous drainage cannula
o Also limited by greater risk of recirculation and hemolysis
- Increase blood oxygen-carrying capacity
o Transfuse PRBCs – some advocate for goal hemoglobin 12-14, though institutional practices vary significantly
2. Minimize recirculation
- Maximize distance between drainage and return cannulae
3. Reduce oxygen consumption
- Optimize sedation and neuromuscular blockade. (This is not the appropriate scenario for awake ECMO.)
- Consider therapeutic hypothermia
4. Decrease cardiac output and intrapulmonary shunt
- Consider beta blocker (esmolol) infusion
- Prone positioning (only if staff are experienced with proning on ECMO as this poses significant risk of cannula displacement)
5. Consider switching to hybrid configuration (VVA – continued venous drainage cannula and venous return cannula with addition of arterial return cannula)
Montisci A, Maj G, Zangrillo A, Winterton D, Pappalardo F. Management of Refractory Hypoxemia During Venovenous Extracorporeal Membrane Oxygenation for ARDS. ASAIO J. 2015;61(3):227-236. doi:10.1097/MAT.0000000000000207.
Category: Critical Care
Posted: 3/20/2018 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
Peri-Intubation Cardiac Arrest
De Jong A, et al. Cardiac arrest and mortality related to intubation procedure in critically ill adult patients: A multicenter cohort study. Crit Care Med. 2018; 46:532-9.
Category: Critical Care
Keywords: ICU, fungal infection, septic shock, antifungal therapy, empiric (PubMed Search)
Posted: 2/27/2018 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
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
Posted: 2/21/2018 by Ashley Menne, MD
Click here to contact Ashley Menne, MD
-Nonischemic cardiomyopathy, classically seen in post-menopausal women preceded by an emotional or physical stressor
-Named for characteristic appearance on echocardiography and ventriculography with apical ballooning and contraction of the basilar segments of the LV – looks like a Japanese octopus trap or “takotsubo" (pot with narrow neck and round bottom)
-Clinical presentation usually similar to ACS with chest pain, dyspnea, syncope, and EKG changes not easily distinguished from ischemia (ST elevations – 43.7%, ST depressions, TW inversions, repol abnormalities) and elevation in cardiac biomarkers (though peak is typically much lower than in true ACS)
** Diagnosis of exclusion – only after normal (or near-normal) coronary angiography **
-Care is supportive and prognosis is excellent with full and early recovery in almost all patients (majority have normalization of LVEF within 1 week)
-Supportive care may include inotropes, vasopressors, IABP, and/or VA ECMO in profound cardiogenic shock
** LVOT Obstruction **
-occurs in 10-25% of patients with Takotsubo’s cardiomyopathy
-LV mid and apical hypokinesis with associated hypercontractility of basal segments of the LV predisposes to LV outflow tract obstruction
-Important to recognize as it is managed differently:
-may be worsened by hypovolemia, inotropes, and/or systemic vasodilatation
-mainstay of treatment is avoidance of the above triggers/exacerbating factors while increasing afterload
*phenylephrine is agent of choice +/- beta blockade
Take Home Points:
***Diagnosis of exclusion!!! Presentation very similar to ACS and ACS MUST be ruled out
* Treatment is supportive and similar to usual care for cardiogenic shock. Can be severe and require mechanical circulatory support!
*10-25% have LVOT obstruction. Manage with phenylephrine +/- beta blockade
Weiner MM, Asher DI, Augoustides G, et al. Takotsubo Cardiomyopathy?: A Clinical Update for the Cardiovascular Anesthesiologist. J Cardiothorac Vasc Anesth. 2017;31(1):334-344. doi:10.1053/j.jvca.2016.06.004.
Category: Critical Care
Posted: 2/6/2018 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
Hyperoxia and the Post-Arrest Patient
Roberts BW, et al. Association between early hyperoxia exposure after resuscitation from cardiac arrest and neurological disability: a prospective multi-center protocol-directed cohort study. Circulation 2018; epub ahead of print.
Category: Critical Care
Keywords: sepsis, septic shock, glucocorticoids, steroids, hydrocortisone (PubMed Search)
Posted: 1/29/2018 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
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
Posted: 1/9/2018 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
Click here to contact Mike Winters, MBA, MD
Septic Cardiomyopathy
Beesley S, et al. Septic cardiomyopathy. Crit Care Med 2018. [epub ahead of print]
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)
Click here to contact Kami Windsor, MD
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
Posted: 12/12/2017 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
Click here to contact Mike Winters, MBA, MD
Sedating The Critically Ill Patient
Metha S, et al. What's New in Intensive Care: Ten Tips for ICU Sedation. Intensive Care Med 2017. [epub ahead of print].
Category: Critical Care
Posted: 12/5/2017 by Ashley Menne, MD
(Updated: 2/18/2025)
Click here to contact Ashley Menne, MD
Severe acute respiratory failure among patients with PCP pneumonia, especially among those newly diagnosed with AIDS, remains a disease of high morbidity and mortality. Among those requiring mechanical ventilator support, the mortality rate has been reported between 50-70%.
According to ELSO guidelines, pharmacologic immunosuppression (specifically neurtrophil <400/mL) is a relative contraindication. Furthermore, a status predicting poor outcome despite ECMO should also be considered a relative contraindication.
That said, there are several case reports now of successful use of ECMO in AIDS patients, particularly those suffering with PCP pneumonia.
In a case report and literature review published in BMJ in Aug 2017, 11 cases of ECMO (including 1 VA) in AIDS patients were described.
Bottom Line: HIV/AIDS is not an absolute contraindication to VV ECMO therapy in ARDS and may be particularly useful in the treatment of severe PCP pneumonia. Initiation of ECMO in this patient population should be considered on an individual case by case basis.
Lee N, Lawrence D, Patel B, Ledot S. HIV-related Pneumocystis jirovecii pneumonia managed with caspofungin and veno-venous extracorporeal membrane oxygenation rescue therapy. 2017. doi:10.1136/bcr-2017-221214.
Category: Critical Care
Keywords: sepsis, resuscitation, obesity, IV fluids, bolus (PubMed Search)
Posted: 12/5/2017 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
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
Posted: 11/14/2017 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
Click here to contact Mike Winters, MBA, MD
Mechanical Ventilation in Shock
Gidwani H, Gomez H. The crashing patient: hemodynamic collapse. Curr Opin Crit Care 2017; 23:533-540.
Category: Critical Care
Keywords: ICU, risk factors, upgrade, decompensation (PubMed Search)
Posted: 11/7/2017 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
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:
Category: Critical Care
Posted: 11/3/2017 by Ashley Menne, MD
(Updated: 2/18/2025)
Click here to contact Ashley Menne, MD
Core Temp <32 degrees leads to impaired shivering and confers increased risk for malignant ventricular dysrhythmias. Core Temp <28 degrees substantially increases risk of cardiac arrest.
If in cardiac arrest:
If perfusing rhythm:
Consider addition of more invasive rewarming techniques in those with hemodynamic/cadiac instability or without access to VA ECMO/CPB:
Consider stopping resuscitation efforts if/when:
Douglas J. A. Brown, Hermann Brugger, Jeff Boyd, Peter Paal. (2012). Accidental Hypothermia. New England Journal of Medicine. https://doi.org/10.1056/NEJMra1114208
Category: Critical Care
Posted: 10/17/2017 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
Click here to contact Mike Winters, MBA, MD
Improving CPR Performance
Nassar BS, et al. Improving CPR performance. Chest. 2017. {epub ahead of print]
Jentzer JC, et al. Improving survival from cardiac arrest: A review of contemporary practice and challenges. Ann Emerg Med. 2016; 68:678-89.
Category: Critical Care
Keywords: liver failure, dialysis, MARS, Molecular Adsorbent Recirculating System (PubMed Search)
Posted: 10/10/2017 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
Molecular Adsorbent Recirculating System (MARS) is an artificial liver support system colloquially known in the medical field as "dialysis for the liver."
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
(http://findbesttreatment.com/images/healthnet_dialyse_schema.gif)
Molecular Adsorbent Recirculating System (MARS) is an artificial liver support system colloquially known in the medical field as "dialysis for the liver."
Its use demonstrates apparent effective replacement of liver function, with consistently-proven improvements in hemodynamics, hepatic encephalopathy, hepatorenal syndrome, drug clearance, hyperbilirubinemia, and other markers of hepatic homeostasis.
It has been repeatedly demonstrated to work well as a short-term bridge to liver recovery or liver transplant in severe ALF of various causes, especially those that are generally reversible with support and time severe trauma, toxic ingestions, and acute alcoholic hepatitis.
Mortality benefit remains unclear and may be dependent on the subtype of acute liver failure. Most of the current literature is made up of case reports, or case studies with small study populations. In acute on chronic liver failure, the 23-patient randomized, controlled RELIEF trial failed to show survival advantage at 28 days. Gerth et al, however, found a 14-day mortality benefit in ACF patients by retrospective analysis, which may indicate that MARS use as a bridge to transplant is the most appropriate utilization in this patient population.
Category: Critical Care
Posted: 10/4/2017 by Ashley Menne, MD
(Updated: 2/18/2025)
Click here to contact Ashley Menne, MD
Risk of Pneumocystis pneumonia (PCP) increases with degree of immunosuppression. If clinical suspicion exists (CD4 <200 with cough, pulmonary infiltrates, hypoxic respiratory failure), it is reasonable to initiate empiric therapy.
First line treatment is trimethoprim-sulfamethoxazole (TMP-SMX) orally or IV for 21 days. IV pentamidine has equivalent efficacy to IV TMP-SMX but greater toxicity and is generally reserved for patients with severe PCP who cannot tolerate or are unresponsive to TMP-SMX.
Importantly, adjunctive corticosteroids have been shown to significantly improve outcomes (mortality, need for ICU admission, need for mechanical ventilation) in HIV-infected patients with moderate to severe PCP (defined by pO2 <70 mmHg on Room Air).
· Ideally steroids should be started BEFORE (or at the same time as) Pneumocystis-specific treatment to prevent/mitigate the sharp deterioration in lung function that occurs in most patients after initiation of PCP treatment. This is thought to be secondary to the intense inflammatory response to lysis of Pneumocystis organisms, which can cause an ARDS-like picture.
· Recommended dosing schedule: 40mg prednisone twice daily for 5 days, then 40mg once daily for 5 days, followed by 20mg once daily for the remaining 11 days of treatment.
Bottom Line: In patients with moderate to severe PCP (pO2 <70 mmHg on RA), don’t forget to initiate adjunctive corticosteroids early (at the same time you initiate empiric therapy for PCP).
Wang RJ, Miller RF, Huang L. Approach to Fungal Infections in Human Immunodeficiency Virus–Infected Individuals. Clin Chest Med. 2017;38(3):465-477. doi:10.1016/j.ccm.2017.04.008.
Bozzette SA, Sattler FR, Chiu J, et al. A Controlled Trial of Early Adjunctive Treatment with Corticosteroids for Pneumocystis carinii Pneumonia in the Acquired Immunodeficiency Syndrome. N Engl J Med. 1990;323(21):1451-1457. doi:10.1056/NEJM199011223232104.
Montaner JS, Lawson LM, Levitt N, Belzberg A, Schechter MT, Ruedy J. Corticosteroids prevent early deterioration in patients with moderately severe Pneumocystis carinii pneumonia and the acquired immunodeficiency syndrome (AIDS). Ann Intern Med. 1990;113(1):14-20. http://www.ncbi.nlm.nih.gov/pubmed/2190515.
Category: Critical Care
Posted: 9/19/2017 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
Click here to contact Mike Winters, MBA, MD
Post-Arrest Tidal Volume Setting
Beitler JR, et al. Favorable neurocognitive outcome with low tidal volume ventilation after cardiac arrest. Am J Respir Crit Care Med. 2017; 195:1196-1206.
Category: Critical Care
Keywords: respiratory failure, pulmonary edema, airway obstruction (PubMed Search)
Posted: 9/12/2017 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
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.
Negative-pressure pulmonary edema (NPPE), also called post-obstructive pulmonary edema, can occur after any event in which a patient exerts strong inspiratory effort against an obstructed airway. This obstruction can be essentially due to any cause; in adults it is most well-documented secondary to post-extubation laryngospasm, in children the etiology is usually infectious, such as in epiglottitis. It has also been documented secondary to laryngeal edema, tumor, trauma, biting on an endotracheal tube, vent dyssynchrony, as well as disruptions to breathing mechanics during generalized seizures, among other causes.
It is noted that many of the documented cases involve patients who are relatively young and otherwise healthy, and thus capable of creating a strong negative intrathoracic pressure. The pathophysiology is thought to be related to hydrostatic mechanisms rather than a “leaky-capillary” permeability edema, and it usually resolves quickly if managed appropriately, within 24-48 hours. Diffuse alveolar hemorrhage, related to capillary rupture from the negative pressure, has been documented to occur in severe cases but is rare.
Consider the diagnosis in patients with an appropriate clinical picture or witnessed event leading to abrupt respiratory distress and/or failure. The diagnosis is even more strongly supported if they had absence of respiratory symptoms, or a clear chest x-ray prior to the event, with a chest x-ray demonstrating pulmonary edema afterwards.
Appropriate management of these patients includes:
1. Alleviation or bypass of the upper airway obstruction, which usually requires intubation.
· Depending on the etiology of obstruction (e.g. epiglottitis), endo/nasotracheal intubation may be difficult and a surgical airway may be necessary. Be prepared for this possibility.
· Ventilated patients who develop NPPE may require sedation to prevent biting on the ETT or to promote vent synchrony
2. Provide with positive-pressure ventilation to counteract the negative airway pressures, and oxygen supplementation to decrease pulmonary vascular resistance.
3. Lung-protective ventilation with low tidal volumes is generally accepted as the preferred ventilation strategy in these patients, extrapolated from data regarding its use in acute lung injury.
4. In cases of moderate to severe hypoxemia without the presence of shock, add a diuretic agent.
5. For refractory hypoxemia, consider early utilization of additional therapies, including neuromuscular blockade, proning, and ECMO.
Bhattacharya M, Kallet RJ, Ware LB, Matthay MA. Negative-pressure pulmonary edema. Chest. 2016;150(4):927-33.
Contou D, Voiriot G, Djibre et al. Clinical features of patients with diffuse alveolar hemorrhage due to negative-pressure pulmonary edema. Lung. 2017;195(4):477-487.
Category: Critical Care
Keywords: Mechanical ventilation, sedation (PubMed Search)
Posted: 8/30/2017 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
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:
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.
Stephens, R.J., et al., Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED: A Cohort Study. Chest, 2017 [Epub ahead of print].
Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, et al.; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263–306.