UMEM Educational Pearls - Critical Care

Spontaneous Bacterial Peritonitis

  • Critically ill patients with end-stage liver disease (ESLD) may be some of the sickest patients you'll ever manage.
  • Recall that patients with ESLD have higher rates of infection and worse outcomes.
  • Always consider spontaneous bacterial peritonitis (SBP) in the sick patient with ESLD.  In fact, SBP is the most common infection in ESLD patients.
  • Physician impression alone has been repeatedly shown to be inaccurate in ruling out SBP.
  • In the critically ill patient with ESLD and ascites, tap the belly!

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Category: Critical Care

Title: Axillary Arterial-Lines

Keywords: Procedures, Arterial lines, Axillary, hemodynamic monitoring (PubMed Search)

Posted: 9/13/2011 by Haney Mallemat, MD
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Radial and femoral arteries are common sites for arterial-line placement, but are not without complications (e.g., Radial artery: malfunction with positioning and Femoral artery: contamination and infection); an alternative site to consider is the axillary artery.

The axillary artery's superficial location and large size make it a desirable choice for cannulation.

The "anatomical-landmark" and "palpation" methods have been the traditional techniques of axillary arterial cannulation, however these methods may be difficult for to a variety of reasons (e.g., obesity, anasarca, arterial disease, etc.)

Ultrasound allows visualization of the axillary artery and avoids unintended injury to structures in close proximity (e.g., brachial plexus, pleura, axillary vein, etc.); please see figures 1 and 2 in the referenced Sandhu article and http://www.youtube.com/watch?v=Z31YiyV7cNQ.

A recent study (Killu, 2011) found that ultrasound increases success rates when compared to the traditional landmark approach.

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Category: Critical Care

Title: Fungal Sepsis

Posted: 9/6/2011 by Mike Winters, MD (Updated: 3/3/2024)
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Fungal Sepsis in the Critically Ill

  • In recent years, the incidence of invasive fungal infections has risen dramatically.
  • Candida species (C. albicans, C. glabrata, C. parapsilosis, C tropicalis, C. krusei) account for the majority of invasive infections in the critically ill patient.
  • Key risk factors for invasive candidal infections include:
    • Exposure to broad spectrum antibiotics
    • Cancer chemotherapy
    • Indwelling catheters
    • TPN administration
    • Neutropenia
    • Hemodialysis
  • Given the significant mortality of invasive fungal infections, early and appropriate antifungal therapy is paramount.
  • First-line empiric antifungal therapy recommendations from the Infectious Disease Society of America include caspofungin, micafungin, or fluconazoleAmphotericin B is now reserved for patients who are either intolerant or not responding to the echinocandins (caspofungin, micafungin).

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Category: Critical Care

Title: Tracheal Rapid Ultrasound Exam (T.R.U.E.)

Keywords: ultrasound, tracheal intubation, esophageal intubation, critical care, airway (PubMed Search)

Posted: 8/30/2011 by Haney Mallemat, MD
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  • Multiple methods of confirming endotracheal tube placement exist, however quantitative waveform capnography is the most reliable method. Unfortunately this may not be immediately available at all medical centers.

  • Recent studies demonstrate that bedside ultrasound may assist in the detection of proper endotracheal tube placement.

  • The T.R.U.E. (Tracheal Rapid Ultrasound Exam) was demonstrated to be 99% sensitive, 94% specific, 99% PPV, and 94% NPV during intubation.

  • The basic exam involves placing a high-frequency linear-array probe on the anterior neck above the sternal notch and identifying the trachea and esophagus during intubation.

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Re-expansion Pulmonary Edema After Chest Tube Placement

  • Tube thoracostomy is a common procedure in the emergency department.
  • For patients who develop respiratory distress after chest tube placement, think about re-expansion pulmonary edema.
  • While a rare occurrence, re-expansion pulmonary edema is reported to have a mortality rate of up to 20%.
  • The mechanism by which edema forms remains controversial, but is thought to be due to increased alveolar-capillary membrane permeability in the expanding lung.
  • Treatment is supportive with supplemental oxygen and diuretics.  Some patients may require mechanical ventilation depending on the degree of distress and hypoxia.

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Category: Critical Care

Title: Bougie-Assisted Cricotyrotomy

Keywords: bougie, cricothyrotomy, trauma, critical care, intubation, failed airway (PubMed Search)

Posted: 8/16/2011 by Haney Mallemat, MD
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The open cricothyrotomy technique is taught as the trauma airway standard when one “cannot intubate and cannot ventilate” however, it is not without difficulty and limitations. The B.A.C.T. (Bougie-Assisted Cricothyrotomy Technique) may improve the procedure by using a bougie to assist.

Steps for the B.A.C.T. (as described in the paper):
1. Stabilize the larynx with the thumb and middle finger, then identify the cricothyroid membrane.
2. Make a transverse stabbing incision with a scalpel through both skin and cricothyroid membrane.
3. Insert tracheal hook at the inferior margin of the incision and pull up on the trachea.
4. Insert a bougie through the incision with curved tip directed towards the feet
5. Pass 6-0 endotracheal tube or Shiley over bougie into trachea.

Advantages of a bougie:
1. Thin and easy to insert into incision
2. Tactile feedback from tracheal rings confirms proper placement
3. Ensures that stoma will not be lost during procedure

EMRAP.tv has a great video of Dr. Darren Braude demonstrating the procedure;
http://bit.ly/nB3BMG

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When may an ED thoracotomy be futile?

  • Performing an ED thoracotomy is incredibly stressful and a resource-intense procedure.
  • While we've all learned that stab wounds to a ventricle have the highest survival rate, what about indicators that an ED thoracotomy may be futile?
  • A recent study of 18 trauma centers across the US found that ED thoracotomy was unlikely to yield productive survival in the following:
    • Blunt trauma patients that require > 10 min of prehospital CPR without response
    • Penetrating trauma patients that require > 15 min of prehospital CPR without response
    • Patients presenting in asystole without evidence of pericardial tamponade on bedside ultrasound.

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Category: Critical Care

Title: Pregnancy Pearls in Trauma

Keywords: trauma, resuscitaiton, pregnancy, IVC, supine hypoventilation, edema, intubation, RSI, desaturaiton (PubMed Search)

Posted: 8/2/2011 by Haney Mallemat, MD
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Pregnancy causes many physiologic changes, which may be challenging during trauma resuscitations. A few pearls on the ABC’s:

Airway

  • Increased progesterone levels cause mucosal hyperemia and edema, increasing risk of bleeding and smaller (i.e., edematous) airway.
  • PEARL: Have smaller tubes ready and let the most experienced person intubate.

Breathing

  • The enlarging uterus pushes the diaphragms into the thorax, reducing the total lung capacity and the functional residual capacity.
  • PEARL: During intubation, patients in late pregnancy may have less oxygenation reserve and apnea time, desaturating faster during RSI.

Circulation

  • The late stage uterus can compress the IVC when supine, reducing venous return to the heart (i.e., the Supine-Hypotension syndrome) subsequently reducing cardiac output.
  • PEARL: Have a 30-degree wedge placed under patient's right hip, moving the uterus off IVC and improving venous return.
  • BONUS PEARL: During resuscitation, ask medical students to manually move the uterus midline, relieving the compressed IVC. They will appreciate that you got them clinically involved.

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Blood Pressure in the Critically Ill Obese Patient

  • Recall that incorrectly sized cuffs can significantly overestimate blood pressure, especially in obese patients.
  • In fact, some studies show that false BP readings can occur in up to 75% of obese patients.
  • By relying solely on noninvasive BP measurements, many of your critically ill obese patients may actually be hypotensive and under perfused.
  • When you've got a sick obese patient, strongly consider early placement of an arterial line to assess and monitor blood pressure.

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Category: Critical Care

Title: Heat Stroke? Time to Chill.

Keywords: heat stroke, critical care, acute kidney injury, seizures, neurological (PubMed Search)

Posted: 7/19/2011 by Haney Mallemat, MD
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Heat stroke is hyperthermia (>41.6 Celsius / 106 Fahrenheit) plus neurologic findings (e.g., altered mental status, seizures, coma, etc.); it also causes systemic inflammation response syndrome (i.e., cytokine release), coagulation disorders (e.g., thrombosis in end organs) and tissue abnormalities (e.g., acute kidney injury and rhabdomyolysis)

Two classifications exist:

  • Exertional heatstroke (young people engaged in strenuous physical activities in hot climates)
  • Non-exertional heatstroke occurring in sedentary people (elderly, debilitated, or chronically-ill patients) who are unprotected from the elements (e.g., trapped in apartments during heat waves)

Treatment includes:

  • Insertion of a continuous core thermometer
  • Supporting ABC’s
  • Cooling by at least to 0.2 degrees celsius per minute to 39 degrees (to avoid overshoot)
  • Benzodiazepines for sedation, shivering, and seizures
  • Antipyretics and phenytoin have not been shown beneficial
  • Support and protect end-organs with particular attention to kidneys; increased risk of kidney injury from rhabdomyolysis, ischemia and systemic inflammation.

Despite the most aggressive therapy, up to 30% survivors may have permanent neurologic or multi-organ system dysfunction months to years after recovery

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Hemodynamic Optimization in the Post-Arrest Patient

  • Hemodynamic instability is common in the post-cardiac arrest patient.
  • While the optimal targets remain unclear, hemodynamic stabilization often consists of intravenous fluids, vasopressors, and in rare cases mechanical support, such as an intra-aortic balloon pump or left-ventricular assist device.
  • Based on recent literature, current recommendations for mean arterial pressure (MAP) in the post-arrest patient range from 65-100 mm Hg.
  • Depending upon the baseline blood pressure and degree of myocardial stunning, many post-arrest patients will need a higher MAP (80-100 mm Hg) in order to maintain critical perfusion pressure to vital organs such as the brain.

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Category: Critical Care

Title: Hepato-Renal Syndrome

Posted: 6/28/2011 by Mike Winters, MD (Updated: 3/3/2024)
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Hepato-Renal Syndrome

  • Hepato-renal syndrome (HRS) is the development of acute kidney injury (AKI) in patients with advanced cirrhosis.
  • HRS is traditionally divided into two types based upon how quickly AKI develops:
    • Type I: a rapid decline in function in less than 2 weeks
    • Type II: a slow decline in function over weeks to months
  • Type I is more likely to be seen in the ED and is often due to a precipitating event such as:
    • GI bleed
    • Spontaneous bacterial peritonitis (SBP)
    • Hypovolemia from aggressive diuresis
  • In ED patients with advanced cirrhosis and new, or worsening, AKI think about HRS. 
  • If suspected, look for precipitants (i.e. SBP), restore volume with IVFs, avoid nephrotoxins (IV contrast), and administer vasopressor therapy when indicated.

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Category: Critical Care

Title: Cancer and Acute Kidney Injury (AKI)

Keywords: AKI, critical care, ICU, cancer, renal failure, acute kidney injury (PubMed Search)

Posted: 6/21/2011 by Haney Mallemat, MD
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Cancer patients admitted to ICUs with AKI or who develop AKI during their ICU stay have increased risk of morbidity and mortality. AKI in cancer patients is typically multi-factorial:

Causes indirectly related to malignancy

  • Septic, cardiogenic, or hypovolemic shock (most common)

  • Nephrotoxins:

    • Aminoglycosides

    • Contrast-induced nephropathy

    • Chemotherapy 

  • Hemolytic-Uremic Syndrome

Causes directly related to malignancy

  • Tumor-lysis syndrome

  • Disseminated Intravascular Coagulation

  • Obstruction of urinary tract by malignancy

  • Multiple Myeloma of the kidney

  • Hypercalcemia

Because AKI increases the already elevated morbidity and mortality in these patients, prevention (e.g., using low-osmolar IV contrast, avoiding nephrotoxins), early identification (e.g., strict attention to urine output and renal function), and aggressive treatment (e.g., early initiation of renal replacement therapy) is essential.

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AKI in the Critically Ill Cancer Patient

  • Acute kidney injury (AKI) is common in the critically ill cancer patient and associated with worse outcomes.
  • The incidence seems to be higher in patients with hematologic malignancies.
  • Despite many different etiologies for AKI in cancer patients (tumor lysis syndrome, hypercalcemia, chemotherapeutic drugs, etc) the most common cause is sepsis, accounting for 58-65% of causes.
  • Given the emphasis on early antibiotic administration in sepsis, be sure to double check the potential for nephrotoxicity of antibiotics for this patient population.  When possible, avoid nephrotoxic meds, such as aminoglycosides, that can worsen AKI.

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Category: Critical Care

Title: Controlling uremic bleeding

Keywords: uremia, bleeding, ddavp, estrogens, epogen, cryoprecipitate (PubMed Search)

Posted: 6/6/2011 by Haney Mallemat, MD (Emailed: 6/7/2011) (Updated: 6/7/2011)
Click here to contact Haney Mallemat, MD

Bleeding associated with uremia is a spectrum, from mild cases (e.g., bruising or prolonged bleeding from venipuncture) to life-threatening (e.g., GI or intracranial bleed). The exact pathologic mechanisms are not understood, but are likely multi-factorial (e.g., dysfunctional von Willebrand’s Factor (vWF) and factor VIII, increased NO, etc.)

Besides dialysis, treatments for uremic bleeding include:

  1. DDAVP (fastest)
    1. 0.3-0.4 micrograms/kg IV or SC
    2. Increases vWF and factor VIII release
    3. Advantages: Begins < 1 hour
    4. Disadvantages: Tachyphylaxis; Stored factors deplete
  2. Cryoprecipitate
    1. Replaces fibrinogen, vWF, and factor VIII
    2. Advantages: Works 1-4 hours
    3. Disadvantages: transfusion reactions, infections, pulmonary edema, etc.
  3. Conjugated Estrogens
    1. Unclear mechanism; possibly increases ADP and thromboxane activity
    2. 0.6 mg/kg once daily x 5 days
    3. Advantages: Short and long-term effects
    4. Disadvantages: Hot flashes (males too!)
  4. Recombinant Erythropoietin (slowest)
    1. 40-150 U/kg three times weekly
    2. Multiple mechanisms
    3. Advantages: Helps anemia (common in renal failure) as well as bleeding complications.
    4. Disadvantages: Up to 7 days to observe effects

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Cardiovascular Complication of ESLD

  • Patients with end-stage liver disease (ESLD) can develop a number of complications that lead to, or complicate, critical illness.
  • Regarding the cardiovascular system, ESLD patients can develop:
    • Hyperdynamic vasodilated cardiovasculature: low baseline blood pressure and high cardiac output
    • "Cirrhotic cardiomyopathy": impaired systolic response to stress or altered diastolic relaxation
    • Autonomic dysfunction: reduced responsiveness to vasoconstrictors
  • ESLD patients also tend to have a normal or near-normal lactate at baseline, despite lactate being cleared more slowly.
  • When managing the critically ill patient with ESLD, look for signs of heart failure, expect an abnormal response to vasopressors, think about steroids for persistent shock, and don't ascribe an elevated lactate simply to impaired hepatic clearance.

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Category: Critical Care

Title: Typhlitis

Keywords: neutropenia, sepsis, abdominal pain, necrotizing enterocolitis (PubMed Search)

Posted: 5/23/2011 by Haney Mallemat, MD (Emailed: 5/24/2011) (Updated: 5/24/2011)
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  • Necrotizing enterocolitis with predilection for cecum.
  • Occurs in the immunosuppressed, especially when neutropenic (<500 PMNs)
  • Typically a polymicrobial infection; gram positive cocci, gram negative rods, anaerobes, and/or fungal. 
  • Classically, right lower quadrant pain but can present with diffuse abdominal pain and peritoneal signs.
  • CT scan with IV and PO contrast is diagnostic (see below)
  • Treatment:
    • Culture and begin broad spectrum antibiotics (cover anaerobes) and antifungals (if suspected) 
    • Aggressive resuscitation
    • Surgical consult for GI perforation or clinical deterioration
  • High mortality (40-50%)

TIP: Suspect when abdominal pain presents 10-14 after chemotherapy (when PMNs are lowest).

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Category: Critical Care

Title: Acute Liver Failure

Posted: 5/17/2011 by Mike Winters, MD (Updated: 3/3/2024)
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Acute Liver Failure (ALF)

  • ALF is defined as sudden and severe liver failure in a patient without preexisting liver disease.
  • The clinical presentation can include altered mental status, coagulopathy, MODS, & cerebral edema.
  • In the US, the most common cause of ALF is drug-induced (e.g. acetaminophen).
  • Important components of the ED management of patients with ALF include:
    • Monitoring and correcting hypoglycemia (may need infusion of D20)
    • Monitoring and maintaining a normal sodium concentration
    • Volume resuscitation with isotonic crystalloids or colloids
    • Prophylactic administration of broad spectrum antibiotics (given high incidence of sepsis)
    • Consideration for continuous veno-venous hemodiafiltration (CVVHD) for severe elevations in ammonia and acidosis (even if renal function is normal)
    • Transfer to center capable of liver transplantation

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Category: Critical Care

Title: Treating Clostriudium difficile in the critically-ill

Keywords: Clostridium difficile, diarrhea, critical, ICU, sepsis, abdominal pain, vanocmycin,metronidazole, fidaxmicin (PubMed Search)

Posted: 5/10/2011 by Haney Mallemat, MD
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Although oral metronidazole is indicated for mild to moderate Clostridium difficile associated diarrhea, oral vancomycin should be considered first-line therapy in critically-ill patients with moderate to severe disease. Vancomycin dosing should begin at 125mg PO q6 and increased to 250mg q6 if poor enteral absorption exists. Consider adding metronidazole IV if either reduced enteral absorption or severe disease exists. 

Recently, fidaxomicin has been shown to be non-inferior to oral vancomycin in the treatment of mild to moderate C. difficile. While promising, the study population was not critically-ill and extrapolation should be avoided.

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Gastrointestinal Changes of Obesity that Complicate Critical Illness

  • Obesity predisposes patients to several gastrointestinal abnormalities that can cause, or complicate, critical illness.
  • Important abnormalities to keep in mind when managing a critically ill obese patient include:
    • Increased intra-abdominal pressure which predisposes to abdominal compartment syndrome
    • Increased incidence of nonalcoholic fatty liver disease which may lead to prolonged drug metabolism
    • Increased incidence of cholelithiasis which may result in pancreatitis or cholangitis

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