Category: Critical Care
Posted: 9/6/2011 by Mike Winters, MBA, MD
(Updated: 7/26/2024)
Click here to contact Mike Winters, MBA, MD
Fungal Sepsis in the Critically Ill
Lepak A, Andes D. Fungal sepsis: Optimizing antifungal therapy in the critical care setting. Crit Care Clin 2011; 27:123-147.
Category: Critical Care
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.
The following video is an example of what you DO NOT want to see during an intubation: http://www.youtube.com/watch?v=LvfThxhQ93A
Chou, H. et al. Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation. Resuscitation. Jun 2011
Werner SL,et al. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med 2007;49:75–80.
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Category: Critical Care
Posted: 8/23/2011 by Mike Winters, MBA, MD
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Re-expansion Pulmonary Edema After Chest Tube Placement
Hsu KF, et al. Re-expansion pulmonary edema after insertion of chest tube for pneumothorax. J Trauma 2011;70(3):761.
Category: Critical Care
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
Hill, C., et al. Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab. Academic Emergency Medicine17(6), 666–669.
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Category: Critical Care
Posted: 8/9/2011 by Mike Winters, MBA, MD
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When may an ED thoracotomy be futile?
Moore EE, Knudson M, Burlew CC, Inaba K, et al. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma 2011;70:334-9.
Category: Critical Care
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
Breathing
Circulation
Chesnutt, A. Physiology of normal pregnancy. Crit Care Clinics 2004 Oct;20(4):609-15.
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Category: Critical Care
Posted: 7/26/2011 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
Blood Pressure in the Critically Ill Obese Patient
King DR, Velmahos GC. Difficulties in managing the surgical patient who is morbidly obese. Crit Care Med 2010; 38(S):S478-82.
Category: Critical Care
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:
Treatment includes:
Despite the most aggressive therapy, up to 30% survivors may have permanent neurologic or multi-organ system dysfunction months to years after recovery
Leon, L. Heat stroke: role of the systemic inflammatory response. Journal of Applied Physiology 2010 Dec;109(6):1980-8
http://emedicine.medscape.com/article/166320-overview
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Category: Critical Care
Posted: 7/12/2011 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
Hemodynamic Optimization in the Post-Arrest Patient
Stub D, Bernard S, Duffy SJ, Kaye DM. Post cardiac arrest syndrome: a review of therapeutic strategies. Circulation 2011; 123:1428-1435.
Category: Critical Care
Posted: 6/28/2011 by Mike Winters, MBA, MD
(Updated: 7/26/2024)
Click here to contact Mike Winters, MBA, MD
Hepato-Renal Syndrome
Bagshaw SM, Bellomo R, Devarajan P, et al. Review article: Acute kidney injury in critical illness. Can J Anesth 2010; 57:985-998.
Category: Critical Care
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.
Benoit D. Acute kidney injury in critically ill patients with cancer. Critical Care Clinics 2010 Jan; 26(1): 151-79
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Category: Critical Care
Posted: 6/14/2011 by Mike Winters, MBA, MD
(Updated: 7/26/2024)
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AKI in the Critically Ill Cancer Patient
Benoit DD, Hoste EA. Acute kidney injury in critically ill patients with cancer. Crit Care Clin 2010;26:151-79.
Category: Critical Care
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:
Hedges, SJ. Evidence-based treatment recommendations for uremic bleeding.NatClinPractNephrol.2007 Mar;3(3):138-53.
Category: Critical Care
Posted: 5/31/2011 by Mike Winters, MBA, MD
(Updated: 7/26/2024)
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Cardiovascular Complication of ESLD
Al-Khafaji A, Huang DT. Critical care management of patients with end-stage liver disease. Crit Care Med 2011; 39:1157-66.
Category: Critical Care
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)
Click here to contact Haney Mallemat, MD
TIP: Suspect when abdominal pain presents 10-14 after chemotherapy (when PMNs are lowest).
Blijlevens NM, et al. Mucosal barrier injury: biology, pathology, clinical counterparts and consequences of intensive treatment for haematological malignancy: an overview. Bone Marrow Transplant 2000 Jun;25(12):1269-78
http://emedicine.medscape.com/article/375779-overview
Category: Critical Care
Posted: 5/17/2011 by Mike Winters, MBA, MD
(Updated: 7/26/2024)
Click here to contact Mike Winters, MBA, MD
Acute Liver Failure (ALF)
Larsen FS, Bjerring PN. Acute liver failure. Curr Opin Crit Care 2011; 17:160-4.
Category: Critical Care
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.
Riddle, D. Clostridium difficile infection in the intensive care unit. Infect Dis Clin North Am. 2009 Sep;23(3):727-43.
Category: Critical Care
Posted: 5/3/2011 by Mike Winters, MBA, MD
(Updated: 7/26/2024)
Click here to contact Mike Winters, MBA, MD
Gastrointestinal Changes of Obesity that Complicate Critical Illness
Ashburn DD, Reed MJ. Gastrointestinal system and obesity. Crit Care Clin 2010;26:625-7.
Category: Critical Care
Keywords: sepsis, shock, antimicrobials, combination, antibiotics (PubMed Search)
Posted: 4/26/2011 by Haney Mallemat, MD
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A mortality benefit from combination antimicrobial therapy has not been clearly demonstrated in sepsis. However, when only the most severely-ill patients (i.e., septic shock) are considered in subgroup analysis, there appears to be a mortality benefit to using two antimicrobials against a suspected organism.
Combination antimicrobial therapy may reduce mortality through three mechanisms.
Always obtain appropriate cultures before initiating therapy. Although identification and susceptibility of the organism may take some time, eventually narrowing antimicrobial therapy to monotherapy in the ICU is still recommended.
Abad, C. Antimicrobial Therapy of Sepsis and Septic Shock: When are Two Drugs Better Than One? Crit Care Clinic 27 (2011) e1-e27.
Category: Critical Care
Keywords: staphylococcal aureus, aminoglycoside, monotherapy, combination therapy (PubMed Search)
Posted: 4/19/2011 by Mike Winters, MBA, MD
(Updated: 7/26/2024)
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Combination Antimicrobial Therapy for Gram (+) Bacteremia
Abad CL, Kumar A, Safdar N. Antimicrobial therapy of sepsis and septic shock - When are two drugs better than one? Crit Care Clin 2011;27:e1-e27.