Category: Critical Care
Posted: 3/5/2010 by Evadne Marcolini, MD
(Updated: 2/18/2025)
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Primary Intracranial hemorrhage is associated with the following risk factors:
Common causes of secondary ICH are as follows:
The question of how to address elevated blood pressure in spontaneous intracranial hemorrhage has been debated. High blood pressure may cause hematoma expansion, but this has not been proven. Lowering blood pressure may help reduce neurologic deterioration, but this has also not been proven in the literature.
The AHA recommended guidelines for blood pressure management in spontaneous ICH are as follows:
If SBP>200 or MAP>150, consider aggressive reduction of BP with continuous IV infusion, monitoring BP every 5 minutes
If SBP>180 or MAP>130, with evidence or suspicion of elevated ICP, consider monitoring ICP and reducing BP using intermittent or continuous IV medications to keep CPP>60 to 80
If SBP>180 or MAP>130 without evidence or suspicion of elevated ICP, then consider a modest reduction of BP (MAP of 110 or targeted SBP 160/90) using intermittent or continuous IV medications, monitoring BP every 15 minutes
Nyquist P: Management of Acute Intracranial and Intraventricular Hemorrhage. Crit Care Med 2010;38(3):946-953
Category: Critical Care
Posted: 3/2/2010 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Ventilating the Patient with Traumatic Brain Injury
Young N, Rhodes JKJ, Mascia L, Andrews PJD. Ventilatory strategies for patients with acute brain injury. Curr Opin Crit Care 2010; 16:45-52
Category: Critical Care
Posted: 2/22/2010 by Evadne Marcolini, MD
(Updated: 2/23/2010)
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The question of hyperglycemia in the critically ill and how to address it has been the topic of considerable study over the years.
There have been several attempts to try to quantify the best target glucose levels in critically ill patients. This is still a moving target, but a recent study sheds some light on the effect of different levels of hyperglycemia and the types of patients who are particularly vulnerable.
This is a retrospective cohort study whic reviewed 259,000 ICU admissions over a three year period at 173 separate sites. Their findings were as follows:
Compared with normoglycemic patients, the adjusted odds for mean glucose 111-145, 146-199, 200-300, and >300 was 1.31, 1.82, 2.13 and 2.85 respectively.
There is a clear association between the adjusted odds of mortality related to hyperglycemia in patients with AMI, arrhythmia, unstable angina, pulmonary embolism, pneumonia and gastrointestinal bleed.
Hyperglycemia associated with increased mortality was independent of type of ICU, length of stay and/or pre-existing diabetes.
So, even though we have not come to solid conclusions about how far down to keep the glucose levels down, it makes sense to pay particular attention and be more vigilant of the blood glucose levels, especially in the higher-risk patients listed above.
Flaciglia M, Freyberg RW et al: Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med 2009;37:3001-3009
Category: Critical Care
Posted: 2/3/2010 by Evadne Marcolini, MD
(Updated: 2/18/2025)
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There are several conditions that alter ionized calcium levels, including:
The bottom line is to measure ionized calcium, and consider all other factors that can be contributing to hypocalcemia in addition to repleting it.
Category: Critical Care
Posted: 2/2/2010 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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The Rapid Ultrasound in Shock (RUSH) Exam
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill. Emerg Med Clin N Am 2010; 28:29-56.
Category: Critical Care
Posted: 1/26/2010 by Evadne Marcolini, MD
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Patients in the Critical Care setting may develop HIT as a result of chronic pre-existing risk factors (malignancy, obesity, hypertension, diabetes or medications) or acquired factors secondary to their ICU stay (post-operative state, trauma, central lines or medications such as heparin).
Diagnosis of HIT:
Treatment of HIT:
Critical Care Med 2010 Vol. 38, No. 2 (Suppl.)
Category: Critical Care
Posted: 1/19/2010 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Defining Acute Kidney Injury (AKI)
Dennen P, Douglas IS, Anderson R. Acute kidney injury in the intensive care unit: An update and primer for the intensivist. Crit Care Med 2010; 38:261-27
Category: Critical Care
Posted: 1/12/2010 by Evadne Marcolini, MD
(Updated: 2/18/2025)
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The term Sepsis is frequently and colloquially used to describe "sick" patients; but accuracy requires understanding the specific criteria of Sepsis and its associated syndromes. Following are the defining criteria for SIRS and Sepsis:
SIRS
at least 2 of the following:
Temp >38C or <36C
Heart rate >90
RR> 20 or pCO2<32mm Hg
WBC>12,000, <4,000 or >10% bands
Sepsis:
Systemic response to infection, manifested by 2 or more SIRS criteria with a source of infection confirmed by culture or a clinical syndrome pathognomic for infection.
Severe Sepsis:
Sepsis associated with acute organ dysfunction, hypoperfusion or hypotension; including lactic acidosis, oliguria or altered mental status.
Septic Shock:
Sepsis-induced hypotension not responsive to fluid resuscitation.
Category: Critical Care
Posted: 1/5/2010 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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AKI and the Critically Ill
Dennen P, Douglas IS, Anderson R. Acute kidney injury in the intensive care unit: An update and primer for the intensivist. Crit Care Med 2010; 38:261-27
Category: Critical Care
Posted: 12/28/2009 by Evadne Marcolini, MD
(Updated: 2/18/2025)
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Category: Critical Care
Posted: 12/22/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Appropriate Antimicrobial Therapy for Sepsis
Kumar A, Ellis P, Arabi Y, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest 2009; 136:1237-48.
Category: Critical Care
Posted: 12/15/2009 by Evadne Marcolini, MD
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Red blood cell transfusion in the critically ill patient has been and continues to be surrounded by controversy and lack of hard data. Up to 90 percent of transfusions in the ICU are given for anemia, an indication which is least supported by the data. The joint taskforce of EAST, ACCM and SCCM has published a clinical practice guideline which outlines recommendations and rationale. These recommendations are summarized as follows:
Napolitano LM et al: Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care: Crit Care Med 2009;37:3124-3157
Category: Critical Care
Posted: 12/8/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Early Recognition of Shock
Strehlow MC. Early identification of shock in critically ill patients. Emerg Med Clin N Am 2010:28:57-66.
Category: Critical Care
Posted: 11/30/2009 by Evadne Marcolini, MD
(Updated: 2/18/2025)
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Calciphylaxis is a rare disorder caused by systemic arteriolar calcification which leads to ischemia and necrosis. It is characterized by painful ischemic necrotic lesions on adipose tissue areas such as abdomen, buttock and thighs. This commonly occurs in patients with ESRD on hemodialysis or after transplant, but can also occur with other patients, such as those with hyperparathyroidism.
Diagnosis is made clinically, with the help of a skin biopsy as needed. Differential diagnosis includes cholesterol embolization, warfarin necrosis, cryoglobulinemia, cellulitis and vasculitis. There are no specific laboratory findings, although patients may manifest elevated PTH, phosphorous, calcium or calcium x phosphorous product.
Infection is usually the cause of the high mortality rate of this condition, which has a reported mortality of 46%, or 80% if ulceration is present.
Treatment includes local wound care, trauma avoidance, electrolyte correction, increased frequency of dialysis or parathyroidectomy as needed. Surgical debridement is controversial; as the risk of infection may outweigh the benefit in terms of outcome.
Reference:
Category: Critical Care
Posted: 11/17/2009 by Evadne Marcolini, MD
(Updated: 2/18/2025)
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There is no prospective, randomized study to elucidate propofol’s effect on the critically ill patient. By definition, Propofol Infusion Syndrome (PRIS) has the following characteristics:
It has been thought that PRIS was limited to patients with prolonged use, but we now know that this is not necessarily true.
It has been shown that PRIS is more likely with the following risk factors:
The treatment for suspected PRIS is:
Fudickar A, Bein B Propofol infusion syndrome: update of clinical manifestation and pathophysiology. Minerva Anestesiologica 2009;75:339-44.
Vernooy K, Delhaas T, et al. Electrocardiographic changes predicting sudden death in propofol-related infusion syndrome. Heart Rhythm 2006;3:131-7
Category: Critical Care
Posted: 11/10/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Severe Acute Pancreatitis
Greer SE, Burchard KW. Acute pancreatitis and critical illness: A pancreatic tale of hypoperfusion and inflammation. Chest 2009;136:1413-19.
Category: Critical Care
Posted: 11/3/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Hypoxemia in the Intubated Asthmatic
Brenner R, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the asthmatic patient in respiratory failure. JEM 2009;37(2S):S23-34.
Category: Critical Care
Posted: 10/27/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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This week's pearl is courtesy of Dr. Evie Marcolini. Thanks Evie!
Abdominal Compartment Syndrome in Burn Patients
Latenser BA. Critical care of the burn patient: The first 48 hours. Crit Care Med 2009;37:2819-2826.
Category: Critical Care
Posted: 10/20/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Extracorporeal Membrane Oxygenation
Schuerer DJE, Kolovos NS, Boyd KV, Coopersmith CM. Extracorporeal membrane oxygenation: Current clinical practice, coding, and reimbursement. Chest 2008;134:`79-84.
Category: Critical Care
Posted: 10/13/2009 by Mike Winters, MBA, MD
(Updated: 2/18/2025)
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Critically Ill Patients with H1N1
Dominguez-Cherit G, Lapinsky SE, Macias AE, et al. Critically ill patients with 2009 influenza A (H1N1) in Mexico. JAMA (published online October 12, 2009) doi:10.1001/jama.2009. 1536.
Kumar A, Zarychanski R, Pinto R, et al. Canadian Critical Care Trials Group H1N1 Collaborative. Critically ill patients with 2009 influenza A (H1N1) infection in Canada. JAMA (published online October 12, 2009) doi:10.1001/jama.2009. 1496.
The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) influenza Investigators. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome. JAMA (published online October 12, 2009) doi.10.1001/jama.2009. 1535.