UMEM Educational Pearls - Critical Care

Hemofiltration

• Renal replacement therapy (RRT) involves the use of semipermeable membranes to remove fluid and toxic substances from the bloodstream
• The basic methods of RRT are hemodialysis (HD) and hemofiltration (HF)
• There have been a few cases in our ED in which our Renal consultants have used HF
• Hemofiltration can remove large volumes of fluid (up to 3 Liters per hour)
• Major advantages to HF: less likely to produce hypotension than HD, can remove larger molecules than HD
• Disadvantages to HF: must be done continuously to provide effective dialysis, requires anticoagulation to maintain circuit patency, not well suited for hypotensive patients (requires a hydrostatic pressure gradient for solute clearance)

Critical Care Billing Pearls:

As the table shows Critical Care billing will earn you approximately 25% more with no additional overhead.  Critical care time must be at least 30 minutes, and the following procedures are included in the critical care code:   

• Interpretation of ABG and labs
• Interpretation of CXR
• IV insertation
• Transcutaneous pacing
• Blood Draws
• NG Tube placement

The following procedures are not bundled into critical care time, so they can be billed separately, therefore the time you spend doing these procedures can not be included in your total critical care time:

• Central Line Placement
• Lumbar Puncture
• Intubation
• Transvenious pacemaker placement
• Arterial Line Placement
• Chest Tube Placement
• CPR

Remember critical care time does not need to be continuous but you need to be immediately available to the patient for the time to count.  You can not count time going off the floor to review an xray or CT, but this time can be counted if you do it in the immediate vacinity of the patient.

FINAL CAVEAT  To help your coders bill appropriately it helps to include a statement such as "Critical Care time XX minutes where I was directly involved in the care of this patient exclusive of all other separately billable procedures."

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Catheter Positioning

• Central venous catheters (CVC) inserted from the left side must make an acute angle downward when the enter the SVC from the innominate vein
• CVCs that do no make this turn can end up with the tip pointing directly at the lateral wall of the SVC
• CVCs in this position can cause perforation of the SVC
• If the catheter tip is pointing at the SVC, then advance the catheter further down

Central Venous Catheter Occlusion

• Many of us care for patients that present with pre-existing CVCs
• Catheter occlusion is the most common complication associated with CVC
• Thrombosis is the most common cause of obstruction of CVCs
• Thrombosis is often be due to insoluble precipitates; meds such as diazepam, digoxin, phenytoin, and TMP-SMX can cause these precipitates
• Local instillation of a thrombolytic agent (tPA) can be effective in restoring CVC patency
• One protocol for use of tPA in CVC occlusion is to:
  • reconstitute a 50 mg vial with 50 mL sterile water (1 mg/mL)
  • draw up 2 mL in a 5 cc syringe and inject into the CVC - total tPA dose 2 mg
  • leave in place for approximately 2 hours
  • attempt to flush the CVC with a saline solution
• If the catheter remains obstructed, a new CVC should be placed at a new site
• The total drug dose in this regimen (4 mg) is too small to cause systemic thrombolysis

Hemodialysis Catheters

Two weeks ago, we had a PEA arrest of a patient receiving HD.  A significant delay occurred in administering fluids and medications as a result of "no iv access".  Don't forget that in these situations you can use the hemodialysis catheter.

• Typically these are double-lumen catheters in the IJ or femoral vein; one lumen carries blood to the HD machine and the other returns it to the patient
• Importantly, each lumen is equivalent in diameter to an introducer catheter (8 French) - permitting rapid flow
• Fluids and medications can be rapidly given through these catheters in code situations

Stress Related Mucosal Injury (SRMI)

• As the length of stay for many of our critically ill patients continues to rise, it is important to think about some preventative therapies
• SRMI is the term used to describe gastric mucosal erosions that occur in the critically ill
• SRMI can be demonstrated in 75 - 100% of critically ill patients within 24 hours and can cause clinically apparent bleeding in up to 25%
• Independent risk factors for SRMI include mechanical ventilation, coagulopathy, and a prior history of gastritis or peptic ulcer disease
• Additional risk factors in our ED patient population include sepsis, hypotensive states, severe head injury, multisystem trauma, and renal failure
• Typically an H₂ antagonist is provided (i.e. ranitidine or famotidine).  Currently there is no evidence of superiority of PPIs over H₂ antagonists in preventing SRMI
• Pearl:  the best agent to give is probably sucralfate - there is a slightly higher incidence of bleeding compared to ranitidine; however, ranitidine is associated with a much higher incidence of nosocomial pneumonia.  The risk and mortality associated with nosocomial pneumonia in these patients outweighs the minimal risk of major hemorrhage associated with SRMI

Dopamine in the ED

• Recall that dopamine is an endogenous catecholamine that is a precursor for norepinephrine synthesis
• Despite the popularity of norepinephrine, dopamine is still used by many EPs in the setting of septic shock
• Dopamine produces progressive alpha-receptor stimulation at doses > 10 mcg/kg/min
• Tachyarrhythmias (namely sinus tachycardia) is the predominant adverse effect
• When selecting a vasopressor agent, be sure to check the HR.  If the patient is already tachycardic, the addition of dopamine will only worsen the tachycardia
• Additional important adverse effects are increased intraocular pressure and delayed gastric emptying

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Seizures in the Critically Ill

• Seizures are a common complication in medical and surgical patients commonly arising from coexisting conditions associated with critical illness
• Most seizures in the critically ill are generalized convulsions rather than focal
• The majority of seizures occur in patients without a pre-existing history of seizure disorder
• Common causes of seizures in the critically ill include sepsis, cardiovascular disease, metabolic abnormalities, medications, and drug intoxication/withdrawal
• Metabolic abnormalities account for 30 -35% of causes
• The most common metabolic abnormalities include hyponatremia, hypocalcemia, hypophosphatemia, uremia, and hypoglycemia
• Be sure to check these labs in ICU patients with a seizure

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Auto-PEEP in the non-COPD patient

• In previous pearls we have discussed the concept of auto-peep in patients with expiratory flow limitation (asthma and COPD)
• Unexpected auto-peep can also occur in up to 35% of patients without asthma or COPD
• In these patients, auto-PEEP typically occurs with high minute ventilations (> 20 L/min) with shortened exhalation times or if exhalation is blocked (blocked ETT, exhalation valve, or PEEP valve)
• Recall that auto-PEEP increases the work of breathing, worsens gas exchange, and can cause hemodynamic compromise 
• Treatment of auto-PEEP can be as follows:
  • Change ventilator settings
    • increase expiratory time
    • decrease respiratory rate
    • decrease tidal volume
  • Reduce ventilatory demand
    • reduce anxiety, pain, fever with sedatives
  • Reduce flow resistance
    • large-bore ETT
    • frequent suctioning
  • Apply external PEEP

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Ventilator Therapy for ED Patients with ARDS

• As we manage critically ill patients for longer periods of time, it is likely that many of us will manage patients who develop ARDS
• Current mortality for patients with ARDS ranges from 30-40%
• ED treatment for patients with ARDS includes treating the inciting event, supportive critical care, and ventilator management
• Current ventilator management in patients with ARDS includes:
  • avoiding alveolar overdistention (tidal volumes of 6 ml/kg)
  • maintaining F_iO₂ < 60% (mitigates oxygen toxicitty)
  • PEEP to prevent alveolar derecruitment (levels of 10-15 cm H₂O)
  • permissive hypercapnea

 Influenza and the Critically Ill

• It is that time of year again to be vigilant for cases of influenza
• Influenza is not benign and causes > 40,000 deaths per year and is the 7th leading cause of death in the US
• In the critically ill, the most severe disease occurs in patients > 65 and those with underlying cardiopulmonary disease
• Critically ill patients with influenza can present with fever, cough, bilateral interstitial infiltrates, hypoxemia, and leukopenia
• Other serious complications include myocarditis, encephalitis, and Reye syndrome
• Amantadine and rimantadine should no longer be used, as the resistance has risen to > 90% in some populations
• Oseltamivir (PO) and zanamivir (powder/inhalation) are the approved neuraminidase inhibitors; both decrease the severity and duration of illness; should be given as early as possible, preferably within 36 hours

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Tension gastrothorax?

• Tension gastrothorax is a life threatening condition characterized by herniation of the stomach through a defect in the diaphragm with compression of the mediastinal contents
• Although many cases occur in pediatric patients (secondary to congenital defects), adults with a history of diaphragmatic injury are at risk (also patients with a type III or IV hiatal hernia)
• The clinical presentation is the same as a tension pneumothorax - hypotension, tachycardia, hypoxia, JVD, and decreased breath sounds
• CXR appearance can be very similar to tension pneumothorax, however, the treatment is substantially different
• Needle decompression and tube thoracostomy are contraindicated, as this may cause visceral perforation
• The treatment of choice is NGT (or OGT) decompression followed by surgical repair

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Subcutaneous Insulin in the Critically Ill

• Although intensive insulin therapy in the critically ill remains controversial and a matter of much debate, hyperglycemia is common in the critically ill ED patient
• Hyperglycemia is associated with worse outcomes in this patient population
• When treating hyperglycemia in the critically ill ED patient, use caution with subcutaneous insulin
• Absoprtion of insulin administered subcutaneously is slow, erratic, and highly variable often due to poor perfusion, hypotension, and/or vasopressor therapy
• In these patients, IV insulin is a better route of administration and leads to more reliable control of hyperglycemia
• Recall that the onset of action of insulin given IV is 10 - 30 minutes, with a duration of action of about 1 hour

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AIDS: coming to a critically ill patient in your ED

• Acute intestinal distress syndrome (AIDS) is a recently coined term used in the continuum of intraabdominal hypertension (IAH) to abdominal compartment syndrome (ACS)
• In previous pearls we have discussed the importance of IAH in the critically ill and how to measure intraabdominal pressure (IAP)
• Recall that IAH is defined as a sustained elevation of IAP > 12 mmHg
• The focus of attention is shifting to "secondary ACS" - it is highly prevalent in the critically ill and is independently associated with increased mortality
• Sepsis is a cause of secondary ACS and is the most likely condition we will encounter in our critically ill patient population
• Current recommendations suggest that IAP be measured daily in patients at risk for IAH (i.e. the septic ED patient)

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Intraabdominal Hypertension and the Critically Ill

• Intraabdominal hypertension (IAH) is increasingly recognized in a wide variety of critically ill patients and is associated with significant morbidity and mortality
• Normal intraabdominal pressure (IAP) is 5 - 7 mm Hg
• IAH is defined as the sustained elevation in IAP of at least 12 mm Hg
• Physical exam is inaccurate in detecting IAP with sensitivities of 40-60%
• The most common method of measuring IAP is intravesicular (bladder)
• Importantly, IAP should be measured at end-expiration after ensuring that abdominal muscle contractions are absent, with the patient in the supine position, and with the transducer zeroed in the midaxillary line at the level of the iliac crest

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Bicarbonate for severe lactic acidosis from shock?

• In critically ill patients, one of the most common causes of acidosis is hypoperfusion induced lactic acidosis
• Importantly, the source of lactic acid during hypoperfusion/shock is intracellular, and the intracellular compartment is not readily accessible to extracellular bicarb
• Exogenous bicarbonate will certainly raise extracellular pH but does not readily correct intracellular acidosis
• This increase in pH is transient and typically lasts approximately 30 minutes
• In studies to date, exogenous bicarbonate did raise pH, serum bicarbonate concentrations, and P_aCO₂ but importantly did not improve cardiac output, mean arterial pressure, or sensitization to catecholamines
• Take Home Point: Based on available literature, there is no utility to giving bicarbonate in hypoperfusion induced lactic acidosis when the pH is > 7.0

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 Phentolamine for vasopressor extravasation

I was recently informed of a case from an another institution in which a patient was started on a vasopressor medication via a peripheral IV while attempts at central access where attempted.  The patient unfortunately suffered permanent extremity ischemia due to significant extravasation of the vasopressor medication into the soft tissue.

• Phentolamine is reportedly the antidote for vasopressor extravasation into the skin and soft tissues (the evidence is not robust and limited primarily to case reports and animal data)
• Phentolamine is a non-specific alpha-blocking agent that inhibits vasoconstriction and theoretically improves blood flow through the affected area
• Take 5-15 mg of phentolamine and mix in 10 mL of normal saline - inject this into the affected area as soon as possible
• Give the patient concurrent IVFs in the event of some systemic absorption

PEEP in Nonhypoxemic Respiratory Failure

• Patients with ALI/ARDS typically receive PEEP to improve oxygenation
• Patients without ALI/ARDS, however, receive PEEP less frequently (some recent reports indicate that < 50% of these patients receive PEEP)
• A recent study by Spanish investigators found that the use of PEEP (5 - 8 cm H₂0) in nonhypoxemic patients decreased the incidence of ventilator-associated pneumonia and decreased the number of patients who developed hypoxemia
• Interestingly, no differences were found in hospital mortality, duration of mechanical ventilation, or ICU LOS
• Take Home Point: In nonhyoxemic intubated patients, the addition of 5-8 cm H₂0 of PEEP is a reasonable practice and may be beneficial in preventing VAP (pending further study)

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Pressure Regulated Volume Control (PRVC)

• PRVC is a mode of mechanical ventilation that combines both volume and pressure control modes
• The main advantage to PRVC is that the tidal volume / minute ventilation is guaranteed while controlling airway pressures, thereby reducing the risk of ventilator induced lung injury
• In PRVC, the ventilator delivers a pressure-controlled breath, but tidal volume is the key setting
• The ventilator will automatically adjust inspiratory pressures until the desired TV is achieved
• When using PRVC you need to set: target TV, RR, peak pressure alarm, inspiratory time, FiO2, and PEEP

Post-intubation deterioration?  Remember DOPE

• The pneumonic DOPE can help you remember the most common causes of post-intubation hypoxia or deterioration
• Displacement: check the endotracheal tube for displacement (right mainstem) or dislodgement
• Obstruction: check the ETT for obstruction (mucous plug, kink in ventilator tubing)
• Pneumothorax - get an xray
• Equipment failure(unusual): disconnect patient from the ventilator and bag manually