Category: Critical Care
Keywords: thrombocytopenia, bleeding, hemorrhage, platelets, transfusions, central lines, CVCs (PubMed Search)
Posted: 5/30/2023 by Kami Windsor, MD
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Background: In general practice, platelets are typically transfused for invasive procedures when the platelet count falls below 50 x 109/L. Regarding the placement of central venous catheters (CVCs), there is minimal data to support or refute decisions to transfuse platelets in these patients, although the 2015 Clinical Practice Guideline from the AABB (formerly, the American Association of Blood Banks) recommends deferring platelet transfusion until a platelet count of 20 x 109/L for CVC placement [weak recommendation, low quality evidence].1
In a study published this month in NEJM,2 van Baarle et al. performed a multicenter randomized controlled noninferiority trial comparing platelet transfusion to no transfusion in patients with platelets 10 to 50 x 109/L prior to US-guided CVC insertion. The primary outcome was the occurrence of catheter-related bleeding Grades 2-4 (Grade 1 = oozing; managed with <20 min of manual compression, not requiring RBC transfusion, & Grades 2-4 is everything else up to death) within 24 hours post-procedure.
Bottom Line: The jury is still out on best platelet transfusion practices prior to CVC placement, but I would strongly consider prophylactic platelet transfusion in patients with platelets < 30 x 109/L, those with underlying hematologic malignancy, and patients receiving larger CVCs such as dialysis lines. How much to transfuse in those with more severe thrombocytopenia is uncertain.
Separately, I would also strongly recommend use of US-guidance for any CVC placement in this population as well, based on practical common sense and some supportive literature as well.5
Additional Background: Data in pediatric oncology patients indicates that CVC placement with platelets <50 x 109/L is associated w/ increased occurence of minor but not major post-procedure bleeding,3 while adult data indicates that CVC placement can be performed until a threshold of 20 x 109/L before transfusions are needed to prevent severe bleeding.4
Additional Study Data:
Category: Critical Care
Keywords: Intubation, Trauma, Cervical Spine, Laryngoscopy (PubMed Search)
Posted: 5/23/2023 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD
Ability to move the head and neck freely can be clutch in endotracheal intubation, so in patients such as certain trauma patients who may have c-spine instability and need to be immobilized, it's all the more important to choose the optimal intubation approach to maximize success and minimize head movement.
Choi et al recently published a study in Anesthesia looking at:
-Video laryngoscopy with a standard geometry Mac blade
vs
-Fiberoptic intubation
as the initial method for intubating patients in c-collars about to undergo spinal surgery. This is an interesting contrast between two extremes, as standard geometry is the most "traditional" approach, whereas fiberoptic is kind of the opposite end of the spectrum, jumping to a more advanced method which might be more flexible (no pun intended) but also introduces new complexities.
All outcomes actually favored standard geometry VL over fiberoptic, including first pass success (98% vs 91%), time to intubation (50s vs 81s) and need for additional airway maneuvers (18% vs 56%). There was no difference in complication rates, although a bigger study might be needed to find rare complications (this study had 330 patients).
In my opinion, it's unfortunate they didn't include hyperangulated VL, as it would be interesting to see how this approach compares. Personally I think of hyperangulated VL in these patients as a nice blend of the two methods, bringing the familiarity and speed of typical VL intubation, but often requiring less neck movement like fiberoptic.
Bottom Line: This study does not support a fiberoptic first approach to intubating patients with cervical spine instability. In fact, it may cause harm.
Choi S, Yoo HK, Shin KW, Kim YJ, Yoon HK, Park HP, Oh H. Videolaryngoscopy vs. flexible fibrescopy for tracheal intubation in patients with cervical spine immobilisation: a randomised controlled trial. Anaesthesia. 2023 May 5. doi: 10.1111/anae.16035. Epub ahead of print. PMID: 37145935.
Category: Critical Care
Posted: 5/16/2023 by Mike Winters, MBA, MD
(Updated: 12/13/2024)
Click here to contact Mike Winters, MBA, MD
Bicarbonate Use for Lactic Acidosis?
Wardi G, et al. A review of bicarbonate use in common clinical scenarios. J Emerg Med. 2023; online ahead of print.
Category: Critical Care
Keywords: OHCA, Critical Care, Whole Body CT, Post Cardiac Arrest Care (PubMed Search)
Posted: 5/9/2023 by Lucas Sjeklocha, MD
Click here to contact Lucas Sjeklocha, MD
Just scan ‘em? Should everyone with unexplained out-of-hospital cardiac arrest get whole-body CT/CTA?
Background: Determination of the cause and subsequent management of out-of-hospital cardiac arrest is clinically challenging in those patients who survive to hospital admission without a clear diagnosis. CT imaging is often used to ascertain the cause of an arrest, find potentially intervenable etiologies, and assess for neurological injury but this practice and diagnostic yield are inconsistent and not well studied.
Study and Methods: The CT FIRST study is a single center cohort study using head-to-pelvis contrasted triple phase CT within 6 hours for cardiac arrest without obvious cause (sudden death CT or SDCT) studied in a before and after manner compared to usual care to determine the influence of early pan CT on diagnostic yield and outcomes. The primary outcome was diagnostic yield following SDCT and secondary outcomes include time to diagnosis of “time critical” findings and survival to discharge. 104 patients undergoing SDCT were compared to 143 historical controls after study implementation. Patients deemed to have a clear cause or are too unstable for CT were among exclusions.
Results: For the primary outcome of diagnostic yield: 92% of SDCT cohort received a separately adjudicated diagnosis for the arrest compared to 75% of the control cohort (p = 0.001). With time to such diagnosis of 3.1hrs in SDCT versus 14.1hrs of controls, with 39% versus 17% being made by CT. Time critical diagnoses including MI, PE, aortic dissection, pneumonia, embolic or hemorrhagic CVA and abdominal catastrophe were identified in 32% versus 24% (non significant) of the cohorts with delay greater than 6hrs to diagnosis reported in 12% in SDCT versus 62% in usual care (p=0.001).
There was no difference in survival to hospital discharge and no difference in safety measures and no evaluation reporting changes to and timing of patient managements.
The SDCT cohort had 100% scan rate compared to usual care where 81% received early head CT with chest CT and abdominal CT done in 36% and 18%, respectively. Notably there were no CT reported diagnoses that were later reversed on adjudication in either cohort. The planned economic and resource analysis was not reported in this study.
Discussion: There was a notable increase in diagnostic yield based on the study design with faster time to potentially time sensitive diagnoses. There were, however, no differences in mortality and it was not clear the degree to which these diagnoses influenced patient management given the limited numbers in this study and diverse set of diagnoses associated with cardiac arrest. Like previous studies of selective versus whole body CT in trauma populations, the increased diagnostic yield was not associated with reduced mortality or reported changes in management. The yield numbers suggest increased confidence by exclusion as much as positive findings of the cause. As always, the caveats of a relatively small single center before-and-after cohort study apply.
An interesting twist is that no CT diagnosis pointing to the cause of the arrest was reversed on subsequent review, this may speak to the accuracy of modern CT and radiology interpretation, but I sometimes worry that this can also be reflective of diagnostic fixation, especially with “objective” tests, as well as nihilism about the utility of clinical diagnosis.
That said, non-selective CT has many potential benefits for many critically ill and unexaminable populations with diagnostic uncertainty, as demonstrated here, which must be balanced against risks of intrahospital transport and of resource utilization as we do not yet have clear data that patients benefit from the practice despite increased diagnostic yield.
Kelley R.H. Branch, M.O. Gatewood, P.J. Kudenchuk et al., Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study, Resuscitation, https://doi.org/10.1016/j. resuscitation.2023.109785
Category: Critical Care
Keywords: etomidate, intubation, critically ill, mortality (PubMed Search)
Posted: 5/2/2023 by Quincy Tran, MD, PhD
(Updated: 12/13/2024)
Click here to contact Quincy Tran, MD, PhD
As emergency physicians, we use etomidate to intubate patients most of the time, although there was controversy whether etomidate would suppress critically ill patients’ cortisol production. Whether etomidate was associated with mortality was controversial. A recent meta-analysis investigated the issue again.
Methods: meta-analysis of randomized trials using etomidate for intubation versus other agents. Outcome = mortality as defined by the authors. Mortality was defined from 24 hours to 30 days by study’s authors.
Results: 11 RCTs, including one new RCT in 2022
319 (1359, 23%) patients received etomidate died vs. 267 (1345, 20%) receiving other agents died; Risk Ratio 1.16, 95% CI 1.01-1.33, P = 0.03.
Etomidate was also associated with higher risk ratio for adrenal insufficiency, when compared with other control agents (147/695, 21% vs. 69/686, 10%, RR 2.01, 95% CI (1.59-2.56), P < 0.01.
Etomidate was also associated with higher risk ratio of mortality, when compared with ketamine, for mortality, as defined by each study’s author (273/1201, 23% vs. 226/1198. 19%. RR 1.18, 95% CI 1.02-1.37, P = 0.03).
Discussion:
The authors used fixed effects model, as they claimed that their meta-analysis had low heterogeneity (I2 =0%). However, fixed effects model should only be used when there is no difference among patient population. In this study, the outcome definitions were different, the patient populations were different (trauma, pre-hospital, ED, ICU). Therefore, random effects model should be used. Random effects models tend to yield larger 95% CI, thus, more likely yield non-statistically significant results.
The authors claimed a Number Needed To Treat (NNT) for etomidate of 31, so basically many ED patients would die, while most of patients being intubated by Anesthesiology, regarding settings, would not die, as anesthesiologists mostly use propofol.
Category: Critical Care
Posted: 4/25/2023 by Caleb Chan, MD
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Hypoxemic respiratory failure is a common presentation of critically ill patients. If the degree of hypoxemia is severe and disproportionate to the patient's radiographic findings and not responding to increasing FiO2, a right-to-left shunt should be considered. To evaluate for an anatomic shunt, an intravenous agitated saline contrast (ASC) echocardiographic evaluation can be conducted by an ED provider at the bedside.
Technique:
Interpretation:
Millington SJ, Mayo-Malasky H, Koenig S. Agitated saline contrast injection in patients with severe hypoxemia. J Intensive Care Med. 2023;38(5):479-486.
Category: Critical Care
Posted: 4/20/2023 by William Teeter, MD
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CCM recently published Stanford's experience with their Emergency Critical Care Program (ECCP), an ED based intensivist consultation/management model staffed by EM/CC during peak hours with the "goals of improving care of the critically ill in the ED, offloading the ED team, and optimizing ICU bed utilization without the need for a dedicated physical space."
Conclusions:
This is the third group to document decrease in overall mortality utilizing an early or dedicated critical care consult model. EC3 and the CCRU here at UMMC have also both shown improvements in patient transfer and resource utilization metrics. As with all studies in this space, there are many limitations to these studies in both design and generalizability, even amongst each other. However, the literature is replete with data that increased boarding time in the ED for critically ill patients is associated with worse outcomes and these studies are now a body of complementary and growing evidence that teams such as this can perhaps bridge that gap. Hopefully come to an ED near you soon...
Study Details:
Objectives: To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED).
Design: Single-center, retrospective cohort study from a tertiary academic medical center using ED-visit data between 2015 and 2019 for adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival.
Pre and post intervention (2017) cohort analysis of patients when facility implemented dedicated bedside critical care by an ED-based intensivist "following initial resuscitation by the ED team". A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015–2017) and the intervention period (2017–2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours).
Primary outcomes: In-hospital mortality and proportion of patients downgraded to non-ICU status while in the ED within 6 hours
Results:
Mitarai, Tsuyoshi; Gordon, Alexandra June; Nudelman, Matthew J et al. Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department. Critical Care Medicine ():10.1097/CCM.0000000000005835.
Gunnerson KJ, Bassin BS, Havey RA, et al.: Association of an emergency department–based intensive care unit with survival and inpatient intensive care unit admissions. JAMA Netw Open 2019; 2:e197584
Tran QK, O’Connor J, Vesselinov R, et al.: The critical care resuscitation unit transfers more patients from emergency departments faster and is associated with improved outcomes. J Emerg Med 2020; 58:280–289
Category: Critical Care
Keywords: Glucagon, Beta Blocker, Calcium Channel Blocker, Overdose (PubMed Search)
Posted: 4/11/2023 by Zach Rogers, MD
Click here to contact Zach Rogers, MD
Glucagon therapy in beta blocker and calcium channel blocker overdose is controversial and no high level evidence is available to support or refute its use in overdose treatment.
Glucagon has the ability to bypass adrenergic blockade from beta and calcium channel blocking agents and theoretically increase myocardial contraction, increase heart rate, and increase AV conduction through cyclic AMP production.
However, practically, the use of glucagon is limited due to high risk of vomiting and subsequent risk of aspiration with administration as well as the high cost and limited hospital stock available for continued use.
Given these limitations, glucagon therapy is no longer recommended for calcium channel blocker overdose in the 2017 Critical Care Medicine Expert Consensus*. The use in beta blocker therapy is still recommended. However, caution must be taken to ensure that more advanced (and possibly more efficacious) therapies such as vasopressors and high dose insulin are administered without delay.
The dose of glucagon therapy for this indication is 3-10 mg IV. You can repeat this dose a second time if no response is seen with the first dose. If clinical response is seen with bolus dosing, transition to continuous infusion at the dose of clinical response (eg. if two 5 mg boluses produced the desired response; start 10 mg/hr infusion). Antiemetic administration prior to initial bolus dose is highly recommended to avoid vomiting.
Peterson CD, Leeder JS, Sterner S. Glucagon therapy for beta-blocker overdose. Drug Intell Clin Pharm. 1984 May;18(5):394-8. doi: 10.1177/106002808401800507. PMID: 6144498.
*St-Onge M, Anseeuw K, Cantrell FL, Gilchrist IC, Hantson P, Bailey B, Lavergne V, Gosselin S, Kerns W 2nd, Laliberté M, Lavonas EJ, Juurlink DN, Muscedere J, Yang CC, Sinuff T, Rieder M, Mégarbane B. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med. 2017 Mar;45(3):e306-e315. doi: 10.1097/CCM.0000000000002087. PMID: 27749343; PMCID: PMC5312725.
Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2023 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448097/
Category: Critical Care
Keywords: pneumonia, acute hypoxic respiratory failure, steroids (PubMed Search)
Posted: 4/5/2023 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
Background: The use of steroids in pneumonia has long been controversial with conflicting data, and the recent ESCAPe randomized controlled trial by Meduri et al. showing no mortality benefit with their use, but likely underpowered due to recruitment issues. The recently published CAPE COD study by Dequin et al. may change the game.
Design: Double-blind, placebo-controlled, multicenter, RCT
Intervention: Early hydrocortisone within 24 hrs, 200mg/day x 4-8 days depending on improvement, then preset taper
Primary outcome: Death at 28 days
Secondary outcomes:
Bottom Line: The addition of hydrocortisone to antibiotics in severe CAP may decrease need for intubation and development of shock, and in this well-done study, decreased 28 and 90-day mortality.
Meduri GU, Shih MC, Bridges L, et al; ESCAPe Study Group. Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia. Intensive Care Med. 2022 Aug;48(8):1009-1023. doi: 10.1007/s00134-022-06684-3. Epub 2022 May 13. PMID: 35723686.
doi: 10.1056/NEJMoa2215145. Epub ahead of print. PMID: 36942789.
Category: Critical Care
Keywords: Pancreatitis, IV Fluids, Hydration (PubMed Search)
Posted: 3/28/2023 by Mark Sutherland, MD
(Updated: 12/13/2024)
Click here to contact Mark Sutherland, MD
The classic teaching is that patients with acute pancreatitis should be aggressively hydrated with IV fluids. But as we increasingly question heavy handed fluid strategies in other areas such as sepsis, should we look at pancreatitis management too?
Li et al did a systematic review of the literature on aggressive fluid resuscitation (the exact protocol/definition varied per study, but we're mostly talking 15-20 mL/kg boluses followed by 3-5 mL/kg/hr infusion) vs less aggressive fluid resuscitation (mostly 10 mL/kg boluses followed by 1.5 mL/kg/hr infusion). They found that aggressive resuscitation worsened mortality in severe pancreatitis (RR 2.45) and trended towards worse mortality in non-severe pancreatitis (RR 2.26, but CI crossed 1). Aggressive was associated with more complications in both severe and non-severe pancreatitis pancreatitis.
Multiple society guidelines still call for aggressive IVF resuscitation for acute pancreatitis, but probably need to be updated given mounting evidence that this is harmful. More recent guidelines suggest "goal-directed therapy", but no one is completely sure what that means.
Bottom Line: In acute pancreatitis, a more conservative empiric IVF resuscitation is probably better than the clasically taught aggressive approach. Whether even less fluids would be better or worse is not known, but for now it's probably best to stick to a 10 mL/kg bolus and 1-2 mL/kg/hr infusion when ordering fluids for these patients unless you have another indication.
Li, XW., Wang, CH., Dai, JW. Comparison of clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis: a systematic review and meta-analysis. Crit Care 27, 122 (2023). https://doi.org/10.1186/s13054-023-04401-0
de-Madaria E, Buxbaum JL, Maisonneuve P, García García de Paredes A, Zapater P, Guilabert L, Vaillo-Rocamora A, Rodríguez-Gandía MÁ, Donate-Ortega J, Lozada-Hernández EE, Collazo Moreno AJR, Lira-Aguilar A, Llovet LP, Mehta R, Tandel R, Navarro P, Sánchez-Pardo AM, Sánchez-Marin C, Cobreros M, Fernández-Cabrera I, Casals-Seoane F, Casas Deza D, Lauret-Braña E, Martí-Marqués E, Camacho-Montaño LM, Ubieto V, Ganuza M, Bolado F; ERICA Consortium. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022 Sep 15;387(11):989-1000. doi: 10.1056/NEJMoa2202884. PMID: 36103415.
Category: Critical Care
Posted: 3/21/2023 by Mike Winters, MBA, MD
(Updated: 12/13/2024)
Click here to contact Mike Winters, MBA, MD
Things to Consider for Persistent or Worsening Septic Shock
Teja B, et al. How we escalate vasopressor and corticosteroid therapy in patients with septic shock. Chest. 2023; 163:567-74.
Category: Critical Care
Keywords: ECG; status epilepticus (PubMed Search)
Posted: 3/7/2023 by Quincy Tran, MD, PhD
(Updated: 12/13/2024)
Click here to contact Quincy Tran, MD, PhD
Title: Electrocardiographic Changes at the Early Stage of Status Epilepticus: First Insights From the ICTAL Registry.
As the song goes: “the thigh bone is connected to the hip bone, the hip bone is connected to the back bone.” It turns out that the brain electrical activities are also connected to the heart conduction activities.
In a multi-center (23 French ICUs) retrospective analysis of 155 critically ill patients with status epilepticus, ECGs were done within 24 hours of onset of status epilepticus, and were independently reviewed by cardiologists showed abnormalities in 145 (93.5%) of patients.
Below is a list of events that occurred more than 10% of events.
Abnormal rate (<60 or > 100 beats/min 64 (44%)
Negative T-waves 61 (42%)
Flattened T-waves 18 (12%)
ST elevation 24 (16.6%)
ST depression 26 (17.9%)
Left axis deviation 22 (15.9%)
Discussion:
Major ECG abnormalities were not associated with 90-day functional outcome in multivariable logistic regression.
The brain-heart axis could be affected by antiseizure medication. For example, phenytoin, lacosamide are sodium channel blockers while benzodiazepines, propofol, barbiturates with their GABAnergic effects will also display cardiac side effects. This current study was not able to tease out whether the cardiac effects were from medication. Therefore, further studies are needed to figure out the cardiac effect for patients with status epilepticus.
Chinardet P, Gilles F, Cochet H, Chelly J, Quenot JP, Jacq G, Soulier P, Lesieur O, Beuret P, Holleville M, Bruel C, Bailly P, Sauneuf B, Sejourne C, Galbois A, Fontaine C, Perier F, Pichon N, Arrayago M, Mongardon N, Schnell D, Lascarrou JB, Convers R, Legriel S. Electrocardiographic Changes at the Early Stage of Status Epilepticus: First Insights From the ICTAL Registry. Crit Care Med. 2023 Mar 1;51(3):388-400. doi: 10.1097/CCM.0000000000005768. Epub 2022 Dec 19. PMID: 36533915.
Category: Critical Care
Posted: 3/1/2023 by Caleb Chan, MD
Click here to contact Caleb Chan, MD
Background:
There have been a few studies that suggested that there may be some neuroprotective effect with a higher MAP goal in post-arrest patients. However, these studies were small and/or observational.
Intervention:
-The BOX trial was a double-blind, dual-center (Denmark), randomized trial
-Study population: >18 yo, OHCA of presumed cardiac cause
-Pts randomized to higher (77 mmHg) vs. lower (63 mmHg) MAP goal
-double-blinded by attaching a module that reported a BP that was 10% higher or lower than the pt’s actual BP
-Notable exclusion criteria:
-unwitnessed asystole or suspected intracranial bleeding/stroke
Results/Primary outcome:
-No sig difference in composite of death + Cerebral Performance Category of 3 or 4 (3= severe disability, 4= coma) within 90 days
-133 patients (34%) in the high-target group vs 127 patients (32%) in the low-target group (hazard ratio, 1.08;95%CI, 0.84 to 1.37; P=0.56)
Caveats/Takeaways:
-Mean difference in BP was 10.7 mmHg (95[CI], 10.0 to 11.4) which is still relatively clinically significant, but was lower than their goal difference of 14 mmHg
-They used IVF to target a CVP of 10 mmHg prior to initiation of norepi and used dopamine "if necessary"
-Consider generalizability given study population was patients with presumed cardiac cause of arrest
-Keeping a lower MAP goal of >65 mmHg is reasonable in post-arrest patients
Kjaergaard J, Møller JE, Schmidt H, et al. Blood-pressure targets in comatose survivors of cardiac arrest. N Engl J Med. 2022;387(16):1456-1466.
Category: Critical Care
Posted: 2/21/2023 by William Teeter, MD
(Updated: 2/22/2023)
Click here to contact William Teeter, MD
Given my previous post on APRV (11/6/2022) and while I take issue with many of the author's statements, I wanted to share a very well referenced article with an excellent discussion on the current gaps in the knowledge around APRV and its use.
One statement I do agree with is the need for a well-designed and adequately powered trial of this mode in an admittedly difficult-to-study population.
Fortunately, this article has an invited rebuttal pending from Dr. Habashi which I am sure will appear in the Educational Pearls in short order.
Good luck to the residents on the ITE!
Parhar, Ken Kuljit S. MD, MSc1,2,3; Doig, Christopher MD, MSc1,2,4. Caution—Do Not Attempt This at Home. Airway Pressure Release Ventilation Should Not Routinely Be Used in Patients With or at Risk of Acute Respiratory Distress Syndrome Outside of a Clinical Trial. Critical Care Medicine ():10.1097/CCM.0000000000005776, January 20, 2023. | DOI: 10.1097/CCM.0000000000005776
Article at https://pubmed.ncbi.nlm.nih.gov/36661571/
Category: Critical Care
Keywords: high dose, nitroglycerine, SCAPE, Sympathetic Crashing Acute Pulmonary Edema, flash pulmonary edema (PubMed Search)
Posted: 2/14/2023 by Zach Rogers, MD
Click here to contact Zach Rogers, MD
Sympathetic Crashing Acute Pulmonary Edema (SCAPE) (also known as flash pulmonary edema) is an extreme form of hypertensive acute heart failure where a surge of high blood pressure from catecholamine surge and sudden vascular redistribution causes sudden onset decompensated heart failure hallmarked by rapid pulmonary edema and symptoms of hypoxia and dyspnea.
This is treated by systolic blood pressure control and venous vasodilation with IV nitroglycerine, bilevel positive airway pressure (BPAP), and diuretics if needed. A common error in treatment is administration of the traditional IV nitroglycerine infusion dosing protocol in which the nitroglycerine infusion is started at 5 mcg/min and slowly increased by 5 mcg/min increments until the clinical response is seen. However, in this syndrome, rapid blood pressure control and correction of vascular redistribution is critically important to reverse the central factor for patient decompensation. Lack of blood pressure control places the patient at risk of further cardiac decompensation or respiratory failure ultimately requiring intubation.
Increasing literature has been published on the concept of high dose or push dose IV nitroglycerine for the treatment of this syndrome. Many of these studies show decreased rates of intubation, decreased ICU admissions, and shorter hospital length of stays with high dose or push dose nitroglycerine, while also demonstrating low risk of hypotension.
The actual dose of the high-dose nitroglycerine administered in these trials is variable, with some trials administering nitroglycerine 1-2 mg IV pushes every 3-5 minutes, and other trials using a nitroglycerine infusion at a much higher starting rate (between 200-400 mcg/min) with rapid down-titration as blood pressure is controlled.
Collins, S., Martindale, J. Optimizing Hypertensive Acute Heart Failure Management with Afterload Reduction. Curr Hypertens Rep 20, 9 (2018). https://doi.org/10.1007/s11906-018-0809-7
Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017 Jan;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. Epub 2016 Oct 18. PMID: 27825693.
Mathew R, Kumar A, Sahu A, Wali S, Aggarwal P. High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study. J Emerg Med. 2021 Sep;61(3):271-277. doi: 10.1016/j.jemermed.2021.05.011. Epub 2021 Jun 30. PMID: 34215472.
Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017 Jan;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. Epub 2016 Oct 18. PMID: 27825693.
Paone S, Clarkson L, Sin B, Punnapuzha S. Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10. PMID: 29776826.
Category: Critical Care
Keywords: sodium bicarbonate, bicarb, OHCA, cardiac arrest, CPR, resuscitation (PubMed Search)
Posted: 2/8/2023 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
Background: The use of sodium bicarbonate in the treatment of out-of-hospital cardiac arrest (OHCA) has been longstanding despite conflicting data regarding its benefit, outside of clear indications such as toxic ingestion or hyperkalemic arrest.
Study: A recent retrospective cross-sectional study by Niederberger et al.1 examined prehospital EHR data for ALS units responding to nonpregnant adults with nontraumatic OHCA, noting use of prehospital bicarb and the outcomes of 1) ROSC in the prehospital encounter and 2) survival to hospital discharge. They created propensity-matched pairs of bicarb and control patients, with a priori confounders: age, sex, race, witnessed status, bystander CPR, prearrival instructions, any defibrillation attempt, use of CPR feedback devices, any attempted ventilation, length of resuscitation, number of epi doses.
There were 23,567 arrests (67.4% asystole, 16.6% PEA, 15.1% VT/VF), 28.3% overall received sodium bicarb.
Results:
In the propensity-matched sample, survival was higher in bicarb group (5.3% vs. 4.3%; p=0.019).
There were no differences in rate of ROSC overall, but looking at the different rhythms, ROSC was higher in the bicarb group with asystole as the presenting rhythm (bicarb 10.6 vs 8.8%; p=0.013) but not PEA or VT/VF.
*There is no indication by the authors as to the dosing of bicarb most associated with survival to hospital discharge (or ROSC in asystole) in the study, however a previous study has indicated that a single amp of bicarb is unlikely to significantly improve severe metabolic acidosis (pH <7.1),2 so the general recommendation of at least 1-2mEq/kg should be employed.
Bottom Line: The use of sodium bicarb may increase survival in OHCA with initial PEA/asystole. The recommended initial dose is 1-2mEq/kg; giving at least 2 amps of bicarb (rather than the standard 1) should achieve this in many patients.
Between 1/2019 and 12/2020, there were 23,567 arrests that met inclusion criteria.
Overall EMS ROSC: 18.4%
Overall survival to hospital discharge: 7.6%
In the propensity-matched sample – survival was higher in bicarb group (5.3% vs. 4.3%; p=0.019).
There were no differences in rate of ROSC overall, but looking at the different rhythms, ROSC was higher in the bicarb group with asystole as the presenting rhythm (bicarb 10.6 vs 8.8%; p=0.013) but not PEA or VT/VF.
Overall, bicarb use was associated with improved survival (OR 1.25 (1.04-1.51) / aOR 1.3 (1.06-1.59) but not increased ROSC.
Category: Critical Care
Keywords: Vasopressors, Vasoactive agents, Norepinephrine, Dobutamine, Shock (PubMed Search)
Posted: 1/31/2023 by Mark Sutherland, MD
(Updated: 12/13/2024)
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When managing a hypotensive patient who may have some element of cardiogenic shock, it has long been debated whether it is better to start an inodilator like dobutamine, and use a true vasopressor like norepinephrine to offset the vasodilation, or start an inopressor like epinephrine. Currently, this is largely a practice pattern issue, with different providers and specialties tending to make different choices (in my anecdotal experience, medical intensivists tend to do norepi+dobutamine, whereas cardiac surgeons and intensivists tend to use epi).
Banothu et al recently studied this question in children with "cold" septic shock (they do not specify how this was defined) and found quicker time to resolution of shock with norepi+dobutamine vs epinephrine. It should be noted that this was a secondary outcome, was a small study, was in children (who I'm told are not just little adults), and no difference in mortality or patient oriented outcomes was found. However, this is a good opportunity to review what is known on this topic:
-A small RCT in Lancet 2007 by Annane et al found no difference
-A very small RCT in Acta Pharmacologica Sinica 2002 by Zhou et al suggested norepi-dobutamine has favorable effects on gastric mucosa and tissue oxygenation relative to epi or dopamine
-A small RCT in Intensive Care Medicine 1997 similarly suggested that oxygenation in the splanchnic circulation may be better with norepi+dobut than epi.
Take Home: There is very limited evidence in either direction when choosing between an inodilator + vasopressor (e.g. norepi + dobutamine) vs single inopressor (e.g. epi) strategy for a hypotensive patient in which inotropy is desired. There is some weak evidence that norepi + dobutamine may be better for maintaing gut oxygenation and may resolve shock faster. Personally, I would weakly recommend norepi + dobutamine over epinephrine, but continuing to follow provider preference and go with the agent(s) you're most comfortable with is also very reasonable. If using the inodilator/vasopressor combination, it is recommended to titrate the vasopressor (e.g. norepi) to MAP and inodilator (e.g. dobutamine) to a measure of cardiac function such as CO/CI.
Banothu KK, Sankar J, Kumar UV, Gupta P, Pathak M, Jat KR, Kabra SK, Lodha R. A Randomized Controlled Trial of Norepinephrine Plus Dobutamine Versus Epinephrine As First-Line Vasoactive Agents in Children With Fluid Refractory Cold Septic Shock. Crit Care Explor. 2022 Dec 28;5(1):e0815. doi: 10.1097/CCE.0000000000000815. PMID: 36600781; PMCID: PMC9799172.
Annane D, Vignon P, Renault A, Bollaert PE, Charpentier C, Martin C, Troché G, Ricard JD, Nitenberg G, Papazian L, Azoulay E, Bellissant E; CATS Study Group. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet. 2007 Aug 25;370(9588):676-84. doi: 10.1016/S0140-6736(07)61344-0. Erratum in: Lancet. 2007 Sep 22;370(9592):1034. PMID: 17720019.
Zhou SX, Qiu HB, Huang YZ, Yang Y, Zheng RQ. Effects of norepinephrine, epinephrine, and norepinephrine-dobutamine on systemic and gastric mucosal oxygenation in septic shock. Acta Pharmacol Sin. 2002 Jul;23(7):654-8. PMID: 12100762.
Levy B, Bollaert PE, Charpentier C, Nace L, Audibert G, Bauer P, Nabet P, Larcan A. Comparison of norepinephrine and dobutamine to epinephrine for hemodynamics, lactate metabolism, and gastric tonometric variables in septic shock: a prospective, randomized study. Intensive Care Med. 1997 Mar;23(3):282-7. doi: 10.1007/s001340050329. PMID: 9083230.
Category: Critical Care
Posted: 1/24/2023 by Mike Winters, MBA, MD
(Updated: 12/13/2024)
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An Uncommon Cause of Shock
Narayan S, Petersen TL. Uncommon etiologies of shock. Crit Care Clin. 2022; 38:429-441.
Category: Critical Care
Keywords: thoracic ultrasound, critically ill, ICU, clinical management (PubMed Search)
Posted: 1/10/2023 by Quincy Tran, MD, PhD
(Updated: 12/13/2024)
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Title:
The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study
Settings: 4 hospitals (3 in Netherlands and 1 in Italy)
Participants: All adults patients who were admitted to the ICU but patients who died within 8 hours of thoracic ultrasound were excluded.
Thoracic ultrasound procedure: cardiac, lung, diaphragm, inferior vena cava. The main indicators were Respiratory, Cardiac and Volume status.
Study Results:
725 thoracic ultrasound examinations and 534 patients. Clinical management occurred in 247 (88.5%) patients within 8 hours of ultrasound.
Thoracic ultrasound was performed by 111 operators, ranging from inexperienced to very experienced.
Common findings from thoracic ultrasound among these ICU patients.
Discussion:
Conclusion: Thoracic ultrasound provided a significant change in management of critically ill patients.
Heldeweg MLA, Lopez Matta JE, Pisani L, Slot S, Haaksma ME, Smit JM, Mousa A, Magnesa G, Massaro F, Touw HRW, Schouten V, Elzo Kraemer CV, van Westerloo DJ, Heunks LMA, Tuinman PR. The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study. Crit Care Med. 2022 Dec 23. doi: 10.1097/CCM.0000000000005760. Epub ahead of print. PMID: 36562620.
Category: Critical Care
Keywords: angioedema, stroke, CVA, t-PA, alteplase, thrombolysis (PubMed Search)
Posted: 12/20/2022 by Zach Rogers, MD
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Thrombolytic-induced angioedema is a known complication of alteplase or tenecteplase administration, occurring in 0.9-5.1% of patients who received thrombolytics due to ischemic stroke. Angioedema occurs due to activation of the kinin and complement pathway by plasminogen, leading to both bradykinin and histamine release.
Swelling most commonly occurs acutely while the t-PA is infusing, but can have a delayed presentation up to 24 hours post administration. It normally has an orolingual distribution, although in severe cases there can be laryngeal involvement as well. There is a 4-fold-increase occurrence in patients who take ACE inhibitor medications [1] with some studies noting a high prevalence in strokes involving the right insular brain region [2].
Once identified, the t-PA infusion should be immediately discontinued. As there may be histamine involvement in angioedema formation, patients are initially treated with steroids, H1, and H2 blockers with as needed epinephrine injections.
Given the orolingual predominance, airway obstruction must be ruled out and the patient closely monitored with emergent intubation performed if necessary.
As the kinin pathway (bradykinin) appears to play the largest role in angioedema formation, C1 esterase inhibitors and bradykinin inhibitors can be used in severe or refractory cases [3,4].
However, most cases are mild and resolve with t-PA discontinuation and the initial steroid and histamine blockade.
1. Lin SY, Tang SC, Tsai LK, Yeh SJ, Hsiao YJ, Chen YW, et al. Orolingual angioedema after alteplase therapy of acute ischaemic stroke: incidence and risk of prior angiotensin-converting enzyme inhibitor use.Eur J Neurol. 2014; 21:1285–1291. doi: 10.1111/ene.12472
2. Fröhlich K, Macha K, Gerner ST, Bobinger T, Schmidt M, Dörfler A, Hilz MJ, Schwab S, Seifert F, Kallmünzer B, Winder K. Angioedema in Stroke Patients With Thrombolysis. Stroke. 2019 Jul;50(7):1682-1687. doi: 10.1161/STROKEAHA.119.025260. Epub 2019 Jun 11. PMID: 31182002.
3. Pahs L, Droege C, Kneale H, Pancioli A. A Novel Approach to the Treatment of Orolingual Angioedema After Tissue Plasminogen Activator Administration. Ann Emerg Med. 2016 Sep;68(3):345-8. doi: 10.1016/j.annemergmed.2016.02.019. Epub 2016 May 10. PMID: 27174372.
4. Brown E, Campana C, Zimmerman J, Brooks S. Icatibant for the treatment of orolingual angioedema following the administration of tissue plasminogen activator. Am J Emerg Med. 2018; 36:1125.e1–1125.e2. doi: 10.1016/j.ajem.2018.03.018