UMEM Educational Pearls - By Mike Winters

Acute on Chronic Liver Failure

  • Patients with cirrhosis can comprise up to 5% of an ICU population.
  • Many of these patients will present to the ED, and be admitted to the ICU, for acute on chronic liver failure.
  • A few management pearls for these patients include:
    • Consider albumin in patients with hepatorenal syndrome, large-volume paracentesis (> 5 L), and SBP
    • Norepinephrine is the initial vasopressor of choice; target a MAP ≥ 60 mm Hg
    • The INR does not accurately reflect bleeding in these patients.  Use platelet count and fibrinogen.
    • There is no need to correct coagulation abnormalities prior to routine procedures (e.g., central venous catheterization)

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Peri-Intubation Cardiac Arrest

  • Endotracheal intubation is a high-risk procedure, especially in the critically ill patient.
  • The incidence of peri-intubation cardiac arrest ranges from 2% to 5%, and is associated with significant increases in morbidity and mortality.
  • Authors of a recent retrospective analysis across 64 French ICUs sought to determine risk factors for cardiac arrest during ICU intubation.
  • Among 1,847 intubations, the main predictors of cardiac arrest during intubation were:
    • Pre-intubation arterial hypotension (SBP < 90 mm Hg) (OR 3.4)
    • Pre-intubation hypoxemia (OR 3.99)
    • Absence of preoxygenation (OR 3.58)
    • Obesity (OR 2)
    • Age > 75 years of age (OR 2.25)
  • Take Home Point
    • Pay close attention to these risk factors and "resuscitate before you intubate".

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Hyperoxia and the Post-Arrest Patient

  • Current post-arrest guideilnes recommend titrating supplemental O2 to avoid hypoxia and limit exposure to hyperoxia.
  • Importantly, these recommendations are based primarily on retrospective studies that have used ABG values within the first 24 hours following ROSC.
  • The latest study to evaluate the impact of hyperoxia following cardiac arrest was just published in Circulation
  • This study is a prospective, cohort study that evaluated the association between early hyperoxia and poor neurologic outcome in adults following cardiac arrest. (ABGs were obtained at 1 hour and 6 hours following ROSC)
  • Of 280 patients, 38% were exposed to early hyperoxia (defined as a PaO2 > 300 mm Hg)
  • Take Home Points
    • Early hyperoxia was found to be an independent predictor of poor neurologic outcome at hospital discharge.
    • One hour longer duration of hyperoxia was associated with a 3% increase in the risk of poor neurologic outcome
    • SaO2 could not reliably exclude the presence of hyperoxia.

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Category: Critical Care

Title: Septic Cardiomyopathy

Posted: 1/9/2018 by Mike Winters, MD (Updated: 8/13/2022)
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Septic Cardiomyopathy

  • Cardiac dysfunction is common in patients with sepsis.
  • Though mulitiple definitions exist, sepsis cardiomyopathy (SCM) is generally defined as an "acute syndrome of cardiac dysfunction that is unrelated to ischemia in patients with sepsis".
  • Depending on the study, the incidence of SCM ranges anwywhere from 7% to 70%.
  • Risk factors for SCM include:
    • Male
    • Younger age
    • High lactate at admission
    • History of heart failure
  • The best approach to treating patients with SCM is to maximize your treatment of sepsis.
  • Dobutamine is no longer routinely recommended for SCM based solely on measurements of ScvO2.

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Sedating The Critically Ill Patient

  • Sedating critically ill ED patients can be challenging.
  • Excessive sedation is associated with a prolonged duration of mechanical ventilation, ICU LOS, and may increase mortality.
  • Important pearls to consider when managing these patients include:
    • Prioritize pain management first - may reduce the need for sedative medications
    • When possible, target a calm and interactive patient shortly after intubation - consider adding a atypical antipyschotic with propofol or dexmedetomodine
    • Use a validated tool (i.e., RASS) to dose opioids and sedative medications
    • Avoid continuous infusions of benzodiazepines

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Mechanical Ventilation in Shock

  • Emergency physicians and intensivists routinely resuscitate patients in shock.
  • For patients who manifest signs of persistent shock (i.e., rising lactate), consider intubation and mechanical ventilation, even in the absence of acute respiratory failure.
  • The respiratory muscles are avid consumers of oxygen.  In fact, up to 50% of available O2 can be used by the respiratory muscles to perform the work of breathing.
  • Initiation of mechanical ventilation can reduce oxygen consumption and allow oxygen to be shunted to other vital organs.

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Category: Critical Care

Title: Improving CPR Performance

Posted: 10/17/2017 by Mike Winters, MD (Updated: 8/13/2022)
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Improving CPR Performance

  • High-quality CPR is the cornerstone of successfull resuscitation from cardiac arrest.
  • In fact, high-quality CPR is considered the most important intervention for achieving ROSC and good neurologic recovery.
  • Pearls for optimizing CPR performance include:
    • Use a team-focused approach
    • Avoid leaning and ensure complete recoil of the chest
    • Target a chest compression fraction of at least 60%
    • Use POCUS, but pay attention to the duration of hands-off time
    • Target ETCO2 of > 20 mm Hg

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Post-Arrest Tidal Volume Setting

  • Most patients with ROSC from out-of-hospital cardiac arrest undergo endotracheal intubation and mechanical ventilation.
  • Optimal management of mechanical ventilation for the post-arrest patient is currently not well defined.
  • A recent retrospective cohort study sought to determine if a lower tidal volume (Vt) was associated with improved neurocognitive outcome at hospital discharge.
  • Of 256 patients included in the study, investigators found:
    • 38% were ventilated with Vt > 8 ml/kg predicted body weight
    • Lower Vt was significantly associated with favorable neurocognitive outcome, decreased duration of mechanical ventilation, and decreased ICU length of stay
  • Take Home Pearl: Pay attention to Vt in the post-arrest patient.

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Hyponatremic Encephalopathy

  • Hyponatremic encephalopathy is a true emergency and due to hypoosmolar-induced cerebral edema.
  • In contrast to the asymptomatic patient with hyponatremia, treatment of hyponatremic encephalopathy is determined by symptoms and not the duration of hyponatremia.
  • Clinical manifestations include nausea, vomiting, headache, confusion, seizures, respiratory failure, and coma.
  • Hypertonic saliine is the treatment of choice
    • Administer 2 ml/kg 3% hypertonic saline (100 ml in many cases)
    • This will typically raise serum sodium 2 mEq/L
    • In most cases, a 4-6 mEq/L rise will reverse neurologic symptoms

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Improving Resuscitation Performance

  • Resuscitating the critically ill patient can often be quite stressful.
  • Stress has been shown to decrease the quality and effectiveness of decisions, decrease the amount of information a person can process, and lead to short-term memory deficits.
  • Recently, there has been emphasis on the use of performance-enhancing psychological skills (PEPS) to allow providers to think clearly, maintain situational awareness, recall important information, and perform skills efficiently.
  • A recent article highlights 4 key elements of an EM model for PEPS that can be used to improve performance in resuscitations.
    • Breathe - consider tactical breathing
    • Talk - positive instructional or motivational self-talk
    • See - visualize the steps of a procedure before actually performing it
    • Focus - use a trigger word as a prompt to shift attention to a prioritized task

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Category: Critical Care

Title: Ventilation During Cardiopulmonary Resuscitation

Keywords: CPR, ventilation, respiratory rate, PaCO2 (PubMed Search)

Posted: 6/27/2017 by Mike Winters, MD
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Ventilation During Cardiopulmonary Resuscitation  

  • Cardiopulmonary resuscitations are often highly stressful and chaotic situations.  As a result, it is no surprise that ventilation rates can be as high as 60 breaths per minute.  
  • Hyperventilation during cardiopulmonary resuscitation can increase intrathoracic pressure, impair venous return, decrease coronary perfusion pressure, and ultimately decrease survival.
  • It is imperative that the team leader pay close attention to ventilation and ensure that approximately 8 to 10 breaths per minute are delivered.
  • Once ROSC is achieved, the respiratory rate should be adjusted to maintain a PaCO2 between 40 and 45 mm Hg.  

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Antibiotics in Sepsis

  • Currently international guidelines for the management of sepsis and septic shock recommend antibiotic administration within 1 hour of recognition.
  • With the persistent problem of ED boarding, many patients with sepsis and septic shock remain in the ED long after the initial dose of broad-spectrum antibiotics.
  • A recent single center, retrospective cohort study demonstrated that 1 out of 3 patients with sepsis or septic shock experienced major delays in the time to the second dose of antibiotics.  In fact, over 70% of patients who were given an initial antibiotic with a 6-hr recommended dosing interval experienced major delays.
  • Inpatient boarding in the ED was found to be an independent risk factor for major delays.
  • Take Home Point: Don't forget to write for additional doses of antibiotics in your boarding patients with sepsis.

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Ventilator Settings for the Post-Arrest Patient

  • The majority of patients with ROSC from OHCA require intubation and mechanical ventilation.
  • Correctly managing the ventilator in the post-arrest patient is critical for improving outcomes.
  • As patients are at high risk for ARDS, use lung-protective ventilation with tidal volumes between 6 to 8 ml/kg of ideal body weight and PEEP of 5 to 8 cm H2O.
  • There is a U-shaped relationship between neurologic outcomes and both PaO2 and PaCO2.
    • Target normoxia (SpO2 94% to 96%) and avoid hyperoxia and hypoxia.
    • Target normocapnia (PaCO2 40 to 50 mm Hg) and avoid hypercapnia and hypocapnia.
  • Use an analgosedation approach with short-acting analgesics and sedatives, such as fentanyl and propofol.

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Category: Critical Care

Title: Ketamine is Not Without Risk

Posted: 3/28/2017 by Mike Winters, MD (Updated: 8/13/2022)
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DSI, Ketamine, and Apnea

  • In recent years, delayed sequence intubation (DSI) with ketamine has been used in select patients to maximize preoxygenation and dinitrogenation. 
  • Importantly, DSI is not well studied. In the only prospective trial of DSI, patients received approximately 1.4 mg/kg of ketamine.
  • Driver, et al. report the abrupt onset of apnea in a patient who received a much lower dose of ketamine (25 mg) for DSI.
  • Take Home Point: If DSI is a part of your preoxygenation armamentarium, apnea can occur even at low doses of ketamine.  Stand at the patient's bedside and be ready to immediately intubate the patient.

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Preoxygenation in Critically Ill Patients

  • Achieving adequate preoxygenation and denitrogenation prior to intubating critically ill patients can be challenging.
  • Critically ill patients have physiologic alterations (i.e., derangements in oxygen consumption, anemia, reduced cardiac output, air space disease) that can markedly reduce safe apnea time.
  • For patients with significant air space disease and shunt physiology, noninvasive ventilation (NIV) can decrease shunt fraction, increase functional residual capacity, improve PaO2, and lengthen safe apnea time.
  • Importantly, NIV should be used for at least 3 minutes to achieve improvements in alveolar recruitment.
  • It is also important to remove NIV just prior to larygnoscopy, as alveoli will begin to derecruit when NIV is removed.

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Category: Critical Care

Title: Sepsis Mimics

Posted: 2/14/2017 by Mike Winters, MD (Updated: 8/13/2022)
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Sepsis Mimics

  • Emergency physicians are well versed in the resuscitation of patients with sepsis and septic shock.
  • With the recent publication of the 2016 SSC Guidelines and the emphasis in meeting various quality measures, sepsis is routinely included in the differential diagnosis of critically ill patients.
  • Notwithstanding, it is important to consider other disease states that can present similarly to sepsis or septic shock.  Some of these include:
    • Anaphylaxis
    • Adrenal insufficiency
    • DKA
    • Thyroid storm
    • Toxic ingestion or withdrawal

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Epinephrine in Anaphylaxis

  • Delayed administration of epinephrine for patients witih anaphylaxis is associated with increased morbidity and mortality.
  • Providers are often hesitant to administered epinephrine to older patients with anaphylaxis for fear of precipitating an adverse cardiovascular event.
  • A recent retrospective study of almost 500 patients demonstrated that older patients were significantly less likely to receive epinephrine, despite meeting the definition for anaphylaxis.
  • Furthermore, cardiovascular complications occurred in just 9 patients, 6 of which received an excessive dose via the IV route.
  • Take Home Point: There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis.  Give the initial dose IM into the anterolateral thigh.

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PaCO2 and the Post-Arrest Patient

  • Alterations in PaCO2 are common during the post-arrest period and have been associated with worse patient centered outcomes.
  • Hypercarbia can dilate cerebral vessels, increase cerebral blood flow, and may increase intracranial pressure.
  • Conversely, hypocarbia can constrict cerebral vessels and may reduce cerebral blood flow.
  • Though the current evidence is primarily limited to observational trials, a recent meta-analysis found that "normocarbia" was associated with improved hospital survival and neurologic outcome. 
  • Take Home: Adjust mechanical ventilation to target normocarbia (PaCO2 or ETCO2) in the post-arrest patient.

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Mechanical Ventilation in the Obese Patient

  • Obesity can result in decreased lung volumes, decreased lung and chest wall compliance, and increased work of breathing.
  • Unfortunately, there is very little literature to guide the emergency physician on mechanical ventilation in obese patients.
  • A recent study of intubated ED patients by Goyal, et al found that over 1 in 5 patients were ventilated with potentially injurious tidal volumes.
  • Importantly, obesity increased the odds of inappropriate ventilator settings.
  • In the intubated obese patient, be sure to set tidal volume based on ideal body weight and consider starting with a higher PEEP setting (i.e., 10 to 15 cm H2O).

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Category: Critical Care

Title: Cardiac Arrest - What Matters?

Posted: 11/22/2016 by Mike Winters, MD (Updated: 8/13/2022)
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What Matters in Cardiac Arrest?

  • Approximately 500,000 adults suffer sudden cardiac arrest each year in the United States.
  • The most important components of cardiac arrest care that have been shown to improve outcomes are:
    1. High-quality CPR with little to no interruptions
    2. Defibrillation for ventricular arrhythmias
    3. Optimal post-arrest care
      • Target an SpO2 of 94-98%
      • Target an ETCO2 of 35-40 mm Hg (PaCO2 of 40-45 mm Hg)
      • Targeted temperature management
      • Early cardiac catheterization

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