UMEM Educational Pearls - By Kami Windsor

Category: Critical Care

Title: Sodium Bicarbonate in Severe Metabolic Acidosis

Keywords: acidosis, acidemia, sodium bicarbonate, shock (PubMed Search)

Posted: 9/11/2018 by Kami Windsor, MD
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The recently published BICAR-ICU study looked at the use of bicarb in critically ill patients with severe metabolic acidemia...

  • Multicenter, open-label, RCT, 26 French ICUs
  • Adult patients with pH < 7.2 not secondary to hypercapnia, serum bicarb < 20 not due to bicarb wasting process 
  • SOFA score > 4 or lactate > 2
  • No bicarb versus 4.2% sodium bicarb infusion titrated to pH >7.3
  • Primary outcome: Composite measure of 28-mortality and presence of any organ failure at 7 days post-randomization
  • Secondary outcomes: Need for/length of life support measures (renal-replacement, vasopressors, mechanical ventilation), SOFA score after enrollment, electrolyte effects, occurrence of ICU-acquired infections, and ICU length of stay
  • Major findings:
    • No difference in primary outcome overall
    • No difference in pressor-free days, days off RRT, dialysis dependence at ICU discharge, ICU LOS
    • Bicarb group had less need for RRT during ICU stay (35 vs 52%, p=0.0009)
    • In patients with AKI and AKIN score 2-3*, the bicarbonate group had a decrease in both 28-day mortality (46 vs 63%, p=0.0166) and presence of any organ failure at day 7 (66 vs 82%, p=0.0142)
  • Limitations:
    • Unblinded
    • A quarter of the control group actually received bicarb
    • No data regarding vent settings, ABGs to r/o ventilation effects on pH
    • 4.2% is not a standard concentration of bicarb used in the U.S.

Bottom Line

Consider administration of sodium bicarbonate for your critically ill ED patients with severe metabolic acidosis and AKI, especially if acidosis &/or renal function is not improved with usual initial measures (such as IVF, etc).

 

 

*Acute Kidney Injury Network Staging Criteria

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Category: Critical Care

Title: Epinephrine in OHCA

Keywords: Resuscitation, OHCA, prehospital medicine, cardiac arrest, epinephrine (PubMed Search)

Posted: 8/14/2018 by Kami Windsor, MD (Updated: 9/23/2020)
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Takeaways

The highly-awaited PARAMEDIC2 trial results are in:

  • Multicenter, double-blinded, randomized controlled trial of prehospital OHCA care
  • 1mg IV epinephrine vs saline placebo, every 3-5 minutes
  • 8014 OHCA patients over the age of 16 (excluded pregnant patients, anaphylactic and asthmatic cardiac arrests)
  • Primary outcome: 30 day survival
  • Secondary outcomes: 
    • Survival to hospital admission
    • ICU and hospital LOS
    • Survival to hospital discharge and at 3 months
    • Neurologic outcomes at hospital discharge and at 3 months, "favorable" if mRS≤3
  • Results: 
    • Higher 30 day survival in Epi group (3.2 vs 2.4%, unadj OR 1.39; 95% CI 1.06 to 1.82; P=0.02)
    • No difference in ICU or hospital LOS
    • No difference in favorable neurologic outcomes at discharge or 3 month
    • Worse neurologic outcomes in the epinephrine survivors (mRS 4 or 5 in 31% of epi group vs. 17.8% of placebo)

 

Interestingly, the authors also queried the public as to what mattered to them most: 

 

Bottom Line:

  • As has been demonstrated in previous studies, use of bolus-dose epinephrine results in increased rates of ROSC. 
  • This survival comes with the trade-off of worsened neurologic function, a condition not in a majority of patients' personal wishes.
  • Epinephrine "1mg every 3-5 minutes'" should no longer be the dogma of OHCA resuscitation.

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Category: Critical Care

Title: Noninvasive Ventilation in Do-Not-Intubate Patients

Keywords: noninvasive positive pressure ventilation, NIV, NIPPV, DNI, do-not-intubate, palliative care, end-of-life, respiratory distress (PubMed Search)

Posted: 7/17/2018 by Kami Windsor, MD
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When a do-not-intubate (DNI) hospice patient arrives in the ED with respiratory distress, consideration of non-invasive positive pressure ventilation (NIPPV) could invoke either a “What other option do I have?” or “Why torture the patient and prolong the dying process?” sentiment.

 

But what’s the data?

A recently-published meta-analysis1 found that in DNI patients receiving NIPPV, there was a 56% survival rate to hospital discharge and 32% survival to 1-year.

  • Higher survival was seen in patients with COPD and pulmonary edema as the cause of their respiratory failure, as opposed to pneumonia or malignancy.
  • In surviving patients, there was no decrease in quality of life at 3 months; quality of life was not assessed in the time before death in nonsurvivors.
  • In comfort-measures only (CMO) patients, patients receiving NIPPV had a mildly lower dyspnea score with less opiates required/administered.

 

Independent studies have demonstrated:

  • Better survival with NIPPV for DNI COPD and CHF patients2,3,4 who are awake and have a good cough.4
  • No decrease in health-related quality of life or post-ICU psychological burden (symptoms of PTSD, anxiety, or depression) in DNI survivors receiving NIPPV.3
  • 63% survival to hospital discharge & 49% survival to 90 days in DNI patients receiving NIVV, with no decrease in health-related quality of life in survivors. Survival was lower for CMO patients (14% and 0% at discharge and 90 days, respectively).5

 

Bottom Line:

  1. NIPPV can benefit DNI patients -- most identifiably those with COPD or cardiogenic pulmonary edema as the etiology for their respiratory distress.
  2. Mild benefits to dyspnea have been seen in CMO patients, without survival benefit. A trial of NIPPV therapy may be reasonable (especially in COPD or CHF) after frank discussion with the patient and his/her loved ones, with quick cessation if comfort is not achieved and/or more discomfort is caused.

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Although not specifically a part of current recommendations due to lack of data, the AHA has previously recommended shifting upward on the sternum during CPR in the pulseless pregnant patient in order to account for upward displacement of the heart by a gravid uterus. Should the same be done for our obese patients?

Lee et al. performed a retrospective study that reviewed chest CTs to determine the location on the sternum that corresponded to the optimal point of maximal left ventricular diameter (OPLV), in both obese and non-obese patients. 

They found that the OPLV was higher (more cranial) on the sternum for obese patients than for patients with normal weight, although 96% of obese patients' OPLV fell within 2cm of where the guidelines recommend standard hand placement should be, compared to a notable 52% in non-obese patients.

*as measured from the distal end of the sternum

 

Bottom Line: Radiographically, the location on the sternum that corresponds to optimal compression of the LV is more cranial in obese patients than in non-obese patients. It remains to be seen whether the recommendations for hand placement in CPR should be adjusted, but we may want to consider staying within 4cm of the bottom of the sternum in patients of normal weight. 

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Category: Critical Care

Title: 2018 Surviving Sepsis Update

Keywords: sepsis, septic shock, guidelines (PubMed Search)

Posted: 5/22/2018 by Kami Windsor, MD
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  • The Surviving Sepsis Campaign recently republished the 2018 update to their guidelines, namely, the recommendation that physicians initiate treatment measures using a "1-Hour Bundle" rather than the 3 and 6-hour bundles previously recommended:

  • Also included was the level of evidence for each bundle component. There was no additional evidence provided to support the within-one-hour recommendation. 

  • There has been no well-designed, randomized trial to demonstrate benefits to administration of the various bundle components at specific time points. There are observational studies that show benefits to early protocolized therapy, including a restrospective study by Seymour et al. that showed benefits to earlier administration of antibiotics (but notably, not IV fluid administration), primarily in patients with septic shock requiring pressors.2
  • There have been a variety of studies demonstrating harm with unecessary IV fluid administration,3-5 and inappropriate antibiotic use puts patients at risk for C.difficile colitis, drug reactions, and promotes drug-resistant organisms. Studies to date do not examine adverse events in patients initially treated for sepsis who do not end up being septic.

Take Home Points: 

  1. Early recognition of sepsis is crucial to initiating necessary therapies and improving outcomes.
  2. Patients with sepsis and septic shock benefit from early appropriate antibiotics, source control, and appropriate resuscitation.
  3. Empiric treatment of all-comers with possible sepsis with broad spectrum antibiotics and 30ml/kg of IV fluids, in order to meet a 1-hour deadline, has definite potential for harm. 

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Category: Critical Care

Title: Predicting Failure of Non-invasive Ventilation and High Flow Nasal Cannula

Keywords: acute hypoxic respiratory failure, intubation, noninvasive positive pressure ventilation, high flow nasal cannula, BiPAP, vapotherm (PubMed Search)

Posted: 4/25/2018 by Kami Windsor, MD
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ED physicians frequently utilize modailities such as noninvasive positive pressure ventilation (NIV) and high flow nasal cannula (HFNC) to support and potentially avoid intubation in patients presenting with acute hypoxic respiratory failure. Unfortunately, failure of these measures, resulting in "delayed" intubation, has been associated with increased mortality.1,2

A recent post-hoc analysis of data from a multicenter randomized controlled trial evaluated 310 patients with acute hypoxic respiratory failure managed with supplemental O2 by regular nasal cannula, HFNC, or NIV.3

The following factors were predictive of eventual intubation in the different groups: 

  • For nasal cannula patients, RR > 30 at 1 hour
  • For HFNC patients, tachycardia at 1 hour (No respiratory variables were found to predict intubation).
  • For NIV patients, tidal volume > 9ml/kg predicted body weight or PaO2:FiO2 ratio < 200 at 1 hour

Of note, 45% of the 310 patients eventually required intubation, and these patients in general had a higher initial respiratory rate and lower PaO2 at presentation, and were more likely to have bilateral infiltrates on CXR. 

Bottom Line: Reevaluate your patients frequently. If RR remains high, P:F ratio remains low, or patient respiratory effort/work of breathing is not alleviated by noninvasive measures, consider pulling the trigger on intubation earlier.

 

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Category: Critical Care

Title: Avoid Hyperoxia Post-Cardiac Arrest!

Keywords: cardiac arrest, OHCA, ROSC, targeted temperature management, oxygen, hyperoxia (PubMed Search)

Posted: 3/27/2018 by Kami Windsor, MD (Updated: 9/23/2020)
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Background:

Animal studies in post-ROSC management after cardiac arrest have repeatedly demonstrated poorer neurological outcomes with higher amounts of oxygen administration.Studies in humans have also demonstrated dose-dependent associations between hyperoxia and poorer neurologic outcomes, as well as in-hospital mortality.2,3

Recent Data

A retrospective analysis of prospectively-collected data in 187 OHCA patients undergoing postarrest care with targeted temperature management found worse neurologic outcomes in patients experiencing hyperoxia in the first 6 hours following ROSC.4

This association was dose-dependent, with worsening outcomes as with higher PaO2 levels >200.

  • Adjusted OR 1.659 [95% CI, 1.194–2.305] at 200 mmHg
  • Adjusted OR 3.969 [95% CI, 1.450–10.862] for 300 mmHg
  • Trend towards worsening at 150 mmHg that did not reach statistical significance

Bottom Line:

  • Our initial management of these patients in the ED is crucial
  • In post-cardiac arrest patients, titrate immediate FiO2 to SpO2 ≥ 94% and PaO2 75 to 150/200 mmHg to avoid hyperoxia and worsening neurologic and survival outcomes. 

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Category: Critical Care

Title: Empiric Antifungal Therapy in Septic Shock

Keywords: ICU, fungal infection, septic shock, antifungal therapy, empiric (PubMed Search)

Posted: 2/27/2018 by Kami Windsor, MD
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Takeaways

Which septic patients should receive empiric antifungal therapy?

Patients with fungemia only make up about 5% of patients presenting with septic shock, but invasive fungal infections are associated with increased hospital mortality (40-50%), prolonged ICU and hospital length of stay, and increased costs of care.1

The EMPIRICUS trial showed no mortality benefit to empiric antifungals for all, even patients with candidal colonization and recent exposure to antibiotics.2

Bottom Line

Therapy should always be tailored to the specific patient, but providers should strongly consider admininistering empiric echinocandin (micafungin, caspofungin) over fluconazole in patients with severe sepsis/septic shock and:

  • Immunosuppression (chronic steroids, neutropenia, organ transplant)
  • Prolonged central venous catheters
  • TPN
  • Yeast colonization
  • Severe pancreatitis
  • Recent abdominal surgeries or procedures (perforation repairs, resections, etc.) or concern for impaired gut integrity

*Especially consider addition of antifungal in patients who do not show improvements after initial management with IVF and broad spectrum antibiotics in the ED.*

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Category: Critical Care

Title: Is there a benefit to steroids in septic shock?

Keywords: sepsis, septic shock, glucocorticoids, steroids, hydrocortisone (PubMed Search)

Posted: 1/29/2018 by Kami Windsor, MD (Emailed: 1/30/2018)
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As hospital volumes increase and ED patient boarding becomes more commonplace, emergency physicians may find themselves managing critically ill patients beyond the initial resuscitation.

The benefit of glucocorticoids in critically ill patients with septic shock has remained a topic of controversy for decades due to conflicting studies, including the 2002 Annane trial and the 2008 CORTICUS trial, which had opposing results when it came to the mortality benefit of steroids.

The results of the eagerly-awaited ADRENAL trial, a multicenter randomized controlled trial investigating the benefit of steroids in septic shock, were released earlier this month:

  • 3658 patients from 69 different medical and surgical ICUs
  • Adults with septic shock requiring mechanical ventilation (including noninvasive) and vasopressors/inotropes for at least 4 hours
  • Continuous infusion hydrocortisone 200mg/day vs placebo for 7 days or until ICU discharge, if shorter
  • No mortality benefit at 90 days (primary outcome) or at 28 days (secondary outcome)
  • Other secondary outcomes:
    • Hydrocortisone group = Shorter ICU LOS, shorter duration of shock, shorter duration of initial mechanical ventilation, fewer # of patients receiving a blood transfusion
    • No difference in: mortality at 28 days, hospital LOS, recurrence of shock, total vent-free days, mean volume of blood transfused in patients receiving blood products, use of renal replacement therapy, development of new bacteremia/fungemia

 

Take Home Points:

1. Administration of standard daily dose hydrocortisone by infusion does not seem to affect mortality in septic shock.

2. Emergency providers should continue to consider stress-dose steroids in patients with shock and a high risk of adrenal insufficiency (e.g., chronic steroid therapy, genetic disorders, infectious adrenalitis, etc).  

 

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Category: Critical Care

Title: Peri-Intubation Cardiac Arrest

Keywords: endotracheal intubation, cardiac arrest, airway, respiratory failure (PubMed Search)

Posted: 1/2/2018 by Kami Windsor, MD (Updated: 1/4/2018)
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Although the data is limited, current published rates of in-hospital, non-operating room peri-intubation cardiac arrest (PICA) range from 2 to 6%.1,2,3

Several risk factors associated with PICA have been identified and include:

  • Preintubation hemodynamic instability (shock index ≥ 1 or systolic blood pressure < 90mmHg)1,2,3
  • Elevated Body Mass Index (and increased risk with every 10kg body weight)1
  • Use of succinylcholine as paralytic3
  • Intubation occurring within one hour of nursing shift change3

Other common findings:

  • Most PICA occurs within 10 minutes of rapid sequence induction (RSI)1,2
  • PEA is the initial recorded rhythm 80-100% of the time.1,2,3
  • Even if ROSC obtained, PICA is associated with higher rates of in-hospital mortality compared to patients requiring emergent intubation who do not experience cardiac arrest.1,2,3

 

Bottom Line:  Endotracheal intubation is one of the riskiest procedures we regularly perform as emergency physicians.

  • Resuscitate hypotensive patients prior to or concomitantly with RSI and/or have a vasopressor at the ready in patients with higher risk of cardiovascular collapse.
  • Consider use of vecuronium or rocuronium, rather than succinylcholine, in patients who require a paralytic for intubation but are at higher risk of hyperkalemia or have an unknown history. 

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Category: Critical Care

Title: IVF Resuscitation in Obese Septic Patients: Not one-weight-fits-all?

Keywords: sepsis, resuscitation, obesity, IV fluids, bolus (PubMed Search)

Posted: 12/5/2017 by Kami Windsor, MD
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Background:

We are all familiar with the Surviving Sepsis Campaign recommendation (& CMS core measure) for an initial 30ml/kg bolus of IV crystalloid within the first 3 hours for our patients with septic shock. There is minimal data, however, on how much IVF we should be giving our patients with BMIs ≥30.

 

A recent study in obese patients with septic shock retrospectively stratified the total fluids administered at 3 hours into 3 different weight categories, to categorize patients as having received 30mL per kg of ___ body weight, whether actual (ABW), adjusted (AjdBW), or ideal (IBW**).

AdjBW = (ABW – IBW) *40% + IBW

They found:

  • Most patients received fluids based on actual body weight, BUT
  • Patients at highest BMIs received ABW fluids less often
  • 30ml/kg dosing according to adjusted body weight was associated with improved mortality compared to IVF per actual or ideal body weight.

 

Bottom Line:

  • If the 30ml/kg IVF bolus seems clinically appropriate for your obese patient, consider administering according to Adjusted Body Weight first.
  • As always, reevaluate your septic shock patients frequently to determine if additional fluids are necessary, and go to vasopressors early if they are not fluid responsive.

 

**IBW calculated using Devine’s formula for men and women:

  • Males:  IBW = 50 + 2.3*(# inches over 5 feet)
  • Females: IBW = 45.5 + 2.3*(# inches over 5 feet)

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Category: Critical Care

Title: Unplanned Transfers to the ICU

Keywords: ICU, risk factors, upgrade, decompensation (PubMed Search)

Posted: 11/7/2017 by Kami Windsor, MD
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Should that patient be admitted to the floor? 

Several studies have evaluated factors associated with upgrade in admitted patients from the floor to an ICU within 24 or 48 hours. Elevated lactate, tachypnea, and "after-hours" admissions have been repeatedly identified as some of the risk factors for decompensation. 

Two recent studies tried again to identify predictors of eventual ICU requirement...

Best predictors of subsequent upgrade:

  • Hypercapnia*
  • Tachypnea (in sepsis patients)*
  • Hypoxemia (in pneumonia patients)
  • Nighttime admission
  • Initial lactate ≥ 4

The most common reasons for upgrade:

  1. Respiratory failure
  2. Hemodynamic instability

Effect on mortality

Despite a more stable initial presentation, mortality of patients who decompensated on the floor (25%) matched that of patients initially admitted to the ICU.

*One of the studies noted that although respiratory rate was demonstrated to be the most important vital sign, it was missing in 42% of the study population, while PCO2 was only obtained in 39% of patients.

Bottom Line: 

  • Make sure to physically reassess patients you've stabilized/improved in the ED with current vital signs (including an accurate respiratory rate!) before okaying their admission/transfer to the floor. 
  • If you get a blood gas, make sure to pay attention to the PCO2 and address any abnormalities appropriately.

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Category: Critical Care

Title: Liver Dialysis on MARS (Molecular Adsorbent Recirculating System)

Keywords: liver failure, dialysis, MARS, Molecular Adsorbent Recirculating System (PubMed Search)

Posted: 10/10/2017 by Kami Windsor, MD
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Takeaways

Molecular Adsorbent Recirculating System (MARS) is an artificial liver support system colloquially known in the medical field as "dialysis for the liver."  

  • Limited data, small studies
  • Consistently shown to improve hemodynamics, toxin clearance, and hepatic homeostasis
  • No consistent proven mortality benefit
  • Only performed by limited number of US hospitals (including the University of Maryland)
  • May depend on the acute liver failure subpopulation, but best use currently seems to be for severe acute liver failure due to a potentially reversible/recoverable cause (toxin ingestion, trauma, acute alcoholic hepatitis, etc) or as a bridge to transplant

Take-Home:

1. Consider MARS in your patient with severe acute liver failure due to potentially reversible/recoverable etiology

2. Know if and where MARS is offered near you

 

(http://findbesttreatment.com/images/healthnet_dialyse_schema.gif)

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Category: Critical Care

Title: Negative-Pressure Pulmonary Edema

Keywords: respiratory failure, pulmonary edema, airway obstruction (PubMed Search)

Posted: 9/12/2017 by Kami Windsor, MD
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Takeaways

Negative-pressure pulmonary edema (NPPE) is a well-documented entity that occurs after a patient makes strong inspiratory effort against a blocked airway. The negative pressure causes hydrostatic edema that can be life-threatening if not recognized, but if treated quickly and appropriately, usually resolves after 24-48 hours. These patients may have any type of airway obstruction, whether due to edema secondary to infection or allergy, laryngospasm, or traumatic disruption of the airway, such as in attempted hangings.

Management: 

1.     Alleviate or bypass the airway obstruction.

·      Usually via intubation; may require a surgical airway

·      If obstruction in an intubated patient is due to biting on tube or dyssynchrony, add bite-block (if not already in place), sedation, and even paralysis if needed.

2.     Provide positive pressure ventilation and oxygen supplementation.

3.     Use low tidal volume ventilation.

4.     In severe hypoxemia without shock, add a diuretic agent and consider additional measures such as proning and even ECMO if the hypoxemia is refractory to standard therapy.  

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Background: Sedation and analgesia are key components for mechanically ventilated patients. While significant data exists regarding how to manage sedation and analgesia in the ICU setting, very little data exists on management in the ED.

Data: A prospective, single-center, observational study of mechanically-ventilated adult patients used linear regression to identify ED sedation practices and outcomes, with a focus on sedation characteristics using the Richmond Agitation-Sedation Scale (RASS).

Findings:

  • 15% of intubated patients had no sedation or analgesia ordered
  • 64% of intubated patients were documented as deeply-sedated (RASS -3 to -5)
  • Deep sedation was not only associated with more ventilator days, but also increased mortality, with an adjusted OR of 0.77 (95% CI 0.54-0.94) favoring patients with lighter sedation.


Bottom line:  Avoid early deep sedation in your intubated patients as this may be directly associated with increased mortality. Instead, a goal RASS of 0 to -2 should be appropriate for most non-paralyzed, mechanically-ventilated ED patients, extrapoloating from ICU guidelines.

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Category: Critical Care

Title: Catastrophic Antiphospholipid Syndrome

Keywords: autoimmune, rheumatology, thrombosis, hematology (PubMed Search)

Posted: 8/15/2017 by Kami Windsor, MD
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Catastrophic Antiphospholipid Syndrome (CAPS):

A life-threatening “thrombotic storm” of multi-organ micro & macro thrombosis in patients with antiphospholipid syndrome (known or unknown).

Triggered circulating antibodies (usually by infection, but can be prompted by malignancy, pregnancy, and lupus itself) cause endothelial disruption and inflammation leading to prothrombotic state, commonly with SIRS response.

Mortality is high at an estimated 40%.

Confirm diagnosis with antiphospholipid antibody titers.

Treat ASAP with unfractionated heparin, corticosteroids, and Hematology consultation for plasma exchange and/or IVIG.

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Category: Critical Care

Title: Benefits of Family Presence During CPR

Keywords: Resuscitation, CPR, family, policy (PubMed Search)

Posted: 7/17/2017 by Kami Windsor, MD
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Takeaways

When surveyed, half of general medicine patients interviewed stated that they would prefer to have a loved one present if they were to develop cardiac arrest and require CPR. So far, studies have demonstrated that…

Allowing family presence during CPR is associated with the following benefits to family members:

  • Decreased rates of PTSD-related symptoms
  • Decreased scores on anxiety and depression scales
  • Decreased incidence of complicated grief
  • Decreased incidence of family member regret (at having been present vs absent during CPR)

And is NOT associated with a difference in:

  • Survival rate
  • Duration of resuscitation efforts
  • Type or dose of administered medications
  • Number of shocks delivered
  • Emotional stress level of medical providers
  • Occurrence of medicolegal conflict

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Takeaways

In patients with persistent VT/VF cardiac arrest, giving epinephrine before the 2nd defibrillation attempt (which should follow initial shock and 2 minutes of CPR) is associated with decreased ROSC, decreased hospital survival, and decreased functional outcome. 

Take Home Point:

"Electricity before Epi" in patients with persistent VT/VF arrest, at least for the initial epinephrine dose.

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Takeaways

High flow nasal cannula (HFNC) is a valid option in the management of acute hypoxic respiratory failure (AHRF) without hypercapnia, as evidenced by multiple studies including the FLORALI trial. Failure of HFNC, however, may result in delayed intubation and worsened clinical outcomes. 

Factors predicting HFNC failure and subsequent intubation include:

  • Lack of RR improvement at 30 and 45 minutes after initation of HFNC
  • Lack of SpO2% improvement at 15, 30, and 60 minutes
  • Persistence of paradoxic breathing (thoracoabdominal dyssynchrony) at 15, 30, 60, and 120 minutes
  • Presence of additional organ system failure, especially hemodynamic (shock) or neurologic (depressed mental status)

Consider whether or not HFNC is appropriate in your patient with AHRF, and if you use it, reevaluate your patient to ensure improvement, or escalate their respiratory support. 

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Category: Critical Care

Title: Use Ultrasound to confirm CVC placement

Keywords: Central venous catheter, ultrasound (PubMed Search)

Posted: 4/18/2017 by Kami Windsor, MD (Updated: 9/23/2020)
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Takeaways

Save time by using bedside ultrasound to confirm above-the-diaphragm central venous catheter (CVC) placement rather than waiting for chest x-ray confirmation:

1. Perform rapid push of saline (it doesn’t have to be agitated) through CVC while cardiac probe is placed with right atrium in view. Immediate visualization of bubbles (or “atrial swirl”) essentially confirms correct placement.

2. Perform the usual search for ipsilateral lung-sliding and the waves-on-the-beach to rule out procedural pneumothorax.

 

 

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