Category: Critical Care
Keywords: trauma, resuscitaiton, pregnancy, IVC, supine hypoventilation, edema, intubation, RSI, desaturaiton (PubMed Search)
Posted: 8/2/2011 by Haney Mallemat, MD
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Pregnancy causes many physiologic changes, which may be challenging during trauma resuscitations. A few pearls on the ABC’s:
Airway
Breathing
Circulation
Chesnutt, A. Physiology of normal pregnancy. Crit Care Clinics 2004 Oct;20(4):609-15.
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Category: Critical Care
Posted: 7/26/2011 by Mike Winters, MBA, MD
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Blood Pressure in the Critically Ill Obese Patient
King DR, Velmahos GC. Difficulties in managing the surgical patient who is morbidly obese. Crit Care Med 2010; 38(S):S478-82.
Category: Critical Care
Keywords: heat stroke, critical care, acute kidney injury, seizures, neurological (PubMed Search)
Posted: 7/19/2011 by Haney Mallemat, MD
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Heat stroke is hyperthermia (>41.6 Celsius / 106 Fahrenheit) plus neurologic findings (e.g., altered mental status, seizures, coma, etc.); it also causes systemic inflammation response syndrome (i.e., cytokine release), coagulation disorders (e.g., thrombosis in end organs) and tissue abnormalities (e.g., acute kidney injury and rhabdomyolysis)
Two classifications exist:
Treatment includes:
Despite the most aggressive therapy, up to 30% survivors may have permanent neurologic or multi-organ system dysfunction months to years after recovery
Leon, L. Heat stroke: role of the systemic inflammatory response. Journal of Applied Physiology 2010 Dec;109(6):1980-8
http://emedicine.medscape.com/article/166320-overview
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Category: Critical Care
Posted: 7/12/2011 by Mike Winters, MBA, MD
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Hemodynamic Optimization in the Post-Arrest Patient
Stub D, Bernard S, Duffy SJ, Kaye DM. Post cardiac arrest syndrome: a review of therapeutic strategies. Circulation 2011; 123:1428-1435.
Category: Critical Care
Posted: 6/28/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Hepato-Renal Syndrome
Bagshaw SM, Bellomo R, Devarajan P, et al. Review article: Acute kidney injury in critical illness. Can J Anesth 2010; 57:985-998.
Category: Critical Care
Keywords: AKI, critical care, ICU, cancer, renal failure, acute kidney injury (PubMed Search)
Posted: 6/21/2011 by Haney Mallemat, MD
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Cancer patients admitted to ICUs with AKI or who develop AKI during their ICU stay have increased risk of morbidity and mortality. AKI in cancer patients is typically multi-factorial:
Causes indirectly related to malignancy
Septic, cardiogenic, or hypovolemic shock (most common)
Nephrotoxins:
Aminoglycosides
Contrast-induced nephropathy
Chemotherapy
Hemolytic-Uremic Syndrome
Causes directly related to malignancy
Tumor-lysis syndrome
Disseminated Intravascular Coagulation
Obstruction of urinary tract by malignancy
Multiple Myeloma of the kidney
Hypercalcemia
Because AKI increases the already elevated morbidity and mortality in these patients, prevention (e.g., using low-osmolar IV contrast, avoiding nephrotoxins), early identification (e.g., strict attention to urine output and renal function), and aggressive treatment (e.g., early initiation of renal replacement therapy) is essential.
Benoit D. Acute kidney injury in critically ill patients with cancer. Critical Care Clinics 2010 Jan; 26(1): 151-79
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Category: Critical Care
Posted: 6/14/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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AKI in the Critically Ill Cancer Patient
Benoit DD, Hoste EA. Acute kidney injury in critically ill patients with cancer. Crit Care Clin 2010;26:151-79.
Category: Critical Care
Keywords: uremia, bleeding, ddavp, estrogens, epogen, cryoprecipitate (PubMed Search)
Posted: 6/6/2011 by Haney Mallemat, MD
(Updated: 6/7/2011)
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Bleeding associated with uremia is a spectrum, from mild cases (e.g., bruising or prolonged bleeding from venipuncture) to life-threatening (e.g., GI or intracranial bleed). The exact pathologic mechanisms are not understood, but are likely multi-factorial (e.g., dysfunctional von Willebrand’s Factor (vWF) and factor VIII, increased NO, etc.)
Besides dialysis, treatments for uremic bleeding include:
Hedges, SJ. Evidence-based treatment recommendations for uremic bleeding.NatClinPractNephrol.2007 Mar;3(3):138-53.
Category: Critical Care
Posted: 5/31/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Cardiovascular Complication of ESLD
Al-Khafaji A, Huang DT. Critical care management of patients with end-stage liver disease. Crit Care Med 2011; 39:1157-66.
Category: Critical Care
Keywords: neutropenia, sepsis, abdominal pain, necrotizing enterocolitis (PubMed Search)
Posted: 5/23/2011 by Haney Mallemat, MD
(Updated: 5/24/2011)
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TIP: Suspect when abdominal pain presents 10-14 after chemotherapy (when PMNs are lowest).
Blijlevens NM, et al. Mucosal barrier injury: biology, pathology, clinical counterparts and consequences of intensive treatment for haematological malignancy: an overview. Bone Marrow Transplant 2000 Jun;25(12):1269-78
http://emedicine.medscape.com/article/375779-overview
Category: Critical Care
Posted: 5/17/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Acute Liver Failure (ALF)
Larsen FS, Bjerring PN. Acute liver failure. Curr Opin Crit Care 2011; 17:160-4.
Category: Critical Care
Keywords: Clostridium difficile, diarrhea, critical, ICU, sepsis, abdominal pain, vanocmycin,metronidazole, fidaxmicin (PubMed Search)
Posted: 5/10/2011 by Haney Mallemat, MD
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Although oral metronidazole is indicated for mild to moderate Clostridium difficile associated diarrhea, oral vancomycin should be considered first-line therapy in critically-ill patients with moderate to severe disease. Vancomycin dosing should begin at 125mg PO q6 and increased to 250mg q6 if poor enteral absorption exists. Consider adding metronidazole IV if either reduced enteral absorption or severe disease exists.
Recently, fidaxomicin has been shown to be non-inferior to oral vancomycin in the treatment of mild to moderate C. difficile. While promising, the study population was not critically-ill and extrapolation should be avoided.
Riddle, D. Clostridium difficile infection in the intensive care unit. Infect Dis Clin North Am. 2009 Sep;23(3):727-43.
Category: Critical Care
Posted: 5/3/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Gastrointestinal Changes of Obesity that Complicate Critical Illness
Ashburn DD, Reed MJ. Gastrointestinal system and obesity. Crit Care Clin 2010;26:625-7.
Category: Critical Care
Keywords: sepsis, shock, antimicrobials, combination, antibiotics (PubMed Search)
Posted: 4/26/2011 by Haney Mallemat, MD
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A mortality benefit from combination antimicrobial therapy has not been clearly demonstrated in sepsis. However, when only the most severely-ill patients (i.e., septic shock) are considered in subgroup analysis, there appears to be a mortality benefit to using two antimicrobials against a suspected organism.
Combination antimicrobial therapy may reduce mortality through three mechanisms.
Always obtain appropriate cultures before initiating therapy. Although identification and susceptibility of the organism may take some time, eventually narrowing antimicrobial therapy to monotherapy in the ICU is still recommended.
Abad, C. Antimicrobial Therapy of Sepsis and Septic Shock: When are Two Drugs Better Than One? Crit Care Clinic 27 (2011) e1-e27.
Category: Critical Care
Keywords: staphylococcal aureus, aminoglycoside, monotherapy, combination therapy (PubMed Search)
Posted: 4/19/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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Combination Antimicrobial Therapy for Gram (+) Bacteremia
Abad CL, Kumar A, Safdar N. Antimicrobial therapy of sepsis and septic shock - When are two drugs better than one? Crit Care Clin 2011;27:e1-e27.
Category: Critical Care
Keywords: Vancomycin, Daptomycin, Linezolid, MRSA, gram positive, infections, sepsis, pneumonia (PubMed Search)
Posted: 4/12/2011 by Haney Mallemat, MD
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Vancomycin is often started empirically for gram-positive and MRSA coverage. Although effective and generally well-tolerated, emerging resistance and side-effect profiles limit its use in some patients. Two alternatives are Linezolid and Daptomycin.
Linezolid
Daptomycin
Alder, J. The Use of Daptomycin for Staphylococcus Aureus Infection in the Critical Care Medicine. Crit Care Clin 24(2008); 349-363.
Category: Critical Care
Keywords: bilevel ventilation, bipap, cpap, respiratory failure, respiratory distress, copd, acute pulmonary edema (PubMed Search)
Posted: 3/29/2011 by Haney Mallemat, MD
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Emergency Medicine physicians are gaining experience with non-invasive ventilation (i.e., Bi-level ventilation and continuous positive-pressure ventilation) in managing respiratory distress and failure. Although NIV is commonly used across a variety of pathologies, the best data exists for use with COPD exacerbation and cardiogenic pulmonary edema (CHF, not an acute MI)
Although other indications for NIV have been studied, the data is less robust (eg., smaller study size, weak control groups, etc.). If there are no contraindications, however, many experts still support a trial of NIV in the following populations:
Failure to clinically improve during a NIV trial should prompt invasive mechanical ventilation.
Keenan, S. et al. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011 Feb 22;183(3):E195-214. Epub 2011 Feb 14.
Category: Critical Care
Posted: 3/22/2011 by Mike Winters, MBA, MD
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Aspiration Pneumonitis and Pneumonia
Ragavendran K, Nemzek J, Napolitano LM, Knight PR. Aspiration-induced lung injury. Crit Care Med 2011; 39:818-26.
Category: Critical Care
Keywords: pulmonary physiology, critical care, respiratory alkalosis (PubMed Search)
Posted: 3/15/2011 by Haney Mallemat, MD
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Many changes in pulmonary physiology occur during pregnancy. These changes are generally well tolerated but can become problematic when pathologic states arise.
Here are a few examples of the normal changes and potential consequences:
Progesterone increases tidal volume and respiratory rate.
“Normally" a mild respiratory alkalosis pH 7.4-7.47, PaCO2 28-32, and bicarbonate 17-22 (renal compensation).
Low metabolic reserve with systemic illness.
Weight gain, anasarca, and breast size reduces chest wall elasticity.
Potential for restrictive physiology and reduced lung volumes.
Can be challenging to to mechanically ventilate due to decreased compliance and intra-thoracic pressure
Mechanical displacement of abdominal and thoracic contents by growing uterus.
Reduced lung volumes leading to reduced oxygen reserve and decreased apnea time.
Aim higher if placing chest tube (avoid abdominal contents)
Uterine pressure on stomach can increase aspiration risk and pulmonary injury.
Chestnutt, A. Physiology of Normal Pregnancy. Crit Care Clinic 20 (2004) 609-615
Category: Critical Care
Posted: 3/8/2011 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
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The Severely Hypoxemic ED Patient
Patroniti N, Isgro S, Zanella A. Clinical management of severely hypoxemic patients. Curr Opin Crit Care 2011; 17:50-56.