UMEM Educational Pearls - Critical Care

Category: Critical Care

Title:

Keywords: Alarm Fatigue (PubMed Search)

Posted: 5/20/2019 by Robert Brown, MD (Emailed: 8/11/2020) (Updated: 8/11/2020)
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Takeaways

In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.

While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.

Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229

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Category: Critical Care

Title: Utilization of the Mechanical Ventilator in Cardiac Arrest

Keywords: CPR, Cardiac Arrest (PubMed Search)

Posted: 11/15/2016 by Rory Spiegel, MD (Emailed: 8/11/2020)
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It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode at 6-7 mL/kg and 10 breaths/minute (3).

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Category: Critical Care

Title:

Keywords: amikacin, Torsades de pointes, QT prolongation (PubMed Search)

Posted: 8/20/2019 by Quincy Tran, MD (Emailed: 8/11/2020)
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Torsades de pointes and QT prolongation Associated with Antibiotics

 

Methods

The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).

Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS

Results

FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).

 

Macrolides               ROR 14 (95% CI 11.8-17.38)

Linezolid                  ROR 12 (95% CI 8.5-18)

Amikacin                 ROR 11.8 (5.57-24.97)

Imipenem-cilastatin ROR 6.6 (3.13-13.9)

Fluoroquinolones   ROR 5.68 (95% CI 4.78-6.76)

 

Limitations:

These adverse events are voluntary reports

There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.

 

Bottom Line:

This study confimed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study  found new association between amikacin and Torsades de pointes/QT prolongation.

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Category: Critical Care

Title: Predicting peri-Intubation hypotension

Keywords: peri-Intubation, shock index (PubMed Search)

Posted: 2/7/2017 by Rory Spiegel, MD (Emailed: 8/11/2020)
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Identifying patients at risk of hypotension during intubation is not always straight forward. The prevalence of peri-intubation hypotension in the Emergency Department has been demonstrated to be approximately 20%.1 And while certain variables increase the likelihood of peri-intubation hypotension (ex. Shock index> 0.80), no single factor predicts it accurately enough to be used at the bedside.2 In the majority of patients undergoing intubation, clinicians should be prepared for peri-intubation hypotension with either vasopressor infusions or push dose pressors.

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Category: Critical Care

Title: Lung Protective Ventilation in the Emergency Deparment

Keywords: lung protective ventilation, ARDS (PubMed Search)

Posted: 3/21/2017 by Rory Spiegel, MD (Emailed: 8/11/2020)
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While lung protective ventilatory strategies have long been accepted as vital to the management of patients undergoing mechanical ventilation, the translation of such practices to the Emergency Department is still limited and inconsistent.

Fuller et al employed a protocol ensuring lung-protective tidal volumes, appropriate setting of positive end-expiratory pressure, rapid weaning of FiO2, and elevating the head-of-bed. The authors found that the number of patients who had lung protective strategies employed in the Emergency Department increased from 46.0% to 76.7%. This increase in protective strategies was associated with a 7.1% decrease in the rate of pulmonary complications (ARDS and VACs), 14.5% vs 7.4%, and a 14.3% decrease in in-hospital mortality, 34.1% vs 19.6%.

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Category: Critical Care

Title: Oxygenation goals

Posted: 3/11/2009 by Mike Winters, MD (Emailed: 8/11/2020) (Updated: 8/11/2020)
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Oxygenation goals

  • In recent pearls we have talked about 'lung protective' ventilation strategies to reduce volutrauma, barotrauma, and oxygen toxicity.
  • Using 'lung protective' strategies, such as low tidal volumes, results in higher levels of CO2 and a lower pH.  These are tolerated in favor of lower and safer alveolar pressures.
  • In addition to higher pCO2 values and lower pH, oxygenation goals are slightly lower than conventional teaching.
  • In these patients, you want to maintain SpO2 > 88% and PaO2 > 55 mm Hg.

While chest X ray (CXR) is routinely obtained in the setting of traumatic injury, ultrasound (US) is a fast and reliable way to evaluate for life-threatening traumatic injuries requiring emergent intervention, and is supported by the Eastern Association for the Surgery of Trauma (EAST) guidelines. A recent Cochrane Review compared the test characteristics of chest US vs CXR for detection of traumatic pneumothorax when using Chest CT or thoracostomy as the gold standard.

  • Primary end point: sensitivity and specificity for pneumothorax
  • US performed by nonradiologists.
  • 9 studies, 1271 patients, 410 of which had a pneumothorax
  • Summary sensitivity: US 0.91 (95% CI 0.85-0.94), ranging from  0.82-0.98 in the included studies, vs. CXR 0.47 (95% CI 0.31- 0.63) ranging from 0.09 to 0.75
  • Summary specificity: US 0.99 (95% CI 0.97-1.00, ranging from  0.96-1.00 vs. CXR 1.00 (95% CI 0.97- 1.00), ranging from 0.98 to 1.00

There possible weaknesses of this study, including blinding in the original studies, and several studies may or may not have been at risk for bias as their risk of bias was ‘unclear’.  However, the results were consistent across the studies analyzed and remained similar after sensitivity analysis.

Several anatomical as well as patient care issues may confound US findings for pneumothorax such as the presence of bleb, prior thoracic surgery or pathology, as well as main stem intubation.

Bottom line:  While the presence of pneumothorax is on either CXR or US is highly likely to represent the a true pneumothorax, ultrasound is a far superior screen for the detection of pneumothorax in the trauma patient.

 

 

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Category: Critical Care

Title: Adrenal Insufficiency

Posted: 4/12/2013 by Haney Mallemat, MD (Emailed: 8/11/2020) (Updated: 8/11/2020)
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Adrenal insufficiency (AI) can be a life-threating condition and is classified as primary (failure of the adrenal gland) or secondary (failure of hypothalamic- pituitary axis).

Common causes of primary adrenal insufficiency include autoimmune destruction, infectious causes (TB and CMV), or interactions with drugs (e.g., anti-fungals, Etomidate, etc.). Secondary causes are usually due to abrupt withdrawal of steroids after chronic use, although sepsis and diseases of the hypothalamus or pituitary (e.g., CVA) may occur.

Signs and symptoms include fatigue, weakness, skin pigmentation, dizziness, abdominal pain, and orthostatic hypotension; it should be suspected with any of the following: hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia, low free-cortisol level, and hemodynamic instability despite resuscitation.

Treatment:
• Correct underlying the disorder
• Resuscitation and hemodynamic support
• Correct hypoglycemia and electrolyte abnormalities
• Treat with hydrocortisone, cortisone, prednisone, or dexamethasone +/- fludrocortisone (Note: dexamethasone is attractive choice in the ED because it will not interfere with ACTH stimulation test)


 

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