For some spaced repetition, here’s a review of this week’s content:
Driving Pressure & PEEP Titration by Matt Siuba and Kshitij Chatterjee
- Driving pressure is calculated as PPlat – PEEP in a passive patient
- ΔP = Vt/Crs
- Some evidence suggests that lower ΔP is associated with better outcomes in ARDS, however, no RCTs are available
- ΔP is a useful parameter at the bedside to determine optimal PEEP to minimize ventilator-induced lung injury in ARDS.
- ΔP may also be a better target for ventilator changes than PF ratio!
- The headline figure in this paper is astounding – 43% functional survival from OHCA!
- However, you cannot read this paper as “ECPR is the difference maker.” This needs to be interpreted in the context that it is not just the ability to perform ECPR on these patients that is beneficial, but that it takes a systems-based approach of appropriate patient identification, training of a small cohort of clinicians to respond and perform the key intervention, as well as that same team continuing to care for these patients en-route to the centralized ECMO ICU.
Pearls and Pitfalls: CMS and Sepsis by Fraser Mackay
- Since the metrics are publicly reported and may soon be tied to hospital reimbursement or penalties, they also can’t simply be shrugged off.
- That said, there are ways through the nonsense so that you can BOTH get credit for doing the right thing AND provide good care to patients with sepsis.
Shocky Patient With Aortic Stenosis by Gurkeerat Singh
- A hypotensive patient with a thick AV with restrictive movement seen on POCUS, needs to be evaluated for severe AS.
- Patients with severe AS need the absolute correct fluid balance. Too much fluid (preload) can cause pulmonary edema and too little fluid can lead to hypotension.
- In severe AS, phenylephrine is considered by many as the least harmful vasopressor.
- Loss of atrial kick can lead to shock and pulmonary edema depending on the fluid balance
The Vitals: Pulling the Tube – Advanced Techniques, Tips, and Tricks by Sunil Ramaswamy
- Listen to the respiratory therapist! A good RT is an ESSENTIAL part of the ICU team, and you must incorporate their input into your rounds. They have the best knowledge of the patient’s respiratory status. Check in with the RT often – If the RT is worried, you should be worried too!
- Dry lungs are happy lungs5! Try to keep your patient’s fluid balance net negative in the ICU. This is especially true if the primary reason for your patient’s respiratory failure was due to pulmonary edema.
- 30 minutes of SBT on pressure support is PROBABLY enough for you to make a determination about your patient’s readiness to be extubated.
- Every clinician will have their own recipe for judging readiness for extubation. Listen and learn from everyone, and then find a method that works for you.
- LISTEN TO THE RESPIRATORY THERAPISTS!
Sweet like Apple Pie, and Spices that Make You High by Rachel Rafeq
- The dose makes the poison
- Treatment of abuse from cinnamon, nutmeg, clove, or black mamba spice is symptomatic and supportive. Benzodiazepine and antipsychotic therapies may be utilized to manage associated agitation and psychosis that may occur.
- Suspected hypercoagulable state from synthetic cannabinoids may be managed similar to warfarin toxicity. No clear doses are described although consistently vitamin K doses are high upwards of 200 mg daily and due to the long half-life of Brodifacoum it may be prudent to discharge the patient with a prescription for vitamin k to be continued outpatient.
- Don’t follow this recipe!