Week in Review: 11/1/20

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Shyam Murali
Shyam Murali
Fellow in Trauma and Surgical Critical Care - University of Pennsylvania, Senior Editor - CriticalCareNow.com, Writer - RebelEM.com, Saxophonist, EDM remixer, husband, puppy father, and new human father

For some spaced repetition, here’s a review of this week’s content:

The Battle for Cor Pulmonale by Matt Siuba and Brendan Riordan

  • RV function is directly influenced by lung function
  • Hypoxemia, hypercapnia and acidemia all worsen PVR
  • ACP is RV dysfunction related to an acute rise in PVR, frequently this is due to ARDS or pulmonary embolism
  • ACP is probably under-recognized 
  • Risk factors for ACP in ARDS include pneumonia as an etiology for ARDS, hypoxemia, hypercapnia, and elevated driving pressure
  • New hypotension in a patient with ARDS? Think about ACP!
  • Of course, respect #ThePeoplesVentricle

Supraglottic Airway or Tracheal Intubation for Out-of-Hospital Cardiac Arrest by Jeff Pepin

  • In out-of-hospital cardiac arrest, there was no difference in survival with good neurologic function between SGA or ETT at 3 and 6 months

What is the Pulsatility Index? by Colin McCloskey

  • The pulsatility index of LVADs represents the magnitude of flow pulse through the LVAD.
  • It is a marker of circulating blood volume and native LV contractility. A fall in PI should prompt evaluation of volume status and native LV function.

Systolic Anterior Motion in Takotsubo’s Cardiomyopathy by Siri Chamarti

  • Systolic Anterior Motion causes transient LVOTO in critically ill patients.
  • Consider optimizing volume status and use of phenylephrine as a preferred pressor choice in these patients
  • In Takotsubo’s, dynamic LVOTO requires early identification and prompt treatment.

The Vitals: Barotrauma by Obiajulu Anozie

  • Barotrauma occurs when transpulmonary pressures exceed a threshold
    Transpulmonary pressure = Plateau Pressure – Pleural Pressure
  • Barotrauma as a form of VILI that can occur when the lungs are exposed to excessive transpulmonary pressures. To minimize this risk, it is always imperative to employ lung protective ventilation strategies.

How to Deal With That Wire? by Haney Mallemat

  • Reload the wire into the wire casing to maintain control of the wire
  • It can then be reused easily or discarded safely

Evidence-Based Treatment of “The Dwindles” by Nick Mark

  • Persistent hypotension requiring vasopressors is a common situation in the ICU. Doing “nothing” is acceptable but entails exposing patients to increased risk of infections and delays their recovery.
  • Four strategies are available, three of which are supported by evidence:
    • (1) choose a MAP goal of >60
    • (2) wean NE before vasopressin
    • (3) consider adding corticosteroids
  • Ongoing studies may support a role for oral vasopressors, but the current data is lacking. 

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