Week in Review: 11/29/20

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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:

Pre-Ox Like a Pro! by Steve Haywood

  • A non-rebreather at flush rate is a cheap, easy intervention that leads to high levels of EtO2. 
  • A BiPAP can also achieve high levels of EtO2, although, if it is not already being used, it is more cumbersome and costly to set up only for the purpose of pre-oxygenation. 
  • If BiPAP is needed for pre-oxygenation, most modern ventilators have a non-invasive mode that can be used to deliver positive pressure breaths through a mask. The mask that comes with the BVM can be attached to the circuit and held tightly against the patient’s face. Once the patient is intubated remember to change the vent back to invasive mode before attaching to the ETT.
  • HFNC and BVM do achieve high levels of EtO2, although not quite to the recommended levels. 
  • If using an NRB, always turn the flow to flush as 15LPM is inadequate for preoxygenation.

An Arresting Development: A Community Approach to ECPR for OHCA (Part 2) by Zaf Qasim

  • Again, the headline figure in this paper is astounding – 43% functional survival from OHCA versus only 7% in the ACLS group
  • Given the incredibly poor outcomes from standard ACLS despite years of attempting to tweak various variables, this is to be applauded. The fact that this benefit was seen early in the trial leading it to be stopped shows that is really a paradigm shift in management.
  • ECMO provides numerous benefits including reliable perfusion, mechanical cardiac support, and the ability to facilitate treatment of causes of refractory arrest. 
  • However it is dependent on a skilled clinician group, both for the procedure itself and for the post-procedure critical care which would likely only be based at major academic centers. 
  • Furthermore, it is dependent on a system of care that can reliably identify and deliver patients to these clinicians, as discussed in part 1 of this post. 
  • Focusing on these systems issues can go some way to shortening the time from the 911 call to ECPR initiation. 
  • Given the building body of evidence in support of this therapy for out-of-hospital arrests, it is time to really address the possibilities of providing this level of care in the wider United States – and worldwide

Classic Studies in MCS: The ADVANCE Trial by Colin McCloskey

  • The third generation, continuous flow, centrifugal pump is non-inferior to its continuous flow axial forebears. This laid the groundwork for two randomized control trials comparing the designs, Momentum and Endurance.

Just Go With the FLO-Lan by Nishika Patel

  • Utilize institution-specific epo dosing protocols to ensure consistent and safe care with this medication.
  • Coordination with all specialties (intensivists, pharmacists, respiratory therapists, and nurses) is important to ensure treatment goals are understood and therapy is not interrupted prematurely.
  • Taper epo slowly to avoid rebound pulmonary hypertension. Monitor patients for hypotension and bleeding.
  • For inhaled epo with fixed dosing, the solution concentration should be halved each time tapering is indicated, but the nebulized rate should consistently remain at 8mL/hr.

CritBits: What is Hi-Flow Nasal Cannula by Haney Mallemat

  • Use it for Type I respiratory failure
  • It is heated and humidified and can provide large amount of flow (20 to 60 LPM)
  • HFNC can provide a small amount of PEEP
  • It is effective at CO2 washout

CT Perfusion Confusion by Rupal Jain

  • #1: CT perfusion allows us to identify tissue that is irreversibly dead (infarcted core) versus that which is salvageable (ischemic penumbra) in a patient with suspected large vessel occlusion. When there is a mismatch between infarcted core and ischemic penumbra (i.e. ~ mismatch volume of 15mL or mismatch ratio > 1.8), this indicates thrombectomy may reverse some functional damage. 

  • #2: Currently, most protocols entail scanning 1-2 slabs of the brain. The increased scan time in a short segment of the brain confers increased radiation to this tissue. Therefore it is important to choose this scan wisely.

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