Week in Review: 12/27/20

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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:

Acute Cor Pulmonale in ARDS: Top 10 Things you Need to Know by Matt Siuba

  • RV function is directly influenced by lung function
  • Hypoxemia, hypercarbia, and acidemia increase PVR
  • In ACP, RV dysfunction is due to acute increase in PVR
  • ACP is probably still underrecognized
  • ARDS patient turning “septic?”- think about ACP
  • Diagnose it! TTE/TEE, invasive monitoring. 
  • Prevent strategies include RV-protective ventilation, decongestion, and consideration rescue therapies early.

Understanding the Enemy: In-Hospital Cardiac Arrest in COVID19 by Jeff Pepin

  • COVID patients that were younger with fewer comorbidities and were admitted to larger institutions were more likely to survive their critical illness of COVID19.
  • The authors reference that cardiac arrest in critically ill patients with COVID19 appeared to be predominantly related to non-cardiac causes.
  • Respiratory failure and prothrombotic events that have been extensively described in patients with covid-19 are probably significant contributors to in-hospital cardiac arrest in this setting.

Simplified Algorithm for ACLS in LVAD Patients by Andrew Phillips

  • Establish perfusion, not pulses.
  • Shock and do compressions as you would with anyone else in the ACLS algorithm.
  • Consider gingerly providing epinephrine in complete arrests, rather than full, 1mg slugs q3-5 min.

The Art of Pediatric Ventilation: Flow Inflating Bag by Tammy Dutch

  • Flow inflating bags must have oxygen or compressed air to operate. 
  • The adjustment wheel sets the desired peep. 
  • Maintain the sniffing position without hyperextension of the neck in children.

The COVID Variant by Matthew Tyler

  • Yes, the virus mutates…a lot. That’s expected. 
  • Yes, this particular lineage made a big mutant jump compared to prior variants.
  • No, we don’t have enough solid information to know how infectious this strain is or if it is any more lethal than prior variants.
  • No, it’s unlikely the vaccines will become obsolete this quickly.
  • Yes, we need to collect more data to make any meaningful conclusions.
  • Yes, everyone still needs to wear masks, practice social distancing, and get the vaccine when available to them.

What is RV Fractional Area Change? by Segun Olusanya

  • Fractional area change adds (yet) another tool to assess RV function
  • It’s defined as the difference between end-diastolic and end-systolic RV areas, divided by end-diastolic area
  • It correlates well with MRI measured RV ejection fraction
  • It’s measured in an RV Focused apical 4 chamber view, by tracing end-diastolic and end-systolic areas
  • Care should be taken to ensure the accuracy of the tracings
  • While it improves the sensitivity of RV assessment by including the free wall, it’s highly user-dependent


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