Week in Review: 12/6/20

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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:

HFNC for Apneic Oxygenation by Terren Trott

  • There does not exist strong evidence to support the routine use of HFNC during the apneic period. 
  • HFNC was not reported to complicate or impede intubation.
  • The subgroups that still need more investigation include those who are severely hypoxic at baseline, those with prolonged intubations, those who are morbidly obese.

Dilated RV? Proceed with Caution! by Jeff Pepin

  • Ultrasound is merely a tool
  • When deciding if right heart strain patterns should lead you to consider using intra-arrest tPA, there needs to be a reasonably convincing pretest probability of a pulmonary embolism rather than relying on the ultrasound findings alone
  • A dilated RV during intra-arrest echo may be just an inherent part of cardiac physiology
  • Until we have more studies that look at this topic, RV dilation during cardiac arrest should be taken with a grain of salt.

LVADs 401: When the Dueling Banjos Act Comes to Town by Andrew Phillips

  • RV failure in the setting of an LVAD has support options but each comes with some significant challenges.
  • When using a R-ECMO circuit plus an LVAD, keep the LVAD flow slightly faster than the R-ECMO flow.
  • When using a R-ECMO circuit, keep vigilant for fluid shifts; use the ultrasound frequently to keep the interventricular septum midline to slightly left-ward bowing.

Doing Insulin Like a Pharmacist by Lauren Igneri

  • Initiate insulin therapy when BG >150 mg/dL, with the goal of maintaining a blood glucose less than 180 mg/dL. Evaluate patients’ glycemic control and insulin requirements daily.
  • IV insulin infusion dosing protocols should be initiated in patients with marked hyperglycemia.
    • Once at goal, convert 50-70% of the 24-hour requirements into basal insulin such as NPH (intermediate-acting) given q12 hours or glargine (long-acting) given once daily plus correctional coverage.5
    • Beware of converting to subcutaneous regimens if there is acute kidney injury and/or escalating or high-dose vasopressor requirements since insulin is renally eliminated and subcutaneous absorption may be impaired in shock.
  • For patients maintained on subcutaneous regimens that are still above goal, add 50% of 24-hour correctional insulin requirements to the basal regimen and reassess.
  • Depending on the baseline diabetic status, most patients with diabetes will require basal insulin administration even if they’re NPO.
    • May initiate a 50% reduced basal regimen if there is significant risk for hypoglycemia.

What is Pulmonary Function Testing? by Stephen Biehl

  • Although the spirometry portion of pulmonary function testing isn’t complicated, it can be a bit challenging to perform
  • It’s understandable how patients could feel like they don’t have enough air or that they failed the test. As I tell all of my patients, if you feel like you have air left when we finish, we did something wrong. And that the test will always feel like it wins.
  • But the testing does provide crucial information that will dictate how they are treated and what interventions are to be done.

The Vitals: Indications for Central Line Placement by Shyam Murali

  • There are a number of indications for central line placement, some of which are slightly controversial
  • Not all central lines were made equal; infusion rates vary
  • Consider using IOs and RIC catheters instead

It’s More Than Just Squeezing a Bag by Danella Howard

  • Make sure your BMV has a reservoir and at least 15LPM of oxygen flow. 
  • Do not use 2 hands to bag! Consider using a pediatric BVM for adults. 
  • Get a good seal! Use the C-E technique when you can only use one hand to hold the seal. Use the V-E technique when you can use 2 hands to hold the seal.

A Cool Little Tool for Central Lines by Haney Mallemat

  • Consider using the catheter-needle combo from your central line kit for:
    • trainees who are still learning the fine motor skills
    • patients who have significantly collapsing internal jugular veins

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