Week in Review: 2/21/21

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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:

Basics of Transpulmonary Pressure: Towards a Better Surrogate of Lung Stress by Aman Thind

  • End-inspiratory and end-expiratory transpulmonary pressures are the best surrogates of inspiratory and expiratory lung stress respectively.
  • Mathematically, end-inspiratory transpulmonary pressure = Pplat – Ppl & end-expiratory transpulmonary pressure = totalPEEP – Ppl
  • Patient populations at special risk of developing high Ppl are those with (a) Class-III obesity and (b) abdominal compartment syndrome. Optimal PEEP for these patients is higher than average.
  • The major challenge in determining true lung stress is the lack of knowledge of Ppl. Esophageal pressure can be used as a surrogate. If not feasible, driving pressure can be extremely helpful to guide PEEP selection.

Roses are red, Violets are Blue, I Need to Open Your Chest, so What do I Do? by Zaf Qasim

  • The ED physician may need to do a resuscitative thoracotomy in select circumstances. 
  • Think about whether the system would support you doing this prior to proceeding – ultimately this patient will need the OR. Have a plan set up with your surgeons well beforehand
  • Have a tray set-up that is simple and does not fluster you when you need to be on top of your game. 
  • Continue your blood product resuscitation. 
  • Address other obstructive pathologies like tension pneumothorax first. 
  • Finally, if the need arises, follow the steps above for the best chance of success.

Choosing Wisely in the ICU: 2021 by Colin McCloskey

  • Achieving value in healthcare involves eliminating wasteful practices that do not contribute to patient-centered outcomes or can otherwise cause harm 
  • The original “Choosing Wisely” practices are reasonable and evidenced-based, though compliance has been challenging
  • The next five “Choosing Wisely” practices demand the cessation of unnecessary catheters, mechanical ventilation, and antibiotics. They encourage early mobilization and patient-centered goals of care.

Performance Skill for the Educator: Vocal “Problems” by Jenny Beck-Esmay

  • Vocal fry, the use of the lowest vocal register of your voice creating a creaky tone, can be interpreted as either irritating and unnatural or informal and approachable, depending on the audience.
  • Upspeak can be used to convey uncertainty, but can also be used to engage an audience in active listening and as a form of floor-holding.
  • In conversation, filler words can serve a useful purpose, allowing both speaker and listener time to process.  In formal speech, however, there are alternative tactics that are likely less distracting to the audience.

Don’t Forget the Calcium (in Trauma) by Ruben Santiago

  • Pathways dependent on calcium such as platelet function, coagulation, and cardiac contractility are disrupted during hemorrhagic shock and subsequent resuscitation with blood products containing citrate. 
  • Hypocalcemia is a clinically significant electrolyte disturbance that occurs in trauma patients due to hemorrhage and further exacerbated by resuscitation with blood products. 
  • Calcium chloride contains 3 times more elemental calcium versus calcium gluconate.
  • Once resuscitative efforts with blood products have started for a trauma patient in hemorrhagic shock, calcium supplementation should be considered (calcium gluconate 2 – 3 g or calcium chloride 1 g) when 2 – 4 units of PRBCs have been administered. 
  • When resuscitating your trauma patient, don’t forget about the calcium.

Riding the Waves: Waveform Interpretation Part 2 by Danelle Howard

  • Patient-ventilator dyssynchrony can cause a poor outcome
  • Treat underlying issues like intrinsic PEEP, COPD, bronchospasm, etc
  • Appropriate mode, sensitivity, flow rate, volume, pressure, and timing should be adjusted and set 
  • PAV and NAVA are two new potential approaches to ventilator synchrony

The Vitals: A Good Death – Palliative Care in the ICU by Sunil Ramaswamy

  • Review your institution’s comfort measures orderset and be familiar with what medications are available.
  • Be respectful of the family and what traditions, prayers, or religious ceremony they may wish to enact at the end of life. Death rituals are immensely important in many cultures and should be respected.
  • Please do not fear overdosing your patients with opiates – you are ethically obligated to treat your patient’s discomfort if their goal is to be comfortable, and there is no good evidence that suggests opiate administration at the end of life hastens death.
  • COMMUNICATE! Be in constant contact with the patient’s nurse and RT. Promptly respond to all needs.
  • Check up on your team and make sure they are okay; losing a patient is not an easy process and is emotionally taxing.

COVID & The Lung (Ultrasound) by Gurkeerat Singh

  • Lung ultrasound ideally should be performed if it would change your clinical management or to answer a clinical question. 
  •  In the ED, if you have decided to admit a patient to the medicine floor or the ICU based on your clinical assessment, then a thoracic ultrasound should not change that decision. A patient with typical lung ultrasound findings may be at a higher risk for worsening disease so it may help with risk stratification. 
  • In the ED if you have decided to discharge a patient home, then a lung ultrasound should not change that decision. 
  • On the medicine floor, patients with typical lung ultrasound signs may be at a higher risk for worsening disease.
  • In the ICU, lung ultrasound can help guide ventilator management. A patient with typical loss of aeration of the lower lobes (i.e. atelectasis ) may benefit from a ventilator strategy with higher mean airway pressures.

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