Week In Review: 5/16/21

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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:

Failed Triggering and Detecting Airway Resistance by Matt Siuba

  • Failed triggering is common, with the most concerning cause being high airway resistance and intrinsic PEEP
  • Understanding expiratory flow waveforms and the time constant can help treat resistance and intrinsic PEEP
  • NAVA is an alternative mode of ventilation which can be used to avoid this particular dyssynchrony
  • For more on detecting whether airway resistance is an issue, view these posts by Aman Thind and Komal Parikh on airway pressures.

Calcium for Cardiac Arrest. Let’s get to the Brass Tacks! by Jeff Pepin

  • The indiscriminate administration of Calcium during cardiac arrest is not supported by current evidence.
  • Clinicians should focus on minimizing the interruption of high-quality chest compressions and early defibrillation when indicated.
  • The administration of medications not supported by evidence during cardiac arrest will add to the cognitive load of the resuscitationists and distract them from performing important procedures and giving life-saving medications.
  • Calcium may be indicated in the setting of a confirmed or suspected overdose of a calcium channel blocker, or hyperkalemia.

Pillars of Mentorship by Danya Khoujah

  • Whether you’re a mentor or mentee, be mindful of the four pillars of mentorship: trust, respect, expectation, and communication.
  • Investing a few minutes to explicitly discuss the relationship expectations and communication logistics will pay dividends in decreased frustration and improved satisfaction. 
  • Expectations and communication may change with time; trust and respect create the space for this discussion to occur smoothly.

Vasoplegia: What to do When Your Patients’ Vasculature has the Tone of a wet Noodle by Colin McCloskey

  • Vasoplegia is a consequence of cardiopulmonary bypass and is defined by a low SVR and hypotension despite an adequate cardiac output.
  • Vasoplegia will resolve with time, but blood pressure support is necessary with vasopressors.
  • Vasopressin and catecholamine vasopressors are good initial choices; steroids, methylene blue, hydroxocobalamin and angiotensin II are salvage therapies.

Propofol Infusion Syndrome? by Lauren Igneri

  • Propofol infusion syndrome (PRIS) is a rare and potentially fatal condition caused by shifts in intracellular energy production.
  • Clinical features including fever, hyperkalemia, hypotension, ECG changes, traumatic brain injury, mean infusion rate >5 mg/kg/h, duration of infusion >48 hours, and cumulative dose >240 mg/kg are associated with increased mortality in PRIS.
  • Propofol should be dosed using ideal body weight in obese patients to minimize the risk for developing PRIS.

The Matter of Bags by Danelle Howard and Rahel Gizaw

  • Lung protective ventilation reduces morbidity and mortality.
  • Pediatric BVM provides safer and more consistent lung-protective ventilation volumes. 
  • Studies show that manually ventilating an adult patient with a pediatric BVM is possible 
  • Read more HERE on the basics of manually ventilating a patient.

The Vitals: Understanding the Respiratory Drive II – Metabolic Acidosis by Obiajulu Anozie

  • Metabolic acidosis stimulates the peripheral chemoreceptors, sending feedback signals to the respiratory centers to drastically increase alveolar ventilation.
  • Avoid invasive ventilation in these patients if possible, a trial of NIV should be attempted first.
  • Bicarbonate therapy may be detrimental and yield the opposite effect if used to facilitate intubation.
  • If invasive ventilation cannot be avoided, maintaining spontaneous respiration throughout the process is key.
  • Improve patient-ventilator interaction post-intubation by utilizing pressure modes where the patient can set their own respiratory rate.

Ultrarounds: Silent Hypoxemia by Gurkeerat Singh

  • “Silent hypoxemia” is commonly seen in COVID 19 patients. 
  • Non-COVID-19 ‘silent hypooxemia’ and hypoxemia can also exist in patients with intracardiac and intrapulmonary shunts. 
  • Not every patient with silent hypoxemia is COVID

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