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.
- 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 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