Week In Review: 6/20/21

Reading Time: 3 minutes

St. Vincent's Emergency Medicine Resident, PGY-1

For some spaced repetition, here’s a review of this week’s content:

APRV 101: PEEP to the Max by Richard Cunningham

APRV is an additional form of mechanical ventilation that applies a high constant pressure (P_high) in order to increase alveolar recruitment and oxygenation
APRV has timed releases to a low pressure (P_low) for a brief period in order to allow for ventilation while preventing alveolar collapse
The four settings unique to APRV are P_high, P_low, T_high, and T_low
Patients can (and should!) spontaneously breathe while on APRV, which increases comfort and contributes to ventilation
While APRV improves oxygenation, it has not been shown to lower mortality; Further studies are needed to determine how and when to optimally apply APRV
Look out for a post in the future on how to set APRV more precisely

CRRT Basics by Caitlyn Stough

First things first, always check and verify the machine’s orders, pre-filter (if ordered), and the dialysate bags used for the current therapy.
Check the line and tubing for kinks and clamps, as well as any air or forming clots.
When in doubt of the circuit clotting, rinse back. If the patient is getting more hypotensive or unstable, stop treatment and rinse back.
The arterial (red) line PULLS patient blood, and venous (blue) line PUSHES filtered blood back to the patient.
Never push air back to the patient.
Troubleshoot any red alarms- mute alarm first, information, stop treatment. The information book/“I” in the app bar will walk through the steps or possible interventions needed to get the system back up and running and should always be utilized!

IV vitamin K, in addition to 4-PCC, should be given for emergent reversal of warfarin
Most guidelines recommend vitamin K 5-10mg IV for emergent reversal
Lower doses of vitamin K may be appropriate in non-life-threatening bleeds and/or in patients where lowering the INR below goal could be more detrimental
Baseline INR prior to reversal is also important as low doses of vitamin K may not reverse significantly elevated INRs. Likewise large doses of vitamin K may not be needed if INR is slightly above goal range.

So how do we achieve this magical moment, especially in our busy clinical environments? We oftentimes let the bustle of our clinical environments get in the way and we try to educate on the fly, frequently poorly. We often resort to short lectures and lose the engagement that has been gifted to us. What I hope to do over this series is focused on techniques you can use to find that learnable moment in all of your learners. Whether it be through pimping (I hate that name and will call it “RFQ” when you see the post), “what if” questions, gaming, VR, simulation, you name it. It is our task as educators to discover that learnable moment.
So before your next shift, think of ways you can find that learnable moment in your learners. Stay tuned.

Timing the Rise by Sabrina Kroft

PCT is upregulated within 6-12 hours of the onset of bacterial infections and levels decline rapidly with a resolution of inflammation.
Serial PCT evaluation in patients with sepsis is associated with a significantly reduced 30-day mortality and duration of antimicrobial therapy.
Measure PCT at baseline and daily. Consider early antimicrobial discontinuation if the patient is clinically stable, >80% reduction in PCT from baseline and the absolute PCT <0.5-1 mcg/L.
- Consider broadening therapy if unable to achieve goals by day 4.
Interpret PCT cautiously in the setting of renal failure, pancreatitis, severe cardiogenic shock, or trauma

Tissue Doppler imaging is a type of pulsed wave Doppler imaging that uses various filters to focus on the velocity of tissue movement rather than blood.
Tissue Doppler has many uses including various assessments of ventricular function or estimating right or left atrial pressures