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Melina Alexander
St. Vincent's Emergency Medicine Resident, PGY-1
CRITICALCARENOW TURNED 1 YEAR OLD THIS WEEK! THANK YOU FOR ALL YOUR SUPPORT OVER THE PAST YEAR!
For some spaced repetition, here’s a review of this week’s content:
Spontaneous Modes and the Horribly Underappreciated Flow Cycling by Aman Thind
- Spontaneous modes allow the patient to exert some control over when the breath is cycled. This is most commonly achieved via flow-cycling.
- In flow-cycling, a breath is cycled when the inspiratory flow drops to a certain percentage of peak inspiratory flow that is set by the user (ETS).
- Spontaneous (flow-cycled) modes enhance cycle dyssynchrony compared to controlled (time-cycled) modes.
- Nonetheless, cycle dyssynchrony may still occur with flow-cycling. Fine-tuning of ETS and avoidance of under- or over-assistance are the key ways to enhance synchrony. ΔPocc can be used to titrate the degree of pressure support.
- In an awake spontaneously breathing patient, switching from pressure support to pressure control to “rest the patient” is a fallacious argument that will likely worsen synchrony.
Peripheral Vasopressors by Tyler Jones
- Peripheral vasopressors have been noted to have a low incidence of extravasation events and few major complications
- If placing a US guided PIV for vasopressors use the longest length catheter for reduced chance of extravasation.
- Peripheral vasopressors could help reduce time to vasopressor administration and ultimately reduce mortality of the patient
- Save the patient adverse events from CVC placement and reduce the risk for CLABSIsÂ
- Have a protocol in place per your institution
- Be confident that peripheral vasopressors are safe!
A Cold-Case by Jen Axelband
- The HYPERION Trial showed that a higher percentage in the hypothermia group survived with favorable neurologic outcomes.
- Check out the post for a more in-depth analysis of the study.
Dopamine – Not so Dope by Samantha Dallefeld
- Epinephrine and norepinephrine are preferred over dopamine in septic shock.
- Think about epinephrine for myocardial dysfunction and low cardiac output.
- Think about norepinephrine for increasing systemic vascular resistance.
- Epinephrine may be preferred over norepinephrine if only peripheral access is available.
What’s in Your Toolbox? MRSA Screening by Lauren Igneri
- MRSA nares screening is a valuable tool for antimicrobial stewardship (AMS) initiatives to streamline empiric antibiotic therapy in patients with pneumonia.
- High specificity and NPV for ruling out MRSA pneumoniaÂ
- Significantly reduces the duration of empiric anti-MRSA therapy
- Appropriate interpretation of MRSA nasal screens and continuous patient follow-up is needed for antimicrobial de-escalation strategies.
High-Frequency Percussive Ventilation – Using the VDR-4 by Linda Melchor
- HFPV combines diffusive high-frequency mini-bursts and convective ventilation patternsÂ
- Unique gas flow mobilizes significant volumes of pulmonary secretions, facilitating improved gas exchange Â
- Benefits include enhanced oxygenation and hemodynamics, alveolar recruitment while providing hypothetic lung-protective ventilation
The Vitals: Lactic Acidosis by Obiajulu Anozie
- Critical lab findings are the result of significant, pathophysiological perturbations that demand an equally physiological approach to properly address.
The Many “Flavors” of Doppler by Gurkeerat Singh
- The Doppler effect is utilized in ultrasound to detect movement of blood towards and away from the ultrasound probe
- Check out the post to learn how to best use Color Doppler, Continuous Doppler, Pulse Wave Doppler, and Tissue Doppler.
