Week In Review: 7/25/21

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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 CLABSIs 
  • 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 pneumonia 
    • 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 patterns 
  • Unique gas flow mobilizes significant volumes of pulmonary secretions, facilitating improved gas exchange  
  • 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.

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