Week In Review: 8/15/21

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

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

Ventilating Asthma or COPD? I:E Is Not The Goal by Steve Haywood

  • Intubated patients with severe obstructive lung disease can be some of the most challenging to manage. 
  • Continue to dose albuterol and treat the underlying disease. 
  • You may have to hit the reset button while you optimize the ventilator. 
  • You may be able to increase the tidal volumes if the plateau pressures are low. 
  • As paralytics are added and spontaneous inspiration is removed, the respiratory mechanics change and turbulent flow may be reached at higher inspiratory times. The rate may need to be lowered even more. 
  • As you treat the disease, you may be able to increase the rate. 
  • While the process is broken down in a simple fashion, there is nothing simple about managing these patients. 
  • Look at your I:E ratio. You need to get it low (1:5 or lower), but do not fixate on it. It is all about giving the patient as much time as possible to exhale.
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Pearls and Pitfalls: CMS and Sepsis by Fraser Mackay

  • We are going to be doing a few more of these “Pearls and Pitfalls” for surviving CMS Sepsis measures. Again, these pieces are more about how to navigate and anticipate CMS case adjudication rather than ask the question of whether or not they should be done. Examples like the ones mentioned only scratch the surface of the headaches these core measures inflict, but unfortunately, the US government is not going to change this any time soon. Since the metrics are publicly reported and may soon be tied to hospital reimbursement or penalties, they also can’t simply be shrugged off. That said, there are ways through the nonsense so that you can BOTH get credit for doing the right thing AND provide good care to patients with sepsis.

TXA: Still A Gold Medal for Stopping the Bleed? by Ruben Santiago 

  • TXA is an antifibrinolytic agent that is used for multiple etiologies of hemorrhage
  • Small studies and systematic reviews support the use of TXA as a viable option for acute epistaxis
  • Although the largest trial demonstrates similar results versus placebo, TXA may still be considered as it is a low cost, noninvasive, nonpainful treatment option with a low adverse event rate
  • When administered topically, the IV formulation of TXA 500 mg/5 mL may be utilized and soaked onto a cotton pledget and placed in the bleeding nostri

The Extubation Series: Part 3, Extubate to What? by Danelle Howard 

  • Studies show small benefits in high-risk patients.  There is not enough data to support these modalities in patients at low risk or reintubation. 
  • Consider the patient population when choosing a modality to extubate to 
  • More large-scale studies are still needed
  • See more on how to properly set the rise time on NIV for better patient outcomes in Timing the Rise

The Vitals: IV Fluids – Lactated Ringers (Part 2) by Jon Pickos and Sam Epstein

  • LR contains sodium lactate, not lactic acid, and as evidenced by prior studies, does not significantly raise lactate levels, a lab typically monitored in critically ill patients
  • Lactate can be utilized as an energy source by the body in critical illness and rising levels are likely the body trying to provide increased substrates for energy.
  • Sodium lactate is associated with multiple potential benefits including cerebral blood flow circulation, healing, energy production, and improved hemodynamics through better cardiac function.
  • Additionally, the sodium lactate in LR provides an additional source of bicarbonate, a much needed component of the buffer system in the body, especially in shock states.
  • The lactate in LR is not to be feared, but embraced, and provides added support for the use of LR as the primary fluid for balanced and pH guided resuscitation in critically ill patients

An Uncommon Type of Hypertrophic Cardiomyopathy by Gurkeerat Singh

  • Apical cardiomyopathy is a rare type of hypertrophic cardiomyopathy in the US population. 
  • Outflow obstruction is not common.
  • Echo with contrast to identify a typical spade shape LV cavity.
  • The prognosis is reasonable. 

 

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