Week in Review: 8/16/20

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Picture of Shyam Murali
Shyam Murali
Fellow in Trauma and Surgical Critical Care - University of Pennsylvania, Senior Editor - CriticalCareNow.com, Writer - RebelEM.com, Saxophonist, EDM remixer, husband, puppy father, and new human father

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

A Better Offense: Preventing Peri-Intubation Hypotension by Terren Trott

  • Consider the pathophysiology specific to your patient, choose an intubation strategy to protect your patient from hemodynamic collapse
  • Choose ideal induction agent that fits your intubation and hemodynamic needs
  • Consider early and aggressive use of vasopressors to mitigate hypotension

Neurogenic Shock by Mohamed Hagahmed

  • Neurogenic Shock is a diagnosis of exclusion. Consider it in your trauma patient with unexplained hypotension and bradycardia after ruling out hemorrhage or other internal injuries (Tension Pneumothorax, Pericardial Tamponade, etc.)
  • In elderly patients, factors such as medications (Beta Blockers) or age-related neurocognitive deficits can mask the severity of their symptoms. Maintain a low threshold for considering spinal injuries in these patients.

Acute on Chronic Liver Failure in the ICU: Part 1 by Fraser Mackay

  • ACLF is a complex disorder that requires early recognition and treatment. Check out Dr. Mackay’s post to learn how to identify and risk stratify it.
  • Beware the ACLF spiral of death
Figure 3: Schematic for Acute on Chronic Liver Failure and worsening feedback cycle of MODS. Image created by Fraser Mackay.

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.

The Vitals: Pulmonary Artery Catheter by Tim Montrief

  • The PA catheter can provide you with some valuable information about your patient including, but not limited to:
    • Right atrial pressure
    • Right ventricular pressure
    • Pulmonary artery pressure
    • Pulmonary capillary wedge pressure
    • Cardiac output

Drugs, ECMO, & Rubber Ducks by Lauren Igneri

  • ECMO can alter the pharmacokinetics and pharmacodynamics of medications
  • Just think of the ECMO circuit as a full bathtub with rubber ducks and a pesky clog!

AKI and Arterial Intra-Renal Doppler (IRD) by Eduardo Argaiz

  • Doppler waveform of flow of the inter-lobar vessels of the kidney can be used to calculate de Renal Resistive Index (RRI)

  • Monitoring the change in RRI could provide real-time (immediate) feedback to determine the effectiveness of resuscitation efforts

  • Increased RRI has been linked with AKI and RRI can be modified with resuscitation strategies like vasopressors or fluids

  • Although mainly determined by pulse pressure and compliance, intrinsic resistance vascular can also alter RRI

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