Week In Review: 8/29/21

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

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

Pros and Pitfalls of Disconnecting the Ventilator During Acute Respiratory Decompensation by Aman Thind

  • Disconnecting the ventilator and manual BMV should be performed in cases where device malfunction is the primary cause of decompensation. These instances are quite rare.
  • Disadvantages of switching to BMV include loss of diagnostic information, risk of decruitment, lack of tidal volume and respiratory rate control.
  • Attention to waveforms is crucial.
  • A systematic initial approach to these scenarios would obviate the need for ventilator disconnection in most instances

KCENTRA® : Some “FUN”-damentals You Might Not Have Known by David Zimmerman 

  • Kcentra® is a 4-factor PCC that is FDA approved for the reversal of warfarin
  • Kcentra® contains factors II, VII, IX, and X but also contain other components like heparin, Antithrombin III, protein C, and Protein S
  • Kcentra®  is dosed based off of the Factor IX content and this can vary to a small extent from one lot to the next

Portal Vein Pulsatility Index to Differentiate Hypervolemic and Hypovolemic Hyponatremia by Sharad Patel 

  • Hypervolemic and hypovolemic hyponatremia can be difficult to distinguish; therefore, treatment can often be inappropriate.
  • Portal vein pulsatility can indicate venous congestion. Venous congestion can lead to high neurohormonal and RAAS activation, predisposing to hyponatremia and
  • Portal vein pulsatility index may be a good marker to distinguish hypervolemic and hypovolemic hyponatremia when the physical examination is inconclusive/difficult, but further studies are warranted

Pimpin’ Aint Easy, But is it Necessary? by George Willis

  • Certainly, consider the use of RFQ, formerly known as pimping, on your next shift, and consider using some of the pro tips above to increase the learning opportunities and decrease the negatives associated with this teaching style.

More Magnesium, Please! by Lauren Igneri

  • IV magnesium when combined with standard HR control (beta-blockers, non-dihydropyridine calcium channel blockers, or digoxin) is associated with achieving significantly increased rate and rhythm control.
  • Magnesium doses <5 g were associated with increased rhythm control and less risk of flushing compared to higher doses
  • Consider dosing magnesium 4 g IV over 15-20 minutes in the setting of continuous cardiac monitoring for rapid A

Riding the Wave: Waveform Interpretation Part 2 by Danelle Howard 

  • Patient-ventilator dyssynchrony can cause a poor outcome
  • Treat underlying issues like intrinsic PEEP, COPD, bronchospasm, etc
  • Appropriate mode, sensitivity, flow rate, volume, pressure, and timing should be adjusted and set 
  • PAV and NAVA are two new potential approaches to ventilator synchrony 


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