Week in Review: 8/30/20

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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:

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 lower even more. As you treat the disease, you may be able to increase the rate.
  • 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.

Pulse Checks in Cardiac Arrest by Jeff Pepin

  • Palpation: should go the way of the rotary phone
  • ETCO2: most practical with few limitations
  • POCUS Pulse Check: Newcomer on the block with some limitations
  • TTE: Gold standard but has limitations
  • TEE: Awesome when used appropriately and available
  • Arterial line: Great if you have the time

Outcomes for Septic Shock Survivrs: ADRENAL Follow-up by Fraser Mackay

  • Hydrocortisone does not affect quality of life for sepsis survivors.
  • Among septic shock survivors in the ADRENAL study, at 6 month follow up: 
    • 20% had moderate to severe disability
    • Only about 50% felt they were disability free

UltraRounds: Knobology by Segun Olusanya

  • Pearl #1: Good image quality is not just helpful for you to make better diagnoses, but for everyone to be able to make those diagnoses with you.
  • Pearl #2: Have what you are looking for in the center of the screen, as big as possible, and as smooth and as clear as possible.
  • Pearl #3: Think about depth, gain, focus, and sector width every time you are imaging a body structure.

The Vitals: Central Venous Pressure by Michael Javid

  • CVP is not appropriate for guiding fluid therapy; there are numerous other methods to assess for fluid responsiveness
  • Consider using it when you are concerned for right ventricular function

A Push for a (First-Dose) Push by Rachel Rafeq

  • IV push is likely a feasible option for the first dose of antibiotics
  • Speak with your pharmacists to ensure that the concentration is less than 900mOsm/L
  • Check out the post for a handy chart that helps you convert common antibiotics into push-dose versions!

More Bad News About COVID-19 by Puja Singh

  • COVID-19 may have a link to Guillain-Barre Syndrome so be on the lookout for signs and symptoms concerning for GBS


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