Week in Review: 9/13/20

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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 Curious Case of Refractory Hypoxemia by Matt Siuba

  • Start with the simple things. Equipment checks are vital!
  • Consider shunt physiology (of many forms) when evaluating the patient with hypoxemia out of proportion to other findings.
  • Given the inexpensive and non-invasive nature of POCUS, it is reasonable to perform echo and lung ultrasound on all unexplained cases of respiratory failure. It is part of my physical exam.
  • Refractory hypoxemia deserves a careful, systematic approach to its evaluation. For an approach to hypoxemia in ARDS, see the following post: https://criticalcarenow.com/2020/05/21/how-to-manage-refractory-hypoxemia

Ventilation During CPR by Jeff Pepin

  • Don’t hyperventilate or hypoventilate
  • Provide enough tidal volume to see the chest rise
  • Passive oxygenation may be beneficial in early witnessed cardiac arrest

Anatomy of an External Ventricular Drain by Fraser Mackay

  • EVDs are commonplace in neuro-critical care units and require standardized setup and protocols to help monitor ICP and drain CSF.
  • EVDs are made of basic components that allow for diagnostic monitoring of ICP and therapeutic drainage of CSF.
  • There are basic safety concerns that you should be aware of, especially if the neurologic exam changes or if EVD infection is suspected.

Velocity-Time Integral (VTI): Clinical Tips for Your Patients in Shock by Gurkeerat Singh

  • VTI can be used instead of calculating SV every time. Less time and risk for error. Some US machines do this automatically
  • VTI is just a number if you are not looking at the LV, RV, IVC, and interpreting the data in clinical context!
  • A passive leg raise is an automatic reversible fluid bolus that can be very helpful. 
  • Anticipate fluid response and fluid tolerance.

The Vitals: Priorities in Cardiac Arrest Part 1 by Shyam Murali

  • Priority #1 in cardiac arrest is high-quality chest compressions with minimal interruptions. Do everything you can to maximize compression fraction.
  • Priority #2 is early defibrillation when appropriate; this is the definitive therapy for VFib/VTach

Corticosteroids in COVID19: The Pendulum Swings Back by Nick Mark

  • Corticosteroid treatment is associated with numerous benefits: less time in the hospital, lower likelihood of requiring mechanical ventilation, and decreased mortality.
  • All hospitalized COVID19 patients who are hypoxemic enough to need supplemental O2 seem to benefit from steroids. As there is a trend towards increased mortality in patients who are not on oxygen, hospitalized COVID patients, not on supplemental oxygen should not receive corticosteroids.
  • The choice of steroids does not seem to matter, and there is no advantage to higher doses. It is, therefore, reasonable to use the lowest effective dose: both the NIH COVID19 Treatment Guidelines and the WHO Guidelines recommend Dexamethasone 6mg IV or PO daily for 10 days or until discharge (whichever comes first).
    • If Dexamethasone is not available you can substitute other corticosteroids: Prednisone 40 mg/day, Methylprednisone 32 mg/day, or Hydrocortisone 160 mg/day.
  • There does not appear to be a right or wrong time to give steroids; patients appear to benefit if corticosteroids are started promptly or >1 week after symptom onset.

Steroids or Bust: The Case for Corticosteroids in COVID-19 Associated ARDS by Lauren Igneri

  • Patients with COVID-19 requiring oxygen support, especially those requiring mechanical ventilation, should be considered for corticosteroid therapy due to improved mortality
  • Numerous corticosteroid dosing regimens have been evaluated in ARDS and in COVID-19 associated ARDS.
    • Dexamethasone 6 mg daily x 10 days may be preferred for COVID-19 patients based on the preliminary findings of the RECOVERY trial. Further review of patient baseline severity of illness in this study is needed to clarify if these findings can be extrapolated to patients with severe ARDS.
    • Dexamethasone 20 mg IV daily x 5 days followed by 10 mg IV daily x 5 days based on the DEXA-ARDS trial may be considered for patients with COVID-19 and severe ARDS.
    • Long, tapered methylprednisolone regimens may be considered for COVID-19 patients who present in late stage ARDS.

Nutrition in the ICU by Eddy Gutierrez

  • It seems there are more questions than answers with feeding ICU patients
  • What is clear, however, is that your decisions should be based on your patients needs and local guidelines

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