Wednesday, August 21, 2019

Docusate in the Hospital: Cut the Crap




Everybody poops. There’s a book about it. Read it. It’s worth your while. You know what’s not worth your while? Something that I’ve been guilty of doing my whole career. Providing docusate just because. I’m a bit embarrassed but I was sent this article by bedsideroundz and doctorwarsgame yesterday evening so I could take this apart. Well, no need for me to take it apart. The authors did a great job at reviewing the data and concluding that we should just stop prescribing docusate. Hope no one holds shares in the companies who manufacture this medication as it is earning them $100,000,000 a year for a product with crappy results. Was that a pun? Perhaps the most important part of the article is towards the end where they provide recommendations regarding alternatives. I know what the nurses in the crowd are saying... “oh I’m not going to request lactulose for my patient”. Everything in moderation, team. Bowel movements are importante. 💩

Link to Article

Link to PDF

Robert J Fakheri, MD, Frank M Volpicelli, MD, Things We Do for No Reason: Prescribing Docusate for Constipation in Hospitalized Adults. J. Hosp. Med 2019;2;110-113. doi:10.12788/jhm.3124

Why we should NOT be checking for residual tube feeds

Do you as a nurse spend any part of your day checking for residuals on your patients who are on mechanical ventilation and receiving tube feeds/enteral feeding? Did you know that since 2016, the ASPEN guidelines have recommended against this? Now may be your opportunity to present this data to the powers that be and let you have your time back so you can "play cards" (obvious joke) and do more important things in patient care. It's 2019, think of all the time you've spent partaking in this practice. Sigh. Okay don't think about it. We NEED you at the bedside. In the McClave study there was no support for using residual volumes as a marker for the risk of aspiration. the frequency was 21.6% vs 22.6%. The Poulard study from 2010 was calling checking residual gastric volume "standard practice". I guess that's why some institutions are still doing it. They wanted to do the study because there was no data to find a correlation between residuals and adverse events. Know what they found? That not checking residuals allowed for a greater daily volume of enteric feeds. No difference in vomiting between the two groups nor was there a difference in ventilator associated pneumonia. Worth it to check residuals? Still not convinced? Lets look at more data then. Last but definitely not least, the Reignier study in 2013, 3 years after the 2010 study showed that there wasn't a benefit to checking residuals (in all fairness the study took place in 2010) looked at ventilator associate pneumonia as the primary endpoint. Did they find a difference? They found a whole bunch of NOPE. Does that settle the argument in your mind? Yes, I know that we all had that ONE patient who aspirated and got sick. It's not perfect. But the data is there, actually, right here. Three articles that you can obtain on my website. A little literature review from me, if you will. Hope you got something out of it and your time will now be saved. Share this with your nurse managers, dietitian teams, and fellow nurses so everyone can benefit.

I'm sorry that I can't get you these articles as they are hidden behind the dreaded paywall but the ASPEN guidelines are free.

-EJ





Link to Article

Reignier, J. (2013). Effect of Not Monitoring Residual Gastric Volume on Risk of Ventilator-Associated Pneumonia in Adults Receiving Mechanical Ventilation and Early Enteral Feeding. JAMA, 309(3), 249. 



Link to Article

McClave, S. A., Lukan, J. K., Stefater, J. A., Lowen, C. C., Looney, S. W., Matheson, P. J., … Spain, D. A. (2005). Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients*. Critical Care Medicine, 33(2), 324–330.



Link to Abstract

Poulard, F., Dimet, J., Martin-Lefevre, L., Bontemps, F., Fiancette, M., Clementi, E., … Reignier, J. (2009). Impact of Not Measuring Residual Gastric Volume in Mechanically Ventilated Patients Receiving Early Enteral Feeding. Journal of Parenteral and Enteral Nutrition, 34(2), 125–130.



Can early enteral nutrition decrease mortality?




Link to Abstract

Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials.

In my quest for sort out the answer of when to initiate enteral nutrition in my critically ill ICU patients, the data leans toward starting early. In this meta-analysis that was published in 2009, despite the sample sizes being very small, they were able to find a benefit regarding mortality and pneumonias when you start feeding patients within 24 hours. How small you ask? Well, 234 in the group that determined a benefit in mortality and just 80 in the group that determined a benefit towards pneumonia of early feeding. We need larger studies. All these authors admit this. We need some super ambitious RD's out there to take this bull by the horns and definitely answer these questions for us! A 🎩 tip to the authors!

-EJ


Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials. Intensive Care Med. 2009;35(12): 2018-2027.

Tuesday, August 20, 2019

When should we start enteral nutrition in our mechanically ventilated patients? Day 1 or 4?





Link to Abstract

Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patient.

When trying to decide when to initiate enteral nutrition in our critically ill patients who are on mechanical ventilation, there is not a great amount of data. Should we start on day 1, 2, 3, 4, 5... on and on. This study shows us that we should definitely NOT wait until day 4 to get started. Although these was no difference in mortality, the authors were able to see an increase in days of mechanical ventilation as well as a prolonged ICU length of stay in the patients who received enteral nutrition on day 4 as opposed to day 1. The authors hypothesized that not feeding the patients when they were ill creates intestinal atrophy and ulceration, therefore leading to disruptions of the intestinal tract that proved harmful to patients. The patient population of this study, 28 patients, was small but it provides some insight as to what we should be doing. The next questions should be "start at day 1 vs day 2" or "start at day 1 vs day 3"? We do not know those answers yet. 
🎩 tip to the authors! 

- EJ


Nguyen, N. Q., Besanko, L. K., Burgstad, C., Bellon, M., Holloway, R. H., Chapman, M., … Fraser, R. J. L. (2012). Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients*. Critical Care Medicine, 40(1), 50–54. 

Sunday, August 18, 2019

Pharmacists save lives!



Link to Abstract

To those who say that only doctors and nurses save lives. There's a new teammate to share the glory with. Now, to any of us who have spent just 15 seconds in the ICU, this is NOT news. But it is always nice to be recognized, right? It is a little shady that all the authors are pharmacists, but we will excuse that because we all know the findings are true.
What have we learned from this article?
1. No matter how they juggled the data, pharmacists decrease mortality
2. Patients stay in the ICU for a shorter period of time because of pharmacists
3. This one is a no-brainer because it basically reflects that pharmacists are doing their job but they decreased both preventable and non-preventable adverse drug events.
So how about a little hip-hip-horray for our pharmacy colleagues? Tag your favorite ICU pharmacist. Much love to all.
A hat tip to the authors!

-EJ

Saturday, August 17, 2019

Blood Pressure Measurements in the ICU: Trust ONLY the MAP in Oscillometric Devices!




Link to Abstract

Link to Article

Full disclosure. I did not learn this until I was a fellow in Critical Care Medicine. It is not widely taught. Do not feel bad that you did not know this. All I ask is for your help to share this with others so we all speak the same language and do the best for our patients.

What are the normal sounds you hear with the "old fashioned"/auscultatory method of taking a patients blood pressure?
Those sounds define the systolic blood pressure and diastolic blood pressure respectively.
Then you do math and could calculate the mean arterial pressure (MAP) by using the formula of (2xDBP)+SBP/3 but there are a number of different ways to derive the MAP.
Does the BP cuff you have in the ICU, hospital or throughout the majority of doctor offices have ears? We if that's the case, you CANNOT assume that the SBP and DBP provided by these devices are exact.

How do oscillometric devices work?
The device measures the oscillations from the blood vessel wall during cuff deflation. The maximal oscillation point is the MAP. The device uses an algorithm that is proprietary to define the SBP and DBP. Those algorithms are closely kept secrets to the manufacturers.

Why is this important, well, BP is GOLD in the ICU world. My nurses titrate pressors based on MAP number, as the guidelines suggest, but I have too often seen nurses whipping out their phone calculating the MAP by hand as they feel that the numbers generated on the screen are inaccurate. Now, this occurred when I trained in community academic hospital, then ivory tower fancy pants hospital, and now in a community hospital which is why I feel writing this post is so important. We need to understand how our technology works!
It is known, however, that the MAP is the most important value generated by the device.

The study listed above noted that there was a significant difference between calculated MAP, i.e. the nurses/staff doing the calculation themselves, and the observed MAP (generated by the machine). They found that the generated MAP could either be lower or higher that the observed MAP. These differences were amplified even further when analyzed on individual patients rather than the cohorts. Would you feel comfortable treating your patients like this? I sure don't.

The authors discuss a trial where patients had their BP taken via oscillometric device in the OR vs. intraarterial and there was no statistically significant difference in the MAP. There was a difference in the SBP by 19mmHg, though. Could you imagine treating these patients based on an algorithm generated SBP? You'd be treating them (or not treating them) inappropriately!

Now, this post may seem like it's being directed at nurses, after all, you all are the main ones at the bedside, but we all need to get better. The docs needs to stop presenting patients to each other by referencing the SBP. Docs need to stop telling nurses to hit SBP goals for their pressors instead of MAPs.

Well, now you know how this all works and you won't make silly comments anymore. I hope I taught you something.

- EJ










Friday, August 16, 2019

Enteral nutrition in the ICU: How we should be feeding our critically ill patients.


Link to Article

Link to PDF

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

These are the ASPEN guidelines that were published in 2016. They were created to assist us in providing patients with appropriate nutrition while they recover from critical illness. This paper is free and although the 53 pages seem intimidating, the last 11 pages are the references. Also, the font is large and the format is easy to digest as it is laid out in a question/answer type format. I honestly look forward to the updated guidelines but these have a bunch of goodies that I do not feel the vast majority of my colleagues are aware of. I must admit, the majority of the recommendations are based on consensus rather than solid data. If that's what we have, though, we must make do while asking healthy questions.

Fun facts I've picked up on re-reading these guidelines that I had missed out on previous reads and that I may or may not have known:
- clear liquid diet is not necessary after post-op. Patients can be provided with solid food.
- patients should be getting 1.2-2.0g/kg of body weight of protein/ day. Some standard tube feeds may not reach this target in certain patients.
- I knew this but it begs reminding: DO NOT CHECK RESIDUALS!
- fancy formulas may be more confusing that practical for a standard patient in the MICU at the time of this publication.
- they made no recommendations for probiotics but I have found data stating otherwise.
- don't bother with high-fat low carb formulations for reps failure
- check phosphorus levels regularly in respiratory failure patients. That was you can replace the K with K/Phos instead of compartmentalizing the electrolytes.
A 🎩 tip to the many contributors to this guideline.

That's enough for today
-EJ


 

Thursday, August 15, 2019

The gut microbiome alters immunophenotype and survival from sepsis



Link to Article

I've had very similar patients with very similar infections where one was out of the ICU in a short amount of time and the other died in flames. Many variables in play, of course, but you get my point. Could the gut microbiome hold a key regarding which patients do well and which patients don't? My ignorance on the matter is through the roof and my research made me stumble on this gem of a study. I am usually not a fan of mice studies but they have their place in medicine. Here, they showed how mice with almost genetically identical backgrounds who underwent cecal ligation and puncture to make them septic, and had completely different rates of death. One group obtained from a certain location had a mortality rate of 90% whereas the other group had a mortality rate of 53%. Then they had another group subset where they mixed females of the two groups (bc the males rip each other to shreds) for 3 weeks and then performed the same process. The group with the 90% mortality, after being cohoused, had the same mortality rate as that which had the 53% mortality. That’s absolutely fascinating! Now, the authors admit that there are other factors at play, but they did a ton of fancy genetic and bacterial testing to help explain the differences. I leave it up to them to better explain it. A definite 🎩 tip to them.

-EJ

Wednesday, August 14, 2019

Enteral Nutrition Can Be Given to Patients on Vasopressors



Link to Article (Not Free)

I have always been interested in the nutritional status of our patients in the ICU and I don't quite have my mind made up regarding a lot of things. Actually, within the next few months I am going to be asking my registered dietician colleagues here for help with a number of clinical questions.
Truth is that there is a void of solid data regarding nutrition, when to start, how much, how much protein, etc. I understand the ASPEN guidelines have provided some consensus, but much of it is expert opinion rather than actual data. I digress. A topic for another day.
Regarding this article that was published yesterday, the author detailed the vasopressors doses at which one should start feeds (or not start, norepinephrine > 0.3-0.5mcg/kg/min is a no-no), resuscitation markers that should make us feel more comfortable with starting feeds such as decreasing downtrending vasopressor doses.  He also describes the feeding strategy of starting with tropic feeds at 10-20cc/hr.  Lastly, he describes signs of intolerance including residuals > 500cc, note, not 250, not 300... 500.
I have some honest questions for which I personally do not know the answer, though. I need help with this if someone knows the answer. From an evolutionary standpoint, we do not eat when we are ill. Just remember your appetite for a big delicious meal when you last had a significant viral illness. Should we really start to immediately feed these patients? Also, I do not feel that our bodies are accustomed to this whole continuous feeds phenomenon. We normally bolus feed ourselves. Are we shocking the system by doing continuous feeds? See? This is why I need help from some badass registered dietitians.
🎩 tip to the author!

-EJ

Prediction of fluid responsiveness: an update



Link to Article

Link to PDF

If your way of determining whether a patient is fluid responsive or not is to see if the blood pressure went up after giving a bolus, you are doing it WRONG! You need to stop, take a deep breath, and reassess your way of thinking about fluid responsiveness. This (FREE!) article dives into why fluids should not be provided arbitrarily go make us feel good inside and make us feel like we at least "did something" in response to that low mean arterial pressure. No, I do not use SBP and DBP off of the BP cuff in my practice. More on that at another time. This article also goes briefly into why we should not be checking CVP (duh). Bottom line is that we can't accurately predict fluid responsiveness without an arterial line and some sort of device to predict stroke volume, stroke volume variation, cardiac index/output. You could have some really good echo nunchuck skills as well. This study also emphasizes why looking at IVC variations is not the best test. Ultimately, we all need to get better at this, myself included. I feel that this article is particularly important for nurses as you all are the ones who relay the BP concerns to the clinicians essentially ordering the fluids. These three authors are legends of critical care. A real treat that Annals of Intensive Care published this for free.
This article is going to be part of the bibliography for the talk I will be giving in Portland, OR in August of 2020.

-EJ