Friday, October 13, 2017

Journal Club-ish 4.1

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association
http://circ.ahajournals.org/content/early/2017/09/18/CIR.0000000000000525

This an open access from the AHA regarding management of Cardiogenic Shock. This is good stuff. There's nothing brand new (to me at least) but it's always good have the (mostly) updated data in one place. Of course, I'm solely going to touch on the topics of Medical Management because I can't perform PCI nor introduce Impellas (yet). 

Here are a couple of key points that I like: 
  • "Although the CICU environment may be best suited to centralize cardiac care of patients with CS, attending cardiologists and teams may not have the dedicated training to address the ancillary multi-system organ failure often associated with CS." There are little smiling emojis with the hearts for eyes all over this point. I don't want to incite a specialty war here, but I prefer to be involved in the care of these patients. That's my specialty-induced bias. 
  • They don't recommend a set MAP target. This makes a lot of sense to me since everyone is different and BP does not equal a good cardiac output. Lots of training in the CVICU world proved this to me (thanks fellowship!). What they recommend is to look at the patient, check lactates, mixed venous blood gases, UOP, LFTs, renal function, temperature, and, of course, look at your patient! I purposefully repeated the last part to emphasize it.
  • This next point is a mixed bag. First of all, they call out dopamine for what it is; "Dopamine was associated with a higher rate of arrhythmias in the CS and overall populations and was associated with higher risk of mortality in the CS subgroup". But then they go ahead and list it as first line using either it or Norepinephrine in table 5 for initial vasoactive management considerations (which is a great table, by the way). They also show a dose-related receptor binding model which I could've sworn was disproven. I need to find that data now for you all. 
  • Thank you for not touching on the mode of mechanical ventilation in these patients. Also, good job in addressing the "potential deleterious effect of hyperoxia in patients with ACS, HF, and OHCA and in general ICU patients". That's something we see too often that we need to improve upon. 
  • Did I already mention that I liked table 5? Well, I like table 5. 
A couple points I don't like: 
  • They recommend checking CVPs. Ugh. I guess if you trend the number instead of of just taking the textbook numbers as being normal then you may be okay. Ultimately, I recommend that you become comfortable with bedside echo, the intensivists new best friend. At the time of this writing, the ever elusive method to volume status continues to be ever elusive. 
  • They don't really dig in to the argument of using CRRT/ultrafiltration to offload the heart which I believe is reasonable. I'm not going to go into the studies of early vs. late dialysis nor the studies of using ultrafiltration to offload the heart. That's a topic for another day. I guess the AHA felt the same way. 
  • The whole dopamine thing I ranted about above. Yeah, I don't like that. 
At the end of it all, just read the article for yourself. It's worth your time instead of scrolling through Instagram a few times. Thanks to the authors. These things must be a beast to put together.

I was going to write JC-ish 5.0 but this article got me all excited and took up far more time than intended as I was dissecting it. I'll just call it 4.1.   

-EJ

Tuesday, October 10, 2017

Journal Club-ish 4.0

2017 EACTS Guidelines on perioperative medication in adult cardiac surgery
A 29 page PDF which is pretty extensive in its coverage of the perioperative management regarding medications in the CTS patients. It's free and a must-read for everyone taking care of this patient population

Antibiotic therapy, supportive treatment and management of immunomodulation-inflammation response in community acquired pneumonia: review of recommendations
This is also an open access article.  Some of the goodies of the include: 
"There are no specific recommendations regarding the proper duration of antibiotic treatment"
- So the 8 days vs. 14 days assumptions go out the door. 
"the duration of antibiotic treatment can be guided by the trend of procalcitonin levels; antibiotic could be interrupted when PCT levels reach 0.1 ng/ml"
- We should be checking PCT, acknowledging the limitations of this, during the course of the ICU stay.
"patients with more severe respiratory failure (PaO2/FiO2 < 200) had lower risk of intubation if treated with HFNC compared to traditional oxygen or NIV, indicating a possible role of this technique in this type of patients"
- There are other studies that show HFNC to be superior to NIV(BiPAP) in PNA. 
We also don't need to give vancomycin and zosyn to everyone who comes to our ICU's with PNA

Acute-on-chronic liver failure: recent update 
This is more of a pathophysiology article rather and a how to manage article. I am not going to lie, I just skimmed through this article as it was a bit too dense for what I can process right now. I'll get back to this one at some point soon. 

Update in Management of Severe Hypoxemic Respiratory Failure
This one is a contemporary review from Chest; the need to know articles. 
Key points:
- if the P/F ratio <150, think about paralyzing and proning 
- tidal volume of 4-8 cc/kg of IBW, decrease to 4 if plateau presses > 30 (if chest wall is normal)
- there's some cool info regarding high PEEP vs. low PEER and mortality
- they explain some recruitment maneuvers 
- table 3 has some key potential benefits of prone positioning
- there's a nice management flow chart towards the end.
- needless to say, I printed a bunch of these out and handed them to my staff. 

Efficacy and safety of a balanced salt solution versus a 0.9% saline infusion for the prevention of contrast-induced acute kidney injury (BASIC trial): a study protocol for a randomized controlled trial
A heads up on a study being performed in South Korea which is basically NS vs. what we call plasma-lyte here in the States. He's the kicker, it's being sponsored by the pharmaceutical company producing the balanced salt solution. 

Once again, thanks to Rob Mac Sweeney at criticalcarereviews.com. You should definitely subscribe to his email list and check out his work.

-EJ

Brachial Arterial Catheterization

Since I've started working at my new institution, I've placed two brachial arterial lines and an axillary line. As any intensivist will admit, if you're looking elsewhere from the radial, it means that the patient is pretty sick and you need some results, quickly.

While performing this procedure, I've received strange looks from the nurses as they are unfamiliar with the location. Where I trained, I saw anesthesia commonly place these without any issues in the cardiac surgery population. I decided to do a bit of a search for the data behind the safety of this procedure.

First of all, why should we worry? The brachial artery lacks collateral circulation. As with any other line, we worry about clinical ischemia, nerve injury (which is the median nerve in the case of the brachial artery), and infection. What's the data behind these, though?

Here are some of the more recent studies. I'll let you all decide for yourselves after you read the articles. Thanks to the authors!

Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine
Published in 2002 in Critical Care. This is an open access article. 
"Only one serious complication was found in a study of 1000 patients in which the brachial artery was used for invasive monitoring in ambulatory patients. This complication was an infected haematoma arising from a pseudoaneurysm. Another study that employed the brachial artery for arterial blood sampling in 6185 patients also showed a small number of complications (incidence 0.2%), mainly paresthesias." 

Brachial Arterial Pressure Monitoring during Cardiac Surgery Rarely Causes Complications
I cannot obtain full access to this study published in June of 2017 but it can be found here: 
Review of their abstract shows that their study population was exclusively in cardiac surgery patients and they looked at vascular issues, nerve injury, and infections as complications
They concluded that "Among 21,597 qualifying patients, 777 had vascular or nerve injuries or local infections, but only 41 (incidence 0.19% [95% CI, 0.14 to 0.26%]) were potentially consequent to brachial arterial cannulation. Vascular complications occurred in 33 patients (0.15% [0.10 to 0.23%]). Definitely or possibly related infection occurred in 8 (0.04% [0.02 to 0.08%]) patients. There were no plausibly related neurologic complications."

Brachial Artery Catheterization: An Assessment of Use Patterns and Associated Complications

Published in 2012 in Anesthesia and Analgesia. This is open access so you can obtain a copy for yourself! 
This was a retrospective study with 858 patients. "the overall rate of vascular and neurologic complications was low in both brachial and radial artery catheterization groups (3 [0.35%] vs 1 [0.03%], brachial versus radial, respectively; P = 0.03). No cases of catheter-related bloodstream infection were identified in either cohort."

There are some older studies which I need to briefly glance at but I wanted to get this out there and I'll add some more goodies later. 

-EJ

Thursday, October 5, 2017

Journal Club-ish 3.0

Disclaimer and full disclosure: Bigtime bias alert: I LOVE HFNC! We haven’t even kissed the edge of it’s capacity. Here’s more data supporting how glorious it is!

"In the absence of high-quality data, nicotine replacement therapy cannot currently be recommended for routine use to prevent delirium or to reduce hospital or ICU mortality in critically ill smokers."
I do have to say, I was wrong on this. I thought that placing nicotine patches would make smokers on the vent less crazy but the data isn’t there. Guess I’ll stop using nicotine patches in the ICU. 

“EN was associated with a significant reduction in overall mortality (risk ratio (RR)=0.36, 95%confidence interval (CI) 0.20–0.65, P=0.001) and the rate of multiple organ failure (RR=0.39, 95% CI 0.21–0.73, P=0.003). EN should be recommended as the preferred route of nutrition for critically ill patients with severe acute pancreatitis.
Just another paper saying EN is superior to PN. TPN --> higher overall mortality and more organ failure. Think about this just about every time we have a patient on TPN. 

Outcomes of restrictive versus liberal transfusion strategies in older adults from nine randomised controlled trials: a systematic review and meta-analysis
Uh-oh. This is the first paper where it says that liberal transfusions are better in geriatric pts. Here goes the roller coaster of recommendations for blood transfusions! They consider geriatric pts to be >65yo. I think I posted something contrary to this in Journal Club-ish 1.0

Diagnostic testing for Legionnaires’ disease
Remember to send off the urine Legionella antigen. This should come back pretty quickly. Although they should still be sent out, the respiratory cultures take 3-5 days to return. There are other fancy tests described there but I honestly don’t know what our institution has the capacity to do. 

Opioid-associated iatrogenic withdrawal in critically ill adult patients: a multicenter prospective observational study
We give just about every patient on the vent opioids, they’re going to withdraw of course, right? 17% withdrew per this study. No, this is not something that happened while the patient was in the ICU, but it could be something that creates some havoc on the floor once they’re transferred from the unit. Note that the largest group of the people in the study were trauma patients and only 15% were respiratory issues. Of note, needing more opioids led to more withdrawal, as one would think. Also, use of benzos led to more withdrawal, too. People on precedex and propofol had less withdrawal.

Percutaneous tracheostomy: a comprehensive review 
A cool study on resuscitation that you probably can guess what the outcome is, but it’s always good to know the data behind it. Published in SCCM. 

Treatment of Hyponatremic Encephalopathy in the Critically Ill
This is extremely important and it’s a Concise Definitive Review from SCCM. These are the big papers. We have all been trained to have a health respect for hyponatremia and should not need nephrology to manage this for us. This is a good read, if you have access. 

Central Venous Catheter Insertion and Bedside Ultrasound: Building a New Standard of Care?
Using ultrasound to get rid of CXR to confirm central line positioning. Sounds like we’re saving money here. Less radiation to the patients. I like this idea. Possibly too soon to implement, though.

Incorporating Dynamic Assessment of Fluid Responsiveness Into Goal-Directed Therapy: A Systematic Review and Meta-Analysis
Almost last, but definitely not least. 
Don’t blindly give fluids. Have an objective and pursue it. 
Dont use CVP: "Static indices such as the central venous pressure (CVP) consistently fail to predict fluid responsiveness, calling to question their utility in goal-directed therapy algorithms”
"goal-directed therapy guided by assessment of fluid responsiveness appears to be associated with reduced mortality, ICU length of stay, and duration of mechanical ventilation”

PS: I am definitely open to suggestions. 
-EJ


Journal Club-ish 2.0

New and fun stuff!

DETO2X–SWEDEHEART Trial
This is a big deal. "supplemental oxygen offers no benefit in patients with acute myocardial infarction who have normal oxygen saturation."  Time to take away the O from MONA for ACS if the patient doesn't need it. 

Quality sleep using earplugs in the intensive care unit: the QUIET pilot randomised controlled trial
You heard it here first, in a couple years we're likely going to be putting earplug in our patients overnight to improve sleep and reduce delirium. This is a pilot/feasibility study. No important data comes from those but it sets up a much bigger trial. Just be aware it exists. Only read if you're really curious. 

Continuous versus intermittent neuromuscular blockade in patients during targeted temperature management after resuscitation from cardiac arrest—A randomized, double blinded, double dummy, clinical trial
Now there's data suggesting using continuous drips for paralytics in cardiac arrest pts versus bolus doses. 

Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study
This study looked to see if early feeding was good enough to prevent GI bleeds in critically ill pts.  They had no difference in the two groups of pts but they only enrolled 104 pts. Not enough to change my practice. Next! 

Effects of intraoperative and early postoperative normal saline or Plasma-Lyte 148® on hyperkalaemia in deceased donor renal transplantation: a double-blind randomized trial
"Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic". I'll just keep dumping the evidence to use plasma-lyte until we finally get it. 

Protein delivery and clinical outcomes in the critically ill: a systematic review and meta-analysis
My inherent bias wants there to be a mortality benefit to giving protein via the gut but the data just isn't there..... for now....

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review
Bottom line: if the RT places the glidescope next to the bed immediately, use it. The first couple days I fought to use DL but I've conceded. VL is just so much easier. This Cochran review reflects that. 

Central venous catheter placement in coagulopathic patients: risk factors and incidence of bleeding complication
Platelets of 50? INR of 1.5? PTT of 45? Who cares! Drop that line. Platelets less than 20 and INR > 3, think about it. 

The ADRENAL Trial (coming soon... next couple years!)
Statistical analysis plan for the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial You all don't need to read this one, but it's really exciting to know that someone is finally going to put the stress dose steroid question to bed as to whether we should or shouldn't do it! Stay tuned!

REFRESH Trial
While we're on the subject of other things that may be complete BS, they've just started a study where they're challenging the 30cc/kg boluses that everyone gets in the ED when they're sick. 
I am in the school of thought that every bit of fluid we give a patient needs to be justified and not arbitrary. As it could be life or death in the article right under this.... 

The Right Ventricle in ARDS
This one is very important and one of my soapbox topics. Please read. I sent you another article on the same topic last week but it goes to show how important all this is, especially with flu season around the corner again. Not to mention, it's quite sexy. 

Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice
How to place a central line. This is probably the most important article for those of you who need some experience placing lines. A free full article! 


-EJ


Journal Club-ish 1.0

This was sent out to my staff on 8/28

A Randomized Clinical Trial of Red Blood Cell Transfusion Triggers in Cardiac Surgery
http://www.annalsthoracicsurgery.org/article/S0003-4975(17)30781-6/fulltext
Bottom line: transfuse to Hb of 8 (HCT of 24). But I'll post something that contradicts this in Journal Club V2. 

A systematic review of diagnostic methods to differentiate acute lung injury/acute respiratory distress syndrome from cardiogenic pulmonary edema
https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1809-8
Bottom line: there's no one test to tell the difference. It's cool bc it describes a bunch of fancy biomarkers that we don't use in our clinical practice that ultimately don't make a difference. Hopefully one of these will show more promise. 

Below is a link to going to a whole journal issue focused on ARDS. It's all free, too!
http://atm.amegroups.com/issue/view/585
I like this for you all because they are review articles, no need to analyze confidence intervals. Someone smarter than me already did this for you!

Tidal volume in acute respiratory distress syndrome: how best to select it
http://atm.amegroups.com/article/view/15712/html
Basically 6cc/kg IBW. There are variations to this and recently Rory Speigel over at www.emcrit.org wrote this piece discussing the ARMA trial which I found to be quite interesting.
https://emcrit.org/emnerd/case-ugly-truth/

Prone positioning acute respiratory distress syndrome patients
http://atm.amegroups.com/article/view/15476/html
Just do it already. Recognize that barely anyone can afford those fancy beds. You can do it at your shop, too. 

Recruitment maneuvers in acute respiratory distress syndrome
http://atm.amegroups.com/article/view/15713/html
You've heard of recruitment maneuvers on the vent. Here they explain how to do them. 

Sedation and neuromuscular blocking agents in acute respiratory distress syndrome
http://atm.amegroups.com/article/view/15714/html

Right heart function during acute respiratory distress syndrome
http://atm.amegroups.com/article/view/15613/html
I love right heart pathology. This one is a bit basic but it's still good. One thing they fail to mention is how you should avoid large fluid boluses in patients with RV failure. That's a reason why bedside echocardiography is becoming so important for clinicians in the ICU. I've even heard of some curious nurses putting the echo probe on the chest to have a look (you know who you are!). Notice that the article says daily bedside echo's. If you've given a patient a generous amount of fluid and they're still really sick, a probe needs to be on the chest to see where it's going. 

High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic respiratory failure
http://atm.amegroups.com/article/view/15608/html
A sweet little review on HFNC and NIV. The goodies in here live in the oxygenation and PEEP section. Also, if you're bored, the references are good here and in all these articles bc they contain the actual studies. 

The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review
https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1810-2
Still no definitive data on when and how much to feed our patients. Sigh. I personally like to start ASAP but that obviously doesn't mean I'm right. Too many confounders in every study which will make the likelihood of getting a definitive answer pretty challenging to obtain. 

Until the next one...
-EJ

Journal Club-ish: An Introduction

As part of my job, I read A LOT. I read articles that are great and articles that aren't so great. I intend to create a regular journal club that is piggy-backed on the work of Rob MacSweeney who sends out a weekly email including the best posts of the week from criticalcarereviews.com. What I am doing is just taking the most clinically relevant studies that he sends out, digesting and sharing them with you on this format.

I also have subscriptions to Critical Care Medicine by SCCM, Chest, and a couple other open access journals that put out some quality stuff. I'm definitely NOT a researcher so I like to show off the prowess of better-than-me clinicians/researchers.

There's nothing better than some healthy academic discussions. Hopefully this will serve as a format for that. The first couple versions will be things that I have already sent out to the ARNP's and various RN's at my shop. Hopefully you'll benefit from this, too!

PS: sorry I can't post the full versions but I don't want to get dinged by the copyright folks.

-EJ

Monday, October 2, 2017

Lithium Toxicity: To Dialyze or to Monitor?

(Hypothetical) Case scenario: Patient comes in, accidental overdose of lithium, HD stable, physical exam unremarkable, labs pristine, lithium level of 2.x. Poison control called. ED interventions performed flawlessly. Nephro consulted in the ED and recommends HD if level is above (insert arbitrary number here). On recheck several hours later, pt looks GREAT clinically but the lithium value has increased closer to (insert arbitrary number here). 

Now, I'm an intensivist and make my living off of placing vascular catheters but only if there's appropriate data behind it. It is time to look up the data. No, I won't even pretend to know everything. 

Hey, look! There's a Cochrane review about it!
Full (free) article: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007951.pub2/epdf



Here are a couple things that caught my attention regarding this review: 
"No randomized controlled trials of hemodialysis therapy for lithium poisoning were identified."
This is definitely reasonable. I mean, imagine the complexity of consenting these patients who are on lithium already for an unfortunate reason and have overdosed for one reason or another where their capacity may be questioned. IRB permission, sigh.  

Hence, after a very thorough review of all the data including the more recent (2015) Extracorporeal Treatments in Poisoning (EXTRIP) workgroup systematic review, the author concludes that: 
"Although the use of hemodialysis to enhance the elimination of lithium in patients with lithium poisoning is logical, there is no research from randomized controlled trials on its benefits and harms in patients with lithium poisoning. Most patients with lithium poisoning recover fully, but the available data do not provide a reliable way to predict which patients will have a good or poor outcome. Until higher-quality evidence can be developed, the decision to use hemodialysis in addition to standard therapy with intravenous fluids will continue to be based on clinical judgment. Hemodialysis treatment should ideally be given as part of a randomized controlled trial."
This conclusion is to be expected, we like data, any good data, and we just don't have it here. 

The fine investigators in the EXTRIP workgroup published this fine piece of work which gave way to the table listed below. 
Full (free) article:http://docs.wixstatic.com/ugd/363318_f36816033c994d129d7663213a31ea71.pdf



This makes a lot more sense. Choosing an arbitrary number has no data behind it. Fortunately, my patient has great renal function, a stable mental status, and her heart is lovable. Let's hold off on HD. At least that's what I'm going to do, for now. 

In the words of one of my favorite attending physicians during my fellowship, sometimes you have to just "do something". I'm not going to listen to him this time. 

A big hat tip to the researchers involved because I just dislike doing research. 
-EJ

Sunday, October 1, 2017

How to position your patient prior to intubation: ramped vs. sniffing

We still don’t know what’s the best way to position our patients to intubate them; ramped position (torso and head elevated) which has had some theoretical OR benefits vs. sniffing position (torso supine, neck flexed forward, and head extended). Patients did worse with the ramped position. An important takeaway is listed below. I do recommend that you add the Cormack-Lehane Grade views to your airway notes. This, combined with what medications you used, what size glidescope or blade you used definitely helps with future intubations. You should learn to look for prior intubation notes to prepare for difficult airways. All it takes is one bad one and your confidence will be shattered. Don’t let it happen to you. A hat tip to the investigators. 



A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults

Semler, Matthew W.Janz, David R. et al.

Pre-intubation Checklist

This was essentially a negative trial but I do feel the checklist they used is very helpful for house-staff; especially those who take call without direct supervision (as I did just a few short years ago). A hat tip to the investigators. Article linked below.

A multicenter, randomized trial of a checklist for endotracheal intubation of critically ill adults. Janz DR1, Semler MW2, Joffe AM3, Casey JD2, Lentz RJ2, deBoisblanc BP4, Khan YA4, Santanilla JI5, Bentov I3, Rice TW2; Check-UP Investigators; Pragmatic Critical Care Research Group.
Chest. 2017 Sep 13. pii: S0012-3692(17)32685-5. doi: 10.1016/j.chest.2017.08.1163.
http://journal.chestnet.org/article/S0012-3692(17)32685-5/pdf

Saturday, September 23, 2017

Trying something new... stay tuned...
-EJ