Saturday, December 14, 2019

Continuous Infusion of Lidocaine

I covered the 2015 version of meta-analysis back in April when I couldn't get my hands on this one, the 2018 version. I appreciate the Cochrane Library for making this free. You could get to it from my website. The last time I posted about Lidocaine was in April when I had fewer than 1500 followers and this community is extremely helpful in shaping how we all practice. Not to mention that my posts at that time were even harder to read than they are now!
At that time, a follower named @ameliahlaws commented on how her shop uses lidocaine for their trauma patients and have seen great results. That was definitely encouraging. I do not have experience with this in my practice because it cannot be used in patients with renal nor heart failure due to the active metabolites which can cause accumulation and toxicity respectively. As I primarily take care of medical ICU patients at the moment, using this medication would not be helpful.

This meta-analysis was one heck of an endeavor. Let me summarize the 285 pages in several words: we need more data. That was the conclusion that these authors came to as well because ultimately the quality of the data is so poor, or how they described it "very low quality". It hurts to write that because, as many of you know, I do not do research myself, and that seems like a kick in the face to those out there who work so hard doing the necessary research that ultimately improves patient care.

I have added the Forest Plots to my slides because they look pretty and make it seem like it's of substantial impact but in reality it's not. Sigh.

As mentioned, many of the findings were "very low quality". That doesn't mean that it doesn't work, nor that future studies won't prove that it does work, but rather that we just don't know YET.

The authors are recommending someone, anyone, conduct a study with more than 200 patients. I guess that's why this is "cutting edge" stuff at the time of this post. They also cannot make any recommendations regarding dosing, duration, timing, and the type of surgery where this would benefit the most.

-EJ


Link to Article (FREE)

Link to PDF

Weibel S, Jelting Y, Pace NL, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database of Systematic Reviews 2018; 6: CD009642.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:

You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
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Friday, December 13, 2019

Vitamin C/Ascorbic Acid and Burn Patients.

I can already hear it in my head. "But Eddy, there's no data that Vitamin C does anything for anyone so I refuse to give it even though it's inexpensive and has no side effects based on the CITRIS-ALI study, as well as other studies which have flaws for x, y, and z reasons. I'm going to wait for more data while my patients wait for my ego to come around. And then when that data comes out, I'm going to wait another year just because I'm a contrarian-contrarian."

There are a multitude of reasons why high dose IV Vitamin C (defined as greater than 10gm in 24 hours) should work. This study is wrought with limitations, admitted to by the authors. They conducted some statistical jumping jacks and made some assumptions to make the numbers work. That's just the issue with retrospective studies such as this one where they're trying to make heterogenous populations look alike. It's free meaning you have no excuse to not read it for yourself. I personally do not take care of burn patients. They honestly frighten me. Definite kudos to all the burn unit crews out there who take care of these patients.

I understand that some burn centers in the US are already using IV Vitamin C. Is this a thing at your shop? A hat tip to the authors!

- EJ


Link to Abstract

Link to FULL FREE Article

Nakajima, M., Kojiro, M., Aso, S. et al. Effect of high-dose vitamin C therapy on severe burn patients: a nationwide cohort study. Crit Care 23, 407 (2019)

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:

You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store

Thursday, December 12, 2019

Impella Stuff

This is my first of many posts on the Impella system by Abiomed. It is going to be part of my "Cardiogenic Shock: Rise of the Machines" lecture for Portland in August 2020.

I am planning on covering LVADs, RVADs, ECMO, TandemHeart, etc. in the upcoming months but one does not need to work at an ECMO or transplant hospital to see an Impella. This post is targeted for the clinician or nurse who is caring for the patient and is curious as to what’s the next step. Not intended for repositioning the device or criteria for installing it. I’ll get there. Give me time. Besides, I took a break from the Ketamine for this today.

When managing a patient on the Impella, whichever of their devices, a question always comes up when the patient becomes hypotensive. Do they need vasopressors or ionotropes? This algorithm from the Detroit Cardiogenic Shock Initiative is a helpful guide, definitely not an end-all-be-all but it’s better than flying without any instruments. Every patient with an Impella NEEDS a swan. You need to be able to measure the right heart pressures appropriately. You also need to be able to have an idea of what your SVR is. Without these parameters handy, you’re in the blind and clueless. Honestly, you should consider transferring the patient out to another shop before they get too sick to salvage.

Calculating the CPO and PAPI is something that nurses do and let the physicians know when things are going south. My favorite is to get the call followed by a suggestion to start a new med. that shows they’re vested and I love that.

Even though I do not run ECMO or have an LVAD program at my shop, I’m fortunate that I have colleagues at nearby hospitals who respond to my texts promptly and are around to help. It’s a blessing. My fellowship training provided me with a great amount of experience to where I do what I know how to do and when I need to make that call, I make it. No shame. Patients come over ego.

-EJ

LINK TO PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store

Wednesday, December 11, 2019

Be careful with Ketamine and Catecholamine-dependent Heart Failure

The Ketamine kick continues! I am not going to pretend I knew everything about everything as I've created this page over the last several months. People who walk around saying things like they were born with that knowledge sometimes need to be checked. We all had that one eye-opening day where it was like, "(explicative) I should have known that!"

I had some basic knowledge on ketamine but fortunately I have expanded that substantially over the course of working on my lectures. The whole "negative ionotrope" concept was something I was familiar with, but I never actually looked up in depth until colleagues such as the great Seiha Kim, David Convissar, and other great anesthesia colleagues who have more experience on the matter than I do. Not to mention that Seiha is both a pharmacist and an anesthesiologist.

A healthy heart should not have any issues with ketamine for sedation nor rapid sequence intubation, but, as mentioned in the Christ article linked, you can find a 21% decrease in cardiac index. This also brings me to the point where many clinicians focus on the blood pressure while ignoring the patients cardiac index/cardiac output. It makes us feel all warm and fuzzy inside to see the MAP > 65 as we keep on increasing our pressors but at the same time we have NO IDEA what this afterload increase is doing to the LV. We feel self-reassured but really our patients are going on a downward spiral. That's a discussion for another day. We really need more than a BP cuff or an a-line to get a true grasp of what's going on with our critically ill patient who is otherwise hemodynamically unstable.

-EJ


Link to Abstract

Christ G, Mundigler G, Merhaut C, Zehetgruber M, Kratochwill C, Heinz G, et al. Adverse cardiovascular effects of ketamine infusion in patients with catecholamine-dependent heart failure. Anaesth Intensive Care. 1997;25:255–259.


Link to Abstract

Bovill JG (2006). Intravenous anesthesia for the patient with left ventricular dysfunction. Semin Cardiothorac Vasc Anesth 10: 43–48.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store

Monday, December 9, 2019

Ketamine + Morphine






Link to Abstract

Jennings PA, Cameron P, Bernard S, Walker T, Jolley D, Fitzgerald M, Masci K: Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med. 2012, 59: 497-503. 10.1016/j.annemergmed.2011.11.012.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store

Ketamine: Mechanism of Action





Link to Abstract

Link to FULL FREE Article

K Hirota, D G Lambert, Ketamine: its mechanism(s) of action and unusual clinical uses., BJA: British Journal of Anaesthesia, Volume 77, Issue 4, Oct 1996, Pages 441–444.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store

Tuesday, December 3, 2019

Pregabalin to Avoid Opioids

I’m hard at work on a protocol for my shop to decrease opioid usage as well as preparing my lectures on opioid sparing medications. Amongst those are the gabapentinoids. You’ve seen them often, I’m sure, mostly to treat neuropathic pain such as diabetic neuropathy as well as trigeminal neuralgia but what about for actual painful procedures? This family of medications reduce the abnormal hypersensitivity induced by inflammatory responses or nerve injury. What not just place it in the drinking water for our patients? That’s kind of where I’m going with this.

This study was published in 2011 and they gave patients Pregabalin, also known as Lyrica, to see how much opioids the pts would need. They got 150mg before the surgery and then 75mg twice a day until post-op day 5. The main drawback is how it delayed the time to extubation. I don’t know if I am interpreting the data correctly but patients on Pregabalin were on the vent for about 2 hours longer than those not on it. Perhaps the 150mg 1 hour before the surgery was too much. Either way, as noted on the abstract slide, it reduced the post-op consumption of opioids by 44-48%. That’s a big win.

Do you all routinely use Pregabalin or Gabapentin for pain management at your institutions? I’m going to go through more data on this topic in the upcoming week.


-EJ



Link to Abstract

Link to FULL FREE Article

Pesonen A, Suojaranta-Ylinen R, Hammaren E, Kontinen VK, Raivio P, Tarkkila P, Rosenberg PH. Pregabalin has an opioid sparing effect in elderly patients after cardiac surgery: a randomized placebo-controlled trial. Br J Anaesth 2011;106:873–81


Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
My Amazon Store


Saturday, November 30, 2019

Magnesium for Sedation in Mechanically Ventilated Patients?

This is cool, really cool. We need more data, but this is a great start. I learned a lot of basic science from reading the introduction as well as discussion on this article and it all makes sense. I don't see myself using this anytime soon until there's a study where they add magnesium to a different agent that's not midazolam because I do not use benzodiazepines in my practice for sedation unless there are extreme cases.

I encourage you read this article yourself as it's interesting and I don't want to divulge too much out of respect for the authors.

-EJ



Link to Abstract

Link to FREE FULL PDF

Altun, Dilek. (2019). Can we use Magnesium for sedation in Intensive Care Unit for critically ill patients; Is it as effective as other sedatives?. Ağrı - The Journal of The Turkish Society of Algology. 31.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store

Ketamine Continuous Infusions for Sedation in the ICU

One of the lectures I’m working on is regarding minimizing opioid utilization in the ICU on our critically ill patients on mechanical ventilation.
I honestly do not use ketamine as often as I’d like and I have been reviewing all the data behind continuous infusions over the last two days.
Unfortunately, the data isn’t incredibly robust (small sample sizes, mostly retrospective, heterogenous non-MICU patient populations) and there is a wide variation in the doses used in the different studies. This study published earlier this year used ketamine in conjunction with other agents, mostly propofol or fentanyl. The authors found that using ketamine decreases the doses the other agents with no changes in all the other outcomes. Most clinicians are looking for miracle drugs rather than incremental (albeit small) improvements here and there.
One of the problems I have with ketamine is, depending on how it’s mixed, is the sheer volume of the drip. I try to keep my patients potato chip dry and if the ketamine is basically a maintenance fluid, I’m not going to be as excited about it. 

Do you all use ketamine in your ICU for continuous sedation? Do you use it as monotherapy or with other infusions?



Link to Abstract

Garber, P. M., Droege, C. A., Carter, K. E., Harger, N. J. and Mueller, E. W. (2019), Continuous Infusion Ketamine for Adjunctive Analgosedation in Mechanically Ventilated, Critically Ill Patients. Pharmacotherapy, 39: 288-296.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store




Friday, November 29, 2019

Analgesia and Sedation in the ICU


Link to Abstract

Sessler, C. N., Grap, M. J., & Brophy, G. M. (2001). Multidisciplinary Management of Sedation and Analgesia in Critical Care. Seminars in Respiratory and Critical Care Medicine, 22(02), 211–226.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.
The primary source of compensation I receive for this page and Instagram work is via Amazon Affiliates. All this free education you receive is much out of the kindness of my heart but I also like to receive a check every month from Affiliate Marketing. No one likes to work for free. The best part is that it's of no cost to you. Here's how it works:
You click on the link for Will Owens' awesome ventilator book here: https://amzn.to/2myFxYm and whether or not you purchase the book I receive a small commission for whatever you buy on Amazon for the next 24 hours at no cost to you. For every copy of the Ventilator book people have bought off of my affiliate links, for example, I have earned $0.85. I know it's not big money but it helps motivate me to keep on plugging along doing this heavy lifting in Critical Care. Thank you for supporting my work!
- My Amazon Store