Friday, March 13, 2020

US Ventilator Resources for COVID-19

I have purposefully kept quite and obtained data regarding the COVID-19 outbreak. I don't like to open my mouth or write unless I have a pretty good grasp on what is going on. My crew and I are going to be on the front lines when this thing hits, and I believe it's going to hit. I hope I'm wrong. The majority of the people who follow my page are going to be on the front lines, too. That being said, the system is going to be stressed for resources. I have already heard from different regions of the country and I'm concerned. 

The Society of Critical Care Medicine just sent out an email discussing resource availability. 
I'm more concerned after reading this letter. The data is extremely outdated in many parts. The numbers are obtained from the American Hospital Association which were obtained via voluntary survey. Here's an example: in 2009 we had, in the country, 62000 vents. We have almost 99000 old vents (I don't know what this means nor where they are bc they mention that 23k are NIV, 33k are automatic resuscitators, and 8500 are CPAP units). The strategic national stockpile has 8900 ventilators ready for deployment. 

We're looking at an estimated total of 200,000 ventilators in the country. 

They crunched the numbers based on the number of people who end up on the vent with COVID-19. We could reasonably expect 960,000 to require ventilatory support. I don't know if ventilatory support means non-invasive ventilation + high flow nasal cannula + mechanical ventilation or just MV. I've read about avoiding NIV and HFNC as they aerosolize the virus but I need to learn more. 

It's great to see that we have more critical care beds per capita than anywhere else in the world, but who is going to take care of those patients when there's a limited supply of healthcare professionals who are trained to take care of the critically ill? 

I see this as us being in deep trouble and that all the lockdowns, travel bans, cancellations of everything being justified. My respect for this is growing as I become more educated. I was supposed to go to Greece on Monday. I was bummed out but I reminded myself that this is not about me. 

Stay safe, everyone. 

-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.


Intravenous Fluid Lecture: Citations

I have been missing for a few weeks as I am putting the finishing touches on my lectures that are due on the 15th of this month. The amount of time and effort necessary to write a CME lecture is insane. I've written 7 of them in this last year. Voluntarily, of course. I'm not complaining. For my intravenous fluid lecture, I have cited 43 different articles listed below. I have attempted to cite these articles as well as I know how to but there will be some inevitable errors. If you plan on creating an IVF lecture of your own, this is my gift to you. My only request is that you credit me in some way, shape, or form. Ultimately, I did not write any of these articles. I have to tip my hat to everyone who contributed to the writing of all of these articles. They are the ones who did the leg work and I am ultimately piggybacking on their efforts. 

This lecture discusses the three fluids we use for resuscitation in critically ill patients: 0.9% NaCl, Lactated Ringers, and Plasma-Lyte. I go over the history of the three fluids, and also break down the contents of these fluids, based on the data on how they affect our patients and our organs, then present the relevant data on how these data changes outcomes in our critically ill patients. The reason why this is a controversial topic is because most clinicians use saline because they really do not understand what is in it, nor the effects of it. As I mention in one of my slides, if the FDA had to approve 0.9% NaCl today, chances are that it would not be approved. 

I am sorting out how to provide you all with this lecture, youtube or some other medium. The issue is that youtube has a thing for demonetizing my videos the moment I say the words "mortality", "death" and others. I do earn some income from you all visiting my website, eddyjoemd.com to check out the links and download the articles I share. Thank you all for your support! 

-EJ

Citations:


Lobo DN, Stanga Z, Aloysius MM, et al. Effect of volume loading with 1 liter intravenous infusions of 0.9% saline, 4% succinylated gelatine (Gelofusine) and 6% hydroxyethyl starch (Voluven) on blood volume and endocrine responses: a randomized, three-way crossover study in healthy volunteers. Crit Care Med. 2010;38(2):464–470. doi:10.1097/CCM.0b013e3181bc80f1

Link to Abstract

Ragaller MJ, Theilen H, Koch T. Volume replacement in critically ill patients with acute renal failure. J Am Soc Nephrol. 2001;12 Suppl 17:S33–S39.

Link to Abstract


Link to FULL FREE Article

Bark BP, Persson J, Grände PO. Importance of the infusion rate for the plasma expanding effect of 5% albumin, 6% HES 130/0.4, 4% gelatin, and 0.9% NaCl in the septic rat. Crit Care Med. 2013;41(3):857–866. doi:10.1097/CCM.0b013e318274157e

Link to Abstract

Lobo DN, Dube MG, Neal KR, Simpson J, Rowlands BJ, Allison SP. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr. 2001;20(2):125–130. doi:10.1054/clnu.2000.0154

Link to Abstract

Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr. 2008;27(2):179–188. doi:10.1016/j.clnu.2008.01.008

Link to Abstract

Lewins, Robert. Injection of Saline Solutions into the Veins. (1832). The Boston Medical and Surgical Journal, 6(24), 373–375.


Link to Abstract


Link to FULL FREE Article

Hartmann AF, Senn MJ. STUDIES IN THE METABOLISM OF SODIUM r-LACTATE. II. RESPONSE OF HUMAN SUBJECTS WITH ACIDOSIS TO THE INTRAVENOUS INJECTION OF SODIUM r-LACTATE. J Clin Invest. 1932;11(2):337–344. doi:10.1172/JCI100415

Link to Abstract


Link to FULL FREE Article

Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med. 2016;5(4):235–250. Published 2016 Nov 4. doi:10.5492/wjccm.v5.i4.235

Link to Abstract


Link to FULL FREE Article

Rizoli S. PlasmaLyte. J Trauma. 2011;70(5 Suppl):S17–S18. doi:10.1097/TA.0b013e31821a4d89

Link to Abstract


Link to FULL FREE Article

Brown RM, Wang L, Coston TD, et al. Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial. Am J Respir Crit Care Med. 2019;200(12):1487–1495. doi:10.1164/rccm.201903-0557OC

Link to Abstract


Link to FULL FREE Article

Li H, Sun SR, Yap JQ, Chen JH, Qian Q. 0.9% saline is neither normal nor physiological. J Zhejiang Univ Sci B. 2016;17(3):181–187. doi:10.1631/jzus.B1500201

Link to Abstract


Link to FULL FREE Article

Wilcox CS. Regulation of renal blood flow by plasma chloride. J Clin Invest. 1983;71(3):726–735. doi:10.1172/jci110820

Link to Abstract


Link to FULL FREE Article

Quilley CP, Lin YS, McGiff JC. Chloride anion concentration as a determinant of renal vascular responsiveness to vasoconstrictor agents. Br J Pharmacol. 1993;108(1):106–110. doi:10.1111/j.1476-5381.1993.tb13447.x

Link to Abstract


Link to FULL FREE Article

Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers [published correction appears in Ann Surg. 2013 Dec;258(6):1118]. Ann Surg. 2012;256(1):18–24. doi:10.1097/SLA.0b013e318256be72

Link to Abstract


Link to FULL FREE Article

McCluskey SA, Karkouti K, Wijeysundera D, Minkovich L, Tait G, Beattie WS. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study. Anesth Analg. 2013;117(2):412–421. doi:10.1213/ANE.0b013e318293d81e

Link to Abstract


Link to FULL FREE Article

Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013;369(13):1243–1251. doi:10.1056/NEJMra1208627

Link to Abstract


Link to FULL FREE Article

Noritomi DT, Soriano FG, Kellum JA, et al. Metabolic acidosis in patients with severe sepsis and septic shock: a longitudinal quantitative study. Crit Care Med. 2009;37(10):2733–2739. doi:10.1097/ccm.0b013e3181a59165

Link to Abstract


Link to FULL FREE Article

Neyra JA, Canepa-Escaro F, Li X, et al. Association of Hyperchloremia With Hospital Mortality in Critically Ill Septic Patients. Crit Care Med. 2015;43(9):1938–1944. doi:10.1097/CCM.0000000000001161

Link to Abstract


Link to FULL FREE Article

Suetrong B, Pisitsak C, Boyd JH, Russell JA, Walley KR. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients. Crit Care. 2016;20(1):315. Published 2016 Oct 6. doi:10.1186/s13054-016-1499-7

Link to Abstract


Link to FULL FREE Article

Modi, MP. A comparative study of impact of infusion of Ringer's Lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation.Saudi J Kidney Dis Transpl. 2012 Jan;23(1):135-7.


Link to Abstract


Link to FULL FREE Article

Khajavi MR, Etezadi F, Moharari RS, et al. Effects of normal saline vs. lactated ringer's during renal transplantation. Ren Fail. 2008;30(5):535–539. doi:10.1080/08860220802064770

Link to Abstract


Link to FULL FREE Article

Piper GL, Kaplan LJ. Fluid and electrolyte management for the surgical patient. Surg Clin North Am. 2012;92(2):189–vii. doi:10.1016/j.suc.2012.01.004

Link to Abstract


Link to FULL FREE Article

Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013;88(10):1127–1140. doi:10.1016/j.mayocp.2013.06.012

Link to Abstract


Link to FULL FREE Article

Ichai C, Orban JC, Fontaine E. Sodium lactate for fluid resuscitation: the preferred solution for the coming decades?. Crit Care. 2014;18(4):163. Published 2014 Jul 7. doi:10.1186/cc13973

Link to Abstract


Link to FULL FREE Article

Farkas, Josh. “Three myths about Plasmalyte, Normosol, and LR” https://emcrit.org/pulmcrit/three-myths-about-plasmalyte-normosol-and-lr/\.1/26/15


Link to Abstract


Link to FULL FREE Article

Nalos M, Leverve XM, Huang SJ, Weisbrodt L, Parkin R, Seppelt IM, Ting I, Mclean AS: Half-molar sodium lactate infusion improves cardiac performance in acute heart failure: a pilot randomized controlled clinical trial. Crit Care 2014, 18:R48.


Link to Abstract


Link to FULL FREE Article

Weinberg L, Collins N, Van Mourik K, Tan C, Bellomo R. Plasma-Lyte 148: A clinical review. World J Crit Care Med. 2016;5(4):235–250. Published 2016 Nov 4. doi:10.5492/wjccm.v5.i4.235

Link to Abstract


Link to FULL FREE Article


Spriet I, Lagrou K, Maertens J, Willems L, Wilmer A, Wauters J. Plasmalyte: No Longer a Culprit in Causing False-Positive Galactomannan Test Results. J Clin Microbiol. 2016;54(3):795–797. doi:10.1128/JCM.02813-15

Link to Abstract


Link to FULL FREE Article

Stocker RA. "Normal" Saline and Co: What Is Normal?. Crit Care Med. 2016;44(12):2282–2283. doi:10.1097/CCM.0000000000002030

Link to Abstract


Link to FULL FREE Article

Zampieri FG, Ranzani OT, Azevedo LC, Martins ID, Kellum JA, Libório AB. Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Analysis. Crit Care Med. 2016;44(12):2163–2170. doi:10.1097/CCM.0000000000001948

Link to Abstract


Link to FULL FREE Article

Shaw AD, Bagshaw SM, Goldstein SL, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg. 2012;255(5):821–829. doi:10.1097/SLA.0b013e31825074f5

Link to Abstract


Link to FULL FREE Article

Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GM. Early goal-directed resuscitation of patients with septic shock: current evidence and future directions. Crit Care. 2015;19(1):286. Published 2015 Aug 28. doi:10.1186/s13054-015-1011-9

Link to Abstract


Link to FULL FREE Article

Ince C, Groeneveld AB. The case for 0.9% NaCl: is the undefendable, defensible?. Kidney Int. 2014;86(6):1087–1095. doi:10.1038/ki.2014.193

Link to Abstract


Link to FULL FREE Article

Hammond NE, Taylor C, Saxena M, et al. Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013. Intensive Care Med. 2015;41(9):1611–1619. doi:10.1007/s00134-015-3878-y

Link to Abstract


Link to FULL FREE Article

Mahler SA, Conrad SA, Wang H, Arnold TC. Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis. Am J Emerg Med. 2011;29(6):670–674. doi:10.1016/j.ajem.2010.02.004

Link to Abstract


Link to FULL FREE Article

McFarlane C, Lee A. A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement. Anaesthesia. 1994;49(9):779–781. doi:10.1111/j.1365-2044.1994.tb04450.x

Link to Abstract


Link to FULL FREE Article

Young JB, Utter GH, Schermer CR, et al. Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial. Ann Surg. 2014;259(2):255–262. doi:10.1097/SLA.0b013e318295feba

Link to Abstract


Link to FULL FREE Article

Young P, Bailey M, Beasley R, et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial [published correction appears in JAMA. 2015 Dec 15;314(23):2570]. JAMA. 2015;314(16):1701–1710. doi:10.1001/jama.2015.12334

Link to Abstract


Link to FULL FREE Article

Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018;378(9):819–828. doi:10.1056/NEJMoa1711586

Link to Abstract


Link to FULL FREE Article

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584

Link to Abstract


Link to FULL FREE Article


Young PJ. Balanced Crystalloids or 0.9% Saline in Sepsis. Beyond Reasonable Doubt?. Am J Respir Crit Care Med. 2019;200(12):1456–1458. doi:10.1164/rccm.201908-1669ED

Link to Abstract


Link to FULL FREE Article


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.

Sunday, March 1, 2020

Upcoming Lectures

The following are places where I am going to be doing my lectures in the upcoming months:

2020

April 4: Ponte Vedra Beach, FL: Link to Program

Innovations in Cerebrovascular Science Conference: Topic "Pulmonary Disorders in Acute Neurological Injury"
Cancelled. 

May 14: West Palm Beach, FL: Link to Program 
Topics: Fluids and Metabolic Resuscitation, Lactic Acidosis, NIV and HFNC
Cancelled.

May 25-29: Maui, HILink to Program
Topics: Metabolic resuscitation, Lactic Acidosis, nutrition and gut health, non-opioid pain management, vasopressors, NIV and HFNC, IV Fluids
Cancelled.

August 20-23: Portland, OR: Link to Program
Topics: Cardiogenic shock, resuscitation, HFNC and NIV, nutrition and gut health, lactic acidosis, vasopressors, metabolic resuscitation

October 5-7: Philadelphia, PA: Link to Program
ResusX. Topics to be determined

2021

May 20-23: Brooklyn, NY: Link to Program
Topics: Cardiogenic shock, vasopressors, steroids and metabolic resuscitation, nutrition and gut health, non-opioid pain management, HFNC and NIV, lactate and IV fluids

Reach out to me if you're interested in me coming to your shop to do a Grand Rounds or some sort of presentation. 

Hope to see you all soon! 
-EJ


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.

Saturday, February 29, 2020

Prone Positioning for ARDS

I am a huge fan of proning patients who are in ARDS. At one point or another I'll cover the data behind proning like the PROSEVA trial (no time today or until at least June). There are a variety of ways to prone patients which reflect the disposable income of the facilities where you work and train. At the 3 institutions were I have worked and the others where I have done moonlighting shifts, we've all used some good ol' fashioned muscles and coordination.

The PDF quoted and linked here was published in December 2019 and is usually very key during flu season. I am not going to comment about the coronavirus but these patients are developing an ARDS-like syndrome where proning may work. I haven't seen any data, though. That being said, having the ability to prone patients and do it well could potentially save lives.

In the paper, they cover pretty much everything I would want them to in a document like this that's beneficial to all. They even discuss chest compressions and defibrillation in these patients, something we all fear.

The PDF is completely free and a direct link. I need to find out the citation for this bad boy. The authors did a great job and a big hat tip to them. There's a really nice safety checklist and nursing checklist included. 

How do you all prone at your institution?

Do you not prone at your shop because of fear of the tube coming out?


Have you ever had to perform CPR on a proned patient?




Link to FULL FREE GUIDELINES


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.


Friday, February 28, 2020

Norepinephrine versus Epinephrine for Cardiogenic Shock caused by a Myocardial Infarction

This is one sexy pilot study. The authors here decided to take a look at norepinephrine (NE) versus epinephrine in patients with cardiogenic shock s/p MI. They didn't use dopamine as they had noted an article that I have reference here where I discussed how dopamine actually increases mortality in cardiogenic shock compared to NE. 

The rationale why the authors went to NE was because data has shown that the myocardium may have a more favorable effect on myocardial O2 consumption. Epi was believed to cause more deleterious effects. Ultimately, though, none of this had been proven in a trial. Well, here is the trial. 
Over the course of 5 years they included 57 patients. See why I have such respect for these folks who do trials? I have no idea where I am going to be in 5 weeks, let alone 5 years. They measures a ton of parameters and did their statistical jumping jacks that I will not bore you with (but the article is entirely free for those curious minds out there). 

Ultimately, what we are about is how the patients did. With regards to their MAP, CI, and SVI, they were the same. As one would expect, the HR for the patients on epi was higher. Also expected, as epi hits more of the beta receptors, there was an increase in lactate in these patients (which doesn't mean they need more fluids).  

There was an early termination of the study, though, as 37% of the patients on epi went into refractory shock while just 7% of the patients on NE did the same (p=0.008). 
The authors acknowledge that it is a small trial but they were able to see a clear difference between the two groups. There are numerous other limitations to the study as well that they acknowledged.
When your patients are in cardiogenic shock, how do you all use your vasopressors/inotropes?

-EJ

Levy BC, Clere-Jehl R, Legras A, et al. Epinephrine versus norepinephrine in cardiogenic shock after acute myocardial infarction. J Am Coll Cardiol. 2018;72:173–82.

Link to Abstract

Link to FULL FREE Article



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.

Wednesday, February 26, 2020

Renal dose Dopamine, taking down a myth.

When one looks at the dates where the publications disproved "renal dose dopamine", you see three articles published in 2000, 2003, and 2004. It's 2020 and this has not yet been put to bed. Now, I’m all worked up about this because I’ve had clinicians tell me that it absolutely works. I saw it in residency, fellowship, and now in private practice. I’m sure some of you see it at your institutions, too.
There’s data that it improves urine output transiently but no data that it improves renal outcomes in critically ill patients. No changes in creatinine. No changes in renal replacement therapy rates. In fact, that whole discussion has been put to bed so much that there haven’t been any comments made on it over the last 15 years. No further trials attempting to prove it works. Is that why we’re still seeing it? Well, it’s time to bring the arguments against renal dose dopamine, or even using dopamine altogether back into the fray.
The data about it being beneficial was from the 60’s in animal and healthy human studies. The latest studies, however, say it doesn’t work and in fact may be harmful. I have attached some of my preliminary slides from my Vasopressors in 2020 lecture. These are some of my preliminary slides. More info will come from me directly as I present these but it should provide you with an idea of why we should rarely see dopamine in our ICU's anymore. 
Do you still all use dopamine? If so, what for?
I used to use it during codes as it was already packaged in the code carts. We have since gotten rid of these and my badass pharmacy colleagues prep me levophed drips within seconds. 

Debaveye, Y., and Van den Berghe, G.: “Is There Still a Place for Dopamine in the Modern Intensive Care Unit?” Anesthesia and Analgesia. 98(2):461–468, February 2004.

Link to FREE PDF

Holmes, C., and Walley, K.: “Bad Medicine: Low-Dose Dopamine in the ICU,” Chest. 123(4):1266–1275, April 2003.

Link to CHEST Article

Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial: Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 2000; 356: 2139–2143

Link to NOT FREE Lancet Article

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.

Monday, February 24, 2020

Cardiac Arrest Survival Statistics

We’re getting better with our management of out of hospital cardiac arrest via quality bystander CPR. The majority of this credit should go to the organizations such as the AHA who puts together programs taught by firefighters, paramedics and EMT’s (forgive me if I screw up the semantics) to health care personnel and the lay public which empower those attendees to save lives with their training.

No matter how you look at it, the numbers are still pretty bad, but they’re getting better. 8.8% of cardiac arrest patients lived to be discharged from the hospital. Some nuisances behind those numbers include no quality of life being discussed, nor a breakdown of the etiology behind the arrests by subgroups. Nonetheless, the authors did a great job of compiling data from many different studies to give us an idea of what we can expect when our patients roll into our emergency departments and ICUs. 

Only 22% survive long enough to be admitted to the hospital.
In the last decade we’ve improved the survival to hospital discharge and 1 year survival. We should all pat ourselves on the back to some extent bc were the ones who do and will take care of these patients. I know that we sometimes prolong death, but we’ve all had some big wins that have given us purpose and made our hearts full with satisfaction for what we’re trained to do. A hat tip to the authors.

-EJ

Yan, S., Gan, Y., Jiang, N. et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care 24, 61 (2020). https://doi.org/10.1186/s13054-020-2773-2

Link to FULL FREE Article

Link to Abstract

Yan, S., Gan, Y., Jiang, N. et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care 24, 61 (2020). https://doi.org/10.1186/s13054-020-2773-2

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.

Sunday, February 23, 2020

Dopamine doesn’t belong in the ICU anymore

Link to FREE FULL ARTICLE and 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.

Blood Pressure Measurements: Arterial Line vs Oscillometric Cuffs

We all do this every single day. We measure target many of our interventions in the critically ill patients to blood pressure. Whether it’s fluids, vasopressors, or blood pressure lowering agents, we obsess over these parameters. We feel warm and fuzzy if it’s okay. But are we using the right tool to find out these numbers?

I’ve always harped on arterial lines, although invasive, being the most reliable method of evaluating the blood pressure in our patients. If someone is critically ill on jet fuel, they’re getting an a-line. This is a fun study where they compared the oscillometric BP cuffs to a-lines in 736 patients.

When you look at the mean differences they obtained, the numbers weren’t too bad.
Systolic: 0.8mmHg
Diastolic: -2.9mmHg
Mean Arterial pressure: -1mmHg

This wouldn’t drive any of us crazy, right? We’d be cool with these differences if it avoids invasive (painful) interventions on our patients. But wait, there’s more. There was a large amount of variability which could lead to additional interventions.
Systolic: ± 15.7mmHg
Diastolic: ± 11mmHg
MAP: ± 10.2mmHg

The article goes as far as to say that BP cuffs would not pass the Association for the Advancement of Medical Instrumentation standards. There’s no data as to how this changes outcomes.

This was a post hoc analysis (after the fact). This shouldn’t be too challenging to accomplish a prospective study looking at this in our critically ill patients. We have many patients who have a BP cuffs and an a-line in place. Why not just record cuff pressures every 15 minutes and obtain some data? Obviously it’s more complicated than that.

A hat tip to the authors.

T. Kaufmann, E.G.M. Cox, R. Wiersema, et al., Non-invasive oscillometric versus invasive arterial blood pressure measurements in critically ill patients: A post hoc analysis of a prospective observational study, Journal of Critical Care(2019)

Link to full article (not free)

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.