Methylene Blue in Sepsis Increases the BP

When the CITRIS-ALI study was published just a few months ago they used plasma biomarkers as a method to prove that ascorbic acid in this patient population worked. You know, the study where they gave Vitamin C to patients with acute lung injury and it failed to show its primary endpoint which was SOFA/biomarker changes but..... had a statistically significant decrease in mortality and people scoffed that that since it wasn't the primary endpoint. The study that I am posting today provided methylene blue to patients with severe sepsis and measured TNF-α, IL-1, IL-2 receptor, IL-6, IL-8. As I typed this I realized that I am such a nerd. It's a Sunday and I'm typing about interleukins. I digress. Those endpoints weren't changed by giving these patients methylene blue. You know what did change? The mean arterial pressure on these patients. You know what makes patients survive? Requiring small vasopressor doses and having an improved blood pressure. By no means does this small study mean I'm changing my practice, but I am at least going to think outside the box a little more often in my refractory shock patients who absolutely cannot die on me.
-EJ



Link to Abstract and Article

Memis D, Karamanlioglu B, Yuksel M et al (2002) The influence of methylene blue infusion on cytokine levels during severe sepsis. Anaesth Intensive Care 30(6):755–762.

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.

Methylene Blue in Septic Shock

I don’t know about you all but I’m constantly working on finding new ways to treat my septic shock patients who, based on the numbers from larger studies, have a mortality rate between 25-35%. I have used methylene blue on various occasions for post-CPB vasoplegia but would it possibly work in sepsis? Well, there’s 💩 data for now. I can’t cover every nuisance regarding methylene blue on this post, team, but I chose to share this pilot study from 2001 as it was the first study on the matter (to my knowledge). The third slide in a sneak peek to the lecture I’m creating on metabolic resuscitation.

Has your shop ever used methylene blue for this indication?

I’ll be presenting this data in Hawaii and Portland in 2020.

If you like the content I’m taking apart and posting, please share it with your friends and colleagues. Who knows, maybe it will inspire someone to conduct the larger RCT we need to decide whether this actually works or not.

- EJ



Link to Abstract

Kirov MY, Evgenov OV, Evgenov NV, et al. Infusion of methylene blue in human septic shock: a pilot, randomized, controlled study. Crit Care Med. 2001;29(10):1860–1867. doi:10.1097/00003246-200110000-00002

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.

Vitamin D Supplementation in Critically Ill Patients

I am constantly reading and educating myself in an attempt to gain whatever edge I possibly can for my patients. Their survival and quality of life is what I have personally dedicated my life to. Being someone who is following along on my journey, I can safely assume you're doing the same. I have become quite fond of metabolic resuscitation, using Vitamin C, thiamine, and stress dose steroids, with the Paul Marik data and have been utilizing it in my practice for several years. No harm, cheap drugs, let's do it! I've seen some great results from it but I also would like to see some better data (hopefully next month!).

That being said, this is a brand new article published in the NEJM on December 11th of this year. I can't say I was excited about the prospects of this article, but all in all I was hoping it would help. Unfortunately, it does not. Sigh.

This was a well done study with a high aspiration of enrolling 3000 patients. Unfortunately, they did not get there. They stopped the study early because of futility. I don't know if the researchers let out a sigh of relief at that point that their study was complete, or if they were defeated because they wanted to see a positive outcome. Who knows. Overall I am glad that we have an answer for this question and would like to give a hat tip to everyone who participated in this study.

-EJ



Link to Abstract

National Heart, Lung, and Blood Institute PETAL Clinical Trials Network, Ginde AA, Brower RG, et al. Early High-Dose Vitamin D3for Critically Ill, Vitamin D-Deficient Patients. N Engl J Med. 2019;381(26):2529–2540. doi:10.1056/NEJMoa1911124

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.

HFNC vs. BVM for Pre-oxygenation prior to intubation

A sentinel event is one where, amongst other different outcomes, leads to death. In critical care, anesthesia, and emergency medicine, we often deal with emergent airways on patients who are on the brink of death unless we intervene expediently. Despite having performed many intubations in my young career, I have the utmost respect for every airway. Any one of them can become at catastrophe at any time. If you're not prepared and thinking two steps ahead, you're honestly not adequately trained. If you haven't been burned before, you have not performed sufficient procedures to truly be proficient. Please don't take offense by that, it's just the name of the game. In residency I made sure to hunt down every single airway possible. In med school I hung out with the anesthesiologists to attempt to intubate their patients prior to surgery. Some of the ED attendings during residency had my number and would page/text me to perform the procedure to provide me with more experience. In fellowship I would love to tag along with the anesthesia residents on the "airway team" and go intubate patients throughout the hospital.

A way to mitigate the risk of patient demise is to attempt to pre-oxygenate your patients as much as possible prior to intubation. There are many strategies to do this, a NRB, BVM, NIV, and HFNC which will all deliver 100% FiO2. A regular nasal cannula won't really cut it on the sick patients. Remember, one needs to be prepared for catastrophe to occur on EVERY AIRWAY. This RCT from 2015 which is completely free compared in 40 pts the strategy of pre-oxygenating the patients with either HFNC of BVM prior to intubation. There were largely no significant differences between the two groups in their outcomes, but they did find one significant difference that really caught my eye. The SpO2 dropped significantly in the one minute of apnea after induction in the group that was preoxygenated with the BVM (p=0.001). Sure, that didn't change the outcomes overall in these 40 patients which is admittedly a small sample size, but it only takes one airway to become a true disaster where the patient develops anoxic brain injury or even dies during the intubation due to hypoxia. That would be a sentinel event that will keep you up at night. I do not wish that on anyone. Please be careful with your airway out there. The most important skill is knowing how to bag your patient. You should also be trained in how to cut the neck so that when it does happen, and I wish you never have to go through this yourself, you don't freeze.

-EJ



Link to Article

FREE FULL PDF

Simon M, Wachs C, Braune S, Heer G de, Frings D, Kluge S. High-flow nasal cannula versus bag-valve-mask for preoxygenation before intubation in subjects with hypoxemic respiratory failure. Respiratory Care 2016;61:1160–7.

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20,000 Followers on Instagram

I'm certain that the entirety of this post will not fit in the character limit on IG so you'll have to head over to my website to read it completely (don't blame you if you don't! 😉)

Time to take a deep breath: 20,000 followers. When I was approaching 10,000, I was exchanging messages with Ashley Adkins, RN (@ashleyadkinsrn) about the magnitude of the amount of individuals following us on our journeys. She humbly said something to the likes of "my followers can fill a basketball arena". I paused. stunned, had not thought of it that way. Powerful imagery right there.

You all, my audience, are special people. A special brand of curious, ambitious, health-care professionals along the entire spectrum who are, like me, continuously trying to get better at your craft. You're not here because I share a lavish lifestyle, take pictures of my meals, or wear cool scrubs while being Derek Zoolander levels of really really really ridiculously good looking (although @medelita hooked me up with an awesome white coat and I owe them a photo. Also, my wife is really really good looking). Nothing wrong with all those types of pages, they're just not me.

You all have helped me stumble along as I battle my admittedly awful handwriting. Have helped me with my formatting. Have helped me by sharing my posts with other likeminded colleagues and friends. I can't thank you enough. Following along on my page will guarantee you learn something just about every day, because I know I do. Many people would think, "heck, you're a board certified Intensivist, you should know everything". Well, I don't, and here we are, posting about knowledge gaps of my own that I'm trying to fill in on my journey to become the best expert I possibly can me. You all are along for the ride and I could not have done it without you all and your word of mouth.

When I started the year I had been running my IG account for about 1.5 years and had 761 followers on 1/1/19. The issue wasn't the number, the issue is that I felt I wasn't doing anything to actually contribute to my field, to this medium. I felt I had a ton to offer but no idea how to do it. I set several New Years Resolutions for 2019, something I didn't ever do, but I gave myself the lofty goal of reaching 10,000 followers. How? I had no clue.

It wasn't until I went to a CME conference in March 2019 put together by Northwest Seminars where the wheels began to turn and I came up with the following idea: start posting journal articles. I was already doing plenty of that on my free time, why not use IG as my medium to share the articles I was already reading? During that conference I approached the organizers about potentially speaking at conferences for them. I already had several lectures in my back pocket, why not add a few more? They saw some of my work and agreed, fortunately. The engine on the formula 1 race car that is my mind fired up. It was been a crazy race since then and you all have been exposed to just a fraction of the articles I have actually read. Yes, I'm bragging about what a nerd I am.

To the copycats: keep copying and improve my format! To the people who ask me if I’m upset that people are copying my style I say I don’t really care. It’s flattering. Ultimately, the purpose of all this is to help you, and me in the researching process, take better care of patients. The more nerds out there like me exist, the better. There are a ton of hilarious talented meme creators out there who are all successful at their craft which means there’s room for others like me to teach. I also am not sure I even invented this. I certainly do not want to take credit for it. I don’t think I have an original idea in my head, but that’s a different story. Keep promoting evidence based practices (even though the evidence is always going to be fraught with limitations). Do it better than I do. 

Where to from here? Doing this had opened up a ton of doors for me from a career standpoint. IG has been great for someone's career? What? How? No, I don't earn ANY income from IG, but that's not what it's all about. This one year of 2019 has been extremely positive where I am now connected with so many important people and organizations throughout healthcare that humble-little-me could never have fathomed. This ultimately means, though, that I need to work even harder and push even harder. There's plenty in the gas tank and there are few opportunities I will say no to. I have my lectures in Hawaii and Portland for Northwest Seminars, but there are a multitude of other lectures I am working on behind the scenes which will be challenging and exciting. How am I going to pull this all off? I have no clue! But I won't fail, that just doesn't happen around here. One of my favorite quotes is by Seneca where he stated "Luck is what happens when preparation meets opportunity". I have preparation in spades. All I do is prepare.

My next IG goal is to reach 100,000 followers by the end of 2020. To do that, I will continue to post almost daily. I do not see my journal reading slowing down as it is my responsibility to my patients. You will find so much value in what I post that you will have no choice but to share. You'll want your friends and colleagues to be in on this. Perhaps a bit too much from my part? Perhaps, but I'd want everyone on my team to be on an equal playing field. Oh, and I still have my full time job that I love and is my main dedication professionally. It's not time to take a break. It's time to push harder and get better. Let's get it! 

Thank you for follow along on my insanity,

Eddy Joe

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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.

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.

Impella Medical Device 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

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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.

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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.

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.

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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

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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.

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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.

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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.

Cardiogenic Shock: NICOM vs. Swan-Ganz Catheter

There are four types of shock: cardiogenic, distributive, obstructive, and hypovolemic.

I routinely make a big deal of volume resuscitation regarding septic shock which obviously falls under the distributive shock type. Part of the problem is that with all these well intentioned "Surviving Sepsis Campaigns", I feel that we are under-recognizing cardiogenic shock which can also present with hypotension and an elevated lactic acid. When you provide 30cc/kg of IVF arbitrarily because the "sepsis screen" pops up on your EMR forcing you to give the fluids, you end up causing harm to your patients.

This is where the history and physical plays a huge role. The physical should include a quick targeted POCUS/bedside echo to make sure you're not missing anything that's staring you in the face. If you see an RVOT on the parasternal long axis that's the size of a tennis ball, you're not dealing with sepsis. If you see an LV on the apical four chamber that is barely moving, you're likely not dealing with sepsis. Remember, if the patient is in septic shock, the systemic vascular resistance (SVR) hits the ground. There's no afterload for the LV to deal with. The LV will be clapping happily like a bodybuilder curling a 10lb weight. The "eyeball test" on POCUS is widely criticized but it has some uses.

But once you make the diagnosis of cardiogenic shock, how do you manage that patient? This is where I feel you may have some value in trending a CVP. I know Swan-Ganz catheters are out of favor, but I feel they're very useful if you know what to do with the numbers. Knowing how to apply the numbers clinically, though, takes some practice. Like everything else, you need to get your reps in. I'm fortunate that I trained at an institution where all the post-op hearts came out with a Swan. It was very helpful in my training and allowed me the opportunity to see the value in it rather than just being a nay-sayer. The Swan does have its limitations, though. It's not the easiest procedure to perform and it comes with some potential cardiac risks that I am not going to list here for the sake of my sanity. Is there something that we can use instead?

I will admit that I personally do not have any experience with the NICOM device. I look forward to playing with the technology one day. I like non-invasive things for my patients. I typically use another device which I will not name but I feel it is very helpful when used appropriately. No technology is perfect, not even the Swan. I was excited when I read this article because I was hoping for an out to not have to float Swans in this patient population. I also very much enjoyed how the authors conducted the study. Simultaneous measurements on the same patient was definitely the way to go and I applaud them on that.

Without boring you all with the details, the authors found that the NICOM correlates poorly with indirect Fick and therm-dilution measurements of cardiac output. The authors attribute it to the biorreactance technology being interfered with by pulmonary and interstitial edema. Makes sense to me. They also listed other factors as well which are on the full article. Nonetheless, what method do you use at your institution to manage cardiogenic shock?

-EJ



Link to Abstract

Rali, A. S., Buechler, T., Van Gotten, B., Waters, A., Shah, Z., Haglund, N., & Sauer, A. (2019). Non-Invasive Cardiac Output Monitoring in Cardiogenic Shock – The NICOMTM Study. Journal of Cardiac Failure.

Great article for indirect Fick
De Maria AN, Raisinghani A. Comparative overview of cardiac output measurement methods: Has impedance cardiography come of age? Congestive Heart Failure. 2000;6:60–73.

Indirect Fick Abstract

Indirect Fick PDF

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17 years from research evidence to clinical practice

Link to Abstract

Link to PDF

Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J Roy Soc Med. 2011;104:510–20.

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Awake Intubation Guidelines

Link to Article

Link to PDF

Ahmad, I. , El‐Boghdadly, K. , Bhagrath, R. , Hodzovic, I. , McNarry, A. F., Mir, F. , O'Sullivan, E. P., Patel, A. , Stacey, M. and Vaughan, D. (2019), Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. doi:10.1111/anae.14904

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Spontaneous Breathing Trials: How Does Your Shop Handle This?

There has been quite a bit of variation regarding pressure support trials, spontaneous breathing trials, liberation trials, whatever you want to call it.
I recently looked at the data for my academic curiosity and would like your input as to how you do it at your shop. I’d like to apologize in advance if I don’t write back to each of you in a timely fashion. I’ll try my best.

Here’s how I like to approach it (in the ideal world).
1. Patient isn’t deteriorating and they’ve done well on their spontaneous awakening trial (SAT).
2. RT goes ahead and places them on pressure support (PS or PSV are the lingo)
3. PS for 30 minutes and the RT flips them back into their prior setting on the vent if they don’t fly.
4. If they do fly, I eyeball the patient and have my RT teammate pull the tube.

I usually have HFNC or NIPPV at the bedside in case they have a high likelihood of needing reintubation.

I know many clinicians check ABGs prior to extubating their patients. I very rarely do. I think I’ve checked maybe 2 or 3 prior to extubating in the almost 2.5 years that I’ve been out of training.

A 🎩 tip to the authors.

Let’s reduce the mechanical ventilation days with this! 💪🏼




Link to Abstract

Link to FULL FREE Article

Ouellette DR, Patel S, Girard TD, Morris PE, Schmidt GA, Truwit JD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest. 2017;151:166–180.

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.

Lactate Measurements: Venous or Arterial Samples?

This is a question I remember asking myself quite a bit during my training when I used to check/trend lactate levels more than I do today. Does it really matter whether I check it from an arterial line or from a venous stick?

This study which was a prospective study of 100 patients who had both an arterial line and a central line. The authors compared the values during resuscitation. Short answer is no, there's no statistically significant difference.

Does this reflect the real world? Not really. As much as I would like to have an arterial line in all of my septic shock patients, this does not necessarily happen right away. Arterial lines, even for me who has put in hundreds, is not the easiest of procedures. I actually failed miserably on a patient in 5 different sites several weeks ago. I have excuses but I won't share them ;). Also, it is time consuming and causes the patient discomfort. That being said, when someone is sick sick, they get an arterial line from me or my trusty badass RT's.

The other real-world concern is the central line issue. There's data out there that you don't necessarily need a central line to run vasopressors, some of that data is my own data (my ONLY data out there haha). That being said, these patients will have their venous lactate checked via a peripheral stick, in many cases using a tourniquet. Using a tourniquet has its own problems as that could make the lactate levels unreliable.

Now, let's say that you have both an arterial line and a central line, then you can use this data more appropriately. Sort of. The authors did not specify whether they used the same point-of-care device to check the lactate levels in the venous nor arterial values. You know, some shops use POC for arterial, some have the fancy machine inside the ICU. Some could run the venous blood in that fancy machine, the POC, and some shops have to send it downstairs to the lab. This was not specified. Sigh.

Either way, I need to dissect the data regarding tourniquets for you.

-EJ



Link to Abstract

A. Mahmoodpoor, K. Shadvar, S. Sanaie, et al., Arterial vs venous lactate: Correlation and predictive value of mortality of patients with sepsis du..., Journal of Critical Care, https://doi.org/10.1016/j.jcrc.2019.05.019

Lactic Acidosis has a WIDE Differential (not just Sepsis)

There's a pendulum in medicine. Some things are over recognized and aggressively treated, some things are under appreciated (like subtle decreases in serum bicarb showing that the patient is becoming more acidotic and no one notices because the patient has obesity hypoventilation syndrome and their baseline bicarb is 34 and now has a bicarb of 22 and they look like poop).

At this time, all the rage is serum lactate and lactic acidosis. Every time someone says those words, with my biochemistry knowledge lagging far behind, everyone thinks "SEPSIS!! 30cc/kg IVF STAT!!!!" If you all knew how much this upsets me whenever I see it, you'd wonder how I'm still alive because I see it all the time. I bet you see it at your shop, too. It's very common because the pendulum has swung too far.

In order to correct this, I have embarked on discussing this topic ad nauseum in one of my lectures for Hawaii/Portland in 2020. The article linked below from the New England Journal of Medicine has a table that has been reproduced in many different forms. I will not break down the pathophysiology of each one of the etiologies, but I have been called for an ICU transfer for MANY of these.

Here are some examples where I have been called over the years where patients have received 30cc/kg of saline w/stable vital signs:
1. COPD patient receiving albuterol nebs. Lactic acid elevated because they're A. huffing and puffing, and B. receiving beta-2 agonists.
2. s/p seizure patients who are post-ictal
3. hypoglycemic diabetics
4. leukemia patients just watching TV
5. cocaine/chest pain patients in the ED
6. cardiogenic shock patients on an epinephrine gtt
7. HIV pt on Stauvidine (I should have written this one up)

I'm obviously not getting into the different subgroups of lactic acidosis at this time. Let's walk together before we run. Our job is to fix the underlying cause of the lactic acidosis, not dilute the number down with fluids.

-EJ




Link to Abstract

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.

Lactate is an Alarm, not a Treatment.

I need to eat my words on this one, because now there's data to show that there's a benefit to rechecking lactate levels in septic patients, but not for the reasons why one would think.

During my rounds over the course of the weekend, I recall telling several nurses that there's no data to suggest that trending lactates changes outcomes. This study, which came out last night, tells me I was wrong in saying that. A close examination of the data will show that it has nothing to do with the lactate itself, but rather the fact that the clinicians are prompted to "do something" in response to a number that makes us uncomfortable.

Okay, so the lactic acid is elevated. You're going to do one or two or all three of the following:
a. start vasopressors
b. start antibiotics
c. give more fluids

That's the kicker, we don't know which of those interventions, or combination of which, are what decreased mortality. Maybe it just means that someone gave these patients more attention. It certainly just wasn't the "checking the lactate" part. Lactate is just an alarm of sorts, we still need to be clinicians. I will suggest, though, that earlier initiation of antibiotics plays the most important role in decreasing mortality as there's already data suggesting that earlier antibiotics leads to improved outcomes. I personally start vasopressors pretty early and will share data in the upcoming weeks as to why I do that in my practice. Giving more fluids is only useful if the patients is fluid responsive, you know, if you can prove that giving that fluid will increase the cardiac index/output or increase the stroke volume. Giving fluids just to make the blood pressure go up arbitrarily is just plain dumb. It's 2019. We're better than that.

Ultimately, early lactate measurement did not improve outcomes, nurses relaying the information to the doctors, ARNP's, or PA's did.

-EJ



Link to FULL FREE 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.

Stress dose steroids for septic shock: bolus dosing or continuous infusion

This study published just this month, November 2019, suggests that providing bolus dosing of hydrocortisone, 50mg IV every 6 hours shortens the time a patient needs to be on vasopressors compared to 200mg IV through a continuous infusion every day.

Stress dose steroids are clearly in my armamentarium in the treatment of septic shock. I tend to reach for them when I’m starting my second vasopressors, usually Vasopressin when the norepinephrine hits around 10-15mcg. I also ready for the vitamin C and thiamine at that point, too. Actually, I have a quick little bundle in the EMR where I just check off all these goodies. Sometimes I stray in different directions, of course. Every patient is different and this is not a recommendation on how you should practice. I haven’t gotten on the fludrocortisone train yet, have you?

Either way, the shock reversal is faster with the bolus dosing. This should make all my nurse followers happy as they won’t have a channel and lumen bogged down with this medication and all the compatibility questions that arise with it. Whether bolus or continuous dosing you won’t see a difference in mortality, ventilator days, adverse effects, length of stay, etc.

Also not yet another study where they don’t check cortisol levels before initiating this treatment. I’m not a fan of checking cortisol levels myself. I see it done and I ask, why?

A 🎩 tip to the authors.

-EJ

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.

Inferior Vena Cava Assessments with US

Ultrasound assessment of the inferior vena cava for fluid responsiveness: easy, fun, but unlikely to be helpful

This is where I stand on the matter today, November 3rd, 2020. I am open to changing my mind with new data. Guiding fluid responsiveness, as I’ve covered here, is a huge pain in the butt. But giving patients either too little fluids or too much fluids increases mortality. That little feeling inside of “just doing something” isn’t the best thing.

When I was going to through fellowship, I was trained to perform this assessment of placing the US probe on the patients subxiphoid area and digging around until the IVC was found. I got pretty good at it, but I have to admit that I also haven’t used it in 2 years. I never found it to be as useful or reliable as I initially thought it would be. It’s a tool but it has many caveats. I remember reading this article and got some confirmation bias to how I already felt about the scan.

Fortunately, this article is free and you can download it on my website, eddyjoemd.com. The article illustrates the many caveats which any clinician developing the skill to perform this scan NEEDS to know. He discusses the technical limitations, confounding factors, and reviews the evidence in both patients who are spontaneously breathing and in those who are on the vent.

I’ll repeat again, if you are a medical student, emergency medicine resident, internal medicine resident, or any clinician learning and managing patients based on this scan, you need to know the limitations of it. At least until we find the holy grail of Critical Care where we find a way to know the correct amount of fluids to give our patients. Not a drop more or a drop less.



Link to Abstract

Link to FREE FULL PDF

Millington, S.J. Can J Anesth/J Can Anesth (2019) 66: 633. https://doi.org/10.1007/s12630-019-01357-0

Incorporating Dynamic Assessment of Fluid Responsiveness Into Goal-Directed Therapy: A Systematic Review and Meta-Analysis.

Incorporating Dynamic Assessment of Fluid Responsiveness Into Goal-Directed Therapy: A Systematic Review and Meta-Analysis.

Let’s talk a little bit about resuscitation. I chose to go down this path to start off the weekend bc I frequently see patients receiving arbitrary fluid boluses for SBP less than x (we all know how o feel about using systolics on oscillometric machines), MAP less than 65, or decreased urine output. It makes us feel like we are doing something but we are actually causing harm. At the end of the day, giving fluid just to make the blood pressure pretty does not indicate fluid responsiveness. If I were to give you a liter of fluid, definitely not saline, your BP would go up. That doesn’t mean you’re fluid responsive. Using the technologies listed in this article from 2017 are a step in the right direction. If you read the validation studies for them you’ll learn that they leave much to be desired but they’re amongst the best tools we have today. I’m going to go much deeper down this rabbit hole in the upcoming months.

What do you use at your shop to measure fluid responsiveness?

Link to Abstract

Link to FULL FREE PDF

Bednarczyk JM, Fridfinnson JA, Kumar A, et al. Incorporating Dynamic Assessment of Fluid Responsiveness Into Goal-Directed Therapy: A Systematic Review and Meta-Analysis. Crit Care Med. 2017;45(9):1538–1545. doi:10.1097/CCM.0000000000002554

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.

Fecal Microbiota Transplant related Bacteremia

Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant




Link to Abstract

DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. N Engl J Med. 2019;381(21):2043–2050. doi:10.1056/NEJMoa1910437

Pulmonary Embolism Guidelines 2019

These are the 2019 European Society of Cardiology and European Respiratory Society Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism. I must say, these are my favorite guidelines for PE and they came out just a few weeks ago on August 31st. It seems as if PE is just on every differential, as it respectfully should be, on anyone who is hypotensive with chest pain and short of breath. You definitely have to think about it, but that doesn't mean that everyone needs a CTA of the chest to rule it out. Many times a good history and physical can rule it out.

The images in this article is where much of the value is. The flowcharts simplify the thought process. I encourage those of you who have the ability to learn how to do some simple echocardiography to learn the skills of at least finding the windows. You'll be able to gain a TON of information just by laying the probe on the chest. This is one of those PDFs that you should definitely have accessible and refer to it often until you basically have these guidelines memorized.

A big hat tip to the authors. Again, I LOVE this paper.

-EJ

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)

Link to Abstract

Link to FULL FREE PDF this may or may not work

Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2019; published online Aug 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.

NPO after Midnight: What do the guidelines say?

Is your shop still using strict NPO after midnight for its surgical patients? It’s time to talk to the powers that be to have this changed, supported by evidence, of course.

The controversy of “Strict NPO After Midnight” has been ongoing for many years now as the data has suggested it’s silly but still performed. Well, the American Society of Anesthesiologists put together a task force in 2017 to put an end to the silliness. Let’s try to make the horrible experience of being hospitalized a little less horrible for our patients. #endthenpo

A 🎩 tip to the authors. Happy Sunday!








Link to article where you can download the PDF

Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration*. Anesthesiology

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Corticosteroids and GI bleeds: Do We Really Need To Worry?

Link to Abstract

Butler E, Møller MH, Cook O, et al. The effect of systemic corticosteroids on the incidence of gastrointestinal bleeding in critically ill adults: a systematic review with meta-analysis. Intensive Care Med. 2019;45(11):1540–1549. doi:10.1007/s00134-019-05754-3

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.

Fecal Microbiota Transplantation: So Much to Learn

Link to Abstract

Link to Full FREE Article

Dai, M., Liu, Y., Chen, W. et al. Rescue fecal microbiota transplantation for antibiotic-associated diarrhea in critically ill patients. Crit Care 23, 324 (2019). https://doi.org/10.1186/s13054-019-2604-5

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.

Thiamine and Renal Failure in Septic Shock Patients

Every possible option to decreased morbidity, mortality, and costs are worth looking at in my book. The study that I am reviewing at this moment was published in 2017. I am ashamed that I had not run into it until today. It's challenging to stay up to date in everything. I digress.

Some would quickly bash this study for it being small (n=70) and a post-hoc secondary analysis of a pilot study. I am not going to do that. Why not? Well first of all, I do not participate in research myself. Just reading and enjoying these studies. Also, thiamine has no side effects described in the literature. Third, it is an inexpensive medication. Fourth, if it does turn out to decrease the incidence of acute kidney injury and the need for renal replacement therapy, aren't you going to feel guilty for not adopting these strategies for your patients? I hate resorting to that but my responsibility is for patients. What happens if this data is wrong? Nothing. What happens if this data is right and no one does anything for several years? Many patients may suffer.

This article is completely free and I encourage you to download it and read it for yourself. Amongst the points illustrated by the authors, they mention that it's not only perfusion that injures the kidneys during sepsis. There are other factors listed in the article. The way that it is postulated that thiamine works for these patients is by assisting in the mitochondrial dysfunction. Data that I have found not listed in this article shows that thiamine deficiency could have an incidence between 20-70% of critically ill patients. 

What they found was 21% of the patients in the placebo arm of the trial went on to need dialysis. Just one patient, or 3% in the thiamine group went on to require this. The authors note that acidosis was the primary indication for dialysis in 66% of the patients who required it. I personally would like to dig deeper into these numbers as there is some data that thiamine administration helps decrease lactic acidosis. 

This data should make you wonder if the strategy that many clinicians take of providing more IV fluids to patients whose renal function deteriorates is the correct strategy. Are we going to look in the mirror in a decade and want to punch our past selves in the face?   

- EJ

Link to Abstract

Link to Full Article

ADDENDUM: The prospective RCT is going to be completed in July 2022. Here is the link to clinicaltrials.gov's study details here: LINK

Moskowitz A, Andersen LW, Cocchi MN, Karlsson M, Patel PV, Donnino MW. Thiamine as a renal protective agent in septic shock. A secondary analysis of a randomized, double-blind, placebo-controlled trial. Anns Am Thorac Soc. 2017;14(5):737–41.

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Thiamine, Ascorbic Acid and Corticosteroids: The Mechanisms by which they should help in Sepsis

Want some nerdy stuff? Well this is some nerdy stuff! I'm taking a nice deep look at this figure. I am not going to lie to you at this moment, October 19th, and tell you I know what all this means, because I don't. But people who are more intelligent that I am have suggested that these are the mechanisms by which thiamine, ascorbic acid, and corticosteroids should help in the treatment of septic patients. I have a lot to learn.

I hope I don't get dinged for copyright stuff but honestly if this offends you, let me know. I will take it down. I will likely go deeper into this article at a later time. Wanted to share this image with you right now, though.





Link to Abstract

Link to FREE FULL Article

Moskowitz, A.; Andersen, L.W.; Huang, D.T.; Berg, K.M.; Grossestreuer, A.V.; Marik, P.E.; Sherwin, R.L.; Hou, P.C.; Becker, L.B.; Cocchi, M.N.; et al. Ascorbic acid, corticosteroids, and thiamine in sepsis: A review of the biologic rationale and the present state of clinical evaluation. Crit. Care 2018, 22, 283.

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.

Delirium in Mechanically Ventilated Patients: Let the Natural Light in!

I have great disdain for delirium. Natural light brings me great joy. Today, for example, the sun isn't shining bright. The day is cloudy and gloomy. I am, in turn, a little grouchy. Daylight savings is coming and I'm already upset about it. I can turn on the light but it won't be the same. This study was published today. How's that for so fresh and so clean?

Preventing and treating delirium is something we haven't quite figured out just yet. But studies like this one help us chip away at that giant piece of rock to eventually present a great sculpture. Bad analogy? Yep! In this study, the authors were curious to see whether patients having natural light would affect the incidence of delirium in patients who are on the ventilator (primary outcome). The secondary outcomes included the "duration of delirium, duration of coma, use of antipsychotics to treat agitation, the incidence of hallucinations, the incidence of self-extubation, duration of mechanical ventilation, ICU and hospital length of stay, ICU and hospital mortality."

This was a single centered trial with 195 patients. Out of their measured outcomes, they noted that the patients exposed to natural light had a reduced incidence of severe agitation (p=0.04). In addition, the patients exposed to natural light also had fewer hallucinations (p=0.04). Fortunately, this study is free and you can download it and read it yourself. I like natural light. It's free. It may not ameliorate delirium, but it is another tool in our tool belt to make these patients better.
-EJ

Link to Abstract

Link to full free 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.