Noninvasive positive pressure ventilation in respiratory failure: the guidelines

Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure.
Want to know which patients to use BiPAP on? This guideline published in the American Thoracic Society journal in conjunction with the European Respiratory Society in 2017 provides some good answers for the most common questions we all encounter in our daily practice.
Should NIV be used in COPD exacerbation?
Should NIV be used in ARF due to a COPD exacerbation to prevent the development of respiratory acidosis?
Should NIV be used in established acute hypercapnic respiratory failure due to a COPD exacerbation?
Should NIV be used in ARF due to cardiogenic pulmonary oedema?
Should NIV be used in ARF due to acute asthma?
Should NIV be used for ARF in immunocompromised patients?
Should NIV be used in de novo ARF?
Should NIV be used in ARF in the post-operative setting?
Should NIV be used in patients with ARF receiving palliative care?
Should NIV be used in ARF due to chest trauma?
Should NIV be used to prevent respiratory failure post-extubation?
Should NIV be used in the treatment of respiratory failure that develops post-extubation?
Should NIV be used to facilitate weaning patients from invasive mechanical ventilation?
Fortunately, this article is free for you to download. The link is below.





Link to FREE article

Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017; 50: 1602426

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.

Joint commission is here....

Association between patient outcomes and accreditation in US hospitals: observational study

I’m going to say that while I understand what joint commission is trying to do, they need to provide a better value for their service based on this article. When joint commission walks through the door of the hospital, it’s similar to a large event where everyone in the hospital becomes immediately aware. Everyone on their best behavior. Water bottles only at the water bottle station. Don’t practice real world medicine like titrate your pressors up faster than the order when your patient is crashing and burning. All this trouble has to be good for something, right? Or is this a place where our tax dollars go to die?
This study looked at three fundamental questions that we all think every time that we hear that they are coming. Does being accredited by JCO lead to better outcomes? Is JCO better than the other accrediting institutions? Does patient experience, you know, the important thing here, improve whether the shop is accredited by JCO versus a state institution versus an a different accrediting institution?
The link to the article is down below so you can read their findings for yourself.
Here are their principal findings:
“Among US hospitals, we found no meaningful association between private accreditation and mortality rates. Although the readmission rates for the 15 selected medical conditions (but not the six selected surgical conditions) were lower for accredited hospitals than for state survey hospitals, the differences were modest. Furthermore, accredited hospitals had, on average, modestly worse patient experience scores than state survey hospitals. The lack of meaningful differences in outcomes between accredited and state survey hospitals suggest that a closer examination of the benefits of private accreditation would be useful.”
Joint commission responded, as one would expect, and shredded the study here. Their reputation was at stake. I can’t blame them. There are some flaws to the methodology of the study, just like there are flaws in the methodology of how they want us to practice the art of medicine.
A 🎩 tip to the authors.

-EJ





Link to PDF

Link to 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.

Benzodiazepine use should be minimized for sedation in the ICU

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Team, I'll get to making this whole post prettier in the AM when I have some rest under my belt. I saw everyone chiming in on bedsideroundz’ page how they provide versed/midazolam for sedation in their critically ill patients and I had no choice but to put off my bedtime for a few hours and work on this post instead. A 🎩 tip to bedsideroundz for shining some indirect light to this conversation. Here are the official 2018 guideline statements regarding utilizing benzodiazepines such as midazolam/versed.
"The 2013 guidelines suggested targeting light levels of sedation or using daily awakening trials, and minimizing benzodiazepines to improve short-term outcomes (e.g., duration of mechanical ventilation and ICU LOS)."
"...sedation with benzodiazepines, which are no longer recommended for sedation in critically ill patients"
"The 2013 PAD guidelines suggest (in a conditional recommendation) that nonbenzodiazepine sedatives (either propofol or dexmedetomidine) are preferable to benzodiazepine sedatives (either midazolam or lorazepam) in critically ill, mechanically ventilated adults because of improved short-term outcomes such as ICU LOS, duration of mechanical ventilation, and delirium"
"We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery"
"...shorter time to extubation with propofol versus a benzodiazepine"
"Overall, the panel judged that the desirable consequences of using propofol probably outweigh the undesirable consequences, and thus issued a conditional recommendation favoring propofol over a benzodiazepine."
"We suggest using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults"
"the study by Xu et al also showed reduced delirium with dexmedetomidine use"
"the Dexmedetomidine Versus Midazolam for Continuous Sedation in the ICU (MIDEX) study demonstrated a shorter duration of mechanical ventilation with dexmedetomidine over a benzodiazepine infusion"

I'll post some more later. Please read the article for yourself. Don’t trust what I post.

-EJ.




Link to abstract

Link to PDF

Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, Agitation/Sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.Crit Care Med 2018;46:e825–73.

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.

Pediatric BVM/resuscitator bags in adults? Could this possibly work?

Can EMS Providers Provide Appropriate Tidal Volumes in a Simulated Adult-sized Patient with a Pediatric-sized Bag-Valve-Mask?

A few days ago I discussed how the resuscitator, aka "the ambu" could provide extremely high volumes, up to 1600cc if you get every last cc of O2 out of there, and therefore cause harm to your patient. A new buddy of mine via instagram, Matt, sent me a link to this article discussing this study where the authors wanted to know if our neighborhood EMS crews could ventilate patients appropriately using the smaller bags (450-500cc's). After all, that's the what we are striving for with lung protective ventilation nowadays in the ICU, right? Why not get a head start on this in the field? That was also a secondary endpoint for the study. They also wanted to compare the volumes that patients would receive with a variety of different airway instruments. 
The authors went to their neighborhood EMS and fire stations and put the crews to the test. One thing to consider of course is that they're going to perform their absolute best because they're being watched. You'd do this, too, and so would I. Ultimately, they found that using the Ambu Spur II pediatric BVM, you can get a median tidal volume ranging from 570 to 664ml using an oropharyngeal airway, subglottilc airway and an endotracheal tube. That actually surprised me because I figured they would get less! Utilizing the Adult Ambu SPUR II BVM they got median volumes from 796 to 994.5ml utilizing the same three airway devices. That's a lot of volume. 
This study surprised me on a number of levels where I did not expect to be surprised. First, the pediatric bags provided more volume than I expected. I expected a max of 500cc.  Second, these EMS personnel must've gotten some good seals on those dummies to get those volumes into them. They must've also been pumped that they were involved in a study and squeezed the crud out of those bags. Lastly, this makes me consider how I roll because sometimes the adult sized BVM is large, obstructive, and could be challenging to hold for someone with smaller hands than myself. I've had to bag patients in some tight spots (don't ask) and having a pediatric bag would've definitely helped out the situation. 
I'm fortunate in that I usually have a second set of hands with me when I'm working on an airway but in the OR world, I'm sure there is an anesthetist or two out there who wouldn't mind having a smaller device to handle. I know this study was performed on dummies but I can see one of my anesthesiology colleagues trying this out at an academic center. Any takers? Could be a great project for an aspiring and ambitious CRNA. I can write the trial protocol and potentially be the 6th author of 12. 
A 🎩 tip to the authors!

-EJ





Link to Article

Siegler, J., M. Kroll, S. Wojcik, and H.P. Moy, Can EMS Providers Provide Appropriate Tidal Volumes in a Sim- ulated Adult-sized Patient with a Pediatric-sized Bag- Valve-Mask? Prehosp Emerg Care, 2017. 21(1): p. 74-78.

HFNC/High Flow Nasal Cannual vs. Conventional Oxygen Therapy vs. Non-Invasive Positive Pressure Ventilation

Can High-flow Nasal Cannula Reduce the Rate of Endotracheal Intubation in Adult Patients With Acute Respiratory Failure Compared With Conventional Oxygen Therapy and Noninvasive Positive Pressure Ventilation? A Systematic Review and Meta-analysis

I need help with this. Is it me or is this an apples to oranges study? I ask that because the authors compared high flow nasal cannula to conventional oxygen therapy and then they compared HFNC to NIPPV. Okay, the COT versus HFNC is an easy one to settle. Fewer people are going to be intubated if they’re on HFNC, all comers. But the caveats kick in when the authors compare HFNC to NIPPV which many of you know as BiPAP. My issue is because they included patients who were having acute exacerbations of COPD, acute cardiogenic pulmonary edema, asthma exacerbations, and ARDS in the HFNC vs NIV arm of the study. It is my opinion that that’s a bit ridiculous bc we know (and knew in 2017 when this study was published) that those patient populations more often than not need more support than what HFNC can provide. I will say there is data for HFNC in all those settings, but not enough to prove a benefit to NIV. Can you chime in below with your thoughts? I don’t think they should have looked at all comers for HFNC. Taking it by disease processes which other authors have done would yield actual real world results. These devices need to be carefully tailored to the patients you are treating. I’m more than willing to change my mind but I need help. Thanks.  

-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.

How much volume is in an adult resuscitator? 1600ml

The quick and easy answer to how much volume is in the ventilation bag (the part you squeeze) in an adult resuscitator is 1600ml.

You hear the alarm go through the hospital "CODE BLUE in room XYZ". You, like me, are an ambulance chaser and want to get there as soon as possible to either run the code or handle the airway or all of the above. A patient needs to be saved! Your team sorts itself out with everyone assuming their roles (or being delegated to their roles). Someone in at the head of the bed with the resuscitator, also known in many places as the "Ambu". I sometimes call it the BVM for bag-valve mask. We need to get better at our language in this game. That's besides the point. So someone is at the head of the bed with a huge adrenaline rush pounding away at the resuscitator squishing the bag ferociously trying to get all the O2's that exist into the patients lungs RIGHT NOW. More squeeze equals more air and then that's "more better", right?  This is too common and this post is to hopefully slow us down when we "bag" the patient. I'm not going to go into proper technique to apply the mask because that's a topic for another day. The purpose of this post. The problem is that whether you are utilizing this tool to "bag" someone through a mask or once the endotracheal tube is placed, people bag too much volume and too fast. I've seen several cases now where patients have developed pneumothoraces secondary to this issue. People just don't know the volume of the bag and the fact that you don't have to squeeze it entirely like you're trying to get the last of the lemon into your vodka tonic. 1/3 of the way will do.

The reason for this is because our total lung capacity is approximately 6 liters. From those 6L you need to subtract about 1200ml of residual volume and 1200ml expiratory reserve volume. You have 3600cc left to go. Then you bag, bag, bag without allowing time for exhalation and the lungs end up popping like balloons. Then your patient who just coded ended up on a ventilator, whatever the etiology of the arrest was to begin with, and a couple of chest tubes to seal the deal. Be careful with this tool, team.

Credit to Laerdal for publishing the pretty picture and the volume of their resuscitator.
Resuscitator Link

-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.

Is there a doctor on the plane?

I will start off by stating that this is not a call that should only be responded to by someone with an MD or a DO behind their name. I know of many seriously good critical care nurses who push away physicians who freeze in a tough situation and just handle it. I know nurses who can do much better patient assessments, bag patients, perform better chest compressions than many MD's. ARNP's and PA's, I haven't forgotten about you all. You can respond to this call as well. It all of our duties.
This is going to be you or me who rises up from our seat when duty calls and we need to tend to a sick person on an airplane. I always think that this may happen on my particular flight because, well, I'm insane. As I walk through the aisle and pass through all the rows to the back to the plane because, face it, I am not First Class level, I survey the individuals in the seats to prepare for who may crash and burn. Not talking about the plane, of course. That being said, I can't believe that until this moment I had never thought about what medical equipment is actually available on the flights. This made me do a little deeper dig rather than just "figure it out" when the situation presented itself. Hopefully never, of course. But hey, poop happens and this is what we are trained to do. So let's do it!

-EJ

This table was taken from HERE.

Sphygmonanometer	1
Stethoscope	1
Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent	3
Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent)	1:3 masks
CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large adult, or equivalent	3
IV Admin Set: Tubing w/ 2 Y connectors	1
Alcohol sponges	2
Adhesive tape, 1-inch standard roll adhesive	1
Tape scissors	1 pair
Tourniquet	1
Saline solution, 500 cc	1
Protective nonpermeable gloves or equivalent	1 pair
Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications)	6
Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications)	4
Analgesic, non-narcotic, tablets, 325 mg	4
Antihistamine tablets, 25 mg	4
Antihistamine injectable, 50 mg, (single dose ampule or equivalent)	2
Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent)	2
Aspirin tablets, 325 mg	4
Bronchodilator, inhaled (metered dose inhaler or equivalent)	1
Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent)	1
Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent)	2
Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent)	2
Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent)	2
Nitroglycerin tablets, 0.4 mg	10
Basic instructions for use of the drugs in the kit	1

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.

High Flow Nasal Cannula: Does my patient with pneumonia need to be intubated?

The article I'm referencing in this post is titled: An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. It was published in the American Journal of Respiratory and Critical Care Medicine in June of 2019. 

We see this every day in the intensive care unit. A patient with pneumonia sucking wind. Tachypenic. Slightly altered. Requiring a bunch of oxygen. Should we intubate them and place them on mechanical ventilation, or should we give them a shot and see if they fly on high flow nasal cannula? The data for pneumonia and using BiPAP isn't there so that's not an option. Side note, check the FLORALI trial which I posted on my site as it has some of the same researchers on the matter. I really really don't want to have to intubate the patient with all the risks and complications known to go with that unless it's really really needed. In a joking manner, we all think we're big shots and can call it just by seeing it. You know the type, I am the same way. I can tell a patient needs to be intubated as soon as I lay eyes on them. Big shot. Yep. This is true, or is it? We also know that delaying intubation is far worse for patient populations that just intubating them early on. What ends up happening is that once you finally go ahead and proceed with intubation after the patient has been developing more and more fatigue, you notice that you're in deep poop when the induction agents destroy your patients hemodynamics. Start bolusing fluids. Place a central line and start vasopressors. Death spiral ensues. If this hasn't happened to you in your career, you haven't been working long enough. 

What if there was a tool to help us with this decision? Wouldn't that be great? How about a tool so simple that all you need is a pulse oximeter, a HFNC setup telling you the FiO2 being delivered to the patient, and a set of eyeballs to count a patients respiratory rate (because we all know that whatever device measures RR on the monitor is inaccurate and showing "apneic" more often than it should). Well, we're all in luck! These authors came up with the ROX index which is (SpO2/FiO2)/RR. SpO2 is the number you get from the pulse oximeter and it's on the monitor. It should be entered as a whole number. FiO2 is entered as a decimal. For example room air is 21% so 0.21. RR is, well, respiratory rate. Based on the data provided in this article, it should be a statistically significant prediction of whether your patient is going to be intubated or not. Hopefully the delay of mechanical ventilation we all are dreading should be avoided. This should also help you make the decision to just intubate the person before you leave your partner who is working the opposite shift with an airway dump, one of the worst kinds of dumps. 

I am not going to go deep into the data of this study because this team knows what they are doing far better than I ever will and the truth is that the abstract here is a pretty darn good representation of what is within the bulk of the text. I am curious, however, of why the article was published in its "in press" format in December of 2018 and was not fully released until June 2019. So many people could have benefitted from it. 

Also, a little tidbit that you may or may not have known. The journal where this was published, the American Journal of Respiratory and Critical Care Medicine is the high ranked journal for Critical Care Medicine based on Impact Factor. Don't know what Impact Factor is? You should definitely check it out because it evaluates the quality of the journal. That will keep you from making a mistake that I made where I showed my Program Director in residency an article from this small European journal something about atrial fibrillation and then he proceeded to make fun of me and showed me where to look up the actual data on afib, the American Heart Association Guidelines. Anyway, that's enough of a rant. Enjoy the article and until next time! 

ADDENDUM: Someone who follows my on instagram named Jessie just opened my eyes to a use case for this ROX index that I hadn't thought of before. It could potentially be used to help either alert or calm nurses and respiratory therapists regarding the potential decline of a patient who is on HFNC either in a step-down/PCU/intermediate unit. It could be an objective piece of data that they could provide to physicians to provide evidence that the patient needs to be transferred to the intensive care unit for intubation or that the patient is deteriorating. Wow! I feel silly that I had not thought of that myself but I'm glad she reached out and pointed it out to me. Thanks Jessie! 

-EJ




Link to the 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.

Docusate in the Hospital: Cut the Crap

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

-EJ

Link to Article

Link to PDF

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

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.

Why we should NOT be checking for residual tube feeds

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

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


-EJ














Link to Article

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



Link to Article

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



Link to Abstract

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

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.

Can early enteral nutrition decrease mortality?

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


Link to Abstract

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

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

-EJ

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

Enteral Nutrition: When should we start in our mechanically ventilated patients? Day 1 or 4?

Link to Abstract

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

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

A 🎩 tip to the authors! 

- EJ

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

Pharmacists save lives!

Link to Abstract

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

-EJ

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

Link to Abstract

Link to Article

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

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

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

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

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

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

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

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

- EJ

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.

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

Link to Article

Link to PDF

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

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

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

That's enough for today
-EJ


 

The gut microbiome alters immunophenotype and survival from sepsis

Link to Article

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

-EJ

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.

Enteral Nutrition Can Be Given to Patients on Vasopressors

Link to Article (Not Free)

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

-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.