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.

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.

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

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.

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

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.

Be careful with Ketamine and Catecholamine-dependent Heart Failure

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

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

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

-EJ

Link to Abstract

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

Link to Abstract

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

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

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.

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.

Pregabalin to Avoid Opioids

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

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

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

-EJ

Link to Abstract

Link to FULL FREE Article

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

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