Lactic Acidosis: Does it really mean Hypoperfusion?

Understanding lactatemia in human sepsis: potential impact for early management

Having an elevated lactate in septic acid on admission is bad. Trending it, as studies that I have shown on this page does not change mortality. Seeing the numbers downtrend do give us that warm and fuzzy feeling inside, though. We give off a sigh of relief when that number becomes "euboxic". This article was published in April 2019 and authors explained the different mechanisms by which lactic acid is elevated in septic patients.
1. a deficit in oxygen delivery or extraction
2. shunting
3. stress
4. increased adrenergic stimulation

Notice that none of these mean that we have to drown the lactates with a bunch of fluids thereby diluting the value. We need to go after the etiology of it in a more specific manner. The authors of this study looked at the patients enrolled in the ALBIOS study (you know, the 2014 study where they sorted out that giving patients in septic shock albumin was good for depleting hospital resources but not a survival benefit? I guess I need to cover that trial on here) and used more than 1700 patients in whom lactate and central venous oxygen saturation were measured. They did a bunch of calculations and statistics that I am not going to cover here but you can click on the link for the article and go to town on it if you so wish.

Something really interesting was found in this study. The authors found that 1017 patients had a lactic acidosis but 57% of those patients had a normal serum pH. I would've thought that the number would have been lower. And it's not because these patients were on bicarbonate drip band-aids either.

The Early Goal Directed Therapy trial made us infatuated with checking central venous oxygen sats and our target was to get that to be over 70%. This study showed us that only 35% of that patients they looked at had a value less than 70%. 65% of patients with an elevated lactic acid had a normal or high ScVO2. Strange. We do know that the extremes of ScVO2 are bad and that ultimately ScVO2 has a number of limitations within itself. Anyway, I'm not going to dive too deep into all that, I'll leave it for the authors to explain.

All in all their main conclusion in this study, and the important takeaway is that lactate is not primarily created in sepsis by of the cells not receiving enough oxygen, but rather by impaired tissue oxygen utilization. This is a game changer. In my opinion, it doesn't mean that fluids are the answer, but rather, to find a way to help the tissues use said oxygen. Now let's all change our practice.

Don't take my word as gospel on all this, I could be wrong. Read the article for yourself. A hat tip to the authors.

-EJ



Link to Abstract

Gattinoni, L., Vasques, F., Camporota, L., Meessen, J., Romitti, F., Pasticci, I., … Marini, J. J. (2019). Understanding Lactatemia in Human Sepsis: Potential Impact for Early Management. American Journal of Respiratory and Critical Care Medicine.

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Does using Balanced Crystalloids vs. Saline improve mortality in sepsis?

Balanced Crystalloids Versus Saline in Sepsis: A Secondary Analysis of the SMART Trial

Sometimes we need to make minor adjustments in what we do in the ICU to see a difference. I have been going off for several years now on my instagram account as well as YouTube channel regarding the importance of utilizing balanced crystalloids such as lactated ringers or plasma-lyte and I keep on hearing "there's no mortality benefit". Well, now there's data showing that there is. I knew it was just a matter of time. It just makes sense. This analysis is a piggyback on the SMART trial performed by the good people over at Vanderbilt published last year in the NEJM. In that study and therefore this study, they looked at using saline solution versus either lactated ringers or plasma-lyte. You may be asking yourself "but I thought that study didn't show any mortality benefit". You are correct, it didn't, but that finding was regarding all critically ill patients.

This study looked at 30 day mortality in patients in the MICU who were septic. All in all, they looked at 1641 patients with the diagnosis of sepsis. Note: not necessarily septic shock. 34.1% of patients were on vasopressors and 40% were on the vent.

Here are the outcomes:
30 day mortality: 26.3% in the balanced crystalloids group vs. 31.2% in the saline group (p=0.01)
Patients who received balanced crystalloids had more days free of vasopressors, free of dialysis days, lower plasma lactate concentrations after ICU admission.
Debate settled? Well, no. But check out the article for yourself before taking my opinion as gospel.

-EJ




Link to Abstract

Link to FULL FREE Article

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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.