Fluid responsiveness: how to predict

If your way of determining whether a patient is fluid responsive or not is to see if the blood pressure went up after giving a bolus, you are doing it WRONG! You need to stop, take a deep breath, and reassess your way of thinking about fluid responsiveness. This (FREE!) article dives into why fluids should not be provided arbitrarily go make us feel good inside and make us feel like we at least "did something" in response to that low mean arterial pressure. No, I do not use SBP and DBP off of the BP cuff in my practice. More on that at another time. This article also goes briefly into why we should not be checking CVP (duh). Bottom line is that we can't accurately predict fluid responsiveness without an arterial line and some sort of device to predict stroke volume, stroke volume variation, cardiac index/output. You could have some really good echo nunchuck skills as well. This study also emphasizes why looking at IVC variations is not the best test. Ultimately, we all need to get better at this, myself included. I feel that this article is particularly important for nurses as you all are the ones who relay the BP concerns to the clinicians essentially ordering the fluids. These three authors are legends of critical care. A real treat that Annals of Intensive Care published this for free.

This article is going to be part of the bibliography for the talk I will be giving in Portland, OR in August of 2020.

-EJ

Monnet, X., Marik, P.E. & Teboul, J. Prediction of fluid responsiveness: an update. Ann. Intensive Care 6, 111 (2016). https://doi.org/10.1186/s13613-016-0216-7

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Mechanism of Hypokalemia in Magnesium Deficiency

In the ICU, we are at times obsessed with making our patients “euboxic” or better said, all labs values within normal ranges. That being said, electrolytes are something we replete every day and our nurses often have protocols which instruct them on how to manage and correct these derangement to hopefully optimize the outcomes of our patients. When I was a resident, one of my mentors and a good friend to this day taught me to correct the Magnesium before correcting the potassium. This left me scratching my head. It made no sense. And the he went on to explain the mechanisms listed in this article and my mind was blown. How much other stuff do I not know? How come I wasn’t taught this in med school? Well friends, there A LOT that we weren’t taught in med school or even residency and fellowship training for that matter. That pretty much why I’m on this lifelong learning journey and hopefully bringing you all along for the ride. This article is free and it’s a good review for you all to check out. To the cool nurses on Instagram, mid sharing this with your colleagues? This is also must know medicine for any internal medicine intern and resident working the wards and ICU. Tony Breu totally killed this subject in a much more thorough and intelligent manner than I did several months ago on twitter. Follow him @tony_breu.
-EJ

Link to Abstract

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Huang, C.-L., & Kuo, E. (2007). Mechanism of Hypokalemia in Magnesium Deficiency. Journal of the American Society of Nephrology, 18(10), 2649–2652.

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One-Year Outcomes Following Tracheostomy for Acute Respiratory Failure

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Generally speaking, one has a gut feeling of how long a patient is going to be on mechanical ventilation. Usually around day 7 or 8 I start warning families that a tracheostomy may be in the near future for their loved one and ask if that is something that if the patient knew full and well everything that a tracheostomy would entail, would they want to move forward with the surgical procedure?

This article is a retrospective cohort study where the authors looked at a number of outcomes but primarily mortality. This article is extremely important as it provides data that we can guide those who we take care of with what to expect. In patients 65 years of age or greater, mortality at 30 days is 25%, 90 days is 42% and 1 year is 55%. Those are abysmal numbers and numbers that people should know before putting their loved ones through that. It's definitely something to think about. Just because we can do some things doesn't mean we should.

-EJ

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Iatrogenic anemia: Let's Save Some Blood

Our curiosity is what drove is to our respective fields in medicine. As an intensivist, I LOOOOVE trending numbers and analyzing the minutia of the details to predict in what direction my patient is going. There is a difference, though, between utilizing labs to better serve your patient and using labs to satisfy your academic curiosity. I admit that I have been guilty of this and still am at times, but it's something we should definitely work on. We should not be blindly ordering labs and having the vampires come in the middle of the night sucking blood out just because we like to look at numbers in the morning, but rather because it's providing value to our patients. Are we going to make a specific decision based on that or are we just going to be looking at a mostly pointless white count (while ignoring the bands)? This study was published last night. It's worth a read and it's free! But it should put front and center in the minds of all my colleagues in training as well as nurses to think "why am I ordering this lab and what am I going to do with the result differently that what I'm doing right now?". We can save a ton of money for our broke healthcare system, save the patients from the morbidity of a ton of needle sticks, and save our patients from the undeniable anemia that they will eventually fall into. It's not just something else that they need to recover from at the end of the day.
As always, a hat tip to the authors.

-EJ

Link to Article

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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.

Heparin Shortage: 2019

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Imminent risk of a global shortage of heparin caused by the African Swine Fever afflicting the Chinese pig herd

By no means am I a fear mongering here, but I am legitimately concerned about the inaction of our health care systems to worry about this issue until it was too late. We were warned last year. It's now August. Heparin is on backorder, folks. I know you and I are going to be just fine but our patients may suffer. This is a good time to check out which of your patients could be switched from heparin to lovenox/enoxaparin, fondaparinux/arixtra, and other alternatives. Remember that there are certain vascular surgery and cardiothoracic procedures where there are no alternatives for heparin and we need to make sure that these patients have the medication they need as we try to weather the storm. Have you all had meetings yet to address this issue at your shop? Nurses, have you been kept in the loop of these impending issues? Pharmacists, am I overreacting?

-EJ

Other links:
https://www.ashp.org/drug-shortages/current-shortages/Drug-Shortage-Detail.aspx?id=353
https://www.upi.com/Top_News/US/2019/05/01/Chinas-African-swine-fever-epidemic-could-cause-global-heparin-shortage/5881556646708/
https://www.raps.org/news-and-articles/news-articles/2018/2/concern-over-heparin-supply-prompts-call-for-fda-i
https://www.reuters.com/article/us-congress-heparin-china/congress-seeks-briefing-on-potential-threat-to-u-s-heparin-supply-idUSKCN1UP1TX
https://www.fiercepharma.com/manufacturing/congress-hits-panic-button-over-potential-shortage-chinese-heparin-as-chinese-swine

Estimated Resupply Dates per "https://www.ashp.org/drug-shortages/current-shortages/Drug-Shortage-Detail.aspx?id=353"

•Fresenius Kabi has heparin 5,000 unit/mL 10 mL vials on back order and the company estimates a release date of mid- to late-August 2019. The 5,000 unit/mL 1 mL syringes are on back order and the company estimates a release date of mid-August 2019. The 10,000 unit/mL 4 mL vials are on back order and the company cannot estimate a release date. There are short-dated 20,000 unit/mL 1 mL vials available with an expiration date of < 7 months. All other presentations are on allocation.

•Hikma has 1,000 unit/mL 2 mL vials, 5,000 unit/mL 2 mL vials, and 10,000 unit/mL 2 mL vials on allocation.

•Pfizer has 5,000 unit/mL 1 mL Carpuject syringes on back order and the company estimates a release date of August 2019. The 5,000 unit/mL 1 mL glass vials are on back order and the company estimates a release date of August 2019. The 5,000 unit/mL 10 mL vials are on back order and the company estimates a release date of December 2019. The 1,000 unit/mL 10 mL glass vials are on back order and the company estimates a release date of December 2019. The 1,000 unit/mL 30 mL vials are on back order and the company estimates a release date of August 2019. The 10,000 unit/mL 0.5 mL Carpuject syringes are available in limited supply. The 1,000 unit/mL 10 mL vials (NDC 00069-0058-01) are available in limited supply.

•Sagent has 1,000 unit/mL 2 mL and 10 mL vials on back order and the company estimates a release date of August 2019. The 1,000 unit/mL 1 mL and 30 mL vials are on back order and the company estimates a release date of September 2019. The 5,000 unit/mL 1 mL and 10 mL vials are on back order and the company estimates a release date of August 2019. The 10,000 unit/mL 1 mL and 4 mL vials are on back order and the company estimates a release date of August 2019.

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Balanced Crystalloids Versus Saline in Critically Ill Adults: A Systematic Review and Meta-analysis

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I honestly wonder how much data is enough data to change some minds. This is why I am counting on you all, people who are trying to keep up with this flurry of data to the best of your ability, to go through medical school, residency, possibly fellowship with a healthy respect for 0.9% saline solution. It may seem like it's hopeless from time to time to change decades worth of practice. Heck, my first IVF resuscitation video is almost 2.5 years old and has almost 39000 views! Hopefully the studies which will be published within the upcoming 2 years will hit the nail on the head. You can see the data from the slides, using saline versus balanced salt solutions increased mortality in the critically ill, increased acute kidney injury, and kept the patients on the ventilator for a longer period of time. To those harping about the increased costs of one fluid versus the next, consider the cost of one ventilator day. Consider the risks involved with each day on the vent. Consider the financial strain from working up every-single-case of AKI. This stuff adds up, colleagues. Anyway. A hat tip to the authors! 

- EJ

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Optimal norepinephrine-equivalent dose to initiate epinephrine in patients with septic shock

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I am quite confused by this article. I was hoping for some answers on how to manage norepinephrine and epinephrine in septic shock but instead I am left scratching my head wondering what in the world happened here. If you're on my page and following along in on this journey, then you know a thing or two about septic shock patients. This article was supposed to provide us with some data regarding when to start epinephrine on these patients once levophed was already running. Instead, you find a retrospective observational study with a statistically significant difference between the optimal dose group and the non-optimal dose group. Within the subgroup analysis, though, you can find that 83.3% of the optimal dose group was also on vasopressin while 62.3% of the non-optimal group was on vasopressin (p=0.001). Does this mean that there's a dose to start epinephrine when a patient is on norepinephrine, or does this mean that before starting epi, you should have vasopressin on board? 

-EJ

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Ascorbic Acid, Thiamine, and Steroids in Septic Shock: Propensity Matched Analysis

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Another day, another Vitamin C article. This one came out just two weeks ago, it’s not free, and the results are a bit strange. There are larger trials in the works. If I were part of the group of these authors, I’d be itchy to get my data out ASAP as well. Just 31 patients in each arm of this trial. Heck, even I could replicate this trial in my 20 bed MSICU if I wanted to over 1.5 years. The problem is that my bias admittedly is for the cocktail to work. I am wide openly admitting that, everyone. I have a bias. I want it to work bc I want my patients to live.  

There are numerous parts of this study that seem strange to me. 

1. the ICU mortality of the control arm is 42%. This number should not be quite as high based on the latest data. That could lead the p-value of 0.004 to be perhaps a bit too small. But considering that they used the same strategies to manage septic shock these pts in both arms, it’s still valid for that institution. 

2. The duration of the vasopressors were longer in the experimental arm. This makes NO sense as Vitamin C is a co-factor in the endogenous creation of catecholamines. Heck, even the authors admitted this was strange. 

3. There was no significant difference in hospital mortality. They probably needed a high n to get this to show a difference. The hospital medicine and palliative teams must be great at getting code status’ changed so that people don’t bounce back to the unit. 

4. Pts did not get off of the ventilator faster. Word on the street is that there’s preliminary data suggesting that it helps this process that just isn’t out yet. Stay tuned. 

Lastly, everyone is worried about renal failure. No difference in AKI here, folks. In fact, I am yet to see one report in any of these trials talking about renal calculi secondary to vitamin C in sepsis. 

What are your thoughts on the matter? Is your shop using this yet? Are you a believer or a skeptic?

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Diagnostic accuracy of C-reactive protein and procalcitonin in suspected community-acquired pneumonia adults visiting emergency department and having a systematic thoracic CT scan

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When I was in training, I was taught that Procalcitonin helped to differentiate between bacterial and viral infections. That's the reason why it was approved by the FDA and that's the reason why we use it today. I have seen other clinicians and colleagues suspect infection on a patient, order a PCT, see that it's negative, and then feel good about everything going on. On the same token, I've seen patients with an elevated PCT who are completely asymptomatic be kept in the hospital for extra days to be "observed" to see whether they will present themselves with an infection within the next 24 hours. Unfortunately, many people have not read the most recent studies where you have to tease out the fact that a negative PCT does not completely rule out infection and vice versa. This study, with a bunch of limitations within it, opened my eyes to the fact that you can have a patient with community acquired pneumonia and a negative PCT. Game changer. I no longer use it to make me feel better inside. I only use it when it's elevated in the first place and I have a confirmed bacterial infection to help me deescalate antibiotics and I also use it to help me know whether source control has been achieved. 

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Procalcitonin: should you use it to guide antibiotic treatment

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Oh my good friend, #procalcitonin, we are doing you so wrong. Sometimes we ignore you to stop antibiotics, sometimes we use you inappropriately to differentiate between bacterial and viral infections and end up under treating bacterial infections. I plan on clearing up a bunch of confusion within the next few months but this shall be article one on the subject. This is where I do feel that checking procalcitonin levels is actually useful and now there’s additional data to support it. Trending it to see if you can discontinue antibiotics early, much to the chagrin of some of my #infectiousdisease colleagues, is a place where it is definitely useful. The caveat is that it has to be elevated in the first place. I’m sure we’ve all seen septic patients with a negative procal at this stage of our careers, as frustrating as that may be. Those are the nuisances of these tests that, if employed correctly, will make you one of the Masters of the Universe. Sorry, my nerd brain is on full swing this morning. 

-EJ

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