Join us as we talk through clinical cases in the ICU setting, illustrating important points of diagnosis, treatment, and management of the critically ill patient, all in a casual, "talk through" verbal scenario format.
Lightning rounds #8: Five things you’re getting wrong
Bryan’s off this week, so Brandon flies solo to explain five wrong-headed notions that many people believe without thinking about them.
* Are diuretic infusions more effective than intermittent boluses?* Are antipsychotic (neuroleptic) agents a good treatment for ICU delirium?* Is pressure control or volume control a better form of assist control?* Does renal failure cause chronically elevated troponin levels due to impaired troponin clearance?* If a patient squeezes your hand, does that mean they heard and followed your command?
Episode 38: GI bleeding with Elliot Tapper
Back with returning guest Dr. Elliot Tapper (@ebtapper), gastroenterologist, transplant hepatologist, and director of the cirrhosis program at the University of Michigan in Ann Arbor, to talk about critical GI bleeding.
* Consider the Glasgow-Blatchford score to stratify risk and need for admission, GI consultation, etc.* Octreotide (or terlipressin) is indicated in every cirrhotic with GI bleeding, i.e. patients with confirmed or probable varices.* Proton pump inhibitors are appropriate for bleeding ulcers. Note they are not needed in variceal bleeding, and are not needed if octreotide is also being given; octreotide reduces gastric pH just as much as a PPI.* Bleeding cirrhotics should receive antibiotics. They have a high risk for inpatient infections, whether from bacterial translocation, instrumentation, etc.* By and large, twice-daily PPIs are as good as PPI drips. The latter is mostly an evidence-free Hail Mary addition.* As a general rule, colonoscopy for lower GI bleeding rarely needs to be done urgently; at most, early colonoscopy (within 24-48 hours) may reduce length of stay, but the yield of finding intervenable findings (particularly in unprepped bowel) is extremely low.* In very unstable patients, it is not very common that you would need to place a gastric tube and perform lavage to prove an upper GI bleeding source; just do the EGD. In less obvious cases it can be quite useful, though. Don’t be misled by trace amounts of bleeding, which can occur (due to stress) even in lower GI bleeds.* NG/OG placement in the setting of varices is safe, unless there’s been recent banding performed.* Early CTA is a good approach for severe lower GI bleeding. It is basically never the first line approach for presumed upper GI sources, however; IR embolization is less effective here (due to the redundant blood supplies), and endoscopy will help localize the bleeding source for any needed embolization anyway.* “Early” EGD usually means within 12 hours and is appropriate for active bleeds that are not catastrophic.* Although massive bleeding can result from varices, with good medical treatment it is actually rare. In most cases judicious transfusion can be used to avoid overly increasing venous pressures. * For truly rapid upper GI bleeds, intubate early (to prevent aspiration and facilitate EGD), ensure adequate IV access, and perform emergent EGD; endoscopy remains the first line treatment. Even when visualization is difficult it provides useful information by localizing the bleeding region. Normal (Hgb >7) transfusion targets are not relevant in active exsanguination. A PPI drip is reasonable but is not particularly high yield at this point.* Balloon tamponade (Minnesota or Blakemore tubes) has its own risks, and few clinicians are expert at their placement. Overall it is rarely needed unless endoscopy is not immediately available, such as if a patient needs transfer to another institution.* EGD can lead to rescue surgery if it visualizes bowel perforation, and to IR if a bleeding vessel is found that can’t be addressed endoscopically.* Repeat endoscopy during the same hospitalization is rarely needed. For ulcers, it is common to re-scope in about 8 weeks to make sure it has healed and is not cancerous.
The Glasgow-Blatchford Bleeding Score (GBS) to stratify risk.
Lightning rounds #7: Operationalizing clinical skill
Discussing a pickle of a topic: outside of academic milestones, how do we recognize, acknowledge, reward, and move towards clinical excellence in medicine after one’s training is complete? In fact… do we?
Episode 37: Airway management for COVID-19
Back again with Dr. Ross Hofmeyr (@rosshofmeyr), anesthesiologist in the Department of Anaesthesia and Perioperative Medicine at the University of Cape Town, to discuss an expert’s perspective on airway management in the COVID-19 patient.
* Good practices for intubating COVID patients are, by and large, good practices for intubating anybody. Using a standardized protocol, appropriate PPE, applying best practices to optimize success, and pre-assigning roles has no downside.* Support each other by using “call/response” checklists and buddy checking PPE.* Ross’s protocol: one attempt at intubation, immediate placement of supraglottic airway if it fails, then proceed to another attempt. First line with video laryngoscopy using a Macintosh blade. No mask ventilation (to limit aerosolization) except as third line if SGA fails. Mask with two hands, two operators, and a PEEP valve.* Patients need oxygenation, and to a much lesser extent ventilation, but not tubes per se. Whatever method achieves that in an emergency is okay.* You need PEEP to preoxygenate the hypoxic COVID patient. High flow nasal cannula is okay, but a BVM with PEEP valve provides real PEEP and usually improves preoxygenation. HFNC with a mask on top is less clear as the large cannula can cause air leak.* Learning to bag-mask ventilate on mannequins teaches bad habits. Learning in the OR with real humans and an anesthesia bag is a better place.* Intubate everyone with head of bed elevated PLUS head in a sniffing position. Blankets are better than pillows. Start with more elevation than you need; it’s easier to remove than to insert.* Move the bed. True 360 degree access to the bed makes a difference.* Proper preparation makes most of the difference to success. Even experienced anesthesiologists have dramatically reduced first-pass success when removed from their usual OR setting, likely due to less preparation.* By and large, different types of PPE should not affect intubation success if the team is highly-skilled.* Ross’s team favors induction with fentanyl, etomidate, and succinylcholine (unless hyperkalemic, then rocuronium). The small advantage in speed with sux is worth it in these rapidly-deoxygenating patients.* Use a verbal call/response checklist to make sure nothing has been missed, slow down the pace, and create a shared mental model among the team (particularly if not everyone is part of the usual group). This only takes a significant amount of time if you actually find deficiencies that need correcting (in which case you’ll be glad you took it), and it adds value almost every time.* Many patients will be dehydrated and hypovolemic at the time of intubation, particularly if they’ve been on non-invasive for some time (often not eating/drinking) and most of all if they’ve been on non-humidified oxygen, such as regular cannula and/or masks.
SASA (South African Society of Anaesthesiologists) COVID-19 protocol and recommendations
Lightning rounds #6: Point of care ultrasound
We chat about focused, clinician-performed point-of-care ultrasound (POCUS) in the ICU. How do you learn it? What are our favorite applications? What are some of the particulars and caveats surrounding credentialing, documentation, and billing? All that and more…
Episode 36: Preventing and managing complications
Back in the arena with one of our favorites, Matt Siuba (@msiuba), Cleveland Clinic intensivist and Mr. Zentensivism, to discuss complications in critical care and how to prevent and manage them. Today we focus on atrial fibrillation with RVR and bleeding after thoracentesis and related other procedures.
* Rapid atrial fibrillation in the ICU should be considered a “symptom,” not a disease per se. Look for stressors or triggers for tachycardia, such as infection, agitation, etc. Resume home agents if they exist — or don’t hold them to begin with — especially beta blockers, as rebound can occur with discontinuation. Don’t get too hung up about converting the rhythm. Give magnesium early and often, acknowledging that rapid administration tends to provoke rapid loss to the urine and you may be better served to stretch it out.* A-fib with a rate below the 130s-140s is unlikely to be the cause (rather than an effect) of shock, outside of structurally abnormal hearts that need filling time or atrial kick (such as diastolic failure).* Remember that you have time to address rapid A-fib in a stable, minimally symptomatic patient, regardless of the rate. You can only make them less stable. Go slow and be thoughtful.* Good reasons to perform therapeutic thoracentesis include work of breathing. Less common reasons include hypoxemia. If you suspect you may need to re-tap, consider leaving in a drain.* Under ultrasound, put color doppler on the thoracic wall to confirm there are no unexpected vessels at your puncture site; do this in two planes and use a superficial probe.* You do not need to use real-time ultrasound guidance for the thoracentesis puncture unless the pocket is quite small; you can always ultrasound the wire after it’s in place if the wire entry felt weird. It takes some practice to maintain a good relationship to the rib while also guiding yourself under ultrasound. * Anchor your needle hand to the patient so unexpected movement will not shift your position, and use the smallest needle necessary. Consider performing smaller thoracenteses with a micropuncture kit rather than with a larger catheter like a pigtail; insert the micropuncture sheath and use it to drain the fluid. Small needle, small catheter, safe.* A “dry tap” with your thora needle should prompt a different technique, not repetitions of the same one. Change something or check your position to ensure you’re not below the diaphragm. After one or two attempts, consider handing over to someone more experienced.* Finding blood in your pleural tap should make you pause, but not panic. Traditionally you can send it for a hematocrit, but this is rarely very useful. Generally you can complete the tap and see if it clears. Afterwards, reinvestigate the space under ultrasound to ensure no blood is reaccumulating, and monitor the patient closely; occasionally they may need a CTA and embolization. Consider leaving a drain to monitor output, although be sure to flush it regularly to prevent clotting. Investigate for other reasons there may be hemothorax, such as trauma, previous taps, or malignant exudates.* If you suture a line or other device and it won’t stop bleeding, you may have caught a superficial vessel (e.g. the EJ when performing an IJ). Take those sutures out or it’ll never stop.* Complications happen. They should generally prompt introspection to consider whether practice should be changed: could I have been better prepared to do that? Was I rushed? Was my mindset wrong? Should I be using a different technique? And so on. However, sometimes practice is optimal, and complications are simply the inevitable result of intrinsic risk; in such situations, changing practice can only mean worsening it.
Excellent for anyone who steps foot in an icu
Just curious with the most recent podcast why it was presented as a “54 y/o UNVACCINATED” individual. Why does that matter? Didn’t science & research develop PPE so that we (nurses/docs) can provide care to every, single body regardless if they have a contagion or not and be protected. Vaccination status is not a diagnosis. Another example is someone with HIV does NOT have to disclose that to healthcare providers because we should be using appropriate PPE for every patient. No discrimination. Am I wrong???
As a new grad ICU nurse, this podcast is so incredibly helpful. There’s so much information that can be learned for these case studies. I have listened to several and I feel better prepared for my role as an ICU nurse. Thank you for making this podcast! Please keep them coming!