Monday Back to Basics

Peritoneal Dialysis and Peritonitis with Dr. Carlos Cevallos

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References:

Dialysis Related Emergencies | CorePendium (emrap.org)

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment – Philip Kam-Tao Li, Kai Ming Chow, Yeoungjee Cho, Stanley Fan, Ana E Figueiredo, Tess Harris, Talerngsak Kanjanabuch, Yong-Lim Kim, Magdalena Madero, Jolanta Malyszko, Rajnish Mehrotra, Ikechi G Okpechi, Jeff Perl, Beth Piraino, Naomi Runnegar, Isaac Teitelbaum, Jennifer Ka-Wah Wong, Xueqing Yu, David W Johnson, 2022 (sagepub.com)

Levine, Brian J. EMRA Antibiotic Guide. Emergency Medicine Residents’ Association, 2022.

Peritoneal Dialysis–Related Peritonitis: Towards Improving Evidence, Practices, and Outcomes – ClinicalKey

https://www.kidney.org/content/what-peritoneal-dialysis

Monday Back to Basics

Let’s talk about Rehab with Dr. Katie Selman

Many facilities may have multiple services – often, the same facility will offer subacute rehab and long-term care and memory care services

Instrumental Activities of Daily Living (IADLs) = managing house, finances, transport, medications, shopping

Activities of Daily Living (ADLs) = walking, toileting, bathing, feeding, transferring

  • Is this a rehab-able condition?
    • Rehab-able condition examples: stroke, hip fracture, deconditioning after serious illness
    • Potentially not rehab-able examples: any progressive, gradual degenerative disease in which the patient is expected to continue to decline
  • Why does this matter?
    • Insurance will stop paying for rehab if patient is not improving or making progress based on their PT/OT/ST notes
    • There is a daily copay for patients after 21 days in rehab and the full cost is on the patient after 100 days
      • PT is amazing but cannot fully reverse a months-long decline in 21 days!
  • Will the patient be able to physically and cognitively participate in rehab?
    • Acute inpatient rehab = 3 hours therapy/day
    • Subacute rehab = 3 hours/week
  • Patients are not rehabbed until they can go home safely – patients are rehabbed until they can safely live in a one-story home.
    • So what is the goal after rehab? What is the backup plan if they still can’t go home after 21 days? Will they still need help?

References:

https://www.genworth.com/aging-and-you/finances/cost-of-care.html

https://www.medicare.gov/care-compare/

https://www.aarp.org/caregiving/

Flint LA, David DJ, Smith AK. Rehabbed to Death. N Engl J Med. 2019;380(5):408-409. doi:10.1056/NEJMp1809354

Flint LA, David D, Lynn J, Smith AK. Rehabbed to Death: Breaking the Cycle. J Am Geriatr Soc. 2019;67(11):2398-2401. doi:10.1111/jgs.16128

Burke RE, Jones J, Lawrence E, et al. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. J Gen Intern Med. 2018;33(5):678-684. doi:10.1007/s11606-017-4298-1

Halifax E, Bui NM, Hunt LJ, Stephens CE. Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care. J Palliat Care. 2021 Jan;36(1):61-65. doi: 10.1177/0825859720904802. Epub 2020 Feb 27. PMID: 32106767; PMCID: PMC8127871. 

Tuesday Advanced Cases

DIC with Dr. Alyssa Sinko

Case: 64 M with no PMH presenting with continuous oozing from mass in posterior pharynx. Vital signs significant for: T 98.5, HR 72, BP 130/84, RR 16, SPO2 98%. Patient also found to have petechia on lower extremities. IV access established, and it is noted that there is bleeding from the IV sites.

Pathophysiology of DIC:

Causes of DIC:
– Most common: Sepsis
– Carcinomas, leukemias, TBI, pancreatitis, snake bites, ARDS, transfusion reactions, transplant rejection, crush injuries, burns, fat embolism, liver disease
– Pregnancy associated: Placental Abruption, Amniotic Fluid Embolism, Septic Abortion, HELLP syndrome, Acute fatty liver of pregnancy

Laboratory Testing:

PT used for monitoring over course

Bleeding Differential Diagnosis:

Management:
– Treat to treat underlying trigger
– If purpura fulminans present, treat with protein C concentrate
– Consider heparin if thrombosis is primary symptom
– Repletion to be considered if significant bleeding or impending procedure

  • Fibrinogen < 100 = Cryoprecipitate
  • Platelets <50K with bleeding, <10K without bleeding = Platelets
  • PT/PTT over 1.5x normal limit = FFP
  • Vitamin K and Folate

References:

Tintinalli’s Emergency Medicine Manual, 8e Eds. Rita K. Cydulka, et al. McGraw Hill, 2018

Uptodate.com

Monday Back to Basics

Tracheostomy Complications with Dr. Sean Coulson

Key Questions

How long ago was is placed? Is it a tracheostomy vs a laryngectomy?

Infections

Mediastinitis, tracheitis, pneumonia, lung abscess/aspiration, sternal septic arthritis, cellulitis, fungal infections

Consider a tracheal aspirate culture, suction, hypertonic saline, humidified oxygen

Mechanical Complications

Decannulation or Dislodgement

Tracheostomies < 7 days old require replacement with direct visualization (fiber optic visualization)

Tracheostomies > 7 days old may be re-inserted blindly (but should confirm with fiber optic visualization)

Tracheal Stenosis

Can occur at any point along trachea -> look for stridor

Location of stenotic lesions may make mechanical ventilation or criccothyrotomy difficult, or may require a much smaller airway (consider pediatric sizing). This is a surgical emergency! Consider Heliox to improve laminar flow for oxygenation.

Bleeding

Tracheoinnominate artery fistula & hemorrhage

Majority within 4 weeks of trach placement

Even if small amount of bleeding, take seriously as these are often sentinel bleeds and can lead to massive hemorrhage in 24-48 hours

Treat with external compression to sternal notch, over inflated tracheostomy cuff, consider intubation from above. Consult your surgical/ENT colleagues for evaluation and assistance

References:

https://www.emrap.org/corependium/chapter/reckOdDn9Ljn7sBLy/Complications-of-Tracheostomies

https://rc.rcjournal.com/content/50/4/542.short

https://www.enteducationswansea.org/trachy-lary-differenceshttps://basicmedicalkey.com/larynx-and-respiratory-system/