Critical Care

NIPPV in Hypoxic Respiratory Failure

A 56 year old male comes to the ED via EMS after noting progressive dyspnea and fever.  In the field, the EMS team notes the patient is hypoxic with an SPO2 of 85%.  Despite the low oxygen saturation, he is only using minimal accessory muscles and he is alert and oriented.  His chest X-ray shows a right lobar pneumonia and he is requiring 6LNC oxygen to maintain a saturation greater than 90%. You know there is significant guideline evidence to support the use of non-invasive positive pressure ventilation (NIPPV) for COPD and CHF exacerbations, but what about patients with other causes of hypoxia such as pneumonia?

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Nephron vs. Neuron: Diagnosis and management of diabetes insipidus in the critically ill

50-year-old man requires intubation for encephalopathy. His urine output is > 400 cc/hr and serum Na returns at 179 mEq/L. What is the most likely cause of his polyuria? 

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BVM v. ETT in Cardiac Arrest and Pneumonia

A patient is brought in by ambulance in cardiac arrest.  As is your practice, you start CPR and focus on bag valve mask ventilation (BVM) while the code gets started.  The patient is resuscitated and eventually intubated as they were not conscious after return of spontaneous circulation.  You wonder, if use of BVM is associated with an increased risk of pneumonia given that the airway isn’t defended as well compared to a cuffed endotracheal tube.

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Deflated? Esophageal pressure monitoring in ARDS

Lung protective ventilation limiting tidal volume and plateau pressure improves survival in ARDS. The application of positive end-expiratory pressure (PEEP) further stabilizes the lung by preventing alveolar collapse during expiration, thereby reducing cyclic atelectasis. However, the optimal approach to PEEP titration to minimize ventilator-induced lung injury (VILI) has not been delineated. The EPVent-1 trial demonstrated that esophageal pressure-guided PEEP titration was feasible and safe with a trend toward increased survival and improved oxygenation in mild to moderate ARDS. However, interest in esophageal manometry in ARDS was deflated by the more recent EPVent-2 trial demonstrating no improvement in a composite outcome incorporating mortality and ventilator-free days in patients with moderate to severe ARDS. A new randomized control trial published last week by Wang et al. examined the role of esophageal manometry-guided PEEP titration in a novel subset of severe ARDS patients treated with VV ECMO. 

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Updates in anaphylaxis

A 46 year old woman arrives at the ED with hives, hypotension, difficulty breathing, and stridor after eating dinner with her family.  She is allergic to shrimp, and thought she had avoided it when she ordered from her favorite restaurant.  However, shrimp dishes are on the menu and she wonders if there was cross contamination.  Unfortunately, she couldn’t find her epinephrine auto-injector at home so her family drove her to the ED.  Immediately recognizing anaphylaxis, you give her a dose of IM epinephrine and she improves within several minutes.  After seeing she has stabilized, you wonder how long should she be observed and what the evidence is behind the use of antihistamine and glucocorticoid therapy.

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Out of rhythm: Melatonin dysregulation in critical illness

 

We do not often give thought to the factors controlling our circadian rhythm. And yet the circadian system modulates many physiologic systems, including brain arousal, cardiovascular function, sympathetic tone, appetite, metabolism and immune system function. Similar to the sinoatrial node pacing the heart, the suprachiasmatic nucleus located in the hypothalamus serves as the central pacemaker for the circadian rhythm, directing sleep, motor activity, temperature and autonomic tone. Rhythmic release of melatonin from the pineal gland helps drive this central clock in addition to other circadian biomarkers, including cortisol and core body temperature. In healthy individuals, plasma melatonin concentrations typically measure 10-fold higher at night than during the daytime. How does critical illness affect circadian rhythm, specifically melatonin secretion?

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When the PLT get LOW

A 72 y/o male with PMH type 2 diabetes, CAD, HFrEF, HTN, and HLD is admitted to the MICU for frequent neurologic monitoring after an endovascular thrombectomy for an acute ischemic stroke caused by thrombosis of the M2 branch of the left MCA. While reviewing his chart, you notice that the patient was recently admitted for 1 week about 10 days ago for dyspnea secondary to acute decompensated heart failure. You also note on his admission labs that he is newly thrombocytopenic, with a platelet count of 80,000. His last platelet count on discharge was 250,000, and he has never been thrombocytopenic before. What is causing his thrombocytopenia?

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ECMO: What is the Intensivist’s Role?

 

A 52-year-old man with a history significant for hypertension presented to the emergency department with cough, dyspnea and fever. He progressed to severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 pneumonia. He developed refractory hypoxemia with P/F < 60 mm Hg despite low tidal volume ventilation, paralysis, inhaled epoprostenol and prone positioning. Is this patient a candidate for venovenous ECMO and, if so, who should guide initiation and management of ECMO? The Society of Critical Care Medicine (SCCM) and Extracorporeal Life Support Organization (ELSO) recently published a position paper on the role of the intensivist in the initiation and management of ECMO. 

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