Critical Care

Goldilocks in the ICU: Oxygenation targets for mechanical ventilation

 

Like all medical therapies, we have learned that treatment with oxygen comes at a cost. The medical literature is replete with the detriments of hyperoxia in the management of myocardial infarction, acute stroke, cardiac arrest and septic shock. What is the optimal oxygenation target for critically ill patients requiring mechanical ventilation? Three landmark trials can guide us: Oxygen-ICU, ICU-ROX and LOCO2. The end to the oxygenation fairytale remains to be told, but perhaps Goldilocks is “just right.”  

Hands on defibrillation

A 58 year old male arrives to the ED in cardiac arrest.  CPR is in progress and you are concerned about the amount of time needed prior to defibrillation to stop compressions, ensure all personnel are not touching the patient or the bed, delivering the shock, and then restarting CPR.  It occurs to you that the pads could deliver a shock while CPR is in progress, but wonder about the safety and efficacy.

Mastering mechanical ventilation: what is mechanical power?

Over the last three decades since the introduction of the term ventilator-induced lung injury (VILI), we have recognized that positive pressure mechanical ventilation can injure the lungs. It is widely recognized that the cornerstone of lung protective ventilation requires control of tidal volume and transpulmonary pressure. On the other hand, there has been considerably less focus on the impact of respiratory rate and flow on VILI. Mechanical power unites the causes of ventilator-induced lung injury in a single variable that incorporates both the elastic and resistive load of the positive pressure breath.6 In other words, mechanical power quantifies the energy delivered to the lung during each positive pressure breath by assessing the relative contribution of pressure, volume, flow and respiratory rate.

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POLST Discordant Care

You are working at a community trauma center when an elderly male is brought to the ED after being struck by a car.  The patient is complaining of right sided chest pain and is in respiratory distress. He has a patent airway, is breathing spontaneously and is normotensive.  He is confused and not oriented to place or time. A chest x-ray does not reveal a pneumothorax, but does reveal 5 contiguous rib fractures. The patient is likely to require intubation due to the increased work of breathing.  You review the patient's chart and note that he has a POLST on file indicating a DNR/DNI status as well as identifying his daughter as a medical power of attorney who may override the POLST. A nurse lets you know the patient’s family has arrived.  You wonder how the presence of the POLST form will influence your conversation with the family.

Venous thrombosis after VV ECMO: What is the true prevalence?

 

Venous thromboembolism is considered one of the most preventable causes of in-hospital death. Venovenous extracorporeal membrane oxygenation (VV ECMO) utilization for severe respiratory failure has increased in the decade following the 2009 influenza A H1N1 pandemic and the publication of the CESAR trial.1 The interaction between a patient’s blood and the ECMO circuit produces an inflammatory response that can provoke both thrombotic and bleeding complications. In a systematic review of patients with H1N1 treated with VV ECMO published in 2013, the incidence of cannula-associated deep venous thrombosis (CaDVT) was estimated to be as low as 10 percent; however, more recent data suggests the incidence of venous thrombosis after decannulation is much higher. Additionally, a significant proportion of CaDVT are distal thrombi located in the vena cava, which would be missed with a traditional ultrasound diagnostic approach after decannulation from VV ECMO.  

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Hemodynamic support in Acute Right Heart Failure due to Pulmonary Embolism

A 68 year old male with a history of a right ankle ORIF three weeks ago is transferred to your ICU for management of a pulmonary embolism. He developed acute dyspnea while at physical therapy and was taken to an ED where he was found to have bilateral pulmonary emboli extending into both segmental and subsegmental pulmonary arteries on CTPE. His workup included elevated troponins and an echocardiogram that showed a dilated RV with hypokinesis of the RV free wall and reduced tricuspid valve annular systolic excursion. He was started on a heparin infusion prior to transport and was hemodynamically stable when you took the transfer call. When he arrived to your facility he was mentating well but his BP was 85/50 with a HR of 115 and an spO2 of 96% on 2L NC. How will you address his hypotension?

A Novel Coronavirus (2019-nCoV)

While most coronaviruses cause mild respiratory illness consistent with the common cold, two lethal coronaviruses have been previously identified, including the acute respiratory syndrome coronavirus (SARS-CoV) in 2002 demonstrating 10% mortality and the Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012 producing 37% mortality. In December 2019, a novel coronavirus (2019-nCoV) was isolated from a cluster of patients with pneumonia in Wuhan, China. As reported in the Lancet last week, two thirds of the affected patients in a case series had a history of exposure to the Huanan seafood market.

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Back to Basics: Recurrent Polymorphic VT/Torsades de Pointes

It's pretty easy to remember what to do with unstable polymorphic VT/Torsades de Pointes (shock 'em!), but what are your options with recurrent stable episodes?  

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