Discover and read the best of Twitter Threads about #CriticalCare

Most recents (24)

Is direct discharge to home (DDH) from ICUs safe?

1. Patients are usually transferred to hospital wards from the ICUs and discharged to home after another few days. However, there could be delay in getting a ward bed or patient might have significantly recovered while in ICU.
2. Moreover, some families find it difficult to afford longer duration ICU (& hospital stay) costs. This necessitates direct discharge to home (DDH) in some patients. In a recent study, the safety of DDH was evaluated and compared to those who were transferred to wards from ICUs.
3. For DDH from ICU, compared with ward transfers, there was no difference in the risk of-
*Emergency department visits at 30-days (22.4% vs 22.7%);
*Hospital readmissions at 30-days (9.8% vs 9.6%); or
*90-day mortality (2.8% vs 2.6%).
#MedTwitter #CriticalCare #ICU
Read 5 tweets
An INCREDIBLY intimidating part of the ICU can be the patient exam in the AM:
A 🧵on what to assess at bedside while taking care of an intubated/sedated patient.

(Because @tammamtu made an excellent point on another 🧵)
#MedTwitter #MedEd #Medicine #CritCare #ICU #CriticalCare
1. Talk to the patient, no matter their mental status. You should introduce yourself & announce what you’re doing during a physical exam. Sometimes we forget that there’s a loved one surrounded by all those machines & forget to act the same way we would if they were awake. Don’t.
2. Mental status: If they’re relatively responsive this one is much easier. If they’re not, this one is tough.

Assess sedation level. RASS is a commonly used descriptor. Most patients (not all) should be +1 to -1. If they’re -5 and on max sedation, you should explore that. Image credit: https://inten...
Read 16 tweets
ICU pre-rounding tips:
I feel like early on, knowing what matters in the ICU is REALLY tough. So here’s what I typically do:
A 🧵 inspired by @akhadilkarMD’s pre-round thread (you should check that one out too!)

#MedTwitter #MedEd #CritCare #ICU #medicine #criticalcare
1. If you can get at least some of this information automated for a printout, that can be invaluable. Whether that’s an updateable .dotphrase or a printable page from EPIC/Cerner etc. — save the carpal tunnel for later and just make notes on the data!
2. Start with a page that allows you to trend vitals. Particularly helpful is one with vitals and vasoactive gtts :
Is the MAP the same all night but the levo is down OR struggle to get a MAP >65 & escalate to a second pressor?
The #’s are important, but the TREND is essential.
Read 14 tweets
MAPSE in #IntensiveCare (with examples)🧵#FOAMcc #FOAMed #MedTwitter #Hemodynamic #POCUS #EchoFirst #CriticalCare
Take homes:
1⃣ Redefining "the hyperdynamic heart" with #MAPSE
2⃣ MAPSE is better than EF in the #ICU
3⃣ Linking MAPSE with supply/demand-ischemia
1⃣ Can MAPSE redefine "the hyperdynamic heart?
The term "hyperdynamic LV" - EF > 55% - is misleading. It has no relation to a hyperdyanmic circulation; SV/CO. Someone bleeding to death has a hyperdynamic heart, but the circulation is life-threatening hypodynamic.
MAPSE is cardiac motion, and defining the hyperDYNAMIC heart as good cardiac motion makes perfect sense. Recent geometrical analysis of cardiac pumping shows that MAPSE is the main determinant of SV. Fig from @mugander:
Read 17 tweets
A case of low ScvO2 (60%), high PvaCO2 (8.2 mmHg), fluid intolerance (CVP 11) and fluid responsiveness (PPV 17). What's the physiology and what to do?
#FOAMcc #Hemodynamics #ThePeoplesVentricle #FOAMed #Fluidtolerance #Cardiotwitter #CriticalCare
Post-cardiac surgery. MAP 70, HR 95, low dose pressor. High CVP (11 mmHg) with pathologic waveform of x < y-descent. PPV > 17 despite low Vt (< 6 mL/kg). Normal blood gasses, normal lactate.
#EchoFirst #POCUS #TEE: Mildly reduced LV function; #MAPSE 5.75 mm. EF visually 45-50%. Small EDV.
Read 11 tweets
Reasons I love #neurology
1. 2022 is my 25th year in Neurology. I enjoy this subject many times more than 1998, when I entered this branch as a #resident at @OffCMCVellore I was dissuaded by many of my teachers to take up DM in another specialty but I stuck to Neurology
2. Neurology is vast: If you love reading, there are several topics you can read. There are about 600 common #diseases in Neurology to read about. Newer diseases are being discovered, so there is no dearth of new topics to learn about.
3. History & physical examination are still the most important to arrive at a diagnosis. Whether it is epilepsy, migraine, stroke, Parkinson's disease or Alzheimer's disease, history & physical are more valuable than any investigations. MRI, EEG & EMG contribute but are not final
Read 11 tweets
NEXT:Interfacing ICU data Nicolas Bennet
- Nicolas was very pleased to hear Chris Sauer(earlier speaker) advocating use of 2 -data set at least
@ESICM #criticalcare #ai #ml #icudatasets
showcasing this R dataset

starting with
> library(ricu)
> lact (loaded all lactate data)
@ESICM NEVER THOUGHT THAT I would be tweeting code in an ICU conference :)) @ESICM #datascience :P #datascience #LIVES2022
Read 16 tweets
NEXT Inventory and Comparison of ICU datasets by Christopher SAUER

"Why talk on differences in ICU databases?"
Ans: becuase data is "CORE"
@ESICM #ml #ai #databases #datascience #LIVES2022
@ESICM Merit of publicly available ICU databases
- no randomzined evidence exists for most clinical situations
-data and pt level insights incredibly useful.
-local epidemiology and treatment difers
-real world data sets help deliver optimal treatment policies.
#DataScience #LIVES2022
@ESICM 1st publicly available dataset MIMIC-3 in 2016,
Beth Israel Deaconess Medical Centre, Boston,MA
>70,000 icu stays, 2008 to 2019
now also includes chest x-rays, emergency room data
- large, community developed Github repo.
Read 16 tweets
Day 2. Starting on pitfalls in leveraging EHR by Stephanie HYLAND @ESICM #criticalcare #ehr #datascience #ai #LIVES2022
This problem is mainly for ML engineers who may not have talked to domain expert or clinicians / end users.
Pitfall 1 : sampling bias
"whos included in the analysis"
"who in your EHR"?
- e.g., - COVID prediction dataset where missing all blood tests were removed, but this missingess has a meaning. Thus not generalisable.
e.g., yesterday I mentioned about females < 6% of sample popn
Read 10 tweets
Amsterdam UMC on Implementation: @drPaulElbers Conference conflicts of interest : chair of data science edition.
"Working AI to Implementation"
#criticalcare #DataScience #ai #aitobedside #LIVES2022
@drPaulElbers @ESICM PacMed Model to help discharge patients from ICU. Autokinetics for antibiotic dosing.

These 2 are currently implemented. @patrickthoral also involved in discharge models.
@drPaulElbers @ESICM @patrickthoral - ICU natural habitat
- large vol of data
- frequent decision making
BUT there is a problem in ICU and data.
- high variability
Read 17 tweets
NEXT: Who's "high risk" in ICU? Nicolas Bennett - Zurich, Switzerland.
reminds me of NELA score development in UK.
Declaration : he now works for industry (known side effect for medics doing data science )
@ESICM #criticalcare #ai #datascience #LIVES2022
@ESICM Interesting : eventually end up writing R package.…

#sepsis classification using MIMIC-3 - time series data. Time-series classficiation.
Read 12 tweets
Starting with "Whats *HOT* in data science?" Kirsten COLPAERT
- hype cycle for data science & ML in 2022.
- innovation trigger -> peak of inflated expectations -> trough of disillusionment
#datascience #WeAreICU #TogetherICU #IntensiveCare #CriticalCare @ESICM
Still some time for newer tools. Aiming for path towards productivity.
Potential usage of "Synthetic data" to "preserve privacy" and "augment unbalance/or biased data". This is potentially interesting as it allows more transportability of models from one health care system to others.
Read 11 tweets
FINAL day 2 of 2 : WEANING . Lisanne Roesthuis. Weaning definitions starting with WIND study. #LIVES2022
#weaning #WeAreICU #TogetherICU #IntensiveCare #CriticalCare
@ESICM Successful weaning (or successful separation) - extubation without death or reintubation within next 7 days. same for tracheostomy.
Different groups and trajectories
Read 18 tweets
NEXT :: COPD - Oriole Roca.
Evidence : NIV is great for acute COPD. The classic from Laurent Brochard
but if beyond 24 hours. alternative is High flow nasal cannulae.
@ESICM NIV failure - intubat the patient, COPD patient intubated, Vol Control, 7ml/kg PBW, I:E = 1:4 , RR 20. Then patient is "hypotensive". why?
Read 20 tweets
*Advanced bedside monitoring in Resp failure*. Opening by Luigi Camporota to a room full of ventilation geeks from Paraguay, Australia, and all across Europe 😜 #LIVES2022
Starting with Luigi on the principles of why we ventilate , and linking with Driving Pressure to ensure lung protection (rather than TV)
1. Oesophageal pressure but even if no oesophageal ballon 2. Bedside monitoring by clinician of Resp drive and asynchrony (E.g., breath stacking) is useful since high drive ~ VILI #LIVES2022
Read 8 tweets
Mujer 55 años, cáncer de mama, quimioterapia: fiebre, bulla purpúrica dolorosa rodeada de eritema en el cuero cabelludo.

El recuento de glóbulos blancos y absoluto de neutrófilos: ⬇️(neutropenia)
#dermatology #IDtwitter #MedTwitter Image
Hemocultivos: Pseudomonas aeruginosa


#microbiology #dermatologia #emergency
Al principio, las lesiones de ectima gangrenoso toman la forma de máculas rodeadas de eritema que rápidamente se transforman en ampollas y escaras ulcerativas necróticas.

#criticalcare #MedStudentTwitter #resident
Read 4 tweets
ACEP acaba de sacar estas tarjetas súper útiles para apoyarse en la realización del #pocus cardiaco. Aquí se las dejo! Que les sean de mucha utilidad #ultrasound #criticalcare #emergency #education #FOAMed #medicine
Ahí las tienen… que las disfruten !
Read 3 tweets
Lazarus sign is a reflexive movement seen after or near brain death (BD) w/ arms raising & dropping to chest. It’s essential to know all the reflexes seen with BD to provide realistic expectations to families. 🧵 #neuroscience #brain #CriticalCare
50% of brain dead patients demonstrate spontaneous, reflexive movements. The most common movements are finger jerks, undulating toe flexion sign, triple flexion response, pronation-extension reflex, and facial myokymia.
Do not confuse these reflexive movements with recovery, improved prognosis, or volitional movements, and educate families about their lack of clinical significance. @DL_Hollywood
Read 3 tweets
A 58-YO, toothache: swelling in the neck, sore throat, chills, chest pain; oral cavity indurated & woody, neck adenopathy; erythema spreading from his neck down over his anterior chest wall (A & B)

#MedEd #IDtwitter #dermatology #MedTwitter
DOI: 10.1056/NEJMicm065036
LUDWING´S ANGINA is an infectious process involving the submental, sublingual, and submandibular spaces.

It can rapidly progress to hemodynamic instability and airway obstruction; in rare cases, it spreads into the mediastinum.

#Doctor #MedStudentTwitter #resident
Compromise of the airway can progress rapidly, with lethal consequences; therefore, immediate consideration should be given to surgical débridement of the infected areas and antimicrobial therapy.

#medicine #MedicalStudents #microbiology #surgery
Read 4 tweets
1/🧵Mild Traumatic Brain Injury (TBI) isn’t “Mild” 🧠
Our daughter fell off a high diving board headfirst to cement years ago. Though she had 2 cracks through her foramen magnum, her GCS was 15 & CT had no bleeding.
“She’s OK,” they said.
Wrong answer 😔

#TrackTBI Data…
2/ Mild TBI isn’t mild at all. Lives & entire families are uprooted.
Over half of these N=991 patients with GCS of 15 & negative head CT scan reported incomplete recovery at 6 months.
90% w incomplete recovery were unable to return to preinjury life.
3/ Medicine & Trauma are only now waking up to the realities of this “invisible” yet devastating injury.
I’d been trained in all modern #CriticalCare & you’d think I would know better.

But I didn’t.
Read 4 tweets
Having followed @TrentTelenko deconstruction of logistical doing of the Russian Army, I wanted to take a minute to break down this medical evac aircraft with what is going on.... A 🧵 #Evac #medivac #nursing #Ukraine #medical #transport #Criticalcare
Aeromedical evacuation of sick patients is a logistically complicated task. My direct experience is is slightly over 2 decades and involves pediatric fixed wing, rotor, and ground critical care transport. TO be clear I have performed this level of large scale evac.
Rotor wing transport is ideal in certain circumstances. It is relatively quick and can operate from point to point. ITs disadvantage is that it is unpresurized, has more weather and weight restrictions. The US Military has a robust Casualty evacuation (CASEVAC) or dustoff
Read 23 tweets
‼️ #CriticalCare #Tweetorial ‼️

🫁 Tracheostomy Basics & Trach Emergencies 🫁

Join me on a review tracheostomy tube basics and can't miss emergency situations!

#FOAMcc for #CritCare #EmergencyMedicine #HospitalMedicine #MedEd #Neurocrit #PulmCrit

Goals for this #Tweetorial

1-Review basics of the tracheostomy tube
2- Review anatomy relevant to tracheostomy placement
3- Safety tips for your inpatients with trachs
4- Review emergency situations relevant to trachs

Lets start with a case...

60s y/o male with a left basal ganglia ICH 🧠 who is now s/p bedside percutaneous tracheostomy placement 4 days ago. You are called into the room for a high pressure alarm 🚨

What is your first step?

Read 23 tweets
In 2009 I was involved in an Intensive Care Unit adverse event where our ICU team #failed in its goal and a person died as a result. This set me on a path to thinking about how to respond to these traumatic experiences and how to prevent them at a professional and personal level.
I was given an opportunity to explore this by @theMJA with "A personal reflection on staff experiences after critical incidents."
Knott CI. A personal reflection on staff experiences after critical incidents. Med J Aust. 2014;201(9):550-1. Med J Aust. 2014;201(9):550-1.
I got involved in clinical simulation-based education as a way of developing team-based methods for the 'next generation' to avoid my mistakes with thanks to @NHETSim, @anzics, @sganzics, @ASSH_simaust, @MonashRural. I was able to explore the safe conduct of clinical simulation.
Read 14 tweets
1/7 #PREPAREII showed that a 500-ml fluid bolus does not prevent cardiovascular collapse during tracheal intubation in the ICU. I love efficient study designs - this trial had two features that in my opinion are worth replicating in future #criticalcare #RCTs (a thread 🧵):
2/7 Sample size: the authors calculated that 750 patients would be needed to detect a MCID with an 80% power. After a blinded interim analysis it became clear that the event rate is lower than expected. Smart study design feature no.1️⃣: adaptive sample size re-estimation.
3/7 The goal of sample size re-estimation is to prevent the dreaded "underpowered study" - a situation where the trial can no longer rule out that a clinically meaningful effect exists due to the signal/noise ratio in the data being to low. You can do it using both frequentist &
Read 8 tweets

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