Discover and read the best of Twitter Threads about #critcare
Most recents (24)
Why do we put tracheostomies in patients though?
The rationale for a trachy in ICU is that there are respiratory mechanical benefit (compare to a tracheal tube and a native airway). There are many patient care benefits - oral care, feeding, etc...
#VTA23
The rationale for a trachy in ICU is that there are respiratory mechanical benefit (compare to a tracheal tube and a native airway). There are many patient care benefits - oral care, feeding, etc...
#VTA23
There are problems, including the potential for real patient harm. Tracheostomy emergencies are a problem. Complications (Immediate, Early and Late) are encountered in 30% of patients. #VTA23
PEEP is important - it improves oxygenation, and is an essential component of lung protective strategies.
But PEEP also has some problems - it can cause hypotension and increased pulmonary vascular resistance.
So how does one get optimal PEEP?
#VTA23
But PEEP also has some problems - it can cause hypotension and increased pulmonary vascular resistance.
So how does one get optimal PEEP?
#VTA23
Optimal PEEP has no clear universal definition.
Maybe we should look for appropriate PEEP - a PEEP value that results in adequate oxygenation with the lowest risk of overdistension.
#VTA23
Maybe we should look for appropriate PEEP - a PEEP value that results in adequate oxygenation with the lowest risk of overdistension.
#VTA23
Prof Anthony Holley is speaking next on 'Respiratory Support in the Trauma Patient' #VTA23 #critcare #FOAMcc
The 'trauma' patient is not a single disease entity, but ultimately a mechanism that is characterised by a shared multitude of pathophysiological patterns (TBI, lung contusion, etc...) and interventions (surgery, transfusion) that lead to some common disease processes. #VTA23
These common disease processes include TRALI, ARDS, TIC and many more.
Of concern, ARDS is not uncommon in trauma patients.
#VTA23
Of concern, ARDS is not uncommon in trauma patients.
#VTA23
Next up are two of the Occupational Therapists from CHBAH - Marche van der Heyden and Tiffany Fairbairn - speaking on 'Sensory Stimulation in Critical Care'.
#VTA23 #critcare #FOAMcc
#VTA23 #critcare #FOAMcc
Sensory stimulation is emerging in critical care as a modality to re-establish normal functioning. Our senses are our connection to the world. There are 8 (not 5!) senses - auditory, olfactory, gustatory, visual, tactile/touch, vestibular, proprioception and interoception. #VTA23
The lesser known of these - vestibular, proprioception and interoception - all are key in self-soothing...
Interoception is the sense how different parts of our 'deep' body are feeling. There are a few activities that include all 8 senses - for example eating.
#VTA23
Interoception is the sense how different parts of our 'deep' body are feeling. There are a few activities that include all 8 senses - for example eating.
#VTA23
Midmorning #VTA23 session starting - lots of short talks so expect quick changes in topic! #critcare #FOAMcc
PARDIE stands for Pediatric ARDS Incidence and Epidemiology study. This study is one of the results of the PALISI Conference Group.
doi.org/10.1016/S2213-…
#VTA23
doi.org/10.1016/S2213-…
#VTA23
Last up for the morning session is John Davies, who is talking about 'Mechanical Ventilation during ECMO: all, some or none'.
#VTA23 #FOAMcc #critcare
#VTA23 #FOAMcc #critcare
Essential to remember the components of lung protective ventilation - tidal volume, plateau pressure, respiratory rate, PEEP, FiO2.
#VTA23
#VTA23
Do the rules of LPV change when the patient is on ECMO.
There is little doubt that (in appropriately selected patients) ECMO has a mortality benefit. Have a look at the CESAR and EOLIA trials:
doi.org/10.1016/S0140-…
doi.org/10.1056/NEJMoa…
#VTA23
There is little doubt that (in appropriately selected patients) ECMO has a mortality benefit. Have a look at the CESAR and EOLIA trials:
doi.org/10.1016/S0140-…
doi.org/10.1056/NEJMoa…
#VTA23
Next is Prof Ronel Roos, who will be speaking on 'Mobilisation Patients with Extracorporeal Circuits' #VTA23 #critcare #FOAMcc
There are different types of mobilisation.
There can be passive mobilisation or active/assisted exercises. Functional exercises can include standing, sitting, walking, or even a bike (in or out of bed). #VTA23
There can be passive mobilisation or active/assisted exercises. Functional exercises can include standing, sitting, walking, or even a bike (in or out of bed). #VTA23
Alot of this is about setup. Femoral vs upper body cannulisation makes a difference - femoral makes it more difficult. Securing the lines safely is essential, the tubing must be monitored and long enough. #VTA23
As soon as blood leaves the body, it comes into contact with foreign substances that initiate the clotting/coagulation process. The high surface area of the CRRT filters are usually where these processes are most likely to occur. #VTA23
Preserving filter life is very important, as the circuits are very expensive and cumbersome to replace. More importantly, time off CRRT reduces the efficacy of the RRT and puts the patient at risk. #VTA23
Prof Gavin Joynt speaking on 'Personalised Antibiotic Prescription in the Critically Ill Patient'
#VTA23 #critcare #FOAMcc
#VTA23 #critcare #FOAMcc
Antibiotics are different from fluids in that, although they are crucial in reducing mortality, their effect is not immediately apparent. The consequences of underdosing or overdosing are quite real though. #VTA23
We often worry about overdosing, but underdosing puts not only the individual patient at risk, but also other patients in (or coming to the unit) who may be exposed to the eventual MDR organisms that arise.
doi.org/10.1128/AAC.02…
#VTA23
doi.org/10.1128/AAC.02…
#VTA23
First session of Saturday's session of #VTA23 - Dr Jacqui Brown on 'Personalised Fluid Management' #critcare #FOAMcc
The first buffered IV fluids were administed during the cholera epidemic in the UK in 1832. However, fluid therapy only entered main stream medical practice around the first world war. #VTA23
However, some time has passed since then. We have entered the era of personalised on individualised fluid management. There are many paradigms that can assist with this - ROSE, 7 D's, etc...
#VTA23
#VTA23
First talk of the day - Dr Hilary Klonin, a paediatric intensivist from Hull University Teaching Hospital Trust - on 'Less is more, except when it isn't'. Talking about paediatric BP targets in critical care. #VTA23
Up to 50% of paediatric ICU survivors suffer from some sort of impairment. Could this be because the BP targets in paediatric ICU are unclear and too high a target is used? #VTA23
In 2008, a review at their hospital challenged the BP target of the 50th centile for age, and wanted to compare it to a permissive BP target. This was to be done only in critically ill patients, but started from the ED or ward, until critical illness resolved. #VTA23
Been a while since I’ve done one of these.
A recent personal health related saga motivated me to put this one together. 👇
A 🧵
1/
A recent personal health related saga motivated me to put this one together. 👇
A 🧵
1/
First off, I am now fully recovered.
Thankful to the fantastic clinical teams @WRBethesda for the excellent and timely care provided. 🙏
2/
Thankful to the fantastic clinical teams @WRBethesda for the excellent and timely care provided. 🙏
2/
3 months ago, I began having post-prandial epigastric abdominal pain lasting 30-90 mins would resolve spontaneously…until one night, it just didn’t.
Pain 10/10. Could not sit still, constant with intermittently colicky. Went to the nearest ED.
3/
Pain 10/10. Could not sit still, constant with intermittently colicky. Went to the nearest ED.
3/
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
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.
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.
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
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.
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.
Last for this session is Prof Sean Chetty @seanC001 speaking on 'To Sedate or Not to Sedate'. Is this a ?that is the question? scenario...
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. In modern ICU practice, the modern concept is analgosedation, but this needs to be teased apart a little.
#CCSSA2022
#CCSSA2022
The typical modern ICU patient is older, sicker and more complex than ever before. Pain is generally a root cause of distress for many patients, but there can be others - dyspnea, delirium and sleep deprivation.
#CCSSA2022
#CCSSA2022
Next up is Prof Joao Batista Borges, speaking on "Individualised lung recruitment to minimise VILI - the 'Teen Lung' Concept"
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
To understand recruitment manoeuvres, we need to have a clear understanding of regional lung mechanics, and the concepts of collapse and hyper-distension, along with the lung hysteresis curves.
#CCSSA2022
#CCSSA2022
The 'teen lung' concept is the idea of a lung that is stretched and overdistended, where there is inadequate or insufficient lung recruitement. It is 'partial recruitment' and may be worse than no recruitment at all.
doi.org/10.1186/s13054…
#CCSSA2022
doi.org/10.1186/s13054…
#CCSSA2022
Next is Giancamo Bellani, talking on 'Relationships between oxygenations indices & patient outcomes'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Several indices have been proposed as bedside 'markers' for the development of VILI. They are relevant as they allow us to prognosticate patients, and therefore to determine the need for a higher level of intervention (e.g. ECMO).
#CCSSA2022
#CCSSA2022
PF ratio remains a very robust predictor of mortality, and is the crux for the diagnosis of ARDS.
#CCSSA2022
#CCSSA2022
Next up is respiratory therapist Benevides Netto on 'Optimising Patient Ventilatory Interactions'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
First speaks to how patient-ventilator dyssynchrony is common, and has been found in all modes of ventilation! It has significant consequences, via a variety of mechanisms - see P-SILI (but not only P-SILI!)
How to monitor asynchrony
- Graphic analysis
- Oesophageal pressure
- Diaphragmatic ultrasound
- Electrical impedence tomography
#CCSSA2022
- Graphic analysis
- Oesophageal pressure
- Diaphragmatic ultrasound
- Electrical impedence tomography
#CCSSA2022
Next up is (my office-mate - yes I'm showing off) Dr Susan Murphy @susan_icu talking about 'Preventing Intubation'.
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
So how can we divide patients in whom we want to prevent intubation
- Those we want to prevent primarily intubating (e.g. a patient with acute hypoxaemic respiratory failure)
- THose who were previously intubated who you want to avoid re-intubating
#CCSSA2022
- Those we want to prevent primarily intubating (e.g. a patient with acute hypoxaemic respiratory failure)
- THose who were previously intubated who you want to avoid re-intubating
#CCSSA2022
Often to try prevent intubation, we consider alternative types of respiratory support, which include:
- Simple Oxygen Delivery
- High Flow Humidified Oxygen
- Non-Invasive Ventilation
- Continuous Positive Airway Pressure
#CCSSA2022
- Simple Oxygen Delivery
- High Flow Humidified Oxygen
- Non-Invasive Ventilation
- Continuous Positive Airway Pressure
#CCSSA2022
One of two morning sessions (this one themed 'Take a Breath') at CCSSA2022 - starting with a talk by Prof Charles Feldman on 'E-cigarettes, vaping and lung injury'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Prof starts by saying that vaping is not the panacea that it was hoped.
Electronic cigarettes (e-cigarettes or vapes) work by heating a liquid to produce an aerosol that users inhale into their lungs. The liquid can contain nicotine, THC, CBD, flavourants etc...
#CCSSA2022
Electronic cigarettes (e-cigarettes or vapes) work by heating a liquid to produce an aerosol that users inhale into their lungs. The liquid can contain nicotine, THC, CBD, flavourants etc...
#CCSSA2022
Interesting that many of the THC-containing preparation contain Vitamin E - which when injected or ingested is safe, but when inhaled as an aerosol may have a deleterious effect
doi.org/10.1016/j.amjm…
#CCSSA2022
doi.org/10.1016/j.amjm…
#CCSSA2022
Final paeds session is by Prof Brenda Morrow on 'Sleep - the Final Frontier'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Sleep is critical to normal health, and children need much more sleep than adults. Circadian rhythms are established as early as two months of age.
doi.org/10.1038/497S2a
doi.org/10.2147/NSS.S6…
#CCSSA2022
doi.org/10.1038/497S2a
doi.org/10.2147/NSS.S6…
#CCSSA2022
Sleep deprivation in healthy children has clear deleterious acute and long term effects.
#CCSSA2022
#CCSSA2022
A quick run to the rest of the paeds session, where Tarryn Forsyth @TaForsyth is speaking on 'Post Abdominal Surgery - is TPN still necessary?' in paediatrics
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
The crucial trial in this space is the PEPaNIC trial, from 2016 in the NEJM.
doi.org/10.1056/NEJMoa…
#CCSSA2022
doi.org/10.1056/NEJMoa…
#CCSSA2022
Screening is essential as this may identify patients who need early nutritional supplementation.
Paediatric Methods - PNST, STRONGkids Screening Tool, STAMP. but none validated in the critically ill subpopulation.
#CCSSA2022
Paediatric Methods - PNST, STRONGkids Screening Tool, STAMP. but none validated in the critically ill subpopulation.
#CCSSA2022
Last in the session if Prof Veronia Ueckerman, with a talk entitled - Thiamine, what is all the W(h)ining About?
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Thiamine is a water-soluble vitamin essential for carbohydrate metabolism. It is a cofactor for four enzymes used in ATP production. It has limited storage in the human body, and is absorbed in the small intestine.
#CCSSA2022
#CCSSA2022
Risk factors for thiamine deficiency include
- Malnutrition
- Chronic alcohol consumption
- Pregnancy (due to increased requirements)
- Excess renal losses (chronic diuretic therapy)
- Obesity pre-bariatric surgery and post surgery
#CCSSA2022
- Malnutrition
- Chronic alcohol consumption
- Pregnancy (due to increased requirements)
- Excess renal losses (chronic diuretic therapy)
- Obesity pre-bariatric surgery and post surgery
#CCSSA2022
Next up is Lance Michell, who is giving a talk entitled 'Freshly squeezed - How should Vit C be served in ICU?'
#CCSSA2022 #critcare #FOAMcc
#CCSSA2022 #critcare #FOAMcc
Vit C is famous for having curing scurvy back in the 1700s, but also for Paul Marik's controversial claim of its efficacy for sepsis in a paper in 2017, as part of a coctail of hydrocortisone, thiamine and Vit C.
doi.org/10.1016/j.ches…
#CCSSA2022
doi.org/10.1016/j.ches…
#CCSSA2022
The activity of Vit C in the body includes activity as an antioxidant, helping reduce inflammation.
#CCSSA2022
#CCSSA2022
