A good thread with thoughtful discussion of the idea of anesthesiology "backing up" other departments (e.g. ICU, ED) in their own efforts to manage airways. Knotty issues, but a few general observations (🧵)...
1. In almost all cases, anesthesiology will be the most-experienced, most-trained people to manage an airway.
2. Out-of-OR airways almost always have relatively high risk of complications.
3. Some centers interpret #1 and #2 as meaning anesthesia should handle ALL airways.
4. However, other departments ARE trained to do this, and whether they routinely do depends heavily on the institution and its culture.
5. It is *not* always true that the *most* trained person should do everything; a hierarchy with appropriate "calls for help" is commonly used
6. Centers that cede most airways to anesthesia tend to promote/reinforce this continued practice, since their own trainees and staff get little airway experience (people who don't intubate don't intubate), leading to skill decay and lack of comfort
7. My bias: it may not be good for critical care teams to lose all competence with airway management, because you cannot always wait for help. The people at the bedside should have some ability to oxygenate and ventilate most patients, at least temporarily.
8. IMO the big takeway from @fuzzymittens here is that just waving anesthesiologists at things to "manage risk" is not super fair. For instance, if you ask them to "be nearby" while someone else attempts an airway, it creates a murky area regarding responsibility...
... a *possible* solution is to make things explicit via policy... e.g. "anesthesia should attend all airways, but has no patient care responsibility unless the primary team explicitly requests it, in which case they're in charge." But even this may be easier said than done.
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(Inspired by recent talk)
Skilled proceduralists are often asked to help other providers/teams, such as placing a tough line. Here are some important points for this. It is NOT the same as doing procedures on your own patients. (🧵):
1. You are asked to "help," usually verbally, but you're still responsible for your own care. So this is actually a consultation of sorts. Does the patient actually need what they thought? Usually they know their problem ("we need access") but not always the best answer.
They also may not be aware of all relevant contraindications or technical obstacles... or they may simply not care. In other words, they're expecting YOU to consider these. If you do something dumb, you can't just say "well, someone told me to do it."
A patient suffers STEMI causing biventricular failure, including severe RV infarct. An Impella is placed, and they arrive in the ICU from the cath lab. You see the following. (This arterial line is functioning.)
In this case, the Impella is completely decompressing the LV and taking over its output. There is NO pulsatility to the arterial flow — only laminar flow from the Impella. Can you think of any implications of this for the immediate resuscitation?
1. PULSE oximetry will not function. Absorption or reflection oximetry relies on detecting pulsatility to differentiate arterial blood from other blood and tissues (that’s why it gives you a pleth). You will need to rely on blood gases.
When flow dyssynchrony occurs in VC modes, the first reaction is often to increase the flow rate. Reasonable… but it often fails! Why? Maybe because any fixed (or fixed decelerating) flow can have trouble matching the patient effort at all stages of inspiration. Example:
Here the flow starvation occurs in the latter part of the breath, not the start, creating a biphasic appearance to the flow curve. What if we simply increase the flow?
It’s no better! Now flow is probably too high at the start (initial flow overshoot as evidenced by the steep pressure spike)… but still inadequate at the end. Also, the pressure spike and resulting short I-time contributes to some double triggers.
Michae Levy on refractory VF: resuming immediate compressions after a defibrillation shock may in some cases induce refibrillation after initial (unnoticed) ROSC, due to the mechanical stimulus. #CCPRFSummit2021
Double sequential defibrillation may work, but just changing the vector (moving pads) may work as well.
Daniel Dante Yeh: In first 7 days of critical illness., hypocaloric (<70%) nutrition should be used, can advance to 80-100% after day 3. Use indirect calorimetry if you can. #CCC50
Use high-protein, hypocaloric feeding in obese patients to preserve lean mass while not overfeeding. If 30-50 BMI use 11-14 kcal/kg actual bodyweight, if BMI >50 use 22-25 kcal/kg of ideal bodyweight.
Generally use normal protein goals for kidney failure. If on CRRT, however, need to account for loss of aminos in the membrane, may be ~15-17%.