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Jan 22

Allan Walkey on atrial fibrillation in ICU (#SCCM2023)

Arrigo 2015: cardioversion for secondary A-fib in ICU rarely works (43% remains sinus at 1hr, 23% at 24hr). Diltiazem was more effective at rate control than amio or digoxin.

Walkey 2016: Afib in sepsis? Association on outcome of BB vs CCB, BB vs digoxin, BB vs amiodarone compared. BB had slightly lower mortality than CCB.

Bosch 2021: BB achieved more HR reduction than amiodarone, CCB, and dioxin at 1hr (CCB was highest at 6 hours).

Davey 2005: magnesium was about as effective at rhythm control as amiodarone.

Remember untreated infection, volume status, presence of beta agonists.

Law 2022: phenylephrine vs norepinephrine for shock? HR difference was only about 2-6 only, even in the subgroup with RVR.

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Jan 22

Kevin Betthauser on empiric anaerobic antibiotics in the ICU (#SCCM2023)

gut dysbiosis common in ICU patients. Gut integrity degrades. Reduction in firmicutes and bacteriodetes, increase in proteobacteria. Less commensals, more opportunistic infections.

In animal models, depletion of anaerobes increases susceptibility to bacterial PNA, lung injury, mortality. Preserving anaerobes by SDD associated with less VAP, less mortality. (Szychowiak 2022, Hammond 2022)

ATS/IDSA 2019 CAP guidelines: suggest not routinely covering aspiration pneumonia for anaerobes. Modern syndromes typically CAP organisms, not anaerobic. Kioka 2017, Marrin-Corral 2021, Brummitt 2022 - show anaerobic coverage is downtrending over past five years.

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Jan 22

Richard Branson on bronchodilators (#SCCM2023)

clear standard of care for bronchoconstriction, but mostly used for hypoxemic disease because it "can't hurt". Ehrmann 2013 European survey found 95% used them routinely in mechanically ventilated

BALTI trial: IV B-agonists for ALI improved resolution of alveolar edema and survival
Perkins 2014: salmeterol didn't improve ALI
BALTI-2: salbutamol, stopped for harm

Routine nebs create significant workload and disposable equipment burden

Device types vary by efficiency, but we use so much drug it likely doesn't matter - it gets delivered.

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Jan 22

Shelby Yaceczko on nutrition in critical illness + obesity (#SCCM2023)

malnourished inpatients have 3.4x risk of in-hospital death, but only 2.7% of patients with coded malnutrition actually receive enteral nutrition in the hospital.

malnutrition in ICU associated with length of stay, higher cost of care. ASPEN did a value analysis, shows nutrition support saves money (projected $222 million yearly Medicare savings).

ASPEN 2021 guidelines:

1. How much should you give? No difference between high and low levels of nutrition. Give 12-25 kcal/kg BW in first 7-10 days of ICU stay. (Old recs: depended on disease and malnutrition risk.)

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Jan 22

Sara A Hennessy on managing ICU devices in obesity (#SCCM2023)

BP cuffs taken with too-small cuffs significantly higher. Should be 80% of upper arm circumference, width should be 40% of length. Large cuffs may still be poor fit, eg too long (obese arms aren't longer), and arms are "inverted cones" not cylinders.

Try an appropriate cuff on forearm, hold forearm at level of heart; hoses should exit over radial artery. Will vary by 7-15mmHg from upper arm.

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Jan 22

Sam Galvagno on airway management in obesity (#SCCM2023)

oxygenation normal, but poor reserve - low compliance, compression of small airways at bases. ERV, TLC, FRC reduced.

P's of airways in obesity: Prediction, Positioning, Preox, Performance, Postintubation management

Prediction: obesity = difficult mask, but less clear association with difficult intubation.

Position: sniffing position helps everyone. Ramped position helps the obese - also makes it easier to insert laryngoscope handle.

Modified ramped position can be done with a pyramid-shaped pillow.

Fastest method is just put them in reverse Trendelenburg - better than just elevating head.

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