ICU/ED/OR #Hemodynamics:

IKYK that: i) blood pressure (BP) is the driving force for organ perfusion, but ii) hypotension does not always lead to hypoperfusion

One of my favorite reviews (PMID: 34392972) tries to reconcile the paradox and expand on the topic: Fact:

Although an abundance of cohort studies have suggested an association between hypotension & unfavorable outcomes, several RCTs have failed to demonstrate consistently improved outcomes from maintaining a higher BP

ICU Practice - Return to Basics:

When you prepare for the "average" intubation (no cardiac arrest, no active emesis), how do you pre-oxygenate the patient? In PREOXI, a multicenter, randomized trial conducted in 24 🇺🇸 EDs and ICUs and published in 2024 (PMID: 38869091), 1,301 critically ill adults were randomly assigned to receive preoxygenation with either noninvasive ventilation (NIV) or an oxygen mask (O2M)

ICU Practice - Return to Basics:

For the average RSI - rapid sequence intubation (no cardiac arrest, no active emesis), do you provide bag-mask ventilation between induction and laryngoscopy (I & L)? RSI flow(s):

Decongestion Secrets ("ammo" for rounds):

In a multicenter study of 283 acute heart failure patients, changes in renal filtration markers (cystatin C or creatinine) with aggressive diuresis were not associated with changes in markers of renal tubular injury (NAG, NGAL, or KIM-1) In this aggressively diuresed population (560 mg iv furosemide -> urine output of 8425 mL over 72h), both worsening renal function & increases in tubular injury biomarkers were not associated with adverse outcomes; rather, there was a trend towards improved outcomes

Ten things that -for no good reason- we don't do in the ICU:

OK, in general a "less is more" approach is reasonable & there is a "rationale" behind many of the following but the truth is that they don't make sense if scrutinized

Here it begins:

1. Holding tube feeds or any type of nutrition, because the glucose is "high"...

I see it often when I do morning rounds; the tube feeds were held at 2:00 am (and never restarted) because glucose was 400. Obviously, the right approach is to adjust the insulin regimen and keep feeding the patient.

ICU ID Secrets:

77 yo patient admitted to the ICU from a nursing home w hyperglycemic-hyperosmotic state & acute kidney injury. On day 6, he spikes a temp 38.3. BP 96/59, HR 110/min. UA suggestive of urinary tract infection. The next day, urine culture grows Enterobacter cloacae A day later, the blood culture grows Gram (-) rods (eventually proven to be the same bug). The susceptibility profile is:

(Basic) ICU Hemodynamic “Secrets” - Part2:

I know you know them, but let’s remind ourselves of some additional basic hemodynamic "secrets": 16. Volume status is a nebulous term, but I don’t foresee stop using it anytime soon

(Basic) ICU Hemodynamic “Secrets” - Part1:

I know you know them, but let’s remind ourselves of some basic hemodynamic "secrets": 1. Pressure ≠ volume, even though volume can affect pressure

ICU Snapshots:

Elderly 👴 w interstitial🫁disease was admitted -on NIV- from the ED to StepDown unit w "pneumonia": bil infiltrates/low-grade fever. PF ratio 140. Since I was in the ICU, I asked how he looked. Reply: needs high FiO2 but pulls good tidal volumes

When I saw him: This is not an uncommon scenario: a "low" expired tidal volumes (Vt) makes the staff worried during NIV initiated for hypoxemic respiratory failure but a "high" Vt (even if accurately measured) is left unabated...

The American Thoracic Society (ATS) updated its recommendations on some aspects of the diagnosis and management of community-acquired pneumonia (CAP) This guideline update focuses only on immunocompetent adult patients with a standard diagnosis of CAP

It addresses four clinically relevant questions:

ICU/ED Pharmacology/ID Secrets:

Have you ever managed a septic patient & ordered antibiotics to be given stat only to discover hours later that they were still infusing? If yes, stay tuned

Among several controversies in sepsis management, the early administration of antibiotics
is one of the least debatable ones. Time is life in sepsis!

Even though it's hard to believe that every hr of delay in antibiotics ⬆️ mortality by 8% (this is a different topic...), it's one of my pet peeves when it takes for ever to give antibiotics to a septic shock patient

ICU Upper GI Bleeding (UGIB) Secrets:

Is there anything regarding UGIB that has not been already done, studied or tweeted about? Not much, but all of the following are things I witnessed happening (or not happening…) in two UGIB cases I recently saw in the ICU

Here it begins: 1. If a patient does not have an obvious UGIB as in the clip above, she has just presented with melena & it is still unclear if this is due to upper or lower GIB, a quick & dirty trick is to check the blood urea nitrogen/creatinine (BUN/creat) ratio. There are various published

The patient whose ECG/POCUS clips I posted yesterday has remained hemodynamically stable & neurologically intact

This was the #ECG today; still looking angry:

https://twitter.com/IM_Crit_/status/1916606026742170070

I repeated #POCUS; no significant changes:

ICU Stories:

Walking from room to room in the ICU on a Sunday morning while hoping to have a quiet shift, you notice this 👇 on a patient's monitor (60 yo, admitted, intubated for COPD exacerbation + pneumonia 3 days ago, now sedated/hemodynamically stable) It's unfortunately hard to pretend you didn't see it, so you get an ECG praying that it will not show what you saw on the monitor... 😊

Of note, admission ECG was "ok"

Well, it actually looks more impressive on the 12-lead ECG:

ICU Line Secrets:

Is there anything about "lines" that has not been done or studied already? Not much, I guess, so these actually are not secrets, just things I had to do the last couple of weeks & hopefully you also find useful in your practice

Here it begins:

1. "Twin lines" in the same vessel, if there is anatomical reason/venous thrombosis etc that limits the available options. I have even placed a 3rd line (Swan sheath) in the RIJ at the same time but the more of venous real estate is occupied by catheter lumens,

Refresher on Swan-Ganz catheter: Comparison of pulmonary artery catheterisation with different cardiac output monitoring devices:

ICU Hemodynamics:

If you are managing patients with #vasoplegicshock, this is a nice review article: Vasoplegic shock (VS) is common, contributing up to two-thirds of cases of shock admitted to the ICU

The two most common VS causes: septic shock & vasoplegic shock after cardiopulmonary bypass

There is NO consensus definition of vasoplegic shock

ICU Stories:

Elderly patient with multiple medical problems (HFpEF / A fib / HTN / PE / obesity etc) was admitted w CHF exacerbation. Improved w diuresis but developed left upper extremity edema; diagnosed with extensive DVT for which Interventional Radiology (IR) was consulted
IR found severe L subclavian stenosis at the intersection of the clavicle & 2nd rib & upstream LUE extensive DVT. Performed successful image-guided LUE DVT mechanical thrombectomy & stenotic site angioplasty with near complete resolution of clot burden & improvement of stenosis

ICU Hemodynamics:

Assessment of the efficacy (stroke volume) and tolerance (left ventricular filling pressures) of blood volume expansion using Doppler echocardiography: The 1st fluid challenge resulted in a large ⬆️ in LV stroke volume (38 to 65 mL), whereas the 2nd was unsuccessful (65 to 69 mL). The mitral Doppler profile progressed from “abnormal relaxation” to “restriction to filling” consistent with a gradual ⬆️ in left cardiac pressures

ICU Hemodynamic Secrets – The role of ScvO2:

There is not such a thing as a “normal” cardiac output (CO). A CO of 3.5 l/min may be adequate for a 90 years’ old, 100 pounds sedated patient but inadequate for a 40 years’ old, 250 pounds patient with septic ARDS. Ideally, any CO value should be accompanied by an assessment of the adequacy of perfusion (clinical: mental status, urine output etc or laboratory: central venous O2 saturation, lactate etc)

ICU #POCUS:

This is a recently published, information-dense document. It may be a bit technical for the average POCUS user but if you manage patients who harbor a right heart, consider reading it: It is a 40+ pages' document, so I will just highlight some of the most useful points: