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:

ICU Mechanical Ventilation Secrets:

You can call me lazy but if a patient is admitted to the ICU with pneumonia (& this CXR), is diaphoretic, breathing 50/min, has HR 150/min & O2 Sat 88% on "FiO2 100%", I don't calculate the ROX index or the HACOR score. I just intubate...
The ROX (Respiratory rate-OXygenation) index was introduced in 2016 as a prediction tool to identify the need for IMV in pneumonia patients w AHRF treated wHFNC. It's calculated as [(SpO2/FiO2)/Respiratory Rate] & is typically assessed at 2, 6, & 12 hours after HFNC initiation

ICU Pharmacology Secrets:

Dexmedetomidine (D) (Precedex in 🇺🇸) is one of my favorite ICU drugs. It is a highly selective α-2 adrenoreceptor agonist, w sedative/analgesic/ anxiolytic properties & minimal resp depression. Its main side effects are hypotension & bradycardia Herein I chose 10 less known D's effects/associations with:

1. Hypertension (the opposite from what you would expect): likely due to initial stimulation of peripheral a-1 or a-2b receptors. It is usually transient, mild, & does not require treatment. However, I have seen severe

ICU Pulmonary Embolism Review:

Kudos to the authors for reviewing PE management strategies: An abbreviated spiral of death:

ICU Hemodynamics

We divide patients with circulatory shock into 3 primary hemodynamic phenotypes, namely hypovolemic, vasodilatory/distributive, & cardiogenic (including obstructive)

But we all witness/manage "mixed" shock, an entity lacking a uniform, evidence-based definition By analogy to the cardiorenal syndromes, Jentzer et al categorize mixed shock into 3 principal groups, each defined by the sequence & nature of the insult (ie, primary vs secondary hemodynamic process): cardiogenic-vasodilatory, vasodilatory-cardiogenic, & primary mixed shock:

ICU Hemodynamics

We are all familiar w the concept of "protective ventilation": aiming for normal blood gases entails significant risk
What if we apply the same idea in hemodynamics & try to limit the damage associated w excessive vasoconstriction?

Welcome to the CLEAR strategy The C.L.E.A.R. strategy tries to:

Customize targets
Limit catecholamines
Enhance flow
Adjust fluid balance
Resolve underlying conditions

ICU Hemodynamics:

In this recently published article, the authors propose a classification of different cardiovascular phenotypes potentially observed in septic shock into 3 profiles of LV-centric dysfunction, promptly recognizable by critical care echocardiography (CCE): The figure speaks for itself, but we have to highlight a few points made throughout the paper...

ICU Circulation Secrets:

The phenomenon of "hemodynamic incoherence" is observed when microcirculatory dysfunction persists despite the restoration of macro-circulatory indices

In this case, MAP was 88 mmHg & cardiac index was 2.8 l/min/m2 on a small dose of norepinephrine Despite the apparent normalization of systemic & regional blood flow, sublingual video-microscopy revealed persistent tissue hypoperfusion:

ICU Snapshots - Ventilator waveforms (from a patient I just saw):

Patient on "volume control" (or: VC-CMVs). Please notice the significant change in the pressure waveforms while the flow waveforms remain "mostly" unchanged

What happened? What happened between breath (A) and breath (D)?

ICU - Non-Invasive Ventilation (NIV) Secrets:

Did you ever admit to the ICU a patient with COPD exacerbation who came from the ED on NIV? Or who went home on NIV? If you are a pulmonologist, you will not learn anything from this post but the rest of us from different specialties (I am Internal Medicine) should remember that NIV settings are not just inspiratory/expiratory pressure (IPAP/EPAP) and FiO2

We have to admit that not every COPD patient will do well with “10 over 5” *. So what else should we pay attention to?

Excerpts from:

Echocardiographic Evaluation of a Patient in Circulatory Shock: A Contemporary Approach

Shock parameters: Evaluation of pericardial effusion and signs of cardiac tamponade:

ICU Physiology Secrets - Return to Basics Edition:

If you are placing Swan-Ganz (SG) catheters or you like reading/interpreting their waveforms, this is for you:

You walk in a patient’s room exactly when your fellow intensivist tries to “wedge” a newly placed SG catheter: At which point - approximately – do you think that the pulmonary capillary pressure (Pcap) should be measured?

1. Please assume that the recording is taken during an expiratory hold while on mechanical ventilation
2. Please feel free to choose any point other than these choices

ICU Resuscitation Thoughts:

Every 2 y this time of the year I have to provide my hospital-employer w proof of ACLS recertification. I usually take an on-line course which I finish in a few hours. Sadly, this biennial ritual is also a reminder that we keep following the same #CPR choreography year in & year out without moving the needle. I am not opposing standardization of such a critical intervention as CPR is, if it was not for the persistently dismal outcomes (that are even worse in out-of-hospital (OHCA) compared w in-hospital cardiac arrest (IHCA)

Cardiogenic shock:

I am reading now about the clinical & imaging findings representing indications & contraindications to mechanical circulatory support placement

European Heart Journal - Cardiovascular Imaging (2024) 25, e296-e311 I came across this table:

ICU Stories:

Middle-aged pt w many co-morbidities (CAD/DM2/strokes/seizures/peripheral vasc dz/a.fibrillation/chronic Foley - UTIs etc) was sent from nursing home to the ED for evaluation of fever/hypotension. Urine was purulent. CT A/P: hydronephrosis & bladder wall thickening:
Patient received "sepsis fluid bolus" & antibiotics (meropenem* & vanco); admitted to the hospitalists' service. Urine & blood cultures grew E .coli. Next day, pt was transferred to the ICU with altered mental status & oral bleeding secondary to tongue biting after a seizure

ICU Hemodynamics:

What changed in this case between a and b? What changed in this case (different from the previous) between c and d?

Very nice overview of the current state of affairs in cardiogenic shock (published this week in @TheLancet): Classification systems and key risk factors for cardiogenic shock:

Mixed cardiogenic shock (CS) -herein classified as CS with at least 1 additional contributing cause of shock state- is common (& usually quite challenging to treat...)

20% of all shock patients admitted to contemporary cardiac ICUs have mixed CS

Besides this old-school approach It's good to keep in mind the proposed "normal" hemodynamic compensation & criteria for mixed cardiac-vasodilatory shock: