ICU scenarios (and pet peeves):

- Hey doc, this patient with ileus in bed 6 has a blood pressure of 186/68. What do you want me to give?
- Any worrisome symptoms with this BP?
- No, I am just worried she will stroke out
- Don't give anything
- No hydralazine then?
- No, please This is one of the most common management discussions/topics in the wards or in the ICU. This study tried to shed some light:

ICU Hemodynamics Secrets:

Actually, these are not secrets at all; they reflect common, basic knowledge. But the word “secrets” is more clickbait-y!

Here it begins:

1. You don’t have to check for fluid responsiveness (FR) if the patient is bleeding to death… 2. Preload challenges (eg, end-expiratory occlusion test or tidal volume challenge) are preferable to fluid challenges

Noninvasive ventilation (NIV) has been standard of care treatment for acute exacerbation of COPD (AECOPD) for > 30 years. In this article, the authors describe an evidence-based algorithm of the initiation, titration, monitoring, and weaning of NIV in AECOPD NIV initiation:

An interesting study was recently published in @yourICM and the authors made some sensible - IMHO - suggestions about how to use echocardiography to guide fluid management in critically ill patients

They recognized 3 scenarios where echo can predict fluid responsiveness (FR): 1. Do NOT fill

2. Fill

3. Optional fill

I tried to tabulate their scenarios and recommendations/limitations extracting only information from their paper and not adding any thoughts of mine

Here is begins:

ICU ID Secrets (following up on my post* from last week):

Ten things to remember about methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) nasal swabs: 1. The MRSA nasal PCR is mostly helpful in patients with pneumonia or at least high suspicion of it since nasal colonization correlates with MRSA presence in the rest of the respiratory tract

ICU Snaphots:

Following on my post on underdamping from a couple of days ago: there is a misconception that underdamping is seen only in arterial lines

This 👇 was seen in a central venous catheter today: This is what I saw when I did the flush (square wave) test:

ICU stories:

Patient underwent laparoscopic colectomy complicated by R paracolic abscess (s/p drainage) & fascial dehiscence. On post-op day 8, at 20:30, he called out for his nurse stating he was having trouble breathing & back pain. He was diaphoretic w O2 sat in 70s at 2 l/m. He was placed on 6 l/m nasal cannula w O2 sat 92%. A rapid response was called at 20:45. Pt was then placed on a non-rebreather mask; stat chest x-ray, ECG & blood gases ordered. CXR was later read as "small L basilar atelectasis". ECG (was read as "no acute MI"):

ICU Hemodynamics:

This is a CVP waveform: Assuming we are at end-expiration (the phase where CVP is least affected by the intra-thoracic pressure), at which point should we measure it?

ICU Stories:

70 yo patient, nursing home resident, w hx of dementia / atrial flutter (on anticoag) / hypothyroidism / gout / decub ulcers (among others) is brought to the ED for "altered mental status" and right gaze deviation. Afebrile, normotensive, hr 80s, sat 96% on room air Per report: pt "at baseline" 30' before being found altered. ED exam confirms "minimal responsiveness" & documents presence of a stage III sacral decub ulcer. Labs unimpressive (INR 1.8). CT brain/CT angio: no bleed/stroke/large vessel occlusion. Would u thrombolyse w these data?

Right Heart Involvement in Left-Sided Heart Failure:

Diagram showing the pathophysiologic features of R-sided heart failure in the context of L-sided heart failure: Definition and Classification of HF:

ICU Hepatology Update:

If you feel a bit queasy - I feel the same! - whenever you admit a patient with cirrhosis/acute-on-chronic liver failure (ACLF), you will find useful this excellent document from the American Association for the Study of Liver Diseases (AASLD): No surprise! There are several definitions of ACLF:

ICU Hemodynamics:

The regular Swan-Ganz catheter refresher post based on this article: Typical pressure curves and values assessed during right heart catheterization within the physiological states:

ICU Pharmacology Secrets:

This is another random collection of pharmacology pearls that I witnessed & wrote down during the last two months.

And so it begins:

1. Hydralazine (H) is a widely used arterial vasodilator; especially in 🇺🇸, it is mostly used to treat asymptomatic hypertension in the hospital setting. Has anybody seen the order: “Hydralazine 10 mg iv PRN for SBP > 180”? Medtwitter is full of posts deriding H use, but this practice does not go away & sometimes it even becomes part of the outpatient treatment regimen; probably

ICU Pharmacology Secrets:

Some drug side effects, even if relatively rare, are well entrenched in our memory. For example, most intensivists & hospitalists are aware of cefepime-induced neurotoxicity or clindamycin’s association w C difficile infection (or even the seemingly unimportant piperacillin/tazobactam’s nephrotoxicity!)

This post is a reminder of some side effects I often see going unnoticed in the ICU or the wards. I actually saw 8 out of 10 of them during the last 2 months

And so it begins:

ICU stories (a boring one...)

This is a story that everybody working in an ICU will see several times/month. It's so common it deserves a separate textbook chapter. Its title: "The elderly/obese patient w multiple comorbidities, now w resp failure/drowsiness, who needs ICU care" 85 yo pt w coronary art dz, diastolic heart failure, A.fib, COPD, HTN, HLD, DM2, hypothyroidism & morbid obesity (BMI 45) admitted a wk ago to the Medicine service due to shortness of breath & lower extremities' edema. Managed w NIV & diuretics but creat ⬆️ & diuresis was stopped

ICU snapshots:

What do you think? X: Doc, I try to place a central line in the internal jugular vein (IJv), I have blood return but I cannot advance the wire beyond 10-ish cm
Me: OK, I will take a look 👆

ICU Hemodynamics Tips - Swan-Ganz catheters:

This will not be a comprehensive thread. Just happened to place a couple of Swan-Ganz (SG) catheters this week, so it is a good time to emphasize few basic points/steps. I have made a mistake (more than once) in each one of them…

1. The 110 cm long SG has 5 lumens:
i. White port (proximal infusion) terminating in the right atrium (RA), 31 cm from the catheter tip
ii. Blue port (proximal injectate) terminating 30 cm (still in RA) from the catheter tip, above & on the opposite cath side from the white port

ICU Night Shifts - Ventilator graphs:

Live coverage - 65 yo, respiratory failure, intubated 3 ds ago. First thing I saw on the ventilator screen: A clip:

ICU Extubation Tips:

Let’s admit it. As intensivists, we will never be as good in airway management as our Anesthesia or Emergency Medicine colleagues are. They intubate many more pts than we do & some of them under very suboptimal conditions. So, we can never match their skills On the other hand, we are the ones tasked w extubating the "difficult" cases. Therefore, even if we cannot become the best "intubators", we do need to be excellent “extubators”. To this end, a few points (not emphasized in textbooks!) need to be kept in mind & used in practice:

ICU Hemodynamics:

The weekly reminder of the left ventricular (LV) pressure-volume loop and the concept of ventriculo-arterial coupling: Figure borrowed and edited by a recently published excellent review in @CritCareMed:

ICU Hemodynamics - Return to the Classics:

Approximately 50 years ago Forrester, Diamond, Chatterjee and Swan (yes, this Swan!) published 2 papers in NEJM addressing the medical therapy of acute myocardial infarction:

This was in the era before reperfusion: no thrombolysis or percutaneous coronary intervention were available. The widespread use of hemodynamic monitoring was touted as hugely important in this setting & obviously the recently discovered Swan-Ganz catheter played a central role.