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:

ICU/ED ECG Secrets:

New fear unlocked:

40 yo male, previously healthy, referred to the ED post-CPR after documented ventricular fibrillation
(VF). Vitals & physical exam: OK. No family history of sudden death. No drugs.

Any concern from this 12-lead electrocardiogram (ECG)? What do you think the most likely concern/explanation is?

ICU (Central Venous/Arterial) Line Secrets - Part 3:

Following from where I stopped last week & if you are not already bored by parts 1 & 2, there are some additional points that may be worth noting

Here the (probably) final part begins: 41. If you think that the patient will need dialysis or right heart catheterization in the next few hours, consider placing a dialysis catheter or an introducer sheath from the beginning

ICU (Central Venous/Arterial) Line Secrets - Part 2:

Following from where I stopped last week (that's why I keep same numbering) & without hoping to a provide tutorial about how to place lines, there are some additional points that I find worth mentioning

https://x.com/IM_Crit_/status/1845053731743621346

Here the (more specific) part begins:

21. Femoral vein (FV) catheters have been demonized. A recently published study of 55,663 CVCs showed no difference of catheter-related bloodstream infection incidence rates between the three insertion sites (). IMHO,doi.org/10.1007/s00134…

ECG Secrets:

50 yo ♂︎ with no significant medical history presented to the ED after acute onset of sharp chest pain. No family hx of heart disease, & no tobacco or illicit drug use. Episode lasted ~30 min before pt arrived to the ED. He was pain-free with normal vitals. ECG: Physical exam: no acute distress, & normal heart-lung exam. Labs sent & were all normal: CK, 193; CK-MB, 3.0; troponin T, 0.03. Patient remained pain-free for the next hour

What would you do next?

ECG Secrets:

Do you know this flag? How is it related to ECG interpretation? This is the South African flag pattern with ST elevation in the leads V2 and aVL, with inferior reciprocal ST depression. It is found in first diagonal occlusion

ICU Ventilator Waveforms Secrets:

I am reading an interesting article about patient-ventilator asynchrony in non-invasive ventilation

From top to bottom, waveforms of airway pressure (Paw), flow, and electrical activity of the diaphragm (EAdi) are depicted

In this figure: please focus on the waveforms in the middle column

Do you think there is an asynchrony?

ICU (Central Venous/Arterial) Line Secrets - Part 1:

An ICU where the patients have no central lines & are not connected to ventilators is not a real ICU. This may be a controversial statement but in my humble opinion not far from truth There are so many textbook chapters, online videos & conference courses dedicated to line placement. Is there really anything left to be said about lines that has not already been said?

ICU Secrets:

We are moving away from massive fluid resuscitation & we become less familiar with its metabolic effects

In this study, 2 groups of 12 pts each who underwent major gynecologic surgery were assigned randomly to receive 0.9% saline or lactated Ringer's @ 30 ml/kg/h! Each patient received approximately 6 liters of crystalloids...

ICU Hemodynamics:

Swan-Ganz refresher from 40 years ago: The pulmonary artery occlusion pressure (PAoP) may not adequately reflect the left ventricular end-diastolic pressure (LVEDP) & the LVEDP may bear little relationship to the left ventricular end-diastolic volume (LVEDV)

This is the weekly refresher on basic hemodynamic monitoring:

Hemodynamic variables determining perfusion pressure and oxygen delivery: Dynamic response of the arterial pressure measurement system:

ICU Nephrology Secrets:

1. The definition of insanity* is to give bolus iv 40 mg of Lasix (furosemide) without seeing any effect and then starting Lasix drip at 10 mg/hr hoping for a brisk diuretic response... 🤷‍♂️

#foamed #foamcc #meded #medtwitter #medstudent Along the same lines:

2. Switching the ineffective Lasix drip to Bumex (bumetanide) drip at 1 mg/hr and keep hoping to see this:

ICU studies:

What do you think the mean blood pressure is just before terminal cardiovascular collapse (TCC)? 20? 30? 40?

TCC defined as the abrupt (< 5min) & exponential decrease in heart rate (>50% compared to preceding values) followed by cardiac arrest

Good to know, right? ...