I think the number one challenge here is dilation, because obesity forces you to stick using unfortunate depths and angles. Good tips in the thread, but here's my favorite, which solves most problems: *continuously* rack your wire as you dilate. (thread)

#medtwitter #FOAMcc

https://twitter.com/AlexLawandi/status/1731075400858542490

Many people will pin the wire with their off-hand as they dilate (good), and some will periodically wriggle it in and out (okay); it will "catch" on retraction if you're kinking your wire (dilating off-axis) and making an angle at the tip. But too late! It's already kinked.

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).

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)

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

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).

Bethany Shoulders on Pharmacotherapy in critical illness + obesity (#SCCM2023)

Absorption: may be reduced both enteral and subq
Distribution: Increased
Metabolism: may decrease
Excretion: Often increased B-lactams (inc. cephalosporins, meropenem, pip/tazo): good data on impact of obesity. more treatment failure, longer hospitalizations, risk of cefepime neurotoxicity. Use monitoring! Target 40-100% free time >MIC.

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.

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.

Jan Claassen on coma (#SCCM2023)

Above true coma there is
Vegetative: no evidence of awareness of self/environment although may open eyes (distinct from coma)
Minimally conscious state: reproducible but inconsistent awareness
Can have a higher level of MCS + command following Locked in syndrome: paralysis of limbs and lower cranial nerves, usually still has vertical eye movements (ask them to move their eyes up and down) and eyelid opening.

John Marshall on extracorporeal blood purification #SCCM2023

PLEX for sepsis: Stahl 2022 - does dilute/remove bad things, but fairly modest effect even in terms of numbers alone.

Rimmer systematic review: fewer than 100 patients really studied to show benefit. Faqihi: PLEX for COVID, maybe reduced vent/ICU course?

Laura S. Johnson on TEN/SJS. #SCCM2023

Geography influences most common drug triggers (probably genetic differences).

Europe: more allopurinol
Asia: carbamazepines
US: antibiotics Often presents initially like a URI, which may get them an antibiotic, then once skin findings begin it's hard to know if that was a trigger

(Inspired by recent talk)
Skilled proceduralists are often asked to help other providers/teams, such as placing a tough line. Here are some important points for this. It is NOT the same as doing procedures on your own patients. (🧵):

#medtwitter #FOAMcc #FOAMed #pulmcrit 1. You are asked to "help," usually verbally, but you're still responsible for your own care. So this is actually a consultation of sorts. Does the patient actually need what they thought? Usually they know their problem ("we need access") but not always the best answer.

A good thread with thoughtful discussion of the idea of anesthesiology "backing up" other departments (e.g. ICU, ED) in their own efforts to manage airways. Knotty issues, but a few general observations (🧵)...

#medtwitter #FOAMcc #icu

https://twitter.com/fuzzymittens/status/1560448918957084672

1. In almost all cases, anesthesiology will be the most-experienced, most-trained people to manage an airway.

2. Out-of-OR airways almost always have relatively high risk of complications.

3. Some centers interpret #1 and #2 as meaning anesthesia should handle ALL airways.

A patient suffers STEMI causing biventricular failure, including severe RV infarct. An Impella is placed, and they arrive in the ICU from the cath lab. You see the following. (This arterial line is functioning.)

What do you know about the hemodynamics? 🧵

#FOAMcc #medtwitter In this case, the Impella is completely decompressing the LV and taking over its output. There is NO pulsatility to the arterial flow — only laminar flow from the Impella. Can you think of any implications of this for the immediate resuscitation?

#FOAMed #cardiotwitter

When flow dyssynchrony occurs in VC modes, the first reaction is often to increase the flow rate. Reasonable… but it often fails! Why? Maybe because any fixed (or fixed decelerating) flow can have trouble matching the patient effort at all stages of inspiration. Example: Here the flow starvation occurs in the latter part of the breath, not the start, creating a biphasic appearance to the flow curve. What if we simply increase the flow?

Jonathan Dresner on sudden cardiac arrest among athletes: most common source sports #CCPRFSummit2021 UW offers free online modules to educate clinicians on performing ECG screening for athletes uwsportscardiology.org/e-academy/ecg-…

Michae Levy on refractory VF: resuming immediate compressions after a defibrillation shock may in some cases induce refibrillation after initial (unnoticed) ROSC, due to the mechanical stimulus. #CCPRFSummit2021 Double sequential defibrillation may work, but just changing the vector (moving pads) may work as well.

Daniel Dante Yeh: In first 7 days of critical illness., hypocaloric (<70%) nutrition should be used, can advance to 80-100% after day 3. Use indirect calorimetry if you can. #CCC50 Use high-protein, hypocaloric feeding in obese patients to preserve lean mass while not overfeeding. If 30-50 BMI use 11-14 kcal/kg actual bodyweight, if BMI >50 use 22-25 kcal/kg of ideal bodyweight.

John Teerlink: Cardiac calcitropes (catecholamines, PDE3 inhibitors) increase contractility, ischemia, arrhythmias, mortality. We use them anyway because it's what we've got. #CCC50 OPTIME-CHF: Milrinone for CHF exacerbation when NOT requiring inotropes. No clinical benefit but trend for more MI/death and significant increase in arrhythmias and hypotension.

Xavier Monnet: CNPN doesn't work for fluid responsiveness because it ignores the shape of the Starling curve, which varies by patient. You can't get the intersection of two lines if you don't know one of them. #CCC50 "Mini" fluid challenge (100-150ml) avoids as much overload if it proves negative, but requires very sensitive markers of cardiac output. Maybe pulse counter analysis...

Finally found a PPE regimen that seems to work well. This is the Envo mask (envomask.com) and the Wiley-x SG-1 goggles (sporteyes.com/wiley-x-ssg-1.…). A few notes (thread): #medtwitter #FOAMcc #COVID19 1. The goggles are not 100% sealed and have small vents along the sides. However, I do not think a 100% seal is necessary, and would be an incredible fog-creator. The Wileys are also pricey; consider these, almost as good (amazon.com/gp/product/B00…) but don't seal quite as well.