Critical Matters

Caring for critically ill pregnant patients poses a series of unique challenges for the intensivist. In this two-episode series, we discuss critical care in pregnancy with Dr. Stephen Lapinsky. Dr. Lapinsky is a practicing intensivist and professor of medicine at the University of Toronto. He is a member of the editorial board of the journal, Obstetric Medicine, and sits on the steering committee of the North American Society of Obstetric Medicine. Dr. Lapinsky is also the executive of the Women’s Health Network of the ACCP. Today (Part 1) will cover unique conditions associated with pregnancy that may lead to critical illness. Additional Resources Practice bulletin on Critical Care in Pregnancy from the American College of Obstetrics and Gynecology (ACOG): https://bit.ly/2OtJARU A comprehensive review on acute respiratory failure in pregnancy: https://bit.ly/2DKzwjl AHA scientific statement on cardiac arrest in pregnancy: https://bit.ly/2QpGWtK

In today’s episode, we will discuss the recently released 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patient s in the ICU. Our guest is John Devlin, PharmD, BCCCP, FCCM, FCCP. Dr. Devlin is the lead author of these guidelines and a recognized leader in the field. Additional Resources Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU: https://bit.ly/2wzFNHv Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU: https://bit.ly/2vOyVGP Interpreting and Implementing the 2018 of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Guidelines: https://bit.ly/2waInU7 Nocturnal low-dose Dexmedetomidine to prevent delirium in ICU patients: https://bit.ly/2MJ2TSi Books Mentioned in This Episode Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer: https://amzn.to/2OAfZmD  

In this episode of Critical Matters, we explore the role of the intensivist in the management of patients with ventricular assist devices. Our guest is Dr. John Greenwood, a practicing intensivist who splits his clinical time between the Cardiac & Vascular ICU and the ED-ICU at the Hospital of the University of Pennsylvania. Additional Resources Summary of information presented during the episode kindly provided by Dr. John Greenwood: https://bit.ly/2MJdfSa  HeartWare Waveforms App for iPad: https://apple.co/2NpyQEr Articles Mentioned In This Episode Pratt AK, Shah NS, Boyce SW. Left ventricular assist device management in the ICU. Crit Care Med. 2014;42(1):158-68: https://bit.ly/2MKr3M6  Sen A, Larson JS, Kashani KB, et al. Mechanical circulatory assist devices: a primer for critical care and emergency physicians. Crit Care. 2016;20(1):153: https://bit.ly/2NoreC4 

In this episode of Critical Matters, we continue the discussion of medical errors in healthcare with a specific focus on how to disclose medical errors to patients. Our guest is Dr. Nitin Puri, a practicing intensivist and medical educator at the Cooper Medical School of Rowan University and the Cooper Health System in Camden, New Jersey. Additional Resources This is a CNN story on cardiothoracic fellow wrongly accused and sued for lying about a medical error: https://cnn.it/2vFEnLf The Communication and Optimal Resolution (CANDOR) toolkit from the Agency for Healthcare Research and Quality (AHRQ). CANDOR is a process that health care institutions and providers can use to respond in a timely, thorough and fair way when medical errors occur and cause patients harm: https://bit.ly/2m9fch7 A powerful video on the topic of the disclosure of medical errors: https://bit.ly/2DaD6TD Article Mentioned in This Episode Mistakes Were Made (but Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts: https://amzn.to/2NorssU

In this episode of Critical Matters, we discuss “Compassionomics” with Dr. Stephen Trzceciak. Dr. Trzeciak is a practicing intensivist and prolific researcher. His research interests have focused recently on the hypothesis that compassion matters for patients, for healthcare outcomes, and for providers. Compassionomics is the revolutionary field of science focusing on caring, and the impact compassion has on healthcare. Additional Resources How 40 Seconds of Compassion Could Save a Life: https://youtu.be/elW69hyPUuI Compassionomics: Hypothesis and experimental approach: http://compassionomics.net Article Mentioned in This Episode A Patient’s Story: http://www.theschwartzcenter.org/media/patient_story.pdf

In this episode, we discuss the ABCDEF bundle, a tool used to promote evidence-based care that promotes healing and liberation from critical illness for patients in the ICU. Our guest is Dr. Julia Barr who is currently the Associate Professor of Anesthesia in the Medical Center Line at Stanford Medical School and a staff anesthesiologist and intensivist at the VA Palo Alto Medical Center. Dr. Barr has served as a national faculty member for the SCCM ICU Liberation Campaign ABCDEF Bundle Collaborative and is a member of the SCCM’s ICU Liberation Committee. Additional Resources Society of Critical Care Medicine’s guidelines on management of pain, agitation and delirium: http://www.sccm.org/Research/Guidelines/Guidelines/Pain,-Agitation,-and-Delirium-in-Adult-Patients-in Society of Critical Care Medicine’s guidelines for Family-Centered Care in the ICU: http://www.sccm.org/Research/Guidelines/Guidelines/Family-Centered-Care-in-the-ICU Books Mentioned in This Episode The Power of Habit: Why We Do What We Do in Life and Business: https://www.amazon.com/Power-Habit-What-Life-Business-ebook/dp/B0055PGUYU/ref=sr_1_2?ie=UTF8&qid=1530020419&sr=8-2&keywords=the+power+of+habit

In this episode, we discuss seizures in the ICU. We cover a broad range of topics related to the initial management of seizures, status epilepticus, and EEG monitoring in post-anoxic brain damage. Our guest is Dr. Thomas Bleck. Dr. Bleck is the professor of neurological sciences, neurosurgery, internal medicine and anesthesiology at Rush University Medical Center, where he is a neurointensivist and the director of clinical neurophysiology. Additional Resources Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society: http://www2.soundphysicians.com/l/403342/2018-06-27/cxz5ng/403342/102465/Evidence_Based_Guideline_Treatment_of_Convulsive_Status_Epilepticus_in_Children_an.pdf Guidelines for the Evaluation and Management of Status Epilepticus: http://www2.soundphysicians.com/l/403342/2018-06-27/cxz5nb/403342/102461/Guidelines_for_the_evaluation_and_management_of_status_epilepticus..pdf Clinical classification of post anoxic myoclonic status: http://www2.soundphysicians.com/l/403342/2018-06-27/cxz5nd/403342/102463/Clinical_classification_of_post_anoxic_myoclonic_status.pdf  Books Mentioned in This Episode Tinker, Tailor, Soldier, Spy: A George Smiley Novel: https://www.amazon.com/Tinker-Tailor-Soldier-Spy-George-ebook/dp/B004RKXNDU/ref=sr_1_1?ie=UTF8&qid=1530020470&sr=8-1&keywords=tinker+soldier+le+carre

In this episode of Critical Matters, we discuss the Hour-1 Bundle for sepsis. The Surviving Sepsis Campaign has been working on improving outcomes for patients with sepsis for well over a decade. Today we are fortunate to have one of its leaders as a guest to discuss the 2018 update: The Hour-1 Bundle. Our guest is Mitchell Levy, MD, MCCM. Dr. Levy is Professor of Medicine and Division Chief, Pulmonary and Critical Care Medicine at the Alpert Medical School of Brown University in Providence, Rhode Island. Additional Resources The Surviving Sepsis Campaign website. A wealth of resources for clinicians interested in improving outcomes for patients with sepsis and septic shock. http://www.survivingsepsis.org/Pages/default.aspx The Surviving Sepsis Campaign Bundle: 2018 Update (The Hour-1-Bundle) http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle-2018.pdf Books Mentioned in This Episode Shambhala: The Sacred Path of the Warrior: https://www.amazon.com/Shambhala-Sacred-Warrior-Chogyam-Trungpa/dp/1611802326/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1528317558&sr=8-1

In this episode of Critical Matters, we discuss medical errors in healthcare. Our guest is Dr. Nitin Puri, a practicing intensivist and medical educator at the Cooper Medical School of Rowan University and the Cooper Health System in Camden, New Jersey. We discuss a range of topics related to medical errors in critical care medicine including the incidence of errors in our practice, causes, how to prevent them, and how we should deal with them when they occur. Additional Resources To Err is Human: Building a Safer Health System. The landmark publication y the Institute of Medicine highlighting medical errors as a critical cause of deaths in the US healthcare system: https://www.ncbi.nlm.nih.gov/pubmed/25077248 Medical error – the third leading cause of death in the US: https://www.ncbi.nlm.nih.gov/pubmed/27143499 Books Mentioned in This Episode Haroun and the Sea of Stories:  https://www.amazon.com/Haroun-Sea-Stories-Salman-Rushdie/dp/0140157379/ref=asap_bc?ie=UTF8 Invisible Man: https://www.amazon.com/Invisible-Vintage-International-Ralph-Ellison-ebook/dp/B003WUYR9K/ref=sr_1_2?ie=UTF8&qid=1525281632&sr=8-2&keywords=invisible+man+ralph+ellison

In this episode of Critical Matters, we discuss the role of noninvasive ventilation and high-flow oxygen nasal cannula in respiratory failure. Our guest, Dr. Pratik Doshi, is an academic intensivist and emergency medicine physician at the University of Texas Health Science Center in Houston, Texas. Dr. Doshi is the lead author and investigator of a recently published multicenter randomized clinical trial evaluating this topic. Additional Resources Official ERS / ATS Guidelines for non-invasive ventilation (NIV): https://www.ncbi.nlm.nih.gov/pubmed/28860265 High-velocity nasal insufflation in the treatment of respiratory failure: A randomized clinical trial by Doshi P et al: http://www.annemergmed.com/article/S0196-0644(17)31968-6/fulltext Books Mentioned in This Episode The Alchemist: https://www.amazon.com/Alchemist-Paulo-Coelho-ebook/dp/B00U6SFUSS/ref=sr_1_1?ie=UTF8&qid=1523055572&sr=8-1&keywords=the+alchemist

In this episode of Critical Matters, we explore the role of the intensivist in the postoperative care of the cardiac surgical patient. Our guest is Dr. John Greenwood, a practicing intensivist who splits his clinical time between the Cardiac and Vascular ICU and the ED-ICU at the Hospital of the University of Pennsylvania. In the first of two episodes, we discuss general postoperative care, common complications, and the intensivist-cardiac surgeon relationship. Additional Resources Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care: https://www.ncbi.nlm.nih.gov/pubmed/25962078 Postoperative Critical Care of the Adult Cardiac Surgical Patient: Part II: Procedure-Specific Considerations, Management of Complications, and Quality Improvement: https://www.ncbi.nlm.nih.gov/pubmed/26136101 Critical Care Perspectives in Emergency Medicine – a monthly CME podcast on resuscitation and critical care-related issues that can present to the ED https://www.criticalcareinem.com/ Critical Care Project – a multi-institutional website designed to be a multidisciplinary educational resource on topics in critical care. http://ccproject.com/ Books Mentioned in This Episode How to Win Friends & Influence People: https://www.amazon.com/How-Win-Friends-Influence-People/dp/0671027034/ref=sr_1_3?ie=UTF8&qid=1521825606&sr=8-3&keywords=dale+carnegie The Last Lecture: https://www.amazon.com/Last-Lecture-Pausch-Randy-Hardcover/dp/B011MCWCDW/ref=sr_1_2?ie=UTF8&qid=1521826496&sr=8-2&keywords=the+last+lecture

In our first episode of the Critical Matters podcast, we discussed the potential role of Angiotensin II in the treatment of distributive shock based on the results of the ATHOS 3 clinical trial. Now Angiotensin II is FDA approved and commercially available as a product named GIAPREZA. In this episode we will discuss this topic further. Our guest is Dr. Lakhmir S. Chawla, Chief Medical Officer of La Jolla Pharmaceutical in San Diego, California. Previously, Dr. Chawla was a Professor of Medicine at the George Washington University. During his tenure at George Washington, Dr. Chawla was the designer and lead investigator of the ATHOS (Angiotensin II for the Treatment of High Output Shock) trial which results led to the ATHOS 3 trial, (The Phase 3 clinical trial of angiotensin II, for the treatment of catecholamine-resistant hypotension). Additional Resources ATHOS-3 Clinical Trial. Randomized controlled trial evaluating the efficacy of Angiotensin II in raising blood pressure in vasodilatory shock.  http://www.nejm.org/doi/full/10.1056/NEJMoa1704154 Outcomes in Patients with Vasodilatory Shock and Renal Replacement Therapy Treated with Intravenous Angiotensin II. https://www.ncbi.nlm.nih.gov/pubmed/?term=Outcomes+in+Patients+with+Vasodilatory+Shock+and+Renal+Replacement+Therapy+Treated+with+Intravenous+Angiotensin+II Prescribing information for Angiotensin II (GIAPREZA ). http://giapreza.com/giapreza-prescribing-information.pdf Books Mentioned in This Episode Atlas Shrugged: https://www.amazon.com/Atlas-Shrugged-Ayn-Rand/dp/0451191145/ref=sr_1_1?ie=UTF8&qid=1522104389&sr=8-1&keywords=atlas+shrugged+book

In this episode of Critical Matters, we explore the intersection of high-altitude medicine and physiology with critical care. Our guest is Robert B. Shoene, MD, FACP. Dr. Shoene is Associate Director, ICU and Critical Care, at St. Mary’s Medical Center in San Francisco. Dr. Shoene is a prolific author and researcher with more than 100 publications. His research has focused on pulmonary physiology and altitude medicine, and he has been part of numerous research expeditions to locations such as Mt. Everest and Denali. Additional Resources: Arterial Blood Gases and Oxygen Content in Climbers on Mount Everest: https://www.nejm.org/doi/full/10.1056/NEJMoa0801581 A comprehensive review on illnesses at high altitude: https://journal.chestnet.org/article/S0012-3692(08)60216-0/fulltext Everest: The West Ridge by Thomas Hornbein: https://www.amazon.com/Everest-West-Ridge-Thomas-Hornbein/dp/1594857075/ref=sr_1_1?ie=UTF8&qid=1520812701&sr=8-1&keywords=everest+the+west+ridge Endurance: Shackleton’s Incredible Journey by Alfred Lansing: https://www.amazon.com/Endurance-Shackletons-Incredible-Alfred-Lansing/dp/0465062881/ref=sr_1_1?s=books&ie=UTF8&qid=1520812797&sr=1-1&keywords=endurance Being Mortal: Medicine and What Matters in the End by Atul Gawande: https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/1250076226/ref=sr_1_1?s=books&ie=UTF8&qid=1520812921&sr=1-1&keywords=Being+mortal Intensive Care, a poem by Dr. Robert Schoene: https://www.jstor.org/stable/1348231?seq=1#page_scan_tab_contents

In this episode, we discuss the practice of respect in the intensive care unit. Our guest is Samuel M. Brown, MD, MS, a practicing intensivist and Director of the Center for Humanizing Critical Care at Intermountain Medical Center in Murray, Utah. Dr. Brown holds an academic appointment as Associate Professor of Medicine at the University Of Utah School Of Medicine, Murray UT. He is a prolific investigator and author with a wide range of interests, including complexity in critical illness, echocardiography, and ethics. Our conversation covers topics such as dignity, respect, compassion and burnout. Join us in a fascinating discussion with a thought leader in bringing humanism to critical care. Additional Resources: Recent article co-authored by Dr. Brown and colleagues reviewing important aspects of the practice of respect in critical care medicine. Click here to read. The Center for Humanizing Critical Care works with researchers and clinicians with the goal of helping patients and family members make it through critical illness with their humanity intact. Learn more here. Speak, Memory: An Autobiography Revisited by Vladimir Nabokov. Click here to learn more.

The use of point-of-care ultrasound (POCUS) has penetrated our clinical practice. In the hands of trained intensivists POCUS can quickly provide valuable diagnostic information and lead to specific therapeutic interventions. Today’s episode explores the use of POCUS during cardiac arrest. Our guest is Haney Mallemat, MD. Dr. Mallemat is board certified in emergency medicine, internal medicine, and critical care medicine and works in the emergency department and intensive care unit at Cooper University Hospital in Camden, NJ. He has lectured both nationally and internationally and has contributed to several emergency medicine and critical care podcasts. He is a firm believer in the benefits of bedside ultrasound for better patient care. Additional Resources The REASON Trial evaluated the role of POCUS in out of hospital cardiac arrest arriving to the emergency department. Click here to read. Point of care ultrasound can be associated with frequent interruptions during CPR. As Dr. Mallemat discusses in the podcast, providers must pay very close attention to this issue. Click here to read more.