Maryland CC Project

Dr. Mayur Narayan is a trauma intensivist who has a special interest in the development of trauma systems, especially in underdeveloped countries.  In this talk Dr. Narayan discusses the challenges to developing an efficient trauma system, the basics to trauma care, and some of the recent advancements in taking care of the critically injured patient. Pearls * Does it matter if non-trauma surgeons manage Trauma ICU patients?  NO!  There have been no proven difference in survival to discharge or better outcomes. * ATLS still teaches ABCs as an initial approach to the trauma patient, but for the patient in hemorrhagic shock – START with circulation! * When to transfer a sick trauma patient?  ASAP.  A common pitfall is waiting until after diagnostic tests (specifically CT scans)  to transfer a sick patient. * You can only prevent secondary neurologic injury by avoiding hypotension and hypoxia.  In the patient with hemorrhagic shock, address the cause of hypotension FIRST.  Remember the 5 compartments: Suggested Reading * ATLS Subcommittee; American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6. * Shere-Wolfe RF, Galvagno SM Jr, Grissom TE. Critical care considerations in the management of the trauma patient following initial resuscitation. Scand J Trauma Resusc Emerg Med. 2012 Sep 18;20:68. * Ahmed JM, Tallon JM, Petrie DA. Trauma management outcomes associated with nonsurgeon versus surgeon trauma team leaders. Ann Emerg Med. 2007 Jul; 50(1):7-12, 12.e1. Epub 2006 Nov 15.

Dr. Munish Goyal comes to us all the way from downtown DC, where at the Georgetown University School of Medicine he acts as Director of Emergency Intensive Care and Associate Program Director for the Pulm/Critical Care Fellowship. Using his positions in both the Emergency Department and the Pulmonary and Critical Care department, he has been able to revolutionize the way cardiac arrests are treated – implementing protocols that transition care from ED to ICU to discharge. In today’s talk he takes us through some common ACLS scenarios and then asks simple questions with some unexpected answers…… In just 57 minutes he just might make you question the way you handle your next crashing patient!!   Handling your next code, The Munish Goyal Method: Chapter 1: Epinephrine * Used for α effects with the goals * Afterload → ↑ Diastolic Pressure → ↑ Coronary Perfusion Pressure (CPP) * CPP = Diastolic Pressure – Right Atrial Pressure * ROSC has been achieved ONLY when CPP > 15mmHg * At the expense of β effects * ↑ HR → ↑ Contractility → ↑ Myocardial O2 Demand * ↓ Microvascular Perfusion (brain, lungs, etc.) * 1mg vs. 5mg Epi? * There is NO change to outcome!! * Same D/C rate, same Neurological Outcome * In fact, studies show NO benefit at ANY dose of Epi!! * “May help, probably doesn’t hurt” TAKE AWAY #1: Epinephrine is a great drug to assist ROSC, however DO NOT use at the EXPENSE of a working organ.  Don’t take away from great CPR just to get access for a drug that  might not really do anything!! Chapter 2: Electricity! * 1) Time to shock is directly correlated with outcome * a) <2 mins = 2/3 achieve ROSC with 39% survival * b) >2 mins = 1/2 achieve ROSC with 22% survival TAKE AWAY #2: Shock the unstable rhythm first, ask questions later! Chapter 3: Chest Compressions 1) Any  pause = ↓ CPP TAKE AWAY #3: Minimize interruptions, even at the expense of lines or tubes Chapter 4: Airway and Oxygenation * No increase in survival with early intubation * Average PAUSE to CPR: 46.5 seconds (please see above!) * Hyperventilation is common and causes ↑ Intrathoracic Pressure → ↓ CPP → ↓ ROSC * Hyperoxia is just as bad as Hypoxia! * a) ↑ Neural Cell Injury * b) ↓ Neurological Outcomes and need for rehab * c) ↑ Mortality!! TAKE AWAY #4: Ventilate with the MINIMUM breaths, FiO2 and PEEP!! Chapter 5: Epi + Vaso + Steroids?!? * Appears to lead to better outcomes: * ↑ Diastolic Pressure * ↓ Inflammatory Markers * ↑ Cerebral Perfusion Pressure * Taken together there ↑ survival to D/C and Improved Neurological Outcome * Unclear whether it is the steroids or vasopressin (or both together) that may improve outcomes TAKE AWAY #5: Jury’s still out, but Epi/Vaso/Methylpred may be the next big discovery!!  Chapter 6: Hypothermia * Proven only in VF and VT (Not Asytole or PEA) * Proven only out of hospital arrests (not floor arrests) * Like all of medicine: Timing is EVERYTHING * Any delay = ↓ survival * At 8 hrs there is no longer a benefit TAKE AWAY #6: You won’t be punished for cooling a patient, but you may if you don’t.  

When not acting as Chief of Surgical Critical care services and Director of the Cardiac Surgery Unit at the University of Maryland, Dr. Dan Herr finds time to be a world renown expert in ICU delirium! His knowledge and experience on the topic has brought him invites to speak all over the world at some of the largest critical care assemblies. Recently Dr. Herr was one of the principle authors of the guidelines for treatment of pain, agitation, and delirium endorsed by ACCM, SCCM, ASHP, & the ACCP! He is gracious to share what he feels are the most important goals of therapy and brings his unique take on the ABCDEs of the ICU. The audio in this week’s lecture is a little spotty at times, so we apologize for that.  We had to move our discussion to a room not equipped with our usual audio.  We’ll be back to normal next week! So let’s review… 1) 60-80% of ICU patients will develop delirium, but only 16% of ICUs screen for it * Delirium = ↑ ICU costs by 31% + ↑ ICU length of stay by 30% * Untreated = ↑ mortality rate by 10% per day (up to 6 months after discharge!!!) * → #1 piece of advice: Control Anxiety  to control Delirium!  2) Avoid over sedation: if you need “daily awakening trials” then you are giving too  much sedation….. * Need specific goals with specific scales; examples: RASS or CAM-ICU * CAM-ICU is used by only 20% of ICUs despite recommendations by guidelines! * → #2 piece of advice: only rely on your own CAM-ICU score!! Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved 3) Simplify your pain medication regimen: one medicine for ALL pain (Fentanyl > Dilaudid or Morphine) * In combination with sedation scales, you must also use PAIN scales (Comfort Sedation vs. Behavioral Pain Scores) * Pre-treat all procedures: chest tube placement, intubation, etc. → increased patient satisfaction scores!  * Supplement with non-narcotics when/if possible (Tylenol, NSAIDs) * → #3 piece of advice: Pain control first, then sedation!! 4) Benzo use = Delirium * Ativan: 1 dose = 20% increase to delirium * Larger doses → increase to risk (additive risk)  5) Dexmedetomidine = 70% less narcotics needed!! Once at steady state HALF all narcotics * DO NOT titrate to RASS, instead aim for HR (suggested target of 80 bpm) * FUN FACT #1: Dex is a potent diuretic * FUN FACT #2: when compared to Versed, Dex decreased LOS by 21.3% (Left the ICU 1.7 days sooner) 6) ABCDE of ICU sedation Morandi A et al. Curr Opin Crit Care,2011;17:43-9   Suggested Reading * Ely EW, Margolin R, Francis J. et al. Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (CAM-ICU). Crit Care Med.2001;29:1370-1379. * Barr J, Fraser GL, Puntillo K, Riker R; SCCM Taskforce. Clinical practice guidelines for the management of pain, agitation and delirium in adult ICU patients. Presented at the SCCM Annual Scientific Meeting. February, 2012. * Joffe AM, Hallman M, Gélinas C, Herr DL, Puntillo K. Evaluation and treatment of pain in critically ill adults.Semin Respir Crit Care Med. 2013 Apr;34(2):189-200.

One of the leading experts in the use of thromboelastography (TEG) is Dr. Mark Walsh from South Bend, Indiana.  We were fortunate enough to have Dr. Walsh come all the way from Notre Dame to Baltimore and discuss the role of TEG in trauma and hemorrhagic shock.  Incorporating TEG into your resuscitations may be a game changer based on the evidence provided in this lecture… Study up, because it will definitely be coming to a resuscitation bay near you SOON. So let’s review… Cell-based Model of Hemostasis – There are 3 phases of hemostasis * Initiation: Factor VIIa + Tissue Factor on injured endothelium & creates a small amount of thrombin •   Corresponds to R (reaction time) * Amplification: Thrombin activates platelets •   Corresponds to K (Clot kinetics) * Propagation: Coagulation factors assemble on activated platelets causing a “thrombin burst” •   Corresponds to α-angle (Clot kinetics) Fibrinolysis Phase: An important part of the TEG because it allows the provider to see how well the patient’s clot is holding up.  Even a minimal decrease in MA shown by the Ly30 has been found to result in an increased mortality. Here is an example TEG and what it all means. Pearls * The traditional end-points of resuscitation (improved LOC, skin perfusion, VS to baseline, UOP, and normal lab values) are DEAD.  The new end-points of resuscitation for the trauma/bleeding patient are: * Normal TEG * Normal pH * Would add – Normothermia * Routine coagulation tests only reflect the initiation phase of hemostasis and consequently cannot be used to monitor coagulopathy. They also do not reflect clot quality or stability. * Dr. Walsh’s TEG translation cheat sheet:   Suggested Reading * Schöchl H, Voelckel W, Grassetto A, Schlimp CJ. Practical application of point-of-care coagulation testing to guide treatment decisions in trauma. J Trauma Acute Care Surg. 2013 Jun;74(6):1587-98. * Holcomb JB, Minei KM, Scerbo ML, et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients. Ann Surg. 2012 Sep;256(3):476-86. * Johansson PI. Coagulation monitoring of the bleeding traumatized patient. Curr Opin Anaesthesiol. 2012 Apr;25(2):235-41.

Dr. Deborah Stein returns for another core content lecture, this time giving a crash course on hemodialysis, CRRT, CVVH, CVVHD, and a number of other concepts about managing acute renal failure in the ICU.  For this lecture, Dr. Stein went “old school” and brought us back to the greaseboard.  This is a must watch primer on renal replacement therapy – something encountered every day in the ICU.  Check out her drawing skills and more below in this week’s core content lecture. STC – CRRT Cheat Sheet.pdf Key Variable Definitions * QB = Blood flow rate through the filter (mL/min) * QUF = Ultrafiltration rate (mL/hour) also known as “PFR – Patient Fluid Removal” when using Gambro pumps * QD = Dialysate flow rate (L/hour) * QSF = Rate of fluid given to the patient pre- or post- filter (L/hour) Pearls * There is no definitive evidence that continuous renal replacement therapy (CRRT) improved morbidity or mortality over intermittent hemodialysis (IHD).  However, many studies comparing the two have excluded hemodynamically unstable patients. * Choose CRRT over IHD for patients with severe rhabdomyolysis and acute renal failure because the IHD filters will not clear myoglobin. * Trisodium citrate is commonly used to anti-coagulate blood running through the dialysis filter.  It is also a potent calcium binding agent.  If using trisodium citrate, it’s important that you aggressively supplement the patient’s calcium (post-filter) to prevent significant hypocalcemia. Suggested Reading * Cerdá J, Ronco C. Modalities of Continuous Renal Replacement Therapy: Technical and Clinical Considerations. Semin Dial. 2009 Mar-Apr;22(2):114-22. * Prowle JR, Schneider A, Bellomo R. Clinical review: Optimal dose of continuous renal replacement therapy in acute kidney injury. Crit Care. 2011;15(2):207.

Dr. Michael Winters returns to discuss IV Fluid resuscitation in the critically ill patient.  Should we abandon Normal Saline? What other options are available?  What is a balanced fluid, and which patient might benefit from a fluid with a lower SID? Learn the answers, and become an expert in one of the most common therapies given in the ICU by watching this fabulous review by Dr. Winters. Pearls * Myth: It takes approximately 3x as much crystalloid when compared to colloid to achieve the same amount of intravascular volume expansion in IVF resuscitation.  Fact:  In the critically-ill patient, there is a degradation of endothelial glycocalyx lining the vascular system reducing the ratio to as low as 1.3:1.   * The pH of a IVF does not determine the effect on the patient’s acid-base status.  What does? * Strong ion difference * Weak acid content (albumin, phosphate) * The ideal balanced solution has a SID of about 24 (roughly equal to a normal bicarbonate level) * Lactated ringers contains about 130 mEq of sodium, so avoid giving LR to patients with: * Traumatic brain injury * Hyponatremia * Cerebral edema * It is recommended that patients diagnosed with SBP should receive albumin (1.5 g/kg of 25% solution) within 6 hours of diagnosis. Suggested Reading * Raghunathan K, Shaw AD, Bagshaw SM. Fluids are drugs: type, dose and toxicity. Curr Opin Crit Care. 2013 Aug;19(4):290-8. * Morgan TJ. The ideal crystalloid – what is ‘balanced’? Curr Opin Crit Care. 2013 Aug;19(4):299-307.

Dr. Michael Winters is an Associate Professor in both Emergency Medicine and Internal Medicine at the University of Maryland.  He is an internationally known speaker in the area of critical care specifically in the Emergency Department setting and an amazing clinician as well.  We were fortunate enough to have Dr. Winters come and speak to us about a topic we frequently encounter in the ICU – upper GI bleeds.  By time they hit the ICU – do you have everything and everyone prepared for the probable “stormy course”?  if not, this is a must listen because you most likely will see this patient in the next couple of days… Pearls * Pre-endoscopy PPIs: Low risk-benefit profile and 2010 ACP guidelines still recommend them.  However, Sreedharan A et al. systematic review – no difference in mortality, need for surgery, or re-bleeding rates. * The dose of vasopressin for massive upper GI bleeding is NOT the same as the vasopressin replacement dosing used in sepsis.  Use an infusion rate of 0.2 – 0.4 units/min IV, and titrate by doubling the dose q 30 min until bleeding stops of MAP > 65. * Early antibiotic therapy is one of the only medications that has a proven mortality benefit in cirrhotics or those with suspected variceal upper GI bleeds.  Most recommend giving a 3rd generation cephalosporin or a fluroquinolone. * Balloon tamponade devices can be left in place for approximately 24 hours; avoid inflating esophageal balloon > 45 mmHg, as this can increase risk of rupture. * TIPS Procedure: Indicated for patient with: * Child B with active bleeding * Child C < 14 points * Consider early: preferably 24 hours, generally within 72 hours. BONUS PEARL: Consider IV erythromycin (+/- NGT) to improve stomach visualization during endoscopy; Dose: 250 mg IV   Suggested Reading * Osman D, Djibré M, Da Silva D, et al. Management by the intensivist of gastrointestinal bleeding in adults and children. Ann Intensive Care. 2012 Nov 9;2(1):46. * Mihata RG, Bonk JA, Keville MP.  Resuscitation Of The Patient With Massive Upper Gastrointestinal Bleeding. EM Critical Care. 2013 Apr 3(2): 1-12.