Maryland CC Project

Dr. Joshua King, Assistant Professor of Medicine and Pharmacy at the University of Maryland and Medical Director of Maryland Poison Control presents on “ICU Toxicology“. Uploaded by Sami Safadi, MD

Dr. Devang Patel, Assistant Professor of Medicine at the University of Maryland, presents on “Antibiotics in the ICU”. Uploaded by Sami Safadi, MD

Dr. Wendy Ziai, Associate Professor of Neurology at Johns Hopkins University. Dr. Ziai’s lecture will cover “ICP, CCP in ICH and IVH.”

Dr. Marie Baldisseri, Professor of Critical Care Medicine at the University of Pittsburgh. Dr. Baldisseri’s lecture will cover “How to Prepare your ICU for a Disaster.” Uploaded by Sami Safadi, MD

Dr. Sam Tisherman, Professor of Surgery at the University of Maryland. Dr. Tisherman’s lecture will cover “Hemorrhagic Shock.” Uploaded by Sami Safadi, MD

Dr. Nicholas Morris, Assistant Professor of Neurology at the University of Maryland. Dr. Morris’ lecture will cover “Brain Death.” Uploaded by Sami Safadi, MD

Dr. Samuel Tisherman, Professor of Surgery at the University of Maryland. Dr. Tisherman presents about Belly Badness. References * Sawyer, Robert G., et al. “Trial of short-course antimicrobial therapy for intraabdominal infection.” New England Journal of Medicine 372.21 (2015): 1996-2005. https://www.nejm.org/doi/full/10.1056/NEJMoa1411162* Carr, John Alfred. “Abdominal compartment syndrome: a decade of progress.” Journal of the American College of Surgeons 216.1 (2013): 135-146. https://www.journalacs.org/article/S1072-7515(12)01197-0/ Uploaded by Sami Safadi, MD

Dr. R. Scott Stephens, Assistant Professor of Medicine and Director, Oncology and Bone Marrow Transplant Critical Care at Johns Hopkins University presents his work on Mechanical Ventilation Management during ECMO for ARDS. Lecture Summary by Dr. Roxana Amirahmadi Introduction The objective of this lecture is to outline best mechanical ventilator practices after the decision has already been made to put a patient with ARDS on ECMO. Background VV-ECMO is used in the setting of ARDS to facilitate oxygenation and carbon-dioxide ventilation during a period when the lungs are less compliant than baseline and at higher risk of sustaining further injury. VV-ECMO A pump uses centrifugal force of generate 4-5 L/min of flow to pump blood outside the body over a membrane, across which there is a controlled and adjustable oxygen gradient (FDO2) that promotes oxygen diffusion into the blood. Dissolved CO2 escapes the serum across this membrane down its gradient, achieving successful ventilation. After the blood contacts this membrane, it returns to the body through a separate cannula. * There are three adjustable parameters:* Flow = A pump that uses centrifugal force of generate 4-5 L/min of flow that pumps blood outside the body and throughout the system* Sweep = Ventilation; VE * FDO2 = oxygen concentration across the membrane that the blood encounters, which establishes an oxygen gradient favoring oxygen diffusion into the blood. * Oxygenation is determined by FDO2, flow rates, and venous mixing, recirculation, cardiac output. Higher flow rates lead to a higher percentage of oxygenated blood accounting for the cardiac output, which leads to higher oxygen saturations.* Typical arterial O2 saturations are between 80-90%. Caring for the lungs after initiating VV-ECMO After deciding to put a patient on ECMO, we run the risk of forgetting about the lungs. There is no established guideline or standard of care of how to manage the lungs on the ventilator while a patient is on ECMO. The lungs have evolved to be mobile and some cyclic stretch may be good for vasculature epithelium as well. In vitro data has shown that low levels of cyclic stretch protect alveolar epithelial cells against oxidant induced cell death. 1 Even anoxic ventilation has been shown to be protective. 2 This suggest that some degree of tidal ventilation might be helpful in ECMO patients. During this talk, we will outline current ventilation practices in patients on ECMO and the best data available to guide clinical practices. Current practices The Lung Safe Study published in JAMA in 2016 showed that around the country, neuromuscular blockade, lung protective ventilation strategies, and proning are underused. 3 The LIFEGARDS study is an international multicenter prostpective cohort that followed patients on ECMO with ARDS in 23 ICUs from 10 countries for 1 year. 4 The following are the main points of this study: * Demographics and daily ventilator settings were tracked in 350 patients on ECMO * ICU and 6-month outcome data were reported* Results revealed that prior to ECMO cannulation, patients were mostly on either Pressure-targeted or Volume-targeted settings, in approximately equal proportions. Lung protective settings were less likely to be utilized prior to ECMO than after placing the patient on ECMO* “Ultra-protective” ventilation was common ...

@import url('https://fonts.googleapis.com/css?family=Merriweather&display=swap'); p, li, h1, h2, h3, h4 {font-family: 'Merriweather', serif;font-size:18px; color:black;} Carl Shanholtz, MD, Professor of Medicine in the Division of Pulmonary and Critical Care and Director of the Medical ICU at the University of Maryland presents the multi-departmental critical care curriculum lecture on ARDS. Lecture Summary by Dr. Jason Nam Introduction * ARDS is a common disorder of acute injury to lungs. It can occur in children. Lack of standard definition prior to 1994. * Why use P/F ratio in the definition? It is a surrogate measure of shunt. Shunt fraction needs to be done with Swann-Ganz. * Consensus Conference definitions- between American and European Characteristic AECC Definition 1994 Berlin Definition 2012 Timing Acute, without any specification Maximum within a week after a trigger insult Imaging Chest X-ray with bilateral infiltrates Chest X-ray or CT scan with bilateral infiltrates, not fully explained by effusion, lung collapse or nodules Non-cardiogenic source of edema Confirmation of non-elevated left atrial pressure Respiratory failure not completely explained by excessive volume loading or cardiac failure Classification Based on PaO2/FiO2 Based on PaO2/FiO2 calculated with PEEP >5 cmH2O   Acute lung injury:<300 Mild: 201-300   ARDS:<200 Moderate: 101-200    – Severe: <100 Predisposing condition Not specified If none identified, then need to rule out cardiogenic edema with additional data Pathophysiology * Active exudative phase. Leads to the pulmonary edema (non-cardiogenic). Loss of compliance and hypoxemia refractory to supplemental oxygen. Loss of capillary surface area and increase in dead space. We get “baby lungs.”* When we try to ventilate, we get VILI. Lung protection strategies * ARMA Trial – mortality was lower, and ventilator-free days higher in the group treated with lower tidal volumes * Improvement in oxygenation doesn’t seem to predict outcome of ARDS. Oxygenation was a bad surrogate for outcome. * Is there a safe plateau pressure? At any quartile. The lower TV patients had an improved mortality. * Is higher PEEP protective? It was thought that moderate-to-severe ARDS patients would benefit from higher alveolar recruitment. Gattinoti, et al, found that moderate-to-severe ARDS patients had more atelectatic and thereby more recruitable lung. * What about driving pressure? driving pressure is directly proportional to mortality regardless of driving pressure and PEEP. No one yet knows how to titrate driving pressures as there is current evidence and interest in closed-lung strategies.* Does lung prevention ventilation strategies prevent ARDS? PReVENT trial. Multicenter RCT in Netherlands. A low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy Fluid Management and ARDS * Fluid and Catheter Treatment Trial – Fluid conservative vs.

@import url('https://fonts.googleapis.com/css?family=Merriweather&display=swap'); p, li, h1, h2, h3, h4 {font-family: 'Merriweather', serif;font-size:18px; color:black;} Samuel M. Galvagno Jr., DO, PhD, MS, FCCM, Associate Professor of Anesthesiology at the University of Maryland SOM & Associate Director, Maryland Critical Care Network at UMMC and Ross Carpenter, MD, Fellow in Cardiothoracic Anesthesia at the University of Maryland, present the weekly multi-departmental critical care fellows’ lecture on “Molecular Adsorbent Recirculating System: Life on MARS.”  Lecture Summary by Dr. Erik Manninen Introduction * Liver transplant is the second most common transplanted organ after kidney.  <10% of global needs are met.* Molecular adsorbent recirculating system (MARS) is an artificial liver support system that was developed in 1993 in Germany and became commercially available in 1999.  * It removes toxins that CRRT does not (although MARS is used in conjunction with CRRT).  * MARS is used as a bridge to transplant or a bridge to recovery.  It is expensive and typically involves 3 sessions at a minimum, which costs about $45,000.* Used successfully to bridge three patients to transplant that suffered heat stroke.   System Components * The system uses three different circuits: blood, albumin and low-flux dialysis. * First, blood is dialyzed against a human serum albumin dialysate solution * Then, the albumin dialysate is regenerated in a close loop in the circuit by:* passing through a low-flux dialysis filter against a standard dialysis fluid to clear water-soluble toxins * passing through two different adsorption columns: activated charcoal to clear protein-bound substances and cholestyramine & an anion-exchange resin to clear anionic substances* For one session 100g of 25% albumin is used.  Indications *  APAP overdose with one or more:  INR>2.5, tbili>3, pH<7.3, and lactate >6mmol/L.* Acute fulminant liver failure in a transplant candidate* Acute on chronic liver failure in a listed transplant candidate* Primary non-functioning post liver transplant and one or more of the following:  * listed for re-transplant, * UNOS criteria for PNF* hepatic artery thrombosis* INR.2, lactate >6, and clinically deteriorating* Patients with multiple organ failure on a case to case basis Other Considerations * N-acetylcysteine dosing should be doubled while on MARS.  Other protein bound drugs also need to have dose adjustment and should be reviewed and your clinical pharmacist can be a big help with your patient while on MARS. * Efficacy of MARS is judged on improving clinical parameters like decreasing dose of vasoactive medicines and improving mental status.  * There may be a role of using MARS to speed recovery of patients with acute liver failure as well, which allows earlier hospital discharge and doesn’t tie up a potential organ, which could be transplanted to a patient who truly needs it.  * While there are no precise recommendations on the effective timing of initiation of artificial liver support systems they can be helpful in select cases.  References * Mitzner, Steffen R. “Extracorporeal liver support-albumin dialysis with the Molecular Adsorbent Recirculating System (MARS).” Annals of hepatology 10.S1 (2016): 21-28.

h1, h2, h3, h4, p, li {font-family: 'Noto Serif', serif;} p, li {font-size:1.3em; color:black;} Erik Osborn, MD, COL, MC USA, Director Adult Extracorporeal Service, Cardiovascular Intensive Care Unit at Inova Fairfax Hospital, presents the weekly multi-departmental critical care fellows’ lecture on “ECMO and the Brain”. Lecture Summary by Dr. Erik Manninen * Neurologic complications are one of the main impairments in the critically ill and neuro prognostication is difficult. * Case example given of a patient with severe DAI (Diffuse Axonal Injury) who had various opinions on prognosis that varied significantly. In 2 months of therapy she was able to follow commands, was performing self-care at 4 months, and walked into a clinic appointment at 8 months post injury. * Complications that occur are neurologic 20% of the time on ECMO. ICH (Intra-cranial hemorrhage 5-15%, stroke 10-20% and seizures 10-25%). Preventative measures * A lower heparin dose/range as there is a build-up of anti-coagulation effect (1/3 of heparin is biologically active)* Avoid rapid decrease in PaCO2* Keep platelets at 50,000-80,000* Avoid hyperoxia by keeping PaO2 60-100 mmHg;* Limit ECMO pump speed to 3,500 rpm Neuro Monitoring tools * NIRS (near infrared spectroscopy)* NPi (neurological Pupil Index)* OND (optic nerve sheath measured on POCUS)* EEG (electroencephalogram)* TCDs (transcranial Doppler) Other pearls * Consider CT Head if you do not have an adequate neuro exam for baseline and for any changes, as intracranial hemorrhage would necessitate cessation of heparin and consideration of ECMO withdrawal.* Treatment of ICH is to give DDAVP, TxA, stop heparin for 3 days or so. Important point to remember The brain has greater regenerative capacity than we think and prognostication is difficult. Uploaded by Sami Safadi, MD

p, li {color: black;font-size: 1.2em;} .has-drop-cap{font-size: 1.4em;} Jonathan Trager, DO, PA Medical Director at Lehigh University EMS & Police Department and PA Medical Director- Emergency/EMS, Transport and Critical Care Transport at St. Luke’s Emergency & Transport Services, presents the weekly multi-departmental critical care fellows’ lecture (Thursday, 6/13) on “Patient Transport: In-between & Within.” Lecture Summary (by Dr. Erik Manninen) * From the horse pulled Moses Ambulance Wagon in 1858 to the first civilian aeromedical service in Australia in 1928 (Royal Flying Doctors Service).  First U.S. aeromedical transport service in Los Angeles in 1947 using fixed wing aircraft.  * Helicopter medivac first used in Burma in 1944 and the first to transport to a medical facility was in 1970 to the Shock Trauma Center in Baltimore, Maryland.* Intra-facility transport (within your hospital) can be more dangerous than inter-facility transport given the lack of standardization/preparation of the former at many institutions.  Usually with inter-facility transportation there is more preparation for patient deterioration. * Pittsburgh Paramedics at the Freedom House founded in 1967 are the first civilian EMS service to be staffed by paramedics in the United States.  * Hand-over tools have helped to standardize communication in transport as well as preparation for transport (e.g., ensuring there are enough medications to last the trip, enough oxygen, etc.). References * Kulshrestha, Ashish, and Jasveer Singh. “Inter-hospital and intra-hospital patient transfer: Recent concepts.” Indian journal of anaesthesia 60.7 (2016): 451. https://www.ncbi.nlm.nih.gov/pubmed/27512159 * Warren, Jonathan, et al. “Guidelines for the inter-and intrahospital transport of critically ill patients.” Critical care medicine 32.1 (2004): 256-262. https://www.ncbi.nlm.nih.gov/pubmed/14707589 * King, Mary A., et al. “Evacuation of the ICU: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.” Chest 146.4 (2014): e44S-e60S. https://www.ncbi.nlm.nih.gov/pubmed/25144509 Uploaded by Sami Safadi, MD

p, li {color: black;font-size: 1.2em;} .has-drop-cap{font-size: 1.4em;} José G. Merino, M.D., M.Phil., FAAN, FAHA, Associate Professor, Department of Neurology at the University of Maryland SOM and US Research Editor, The BMJ, presents the weekly multi-departmental critical care fellows’ lecture on “Appraising manuscripts: an editor’s perspective.” Uploaded by Sami Safadi, MD

Keegan Tupchong, MD, Fellow, Critical Care Medicine, Division of Pulmonary and Critical Care Medicine at the U of Maryland SOM, presents the weekly multi-departmental critical care fellows’ lecture on “Decision-making in Critical Care Triage.” Uploaded by Sami Safadi, MD

p, li {color: black;font-size: 18px;} .has-drop-cap{font-size: 1.4em;} Seth J Koenig, MD, Professor, Dept of Medicine and Cardiovascular and Thoracic Surgery; Professor of Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell; Director, Acute Lung Injury Center, Northwell Health; and Director, MICU at the Long Island Jewish Medical Center, presents on “Transesophageal Echocardiography in the Intensive Care Unit”. Lecture Summary: TEE in the ICU – Seth Koenig Summary by Dr. Keegan Tupchong TEE in the ICU * not dangerous * not hard * can be mastered by non-cardiologists * data show that it helps clinical decision-making Reasons to learn TEE * Anyone who is critically ill probably deserves POCUS * TEE is used for all ECMO cannulations at Long Island Jewish Medical Center * You will be left behind if you don’t start learning TEE in fellowship * the same paradigm used to exist for learning general POCUS as well as critical care TTE, and now everyone has POCUS in their ICUs* Taking good care of a patient means that at least you must know what is wrong * while it does not replace clinical skills, TEE as an adjunct can give you the data needed to become a better clinician* TEE is much less dangerous and complicated than many other procedures required by ABIM: * airway management * CVCs, A-lines, PACs * ventilator management * There may not be an RCT showing improved outcomes with TEE but … * this has yet to be shown for ventilators, CT scans * “we hold these truths to be self-evident” and assume that they benefit patients* Categorizing the shock state is essential * “if you understand the shock state then you know how to treat the shock state” * diagnosis of life-threatening diseases saves lives * hemodynamic profiles change constantly TEE image acquisition: * There are different types of gross movements* vertical (advance/withdraw the probe) * rotational (turning the probe/beam plane) * anteroflexion/retroflexion * lateral flexion * multi beam * Beam path is the opposite of TTE (from inside the chest pointed outwards) Ten Reasons for Performing Hemodynamic Monitoring Using TEE (Vignon, et al, ICM, 2017) * TEE provides a unique window to the heart and great vessels (e.g. dissection) * TEE provides unparalleled information on the mechanism of circulatory failure (e.g. saddle PE, too unstable to go to CT) * TEE allows reproducible and sequential hemodynamic assessments * (e.g. slightly large RV but normal SV (normal HR, VTI) may point towards vasodilatory rather than obstructive shock (with old RV dysfunction))* TEE predicts fluid responsiveness (better than any other cardiac output monitoring paradigm) * TEE is best suited to quantitatively assess cardiac function (e.g. degree of severity of mitral regurgitation) * TEE is key to identifying RV dysfunction at the origin of low flow states (e.g. large ASD) * TEE is the only possibility to monitor hemodynamic status in the context of the use of ECMO (e.g. cannula placement) * TEE is quicker and easier to initiate than other monitoring modalities, and less operator dependent than TTE * Miniaturized TEE probes allow prolonged hemodynamic monitoring * TEE potentially improves ICU performance Complications * Risk of death = 0.0098% (cardiology TEE) * Several large studies combined show ~1 death in 30,