Invasive ventilation is one of the most frequently applied interventions utilized for critically ill patients. However, as with all medical interventions, there are potential risks and harms which must be balanced with perceived benefit. As our understanding of physiology grows, we have found more and more potential harms associated with invasive mechanical ventilation. This review of a recent article published in JAMA explores the impact of different tidal volume strategies for patients who do not have ARDS.Read More
This week, we started Grand Rounds with ED-critical care research brought to us by UC Alumnus Dr. Brian Fuller. He discusses ventilator management in the ED and how ED sedation may affect patient outcomes. Dr. Harrison then presented an overview and common utilization errors of ED observation from his year as a Resident Assistant Medical Director, followed by Dr. McKee’s case of inhalational chlorine exposure. Dr. Alwan discussed updates to the less than 60 day fever protocol at CCHMC and Dr. Zozula walked through the dispatcher assistance protocols to give us an idea of what happens before they enter the ED doors.Read More
Dr. Grosso kicked off Grand Rounds this week with March M&M by diving deep into some core content, including BB and CCA overdoses, influenza, massive transfusion, post-intubation hypotension, and neurological catastrophes causing cardiac arrest. Dr. O'Brien broke down coagulopathy of liver disease and DIC for us while Dr. Golden taught us about febrile seizures. Drs. McKee and Colmer talked through the evidence behind their CPQE pathway on vent management in obstructive lung disease. Drs. Liebman and Powell went head to head in a CPC case about sternal osteomyelitis to round out another excellent week of learning.Read More
This week we had our annual Critical Care Symposium where we invited our own critical care trained faculty and a special guest to have a day chock full of critical care goodness.
Refractory septic shock with Dr. David norton
Dr. David Norton, Assistant Professor of Medicine and Director of the UCMC Medical Intensive Care Unit
Definition of Refractory Shock:
No clear definition exists, but we are generally describing a state of decreased vascular responsiveness despite high vasopressor infusion.Read More
Case 1 - "Bucking the Vent"
You have inherited a patient in the VA MICU at signout. The patient presented with spontaneous bacterial peritonitis and altered mental status and was intubated for airway protection and hypoxic/hypercarbic respiratory failure. The patient’s altered mental status has resolved but the patient remains intubated waiting for a second large-volume paracentesis that can’t be done over the long weekend at the VA. The RT calls you asking for a one time dose of 5mg Versed, but on a quick glance at the chart, the patient has been getting these Q2 hours for the last several days. You go to the bedside and find an agitated patient motioning to take out the tube. “He’s bucking the vent doc!”
Vent settings: AC-VC: TV500 RR12 PEEP8 FiO2 30%Read More
Evidence-Based Emergency Medicine: Vent Management with Drs. Axelson & Scupp
The term Acute Lung Injury (ALI) is being phased out and instead Acute Respiratory Distress Syndrome (ARDS) is now graded mild, moderate, and severe depending on the PaO2:FiO2 ratio
The median onset of ARDS after presentation to the ED was 2 day but could be anywhere from 5 hours to 5 days
ARDS Net was a foundational trial in ventilator management and was a triall of tidal volume and plateau pressures. The primary end point, mortality, was reduced by >20% when folks were on a low TV (6cc/kg) and lower PP (25-30 mm Hg).Read More
Ventilator management can be one of the more intimidating aspects of caring for critically ill patients both in the ED and in the prehospital setting. There are several great #FOAMed resources out there on varying aspects of ventilator management including the well-known series by Dr. Weingart of emcrit.org (here and here). Ventilator management can be an absolutely massive topic but for this post, and specifically for the embedded video below, I wanted to do a little deeper dive on only one of the components of ventilatory management: PEEP.Read More