Stress Ulcer Prophylaxis

http://www.cmepilot.com/activity-demos/aspire/launch.html

Great talk re: use of H2RAs vs PPIs vs sucralfate for stress ulcer ppx in high risk ICU pts. It's part of the daily bundle at the Univ of Michigan to eval if pt needs SU ppx, what kind, and when it can be stopped. They usually start out with H2RAs (also Zantac), but then escalate to PPIs if needed. Sucralfate has some evidence for adverse outcomes and is discouraged. Also, I had never known that tachyphalaxis occurs with H2RAs and often the dose needs to be increased after a couple of days in order to remain effective. The highest risk groups who need to be on SU ppx are pts on mechanical ventilation or on anticoagulants (including ASA 325 and plavix), but there are other subgroups. The above website is a reference of a CME conf, but the guidelines are being updated, and another website should be coming out soon.

Hypovolemic?

In addition to Stu's post re: hypotension as a late manifestation of shock/the need to think of shock before a patient is hypotensive, one quick bedside tip by one of the army docs: if a patient is hypotensive and you're not sure if it's due to hypovolemia, lift his/her legs up in the air. If the BP improves, you have diagnosed hypovolemia without having to wait for other ancillary studies.

CHF and ultrafiltration

For patients who are congested and cold (pulmonary edema and hypoperfused/hypotensive) and failing diuretic treatment, there is evidence to suggest choosing hemo-ultrafiltration earlier rather than giving pressors/inotropes. And, that doesn't necessarily mean CVVH, but now there are peripheral ultrafiltration machines on the horizon where all you need are peripheral IVs.

Colloid Dosing

The crystalloid vs colloid wars are being duked out, but in the meantime, I finally heard a helpful lecture re: colloid equivalents:

NS or LR 500 ml dose = 100-200 ml intravascular
5% albumin (used for resuscitation) 500 ml = 500 ml intravascular
25% albumin (SBP, etc) 100 ml = 300 ml intravascular (because of oncotic pressure pulling in fluid from interstitium)
Hespan 500 ml = 600 ml intravascular (same reason as above)

Pre-Sep Lines

When I used the Pre-Sep line (triple lumen with scvO2 monitoring), sterility was an issue since one part of the line was calibrated by nursing prior to insertion (nonsterile - "in vitro") while the triple lumen part of the line was inserted with maximal barrier precautions - it was a bit of a yoga session to keep sterile and non-sterile separate. Well, according to the Edwards rep, the calibration does not have to happen in vitro and in fact works just as well as long as a venous blood gas is taken from the line to help calibrate the scvO2 monitor. So our Pre-Sep lines can actually be used for septic patients.

Bedside trach placement

Okay, the coolest thing I've seen at this conference which is standard at many hospitals is percutaneous bedside tracheostomy placement under direct bronchoscopic visualization. Saves money (the kit is slightly cheaper than OR trachs PLUS the patient isn't taking up an OR), saves transport-related complications (lines pulling out, etc), saves time (since the procedure is taking place at the bedside and takes no more than 2 minutes by a trained provider). While looking via the scope, a finder needle is inserted into the trachea from the anterior neck (between the 1st and 2nd tracheal rings), a wire passed through, skin incision made, serial dilation over the wire (with blue rhino), and then placement of the trach. Outcomes are identical to OR-placed trachs, and after a training period, this would no longer require precious ENT time.

Bevel Up or Bevel Down?

During the ultrasound teaching session, the advice given by one of the USC anesthesia folks was "Why keep the bevel up on any finder needle? Keep it face down". The needle tip is sharp all around, so there shouldn't be any problems in entering tissues. His theory (which makes sense): if the bevel is down, when you see blood return then the whole needle lumen is inside the vessel which greatly aids wire placement in the Seldinger technique; therefore, wire invasion into the vessel wall or outside of the vessel is less likely to occur. Has anyone else heard of this technique?

We just went to THE BEST acid base lecture EVER

No joke. I'm getting the slides from the lecturer, and I swear that after either Pramita or I give you this talk you will NEVER have a problem with acid base again EVER. For example, using this guys formula we figured out the following acid base problem in under 2 minutes. Can you? Email me or post to the "comments" if you think you have the answer. This is a man who has gotten IV amphotericin. I'll email you back either a "Right!" or a "Nope!". And no fair going to a computer. But I won't give the answer away until either Pramita or I give the lecture. And if you get a "Nope!" don't even THINK about arguing with me!

Na 125
Cl 100
HCO3 8
pH 7.07
pCO2 28
K+ 2.5


Stay tuned!

Rivers has big problems with the Corticus trial

I talked with Rivers today (yes, THAT Rivers) about the Corticus Trial. For those of you unfamiliar with the Corticus Trial, it's the steroid trial that showed that steroids in the ICU has no benefit and may show harm.

Rivers has some problems with it namely:
1) It's underpowered
2) They had to stop the study early because they ran out of study drug and money, so they published before they got enough patients (see #1)
3) The enrolled people up to 72 hours after onset of sepsis.

It's this final point that Rivers has a big problem with. His contention is that by 72 hours, the cat is out of the bag, out of the barn, and halfway to the moon (to mix a few metaphors--my metaphors, not his). So of course, there was no benefit. An analogy (also mine) would be to say that antibiotics don't work in sepsis because the antibiotic isn't given until 3 days after onset of symptoms. Okay not a great analogy, but you get the point.

Rivers still uses steroids, but waits until the patients have been adequately resuscitated (after 6 hours or so). If the patient is still pressor dependent he will start steroids at a dose of 50 mg hydrocortisone q6 hours.

Early ERCP is GOOD in severe acute gallstone pancreatitis

Don't have a reference--it's a Cochrane database thing. But ERCP with sphincterotomy in severe gallstone pancreatitis within 24-72 hours was associated with decreased complications but no change in mortality.

This is obviously a problem for us in that we don't HAVE rapid access to ERCPs. Sigh.

Probiotics are BAD in acute pancreatitis

http://www.thelancet.com/journals/lancet/article/PIIS014067360860207X/abstract

Basically increased mortality.

New Surviving Sepsis Campaign article

2008 guidelines
http://www.tinyurl.com/24wtft

Vigio Flo-trac can be used with anybody with an arterial line

We have a Vigio flo-trac machine in our ICU. It's meant to be put on an arterial line and will give two relevant numbers. The first is cardiac output, and the second is called stroke volume variation (SVV). SVV is a measure of the adequacy of fluid resuscitation. An SVV over 13 indicates hypovolemia.

The rub is that the manual says that it's only useful if the patient is ventilated without any spontaneous ventilations (in effect, control ventilation). I spoke with the Edwards rep today and he said that for SVV, that's true. The patient needs to be intubated without spontaneous ventilation.

But I learned today that the patient does not need to be intubated or can have spontaneous ventilation to measure cardiac output. So in those patients who are critically ill who you need to know the CO, you can use the flo-trac, regardless if the patient is intubated, has spontaneous ventilation (i.e. CPAP) or not.

Antibiotics must be given within two hours of presentation for septic shock

According to this study, mortality significantly increased if there was a delay in antibiotic administration
http://tinyurl.com/ytq7fy

Hydrocortisone is overrated in septic shock

Steroids in sepsis have come and gone and come, and now appears like it's going again. New article in NEJM.
http://content.nejm.org/cgi/content/short/358/2/111

Erythopoetin generally not indicated

From
http://content.nejm.org/cgi/content/full/357/10/965

No reductions in red cell transufsion
Increased Hgb concentration
Mortality not significantly lower
Thrombotic events significantly higher.

Daily chlorhexidine sponge baths may reduce infection

Daily chlorhexidine sponge baths can reduce infection, especially CRBSI.

http://archinte.ama-assn.org/cgi/content/abstract/166/3/306
http://archinte.ama-assn.org/cgi/content/abstract/167/19/2073

C. dificile tough to kill

C. dificile can't be killed by those water-free alcohol based solutions on the walls (assuming, of course, that they're not empty). You MUST wash your hands with soap and water. Also, everything in the patient's room--bed rails, ECG monitor, counter tops, all get contaminated also--and it can't be easily killed with the wipes. You have to use bleach. Ugh.

Thrombolytics for stroke

We went to a lecture on thrombolytics for stroke. Basically TPA needs to be given within 3 hours of onset of symptoms.

More uses for ultrasound

I got some more training on use of ultrasound for placement of IJ as well as SVC lines. I have a better understanding of the neck anatomy and how to use a two handed technique for real-time placement of lines.

Pramita and I also got training in diagnosis of pleural effusion and doing a FAST ultrasound for the diagnosis of abdominal fluid. Turns out I was using the ultrasound probe wrong. When we get back I can show everybody how to properly use it.

Think of shock before hypotension

Hypotension can be a relatively late manifestation of shock, and you need to think of it before. There are localized markers such as sublingual pCO2 which can be useful, but other parameters such as lactate and urine output should also be markers.

You can't diagnose shock if you don't think of it.

Pneumothorax diagnosed with ultrasound

I took a class today that showed how to diagnose pneumothorax with ultrasound. There are several findings that you see in normal individuals

1. Underneath the pleural reflection you see lung moving back and forth
2. By putting "power color flow" you can see movement
3. M mode has a "seashore" sign.
4. Normal people have "comet tails" off the pleural reflection.
   

All of these signs are absent with a pneumothorax. He showed studies that showed that you can pick up a tiny pneumothorax that you would otherwise not be able to see by ultrasound.

When I get back, I can show people the normal findings. I think with just a little training, we can diagnose people pretty easily and quickly at the bedside.