Selective Digestive Decontamination decreases MODS

About 10 years ago we were doing SDD on all our ventilated patients, but we stopped because of a lack of good evidence of efficacy and the fear of developing bacterial resistance. A new Critical Care Medicine systematic review shows that SDD decreases MODS but not mortality.

It's not enough to change our practice, but it's still interesting nonetheless how the same stuff keeps coming up.

Proton pump inhibitors increase the risk of clostridial infection

Patients who were treated with PPI while being treated for clostridial infection had a 42% increased risk of recurrence
http://archinte.ama-assn.org/cgi/content/full/170/9/772

High dose intravenous magnesium drip may help patients with aneurysmal SAH

There was a significant decrease in delayed ischemic infarction in the group that was treated with a high dose magnesium drip to keep the serum magnesium level between 2 and 2.5. There was no statistically significant difference in mortality or GCS, although there was a suggestion to that effect. The morbidity of giving magnesium was nil, and it may help.

Make sure the patient is comfortable at night and can sleep

What happens to you if you’re awoken every 10 minutes? That’s what happens to an ICU patient. If a patient is up all night, they’ll be tired the next day when the time comes to try to extubate. Also, make sure that at night they have adequate ventilator support. Don’t try to wean someone when they’re sleeping.

Always try to allow a patient to say "Good bye" and "I love you"

Often in critically ill patients we are concentrating on stabilizing a patient. If they’re in respiratory distress our priority is getting them intubated. But remember that there will be times that this may be the last time they ever get to speak to their loved ones. So if you can, make sure that you get their family in there so the patient can say “Good bye” and “I love you.”

Endotracheal tube removal requires ability to protect airway

Is a gag reflex present?

Can the patient cough?  (Consider using a "white card" test.  Disconnect the patient from the ventilator, place a white index card in front of the patient, and if they can hock a loogie onto the card, they have an adequate cough)

Are the patients secretions managable?

Can they protect the airway?  (They do NOT need to be completely alert to do this)

Treatment of Septic Shock is all a guideline

I went to a talk by one of the authors of the Surviving Sepsis Campaign. He went through all the points in the SSC. His major point is that the endpoints, such as CVP 8-12, SVO2 >70, MAP>65 are all starting points. You need to use some clinical judgment. For example, let’s say you have a young patient who has a good vascular system. You get the MAP to 60, and the patient starts to pee. Should you push the pressor just to get the MAP to 65? Not necessarily. On the other hand, if you have an elderly patient with atherosclerosis, you may need a higher MAP

More on Nasotracheal intubations

It's important to use Afrin or Neosynephrine in whatever nostril you pick.  You can soak some q-tips in an Afrin solution and then put them in  the nose.  This will vasoconstrict and help prevent bleeding.  Another trick is to get a small nasal trumpet, and coat it with lidocaine jelly.  Stick it in the nose, and leave it there.  Then get a bigger nasal trumpet and coat it with lidocaine jelly.  Give it time to take effect.  Use more Afrin.

Then use the Endotrol tube (see picture) if you have one.  Pull the little loopy thing and that pulls the tip anteriorily.

Nasotracheal intubation tip

If you're stuck doing a nasotracheal intubation, the major problem is getting the tube to go anterior so it'll intubate the larynx.  We do have the "Endotrol" tubes which have a loop that you can use to pull the tube anterior, but if you don't have that, here's a trick.

Use lots of lidocaine jelly into whichever nostril you pick.  Put the tube in.  When you get to the pharynx, inflate the cuff--that'll push the tube anterior.  Advance the tube, and then when you're in the larynx deflate the cuff and intubate past the cords.  Then inflate the cuff again.

Patients don't fight ventilators, ventilators fight patients.

If a patient is having trouble with a ventilator, the first responses of nurses and physicians is often to increase sedation which will make the doctors and nurses feel better, but will ultimately work against the patient.  Sedated patients can't be weaned off a ventilator and every day you're on a ventilator is another day you're on a ventilator.

The first response to a patient "bucking" a vent or "fighting" a vent, is to work with the ventilator settings.  Is the patient getting enough tidal volume?  Is the patient getting too much?  Does the patient need more flow?  If the patient is on volume control ventilation might he be better suited on pressure control (or vice versa)?  Does the PEEP need to be adjusted?

Try those first.  Increase sedation as a last resort.

Weaning

Everybody is fond of weaning people off the ventilator--slowly decreasing the respiratory rate or pressure support.  But does it make any difference?

No.

What makes a difference is DAILY spontaneous breathing trials, ideally paired with sedation vacations.  In fact, the lecturer I went to today suggested that weaning people off the ventilator might be counterproductive because it could tire people out for their spontaneous breathing trial.

So if you want to wean someone off of a ventilator, go ahead.  Just don't tire them out, and make sure that they have their spontaneous breathing trial every day. 

Auto-PEEP

Auto-PEEP.  We've all heard of autopeep.  Most times when people think about it, they're thinking that it's "intrinsic PEEP," and they know it's bad--and they'd be right.  But what causes it and what makes it happen?

Look at the image below

This is a flow vs time diagram.  Above the line is inspiration, and below the line is exhalation.  Note how the flow below the line does not come back to zero.  This means that the patient starts their inspiration before they have a chance to completely exhale.  Try it--it's not comfortable.

What does this mean for a patient on a ventilator?  Well it means that the ventilator will try to give a breath before the patient is done exhaling, and airway pressures will go up and tidal volumes may drop. 

What causes it?   Auto-PEEP is caused by one of three things.

1. High minute ventilation.  Minute ventilation is caused by high respiratory rate and/or high tidal volumes
2. Increased I:E ratio.  If the inspiratory time is too high, relative to the expiratory time, the patient will not have enough time to exhale (see the graph above)
3. Airway trapping, like in asthma or COPD

So how to treat it?
To treat it, you have to think of the three reasons above.

1. High minute ventilation.  This is the easiest to deal with.  Decrease the minute ventilation.  First start with decreasing the respiratory rate, and then the tidal volume.
2. Increased I:E ratio.  Again, decrease the respiratory rate, this will increase the inspiratory time.  You can also try increasing the flow in the ventilator cycle so more of the air goes to the patient at the beginning of the breath.  
3. Airway trapping.  Decreasing the respiratory rate will give time for the air to leave the lungs (think asthma).  Also, increasing the PEEP can help in COPD-related airway trapping.  The way this works, is if, say the auto-PEEP is 10 cm from airway trapping, and the patient has to initiate a breath, they need to pull at least -10 cm before the ventilator will trigger.  Adding PEEP to this will counteract this.  So, say, in this example there is a PEEP of 7, the patient will only need -3 cm to trigger the vent.

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!