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?