Best of #FOAMed / #FOAMcc / #POCUS – August (1)

Here we go again! More trawling and mouse clicking for you all. Here are links and chats about all I see as the best of the bunch this week out there where access is free and open!

To come…

  1. First ED post from Dan Weston
  2. Part 3 of the Fluid series with Manu Malbrain
  3. New regional Anaesthesia portal
  4. More from the Two Jonnys soon!

Take care and happy reading!

JW

Blogs

 

Bring out the Remi!

This is a nice paper supporting the use of remi for our ITU patients. If anything, it gives us a nice reminder of the drugs MOA and pharmacology too. Will I start to use it on ITU…already am!

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Another one on flooding your patients!

A nice one from EMnerd here on observation of dynamic fluid responsiveness strategies in resuscitation. Is the Jury still out then?

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POCUS causes delays!! Surely not…!?

You know I am an absolute fan of all that is POCUS, but this makes for an interesting read. Seems application of POCUS during the rhythm check phase of resuscitation prolongs pulse check. My thoughts…how vital are pulse checks if your views are good enough. No myocardial movement…no pulse, surely. Also, as the rebel EM crew point out, it is very experience dependent. Read on…

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Also, take a look at this article by them on POCUS and ACLS.

IV paracetamol and hypotension….surely not!?

Pharmacy Joe discusses the fact that a multi centre cohort study (only 160 patients included), seemed to indicate that IV paracetamol causes hypotension.

A paper from 2013 also stipulates this on PICCO parameters here

It seems a mammoth leap to stop prescription and administration on the grounds of this and I must say, I have never witnessed this in fit patients. The studies to which PJ elucidates are all in critically unwell ITU patients who are prone to hypotension anyway…I personally would take this with a massive pinch of salt. What’s your opinion?

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When should we go down the airway during in hospital cardiac arrest?

Have a listen to this one…seems controversial, but there is plenty out there to say we may make things worse by diving down the airway expediently! Does the same go for POCUS assessment intra-arrest?? we mentioned this earlier!

  1. Intra-arrest intubation does not appear to improve outcomes. For most patients, support with BVM, or possibly an LMA, is adequate.

  2. Instead of securing an advanced airway, focus on the two things that clearly make a difference in outcomes – good compressions and defibirillation

  3. Good compressions should be fast and hard and you must minimize interruptions in compressions to minimize interruptions in perfusion

  4. Don’t forget that a great resuscitation requires great preparation. Take whatever time you have to discuss with your team and assign roles.

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Are you a bright spark, or just a dim light in the fight to stop AKI!?

Celia Bradford and the crew at TBL take us through this paper looking at whether commencing furosemide infusions will help to halt AKI.

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Here’s the original paper

Papers & Reviews

It ain’t what you do it’s the way that you do it…that’s what get’s results! (Gratuitous Bananarama link!)

So we all fluid challenge, we’ve all read millions of publications on what, when, why and now…how! The speed and timing of fluid challenges is very important evidently to the PR (proportion of responders)….forget volume or type for now. As we have seen, delays in IV fluid challenges in sepsis care bundles didn’t have an outcome impact, but if you are too slow with your challenges…they may be pointless! Do have a look!

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If your elderly…do more running and you may fair better in sepsis!!

Apparently, eNOS is good for your lungs if you have sepsis…you fair better. It seems if we push elderly mice on wheels to exercise a bit more, we induce pulmonary eNOS and they fair better in sepsis. I somehow can’t see a RCT being conducted where we get the elderly to perform interval training! At least not one an ethics committee near us will approve. But, scope for thought!

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Don’t drive too hard!

Low Vt, higher frequency and permissive ‘stuff’; are all ways we know of to optimise outcomes in ARDS patients on the ventilator. But we haven’t paid much attention to driving pressures! Perhaps we should.

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Intervene with the airway in the ‘field’, and you may be increasing mortality?

It seems that mortality is higher if you are intubated out of hospital…seems obvious to me, as surely to warrant that tube in the ‘sticks’, you are in a pretty bad way from the outset. Or is it that there are just more personnel and skilled practitioners in abundance in hospital / it’s calmer and theres more kit etc etc. Not belittling the amazing work the Pre-hospital care guys do at all here by the way.

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We are all just dying!!

They call it autophagy…the process of cell death that is. It is apparent that there are bad parts of our cells affected by the inflammatory process during sepsis that need to be cleared out / eradicated. Too much glucose in our systems (early feeding), as well as various other ITU interventions we commence may actually be delaying or inhibiting this ‘cleanup’.

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See this editorial on the subject here

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It’s all about 2 hits!

A lovely article here about the 2 hit model of Hypoxic brain injury (HIBI). Have a read…because it’s often the point of ROSC onwards where the real damage occurs!

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Decreased cerebral oxygen delivery manifests as reduced neuronal aerobic metabolism, causing reduced cellular adenosine triphosphate (ATP) production. Intracellular calcium accumulation leads to mitochondrial toxicity and further reduced ATP production. Inability to sustain cellular respiration results in cell death and apoptosis. Additionally, in the microvasculature, endothelial dysfunction leads to a porous blood-brain barrier, formation of cerebral edema, formation of microthrombi and limitation of cerebral blood flow with exacerbation of cellular ischemia. AQP 4 Aquaporin-4, RBC Red blood cells, WBC White blood cells

We need to be less liberal then?

Perhaps in cancer patients we do anyway. This editorial discusses the fact there is little evidence to back liberal triggers of >9 for cancer patients.

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Check out my muscles!

So in sepsis…we know the whole problem with circulatory shock often boils down to microcirculatory dysfunction. But what if we focus in on the muscle itself as a marker of impaired oxygenation?

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The thing about ARF is….

So we know that acute respiratory failure leads to mortality, but it’s often due to pre-existing pathology which ha,impeded the patients’ recovery potential in the first place, even before the inciting event. This paper looks at the fact that ARF alone leads to mortality.

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Duff them up early on….never mind later!

So, we know that there is a lot published out there regarding the best time to start physical rehab on our patients. But most of it is with regard to post-ITU care. This paper looks at the impact of intensive physical therapy whilst sick on the unit. Did it make one iota of a difference though?

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We all expect to neuroprotect!

A great piece on what we should all be doing regarding neuroprotection for our patients who sit on the knife edge after TBI. Basically….look after them and treat each parameter as if their life depends on it…because it pretty much does! Oh…and admit them to a good near-ITU!

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What do you know about ECMO?

A really nice review article here regarding this often life saving modality. Tells us about VV Vs VA and some nice bits of physiology / management thrown in too.

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From ACURASYS to this!

A rather nice paper demonstrating that it is eminently feasible for our nurses to lead TOF guided NMB usage. We do not use cis-atracurium on our unit, but i’m starting to think maybe we should. The article also makes reference to the original ACURASYS study and outcome in ARDS. Less is more and NMB’s often allow us tom do exactly that…less damage!

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So…is the good old RCT not all it’s cracked up to be??!

Click below to see what the NEJM are saying about what they would class as their ‘bread and butter’! Interesting thoughts on RCT’s and their flaws!

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Don’t interrupt their meals!!

Heres a nice survey demonstrating the reasons why we interrupt steady rate EN amongst our ITU patients. Lots of airway interventions etc etc. I for one know a lot of ours are due to ‘expected extubation’, and ‘going to theatre’ to name a few. We should exercise care with theses it might adversely affect outcome.

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Procalcitonin…are you going to bite the expense bullet and insist your lab do it?

We don’t in our trust, but many are now monitoring this as a way to rationalise, monitor or stop antimicrobial therapy. Is it worth it though. Seems to me it is an added expense….but whats the evidence for benefit?

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Phiddipides collapsed – the more you read about exercise…the more you feel the couch beckons!

Exercise is good for you. But everything in moderation! I always wonder how it is elite athletes can suddenly collapse and hit the ground, with a cardiac cause. But the more we discover, the more we need to think about the fact these aren’t as rare as we think!

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See our article on SADS here too.

Infographics

Tramadol…not as aspfe as we think!

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Remember your leads!

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A nice reminder of those anaemias!

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We love the mnemonics!

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POCUS

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One to read…avoid those easily made POCUS errors!

A really worthwhile article here on common mistakes we make when performing POCUS…where Imaging can be imagining!

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Seems not all are happy enough..

Here isa survey demonstrating there is still not enough faith in EM POCUS amongst allied specialties. We need to spread the word, train and train more to get this higher up in the ‘trust’ stakes.

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