The 2017 Social Media and Critical Care (SMACC) conference was held in Berlin, Germany. The conference was very inspiring and permitted me the opportunity to get away and explore the beauty and culture of Germany. The highlights will definitely not capture all the key points of the entire conference nor the atmosphere and comradery that that this conference provided…
The future is to train all healthcare providers together, not in silos, with the goal to improve outcomes – Daniel Cabrera
- Woman Trial – Post Partum hemorrhage treatment with Tranexamic acid, found no difference in mortality – question if effective
- Sepsis is typically clinically obvious based on qSOFA data
o Patient is hypotensive and altered
o Or hypotensive and tachypneic
o Or tachypneic and altered
- Time is Sepsis-NY Sepsis Registry every hour increases risk of death by an OR:1.04
o Removing septic shock, difference is lost
o Focus on treating the patient
- RCT’s typically underestimate harm – use 10mg IV Ketorolac vs previous 30mg dose, in adults
- Start Norepinephrine early (DBP <40 mmHg) improves preload & increases cardiac output in sepsis & will subsequently limit the need for more fluid
o Pressors can always be titrated to off, if no longer clinically indicated
- Cognitive dissonance – Pressor angst: time in delay increases mortality.
- Don’t worry about central access. You may safely start vasopressors early
- Ultrasound is highly sensitive for ruling in the diagnosis of Small Bowel Obstruction
o Look for dilated loops and peristalsis
- You may not need CT if recurrent SBO with known etiology (malignancy)
- Limitations: Ultrasound is not sensitive to delineate Ileus vs SBO, It is unable to determine etiology or determine transition point
- Sickle cell disease is a terminal condition
o Life expectancy for these patients is only into the mid-40’s
- Give early IV analgesia
- In the management of acute sickle crisis, consider current opioid regimen & dosing frequency
o Know how to convert different types of narcotics so you don’t under or overdose your patient
David Carr on endocarditis:
- Valve replacement (mechanical or animal) patient’s risk of endocarditis increases 1% per year.
- Up to 95% of endocarditis patients have fever
- Up to 90% of endocarditis patients have a murmur
- Coagulase negative Staph aureus is the 2nd leading cause of endocarditis (25%) in valve replacement patients
- Get 3 culture sets, from 3 different locations, one hour apart
- Empiric treatment for endocarditis = Vancomycin + Rocephin
Marcelo Amato Driving pressure matters:
- Size of tidal volume is not important, it is the pressure generated that leads to lung injury
- Targeting tidal volume is a “one-size-fits-all” approach. It is not right for every patient
- Driving pressure = Plateau pressure – PEEP
o We should be focusing on driving pressure
- Decrease in driving pressure is directly proportional to increase in survival in ARDS
- Although a risk of ketamine abuse is possible, ketamine versus opioid, opioid abuse is far more of a concern
- Ketamine is not for mild to moderate agitation but to be used for severe agitation/excited delirium
- 6-8% of strokes develop ICH. Is the bleed due to fibrinolytic therapy is unknown…
- Patients with greatest drop in fibrinogen have highest risk of bleeding
- The treatment of choice to control bleeding after giving fibrinolytic therapy, is cryoprecipitate
- Other choices but of limited value, include platelets, fresh frozen plasma (not enough factors), and prothrombin complex concentrates
Nikki Stamp, cardiac surgeon on Post-Operative Cardiac Patients
- Causes of the need for resuscitation in these patients include ischemia, mechanical issues, arrhythmias, and unknown causes
- Loss of pacing capture can mean the heart is distending, which is a bad thing
- If this patient arrests, get on the rhythm early because they have a propensity for VT/VF. Deliver 3 sequential shocks (not part of ACLS) and pace early
- LVAD arrest: Check the flow. CPR may not be indicated & consider contacting specialist early for further guidance
o Manual CPR can be done on a patient with a left ventricular assist device, but not mechanical CPR
- Non-Invasive Ventilation (NIV) should be started/considered on every patient in severe respiratory distress.
- SCAPE should be treated with a 1-2 mg bolus of IV Nitroglycerin (mg, not mcg) followed by a drip starting at 100-200 mcg/min. Alternatively; the drip can be started at 400-500 mcg/min
- Perintubation hypotension is associated with cardiac arrest. Strayer recommended the dirty epinephrine drip, while Weingart touted push dose epinephrine
o Strayer “Push-dose pressors are dumb.” Consider the dirty epi drip…
- “Dirty” Epi Drip: 1Amp of Cardiac Epi + 1L NS = 1mcg/mL
Michele Domico Pearls on pediatric cardiac disease
- If you don’t think about it, you will never see it
- A child with unexplained fatigue is not normal
- Beware of “quiet tachypnea.” Increased respiratory rate without increased work of breathing can be a sign of decreased systemic perfusion.
- Beware of cognitive bias. You provide a new set of eyes when you see the patient.
- If a patient has multiple visits to doctors, but is not getting better, consider cardiac etiologies
- BNP measures myocardial stress. Troponin measures myocardial death
o Secondary, BNP may be superior to Troponin when suspecting cardiac disease in a child.
- There are different indications to treat elevated ICP with different levels of risk
- There is no set target for cerebral perfusion pressure
- Use a graded threshold to escalate treatments on an individual basis while detecting and mitigating harm
- Hyperventilation to reduce ICP, this is only a temporizing measure to more definitive treatment
Daniel Cabrera Acute Anaphylaxis
- Only 50% of anaphylaxis patients receive epinephrine
- Only 40% of patients are discharged with an EpiPen
- Only 20% of patients receive appropriate follow up
- Don’t wait for hypotension or respiratory failure to give epinephrine
- 50% of patients will require a 2nd dose of epinephrine. This dose should also be given IM
- ~2% of patients will develop a clinically significant biphasic reaction
- H2 blockers may be considered, but have only been found to decrease rash and pruritic symptoms
- Steroids and antihistamines should be used, however, do not impact mortality
- Consider aggressive volume resuscitation
- Do not forget to remove the offending agent
- Options for refractory anaphylaxis include: epinephrine drip, glucagon, norepinephrine, vasopressin, methylene blue, and ECMO
Resuscitation for the Resuscitationist – Scott Weingart was the chair for this panel
- Vasoplegia is defined as refractory low diastolic blood pressure. Treat the etiology.
- When the protocol provides no solution, do what you can, whether there is evidence or not…
- For refractory VF, consider dual sequential defibrillation.
o If you don’t have two machines and multiple shocks have not worked, consider moving the pads to a different location.
o In attempts to change vector of defibrillation
- Patients in refractory VF can be taken to the cath lab with mechanical CPR in progress
- ECMO in refractory VF is about preserving the brain
- If the cath lab won’t take the patient in refractory VF, the panel felt that thrombolysis was indicated
- In the ED, EtCO2 and the placement of a femoral arterial line were recommended
- Personalized epinephrine doses were discussed.
o Certain patients may require more than 1 mg, while others may need less than 1 mg. To make this decision, an arterial line needs to be in place
- There is some evidence for the use of ketamine, and possibly fentanyl, during CPR induced consciousness.
- The use of mechanical CPR brings calm to the scene and allows cognitive off loading
- It is rare to survive out of hospital cardiac arrest after 40 minutes of high quality CPR. Use ultrasound to assist in making the decision to stop resuscitation
- The panel mostly agreed that “Stay and Play” is an option, unless there is a reason to move (i.e. cath lab, ECMO)
- There is some preliminary data on the Heads Up Resuscitation. This is mechanical CPR being performed with the head of the bed elevated to 45 degrees
o The thought behind this method is that it provides increased venous drainage from the brain
- Should EMS bypass small hospitals to take arrest patients to cardiac arrest centers? ILCOR says yes, but the panel states that it depends on the location and hospital capacity
Ashley Liebig – 5 ways that Teams rule the resus room
- Ergonomics—it is not just for the carts and cabinets. Placing people in the optimum place makes things easier
- Nurse-led codes—Allow nurses to run the code (Nurses are trained in ACLS). This provides a cognitive offload for the doctor to gather more history and determine the cause that can be treated.
- Assigned roles—Having a single role frees people up to perform that role to the best of their ability without having to worry about what else they need to do
- Communication—Free dialogue and closed loop communication insures completion of tasks
- Briefing—breaking down what went well and what can be improved following the resuscitation offers opportunities for improvement.
- We all make mistakes. Our errors are at times catastrophic. Not talking about our fears and anxieties can lead to anxiety, depression, burnout, and ultimately suicide
- Self-compassion is extending compassion to self in instances of perceived inadequacy, failure, or general suffering.
- Self-compassion is a resuscitation skill that needs to be practiced
- Have a failure friend/group = a go to person/group you can talk to when you make a mistake
- Your emotional/psychological state can influence your performance during critical events
- Calling for help is not a sign of weakness.
o Knowing when to ask for help is a learned skill
- Focus on process over outcome to achieve best results, avoiding wide variance in practice
- Develop habits— Practicing a response to a scenario and standardizing a team approach provides a shared mental model and quality control.
- Emergence—bringing individual behavior into alignment; with good team setup and task allocation, teams can solve much more complex tasks than any individual
- Organize teams not by specialty but by a specific goal (i.e. chest tube team, airway team etc…)
- Limit variables—you cannot constrain chaos, but you can minimize the paths available. Remove equipment that is unnecessary.
- Failure isn’t an option” not because you’re not allowed to fail. It’s because it’s not optional; it’s inevitable. So we need to fail in the best ways possible
- Learn from your failures
o “Forgiveness is the final form of love” – Beyonce. (Also Reinhold Niebuhr)
- Graceful failure = The ability of a system to maintain most, if not all, of its function when part of it fails.
Rinaldo Bellomo The problem with Physiology
- The biggest threat to understanding, is the illusion of knowledge
o This is coming from a well published academic
o The biggest danger of medicine isn’t “NOT KNOWING,” it’s “THINKING” you know.”
- Doctors suffer from physiologic seduction.
o We always try to make everything normal, but at times this may actually cause more harm to patients
- In the moments where we should pause and question our judgment, we often ignore this impulse
- You need a discrete dividing point/line to move on from a bad experience
- Get curious—become attuned to your colleagues’ frame and perspective
o Consider it is your best friend in the world whom committed the atrocity you are raging about. Ask yourself, why would they have done this? Get away from judgment
- Instead of saying “I wouldn’t do what they did” ask “Why did it make sense at the time?”
- Don’t be afraid to challenge someone when things are wrong…
- “We” need people prepared to ask questions and then to listen
- Confident humility—confident you have the skills, but humble enough to know you could be wrong
- We are often given the error prone situation in medicine and then are expected to be perfect
*There is a massive gap in healthcare between front line workers and the leader’s perception of their work*
MJ Slabbert Insights of decision-making
- Decisions you make determine the actions you take
- “Without data you’re just another person with an opinion.” -W. Edwards Deming
- Protocols are the safety net for the novice, but can be shackles in difficult situations.
o Experience allows you to go outside the algorithm to direct care of the patient.
- As clinicians we overestimate benefit of tests/interventions and underestimate harm, > 30% of the time
- Rule 20: Testing low risk patients, increases false positives (I.e. the unnecessary urinalysis in an asymptomatic patient)
- Tests won’t always decrease uncertainty. They will ALWAYS increase complexity. Less isn’t more, its better.
Alex Psirides “Everything” at the end of life
- Beware of optimism bias.
o We often overestimate the benefits of what we can do, but underestimate the potential harms
- Give your patients the death you would want
- Remember to provide maximal care to your patients, whether you resuscitate or choose not
Medicine is humbling & demands frequent self-reflection as we strive to improve our clinical practice. Ask yourself, are you a good physician? Can you be better?
– Hijinio C.