ICU Rounds: Recent Episodes
Jeffrey S. Guy, MD, FACS
A podcast dedicated to the teaching of critical care. The focus audience is physicians, residents, medical students, nurses, therapists, and paramedics. These are topics that arise while on teaching rounds in the Burn ICU at Vanderbilt Medical Center. A broad scope of critical care and prehospital topics are presented as well as recent journal articles and medical news.
Throughout the pandemic, there has been considerable discussion about the possibility of running our of ventilators. One potential solution that was brought forward was putting multiple patients on a single ventilator. This is a lot harder than merely attaching a plastic splitter on a ventilator. In this episode, we explain safety and physiological considerations. Also, we briefly discuss specific patient care issues and ventilator settings if your circumstance requires you to adopt this approach.
This week we have a brief conversation about prone mechanical ventilation for ARDS. Does it provide a benefit? When should we use it, and why does it work? I hope this is helpful as prone ventilation has been reported to provide benefit to patients with ARDS secondary to Coronavirus (COVID-19) infection.
Today we discuss the approach to oxygenating and mechanically ventilating a patient suffering from ARDS. We will cover elements relevant and essential in the management of COVID patients and all others with ARDS.
I'm back. I plan on providing you with some useful information when caring for patients infected with COVID-19 (Coronavirus). In this episode, I will provide you an overview of the current evidence and best practices with some explanation and commentary from the recent Surviving Sepsis COVID-19 guidance.
A physiological explanation why random cortisol levels are NOT helpful in evaluating adrenal function
In this episode we talk about the results of the CRASH-2 trial published in Lancet. This trial showed that the EARLY use of Tranexamic acid may improve survivial, but delayed use may be associated with an increased mortality.
If you are using ultrasound to evaluate IVC diamter in children, what is considered a normal IVC diameter? You can determine the IVC/Ao ratio or correct the IVC diamter based on the child's body surface area.
This is a condition that mimics acute coronary syndrome (ACS) that may be caused by acute emotional or physical stress. Patient's may appear to have profound cardiogenic shock, but these patients have a very high survivial rate with little more than supportive care.
This episode will discuss the physiology behind various CO output monitors such as pulmonary artery catheters, PICCO, pulse wave form analysis, and LiDCO.
Now these are the types of lactic acidosis that most people are not familiar. They can be caused by medications, underlying disease, or inborn errors of metabolism.
This podcast is a description of how lactate is produced and metabolized. I will discuss the role of lactate in the diagnosis and management of shock. This podcast will focus on Type A lactic acidosis.
A brief description on what to consider when confronted with a patient with an air leak from the ET tube or a patient that self-extubates.
Smoke Inhalation injuries can be deadly. This episode explains why smoke can be so deadly, and how to care for those patients with suspected smoke inhalation injuries.
Propofol Related Infusion Syndrome is a potentially fatal complication of propofol. If you use this common ICU drug you need this information.
Wedge or PAOP is perhaps the most quoted and poorly understood variable generated by a Swan-Ganz.
The most helpful number for me on a Swan is the SvO2. This is a brief description of how I use this variable in evaluating critically ill and injured patients.
Therapeutic hypothermia after cardiac arrest is part of ACLS and is used by several EMS agencies around the US. Despite good data and improved patient outcomes, many providers fail to used this modality. This podcast will focus on a presentation of the data, methods of cooling, and potential complications.
This is the third in the series on severe pancreatitis and necrotizing pancreatitis. This episode reviews the indications for surgery, morbidity and mortality of surgery, and what are the surgical options.
A brief discussion of the considerations of ICU care of the patient with severe pancreatitis, fluid resuscitation, respiratory, renal, and nutrition.
All the recent emphasis on venous catheter infections has been on central lines. Those peripheral IVs are also dangerous.
Acute Colonic Pseudoobstruction (ACPO) is commonly called Ogilvies Syndrome. ACPO presents massive dilation in critically ill patients, and might result in invasive procedures to avoid ischemia or perforation of the colon.
A brief summary of what are hemoglobin based oxygen carriers (HBOC) and where are they in development.
Discussion of what is the difference between a CVC infection and a catheter-related blood stream infection. They are treated differently so it is important to know the difference.
A discussion of the potential problems encountered while inserting central venous catheters.
This episode discusses the effects and risks of anesthesia on patients with pulmonary disease as well as the effects of anesthesia on pulmonary physiology.
Ingestion of caustic materials can be fatal and difficult to evaluate. These patients are often referred to our burn center.
This is an interview that I did on www.medtalknetwork.com with Dr. Brian Cotton. Dr. Cotton recently left Vanderbilt to take a new position at UT Houston. He is an excellent teacher and his opinions on fluids resuscitation are cutting edge.
Hyponatremia or a low serum sodium is a common electrolyte problem that is dangerous if ignored or treated improperly.
Following the recent crash of the US Airways in the Hudson River, it is an appropriate time to discuss the clinical manifestations and treatment of hypothermia.
Peak inspiratory pressure (PIP) the center of a great deal of discussion of ventilator management. Knowing the factors that increase or decrease PIP are important to those managing critically ill patient. This podcast is steeped in physiology and perhaps more difficult than my typical podcasts. PIP= [Tv/ (Compliance Lung & Thorax)] + (Resistance of airway + flow )
Hyperkalemia is a very common and potentially dangerous electrolyte disorder that commonly occurs in ICU patients.
A brief discussion regarding some of the commonly used values obtained from a pulmonary artery catheter.
Therapeutic Hypothermia following cardiac arrest has been demonstrated to improve outcomes. Starting Jan 1, 2009 Ney York City EMS will dorect patients to those hospitals able to delivery such care.
The US government last week released a report that the threat of a nuclear device used in an act of terrorism is high in the next couple of years. In this episode we discuss the some concepts of the medical care required to those exposed to radiation as well as blast injuries. I hope this is information that none of you will ever need.
This episode explores what is needed to make surgery safer for the patient with cardiovascular disease.
Tight glucose control has been widely introduced into critical care. This meta-analysis, recently published in JAMA, critically evaluates the effects of these trials in reduction of sepsis as well as mortality. The results might surprise you.
This is the second installment of this topic. In this episode we talk about the role of angioplasty and role of various medications in the treatment of the patient having an MI.
It is Sunday 8.31.08 and for hurricane Gustav is bearing down on the city of New Orleans. This podcast will discuss the basic elements of disaster planning and management. (This was reposted due to some technical problems with the server.)
Crush syndrome is a common cause of death following earth quakes, mine and building collapses. Traumatic rhabdomyolysis may also be seen following electrical injury or severe trauma. (This is a reposting due to some previous technical problems with the server.)
Myocardial Infaction (Part 1): This episode will discuss the diagnosis of MI, STEMI, and non-STEMI. We then discuss the indications and types of thrombolytic agents.
The management of pain is a key element of the care of all patients-- ICU or not. Often providers have little understanding of the concepts and medications of pain management. This episode serves as an introduction.
A potentiallylife-threatening electrolyte problem that commonly finds its way into the ICU as well as on exams.
Getting patients comfortable on the ventilator is not an easy task. This podcasts focuses on methods to make patients synchronize with the ventilator as well as a discussion of spontaneous breathing and awake trials
In regards to ventilator care, all the focus has been on low tidal volume and level of peak inspiratory pressure. What level of PEEP shoud we be using to avoid shear trauma and ventilatory induced lung injury.
A limb-threatening complication that might be overlooked by the inexperienced provider.
We continue our discussion of the Surviving Sepsis Campaign (SSC). This includes fluids types, steroids, rhAPC (Xigris), and blood sugar control.
The Surviving Sepsis Campaign (SSC) is concensus document that attempts to provide the best evidence to assist in the care of the septic patient. All providers who provide care to the septic patient should be aware of the contents of the SSC.
In this week's Journal of the American Medical Association a meta-analysis was published that concluded that use of hemoglobin based blood substitutes result in an increased morbidity and mortality. Included in the same journal is an editorial critical of the method the research has been regulated by the US FDA.
There is a large emphasis on intensive control of blood glucose in the ICU, but how accurate are the monitors we use to follow glucose? This episode reviews someof the limitations of deploying an instrument designed for control of outpatient diabetes management to tight control of blood glucose in the ICU.
Clostridium difficile colitis is a problematic complication of antibiotic theraoy in hospitalized and critically ill patients. It is increasing in frequency and can be lethal.
Fluid resuscitation done poorly can result in significant complications to the patient. This episode will present some of the newer considerations in fluid resuscitation in traumatic shock.
Patients are often admitted to the ICU with an entire list of home medications. In this episode I talk about the implications and dangers of polypharmacy.
Prolonged QT is the most common reason why medications are restricted or removed from the US market. This episode will explain what it is and why you should look for it in your ICU patients.
Atrial fibrillation is a common problem in ICU patients, but it is a problem with many potential causes, and not always a well defined treatment.
Pediatric burns: all burns are serious, both big and small. This episode reviews the objectives of burn care to result in the best functional outcome. Also, burn is a very common method of child abuse and we detail how these children are injured and what to look for to identify possible abuse.
In this episode we discuss that ICU care of the patient with sepsis. This includes an introduction to various vasopressors.
Sepsis is a common cause of death in the intensive care unit. In this episode I present some of the statistics on septic deaths, introduce the definitions, and present the basic science. Part 2 will cover fluid and drug therapy for septic shock.
Large numbers of patients in ICUs are on heparin and what is this complication of heparin induced thrombocytopenia?
The onset of cold weather will bring with it an increase in structure fires. The leading cause of deaths in fires is complications from the inhalation of smoke-- not burns. Learn why smoke is so deadly as well as what are the appropriate methods to treat smoke related asphyxiation.
Blood products: pRBCs, fresh frozen plasma, platelets, cryoprecipitate when and how should we use it? What are the risks? You may order them like IV fluids but do you really know how these potentially deadly products are to be used.
A great deal is being presented and published on control of blood sugar in the ICU as well as the postoperative period. How much control is enough and what is the data?
Why do we choose the antibiotics that we do? How long do we continue the course of therapy? Should we use some antibiotics together? These topics are covered in the episode.
Earthquakes are horrible natural events causing loss of lives in the thousands. Following earthquakes, building collapses, and cave-ins, large number of victims will suffer from renal failure and death following crush syndrome.
An introduction of the biology of thermal injuries and the initial care of the patient with thermal injuries in critical condition.
A common problem in the ill or injured patient is a metabolic acidosis. In this episode we will review the common etiology of a metabolic acidosis as well as some lesser known causes.
Bomb and blast injuries: In the past blast injuries were limited to the battlefield of a rare industrial accident. The events of the past week are a reminder that civilian population centers are targets for bombing attacks. Most civilian providers has no to limited knowledge or experience treating patients with such injuries. This episode is dediacated to a discussion of some of the unique properties and injuries associated with blast injuries. In the event of a terrorist attack, like those attempted in London this past week, the injuries will be in the hundreds.
Early surgical excision is likely to be the most significant individual variable to imporve the outcome of a patient (adult or child) with a critical burn. Nevertheless, many nonburn physicians still want to apply to 1970 treatment paradigms to this population of injured patients. This episode will hopefull replace these falsehoods with fact supported in the literature.
Not feeding an injured or ill patient is not that same as a normal individual who is fasting. A pound of weight loss in the stress patient is significantly different than a pound of weight loss in someone on a diet. A basic understanding of stress metabolism is needed prior to a discussion of nutrition.
When should a patient receive a transfuse of blood? What is an acceptable hemoglobin concentration in an ICU patient and should we use EPO? Summer is a time when the blood banks often have a single day's worth of blood. Perhaps with more conservative transfusion practices we can avoid or certainly help with some of the blood shortages. Everyone wants to put patients on Epo, but does it increase the hemoglobin concentration enough to off set its high cost?
Excessive fluid resuscitations lead to horrible complications such as abdominal compartment syndrome. This article takes a critical look and challanges many of our practices in fluid resuscitation of burn patients.
Renal replacement therapy (RRT) is rather a confusing topic. What do all those initials mean and why use one therapy over another? This podcast will explain the difference between intermittent and continous. What are the various forms of continuous and how do they differ? What are the concepts of ultrafiltration, diffusion, and convection? These questions will be answered in this introduction to renal replacement.
Intraosseous vascular access was was developed for use in adult trauma patients over 80 years ago. Only recently has this technique regained popularity for rapid and safe access to the vascular space in patients in extremis.
Don't wean people from their ventilators-- liberate them!! When are people ready to come off the ventilator? What are weaning parameters? How does one do a spontaneous weaning trial? What is the role of noninvasive ventilation (NIV)?
Acute renal failure is a dreaded complication in the ICU. This podcast will review the various types of acute renal failure, the etiology, as well as acute management.
Airway pressure release ventilation (APRV) is not a new mode of mechanical ventilation, but it seems to be gaining a great deal of popularity lately. Many people find this mode very complicated and thick that it is reserved only for the very ill. Neither one of these assumptions are corrrect. This mode is very easy to learn and use. Furthermore, this mode is very physiological and tolerated by all types of patients.
Virtually all patients on ventilators are on PEEP. PEEP has several interactions with various organ systems and some can result in profound complications. An understanding of PEEP and auto-PEEP are required before we can understand modes of ventilation like APRV (Bi-Vent)
All surgical residents know that glutamine is the amino acid known as the fuel for the gut. But what is all the fuss about? The episode will look at the data on glutamine. Does glutamine improve outcomes, and if so and in who? How much should we use and what are the hazards? Enteral versus parenteral. www.burndoc.com
Lightning injuries are rare, but when you do treat a patient they can have facinating presentations. This lecture follows a patient we treated at Vanderbilt. The patient present to a local ED with stroke like symptoms following the lightning strike. Initially, physicians were confused by the presentation, but in this lecture you will learn that his presentation was near textbook. www.burndoc.com
A discussion of the various types of ventilators with a focus on the various ventilator modes and types of ventilator cycles. Also presented is the topic of pressure support ventilation (PSV)
What is the role of giving an adult steroids to prevent stridor or reintubation following extubation. This epidose looks at the data.