January 2, 2020

Background: Traditionally, vasopressors have been given through central venous catheters (CVCs) in the critically ill.However, the time it takes to place a CVC is time a patient could potentially remain hypotensive. Early initiation of vasopressors may be associated with reduced mortality by increasing end-organ perfusion. Therefore, there has been a growing trend to use vasopressors through peripheral IVs (PIVs).  Running pressors through a peripheral IV has a couple of important benefits including faster time to pressor initiation and no need for invasive procedures (i.e. CVC). There islittle evidence to support the safety of this practice other than one systematic review which included case reports and small case series. Now we have two more papers that evaluate this very question…are peripheral pressors safe?

December 9, 2019

You are working at a Level 1 Trauma Center; a 35-year-old female arrives via EMS from the scene of a motor vehicle accident. She was an unrestrained passenger, ejected 50 feet. She was hypotensive and hypoxic on scene with concern for head injury with a GCS of 7. She is clearly in shock on arrival with weak pulses, clammy skin, and a BP of 80/50mmHg, HR 140, sats 85%.  She is intubated, a chest tube is placed on the left (with improvement in O2 sats to 95%), and a pelvic binder is placed for suspected pelvic fracture. eFast demonstrates free fluid in the pelvis. Massive Transfusion Protocol (MTP) has been activated appropriately, and despite rapid delivery of 4 units Packed Red Blood Cells (PRBCs), 2 units of Fresh Frozen Plasma (FFP) and 1 pack of Platelets, she remains hypotensive, with presumed hemorrhagic shock. The patient is destined for the OR, but you ask yourself, in traumatic hemorrhagic shock, is there a role for vasoactive agents?

November 21, 2019

Background: The IOTA trial, was a systematic review and meta-analysis of 25 RCTs enrolling 16,000 patients with sepsis, critical illness, stroke, trauma, MI, cardiac arrest, and/or emergency surgery. In this review it was found that liberal use of O2 resulted in a higher in-hospital and 30d mortality with NNH of 143 and 125 respectively compared to conservative O2 therapy.  Since supplemental oxygen is commonly used in the critically ill, it is important to establish parameters for oxygen supplementation, especially in patients undergoing mechanical ventilation where there is no good data regarding strategies for oxygen administration.

November 18, 2019

Background Information: Therapeutic hypothermia is the use of targeted temperature management to reduce neurologic sequelae resulting from the severe ischemia-reperfusion injury that occurs during cardiac arrest primarily from shockable rhythms.1 Although a mainstay treatment in the Advanced Cardiac Life Support (ACLS) guidelines, its use has been widely debated as beneficial in improving neurologic outcomes in post-cardiac arrest patients with non-shockable rhythms.2-7 Recent studies have also questioned the exact temperature at which patients should be cooled.8 The authors of this study sought to assess whether moderate therapeutic hypothermia, compared with targeted normothermia would improve neurologic outcomes in post-cardiac arrest patients who had a non-shockable rhythm.

November 11, 2019

Background: Peri-intubation cardiovascular collapse (shock, cardiac arrest or death) is an all too common complication of airway management in critically ill patients seen in up to 25% of patients (Jaber 2010, Umobong 2018). The causes for collapse are numerous and include acidosis, pulmonary hypertension, vasodilation, iatrogenic (medications used in intubation) and hypovolemia. Administration of fluids may help to mitigate the hemodynamic effects of intubation, particularly if decreased venous return is an issue, but this approach is untested.