Questions related to Intensive Care Medicine
How do we calculate the pediatric SOFA score if a child is on only milrinone? As per BP cut-offs or equivalent to dobutamine? Has there been any update in the score to account for milrinone/vasopressin?
For the acute resuscitation of adults with COVID-19 and shock, the current recommendations are suggesting, using buffered/balanced crystalloids over unbalanced crystalloids.
The purpose of this discussion is address the need for guidance on fluid resuscitation among severe COVID-19 patients and shock management in resource-limited settings
The study of ventilation during adult cardiac arrest remains challenging due to the unexpected nature of sudden cardiac arrest and the limited resources/personnel on site. This is especially true for interventions that influence outcomes when applied early in the cardiac arrest phase. Therefore, animal models (i.e. pigs, dogs), manikins, human cadavers and computer models have been used to study intra-arrest ventilation. Also, some data has been made available from registries and clinical studies in humans.
While the possible answers to my question heavily depend on the respective research question, personal perspectives on the well known experimental models, as well as lesser known models for this niche of cardiac arrest research, would be very much appreciated.
Please note, that I do not to intend to discuss airway management during cardiac arrest. Although, I'm aware that both intra-arrest ventilation and airway management are closely connected.
Participating in an ICU based study looking at intubated and ventilated COVID patients first out of bed rehabilitation session with Physiotherapists and trying to determine if it is safe by using group analysis to analyse physiological parameters such as systolic and diastolic blood pressure, heart rate and oxygenation. Currently very little data on what the MCID to determine how much of a change in these parameters would be clinically important that may determine if rehabilitation is safe for this patient group.
Any help would be greatly appreciated.
I'm doing a project on emergency team communication (in simulation). The data is videotapes, and I will do a turn-by-turn analysis of the talk.
The Health Technology Assessment (HTA) unit of the CHU de Québec – Université Laval is currently working to get data on integrated early rehabilitation interventions in pediatric intensive care unit.
We define «integrated early rehabilitation interventions» as physical, functional, nutritional, psychological, communicational, social or spiritual rehabilitation activities initiated during the first days of admission of a patient in the pediatric intensive care unit and delivered by each professional according to an intervention plan that has been developed beforehand as a team by these same professionals.
Are early interdisciplinary rehabilitation interventions an established practice in the pediatric intensive care unit of your hospital?
In spite of the metaanalysis (Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares). Published in the
Chest. 2008 Jul;134(1):172-8.
Marik PE, Baram M, Vahid B, with the Conclusion:
(This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/DeltaCVP to predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.) CVP may still the most widely used monitor for fluid management worldwide, do think that is true? Do you think it is accepted practice? And why?
NICUs are implementing care bundles to help decrease IVH in preterm neonates. The bundles start during the Golden Hour of resuscitation and continue the first 72 hours of admission. The bundle includes interventions to prevent fluctuations in cerebral blood flow, as a contributor to IVH.
I want to gather opinions about PACT modules by the European Society of Intensive Care Medicine!
We described the proportion of lung contusion in multitrauma patient that needs to be intubated or we can handle him other way (NIV, or other way etc)
Management of 150 flail chest injuries: analysis of risk factors affecting outcome
Eur J Cardiothorac Surg (2004) 26 (2): 373-376.
Prognostic factors in flail-chest patients.
Eur J Cardiothorac Surg. 2010 Oct;38(4):466-71. doi: 1
First of all Sorry because, my question is not regarding research.
My mom got Acute respiratory distress syndrome due to viral pneumonia and now she is in intensive care unit by giving oxygen in high rate via BiPAP for more than two weeks.
I have attached summary of medication with this question.
Doctor is providing high antibiotics and infection is under control.But she cannot maintain oxygen level without support of BiPAP even for short time. She is maintaining this situation with oxygen level of around 90 and for five days not showing any improvement.
Doctor is saying that oxygenation for a long period is the only method to bring back original breathing.
If any other medications available, can anyone reply?
There are different results in literature for temporary abolishing of aspirin before TURP, neurosurgery and ocular surgery. The difference exist because lack of deffinitive guidelines in these situations. One should have in mind the difference between not only surgeries but also the fact why the patient is having aspirin th.; for primary oe secondary profilaksis?
We´re looking to start measuring nursing workload in high complexity units. There´s evidence of the application of TISS - 28 in cardiac surgery patients but i´m not 100% sure if there is any incovenient to apply in other non surgical cardiac units.
The very old (≥80 year) patients increases as well in the hospital as in intensive care. With ≈ 15% of all ICU admissions belonging to this group, this probably translates to at least 5-600.000 admissions in this group per year in Europe alone. The short and long term outcomes including mortailty is higher than in the younger one, which calls for:
- improved prognostications & triage
- improved treatment in particular post ICU rehabilitation
- probably closer cooperationwith geriatricians
I would like to hear what you say out here, where do we have the unanswered questions regarding this issue?
I am undertaking a systematic review and have the following data for an outcome of interest from one publication (after multiple logistic regression):
Group 1 n=53,482. OR 1 (reference)
Group 2 n=38,077 OR 2.23 (95%CI 2.05-2.42)
Group 3 n=1,597 OR 1.18 (95%CI 0.86-1.61)
Group 4 n=1,916 OR 2.80 (95%CI 2.28-3.43)
I am trying to compare ORs of groups 2 and 4. The 95%CIs overlap, which raises the possibility of them being non-significantly different from each other.
Is there a reasonably straightforward way to calculate a p-value for this, from the data provided above?
I have access to STATA but limited experience so far.
During our Post graduate training we had been under the impression that Fever is the Most difficult symptom to solve and fever does not kill the patients but it can kill a Doctors reputation, But here the story comes : In early 2k, I was on duty as Assistant Professor in Medical wards of a reputed Medical college - Govt. Stanley Medical College, in Chennai - India. At about 4 pm my Post graduate in Medicine admitted an Young 27 years old female with an history of fever since 2 days. She delivered a baby about a week ago ( Full term natural delivery and smooth ante-natal history). She was breast feeding the baby. History and physical examination were unremarkable. I was angry with the post graduate for hospitalising a recent puerperal mother for a short acute febrile illness without any significant physical findings. About an hour later I received a call from the post graduate that She became seriously ill gasping for breath and rapidly desaturating in the ECG room while an ECG was recorded . I became very furious towards the attitude of that postgraduate for sending the patient for an ECG, which I thought was an unwarranted test in a febrile patient. She was shifted to M-ICU intubated and cardiac resuscitation was attempted. In vain. She succumbed to the undiagnosed Acute short febrile illness. But the ECG was very diagnostic in determining the cause of death. Following this experience until now, I order an ECG for every febrile patients.
Quality Improvement group trying to improve care of deteriorating patients and deliver cost effective safe care in a large teaching hospital in the UK.
During controlled mechanical ventilation as compared to spontaneous breathing, less gradient of pressure in the system exists helping with repetitively opening and closing of the alveoli. When lungs are ventilated e.g. using the positive pressure mode, by application of positive end expiratory pressure (PEEP) it prevents alveolar over distension during cycles by avoiding its repetitive opening and closing. The systemic venous blood return still depends on a pressure gradient between the extrathoracic veins and the RA (the right pressure gradient) to create adequate RV preload, but with lesser amount....(can this be quantified, and how?). AM I COMPLETELY WRONG by saying that: during controlled mechanical ventilation the inspiration does not significantly increase this gradient to the level as observed in case of spontaneous breathing to accelerate venous return while enhancing the preload?
I am creating a bathing protocol using CHG in our Cardiac Surgery ICU. Please share with me your practice since CHG is now globaly uses as antiseptic solution. Thank you
My research project is looking at the levels of anaesthetic in artery (ug/ml), vein (ug/ml) and oxygenator anaesthetic gas level (%).
Theoretically, all the 3 compartments should be the same under equilibrium state.
Please correct me if I was wrong. Bland Altman plot is not applicable as part of statistical test because of different units % and ug/ml. My lab is not feasible to create a calibration curve for me to convert the % to ug/ml. I just have to accept the results given by lab.
I would like to check if there is any correlation between these 3 variables. What types of statistical test would you recommend?
Controlling the tidal volumes and the distending pressures when ventilating patients with ARDS is the standard of care. An important publication also showed that the use of paralysis early in the course of disease decreased mortality. That is likely related to better ventilation control and decrease of 'double triggering', which adds two breaths to generate one large breath. However, spontaneous respiratory efforts have benefits. As patients get better they are usually transitioned to assisted spontaneous breathing. How do you decide when to make that transition?
I, an anaesthesiologist from India, presently working in Ireland have created a platform for discussion on relevant academic topic, interesting cases and controversial issues related to anaesthesia, intensive care and pain management. If you feel it is worth to share and gain knowledge, please join the "Anaesthesia Interactive Group" having 11,000+ members with vibrant academic activities which is more than 5 years old.
To join the group please click this link "https://www.facebook.com/groups/Anaesthesiainteractivegroup/" and then click the "Join the group" on the right top hand corner of the page. Make sure to make your speciality, area of interest and practice in the public profile so that all members and Admins can know about you.
There is much discussion on this field, glutamine is recommended when critically ill patients need parenteral nutrition. We agree with this recommendation and use glutamine in our patients when parenteral nutrition is indicated.
Routine PPI use ('stress ulcer prophylaxis') is standard practice in some ICUs, however it has been found that as many as 40% of these patients continue taking the medication on hospital discharge, with the attendant risks of Clostridium difficile infection, community-acquired pneumonia and osteoporosis.
Our ICU is currently developing guidelines on postoperative care for cardiac surgical patients, primarily to provide a basic framework for junior doctors regarding routine practice in the absence of any specific indications/contraindications.
I am interested in hearing how people interpret the risk/benefit profile of giving, for example, 40mg IV pantoprazole daily, to post-cardiac surgical patients as routine practice. Should it be used universally, liberally, sparingly, or not at all for this purpose?
I am currently interviewing SCI patients for my research study and some report the lack of mouthcare in critical care as being particularly upsetting. This should be provided routinely as part of a daily care bundle, however these patients have had to ask for it - despite being non-verbal at that time due tracheostomy/vent.
I'd like to find out about practices elsewhere.
Seeking input from experienced centers, utilizing ICUs without walls and deploy intensivisists in the hospital wards. How can we measure baseline effectiveness and what are the best outcomes to study?
When randomizing patients to two different plasma transfusion strategies, it is important to make sure the coagulation test used to differenciate both groups makes clinical sense.
Would you use INR (not designed for non-AVK patients but very commonly used), TP or aPTT ratios (more complicated to use are different tests yield different results), or ROTEM or TEG (not evaluated outside the massively-bleeding patients, and not often available)?
Is there a correlation between the number of days premature infant required mechanical ventilation increase chance of requiring or needing bronchodilator therapy?
Is there any risk of iatrogenic C1-C2 subluxation in case of transverse facial cleft patient intubations and operations? What if there is no vertebral anomaly visible on CT.
I would grateful if you can help me. It is very difficult to get any publication about that subject.
As described in literature, CGD usually complicates with frequent gram pos. (but not gram neg.) infections. Does anyone know about the severity (i.e. severe sepsis, septic shock, need of ICU administration) of these infections? And about treatment? How well reacts these patient to antibiotic treatment?
What's the most useful tool you rely upon to prevent yourself from making an error, ensuring that you've entertained all the important possibilities? Do you have a favorite saying or memory aid that you teach trainees? This could be for a specific condition (like the Hs and Ts of PEA) or a general approach to ensure you aren't missing something.
Feedback devices seem to improve compliance to Guidelines in CPR. Are there any outcome studies proving improved outcomes (i.e. ROSC, admission to hospital) in humans?
There are numerous studies on Dexmedetomidine use in children, especially in relation to procedural sedation. Are there any newer drugs that are being studied for use as continuous infusion in PICUs?
Why not use a MULTIVIB mattress for transferring sound stimuli to these patients?
It can transfer music as well at VAT stimuli, and will aid the process of ventilation significantly.
I see many anesthesia techniques can be used for kidney transplantation.
In my hospital for recipient we use lower combined epidural & intravenous anesthesia (TCI propofol). Postoperative analgesia achieved by continous ropivacaine 0.15% + fentanyl 2 mcg/mL, rate 8 mL/hr via epidural catheter for 3 days and iv paracetamol.
For laparoscopic living donor we use combined epidural & general anesthesia (volatile). Postoperative analgesia: intermittent epidural bolus (bupivacaine 0.125%, morphine 2 mg, volume 10 mL, 2x/day) + iv paracetamol.
ECG = Electrocardiogram
RR = RR interval (the time elapsing between two consecutive R waves in the ECG; the interval from the peak of one QRS complex to the peak of the next as shown on an ECG. It is used to assess the ventricular rate.)
ICU = Intensive Care Unit
I have two instruments in ICU measuring the RR intervals for some patients. So I have, for a single patient, 2 discrete series of RR intervals with hundreds of values:
RR1 = (823, 825, 884, 830, 900, ...)
RR2 = (843, 835, 874, 820, 910, ...)
I want to know if the two instruments are giving statistically equivalent measures, i.e., if I can use one or another instrument.
I am convinced that I must us statistical techniques to evaluate the reliability and the agreement. Bland-Altman and limits of agreement, Lin's correlation coefficient, but I think I must also use ICC, but which one?
I appreciate if anyone could help me with this or with another ideas / suggestions.
Thanks a lot.
8 kg, 10 month old baby with a type I Chiari malformation.
This is a new procedure for our anesthesia department to be managing and I am looking for any advice/direction that would be helpful. Thank you.
Suggestions for links to articles?
In critically ill patients, they may show some endocrine dysfunction. Waht test is useful in these patients?
The use of pre-blood fluid in the reduction of filter clotting in dialysis is well known, but it is also known to reduce the efficiency of the dialysis abilities.
Could you please explain how your unit overcomes the drawback of the use of pre-blood fluid, and how the use of Filtration Fraction determines the use of pre-blood fluid? Some units determine that pre-blood fluid is not needed if the Filtration Fraction is below 30%.
Does this not then save the unit money if pre-blood fluid is not used? Also, it has been stated that in the use of Heparin in Dialysis, the APTT is irrelevant in the ability to stop the filter clotting off. What APTT therapeutic range does your unit run at?
Any information provided would be appreciated.
Dexmedetomidine is used as an adjuvant to intrathecal local anesthetic (Bupivacaine/ Ropivacaine ). Does it help in prolonging duration of spinal anesthesia? How would you rate it on comparison to fentanyl/ morphine?
I am working on a better system of tracking and cycling IV pumps through central sterile supply and can not find information concerning the cost per pump that is an industry standard (B. Braun Infusomat Series) or the general needs per patient in a Medical ICU, Surgical ICU, PICU, or Post-anestesia units. Any advice would be appreciated.
Are there any specific number of these procedures you need to perform under supervison to achieve competency? How many you need to do to maintain this competency?
In my country some high E:N enteral formulas are fiber-enriched. Some colleagues have concerns in prescribing these kind of formula in critically ill patient, even if these patients achieve hemodynamic stability. I would like to know the experts practice.
I'm looking at the use of Citrate in CVVHDF in the critically ill patients with and without AKI. Do other healthcare professionals endorse it's use or discourage the use of citrate over heparin?
We have performed a study about the knowledge of evidence based medicine (rating) among anesthesiologists and students.I am not familiar in this topic we have asked 90 doctors and 40 students to rate 40 papers by EBM classification. I do not feel that we have the best conclusion. If you are good in this field I send you more infos y mail.
During our studies we have met a problem using nomogramms by Kelman and Nunn. According to their data there is the same correction line at all saturation levels below 80. This should be wrong. At least the values gained for mixed venous blood does not seem to be correct.
Some colleagues claim that inserting a central venous catheter without ultrasound help is a vicium artis. Still, most of my colleagues and I mostly use anatomical landmarks. If several such attempts fail or we have a history of prior fail attempts, we use the ultrasound.
Can anyone tell the negative airway pressure in the trachea during inhalation, during calm respiration but also in a forced deep inhalation, model human 60 - 80 kg?
In some instances, the underlying cause of acute respiratory failure can not be identified using laboratory, radiological and minimally invasive diagnostic procedures (including bronchoscopic BAL). Do you at all consider surgical lung biopsy a useful option in this situation? And if so, what is your trigger to request a biopsy? What are your contraindications?
In our unit (a tertiary care, referral center) a review over a 2 year period revealed the incidence of UVC extravasation to be 4.2%. The most common mode of diagnosis was ultrasound of abdomen with the following features.
In patients with cardiac arrest from accidental hypothermia patients should be transported during ongoing CPR to a hospital with ability to perform "bypass" rewarming.
Most in-hospital deaths in this group is probably because rewarming does not lead to spontaneous circulation, but data is scarce. However, patients may also die after successful rewarming with return of circulation. We have experienced death several days later from sudden development of cerebral oedema and tamponade. This has led us to question the common practice of rapid rewarming to normothermia and extubation.
Should we expand our ICU treatment by controlling the temperature for 2-3 days, aiming for temperature target 34-35 oC and sedation/controlled ventilation before "waking" up? Should we increase the level of neuromonitoring as a routine in the ICU in such patients?
What are your experiences (if any) and views?
We have one completed retrospective data collection and analysis on particular Health indication. Now wanted to published it in index journal.The scientific and ethical approval already has been taken. Can anyone guide me step by step to approach to draft synopsis and research paper/ article. You may provide format if any . It would be great support for me.
Major trauma patients in ICU often require aggressive fluid management. However overzealous crystalloids/blood transfusions have associated problems. Central venous pressures and arterial line waveform are not always helpful in determining need for fluids. What is your experience regarding use of Ultrasound/Echocardiographic imaging of IVC diameter changes in assessing fluid needs of these patients.
Attached is a link to online pdf of the article "Barbier C et. al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med (2004) 30:1740–1746".
Niccomo -the combination of impedance cardiography (ICG) and peripheral impedance plethysmography (IPG).
I have heard of people using APRV, which seems a little odd in the absence of inspiratory efforts. My impression is that there is not much research on this topic. Any thoughts?
PDE-3 inhibitors, like Enoximone, increase cardiac index in some scenarios. Their application usually lowers systemic vascular resistance (SVR) which can lead to a higher cardiac output. I would like to know how much of the effect of PDE-3 inhibitors really bases on sth. like positive inotropy and how much of the effect is a result of decreased SVR (and so could possibly eaten up by the use of noradrenaline).
In mechanically ventilated patients, how often and how do you deduce the PEEP value while monitoring central venous pressure via central venous lines? One way, that I have been taught, is to subtract the PEEP value above 5 from the actual measurement of CVP. Does this hold true for patients with ARDS or with widespread alveolar/interstitial disease?
I know it depends on many factors, however I need to know if awake fibreoptic intubation is your first choice in these patients, or if you do not use it at all, or something in between.
Actually we have a patient of 2 y with RSE trated with midazolam propofol and thiopental
as rescue we use ketamine with good results ....
I am having a look at the validity of the dynamic TIMI score as a predictor of one year mortality in my study cohort. I have a couple of questions:
The heart rate, BP and Killip Class - is this at admission? To my understanding the dynamic score is done throughout the hospital stay, unlike the Base TIMI which is at admission and then cannot be changed. At which point are these variables added to make up the dynamic score?
Also, one variable is if the patient is Anterior STEMI, why only this one?
Were you surprised by the two studies published in the NEJM, Oscar and Oscillate? Is the benefit of HFOV lost in the era of low volume, pressure limited ventilation for ARDS? Will you continue using HFOV for rescue therapy or jump to extracorporeal support instead? Why do you think Oscillate had a higher mortality in the HFOV group?
What's your opinion about using Airtraq laryngoscope in emergency situations? Do you have Airtraq in emergency trolley in your hospital? As the first successful attempt is very important and sometimes life saving, do you use Airtraq as the first choice in cardiopulmonary resuscitations with anticipated difficult airway? What's your preference in difficult emergency cases?
If a person is on a ventilator with a tracheostomy done and has developed ventilator-associated pneumonia along with other complications such as blood loss,blood pressure drop etc. and is in a semi-conscious state. The patient is lying stable but in a crippled condition with no signs of recovery. What are the chances of his/her improvement? "to what end" is it possible to keep the patient dependent on the ventilator?
Lowering body temperature during the first hours after cardiac arrest reduces neurologic injury by disrupting pathological cellular events and cascades that might lead to secondary brain injury. Randomized trials demonstrated that therapeutic hypothermia early after cardiac arrest reduces mortality and improves outcome. Based on preliminary results, it was postulated that a shorter delay to target temperature would further improved outcome. However, those early results were not verified in following randomized trials. Thus, the question if time or delay to therapeutic hypothermia matter in patients resuscitated from cardiac arrest...
Delayed surgery may warrant lower risk of residual shunt but pay an high risk of hemodinamic worsening also when IABP is promptly instituted. ECMO and MCS may warrant optimal haemodynamics to patients arriving to surgery in cardiogenic shock. Do we need to consider this escalation when IABP is not sufficient to delay surgery? When and how do we should revascularize those patients?
An otherwise healthy 54 year old female is admitted with acute abdomen. She is operated, and a colon cancer is found. A hemicolectomy is performed. Postoperatively she experiences rupture of an anastomosis with severe peritonitis and septick shock on day 3 after surgery. She is admitted to the ICU. Over the next weeks her organ dysfunctions gets worse with multi-organ failure (circulation, respiration, renal failure and several small cerebral infarctions). There is no improvement, and we withdraw therapy after 59 days treatment in the ICU after concensus with her family. She dies within 15 minutes.
What would you say about her death:
Sudden? Unexpected? Natural death?
Would you ask for an autopsy?