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from Thinking Critical Care

 

So I got to moderate a panel on Fluids in Sepsis with such luminaries as Manny Rivers, Dave Gaieski, Phillipe Rola, and Terry Clemmer. The panel was incredibly interesting, but in some ways exemplified treatment pathways that I don't quite agree with. If you'd like to listen for yourself, the link is here:

Fluids in Sepsis Panel

Since I felt some of the key messages were slightly askew, I wanted to debrief with my friend Phillipe Rola. Phillipe is a self-described Internist-Intensivist, mad sonographer, ducatista and Brazilian Jujitsu aficionado. He blogs at the site: Thinking Critical Care.

Topics we Discussed

* Fantastic Post on Fluid Tolerance/Responsiveness

* Cerebral and Somatic NIRS

* Hepatic Vein Doppler

* Portal Vein Flow

Now on to the Podcast...

My friend, Paul Marik, is a mythbuster. He has been vindicated in so many viewpoints that were initially branded as crazy. But... sometimes the weapon he chooses, in his war against perceived pseudo-axioms, is hyperbole. This was the case in a few instances in his talk from SMACC-Chicago on Lactate:

http://intensivecarenetwork.com/understanding-lactate-paul-marik/

 

The Paper Paul Cited

* Roberg Article [cite source='pubmed']15308499[/cite]

The Many Retorts Explaining Its Flaws

* If you only read one retort

* [cite source='pubmed']16105825[/cite]

* [cite source='pubmed']16760335[/cite]

* [cite source='pubmed']16105824[/cite]

* [cite source='pubmed']16105823[/cite]

from ALIEM

Post-Publication Peer Review

I wanted to be extra sure about this one before sending it to Paul, so I reached out to the brilliant Dr. David Story:

I agree with your thoughts, I’ll try not to be too random in my response as a Stewartite.

From a Stewart perspective Dr Marik’s comments about lactate seem incorrect.

One of the many attractions of the Stewart quantitative approach to acid-base (Stewart 2009) is that one does not have to do hydrogen ion accounting. What determines hydrogen ion concentration (and pH) in body fluids (plasma, interstitial AND intracellular) is the partial pressure of carbon dioxide, the strong-ion-difference, and the total weak acids (Stewart 2009). Water is the hydrogen ion source.

Lactate has a pKa of 3.9 (pH of 50% dissociation), and is therefore almost completely dissociated in plasma at pH 7.40. In plasma, lactate is a strong anion and acts like chloride in quantitative acid-base assessment. This effect can be easily quantified in clinical chemistry (Story 2016).

The same applies to the intracellular environment (Magder 2009) including skeletal muscle at maximal exercise or any lactate producing cell in sepsis. If lactate increases without a change in other ions the strong-ion-difference will decrease and acidity will increase. At extreme exercise the pH in skeletal muscle will be above 6.2. Even if one were to argue that lactate is no longer acting like a strong anion in pockets of extreme acidity such as lysozymes, it would be acting like a weak acid and increases in total lactate will increase acidity. Therefore if lactate goes up, acidity goes up. The paper referred to Dr Marik by Robergs (2004) demonstrates how confusing acid-base can be if trying to account for hydrogen ions, particularly when considering complex metabolism. Ignore the attempts to account for hydrogen ions in assorted cellular events and stick with the strong-ion-difference and total weak acids: increased lactate causes acidosis in any body fluid.

References

* Stewart PA, Whole-body acid-base balance. IN: Kellum JA, Elbers PWG (Eds) Stewart’s Textbook of Acid-Base. 2nd Ed. www.AcidBase.org, 2009

* Magder S, Intracellular [H+]. IN: Kellum JA, Elbers PWG (Eds) Stewart’s Textbook of Acid-Base. 2nd Ed. www.AcidBase.org, 2009

* Story D. (Open Mind) Stewart Acid-Base: A Simplified Bedside Approach. Anesthesia and Analgesia, 2016 (ePub ahead of print).

* Robergs RA, Ghiasvand F, Parker D. Biochemistry of exercise-induced metabolic acidosis.

This is Part II, you need to Watch Part I First!

So I've been giving this talk for Grand Rounds for a decade now. I've kept it off the podcast so I would have something unheard to discuss when I come to visit a program. I don't do many grand rounds any more--so the time has come, here is:

Laryngoscope as a Murder Weapon: Oxygenation Kills

There are two other LaMW talks:

* LaMW: Ventilatory Kills

* LaMW: Hemodynamic Kills

Most of the things discussed are elaborated upon on the EMCrit Preox Page.

This will be a two-parter. The things we will cover over the course of these two segments are:

* PreOx (Including VaPoX)

* Preventing Deox with ApOx and Apenic CPAP

* ReOx

Need an Audio-Only Version?

Right Click and Choose Save-As

Now on to the Vodcast...

So I've been giving this talk for Grand Rounds for a decade now. I've kept it off the podcast so I would have something unheard to discuss when I come to visit a program. I don't do many grand rounds any more--so the time has come, here is:

Laryngoscope as a Murder Weapon: Oxygenation Kills

There are two other LaMW talks:

* LaMW: Ventilatory Kills

* LaMW: Hemodynamic Kills

Most of the things discussed are elaborated upon on the EMCrit Preox Page.

This will be a two-parter. The things we will cover over the course of these two segments are:

* PreOx (Including VaPoX)

* Preventing Deox with ApOx and Apenic CPAP

* ReOx

See Part II

Part II of LaMW Ox Kills

Need an Audio Only Version

Right-Click here and Choose Save-as

Now on to Part I...

Reddit

Google Plus is surely on its last legs. Let's ditch this dying corpse, my fellow fleas. On to the next corpus: reddit.

CGP Grey on What is Reddit?

so come to emcrit.org/reddit and subscribe to the emcrit subreddit

Subscribe to EMCrit Subreddit

Leave Questions for the Fluid Webinar Here

Questions for Fluids in Sepsis Webinar

 

New York State Partnership for Patients: Fluids in Sepsis Webinar

4/27/2016 at 1400 Eastern Time

Panel Moderator:

• Scott Weingart, M.D., Chief of the Division of Emergency Critical Care at Stony Brook University Medical Center

Panelists:

• Terry P. Clemmer, M.D., Director of Critical Care Medicine, LDS Hospital, Intermountain Healthcare

• David Gaieski, M.D. Co-Director, Early Goal-directed Therapy, Co-Director Clinical Resuscitation, Thomas Jefferson University

• Emanuel Rivers, M.D, M.P.H., Vice Chairman and Research Director, Henry Ford Health System, Department of Emergency Medicine

• Phillippe Rola, M.D., ICU Chief of Service, Santa Cabrini Hospital, Montreal Canada

Register at this Link

 

This is in response to a bunch of comments from this Wildcast EM episode.

Please let me know what you think!

Update

Response and my comments just posted on the new Wildcast EM Site

Now on to the Podcast...

 

VAPOX and Vent-as-Bag

In a concept piece called Preoxygenation. Reoxygenation and Delayed Sequence Intubation in the Emergency Department, I outlined a concept which I called: the vent as a bag. Why would we use the unpredictable and unmeasured BVM, when instead we could use a purpose-built, strictly internally regulated machine like a ventilator. I had stopped talking about the idea when numerous people told me it was unfeasible in their environment--however, I continued this practice for my own patients throughout my practice.

Recently, Grant et al. published a case series using the same concept--they have dubbed their vision of it VAPOX.

Ventilator-assisted preoxygenation: Protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator (DOI: 10.1111/1742-6723.12524)[cite source='doi']10.1111/1742-6723.12524[/cite]

their protocol is very similar to the one I have used:

Non-Invasive SIMV

* Respiratory rate of 6–8 breaths per minute

* Pressure support 0 cm water (I never bothered unless pt had severe acidosis--the authors used PS of 10)

* Positive end expiratory pressure starting at 5 cm water (titrate up to 15 if not getting sats > 95% in preox)

* Fraction inspired oxygen 1.0

* Vt 550 ml

* Inspiratory Flow (30 lpm)

See Grant et al.'s paper for their protocol

Also consider getting some mask straps

And Remember the Nasal Cannula at 15 lpm

For More

See the EMCrit Preoxygenation Page

Now on to the Podcast...

 

Mind of the Resuscitationist

In a previous wees and lectures, we discussed Chapman's Dictum: smoothness=speed; slow is smooth, smooth is fast

So go slow!

Update

Love this quote brought to my attention by G. Harrison:

When I say that I learned to take my time in a gunfight, I do not wish to be misunderstood, for the time to be taken was only that split fraction of a second that means the difference between deadly accuracy with a sixgun and a miss. It is hard to make this clear to a man who has never been in a gunfight. Perhaps I can best describe such time taking as going into action with the greatest speed of which a man’s muscles are capable, but mentally unflustered by an urge to hurry or the need for complicated nervous and muscular actions which trick-shooting involves. Mentally deliberate, but muscularly faster than thought, is what I mean

--Wyatt Earp

Now I will extol the virtues of getting faster...

 

[easyazon_image align="right" height="160" identifier="1847922929" locale="US" src="http://emcrit.org/wp-content/uploads/2016/04/61vO4n86LL.SL160.jpg" tag="emcrit-20" width="104"]The mind palace, also known as the memory palace or the memory theatre, is something I want badly! Ever since I read the incredible book, the [easyazon_link identifier="1847922929" locale="US" tag="emcrit-20"]Art of Memory by Frances Yates[/easyazon_link], I have dreamed of building a mind palace. But in medicine, we should be able to externalize the palace--in fact, we must! The method of loci will not suffice.

Technology should surely have advanced to the point where this is simple--the programming requirements are trivial.

My current mind palace is at CrashingPatient.com. It is quite good, but not perfect.

Factors

Storage

We need a place to store all of the literature, books, and internet posts/media we feel will be valuable. The storage must be durable (if an internet site goes down, the work remains). If we lose our paid access, we retain the full text of the literature.

Readability

The medium should allow comfortable reading of the literature, viewing of the media, etc.

Accessibility

Should be immediately accessible offline or online. Should be firewall resistant.

Ease of Commenting/Summarizing

Need to put the take-home message somewhere. Additional thoughts, new findings. Really two separate things:

* We need the ability to comment on, by which I mean literally on the paper (i.e. scribblings, marginalia, highlighting)

* But also the ability to summarize a Topic and add those papers as citations in a way that would link to the scribbled on paper

Ease of the Edit

Front end editing

Open Source

Or at the very least, immediately exportable to open source

Search

All information should be easily retrievable with logic, operator,  and fuzzy logic based searches

Option to Publish

Should you want to share your memory palace

The Mind Palace Cycle

* Discovery

* Storage for to-be-read/to-be-viewed

* Process=Read/Comment/Summarize

* Storage

* Retrieval/Search

* Publish or Protect as Desired

Possibilities

* Wordpress

* Evernote

* Zotero

* Papers

* Mendeley

image from memorise.org

Want to read more about memory?

The Art of Memory, mentioned above, is amazing--but oh so dense. For a lighter, contemporary read:

[easyazon_image align="none" height="500" identifier="0143120530" locale="US" src="http://emcrit.org/wp-content/uploads/2016/04/51BD8oiyJlL.jpg" tag="emcrit-20" width="326"]

Update

Some additional requirements/desires:

* Self-Updating TOC as frontpage (see crashingpatient.com)

* Search must be browsable by either google or a plug-in and updates in real time

* Need to be able to do edits/additions on firewalled computers in any computer in the hospital.

* Want, but not essential--evernote's real time search of the contents of embedded pdfs would be pretty swell

Now on to the Podcast...

My keynote lecture at SMACC-Chicago was on OODA loops and the supremacy of System I for resuscitation. The lecture was plagued by AV-wankers to the point that I thought the talk was a shambles. I am rerecording the lecture here for EMCrit and the SMACC site. I hope you enjoy--SDW.

The OODA Loop

OODA Loops and John Boyd

* I'm loathe to link to this, but this probably the most accessible description of OODA loops and Boyd Philosophy

Protocols May Cause Harm

* Protocols for the OODA Loop Trilogy

Why I Hate ATLS

* Archaic Trauma Life Support

Guidelines are not for experts

https://twitter.com/Drmanoj_s/status/614443279971520512

Articles

* Conditions for Intuitive Expertise by Gary Klein

* ED Cognition by Croskerry

Croskerry's Loop

More to Read and Watch

* Physiology Inside the Loop

* More on OODA

* Klein Ted Talk

* Klein Strategies of Decision Making

* Croskerry Lecture Thinking Straight Lecture from SMACC

* System 1 vs. System 2

* All things John Boyd

The Book to Buy

[easyazon_image align="none" height="160" identifier="0262516721" locale="US" src="http://emcrit.org/wp-content/uploads/2016/04/414lx3VWCL.SL160-2.jpg" tag="emcrit-20" width="108" popups="n"]

[easyazon_link identifier="0262516721" locale="US" tag="emcrit-20" popups="n"]Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making[/easyazon_link]

Update

Ugggggghhhh. I couldn't see my notes while rerecording and I said Boyd was a Navy Pilot, when of course he was air force. And it was the air force that has reportedly not embraced his work. Sorry Navy. Thanks, Jim!

The Slides

* From SMACC Chicago

Audio Only Version

* Audio-Only OODA

Updates:

ED Docs seem to perform as well as trauma teams

Now On to the Vodcast...