What to do in the Post-Resuscitation

Inspired by my friend Mike Mallin, today I discuss the post-resuscitation. This squarely fits into the Mind of the Resuscitationist (MotR) series.

Parasympathetic Backlash

Follows the adrenaline dump. You are basically performing at a much lower level than normal.

The moment of greatest vulnerability is the instant immediately after victory.

~ Napoleon Bonaparte

We briefly touched on this concept in the On Combat bookclub.

...It doesn’t take a rocket scientist to guess that a soldier must pay a heavy physiological price for an enervating process this intense. The price that the body pays is an equally powerful backlash when the neglected demands of the parasympathetic system become ascendant. This parasympathetic backlash occurs as soon as the danger and the excitement are over, and it takes the form of an incredibly powerful weariness and sleepiness on the part of the soldier.

~ Grossman, On Combat

What to Do?

* Scene Check/360 degree sweep/Stabilization steps

* Eat

* Drink

* Change Clothes

* Nap?

Debrief

* Organized Debrief

* Need your input here

* Guilt Release

Process and Avoid Post-Traumatic Negatives

Go on the Couch

Cliff Reid's Couch

Visualization

Use the highest fidelity simulator, your brain, to replay, re-act, and improve

Meditation

Will discuss on an upcoming podcast

Gaming Processing and Recreation

Play Tetris or Mindcraft

[cite source='doi']10.1371/journal.pone.0004153[/cite], [cite source='doi']10.1177/0956797615583071[/cite]

Jane McGonigal's Ted Talk & her interview on Tim Ferriss' podcast. Read her book: SuperBetter.

What if you actually screwed up?

Jason Brooks-Come Help me...

Post-Traumatic Growth

Resilience may lead people to go down the path of Post Traumatic Growth rather than PTSD

 

 

In Podcast 64, Paul Marik and I discussed the concept of Fluid Responsiveness, and then we had the amazing Jean-Francois Lanctot discussing his four-part assessment with ultrasound to determine fluid use in sepsis. After that talk, I definitely felt I needed to discuss some of these issues further. If you have not listened to those two podcasts, it may be beneficial to go back before listening to this one.

and what has come to me is that perhaps we have been conflating two concepts:

*

Can the RV take it?

*

Can the LV use it?

Perhaps the problem we have been having is that we are trying to blend these two questions into 1. Let's use that as our path to discuss this morass of volume-responsiveness

Fluid Challenge or PLR with CO measurements

Stress the System with PLR or Fluid Challenge

Passive Leg Raise

Worth mentioning, though it should be obvious, PLR demonstrates how ridiculous the practice of Trendelenberg Position for resuscitation

Fluid Challenge

500 ml crystalloid or colloid

10-Second Mini-Fluid Challenge

50 ml bolus over 10 seconds through a central line (Critical Care 2014;18:R108) change in VTI measured immediately afterwards

Then Measure the Response

Can Changes in MAP Predict Fluid Responsiveness?

[cite source='pubmed']22278593[/cite], [cite]20111858[/cite], [cite]22464162[/cite]

Most recent analysis states changes in MAP don't predict CI increase from fluid load in septic shock (Intensive Care Med (2012) 38:422–428)

The Cardiac Output Monitors

Marik's Comprehensive Review Article

and my buddy Seth Manoach wrote a nice review as well [cite source='pubmed']22537573[/cite]

NICOM - Bioreactance

* Marik studied 34 patients in the ICU with PLR, NICOM, SVV, and Carotid Flow (The use of NICOM (Bioreactance) and Carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients (Chest 2012 Marik et al.)

* Big validation study showed good accuracy (Intensive Care Med (2007) 33:1191–1194)

* There were a couple of small studies indicating inaccuracy, but when I looked into these--the authors may have had some conflicts

USCOM - Aorta Ultrasound

* Anaesthesia. 2012 Nov;67(11):1266-71.

PiCCO

* PCA + thermodilution

Pulse Contour Analysis Alone

* Bunch of studies keep going back and forth in the lit. I'm not sure if these track changes in afterload. They don't accurately track pressors/inopressors (Anesth Analg. 2011 Oct;113(4):751-7.)

ETCO2

* A PLR-induced increase in EtCO2 >5 % predicted a fluid induced increase in CI >15 % with sensitivity of 71 % (95 % confidence interval: 48–89 %) and specificity of 100 (82–100) %. (Intensive Care Med (2013) 39:93–100)

* Passive leg raise to etco2 (CCM 2014;42:1585)

Carotid and Brachial Artery Analyses

Search for the evidence on pubmed, it is emerging now

LVOT velocity time integral (VTI)

* Accurate in the hands of experts--kind of annoying to obtain

Jean-Francois Lanctot along with his partner in crime, Maxime Valois, has markedly advanced the field of resuscitative ultrasound. The two of the them also created Echo-Guided Life Support (EGLS) and the Shock Echo app.

Today, Jean-Francois and I discuss the current state of fluid assessment and treatment.

TLDR Take-Home Points

* Rule out obstruction to Venous Return (Can the Right Ventricle Take Volume Loading)

* Look for Left Ventricular Failure (Can the Left Ventricle Take Volume Loading)

* Correct Vascular Tone

* Only then, Decide if the Patient may be Fluid Responsive

Marik and Bellomo on the Fluid Management of Severe Sepsis

from Br J Anaesth

See this amazing fluid physiology lecture from the Ultrasound Podcast Site

An Integrated Approach to Ultrasound-Guided Fluid Management

 

At smaccChicago, I had the honor to host an incredible panel of Sepsis Experts. I think most everyone who heard it was left with more questions than answers. I have already posted a preemptive response to the panel here:

EMCrit Podcast Episode 154

In a few days, I will post a wee with some additional thoughts. I want to hear what you think--post your comments below.

The Blurb from the SMACC Folks

An all-star panel discuss the burning issues in sepsis right now. Hosted by Chris Nickson and I, the conversation on the controversial aspects of sepsis was lubricated with on-stage alcohol (my idea!)

Mervyn Singer (research guru, sepsis expert and self-proclaimed Sex-God) and Paul Marik (iconoclast and dogma-basher) reveal just how hard it is to describe what sepsis is. Flavia Machado (intensivist and researcher) brings common sense and the perspective from South America, representing middle-income countries. Kath Maitland (author of FEAST, African-based paediatrician and clinical trialist) talks about sepsis management issues in Africa, where sepsis strikes its biggest global impact. Heavyweight researcher and clinician John Myburgh, argues that the word “sepsis” should be removed from our language and turns the paradigm on its head, arguing for a more pragmatic approach to sepsis management. Simon Finfer (crit care clinician, clinical trialist, voice of reason) describes the history, the good, the bad and the ugly about the Surviving Sepsis Guidelines, and some of the controversy surrounding them.

There’s a fascinating, very high level discussion on antibiotics which is not as clear cut as you might imagine. You couldn’t discuss fluids without talking about fluids and this panel features several world experts on this topic. Kath Maitland’s insights from FEAST, combined with the opinions of the rest of the panel will hopefully leave you an informed agnostic.

 

We’d highly recommend watching this discussion with your colleagues at work and use it to spark more discussion on this incredibly important topic that still kills so many of our patients.

 

Additional Resources

Mortality after Fluid Bolus in Children with Shock Due to Sepsis or Severe Infection: A Systematic Review and Meta-Analysis

Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial

John Myburgh on Fluids

Surviving Sepsis Guidelines

Simon Finfer on Sepsis in 2014

NEJM article on Sepsis by Angus et al

Now On to the Vodcast...

I am a podcaster. I like audio! But I also love reading well-crafted, incisive blog posts. One of my favorite blogs has been PulmCrit.org by Josh Farkas.

Well now, PulmCrit and EMCrit are merging. This will be a boon for the audiences of both products. You'll be hearing more in the coming weeks.

What do you think?

 

Rounding Sheet

* RACC Rounding Form

The Literature

* Systemic Review of ICU Rounds Practices (Crit Care Med 2013;41:2015)

#HollywoodWeingart

from EDECMO.org

Now on to the Podcast...

 

Matt Semler, MD and colleagues performed an RCT on Apneic Oxygenation in Medical ICU patients. I got a chance to sit down and interview him on the trial.

The Trial

The Fellow Trial (Published ahead of Print)

Bottom Line Review

Trial Summary

Additional Written Comments from Matt Semler

as provided by Matt Anderson (@ccinquisivist)

From: Anderson, Matthew J

Dr Semler

I'm a CCM fellow at the University of Wisconsin, interested in airway mgmt in the ICU.

Just saw your article published in ATS. I had a question about the airway mgmt protocol (or if there was one?). Did the airway team leader/intubator maintain a patent airway (ie were they instructed to do this just prior to the intubation attempt when getting sedation/analgesia and/or NMB)? I am unable to find/get to the supplement which this information may be listed but I didn't see any mention in the main manuscript, which I think is a extremely important discussion point. Previous, studies in the OR w/ or w/o maintenance of airway patency resulted in 'no difference in the non-airway patency (ie jaw thrust/head tilt chin lift) group vs 'stat significant difference in the airway patency group' during apneic oxygenation. If airway patency was maintained in your study this would be one of the first 'negative' results I have seen with apneic oxygenation. If airway patency was not required, this may explain the 'no difference' that was found in your study, which in my opinion, makes the use of apOX still an important part of endotracheal intubation. Until a randomized control trial to evaluate apOx with airway patency versus no apOx with airway patency confirms that previous. Further trials may need 30 degree ramp/optimal positioning, as well?

Thanks for taking the time to answer my questions and publish/perform important ICU airway research.

Matt Anderson

Critical Care Medicine Fellow, PGY5

________________________________________

From: Semler, Matthew

Matt,

Thanks for your interest in the trial.  You ask two really important questions -- actually two of the same points Rich Levitan emphasized when he visited during the conduct of the trial.

(1) When discussing the effect of airway patency on outcomes of apneic oxygenation, the time-period in question is between administration of RSI medications (with anything prior to induction technically a part of pre-oxygenation) and the onset of laryngoscopy (when patency of the airway is directly established by the laryngoscope better by external maneuvers).  Objectively assessing whether the airway is patent during this period is challenging.  For the 30% or so in the trial who were on BIPAP between induction and laryngoscopy, the airway was known to be patent through monitoring of the returned tidal volumes.  In cases where NIV was not present, the operator was charged with maintaining patency of the airway between induction and laryngoscopy.  In 60% of cases this required an oral airway and a head-tilt-chin-lift maneuver.  In around 40 patients, the operator felt the airway was patent without such a maneuver.  Whether these maneuvers were effective in maintaining patency or whether patency was truly present in those patients who were not felt to require a maneuver is difficult to know.  We did analyze the subgroup of those who were on BIPAP and we were certain the airway was patent and there was not a significant effect of apneic oxygenation on lowest oxygen saturation in this group -- though obviously this is a not a large population.

An important thing to consider when thinking about the period between induction and laryngoscopy is that high flows of oxygen...

Listen to Part I - Avoiding Complications

* Confirmation of Proper Placement

Micro-Skills and Deliberate Practice

Image from S. Rezaie

* You definitely need to watch the central line micro-skills video

Steps Of Central Line Insertion

* Go to the Central Line Page

Subclavian Insertion

* Go to the Central Line Page

Dilation

* The wire CAN'T BE ALLOWED TO ADVANCE

* I need to record dilator use as a microskill

* Move wire in out sequentially during dilation (racking the wire)

Internal Jugular

* Keep head in neutral not rotated for IJ (Journal of Emergency Medicine Volume 31, Issue 3 , October 2006, Pages 283-286)

Subclavian

* Subclavian is safe in mech vent pts (Anesthesiology:2009 – Volume 111 – Issue 2 – pp 334-339)

* Use lower shoulder position puncture site just lateral to mid-clavicular line [cite source='pubmed']15564937[/cite]

* Shoulder retraction (padding behind the back) was not helpful (Br. J. Anaesth. (2013) 111 (2): 191-196.)

* If you miss twice, consider abandoning the site (3 on a match)

Ambesh Maneuvers

* Finger in fossa technique to prevent guidewire malposition in subclavians (Ambesh SP, Anesthesiology.  2002; 97(2): 528-529.)

Checking Subclavian Placement after Catheter is In

* After subclav line placement, if you push on IJ and CVP increases 3-5 mmHg then the lumen is in the IJ instead of the SVC (Anesthesiology 2002;97(2):528), IJ occlusion test (Anesthesiology 2001;95(6):1377) and (Anesthesiology 2006;105(5):1062-1063)

Can We Place Central Lines in Anti-Coagulated Patients?

* Central line insertion while anti-coagulated seems safe and complications probably correlate with skill of physician (emerg med j 2011;28(6):536)

* Micropuncture Sets seem to be a very clever way to go

Guidewire Exchange

Guidewire exchange seems safe [cite source='pubmed']24004883[/cite] GWX-CVC’s and NI-CVC’s had similar rates of tip colonization at removal, CA-BSI and mortality. If the CVC removed by GWX is colonized, a new CVC must then be inserted at another site. In selected ICU patients at higher central vein puncture risk, guide-wire exchange may be an acceptable initial approach to line insertion.

Tips for Flushes

Drop a sterile 50 ml bag on to field; slash that bad boy with a scalpel. (Thanks Haney)

Update:

Chris Bond does an interview on hand motion analysis as a means of demonstrating expertise on the procedure

On Monday, I'll be doing the 2nd part of the central line series--this one on placement tips. In anticipation, I had to release this video on central line micro-skills (microskills). These are the steps of the Seldinger technique to which you need to devote deliberate practice time. Thanks to Jeremy Faust for the filming help.

 

Read this Review of Vascular Complications of CVC Placement

(J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)

When to Confirm

I prefer to confirm all non-crash introducers and especially HD caths prior to dilation. There are times I will place a triple lumen and then confirm the line after insertion (do the latter at your own risk)

Confirming Venous Placement (Choose at least 1)

* Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing

* Determination of the of the intravascular pressure using sterile tubing as a venous manometer

* Analysis of the PO2 of a blood specimen drawn from the needle/catheter compared to simultaneously drawn arterial blood (this is stupid!)

* Bubble Test-when saline is rapidly injected through the catheter, there is opacification of the echocardiographic view of the right heart structures.

* Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava)

* Using a contrast study to opacify the venous structures.

Less Desirable

* Guidewire Visualization in the Vein

The Methods in Depth

Pressure Transduction

Easiest way to do this is use the casing of the wire was packaged in--this tip thanks to my friend Taku Taira, MD.

How to Use Wire Casing to Transduce Pressure

[cite source='pubmed']19377052[/cite]

[cite source='pubmed']9412883[/cite]

Numerous other studies cited here: (J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)

Study specifically on using tube transduction (Anesth Analg 2009;109:130)

Or if doing IJ, Just use the Catheter-Over-Needle from the Get-go (but I will lose all respect for you)

thankfully Reub provided the study showing the needle technique is superior [cite source='doi']10.1097/CCM.0000000000001167[/cite]

Or Using a Commercial Device

Compass Single Use Manometers with or without guidewire slot

Bubble Test, Flush Test, Rapid Atrial Swirl Sign (RASS)

Inject 10 ml of saline and observe Right Atrium/Right Ventricle

* [cite source='doi']doi:10.1016/j.ajem.2014.10.010[/cite]

* [cite source='pubmed']24552526[/cite]

* [cite source='pubmed']25624649[/cite]

* [cite source='pubmed']17006130[/cite]

* [cite source='pubmed']19829102[/cite]

* [cite source='pubmed']23242559[/cite]

* Should appear in <2 seconds for properly placed neck line [cite source='pubmed']25550065[/cite]

* Saline Flush and Pneumo Exclusion obviates immediate chest radiography [cite source='pubmed']26112633[/cite]

* For Hemodialysis Caths (Kidney International Reports 2017;2:952

* Crit Care Med 2017;45(7):1192

* SR DOI 10.1097/CCM.0000000000002188

* Ultrasound to Detect Central Venous Catheter Placement Associated Complications: A Multicenter Diagnostic Accuracy Study. Anesthesiology. 2020 Jan 21. doi: 10.1097/ALN.0000000000003126.