The FlightBridgeED Podcast

By FlightBridgeEDHealth & Fitness

The FlightBridgeED Podcast episodes

October 25, 2024 Hypertensive Disorders in Pregnancy
Welcome to another essential episode of the FlightBridgeED Podcast: MDCAST, where we dive deep into the complexities of critical care and continue our high-risk OB transport conversation. This episode focuses on the often overlooked yet rapidly increasing crisis of hypertensive disorders in pregnancy. Host Dr. Mike Lauria and maternal-fetal medicine specialist Dr. Elizabeth Garchar discuss the full spectrum of hypertensive disorders—from gestational hypertension to the life-threatening condition of eclampsia—and share practical insights on managing these critical patients in prehospital and transport settings.

Starting with foundational definitions of specific disorders like pre-eclampsia vs. eclampsia and HELLP syndrome, they explore the physiological mechanisms driving preeclampsia, the increased mortality rates, and why transport providers are seeing more cases in rural or under-resourced facilities. Learn how to distinguish between different diagnoses, manage acute cases in transit, and navigate treatment protocols with a detailed look at magnesium sulfate's role and the right blood pressure control strategies. This episode brings expert-level insight to providers of all backgrounds, from the basics to the most advanced interventions.

Listen to The FlightBridgeED Podcast anywhere you enjoy podcasts, or find this episode and more podcasts at https://flightbridgeed.com/explore. While there, explore our award-winning courses that empower pre-hospital and critical care transport medicine professionals to build their critical care expertise.

Key Takeaways:

• Pathophysiology of Preeclampsia: This condition often arises from placental abnormalities that lead to widespread vascular issues, impacting both the mother and fetus.

• Magnesium Sulfate in Management: Magnesium sulfate is vital for preventing eclampsia and should be monitored for toxicity, especially in patients with reduced kidney function.

• Identification of Hypertensive Disorders: A blood pressure reading of 160/110 mmHg or greater post-20 weeks' gestation is a significant indicator of hypertensive disorders, warranting immediate medical attention.

References

• Sperling JD, Dahlke JS, Huber WJ, Sibai BM. The role of Headache in the classification and management of hypertensive disorders in pregnancy. Obstetrics and Gynecology. 2015; 126:297-302.

• Sabai BM. The HELLP syndrome (hemolysis, elevated liver enzymes and low platelets): much ado about nothing? Am J of Obstetrics and Gynecology. 1990; 162:311-6.

• Steegers EA, von Daselszen P, Duvekot JJ, Pijnenborg R. Pre-Eclampsia. Lancet. 2010; 376:631-44.

• Redman CW, Sargent IL. Latest advances in understanding preeclampsia. Science. 2005; 308:1592-4

• von Dadelszen P, Magee LA, Roberts JM. Subclassification of preeclampsia. Hypertens Pregnancy. 2003; 22:143-8

• Dekker GA, Sibai BM. Etiology and pathogenesis of preeclampsia: current concepts. Am J Obstet Gynecol. 1998; 179; 1359-75.

• Gillon TE, Pels A, von Dadelszen P, MacDonell K, Magee LA. Hypertensive disorders of pregnancy: a systematic review of international clinical practice guidelines. PloS one. 2014; 9(12): e113715.

• Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020 Jun;135(6):e237-e260.
49 min
October 17, 2024 Ventilator Jiu-Jitsu
In this episode of our series on respiratory critical care called Every Breath They Take, Dr. Lauria is joined by EM/Critical Care and Flight Physician Brittney Bernardoni as they discuss how to grapple with optimizing lung protective ventilation in ARDS.

Lung protective ventilation at 6 cc/kg and maintaining plateau pressures of less than 30 cmH2O have been the cornerstones of invasive respiratory support since the findings of the ARMA trial in 2000. In recent years, some interesting new developments have resulted in changes and improvements in lung protective ventilation strategies. With a particular focus on ventilator "jiu-jitsu," this episode explores the intricate adjustments required to optimize patient care during ARDS management. From ventilator modes and plateau pressure to the impact of PEEP, FiO2, and mechanical power, this episode equips listeners with actionable knowledge for mastering the art of ventilation. Whether in the field or the ICU, the nuanced approaches discussed in this episode will enhance your understanding of optimizing respiratory support in critical patients.

Listen to the episode wherever you get your podcasts or directly on our website at https://flightbridgeed.com/explore. While you're there, explore our award-winning courses that have helped thousands of providers clarify and understand the world of critical care transport and pre-hospital medicine.

Takeaways
• Early care in managing respiratory failure in the transport environment is crucial and can significantly impact patient outcomes.
• Lung protective ventilation with low tidal volumes is the foundation of ARDS management.
• The choice of ventilation mode (volume control or pressure control) depends on the clinician's comfort and ability to titrate the settings, but neither has proved superior.
• Permissive hypercapnia is generally well-tolerated in ARDS patients if the pH exceeds 7.15-7.20.
• The initial PEEP setting should be at least eight - several strategies can be used to guide titration.
• High FiO2 levels can be detrimental to ischemic organs, alveolar patency, and the lung tissue itself. Aiming for a FiO2 of less than or equal to 60% is important.
• Set, check, and change parameters to ensure optimal ventilation!
• Driving pressure may be an important factor in patient outcomes.
• Mean airway pressure and inspiratory time can improve oxygenation and minimize lung damage

References
1. Ahn HJ, Park M, Kim JA, et al. Driving pressure guided ventilation. Korean J Anesthesiol. Jun 2020;73(3):194-204. doi:10.4097/kja.20041
2. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. Feb 19 2015;372(8):747-55. doi:10.1056/NEJMsa1410639
3. Azizi BA, Munoz-Acuna R, Suleiman A, et al. Mechanical power and 30-day mortality in mechanically ventilated, critically ill patients with and without Coronavirus Disease-2019: a hospital registry study. J Intensive Care. Apr 6 2023;11(1):14. doi:10.1186/s40560-023-00662-7
4. Battaglini D, Fazzini B, Silva PL, et al. Challenges in ARDS Definition, Management, and Identification of Effective Personalized Therapies. J Clin Med. Feb 9 2023;12(4)doi:10.3390/jcm12041381
5. Battaglini D, Sottano M, Ball L, Robba C, Rocco PRM, Pelosi P. Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome. J Intensive Med. Jul 2021;1(1):42-51. doi:10.1016/j.jointm.2021.01.003
6. Bellani G, Laffey JG, Pham T, et al. Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study. Am J Respir Crit Care Med. Jan 1 2017;195(1):67-77. doi:10.1164/rccm.201606-1306OC
7. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. Jama. Mar 3 2010;303(9):865-73. doi:10.1001/jama.2010.218
8. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. May 4 2000;342(18):1301-8. doi:10.1056/nejm200005043421801
9. Chacko B, Peter JV, Tharyan P, John G, Jeyaseelan L. Pressure-controlled versus volume-controlled ventilation for acute respiratory failure due to acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Cochrane Database Syst Rev. Jan 14 2015;1(1):Cd008807. doi:10.1002/14651858.CD008807.pub2
10. Chiumello D, Carlesso E, Cadringher P, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med. Aug 15 2008;178(4):346-55. doi:10.1164/rccm.200710-1589OC
11. Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med. Sep 2017;70(3):406-418.e4. doi:10.1016/j.annemergmed.2017.01.013
12. Gattinoni L, Collino F, Camporota L. Mechanical power: meaning, uses and limitations. Intensive Care Med. Apr 2023;49(4):465-467. doi:10.1007/s00134-023-06991-3
13. Harvey CE, Haas NL, Chen CM, et al. Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference? Crit Care Explor. Feb 2022;4(2):e0632. doi:10.1097/cce.0000000000000632
14. Laffey JG, Bellani G, Pham T, et al. Potentially modifiable factors contributing to outcome from acute respiratory distress syndrome: the LUNG SAFE study. Intensive Care Med. Dec 2016;42(12):1865-1876. doi:10.1007/s00134-016-4571-5
15. Maddry JK, Mora AG, Perez CA, et al. Improved Adherence to Best Practice Ventilation Management After Implementation of Clinical Practice Guideline (CPG) for United States Military Critical Care Air Transport Teams (CCATTs). Mil Med. Jan 4 2023;188(1-2):e125-e132. doi:10.1093/milmed/usab474
16. Maddry JK, Mora AG, Savell SC, et al. Impact of Critical Care Air Transport Team (CCATT) ventilator management on combat mortality. J Trauma Acute Care Surg. Jan 2018;84(1):157-164. doi:10.1097/ta.0000000000001607
17. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. Jama. Jun 20 2012;307(23):2526-33. doi:10.1001/jama.2012.5669
18. Roginski MA, Burney CP, Husson EG, Harper KR, Atchinson PRA, Munson JC. Influence of Critical Care Transport Ventilator Management on Intensive Care Unit Care. Air Med J. Jan-Feb 2022;41(1):96-102. doi:10.1016/j.amj.2021.10.005
19. Sahetya SK, Hager DN, Stephens RS, Needham DM, Brower RG. PEEP Titration to Minimize Driving Pressure in Subjects With ARDS: A Prospective Physiological Study. Respir Care. May 2020;65(5):583-589. doi:10.4187/respcare.07102
20. Yoshida T, Uchiyama A, Fujino Y. The role of spontaneous effort during mechanical ventilation: normal lung versus injured lung. J Intensive Care. 2015;3:18. doi:10.1186/s40560-015-0083-6
21. Zaidi SF, Shaikh A, Khan DA, Surani S, Ratnani I. Driving pressure in mechanical ventilation: A review. World J Crit Care Med. Mar 9 2024;13(1):88385. doi:10.5492/wjccm.v13.i1.88385
50 min
October 10, 2024 Every Breath They Take: REALLY Delivering Lung Protective Ventilation
In this episode of the FlightBridgeED Podcast, part of our "Every Breath They Take" series on respiratory critical care, Dr. Michael Lauria explores whether we truly protect the lungs during mechanical ventilation. While the best evidence suggests keeping tidal volumes at 6 cc/kg and plateau pressures below 30 cm H2O, is that enough? ARDS is a complex lung pathology, and as we unravel its intricacies, there may be more to consider.

Join us as we explore the popular concept of driving pressure and introduce the emerging idea of mechanical power. While plateau pressure remains the gold standard, these additional metrics may provide further guidance for adjusting ventilation strategies and minimizing ventilator-induced lung injury, especially in critical care transport settings. Whether you're new to the field or a seasoned professional, this episode offers valuable insights into advanced respiratory management.

Listen to FlightBridgeED anywhere you get your podcasts, or visit us at flightbridgeed.com/explore. While there, explore our other fantastic, free content and award-winning courses to help you excel in your critical care practice.

TAKEAWAYS

• Mechanical ventilation is a double-edged sword. It can maintain oxygenation and ventilation but can also damage the lungs.

• Lung protective ventilation prevents ventilator-induced lung injury, especially in acute respiratory distress syndrome (ARDS).

• Maintaining a plateau pressure below 30 cmH2O is an essential goal in lung protective ventilation.

• Driving pressure, the difference between plateau pressure and PEEP, is a surrogate for transpulmonary pressure and may be a useful parameter to consider in lung protective ventilation.

• Keeping driving pressure < 15 cmH2O may be beneficial.

• Driving pressure might be helpful in titrating peep and optimizing lung recruitment, as well as in identifying patients who may benefit from smaller tidal volumes, even if the plateau pressure is below 30.

• Mechanical power, which represents the energy delivered to the lung over time, is a newer concept that requires further research to determine its role in lung protective ventilation.

• Optimizing the ventilatory and inspiratory flow rates (in addition to peep, plateau pressure, and tidal volume) may help reduce mechanical power below 17-22 J/min.

REFERENCES

• Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. Feb 19 2015;372(8):747-55. doi:10.1056/NEJMsa1410639

• Azizi BA, Munoz-Acuna R, Suleiman A, et al. Mechanical power and 30-day mortality in mechanically ventilated, critically ill patients with and without Coronavirus Disease-2019: a hospital registry study. J Intensive Care. Apr 6 2023;11(1):14. doi:10.1186/s40560-023-00662-7

• Battaglini D, Fazzini B, Silva PL, et al. Challenges in ARDS Definition, Management, and Identification of Effective Personalized Therapies. J Clin Med. Feb 9 2023;12(4)doi:10.3390/jcm12041381

• Battaglini D, Sottano M, Ball L, Robba C, Rocco PRM, Pelosi P. Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome. J Intensive Med. Jul 2021;1(1):42-51. doi:10.1016/j.jointm.2021.01.003

• Bellani G, Laffey JG, Pham T, et al. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. Jama. Feb 23 2016;315(8):788-800. doi:10.1001/jama.2016.0291

• Bugedo G, Retamal J, Bruhn A. Driving pressure: a marker of severity, a safety limit, or a goal for mechanical ventilation? Crit Care. Aug 4 2017;21(1):199. doi:10.1186/s13054-017-1779-x

• Chiumello D, Froio S, Mistraletti G, et al. Gas exchange, specific lung elastance and mechanical power in the early and persistent ARDS. J Crit Care. Feb 2020;55:42-47. doi:10.1016/j.jcrc.2019.09.022

• Coppola S, Caccioppola A, Froio S, et al. Effect of mechanical power on intensive care mortality in ARDS patients. Crit Care. May 24 2020;24(1):246. doi:10.1186/s13054-020-02963-x

• Cressoni M, Cadringher P, Chiurazzi C, et al. Lung inhomogeneity in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. Jan 15 2014;189(2):149-58. doi:10.1164/rccm.201308-1567OC

• Duan J, Wang S, Liu P, et al. Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score. Ann Intensive Care. Sep 30 2019;9(1):108. doi:10.1186/s13613-019-0585-9

• Gattinoni L, Collino F, Camporota L. Mechanical power: meaning, uses and limitations. Intensive Care Med. Apr 2023;49(4):465-467. doi:10.1007/s00134-023-06991-3

• Gattinoni L, Marini JJ, Pesenti A, Quintel M, Mancebo J, Brochard L. The "baby lung" became an adult. Intensive Care Med. May 2016;42(5):663-673. doi:10.1007/s00134-015-4200-8

• Gattinoni L, Tonetti T, Quintel M. Regional physiology of ARDS. Crit Care. Dec 28 2017;21(Suppl 3):312. doi:10.1186/s13054-017-1905-9

• Goligher EC, Dres M, Patel BK, et al. Lung- and Diaphragm-Protective Ventilation. Am J Respir Crit Care Med. Oct 1 2020;202(7):950-961. doi:10.1164/rccm.202003-0655CP

• Guérin C, Papazian L, Reignier J, Ayzac L, Loundou A, Forel JM. Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials. Crit Care. Nov 29 2016;20(1):384. doi:10.1186/s13054-016-1556-2

• Ogbu OC, Martin GS, Murphy DJ. A Few Milliliters of Prevention: Lung-Protective Ventilation Decreases Pulmonary Complications. Crit Care Med. Oct 2015;43(10):2263-4. doi:10.1097/ccm.0000000000001234

• Paudel R, Trinkle CA, Waters CM, et al. Mechanical Power: A New Concept in Mechanical Ventilation. Am J Med Sci. Dec 2021;362(6):537-545. doi:10.1016/j.amjms.2021.09.004

• Sahetya SK, Hager DN, Stephens RS, Needham DM, Brower RG. PEEP Titration to Minimize Driving Pressure in Subjects With ARDS: A Prospective Physiological Study. Respir Care. May 2020;65(5):583-589. doi:10.4187/respcare.07102

• Serpa Neto A, Deliberato RO, Johnson AEW, et al. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med. Nov 2018;44(11):1914-1922. doi:10.1007/s00134-018-5375-6

• Simonis FD, Binnekade JM, Braber A, et al. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials. May 24 2015;16:226. doi:10.1186/s13063-015-0759-1

• Tongyoo S, Viarasilpa T, Deawtrakulchai P, Subpinyo S, Suppasilp C, Permpikul C. Comparison of limited driving pressure ventilation and low tidal volume strategies in adults with acute respiratory failure on mechanical ventilation: a randomized controlled trial. Ther Adv Respir Dis. Jan-Dec 2024;18:17534666241249152. doi:10.1177/17534666241249152

• van Meenen DMP, Algera AG, Schuijt MTU, et al. Effect of mechanical power on mortality in invasively ventilated ICU patients without the acute respiratory distress syndrome: An analysis of three randomised clinical trials. Eur J Anaesthesiol. Jan 1 2023;40(1):21-28. doi:10.1097/eja.0000000000001778

• Wu HP, Chu CM, Chuang LP, et al. The Association between Mechanical Power and Mortality in Patients with Pneumonia Using Pressure-Targeted Ventilation. Diagnostics (Basel). Oct 10 2021;11(10)doi:10.3390/diagnostics11101862

• Yehya N, Hodgson CL, Amato MBP, et al. Response to Ventilator Adjustments for Predicting Acute Respiratory Distress Syndrome Mortality. Driving Pressure versus Oxygenation. Ann Am Thorac Soc. May 2021;18(5):857-864. doi:10.1513...
38 min
October 03, 2024 Maternal Sepsis
In this compelling episode of the FlightBridgeED Podcast, Dr. Michael Lauria delves into one of the most critical yet underappreciated aspects of emergency and critical care medicine: maternal sepsis and septic shock. As maternal mortality rates rise across the U.S., critical care transport providers are increasingly faced with the challenge of managing septic mothers and post-partum patients. Dr. Lauria, alongside special guest Dr. Elizabeth Garchar, MD, FACOG, an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care, breaks down the latest evidence and best practices for diagnosing and treating septic shock in obstetrical patients.

Explore the pathophysiology of sepsis, the role of cytokine release in organ dysfunction, and the management strategies for ensuring maternal and fetal well-being. Whether you're in pre-hospital care, the ICU, or critical care transport, this episode is packed with insights for all levels of healthcare providers.

Key Takeaways:

• Early Sepsis Detection & Organ Impact: Sepsis isn't just about blood pressure. Inflammatory cytokines can cause brain dysfunction (septic encephalopathy), kidney damage, and even septic cardiomyopathy. Be vigilant with these patients.

• Unique Obstetric Considerations: Pregnancy causes physiological changes that can mask early sepsis signs. Differentiating between normal pregnancy symptoms and systemic inflammatory response can be challenging but is crucial for survival.

• Aggressive Management is Key: Whether it's antibiotics, fluid resuscitation, or early norepinephrine administration, aggressively managing septic obstetric patients can significantly improve outcomes.

• Antibiotics First, Always: Ensure that septic patients receive broad-spectrum antibiotics within the first hour. It’s a key factor in preventing further deterioration.

• Fluid Responsiveness: Use dynamic assessments to determine fluid responsiveness instead of blindly administering large amounts of fluid.

• Pressors are Safe: Norepinephrine is a safe and recommended first-line vasopressor for septic pregnant patients. Don't hesitate to use it.

Listen anywhere you get your podcasts or directly from our website at flightbridgeed.com. While you’re there, be sure to explore our award-winning courses designed to elevate your critical care expertise.

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References

1. Albright CM, Ali TN, Lopes V, Rouse DJ, Anderson BL. The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy. Am J Obstet Gynecol. Jul 2014;211(1):39 e1-8. doi:10.1016/j.ajog.2014.03.010

2. Barton JR, Sibai BM. Severe sepsis and septic shock in pregnancy. Obstet Gynecol. Sep 2012;120(3):689-706. doi:10.1097/AOG.0b013e318263a52d

3. Bauer ME, Bateman BT, Bauer ST, Shanks AM, Mhyre JM. Maternal sepsis mortality and morbidity during hospitalization for delivery: temporal trends and independent associations for severe sepsis. Anesth Analg. Oct 2013;117(4):944-950. doi:10.1213/ANE.0b013e3182a009c3

4. Chau A, Tsen LC. Fetal optimization during maternal sepsis: relevance and response of the obstetric anesthesiologist. Curr Opin Anaesthesiol. Jun 2014;27(3):259-66. doi:10.1097/ACO.0000000000000077

5. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-Related Mortality in the United States, 2011-2013. Obstet Gynecol. Aug 2017;130(2):366-373. doi:10.1097/AOG.0000000000002114

6. Dellinger RP, Rhodes A, Evans L, et al. Surviving Sepsis Campaign. Crit Care Med. Apr 1 2023;51(4):431-444. doi:10.1097/CCM.0000000000005804

7. Evans L, Rhodes A, Alhazzani W, et al. Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med. Nov 1 2021;49(11):1974-1982. doi:10.1097/CCM.0000000000005357

8. Fan S-R, Liu P, Yan S-M, Huang L, Liu X-P. New Concept and Management for Sepsis in Pregnancy and the Puerperium. Maternal-Fetal Medicine. 2020;2(4):231-239. doi:10.1097/fm9.0000000000000058

9. Guarino M, Perna B, Cesaro AE, et al. 2023 Update on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department. J Clin Med. Apr 28 2023;12(9)doi:10.3390/jcm12093188

10. Guinn DA, Abel DE, Tomlinson MW. Early goal directed therapy for sepsis during pregnancy. Obstet Gynecol Clin North Am. Sep 2007;34(3):459-79, xi. doi:10.1016/j.ogc.2007.06.009

11. Joseph J, Sinha A, Paech M, Walters BN. Sepsis in pregnancy and early goal-directed therapy. Obstet Med. Sep 2009;2(3):93-9. doi:10.1258/om.2009.090024

12. Knowles SJ, O'Sullivan NP, Meenan AM, Hanniffy R, Robson M. Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study. BJOG. Apr 2015;122(5):663-71. doi:10.1111/1471-0528.12892

13. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. Jun 2006;34(6):1589-96. doi:10.1097/01.CCM.0000217961.75225.E9

14. Oud L, Watkins P. Evolving trends in the epidemiology, resource utilization, and outcomes of pregnancy-associated severe sepsis: a population-based cohort study. J Clin Med Res. Jun 2015;7(6):400-16. doi:10.14740/jocmr2118w

15. Plante LA. Management of Sepsis and Septic Shock for the Obstetrician-Gynecologist. Obstet Gynecol Clin North Am. Dec 2016;43(4):659-678. doi:10.1016/j.ogc.2016.07.010

16. Plante LA, Pacheco LD, Louis JM. SMFM Consult Series #47: Sepsis during pregnancy and the puerperium. Am J Obstet Gynecol. Apr 2019;220(4):B2-b10. doi:10.1016/j.ajog.2019.01.216

17. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. May 21 2015;372(21):1996-2005. doi:10.1056/NEJMoa1411162

18. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. Jun 2014;2(6):e323-33. doi:10.1016/S2214-109X(14)70227-X

19. Shields A, de Assis V, Halscott T. Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis. Obstet Gynecol. Aug 1 2021;138(2):289-304. doi:10.1097/aog.0000000000004471

20. Snyder CC, Barton JR, Habli M, Sibai BM. Severe sepsis and septic shock in pregnancy: indications for delivery and maternal and perinatal outcomes. J Matern Fetal Neonatal Med. Mar 2013;26(5):503-6. doi:10.3109/14767058.2012.739221

21. Timezguid N, Das V, Hamdi A, et al. Maternal sepsis during pregnancy or the postpartum period requiring intensive care admission. Int J Obstet Anesth. Jan 2012;21(1):51-5. doi:10.1016/j.ijoa.2011.10.009

22. van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis. Jun 2010;23(3):249-54. doi:10.1097/QCO.0b013e328339257c

23. Wang T, Liao L, Tang X, Li B, Huang S. Effects of different vasopressors on the contraction of the superior mesenteric artery and uterine artery in rats during late pregnancy. BMC Anesthesiol. Jun 30 2021;21(1):185. doi:10.1186/s12871-021-01395-6

24. Xu S, Shen X, Liu S, Yang J, Wang X. Efficacy and safety of norepinephrine versus phenylephrine for the management of maternal hypotension during cesarean delivery with spinal anesthesia: A systematic review and m...
32 min
September 26, 2024 Maternal and Fetal Physiology in Flight
In this episode of the FlightBridgeED Podcast: MDCAST, Dr. Michael Lauria is joined by Dr. Elizabeth Garchar, MD, FACOG, an OB/GYN and Maternal Fetal Medicine (MFM) specialist who has a particular interest in obstetric critical care and is unique in that she flies regularly with our
critical care transport teams as a retrieval OBGYN/MFM. They are also joined by Dr. Alixandria Pfeiffer, an MFM Fellow at the University of Texas in San Antonio. Together, they dive into the complex and underexplored world of obstetric critical care transport. With maternal mortality rates on the rise in the U.S., this episode addresses the vital role critical care transport teams play in improving outcomes for high-risk pregnancies.

The discussion focuses on monitoring pregnant patients during transport, exploring topics such as flight physiology, continuous fetal monitoring (CFM), and the challenges posed by different transport environments. Dr. Pfeiffer shares her groundbreaking research on the feasibility of fetal monitoring during transport and its potential impact on both maternal and fetal outcomes.

Key Takeaways:

• In obstetric transport, continuous fetal monitoring (CFM) is feasible and can provide critical insights during maternal transport, though it poses unique challenges depending on transport type (flight, ground).

• Flight transport often results in a slight decrease in maternal oxygen saturation and systolic blood pressure, suggesting the need for standardized oxygen therapy protocols during transport.

• Understanding fetal physiology and monitoring techniques is essential, especially in high-risk pregnancy transports where the health of both mother and baby is at stake.

Whether you're a seasoned critical care provider or just beginning your journey in EMS or critical care transport medicine, this episode delivers insights into the practical realities of OB transport.

Listen now on any podcast platform or directly from our website at flightbridgeed.com. While you're there, explore our highly successful and award-winning courses, designed to elevate your career in critical care medicine. Thank you so much for listening! We couldn't make this podcast without you.

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References

• Pfeiffer AF, Munter BT, Munoz J, Ramsey PS, Byrne JJ. Maternal Physiologic Adaptations During Transport. Am J Obstet Gynecol. 2023; 228(1): S259-S260.

• Pfeiffer AF, Munoz JL, Neuhoff BK, Boyd AR, Moreno A, Ramsey PS. Fetal Cardiotocographic Monitoring During Maternal Transport. Am J Obstet Gynecol. 2022; 226(1): S609.

• Foley MR, Strong, Jr TH, Garite TJ. eds. Obstetric Intensive Care Manual, 5e. McGraw Hill; . Accessed May 24, 2022. https://obgyn.mhmedical.com/content.aspx?bookid=2379§ionid=185956675

H.R.315 - Improving Access to Maternity Care Act, (2018). Available at: https://www.congress.gov/bill/115th-congress/house-bill/315.
30 min
September 19, 2024 CRASH & BURN: Airway Management in Hemodynamically Unstable Patients - Part 2
In Episode 264 of the FlightBridgeED Podcast: MDCAST, Dr. Mike Lauria, Dr. Jeff Jarvis, and trauma anesthesiologist Dr. Chris Stevens return for Part 2 of their deep dive into airway management in profoundly hemodynamically unstable patients. In this episode, the trio explores controversial topics such as the use of pressors in trauma patients, mechanical ventilation in the pre-hospital setting, and the pharmacology of paralytic agents like rocuronium. They also address the highly debated practice of withholding sedatives in certain critically ill patients and emphasize the importance of proper timing when using neuromuscular blockade. This episode provides practical insights for new and seasoned pre-hospital and critical care transport medicine providers, especially when managing CRASH airways and peri-arrest situations.

Some Takeaways to Listen For in this Episode:

• Pressors in Trauma Patients: Dispels the myth that trauma patients shouldn’t receive pressors. Pressors can temporarily stabilize blood pressure while awaiting blood products or other resuscitation efforts.

• Mechanical Ventilation Post-Intubation: Highlights the importance of gentle, positive-pressure ventilation to avoid worsening hypotension in trauma patients.

• Rocuronium Use: This episode discusses optimal dosing and the importance of waiting the full 60–90 seconds for the drug to take effect to ensure successful intubation.

• Withholding Sedation: Explores the controversial practice of omitting sedatives in patients with a GCS of 3 who are completely unresponsive and peri-arrest. This is common in trauma anesthesia but remains debated in pre-hospital and critical care transport settings.
1 hr 1 min
September 12, 2024 CRASH & BURN: Airway Management in Hemodynamically Unstable Patients - Part 1
In this thought-provoking episode of the FlightBridgeED Podcast: MDCAST, Dr. Mike Lauria is joined by Dr. Jeff Jarvis and Dr. Chris Stevens to tackle the critical and potentially controversial topic of airway management in hemodynamically unstable patients. The discussion dives into complex scenarios, decision-making challenges, and balancing the benefits of sedation with the risks of compromising a patient’s stability. From discussing medication-assisted intubation to exploring the concept of "crash airway" situations, the episode challenges conventional wisdom and encourages providers to think critically about their approach to airway management. This episode not only raises important questions but also provides valuable insights for both new and seasoned practitioners.

Some Takeaways to Listen For in this Episode:

• Balance Between Sedation and Hemodynamic Stability: It is important to understand how sedative agents like ketamine and etomidate affect blood pressure in critically ill patients. Over-sedation, especially in hemodynamically unstable patients, can lead to adverse outcomes. A nuanced approach to dosing is necessary.

• Awareness During Intubation: Awareness under paralysis can increase the risk of PTSD and depression. The conversation highlights the importance of avoiding awareness during airway management, especially using longer-lasting paralytics like rocuronium.

• Resuscitate Before Intubate: Emphasizes the need to stabilize patients, particularly their hemodynamics, before intubation. This can prevent worsening outcomes and cardiac arrest during emergency airway procedures.

• Decision-Making in Airway Management: Highlights that airway decisions are not black and white. Situational awareness, clinical judgment, and crew confidence are crucial, especially in determining whether to intubate pre-hospital or manage the airway in transit.

• Use of Supraglottic Airways: In emergencies where intubation is difficult or risky, supraglottic airways are recommended as a temporary measure to ensure oxygenation and ventilation until more definitive care is available.
49 min
August 20, 2024 PHACTORS: Impacting the "Platinum 10" Post-Intubation
In this engaging and insightful episode of the FlightBridgeED Podcast, Eric Bauer is joined by Dr. Michael Lauria as they delve into the intricacies of post-intubation care and the critical factors that impact patient outcomes during the first 10 minutes after intubation. Building on the well-established concepts of airway management and resuscitation, the discussion introduces the new acronym PHACTORS, which stands for Positive Pressure, Hypoxia, Acidemia, Cardiac Output, Transfer, Ongoing Pharmacology, Resuscitation, and Suction. Eric and Dr. Lauria explore how these elements play a pivotal role in the success or failure of post-intubation management, emphasizing the importance of maintaining vigilance during this critical phase. With practical tips, evidence-based insights, and real-world examples, this episode is a must-listen for anyone involved in pre-hospital critical care.

KEY TAKEAWAYS:

• Prioritize Post-Intubation Monitoring: The first 10 minutes after intubation are critical. Continuously monitor for hypotension and hypoxia, even if the initial intubation appears successful.

• Transition to Ventilator Early: Whenever possible, transition intubated patients from BVM to a mechanical ventilator as soon as possible to ensure consistent and controlled ventilation, which reduces the risk of over- or under-ventilation.

• Use Head-Elevated Positioning: Intubate patients in a head-elevated position (30 degrees) whenever possible to maintain functional residual capacity and reduce the risk of derecruitment and hypoxia.

• Suction Regularly: Proactively suction the ET tube and oral cavity to maintain airway patency. This helps prevent complications like ventilator-associated pneumonia and ensures optimal oxygenation.

• Be Ready with Push-Dose Pressors: Have push-dose pressors ready during and after intubation, especially in trauma patients or those with borderline hemodynamics, to quickly address any sudden drops in blood pressure.

• Assess and Manage Acidosis Individually: Not all acidosis requires aggressive ventilation. Consider the patient's overall condition, and tailor your ventilation strategy based on the specific type and cause of acidosis.

• Regular Sedation and Analgesia Dosing: Avoid under-sedation, particularly with long-acting paralytics like rocuronium. Set regular intervals for administering sedation and analgesia to ensure patient comfort and avoid awareness of paralysis.

• Proactively Manage Cardiac Output: In patients with compromised cardiac function, focus on optimizing preload, afterload, and contractility. Use fluids, inotropes, and vasopressors as needed to maintain stable hemodynamics.

• Secure and Streamline Lines for Transport: Before transferring a patient, ensure all lines are secured and organized to prevent dislodgement or kinking during movement. Keep access points readily available for quick medication administration.

• Understand the Impact of Positive Pressure: Transitioning from spontaneous breathing to mechanical ventilation can significantly impact venous return and cardiac output. Be prepared to manage these changes, especially in hemodynamically unstable patients.

Show Notes...

• A human, even when paying attention can deliver injurious tidal volume breaths that may go in "easy" but are probably injuring the lungs (Dafilou B, Schwester D, Ruhl N, Marques-Baptista A. It's in the bag: tidal volumes in adult and pediatric bag valve masks. West J Emerg Med. 2020;21(3):722–2021.)

• Not only are the volumes too big, but we likely WAY over breath for patients and that can be really, really bad especially after cardiac arrest or in TBI (common reasons patients get intubated...right?) (Dumont TM, Visioni AJ, Rughani AI, Tranmer BI, Crookes B. prehospital ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma. 2010;27(7):1233–41.)

• More issues with BVM ventilation that shows it's not consistent

• Siegler J, Kroll M, Wojcik S, Moy HP. Can EMS providers provide appropriate tidal volumes in a simulated adult-sized patient with a pediatric-sized bag-valve-mask? Prehosp Emerg Care. 2017;21(1):74–8.

• Turki M, Young MP, Wagers SS, Bates JH. Peak pressures during manual ventilation. Respir Care. 2005;50(3):340–4.

• Kroll M, Das J, Siegler J. Can altering grip technique and bag size optimize volume delivered with bag-valve-mask by emergency medical service providers? Prehosp Emerg Care. 2019;23(2):210–4.

• Mechanical ventilation provides more consistency and automation of a simple task with monitoring parameters (alarms) that can make it safe and effective for paramedics to actually put their brain energy to important clinical decisions and complete other tasks (Weiss SJ, Ernst AA, Jones R, Ong M, Filbrun T, Augustin C, Barnum M, Nick TG. Automatic transport ventilator versus bag valve in the EMS setting: a prospective, randomized trial. South Med J. 2005;98(10):970–6.)

• Starting mechanical ventilation and safe ventilator settings in the prehospital setting seems to make ED providers more likley to put in the right settings and continue appropriate lung protective ventilation...at least in ARDS (Stephens RJ, Siegler JE, Fuller BM. Mechanical ventilation in the prehospital and emergency department environment. Respir Care. 2019;64 (5):595–603.)

• Here's a really solid position paper from NAEMSP on it that kind of summarizes everything including the specific clinical times when it may be more helpful like cardiac arrest, trauma, etc (Baez, A. A., Qasim, Z., Wilcox, S., Weir, W. B., Loeffler, P., Golden, B. M., … Levy, M. (2022). Prehospital Mechanical Ventilation: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care, 26(sup1), 88–95. https://doi.org/10.1080/10903127.2021.1994676)
1 hr 27 min
July 29, 2024 Every Breath They Take: Part 2
PART 2 of 2

In this episode, Dr. Michael Lauria is joined by several EM/Critical Care and Transport/Retrieval physicians as we discuss the management of acute respiratory distress syndrome (ARDS) in the critical care transport setting. We cover the pathophysiology of ARDS, the criteria for diagnosis, and the basics of lung protective ventilation. We also explore the concept of driving pressure and its role in determining optimal ventilation settings. The conversation highlights the importance of individualizing treatment based on patient characteristics and monitoring parameters such as plateau pressure, driving pressure, and compliance.

Our team provides practical tips for adjusting ventilation settings and emphasizes the need for ongoing assessment and optimization. In the previous episode, we started out with some fundamental concepts of mechanical ventilation: the approach to low tidal volumes in ARDS patients and the use of point-of-care blood gases. We also explored the use of steroids in ARDS, the target oxygen saturation levels, and the use of paralysis in unstable patients. In addition, we touched on controversial topics such as inhaled pulmonary vasodilators in ARDS as well as the application of evidenced-based therapies such as proning in the transport environment (in this episode, part 2). Also, in this part of the conversation, we review the use of alternative ventilator modes, such as APRV, and the indications for ECMO in refractory ARDS. We emphasize the importance of optimizing conventional, evidence-based therapies before considering ECMO and highlight the need for clear guidelines and training when using these advanced interventions. We also discuss the challenges and potential complications associated with ECMO.

Takeaways

• ARDS is a syndrome characterized by acute onset, bilateral infiltrates on imaging, and hypoxemia.

• The diagnosis of ARDS is based on criteria such as acute onset, infectious or inflammatory etiology, bilateral opacities on imaging, and impaired oxygenation.

• Lung protective ventilation aims to minimize lung injury by using low tidal volumes (6-8 ml/kg), maintaining plateau pressures below 30 cmH2O, and keeping FiO2 below 60%.

• Driving pressure, the difference between plateau pressure and PEEP, is a marker of lung compliance and can be used to guide ventilation adjustments.

• Individualized management is crucial, considering factors such as patient characteristics, response to therapy, and monitoring parameters.

• Regular assessment and optimization of ventilation settings are necessary to ensure effective and safe management of ARDS.

• Low tidal volumes should be based on the patient's pH and PCO2, with a focus on maintaining a safe pH level. If crews are unable to measure these parameters not decreasing tidal volumes lower than 4 cc/kg is reasonable.

• Point-of-care blood gases are essential for monitoring patients on low tidal volumes and making adjustments as needed.

• Oxygen saturation targets should be individualized based on the patient's condition and physiology, with a range above 88-92% often considered reasonable. However, this issue is controversial, and occasionally, lower saturations are considered acceptable.

• Steroids may be beneficial in ARDS patients, especially those with severe pneumonia, but the timing and dosing should be determined based on the patient's specific situation.

• Paralysis can be considered in unstable ARDS patients who cannot tolerate low tidal volumes, but it should be used selectively and in conjunction with deep sedation.

• The use of inhaled pulmonary vasodilators in ARDS is controversial, and no significant mortality benefit has been demonstrated. However, they may be considered a salvage therapy in patients on their way to an ECMO center or when other interventions have been exhausted. Inhaled pulmonary vasodilators, such as epoprostenol, can improve oxygenation and pulmonary arterial pressure in patients with ARDS and RV failure.

• The use of inhaled pulmonary vasodilators should be based on individual patient characteristics and the availability of resources.

• Proning in transport has been shown to be safe and effective. It should be considered for select cases, such as patients with high pulmonary arterial pressure or basilar atelectasis.

• Transport teams should be prepared to continue inhaled pulmonary vasodilator therapy if the patient is already receiving it.

• ECMO should be considered when conventional therapies have failed, and the patient's condition is reversible and not contraindicated.

• ECMO transport requires specialized training, clear guidelines, and ongoing communication with the receiving center.

• Alternative ventilator modes, such as APRV, have not shown significant benefit in large trials. Their use is controversial but not unreasonable in certain circumstances. Implementing these settings requires training, education, and clear protocols. Generally speaking, they should be used judiciously and in consultation with the receiving physician.

• Optimizing conventional therapies and providing high-quality care can often obviate the need for ECMO.

• Transport teams should be proactive in discussing potential ECMO candidates with the receiving physician and considering the appropriateness of ECMO for each patient.

References:

• Abou-Arab O, Huette P, Debouvries F, Dupont H, Jounieaux V, Mahjoub Y. Inhaled nitric oxide for critically ill Covid-19 patients: a prospective study. Crit Care. Nov 12 2020;24(1):645. doi:10.1186/s13054-020-03371-x

• Gattinoni L, Camporota L, Marini JJ. Prone Position and COVID-19: Mechanisms and Effects. Crit Care Med. May 1 2022;50(5):873-875. doi:10.1097/ccm.0000000000005486

• Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. Jul 2023;49(7):727-759. doi:10.1007/s00134-023-07050-7

• Griffiths MJ, Evans TW. Inhaled nitric oxide therapy in adults. N Engl J Med. Dec 22 2005;353(25):2683-95. doi:10.1056/NEJMra051884

• Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. Jun 6 2013;368(23):2159-68. doi:10.1056/NEJMoa1214103

• Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. Jama. Jun 20 2012;307(23):2526-33. doi:10.1001/jama.2012.5669

• Acute Respiratory Distress Syndrome Network; Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/NEJM200005043421801.

• Grasselli G, Calfee CS, Camporota L, et al; European Society of Intensive Care Medicine Taskforce on ARDS. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023 Jul;49(7):727-759. doi: 10.1007/s00134-023-07050-7.

• Qadir N, Sahetya S, Munshi L, Summers C, Abrams D, Beitler J, Bellani G, Brower RG, Burry L, Chen JT, Hodgson C, Hough CL, Lamontagne F, Law A, Papazian L, Pham T, Rubin E, Siuba M, Telias I, Patolia S, Chaudhuri D, Walkey A, Rochwerg B, Fan E. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024 Jan 1;209(1):24-36. doi: 10.1164/rccm.202311-2011ST.
24 min
July 22, 2024 PREOXI Trial Crossover Episode w/ Dr. Jeff Jarvis
This is a must-listen! What’s the best way to pre-oxygenate our patients prior to intubation? The evidence for this question has been mixed for some time. Dr Jarvis discusses the PREOXI Trial, which directly compares preoxygenation with non-invasive ventilation compared to a face mask to see which provides the best protection against peri-intubation hypoxia. This is an important trial that sheds light on a key component of our bundle of care to make intubation safer.

Citations:

• Gibbs KW, Semler MW, Driver BE, Seitz KP, Stempek SB, Taylor C, Resnick-Ault D, White HD, Gandotra S, Doerschug KC, et al.: Noninvasive Ventilation for Preoxygenation during Emergency Intubation. N Engl J Med. (2024)

• Jarvis JL, Gonzales J, Johns D, Sager L: Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Annals of Emergency Medicine. 2018;72:272–9.

• Groombridge C, et al: A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment. Anaesthesia. 2017;72:580–4.

• Groombridge C, et al: Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. Acad Emerg Med. 2016;March;23(3):342–6.

• Baillard C, et al: Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;July 15;174(2):171–7.

• Ramkumar V, et al: Preoxygenation with 20-degree head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. J Anesth. 2011;25:189–94.

• Pourmand A, et al: Pre-oxygenation: Implications in emergency airway management. American Journal of Emergency Medicine. doi: 10.1016/j.ajem.2017.06.006

• Solis A, Baillard C: Effectiveness of preoxygenation using the head-up position and noninvasive ventilation to reduce hypoxaemia during intubation. Ann Fr Anesth Reanim. 2008;June;27(6):490–4.

• April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, et al.: Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;May;162:403–11.

• Trent SA, Driver BE, Prekker ME, Barnes CR, Brewer JM, Doerschug KC, Gaillard JP, Gibbs KW, Ghamande S, Hughes CG, et al.: Defining Successful Intubation on the First Attempt

• Using Both Laryngoscope and Endotracheal Tube Insertions: A Secondary Analysis of Clinical Trial Data. Annals of Emergency Medicine. 2023;82(4):S0196064423002135.

• Pavlov I, Medrano S, Weingart S: Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. AJEM. 2017;35(8):1184–9.
30 min

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The FlightBridgeED Podcast provides convenient, easy-to-understand critical care medical education and current topics related to the air medical industry. Each topic builds on another and weaves…