Critical Care Scenarios

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The hows, whys, logistics, and applications of focused, bedside transesophageal echocardiography performed by critical care and EM providers, with Felipe Teran, assistant professor of emergency medicine at Weill Cornell and director of the Resuscitative TEE Project.

Takeaway lessons

1. As a rule, resuscitative TEE is performed in patients with a secured airway.
2. TEE views are not unlike TTE views, just at a different angle (often backwards/upside down down). The technical skills are very similar, and skilled TTE users will find the learning curve short. There are actually fewer probe manipulations (in and out, left and right, and Omniplane rotation, along with some less-used ones like flexion/extension).
3. The same questions you’d typically ask with TTE can be asked with TEE: is there tamponade? is there cardiogenic shock? is there RV failure? is there hypovolemia? These can be answered even in patients with technically-difficult surface windows.
4. Some questions hard to answer with TTE can be answered with TEE, such as obtaining reliable RV inflow-outflow views and reliable valve assessments.
5. Some new questions can be answered with TEE alone: is there aortic dissection? are catheters and wires (ECMO, Impella, pacing wires, etc) optimally placed?
6. TEE has specific applications in cardiac arrest: are chest compressions optimally positioned on the chest? What is the rhythm? It provides monitoring much more continuous than intermittent TTEs, since it can be left in place.
7. In an ideal world, resuscitative TEE would be handled very much like TTE, and performed in a similar way—not restricted to some small group of “superusers” or for very rare cases.
8. When implemented by trained users in appropriately-selected cases (e.g. in shock with inadequate transthoracic windows), it impacts care virtually 100% of the time.

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An overview of the role and contributions of a clinical pharmacist in the ICU, with Laura Means Ebbitt of the University of Kentucky, a clinical pharmacist specializing in colorectal/ENT surgery and critical care.

Takeaway lessons

1. A clinical pharmacist is a “knowledge pharmacist,” dispensing advice rather than medications. They round with the team to review meds and answer questions about routes, interactions, etc, follow up on patient education and post-discharge coordination, assist with medications during cardiac arrests and other emergencies, and provide other clinically-oriented guidance and oversight. Most have completed post-graduate residency programs.
2. Clinical pharmacists generally have an important role for antibiotic regimen selection, monitoring, and stewardship.
3. They consider cost in a way that providers rarely do.
4. They provide patient education that we typically defer or omit.
5. They’re great at catching deviations in good ICU practices, such as missing DVT or stress ulcer prophylaxis, managing and reconciling home medications, and coordinating nutrition needs (particularly with TPN).

Resources

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Part two of our discussion with fan favorite Matt Siuba (@msiuba), Cleveland Clinic intensivist, on complications in critical care and how to prevent and manage them. Today we focus on respiratory failure after extubation, and unintentional self-extubation.

Takeaway lessons

1. When considering extubation of borderline patients, extubating to high flow nasal cannula or CPAP/BiPAP is often a good compromise. This is probably at least a little better than waiting for them to struggle before applying the support, plus it’s easier to assess their course. They can always come off if they look stellar.
2. Set up for extubation success by first optimizing volume status, sedation strategies, mobility, and other good liberation practices.
3. If concerned about pulmonary edema, a trial of a “tube compensation” mode alone (versus pressure support with PEEP) may be a good “strict” trial, as compared to more primitive ZEEP or T-piece trials.
4. Post-extubation stridor is not always predictable, although known airway trauma should raise suspicions. If severe, or even borderline, patients should be promptly reintubated. If more mild, a trial of a couple hours on medical therapies and NIPPV is reasonable. Try steroids (dexamethasone 10 mg IV or so).
5. Cuff leak tests are not very predictive and as likely to mislead as help. Visual inspection of high-risk airways for laryngeal edema may be helpful, although remember that a large tube in a small airway may never have a leak (and always visually look tight), yet may not be at risk for narrowing after tube removal.
6. Self-extubation should prompt emergent preparation to oxygenate and reintubate, although you can assess their stability before actually doing it. Remove the tube if still stuck in the mouth. Stop sedative drips that suppress breathing.
7. If agitation precludes oxygenation, consider antipsychotics. Dexmedetomidine may be useful in this situation, but takes a good 30-60 minutes to get loaded, so you may need another agent as a bridge. Don’t use a loading dose of dex, but starting at a higher rate (>0.6) is smart.
8. A patient intubated primarily because of agitation will usually do fine after extubation, whether intentional or accidental. The main problem is that agitation precludes a clear, easily-interpretable SBT.
9. “Extubation hesitancy” is a common error in the ICU. Clinicians are overly hesitant about failed extubations but not worried enough about prolonged intubation courses from the failure to try. Accept that a 0% chance of reintubation means leaving people on the vent for too long; acknowledge risks, plan for fallbacks, and don’t take failure personally; optimize the circumstances; but in the end, try. Risk need not be zero, it should just be lower than the risk of continued mechanical ventilation. “Not everybody is going to be ready every day, but you should treat every day like it’s extubation day.”
10. The immediacy of the psychological feedback when a patient self extubates gives it primacy and power in our minds. It’s easy to see its harms, while it’s harder to see the harms of the oversedation that prevents it. “Overcautious” is really “overmedicalizing” and is not a safer flavor of risk.