Mechanical Ventilation Strategies in the Critically Ill Burn Patient: A Practical Review for Clinicians

Burn patients are a unique population when considering strategies for ventilatory support. Frequent surgical operations, inhalation injury, pneumonia, and long durations of mechanical ventilation add to the challenging physiology of severe burn injury. We aim to provide a practical and evidence-based review of mechanical ventilation strategies for the critically ill burn patient that is tailored to the bedside clinician.

Low Blood Flow Continuous Veno-Venous Haemodialysis Compared with Higher Blood Flow Continuous Veno-Venous Haemodiafiltration: Effect on Alarm Rates, Filter Life, and Azotaemic Control

<b><i>Title:</i></b> Low blood flow continuous veno-venous haemodialysis (CVVHD) compared with higher blood flow continuous veno-venous haemodiafiltration (CVVHDF): effect on alarm rates, filter life, and azotaemic control. <b><i>Introduction:</i></b> Continuous renal replacement therapy (CRRT) can be delivered via convective, diffusive, or mixed approaches. Higher blood flows have been advocated for convective clearance efficiency and promotion of filter life. It is unclear whether a lower blood flow predominantly diffusive approach may benefit filter life and alarm rates. <b><i>Materials and Methods:</i></b> Sequential cohort study of 284 patients undergoing 874 CRRT circuits from January 2015 to August 2018 in a single university-associated tertiary referral hospital in Australia. Patients underwent a protocol of either CVVHDF at blood flow 200–250 mL/min or CVVHD at blood flow 100–130 mL/min. Machine and patient data were analysed. Outcomes of azotaemic control, filter life, and warning alarm rates were log transformed and analysed with mixed linear modelling with patient as a random effect. <b><i>Results:</i></b> Both groups had similar azotaemic control (effect estimate on log creatinine CVVHD vs. CVVHDF 1.04 [0.87–1.25], <i>p</i> = 0.68) and median filter life (CVVHDF 16.8 [8.4–90.5] h and CVVHD 16.4 [9.4–82.3] h, <i>p</i> = 0.97). However, circuit pressures were less extreme with a narrower distribution during CVVHD. Multivariate analysis showed CVVHD had a reduced risk of warning alarms (incidence risk ratio [IRR] 0.51 [0.38–0.70]) and femoral access placement also had a reduced risk of alarms (IRR 0.55 [0.41–0.73]). <b><i>Conclusion:</i></b> Low blood flow CVVHD and femoral vascular access reduce alarms while maintaining azotaemic control and circuit patency thus minimizing bedside clinician workload.

Severe lactic acidosis from acute cyanide poisoning after intentional amygdalin ingestion in a teenager

Cyanide poisoning via the oral route is a remarkably rare entity in the United States. Though acute toxicity from this poison may present with classic signs and symptoms (smell of bitter almonds on breath and cherry-red skin), these signs are frequently not clinically observed in the intoxicated patient, making it low on the routine differential diagnosis leading to both diagnostic and therapeutic challenges for the bedside clinician. This is a case of a 17-yearold male with a history of depression who presented to the Emergency Room (ER) with altered mental status, abdominal pain, and emesis. A severely elevated and worrisome lactic acidosis triggered the ER’s septic shock bundle and algorithm, but further investigation ultimately led to the unifying diagnosis of intentional cyanide poisoning.

Contemporary hemodynamic monitoring, fluid responsiveness, volume optimization, and endpoints of resuscitation: an AAST critical care committee clinical consensus

This article, on hemodynamic monitoring, fluid responsiveness, volume assessment, and endpoints of resuscitation, is part of a compendium of guidelines provided by the AAST (American Association for the Surgery of Trauma) critical care committee. The intention of these guidelines is to inform practitioners with practical clinical guidance. To do this effectively and contemporarily, expert consensus via the critical care committee was obtained. Strict guideline methodology such a GRADE (Grading of Recommendations Assessment, Development and Evaluation) was purposefully NOT used so as not to limit the possible clinical guidance. The critical care committee foresees this methodology as practically valuable to the bedside clinician.

P.055 A clinical pathway of combined EEG monitoring in high-risk critically ill neonates

Background: overtreatment of neonatal seizures may result in neurological morbidity. aEEG, despite low sensitivity, is widely used, for ease of bedside interpretation. vEEG, is a limited resource needing expert interpretation. We hypothesize that using aEEG combined with vEEG will increase the sensitivity and specificity of seizure detection and reduce anti-convulsants use compared to aEEG alone. Methods: Prospective cohort of neonates admitted to CHEO NICU with suspected seizures between April 1st 2018 to present. Seizures (clinical/aEEG) were documented by bedside clinicians and compared to the vEEG. Bedside clinicians could call a neurologist for remote review of the vEEG. Outcomes include concordance of aEEG and vEEG events and number of episodes where management was changed based on both readings Results: 27 patients had both modalities recording simultaneously. No seizure was identified by either modality in 23 recordings. Seizures were identified in 4 vEEG recordings; the aEEG partially identified these seizures.aEEG specificity of 0.87, negative predictive value 0.8, sensitivity 0.44 and positive predictive value 0.57Bedside clinician contacted a neurologist 9 times; in 2 cases, this prevented unnecessary treatment.Conclusions: In this small sample, aEEG had good specificity for ruling out seizures, but low sensitivity for detecting them. The new combined pathway may prevent unnecessary treatment.

Professional Nurse Advancement Programs: The Face of Leadership at the Bedside

Aims and ObjectiveThis article reviews a professional nurse advancement program and describes how it benefits patient care, staff engagement, and patient satisfaction.BackgroundExisting literature notes that professional nurse advancement programs can empower nurses to improve nursing care at the bedside and contribute to a safe patient care environment.MethodThe article reviews the qualitative exploration of the activities of participants in a professional nurse advancement program to determine the impact on patient care and identify benefits of the program. The article summarizes findings from thematic and narrative technique analysis of semistructured interviews with nurses, nurse leaders, and nurse administrators, and reviews of nurses’ portfolio information.ResultsImplementation of a professional nurse advancement program correlated with decreased patient falls, increased bedside clinician involvement in research, and positive outcomes in nursing quality indicators.ConclusionA professional nurse advancement program fosters continued professional growth and opportunities for advancement; promotes pride, personal responsibility, and respect for self; and prepares and enables nurses to lead change in advancing health in communities.

Invasive Hemodynamic Monitoring in the Intensive Care Unit

Optimal support of critically ill surgical patients with cardiovascular dysfunction requires that the bedside clinician have both a clear understanding of basic cardiovascular physiology and thorough knowledge of the information available from invasive hemodynamic monitors, including the advantages and pitfalls of each system. Assessment of hemodynamic function in underperfused patients should start with a quantitative assessment of global cardiovascular function. Global variables can be flow derived (e.g., cardiac output), pressure derived (e.g., systolic blood pressure), or both (e.g., ventricular stroke work and power). Any assessment consistent with inadequate global hemodynamic performance should be followed by analysis of the independent determinants of cardiovascular function. These independent determinants include heart rate, preload, afterload, and myocardial contractility. Invasive hemodynamic monitors allow the bedside clinician to measure and quantitate various combinations of global performance and the determinants of cardiac function depending on the monitoring system employed. Central venous lines enable measurement of central venous pressure but limited measure of right ventricular preload. Pulmonary artery catheters offer information pertaining to several global measures and independent determinants. Devices that depend on pulse contour wave analysis, when coupled with a central venous catheter, can measure cardiac output and preload in the context of measurements of stroke volume. However, being invasive, each device carries some degree of risk to the patient, and each monitoring technique employed via these devices carries pitfalls in both measurement and interpretation. It is incumbent upon the bedside clinician to understand the physiologic derangements affecting the patient and the utility and pitfalls of the information available from each device when selecting monitoring systems to be used in any given patient and the supportive therapy that ensues. This review contains 3 figures, 1 table, and 28 references. Key words: afterload, cardiac output, central venous catheter, hemodynamic monitor, myocardial contractility, perfusion, preload, pulmonary artery catheter, pulse contour analysis, stroke volume, stroke volume variability, stroke work, ventricular power

Invasive Hemodynamic Monitoring in the Intensive Care Unit

Optimal support of critically ill surgical patients with cardiovascular dysfunction requires that the bedside clinician have both a clear understanding of basic cardiovascular physiology and thorough knowledge of the information available from invasive hemodynamic monitors, including the advantages and pitfalls of each system. Assessment of hemodynamic function in underperfused patients should start with a quantitative assessment of global cardiovascular function. Global variables can be flow derived (e.g., cardiac output), pressure derived (e.g., systolic blood pressure), or both (e.g., ventricular stroke work and power). Any assessment consistent with inadequate global hemodynamic performance should be followed by analysis of the independent determinants of cardiovascular function. These independent determinants include heart rate, preload, afterload, and myocardial contractility. Invasive hemodynamic monitors allow the bedside clinician to measure and quantitate various combinations of global performance and the determinants of cardiac function depending on the monitoring system employed. Central venous lines enable measurement of central venous pressure but limited measure of right ventricular preload. Pulmonary artery catheters offer information pertaining to several global measures and independent determinants. Devices that depend on pulse contour wave analysis, when coupled with a central venous catheter, can measure cardiac output and preload in the context of measurements of stroke volume. However, being invasive, each device carries some degree of risk to the patient, and each monitoring technique employed via these devices carries pitfalls in both measurement and interpretation. It is incumbent upon the bedside clinician to understand the physiologic derangements affecting the patient and the utility and pitfalls of the information available from each device when selecting monitoring systems to be used in any given patient and the supportive therapy that ensues. This review contains 3 figures, 1 table, and 28 references. Key words: afterload, cardiac output, central venous catheter, hemodynamic monitor, myocardial contractility, perfusion, preload, pulmonary artery catheter, pulse contour analysis, stroke volume, stroke volume variability, stroke work, ventricular power

Prediction of Non-invasive Mechanical Ventilation Response. Moving from Art to Science?

SummaryPredicting the outcome from NIV is important and the study by Martin-Gonzalez and colleagues applies data mining techniques to improve our understanding of the field. Nevertheless, the predictor variables must be robust and reliably available before NIV is applied. A predictive model must be generalisable in other clinical settings. Until models such as this are extremely robust in their predictive ability and have been shown to positively influence patient centered outcomes, they may be able to assist decision making but cannot replace clinical judgement by an experienced bedside clinician.