Critical Matters

In this episode of Critical Matters, we discuss the management of critically ill patients with cirrhosis. Our guest is Dr. Ram Subramanian, Medical Director of Liver Transplantation at the Emory School of Medicine in Atlanta. In his dual role as a transplant hepatologist and an intensivist, Dr. Subramanian is involved in the inpatient care of patients before and after liver transplantation and provides a unique perspective on caring for this complex patient population.      ADDITIONAL RESOURCES Management of critically ill cirrhotic patients: a multidisciplinary perspective: https://bit.ly/2Et9hN5A detailed review on ACLF and the impact of scoring systems on prognosis: https://bit.ly/2AcTtevA recent study evaluating the incidence and outcomes for patients with cirrhosis admitted to the ICU with an associated editorial by our guest: https://bit.ly/2BnQaAJ hhttps://bit.ly/2QzuPPc BOOKS MENTIONED IN THIS EPISODE The McKinsey Edge: Success Principles from the World’s Most Powerful Consulting Firm by Shu Hattori: https://amzn.to/2QVVvZWThe McKinsey Mind: Understanding and Implementing the Problem-Solving Tools and Management Techniques of the World’s Top Strategic Consulting Firm by Ethan M. Rasiel and Paul N. Friga:

In this episode of Critical Matters, we discuss the role of procalcitonin as a biomarker in lower respiratory tract infections and sepsis. Our guest is Dr. David Huang, the primary investigator in the recently published Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infections (ProACT) clinical trial. He discusses lessons learned from this very important study and offers insight into the use of procalcitonin in clinical practice. ADDITIONAL RESOURCES Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infections (ProACT) clinical trial: https://bit.ly/2BTZNsf A meta-analysis evaluating the effect of procalcitonin-guided treatment on mortality in acute respiratory infections: https://bit.ly/2Un6Lgz FDA Executive Summary on Procalcitonin assay: https://bit.ly/2EiBN4r BOOKS MENTIONED IN THIS EPISODE 7 Habits of Highly Effective People by Stephen R. Covey: https://amzn.to/2Ss0mPq Partners of the Heart by Vivien Thomas: https://amzn.to/2QC6vLP

Lung protective ventilation for ARDS includes the use of low tidal volumes, positive-end expiratory pressure (PEEP), and limiting of airway plateau pressure to minimize ventilator-induced lung injury. However, in the sickest subset of patients with ARDS hypoxemia may persist despite optimal lung protective strategies. In this episode of Critical Matters, we discuss salvage therapies for patients with refractory hypoxemia. Our guest is Dr. Robert Hyzy, Medical Director of the Critical Care Medicine Unit and Co-Chair of the Critical Care Committee at the University of Michigan Hospital. ADDITIONAL RESOURCES The PROSEVA clinical trial showed that in patients with severe ARDS prone position ventilation improved mortality: https://bit.ly/2Dp3LdS The ACURASYS clinical study showed that in patients with severe ARDS 48 hours of neuromuscular blockade was associated with improved mortality: https://bit.ly/2FqI7Zn The EOLIA study was stooped early for futility. However, many think that it still has important findings regarding the use of ECMO in severe ARDS: https://bit.ly/2QI1Cxu BOOKS MENTIONED IN THIS EPISODE Evidence-Based Critical Care: A Case Study Approach: https://amzn.to/2PYeD8V

Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure that affects approximately 200,000 patients each year in the United States, resulting in nearly 75,000 deaths annually. In this episode of Critical Matters, our guest Dr. R. Phillip Dellinger discusses the current management of patients with ARDS. Dr. Dellinger is a recognized thought leader in the field, a prolific author, an accomplished researcher, and the recipient of multiple awards for his contributions to critical care. Additional Resources The Berlin Definition: international consensus document published by the ARDS Definition Task Force: https://bit.ly/2PSTs50 An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guidelines on mechanical ventilation in ARDS: https://bit.ly/2GqOoja ARDSnet PEEP charts: https://bit.ly/25SJNh0 Books Mentioned in This Episode So Long, and Thanks for All the Fish (Hitchhiker’s Guide to the Galaxy): https://amzn.to/2OPY2EB

Caring for critically ill pregnant patients poses a series of unique challenges for the intensivist. In part two of this two-episode series, we discuss critical care in pregnancy with Dr. Stephen Lapinsky. Dr. Lapinsky is a practicing intensivist and professor of medicine at the University of Toronto. He is a member of the editorial board of the journal, Obstetric Medicine, and sits on the steering committee of the North American Society of Obstetric Medicine. Dr. Lapinsky is also the executive of the Women’s Health Network of the ACCP. Today (Part 2) we will cover general conditions that may lead to critical illness in pregnant women. Listen to the first part of this series here: https://soundphysicians.com/podcast/critical-care-in-pregnancy-part-1/ Additional Resources Practice bulletin on Critical Care in Pregnancy from the American College of Obstetrics and Gynecology (ACOG): https://bit.ly/2OtJARU A comprehensive review on acute respiratory failure in pregnancy: https://bit.ly/2DKzwjl AHA scientific statement on cardiac arrest in pregnancy: https://bit.ly/2QpGWtK

Caring for critically ill pregnant patients poses a series of unique challenges for the intensivist. In this two-episode series, we discuss critical care in pregnancy with Dr. Stephen Lapinsky. Dr. Lapinsky is a practicing intensivist and professor of medicine at the University of Toronto. He is a member of the editorial board of the journal, Obstetric Medicine, and sits on the steering committee of the North American Society of Obstetric Medicine. Dr. Lapinsky is also the executive of the Women’s Health Network of the ACCP. Today (Part 1) will cover unique conditions associated with pregnancy that may lead to critical illness. Additional Resources Practice bulletin on Critical Care in Pregnancy from the American College of Obstetrics and Gynecology (ACOG): https://bit.ly/2OtJARU A comprehensive review on acute respiratory failure in pregnancy: https://bit.ly/2DKzwjl AHA scientific statement on cardiac arrest in pregnancy: https://bit.ly/2QpGWtK

In today’s episode, we will discuss the recently released 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patient s in the ICU. Our guest is John Devlin, PharmD, BCCCP, FCCM, FCCP. Dr. Devlin is the lead author of these guidelines and a recognized leader in the field. Additional Resources Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU: https://bit.ly/2wzFNHv Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU: https://bit.ly/2vOyVGP Interpreting and Implementing the 2018 of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Guidelines: https://bit.ly/2waInU7 Nocturnal low-dose Dexmedetomidine to prevent delirium in ICU patients: https://bit.ly/2MJ2TSi Books Mentioned in This Episode Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer: https://amzn.to/2OAfZmD  

In this episode of Critical Matters, we explore the role of the intensivist in the management of patients with ventricular assist devices. Our guest is Dr. John Greenwood, a practicing intensivist who splits his clinical time between the Cardiac & Vascular ICU and the ED-ICU at the Hospital of the University of Pennsylvania. Additional Resources Summary of information presented during the episode kindly provided by Dr. John Greenwood: https://bit.ly/2MJdfSa  HeartWare Waveforms App for iPad: https://apple.co/2NpyQEr Articles Mentioned In This Episode Pratt AK, Shah NS, Boyce SW. Left ventricular assist device management in the ICU. Crit Care Med. 2014;42(1):158-68: https://bit.ly/2MKr3M6  Sen A, Larson JS, Kashani KB, et al. Mechanical circulatory assist devices: a primer for critical care and emergency physicians. Crit Care. 2016;20(1):153: https://bit.ly/2NoreC4 

In this episode of Critical Matters, we continue the discussion of medical errors in healthcare with a specific focus on how to disclose medical errors to patients. Our guest is Dr. Nitin Puri, a practicing intensivist and medical educator at the Cooper Medical School of Rowan University and the Cooper Health System in Camden, New Jersey. Additional Resources This is a CNN story on cardiothoracic fellow wrongly accused and sued for lying about a medical error: https://cnn.it/2vFEnLf The Communication and Optimal Resolution (CANDOR) toolkit from the Agency for Healthcare Research and Quality (AHRQ). CANDOR is a process that health care institutions and providers can use to respond in a timely, thorough and fair way when medical errors occur and cause patients harm: https://bit.ly/2m9fch7 A powerful video on the topic of the disclosure of medical errors: https://bit.ly/2DaD6TD Article Mentioned in This Episode Mistakes Were Made (but Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts: https://amzn.to/2NorssU

In this episode of Critical Matters, we discuss “Compassionomics” with Dr. Stephen Trzceciak. Dr. Trzeciak is a practicing intensivist and prolific researcher. His research interests have focused recently on the hypothesis that compassion matters for patients, for healthcare outcomes, and for providers. Compassionomics is the revolutionary field of science focusing on caring, and the impact compassion has on healthcare. Additional Resources How 40 Seconds of Compassion Could Save a Life: https://youtu.be/elW69hyPUuI Compassionomics: Hypothesis and experimental approach: http://compassionomics.net Article Mentioned in This Episode A Patient’s Story: http://www.theschwartzcenter.org/media/patient_story.pdf

In this episode, we discuss the ABCDEF bundle, a tool used to promote evidence-based care that promotes healing and liberation from critical illness for patients in the ICU. Our guest is Dr. Julia Barr who is currently the Associate Professor of Anesthesia in the Medical Center Line at Stanford Medical School and a staff anesthesiologist and intensivist at the VA Palo Alto Medical Center. Dr. Barr has served as a national faculty member for the SCCM ICU Liberation Campaign ABCDEF Bundle Collaborative and is a member of the SCCM’s ICU Liberation Committee. Additional Resources Society of Critical Care Medicine’s guidelines on management of pain, agitation and delirium: http://www.sccm.org/Research/Guidelines/Guidelines/Pain,-Agitation,-and-Delirium-in-Adult-Patients-in Society of Critical Care Medicine’s guidelines for Family-Centered Care in the ICU: http://www.sccm.org/Research/Guidelines/Guidelines/Family-Centered-Care-in-the-ICU Books Mentioned in This Episode The Power of Habit: Why We Do What We Do in Life and Business: https://www.amazon.com/Power-Habit-What-Life-Business-ebook/dp/B0055PGUYU/ref=sr_1_2?ie=UTF8&qid=1530020419&sr=8-2&keywords=the+power+of+habit

In this episode, we discuss seizures in the ICU. We cover a broad range of topics related to the initial management of seizures, status epilepticus, and EEG monitoring in post-anoxic brain damage. Our guest is Dr. Thomas Bleck. Dr. Bleck is the professor of neurological sciences, neurosurgery, internal medicine and anesthesiology at Rush University Medical Center, where he is a neurointensivist and the director of clinical neurophysiology. Additional Resources Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society: http://www2.soundphysicians.com/l/403342/2018-06-27/cxz5ng/403342/102465/Evidence_Based_Guideline_Treatment_of_Convulsive_Status_Epilepticus_in_Children_an.pdf Guidelines for the Evaluation and Management of Status Epilepticus: http://www2.soundphysicians.com/l/403342/2018-06-27/cxz5nb/403342/102461/Guidelines_for_the_evaluation_and_management_of_status_epilepticus..pdf Clinical classification of post anoxic myoclonic status: http://www2.soundphysicians.com/l/403342/2018-06-27/cxz5nd/403342/102463/Clinical_classification_of_post_anoxic_myoclonic_status.pdf  Books Mentioned in This Episode Tinker, Tailor, Soldier, Spy: A George Smiley Novel: https://www.amazon.com/Tinker-Tailor-Soldier-Spy-George-ebook/dp/B004RKXNDU/ref=sr_1_1?ie=UTF8&qid=1530020470&sr=8-1&keywords=tinker+soldier+le+carre

In this episode of Critical Matters, we discuss medical errors in healthcare. Our guest is Dr. Nitin Puri, a practicing intensivist and medical educator at the Cooper Medical School of Rowan University and the Cooper Health System in Camden, New Jersey. We discuss a range of topics related to medical errors in critical care medicine including the incidence of errors in our practice, causes, how to prevent them, and how we should deal with them when they occur. Additional Resources To Err is Human: Building a Safer Health System. The landmark publication y the Institute of Medicine highlighting medical errors as a critical cause of deaths in the US healthcare system: https://www.ncbi.nlm.nih.gov/pubmed/25077248 Medical error – the third leading cause of death in the US: https://www.ncbi.nlm.nih.gov/pubmed/27143499 Books Mentioned in This Episode Haroun and the Sea of Stories:  https://www.amazon.com/Haroun-Sea-Stories-Salman-Rushdie/dp/0140157379/ref=asap_bc?ie=UTF8 Invisible Man: https://www.amazon.com/Invisible-Vintage-International-Ralph-Ellison-ebook/dp/B003WUYR9K/ref=sr_1_2?ie=UTF8&qid=1525281632&sr=8-2&keywords=invisible+man+ralph+ellison

In this episode of Critical Matters, we discuss the role of noninvasive ventilation and high-flow oxygen nasal cannula in respiratory failure. Our guest, Dr. Pratik Doshi, is an academic intensivist and emergency medicine physician at the University of Texas Health Science Center in Houston, Texas. Dr. Doshi is the lead author and investigator of a recently published multicenter randomized clinical trial evaluating this topic. Additional Resources Official ERS / ATS Guidelines for non-invasive ventilation (NIV): https://www.ncbi.nlm.nih.gov/pubmed/28860265 High-velocity nasal insufflation in the treatment of respiratory failure: A randomized clinical trial by Doshi P et al: http://www.annemergmed.com/article/S0196-0644(17)31968-6/fulltext Books Mentioned in This Episode The Alchemist: https://www.amazon.com/Alchemist-Paulo-Coelho-ebook/dp/B00U6SFUSS/ref=sr_1_1?ie=UTF8&qid=1523055572&sr=8-1&keywords=the+alchemist

In our first episode of the Critical Matters podcast, we discussed the potential role of Angiotensin II in the treatment of distributive shock based on the results of the ATHOS 3 clinical trial. Now Angiotensin II is FDA approved and commercially available as a product named GIAPREZA. In this episode we will discuss this topic further. Our guest is Dr. Lakhmir S. Chawla, Chief Medical Officer of La Jolla Pharmaceutical in San Diego, California. Previously, Dr. Chawla was a Professor of Medicine at the George Washington University. During his tenure at George Washington, Dr. Chawla was the designer and lead investigator of the ATHOS (Angiotensin II for the Treatment of High Output Shock) trial which results led to the ATHOS 3 trial, (The Phase 3 clinical trial of angiotensin II, for the treatment of catecholamine-resistant hypotension). Additional Resources ATHOS-3 Clinical Trial. Randomized controlled trial evaluating the efficacy of Angiotensin II in raising blood pressure in vasodilatory shock.  http://www.nejm.org/doi/full/10.1056/NEJMoa1704154 Outcomes in Patients with Vasodilatory Shock and Renal Replacement Therapy Treated with Intravenous Angiotensin II. https://www.ncbi.nlm.nih.gov/pubmed/?term=Outcomes+in+Patients+with+Vasodilatory+Shock+and+Renal+Replacement+Therapy+Treated+with+Intravenous+Angiotensin+II Prescribing information for Angiotensin II (GIAPREZA ). http://giapreza.com/giapreza-prescribing-information.pdf Books Mentioned in This Episode Atlas Shrugged: https://www.amazon.com/Atlas-Shrugged-Ayn-Rand/dp/0451191145/ref=sr_1_1?ie=UTF8&qid=1522104389&sr=8-1&keywords=atlas+shrugged+book

In this episode of Critical Matters, we explore the intersection of high-altitude medicine and physiology with critical care. Our guest is Robert B. Shoene, MD, FACP. Dr. Shoene is Associate Director, ICU and Critical Care, at St. Mary’s Medical Center in San Francisco. Dr. Shoene is a prolific author and researcher with more than 100 publications. His research has focused on pulmonary physiology and altitude medicine, and he has been part of numerous research expeditions to locations such as Mt. Everest and Denali. Additional Resources: Arterial Blood Gases and Oxygen Content in Climbers on Mount Everest: https://www.nejm.org/doi/full/10.1056/NEJMoa0801581 A comprehensive review on illnesses at high altitude: https://journal.chestnet.org/article/S0012-3692(08)60216-0/fulltext Everest: The West Ridge by Thomas Hornbein: https://www.amazon.com/Everest-West-Ridge-Thomas-Hornbein/dp/1594857075/ref=sr_1_1?ie=UTF8&qid=1520812701&sr=8-1&keywords=everest+the+west+ridge Endurance: Shackleton’s Incredible Journey by Alfred Lansing: https://www.amazon.com/Endurance-Shackletons-Incredible-Alfred-Lansing/dp/0465062881/ref=sr_1_1?s=books&ie=UTF8&qid=1520812797&sr=1-1&keywords=endurance Being Mortal: Medicine and What Matters in the End by Atul Gawande: https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/1250076226/ref=sr_1_1?s=books&ie=UTF8&qid=1520812921&sr=1-1&keywords=Being+mortal Intensive Care, a poem by Dr. Robert Schoene: https://www.jstor.org/stable/1348231?seq=1#page_scan_tab_contents

In this episode, we discuss the practice of respect in the intensive care unit. Our guest is Samuel M. Brown, MD, MS, a practicing intensivist and Director of the Center for Humanizing Critical Care at Intermountain Medical Center in Murray, Utah. Dr. Brown holds an academic appointment as Associate Professor of Medicine at the University Of Utah School Of Medicine, Murray UT. He is a prolific investigator and author with a wide range of interests, including complexity in critical illness, echocardiography, and ethics. Our conversation covers topics such as dignity, respect, compassion and burnout. Join us in a fascinating discussion with a thought leader in bringing humanism to critical care. Additional Resources: Recent article co-authored by Dr. Brown and colleagues reviewing important aspects of the practice of respect in critical care medicine. Click here to read. The Center for Humanizing Critical Care works with researchers and clinicians with the goal of helping patients and family members make it through critical illness with their humanity intact. Learn more here. Speak, Memory: An Autobiography Revisited by Vladimir Nabokov. Click here to learn more.

The use of point-of-care ultrasound (POCUS) has penetrated our clinical practice. In the hands of trained intensivists POCUS can quickly provide valuable diagnostic information and lead to specific therapeutic interventions. Today’s episode explores the use of POCUS during cardiac arrest. Our guest is Haney Mallemat, MD. Dr. Mallemat is board certified in emergency medicine, internal medicine, and critical care medicine and works in the emergency department and intensive care unit at Cooper University Hospital in Camden, NJ. He has lectured both nationally and internationally and has contributed to several emergency medicine and critical care podcasts. He is a firm believer in the benefits of bedside ultrasound for better patient care. Additional Resources The REASON Trial evaluated the role of POCUS in out of hospital cardiac arrest arriving to the emergency department. Click here to read. Point of care ultrasound can be associated with frequent interruptions during CPR. As Dr. Mallemat discusses in the podcast, providers must pay very close attention to this issue. Click here to read more.

The advent of targeted temperature management has changed how we treat anoxic brain damage post cardiac arrest. In this episode of Critical Matters, we dive into the challenges and existing evidence regarding neuroprognostication in cardiac arrest survivors. Our guest is Fred Rincon, MD. Dr. Rincon is Associate Professor of Neurology and Neurological Surgery at Thomas Jefferson University in Philadelphia, PA. He is board certified in internal medicine and critical care (ABIM), neurology (ABPN), vascular neurology (ABPN), and neurocritical care (UCNS). Additional Resources Practice Guidelines on reducing brain injury following cardiopulmonary resuscitation. These guidelines are published by the American Academy of Neurology and endorsed by the Neurocritical Care Society. Click here to read.

In this episode, we discuss critical illness-related corticosteroid insufficiency (CIRCI). Our guest is Stephen Pastores, MD, FACP, FCCP, FCCM. Dr. Pastores is Director of the Critical Care Medicine Fellowship Training and Research Programs at Memorial Sloan Kettering Cancer Center in New York, NY. Dr. Pastores co-chaired an international multispecialty task force addressing this important topic. During our podcast, he discusses the recent publications by this task force on corticosteroid insufficiency and the role on corticosteroid replacement in critical illness. Additional Resources Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part 1): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Click here to read. Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative Review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Click here to read. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock​. ADRENAL Trial Investigators. Click here to read.